PRB

(December 2008) Sub-Saharan Africa remains the “last frontier” of fertility decline. Throughout the developing world (including China), the average number of children per woman has dropped from around six in 1965 to just about three today. But in sub-Saharan Africa, there are many countries in which fertility has fallen little, if at all. What’s more, women in some sub-Saharan countries report that they want at least six children. Is sub-Saharan Africa likely to follow the fertility declines that characterized Asia and Latin America, or is this region different? Are there countries in sub-Saharan Africa where population growth rates have fallen and, if so, what makes them different from the rest? And what about HIV/AIDS: Will AIDS mortality contribute to slower population growth or will it cause a reversal of whatever gains have been made?

During a PRB Discuss Online, Steven Sinding, senior fellow at the Guttmacher Institute and former director general of the International Planned Parenthood Federation, London, answered participants’ questions about the potential for fertility decline in Africa.

December 10, 2008 12 PM EST

Transcript of Questions and Answers

Kofi Awusabo-Asare: I am hoping there will be historical dimension to the discussion! What were the state of the economy, political system and support that the countries that SSA countries are being compared with at the time of the onset of fertility decline? For instance, to achieve their current fertility level, China had to adopt the one child per family policy. At the time China implemented her policy, although it was accused of human rights abuses, the concern for human rights was not as strong as it is today. The second dimension is that SSA is being dumped together as a unitary state. This is not the case and that there will be the need to consider area or country-specific issues
Steven Sinding: Very pertinent points. First, fertility decline is underway in much of sub-Saharan Africa. The declines, where they are occurring or have occurred, began later than most other developing regions and countries, but the pattern of decline is similar in that it begins in the largest cities and only gradually moves out, first to secondary cities and towns and then to the rural areas. In much of SSA, rural fertility decline has yet to begin. Second, fertility decline began earlier and is further advanced in Anglophone countries than in Francophone or Lusophone countries. This difference is more attributable to when the countries adopted population policies and family planning programs than to any other factor.
Given that by most measures, SSA scores lower on most pertinent human development indicators than other regions, it is not surprising that fertility decline began later and is less advanced in Africa than elsewhere. Fertility is highly related to such measures as infant/child mortality; literacy and school enrollment rates, especially for girls; female employment outside the home; and urbanization. On all such measures, SSA lags behind other regions and one must assume that the pace of fertility decline will be strongly determined by how well SSA governments do in raising living standards, particularly with respect to health, education and gender. Finally, it should be noted that desired fertility (i.e., the number of children women say they would like by the time they complete childbearing)is still relatively high in much of SSA. Desired fertility is strongly influenced by the socioeconomic factors just listed above. However, there is quite a high level of “unmet need for contraception,” measured by the proportion of women who say they want to limit or space future births but are not using contraception. If all the unmet need were satisfied, fertility would decline in most countries by between 15 and 30 percent. In other words, alongside efforts to raise living standards in general so as to reduce desired fertility, there is also a need for family planning programs to help women and couples realize their present fertility goals.

tembinkosi: isnt it that african countries are now pursuing population policies similar to the North that encourage the use of contraceptives,monogamy etc…?
Steven Sinding: Some are, others are not. Generally the Francophone countries are lagging behind the Anglophone in adopting population policies and reproductive health programs. Serious efforts to provide family planning services have only been mounted in a handful of countries and where they have been provided, fertility has declined. The most well known success stories are in South Africa, Botswana, Zimbabwe and Kenya—and quite recently in Rwanda. In the first four, much of the fertility decline that followed the development of strong programs occurred in the 1980s and ’90s. Since 2000, there has been a real leveling off in Botswana, Kenya and Zimbabwe, mostly because priorities changed and much of the effort that had been directed at high fertility was redicrected to AIDS prevention and treatment—especially treatment. In fact, family planning effort has declined seriously in several countries as population and family planning has declined as a development priority—in part because it was not included in the initial version of the Millennium Development Goals (MDGs).

