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Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary (2016)

Chapter: 4 The Effects of Contraceptive Practice

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Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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4

The Effects of Contraceptive Practice

Contraceptive use is a key factor in fertility rates that came up many times during the workshop, but four presentations provided detailed looks at this factor. Akinrinola Bankole of the Guttmacher Institute spoke about the impact of contraceptive use and abortion on fertility rates. Clémentine Rossier of the Institut National d’Etudes Demographiques addressed the role of traditional family planning methods, and Amy Tsui of Johns Hopkins University discussed data on contraceptive preferences and practices. Donatien Beguy of the African Population and Health Center discussed family planning among the urban poor.

IMPACT OF CONTRACEPTIVE USE AND ABORTION

Bankole explored a variety of data sources in assessing the role of contraceptive use and abortion in limiting fertility, including survey, long-term trend, and demographic data. In most of sub-Saharan Africa, he noted, only about 4 in 10 women wish to avoid pregnancy, and use of contraceptives, particularly modern ones,1 is low, as Figure 4-1 shows. Pregnancy rates among women seeking to avoid pregnancy who use various methods to do so vary: the pregnancy rate for women who use no

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1Modern contraceptives—generally those whose use requires medical assistance—include sterilization, the intrauterine device, birth control pills or injections, and implants. Traditional methods of birth control include periodic abstinence, withdrawal, and folk methods.

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-1 Contraceptive use among women aged 15 to 49 in five sub-Saharan regions in 2003 and 2014.
SOURCE: Bankole (2015).

method at all is 40 percent. Abortion, however, plays an important role in limiting fertility in different parts of the region, he added; rates range from 15 to 38 abortions per 1,000 women aged 15 to 49.

Bankole and his colleagues used a method developed by the Guttmacher Institute to estimate the effects of contraceptives, abortions, and women’s decisions about them by analyzing data on unintended pregnancy outcomes (i.e., live birth, abortion, or miscarriage).2 The analytic approach allowed Bankole and his colleagues to examine scenarios, such as women changing from using no contraceptive to using a modern method, or changing type of method. They estimated pregnancies by intention status and outcome by both country and sub-region, using a variety of data. They also estimated the distribution of women of reproductive age (18 to 49) by their need for contraception for 2003 and 2014, together with other data.

They found that the use of modern contraceptives prevented many pregnancies in both years studied, Bankole reported (see Figure 4-2). Women switching their contraceptive method had substantial effects in the eastern sub-Saharan region, but not in other regions, he added. Modern methods have a much larger effect in preventing unintended preg-

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2See https://www.guttmacher.org/pubs/AddingItUp2014.html for a discussion of methods and data sources [July 2015].

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-2 Effects of modern contraceptive use in 2003 and 2014, per 1,000 women, ages 15-49.
NOTE: Each bar indicates total pregnancies averted. GUFR is general unintended fertility rate, GAR is general abortion rate, and GMR is general miscarriage rate.
SOURCE: Bankole (2015).

nancies than traditional ones do, with the strongest effect in the southern region. Reversible modern methods were more effective than condoms alone, he added. Abortion has an additional effect on total fertility rates, which also varies by region, preventing from 12 to 29 additional births per 1,000 women above the effects of contraception.

Bankole highlighted primary conclusions from the data he presented. Although fertility remains high in sub-Saharan Africa and contraceptive use overall is low, it is clear that the use of modern contraceptives in particular played an important role in preventing rates from being even higher. Abortions also played an important role in limiting fertility. There is a need for community education about the advantages of contraception, he added, and for programs that provide a wide variety of methods as well as adequate counseling. Sufficient and sustained funding and political commitment are both necessary to meet those objectives, he concluded.

ROLE OF TRADITIONAL FAMILY PLANNING METHODS

Despite evidence that modern methods are more effective, Rossier noted, traditional methods are used worldwide and in African nations, as Figure 4-3 shows. She noted, however, that the terms “modern” and

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-3 Use of traditional contraceptive methods in 2011, in percentage.
SOURCE: Rossier (2015). Data from United Nations, Department of Economic and Social Affairs, Population Division (2013). World Contraceptive Patterns 2013. New York: United Nations.

