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Executive Summary This report stems from interest in recent survey results indicating in- creases in contraceptive use in several countries in sub-Saharan Africa. Because Africa is the only region of the world yet to undergo a contracep- tive revolution resulting in fertility decline, there has been substantial de- bate about the implications of these increases for the rest of Africa. The task of the working group was to examine the factors affecting contracep- tive use, with special attention to why use has risen in some areas and not in others. KEY ISSUES To fulfill the task, the report focuses on identifying the key factors that affect the demand for children and the supply of contraception. On the demand side, the conditions under which people in sub-Saharan Africa can be expected to desire smaller family sizes are examined. There is much debate surrounding this issue. On one hand, fertility decline is seen as the result of economic development; as elsewhere in the world, improvements in socioeconomic conditions will stimulate the desire for family limitation. Africa's sustained high fertility is therefore explained in terms of factors that inhibit economic development more generally. From the other perspec- tive, sub-Saharan Africa is described as being different from the rest of the world in its supports for high fertility, which stem from unique features of social organization that are not easily modified by economic development.

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2 FACTORS AFFECTING CONTRACEPTIVE USE Are the past structures so deeply embedded and immutable that high fertil- ity will persist? Or might pronatalist values and constraints give way in the face of new socioeconomic influences, as they have elsewhere in the world? On the supply side, the report examines the effects of family planning policies and programs on the provision of contraceptives. A central ques- tion concerns the conditions under which family planning activities have affected contraceptive use in Africa. Are there particular regions where family planning programs have been particularly successful? Finally, multivariate analysis is undertaken to determine empirically the factors that are associated with observed increases in contraceptive use. The analysis also examines the relative importance of contraceptive use compared to postpartum nonsusceptibility in inhibiting fertility in Africa. FINDINGS In exploring the linkages between economic development and fertility, the report focuses on levels of per capita income, child mortality, educa- tional attainment among adults, and the costs and benefits of having chil- dren. Although the associations between these factors and fertility are not always strong in Africa, especially relative to the experience of Latin America, they are nonetheless important and indicate a receptivity to smaller family sizes among particular groups. The distinct socioeconomic experiences of Botswana, Kenya, and Zimbabwe have contributed to their substantial in- creases in contraception. In particular, the sustained improvements in, and resulting low levels of, mortality in these countries are unique within Af- rica. However, the diverse nature of these socioeconomic linkages in Af- rica suggests that features of African social structure remain important de- terminants of the demand for children. The long-standing forms of African social organization-the high value attached to the perpetuation of the lineage; the importance of children as a means of gaining access to resources, particularly land; the use of kinship networks to share the costs and benefits of children, primarily through child fostering; and the weak nature of conjugal bonds-clearly inhibit contra- ceptive adoption and fertility decline. However, the working group be- lieves that these features are not immutable and are being affected by changing economic conditions in some settings. In particular, there is evidence to suggest that changes in childrearing costs and educational aspirations, as well as deteriorating economic conditions, are resulting in increased conju- gal closeness and shared decision making. Many of these changes are particularly notable in urban areas and among the educated populations that exhibit higher contraceptive prevalence. Our review of family planning programs indicates a clear link between program implementation and contraceptive use. In Botswana, Kenya, and

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EXECUTIVE SUMMARY Zimbabwe, political commitment and the development of population poli- cies supportive of family planning have created environments for the suc- cessful implementation of programs. Private organizations have been in- strumental in demonstrating the acceptability of contraception in Africa and inducing further investments in this sector. However, those countries that show substantial increases in national prevalence all have well-developed public sector service delivery programs. In the empirical examination of the factors affecting modern contracep- tive use, female education emerges as an important determinant of preva- lence at the individual, regional, and national levels. Urbanization and the proportion Muslim are shown to affect schooling levels and thus contracep tive use. Polygyny, a proxy for aspects of the high-fertility rationale, negatively affects contraceptive use at the regional level, providing support for the view that African social organization continues to influence the demand for children. Only in regions in the higher use countries does contraceptive use play a more important role in inhibiting fertility than postpartum nonsusceptibility. If no additional declines in the period of postpartum nonsusceptibility oc- cur, future increases in contraceptive use should directly result in lower fertility. Several primary factors are essential to these future increases in contra- ceptive use: continued improvements in female education, reductions in infant and child mortality, and strengthening of family planning programs. Continued progress in these areas should provide the impetus for the uptake of contraception in other regions of Africa. Thus, the central conclusion of the report is that, although the high-fertility rationale has not disappeared, Africa may be entering a new era of increased contraceptive use.

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