kashif Mahmood: “No law and policy which is against nature of human beings can be implemented and human behaviour is unpridicable.”
In the light of above-mentioned reality how can we predict decline family size in sub-saharan Africa? and what meausres will be taken to modify thinking of people?
Steven Sinding: There is no reason of which I am aware to assume that Africans have a different nature than people living in every other region of the world. Fertility behavior in, in fact, highly predictable and responds to the conditions in which people find themselves. As living standards improve, as employment and residence shift from rural to urban, as incomes rise, as school fees and other costs of children increase, generally people throughout the globe, including in Africa, decide to have fewer children. Also, as the case of Kenya in the 1980s shows, when political leaders decide that fertility is too high and ought to come down, and when they repeat this message over and over again, people do begin to think about whether or not they can and should have fewer children and many decide to do so. As the famous Australian demographer John (Jack) Caldwell has said, much of dramatic decline in fertility that we have witnessed in Asia, the Middle East and Latin America over the past 40 years was the result of changing family size norms—norms that changed in part as the result of communications programs that were deisgned to change them. Another famous demographer, Ronald Freedman, an American, called this “ideational change” and said that it had a powerful independent effect, above and beyond what “development” itself brought about, on fertility behavior.

Jason Bremner: Can you discuss urban/rural differentials in fertility in Sub-saharan Africa, and whether urbanization trends are likely to have any impact on fertility in Sub-Saharan Africa.
Steven Sinding: I have addressed this issue in answwers to the previous questions I answered. In short, urban-rural differentials are very marked in Africa and as the continent continues to rapidly urbanize, I anticipate urbaization will continue to have a powerful impact on fertility. A look at the differential fertility between populations living in urban slums and the rural communities from which they migrated underscores this point quite dramatically. For an excellent treatment of this issues, see Demographic and Health Surveys Comparative Reports, # 18, “Fertility changes in sub-Saharan Africa,” MEASURE/DHS. September 2008.

tembinkosi: How significant is the claim that HIV/AIDS has seriously affected population growth of Africa?l think the issue has been exaggerated.
Steven Sinding: Despite the substantial mortality from AIDS, UN projections for all developing regions, including Africa, predict large further population increases. This is because the annual number of AIDS deaths (2 million) is equivalent to just 10 days growth in the population of the developing world. The population of sub-Saharan Africa is expected to grow by 1 billion between 2005 and 2050 (from 0.77 to 1.76 billion). In fact, no African country is expected to see a decline in its population size between 2005 and 2050 due to high AIDS mortality. Even with the steady future declines in fertility assumed by the UN, most populations in sub-Saharan Africa will more than double in size, several will triple and Niger is projected to quadruple by 2050.

Hussein Hassan: In some religions, specially Islam which is religion of many Sub-Saharan africans, does not discourage people to have many children. So what is the role of religion in Africa to have many children?
Steven Sinding: Religion, or the attitude of religious leaders, sometimes reinforces traditional conservative attitudes. It is important to distinguish this aspect of religion from formal doctrine. In fact, only Roman Catholic doctrine specifically opposes some modern forms of contraception. Nearly all other religions are silent on the matter. Islam, as a matter of fact, preaches that a household head should have no more children than he can properly care for and support. And many Islamic countries have been in the vanguard of population policies and family planning programs. I would mention Indonesia (the world’s largest Muslim country), Iran, Morocco, Tunisia and Bangladesh as just five among several very prominent examples. In other words, religious leaders can sometimes reinforce attitudes and values that are not part of their religion’s formal doctrine. And, as the cases of Indonesia and Iran show, religious leaders can also be very influential in the encouragement of family planning if they choose to do so.