“traditional” are somewhat misleading in the context of contraception. Periodic abstinence and withdrawal are the primary traditional methods used worldwide, she noted; used for the purpose of preventing pregnancy, they are interventions of the modern era. The more modern versions of periodic abstinence identify fertile periods more accurately than some older methods do. Thus, she suggested that these two methods be called “neo-traditional” because they require no device or contact with health services but are based on modern knowledge. The truly traditional means of regulating fertility used in sub-Saharan Africa, she explained, are postpartum abstinence and premarital abstinence, both of which are primarily the result of rules of conduct that are not necessarily intended to prevent pregnancy.

Rossier and her colleagues examined usage of these three types of methods (i.e., modern, traditional, and neo-traditional) among women in 23 countries in three sub-regions of sub-Saharan Africa, using both descriptive and multivariate analysis methods. They characterized women by types of sexual inactivity, life stage, socioeconomic status, and region, and then used logistic regression methods to compare women’s approaches to controlling their fertility.

They found that across the sub-regions, women had similar patterns of sexual activity. Married women spend approximately one-third of their married life sexually inactive, she reported, and postpartum inactivity accounts for only one-third of this inactivity. Women who have never

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-4 Unmet need for contraception by socioeconomic status.
SOURCE: Rossier (2015). Data from United Nations, Department of Economic and Social Affairs, Population Division (2013). World Contraceptive Patterns 2013. New York: United Nations.

married spend the majority of their reproductive years inactive. These patterns vary by education level and rural or urban residence, she added. The three graphs in Figure 4-4 show the distribution of approaches for three different categories of women: unmarried women who have had sexual activity, married women who still want more children, and married women who want no more children. Each group was examined by urban or rural and educational status.

These data show that, because they spend less time wanting a child, being pregnant, or being infertile, women who are financially stable have a greater demand for birth control at every life stage. However, this increasing demand is more than met by their use of both modern and neo-traditional methods, and their overall unmet need is lower than that of less educated rural women.

The multivariate analysis showed, in addition, that patterns vary. For example, women in Central Africa, educated women, and those who live in rural areas are particularly likely to use neo-traditional methods, while unmarried women are more likely to use modern methods than neo-traditional ones.

Rossier suggested several reasons why women might favor neo-traditional methods over modern ones. Some may fear the side effects of

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

hormone-based methods, she noted, and better educated women may have the easiest time transitioning to these methods. Some women may have relatively weak motivation to avoid pregnancy, Rossier added, although she noted that there is little evidence for this hypothesis. Some evidence does suggest, however, that some women may associate modern or neo-traditional methods with promiscuity; and that such women, particularly those who are unmarried, may prefer traditional methods. It is also true, she added, that family planning programs and products are less readily available in rural areas, and therefore women in those areas would have less opportunity to use modern methods.

Overall, Rossier, concluded, there is considerable unmet need for satisfactory contraceptive methods in the region.

CONTRACEPTIVE PREFERENCES AND PRACTICES

Amy Tsui began by noting that sub-Saharan Africa will need improved family planning and that leaders in the field have emphasized that successful family planning will require (Caldwell and Caldwell, 2002)

  • stronger political leadership;
  • programs that meet the needs of all women, not only those who are currently married;
  • support for the market that makes products available; and
  • recognition that hormone-based methods, particularly injectables, are vital.

It will also be important to consider the diversity of the African continent, Tsui added. She noted that the combined history of ethno-linguistic diversity, which was overlaid by the influence of the distinct languages and cultures of European colonizing nations, has presented a unique set of challenges for African nations. The two maps in Figure 4-5 illustrate this diversity. She and her colleagues used national-level Demographic and Health Surveys (DHS) data for the years 1985 to 2013 to review trends and patterns in contraceptive use in that context, attempting to draw out some of the unique aspects of contraceptive practice of the sub-Saharan region.

Tsui laid out a few differences as background for the data that she and her colleagues explored. One is that the context of sexual partnership in the sub-Saharan region differs in some ways from that in other places. Premarital activity, which may occur primarily in the context of less formal marriage arrangements, and polygamy are more common in the region than elsewhere. There is a pattern of postpartum abstinence and amenorrhea that limits exposure to pregnancy risk, and women tend to seek ways to use contraception that are discreet. Family planning pro-

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

grams are weaker in this area than in other regions, but the region also has experienced an ongoing HIV epidemic, which has influenced thinking about contraceptive use.

She noted that policy changes can have a profound impact on contraceptive access and use, as the graph in Figure 4-6 shows. Iran and Rwanda both show how quickly contraceptive behavior can respond to government policies, but the slow and steady growth seen in Colombia, Bangladesh, and Kenya also demonstrate policy’s impact. By contrast, the largest sub-Saharan nation, Nigeria, has not seen an appreciable increase.

To gain a more precise picture of contraceptive practices in the sub-Saharan region, Tsui and her colleagues compiled national-level data to examine rates of use of modern contraception, and particularly of three methods that are discreet (that can be used without others being aware of it) among married and unmarried women. Use of all modern contraceptives has increased for all groups of women, but sexually active unmarried women—a group that is growing—are particularly likely to choose methods that are accessible, under personal control, and discreet. Figure 4-7 shows data on use of any type of contraception for sexually active unmarried women in four countries.

Tsui discussed the effects of other distinguishing characteristics of the sub-Saharan region. She noted that women in polygamous marriages may have lower motivation to use contraception than other women because of a perceived need to compete for the husband’s resources, though polygamy rates are decreasing in the region. Postpartum abstinence and amenorrhea also likely depress demand for contraception, she added, but both of these factors are decreasing in the region. Thus, women who resume sexual activity and fertility sooner may have an increased demand for contraception. Tsui and her colleagues examined data for women in eight sub-Saharan countries who had recently given birth to examine patterns in the adoption of implants or injectable contraceptives after delivery. They found that patterns vary across the countries, which, she explained, suggests that the role of the spouse and the specific cultural practices and expectations surrounding fertility and contraception play a large role in women’s decision making.

Responses from males in the DHS survey data allowed the researchers also to examine husbands’ views of family planning and their understanding of what their wives’ views were, Tsui explained. Data on men’s reports of whether they or their wives approved of family planning show that husbands’ approval has increased somewhat but that spouses tend not to communicate extensively about this issue.

Tsui and her colleagues assessed the strength of family planning programs in the region by examining data on women who discontinued use of contraception for preventable reasons, such as method failure,

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-5 Distribution of ethno-linguistic clusters and Europan colonial influence in Africa.
SOURCE: Harvard WorldMap (Harvard University) showing data from Murdoch, G.P. (1959). Africa: Its People and Their Culture History. New York: McGraw-Hill.

side effects, or problems with access or cost. The weighted average data for 20 sub-Saharan countries and for 3 countries suggest that one-half of discontinuation episodes could be prevented through an effective family planning program. For example, more than 35 percent of discontinuation episodes in Ethiopia came about because of side effects or health concerns, and the total across the 20 countries studied was 24.2 percent.

HIV is a problem throughout the region, Tsui added, and a rising concern is that increased use of contraception that does not also protect

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-5 (cont’d.) 1913 map of Colonial Africa.
SOURCE: Eric Gaba–Wikimedia Commons user: Sting. Available: https://commons.wikimedia.org/wiki/File:Colonial_Africa_1913_map.svg [December 2015].

against HIV will result in increased HIV transmission. Another concern for some is that resources devoted to family planning may take away from the support for HIV prevention and care, she noted. To test this hypothesis, she and her colleagues examined the data on HIV testing for women and men to see whether there was any relationship between having been tested and use of contraception. They found a high correlation between these two services and concluded that there does not seem to be a problem with competition for resources.

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-6 Trends in modern contraceptive prevalence in six countries.
SOURCE: Tsui (2015). Data from United Nations, Department of Economic and Social Affairs, Population Division (2014). World Contraceptive Use 2014. New York: United Nations.

Finally, Tsui and her colleagues used longitudinal regression models with country-level fixed effects to examine differences across the sub-Saharan region. They wanted to understand whether sexual activity, use of modern contraceptives, postpartum abstinence, and use of discreet methods have varied significantly over time or from country to country. The time trend and heterogeneity by country are both very strong and significant, she reported, for each of the outcomes they examined. Thus, treating the sub-Saharan countries as a region with consistent or static characteristics and developments would be unwise, she concluded.