Kazuyo Machiyama: What do you think are potential causes of the recent stagnation of fertility decline in sub-Saharan Africa? (But I believe some of the claimed fertility stalls are spurious.)
Steven Sinding: I don’t think they are spurious and I think the cause is very clear: the redirecting of resources away from family planning and toward other (usually health-related) programs, most especially HIV/AIDS. The data are very clear that expenditures on family planning have declined dramatically (by at least 30 percent between 1995 and 2005)while expenditures on HIV/AIDS, TB and malaria have increased dramatically (by 300 percent over the same period of time). As M. Michel Garenne says in DHS/MEASURE Comparative Studies Report # 18 on Fertiliy change in sub-Saharan Africa, “The speed of the fertility decline, approximately 1 child per decade, also varied markedly among countries, from 1.5 children per decade to less than 0.5 children per decade. In addition, a stall in fertility decline occurred in six of the countries investigated (Ghana, Kenya, Madagascar [urban areas], Nigeria, Rwanda-rural, Tanzania [rural areas]); in five of these countries, this stall occurred in 1995-2005.”

J Kishore: Literacy status of the women, development [level}, particularly standard of living, are linked with decline of fertility. Africa is not doing well due to many reasons in female literacy and standard of living so [not] able to decrease fertility. Progress is slow as compared to other continents. The developed world has to focus on its proper development to bring it in main stream.
Steven Sinding: As my answers to several of the preceding questions demonstrates, I agree with this statement.

Douwe Verkuyl: Where there was a good health service, fertility declined: RSA, Botswana, Namibia, Zimbabwe. [In] Other countries, the personal service and dedication is missing (tanzania 1 doctor to 50.000 people). The last frontier (apart from perhaps West Africa will disappear if services are provided. There is a window of opportunity for delivering FP if that is missed then the failed state scenario through overpopulation/poverty/ lack of work and education is getting more and more likely. King’s Demografic Trap Don’t you think?
Steven Sinding: I think the provision of family planning within health services is extremely important. We have seen that wherever reasonably good health services are offered, if family planning is included it will be used and fertility will decline. Perhaps the most dramatic example is in the experimental program run by the Navrongo Health Research Centre in northern Ghana. There, in one of the most remote and disadvantaged parts of Africa, it was shown that community-based contraceptive services, which also emphasised mother and child health (i.e., good antenatal care, immunisations, etc.)lowered the fertility rate by between 15 and 20 percent, compared with no change in the areas without such services.
Having said that, I think that family planning and community health care must be accompanied by other rural services that improve education, employment opportunities, rural incomes, and women’s status. African fertility will only decline if, as nearly everywhere else in the world, it is addressed comprehensively, with an approach that focuses on raising living standards of poor families at the same time that it provides contraceptive services.

Rei Ravenholt: Does anyone know of a county in a sub-Saharan country where oral contraceptives, condoms, and misoprostol tablets have been offered at every residence, repeatedly; and clinical services for tubal ligation and pregnacy termination are readily and freely available; and where there is an ongoing problem of inadequate use and no decline in the birth rate? If not, then let’s get on with that necessary task.
Steven Sinding: Thanks, Rei. Always great to hear from you.

Debbie Fugate: Can you please discuss how to measure stalls in fertility decline?
Secondly, although this is not an issue unique to Africa, are there aspects of the occurance of a fertility stall in African countries that are different?
Steven Sinding: Fertility trends are usually monitored in developing countries through a series of surveys—the Demographic and Health Surveys. Over a period of years, these surveys track fertility trends in many countries. For example, surveys beginning in 1978 and conducted roughly every five years since showed significant fertility declines in Kenya through the 1980s and the first half of the ’90s, but then stalling and remaining essentially unchanged since the late 1990s. A recent DHS comparative study (#18 in a series) by M. Michel Garenne, shows contemporary fertility stalls in six African countries -Ghana, Kenya, Madagascar (urban areas), Nigeria, Rwanda- (rural), and Tanzania (rural). I think the principal cause of the fertility stalls in these countries is a decline in the funding for family planning and associated reproductive health services. The experience in Asia showed that most countries maintained strong family planning programs over an extended period, enabling them to bring fertility down from high levels to levels much closer to replacement (slightly more than two children). There were very few stalls in decline until countries began to approach replacement because program support remained constant and strong. In recent years, support for family planning programs in Africa declined as donor funding for sexual and reproductive health has declined, leading to the fertility stalls. In Kenya, the case I know best and the one most closely studied, there seems little question that this is what has happened.