Tsui closed with several general observations. First, the use of modern contraception is increasing in sub-Saharan countries, though there is significant geographic variation. Support for the use of family planning methods among husbands is increasing. More than one-half of all contraceptives used in the region are either injectables or implants, she noted, and unmarried females are even more likely than married ones to use modern methods. She suspects that reliance on medical abortion is high, but did not have data on this. In general, when contraceptive use is discontinued, she concluded, it is because health care delivery systems are weak, though newer mobile and community-based models have recently

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 4-7 Contraceptive use among sexually active unmarried women in four countries.
NOTES: Numbers in parentheses indicate the percentage of women in each country who are sexually active and unmarried and are thus included in these survey results. Results are based on pooling of two national survey samples conducted in each country.
SOURCE: Performance Monitoring and Accountability 2020 Project. Available: http://www.pma2020.org [December 2015].

expanded access. Resources for combating the HIV epidemic have carried benefits and costs for family planning programs and practices, she added. “In all it’s quite a varied picture,” she concluded, “the social and structural forces may be the same as ones seen in other regions,” but the internal patterns through which they play out vary from country to country.

FAMILY PLANNING AMONG THE URBAN POOR

Beguy presented evidence from Nairobi, Kenya, to focus on changes in use of family planning methods among the urban poor. As background, he noted that poor economic conditions in many sub-Saharan countries have led people to settle in urban slums with no access to basic services and infrastructure. Informal settlements in urban areas in the sub-Saharan region have mushroomed over the past 30 years. Overall, the population of slum dwellers in the region almost doubled from 103 million in 1990 to 200 million in 2010, though the proportion of urban residents living in slum conditions decreased from 70 to 62 percent.

The primary driver of this growth is natural increase, Beguy noted, rather than migration from rural areas or reclassification of settlements as

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

urban. In the sub-Saharan region, 75 percent of urban growth is accounted for by natural increase, as opposed to 60 percent on average in other developing areas. Moreover, high fertility rates in the region are generally the result of mistimed or unwanted pregnancies, which suggests that the urban poor have high unmet need for effective family planning services. Thus, in Beguy’s view, improving access to those services will be critical to reducing the pace of urban growth in the region and particularly increasing the numbers of people living in slum conditions.

Kenya illustrates well the urban crisis in the sub-Saharan region, explained Beguy. Between 60 and 70 percent of Nairobi’s residents live in slum conditions, and sexual and reproductive health outcomes are poor among those residents. Unmet need for contraception is greatest among the poorest women in these slums—the greatest gap between wanted and unwanted fertility is found among them as well. On the positive side, Beguy added, there is some evidence that the gap between rich and poor in terms of family planning has begun to decline and that family planning programs may be more accessible to the poor populations than in the past.

However, data about the urban poor populations are scarce, Beguy explained, so it is difficult to explore the mechanisms that may be bringing this about or other questions about sexual and reproductive health in these areas. The well-being of the urban poor, in Beguy’s view, will increasingly drive results for national development indicators in Kenya, so it will be critical to understand and address needs in the urban slum areas. He and his colleagues examined cross-sectional survey data on use of family planning services in slum settlements in Nairobi between 2000 and 2012. They examined the role of 10 independent variables (i.e., age, ethnicity, religion, education, wealth, child mortality experience, exposure to family planning, desire for additional children, employment status, and number of living children) in influencing the use of a modern method of contraception (long-acting and permanent methods as well as short-acting ones).

Beguy and his colleagues found a significant increase in the prevalence of modern contraceptive use among women living in Nairobi slums, from 34.4 percent in 2000 to 53.5 percent in 2012. They noted the increase among women in all of the categories studied (i.e., religion, ethnicity, education, age level) and among women with varying fertility preferences, exposure to family planning information, child mortality rates, and number of living children. The only exception was among women undecided about whether they want to have more children.

Beguy and his colleagues analyzed the data to determine which covariates seemed to have the greatest association with increases in the use of modern contraception methods. Beguy explained that if recent

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

interventions to improve access to contraception3 have been successful, then one would expect both an increase in the overall prevalence of modern methods and a reduction of the inequity in access. The results of the analysis corroborate both expectations, he added, because the increase in use of modern methods was highest among the groups who had the lowest access in 2000.

The analysis also showed that changes in women’s behaviors suggest that new strategies for reaching women adopted by family planning programs may have been effective. In particular, he noted that many more women were informed of family planning options when visiting a health facility in 2012 than had been in 2000, and that this change might help to account for the 56 percent increase in use of modern contraception among women who desire no more children during this period. Another important factor is education level, which, Beguy noted, was the factor most strongly associated with increased use of modern methods. This period also saw an improvement in child survival rates, he added, which is associated with increasing demand for contraception.

Beguy concluded from this analysis that family planning services are increasingly reaching slum dwellers, but that barriers remain. Sustained efforts will be needed to build on the improvement he and his colleagues identified, he added.

DISCUSSION

Discussion of the presentations highlighted areas where further data and research would be valuable. The issues that were raised include the following:

  • The reasons for distrust or rejection of modern hormonal methods—what are the roles of rumors about these methods, as opposed to negative personal experiences?
  • The reasons that comparatively more educated women use traditional methods. What are failure rates for these methods? Do failure rates vary by education or place?
  • The practices that women who discontinue use of modern contraceptives use to prevent pregnancy.

One topic that received particular attention was women’s preferences and decision making. One participant noted that the recent trend

___________________

3Beguy noted in particular a reproductive health initiative that targets women in poor urban settlements, funded by the Bill & Melinda Gates Foundation, and efforts to remove financial barriers to providing family planning services.

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

in economic analysis is to incorporate behavioral analysis to better understand real-world choices, because traditional economic analysis is not always adequate to explain decision making. Another noted that whether a behavior is in fact rational depends significantly on the context and circumstances, so that what might seem to be the most rational choice from the perspective of urban, educated women might in practice be much less so for women in different circumstances.

Looking at practical implications, one participant wondered whether it is realistic to expect family planning programs to make every contraceptive option available everywhere, and another agreed that, given budget limitations, it would be reasonable to attempt to do more to match options to women’s preferences. Another participant noted that the means by which people acquire knowledge and information are changing rapidly, which should drastically change the delivery of family planning.

Discussant Ndola Prata offered a few general observations about the presentations and discussion. The presentations clearly demonstrated, she noted, that contraceptive practice can influence the pace of declines in fertility, but that overall demand for contraceptives will be greatly influenced by the supply of good quality services and methods. In general, she added, women are more likely to continue using a contraceptive when they are able to use the option they prefer, so making sure that demand for preferred methods is satisfied is an extremely important element in promoting fertility decline, in her view. Improving the supply of contraceptive options in the sub-Saharan region will require shifts in policies and programs, she added. For example, it is critical that all providers have the skills and capacity to provide at least all reversible methods—she noted that nurse practitioners, for example, can now complete in-service training without being taught how to insert an IUD. That circumstance could be changed through policy, she noted, but also highlights the need for greater innovation and responsiveness to the specific needs of the region, as well as better use of the private sector so that the supply of services and products can meet the need.

Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 35
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
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Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 37
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 38
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 39
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 40
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 41
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 42
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 43
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 44
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 45
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 46
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 47
Suggested Citation:"4 The Effects of Contraceptive Practice." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
Page 48
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Fertility rates and population growth influence economic development. The marked declines in fertility seen in some developing nations have been accompanied by slowing population growth, which in turn provided a window of opportunity for rapid economic growth. For many sub-Saharan African nations, this window has not yet opened because fertility rates have not declined as rapidly there as elsewhere.

Fertility rates in many sub-Saharan African countries are high: the total rate for the region is estimated to be 5.1 births per woman, and rates that had begun to decline in many countries in the region have stalled. High rates of fertility in these countries are likely to contribute to continued rapid population growth: the United Nations projects that the region's population will increase by 1.2 billion by 2050, the highest growth among the regions for which there are projections.

In June 2015, the Committee on Population organized a workshop to explore fertility trends and the factors that have influenced them. The workshop committee was asked to explore history and trends related to fertility, proximate determinants and other influences, the status and impact of family planning programs, and prospects for further reducing fertility rates. This study will help donors, researchers, and policy makers better understand the factors that may explain the slow pace of fertility decline in this region, and develop methods to improve family planning in sub-Saharan Africa.

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