Mwendalubi Maumbi: In Zambia, as is likely the case with other Sub-Saharan countries, some cultural norms actually have it that the more children a man has, the more powerful or respected he becomes. For those that may seem to be modern, they mostly have multiple concurrent sexual partners and so may have 3 children with the wife but are likely to have 1, 2 or 3 from other women outside marriage. Is it just my observation or are the poorest really with the most children? What could be the cause of this?
Steven Sinding: You are quite right that traditional norms mean men prove their strength, masculinity and power through the number of children they father. That is why fertility tends to decline as women gain greater equality with men and are able to have more of a say in how many children they will bear. The education of girls, leading to increasing autonomy and empowerment, is for this reason the single most important determinant of desired fertility. Strong family planning programs then help women to realize their fertility desires.
While the situation varies from country to country, generally fertility is highest in rural Africa where people generally are poorer than those who live in urban centers. Multiple partnerships, such as you describe, don’t necessarily mean higher fertility since fertility is measured in terms of how many children on average a woman bears, as opposed to how many a man may father.

Christopher Mwaijonga: Family planning being repositioned is one of stepping up efforts to save mothers’ lives. Studies have shown a positive correlation between the family planning acceptance and use to levels of morbidity and mortality associated with pregnancy and childbirth, Maternal death and disability rates mirror the huge discrepancies that exist between the haves and the have-nots both within and between countries. We should all work for the survival of mothers, it is a human rights imperative. It also has enormous socio-economic ramifications – and is a crucial international development priority. Both the ICPD/POA and the MDGs call for a 75 per cent reduction in maternal mortality between 1990 and 2015. I hope part of the discussion on the 10th Dec will focus on this fact and how we can jointly help to accelerate implementation and realisation of that dream, that noble dream. We have to ensure that (i) All women have access to contraception to avoid unintended pregnancies, (ii) All pregnant women have access to skilled care at the time of birth, and (iii) All those with complications have timely access to quality emergency obstetric care And evidence shows that in all those countries being cited, significant declines in fertility and subsequently declines in maternal mortality occurred as more women and more women gained access to family planning and skilled birth attendance with backup emergency obstetric care. That said, it is almost not possible, for significant poverty reduction to take place side by side with high fertility. My last humble request, let us put a human face, a face of woman, to these numbers. When and does a man come into this discussion?
Steven Sinding: Eloquently stated.

John Bermingham: Hi, Steve! If possible, would you post a list of stalled fertility countries. Q1. To what extent are contraceptives and abortion readily available in these countries? Q2. Which works best at lowering fertility – free standing fly plg clinics or health facilities in which fly plg is but one of a great many but not very urgent health issues
Steven Sinding: Hi John — I answered the first question just a few minutes ago and you will see the response when my answers are posted. The second question is much harder to answer, and is not an either/or matter. But generally, I would say that the most effective facilities are not stand-alone family planning centers but neither are they ones that try to offer a full range of comprehensive health services. In other words, in Africa the most effective centers have tended to be those that offer a limited range of the most critical services from the standpoint of protecting women’s and children’s health. A “selective primary care approach,” one that includes a range of services that trained para-professional staff can provide in difficult settings, would include family planning, tetanus toxoid, immunization against major childhood diseases, referrals for obstetrical complications, growth monitoring and nutrition education, and treatment for diarrheal diseases and acute respiratory infections. This was the package offered by the Navrongo project in rural northern Ghana, with dramatic effect on both maternal and child health outcomes, and fertility! I should add that both malaria (esp. bednets) and HIV prevention services (VCT and condoms) need to be included in the updated selective primary care package.

jjooo: Does Africa need fertility decline?
Steven Sinding: I believe that many countries, such as Niger where at present fertility the population will double in 15 years, would benefit greatly if fertility was lower. This does not mean that Africa needs fewer people. It does mean that strains on African governments would be less and the prospects for sustained economic development would be far better if the rate of population growth were slower. Most African countries, which have committed themselves to achieving the Millennium Development Goals, have practically no chance of meeting any of those goals at present fertility levels, whether one is talking about poverty reduction, reducing hunger, achieving universal primary school enrollments, reducing infant/young child mortality, reducing maternal mortality, reducing new HIV infection rates, or improving the environment.

Paula Tavrow: To what extent do you think that the high fertility in Africa is attributed to a failure to appreciate and address sufficiently African men’s power and role in fertility decision-making? Can you describe some effective models of African men’s engagement in family planning?
Steven Sinding: Men’s roles are very important, in Africa and elsewhere. But I don’t think the role of men in Africa is different today from what it was in Bangladesh in the 1980s or in Korea in the 1960s and 1970s. Empowering women to negotiate childbearing on equal terms with men is a key factor, and providing women with services that give them a certain degree of independent control over their fertility is equally important. During my time in Kenya, when fertility was falling very fast (1986-1990), I observed that men were especially responsive to the calls of political and other leaders to behave responsibly when it came to childbearing. Helping men to understand the relationship between family size and their aspirations for their children in terms of education and land inhertance played a major role in changing male attitudes, at the same time that family planning services helped women attain greater power in determining the number and spacing of their children.

Barbara Cooper: Have policy makers adjusted their thinking in light of the reality that replacement fertility in much of Africa has to be higher than 2.1 given mortality among women of reproductive age?
Steven Sinding: I doubt it. But if effective primary care programs of the kind I outlined in my response to John Bermingham’s question were offered, I think mortality decline would occur at as fast or faster a rate than fertility decline.

Jacques Emina: Could you discuss about the relationship between probable decline of fertility
in SSA, very low ferility in Europe, risk of selective out-migration in SSA and the future of SSA development?
Steven Sinding: I wish I could but this is a huge question. What I will say is that extremely low fertility in Europe will create an increasing demand for labor which Africans and many others will be ready to fulfill. At the same time, very high fertility in Africa creates a large pool of job seekers who cannot find employment at home. If fertility were lower in Africa, the pressure to migrate out would be correspondingly reduced, assuming job creation rates in Africa remain constant or, one could hope, increase. Of course, the most highly educated Africans are the ones most in demand in the low fertility countries, thus contributing to the brain drain that is such a tragedy for African countries. The answer to the brain drain in Africa is not lower fertility—it is economic development and creation of good employment options in Africa. But economic development itself would be much easier to promote if population pressures were less, enabling governments to invest more in the quality of education and healthcare, thus creating the human capital that is a prerequisite to sustained economic growth.

Ntsoaki Mapetla: Can we expect changes in desired fertility and in turn declines in fertility in SSA due to HIV/AIDS – in other words can we expect significant changes in reproductive choices?
Steven Sinding: This is a very difficult question to answer. Fertility goals are generally thought to be influenced not by adult mortality but by under-five mortality. It is the probability that children will survive to adulthood that largely determines how many children a couple will want to bear. So, at the level of individual families, where fertility goals are usually set, I would not expect AIDS mortality to have a major impact. However, at the broader level of societies, one hears political leaders often expressing concern about “de-population” due to AIDS. Where political leaders, fearing the effects of AIDS mortality, withdraw resources from family planning programs, the effect on fertility could be strong, even though fertility desires of families might not change at all.

Esther Nakkazi: Many sub-Saharan countries introduced free primary education in the past decade. In Uganda it has been in existence over the last ten years or so. But the issue of female literacy does not seem to match fertility rates why is that? Does the high infant mortality rates respond to high birth rates? If countries in sub-Saharan Africa lowered death at birth would it reduce population growths? What does diet have to do with high fertility? It is assumed that because of the diets that have not changed much in rural areas in Africa, the fertility rates have been maintained. One of the issues emerging now is that many HIV positive people are increasingly having many babies because of the prevention-of-mother-to-child programmes. Also that many HIV positive people on ART are getting side effects from these drugs which are increasing their sexual prowess. This is in turn affecting them to have many babies? What are your comments on this?
Steven Sinding: I believe that female education is an extremely important factor but it may not be enough in a country whose leadership is hostile to family planning. High birthrates and high under 5 mortality are closely correlated. Bringing down one usually results in declines in the other. If one works on the two together the results are greatly magnified. It’s a wonderful example of mutual reinforcement—or a virtuous circle.
Diet per se is not related to fertility but nutritional status is. Extremely poor and malnourished women have a harder time getting pregnant and carrying pregnancies to term than better nourished women. But what they eat does not affect fertility. Neither am I aware that ART has any impact on what demographers call fecundability—the ability to conceive.
It is true that PMTCT programs increase the likelihood that children will be born free of AIDS and more likely to survive. Surely that is a good thing! Keeping mortality high is never a good way to approach any population question!

Namita Koppa: How has the food crisis affected migration and fertility? In Malawi, men move to secure work and have the ability to have families with other women. Has this trend been observed in other food insecure countries?
Steven Sinding: I’m not close enough to the situation to know how the present food crisis is affecting either fertility or migration, nor have I read anything recently that comments on these issues. Certainly economic circumstances have a great deal to do with labor mobility throughout Africa and beyond, and men who leave their families behind often do produce children in the places where they are working. However, this does not necessarily affect fertility rates very much. Men working away from home are also prone to engage in risky sexual practices which can result in them infecting their wives with HIV when they return home—an increasingly common and tragic phenomenon in many African countries.

Namita Koppa: How have voluntary family planning programs been linked to other social and environmental outcomes in SSA? Recently, a number of development projects sponsored by USAID and WWF in the Philippines have linked reproductive health promotion with coastal management, using microfinance as a platform.
Steven Sinding: Unfortunately, I do not think family planning programs have very often been linked to other social and economic outcomes in Africa, at least not in a programmatic sense. The argument to undertake family planning programs is often made (usually by outside donor agencies) by linking fertility decline to other social and economic goals. For example, today much of the advocacy on behalf of family planning links it to the achievement of the MDGs, with proponents asserting that unless high fertility rates are reduced, the prospects of achieving the MDGs are slim to none. But efforts such as those you describe in the Philippines are few and far between, in my experience. I think, in fact, that family planning programs have suffered to the extent that they are promoted as stand-alone interventions. The more one can associate the benefits of family planning with other aspects of people’s lives, the more likely they are to adopt family planning. In Bangladesh, the Grameen Bank and BRAC showed that women involved in micro-enterprise programs were more likely to adopt family planning than women who were not. Likewise, health programs that offer family planning alongside safe motherhood and child survival interventions will be more acceptable than family planning standing alone.

Marian Starkey: Hi Steve, I read recently that since 2005, Rwanda’s contraceptive prevalence has increased from 10% to 27% and that (probably as a direct result) fertility has dropped from 6.1 to 5.5 in the same period. What are the factors behind the uptick in new contraceptive users and is this a trend that will likely continue in the most densely populated country in Africa?
Steven Sinding: The Rwandan case is Africa’s latest “success story.” I don’t know the story in detail but it’s my understanding that it’s quite similar to the Kenyan story a decade ago. Pres. Paul Kagame has become convinced that Rwanda’s development depends heavily on bringing down the very high fertility rate, and consequently the population growth rate, in the country. He has made family planning a top priority and is committing the resources necessary to provide reproductive hea