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OCR for page 212
8
Conclusions
In this concluding chapter, we first return to the question motivating
this report: Is sub-Saharan Africa on the brink of a contraceptive revolution
that signals the onset of fertility decline? We then consider the research
needed to answer outstanding questions.
FINDINGS
Although there is considerable uncertainty about Africa as a whole, the
evidence on balance points to an undeniable trend in Zimbabwe, Botswana,
and Kenya. The changes observed in these three countries over the past
decade indicate that selected parts of Africa have joined other regions of the
developing world in a contraceptive revolution.
However, in the vast majority of countries within Africa, the preva-
lence of use of modern methods of contraception is less than 6 percent,
placing them squarely in the "emergent" category with regard to family
planning programs (Destler et al., 1990~. In these countries, postpartum
nonsusceptibility due to lactational amenorrhea and sexual abstinence is
more dominant than modern contraception in restraining fertility.
lone can make this statement not only for countries that have had a major demographic
survey, but also for those that have not, given that in the majority of the remaining countries
there has been little family planning program activity.
212
OCR for page 213
CONCLUSIONS
213
A number of factors are associated with the increased use of modern
contraception. Female education is clearly an important determinant of
contraceptive use at the individual, regional, and national level (see Chap-
ters 2, 3, and 6~. In this sense, Africa follows a pattern common to other
regions of the developing world, although the changes in contraceptive use
associated with changes in female schooling are not as large as in much of
Latin America. As demonstrated in Chapter 6, current use of modern meth-
ods increases above the 10 percent level only in regions that have a mean
length of female schooling of four years or more. No doubt in part because
of the greater educational opportunities available in urban than in rural
areas, urbanity was shown to directly and positively affect contraceptive
use at the individual level and negatively affect fertility at the national level
(see Chapters 2 and 3~. At the regional level, urbanization was shown to
influence the average level of schooling, but otherwise had no direct effect
on contraceptive use (see Chapter 6~.
The percentage of women in a polygynous union, a proxy for features
of social organization that promote high fertility, was also negatively re-
lated to contraceptive use at the regional level. The proportion Muslim
indirectly reduced contraceptive use by influencing the average level of
schooling.
Although significant progress has been made in reducing infant and
child mortality in Africa, the three higher-use countries are clearly distinc-
tive with respect to mortality levels and trends. In our view, steady in-
creases in contraceptive use resulting in fertility decline in other countries
of Africa are doubtful without continued improvements in mortality. Mor-
tality decline has provided parents with greater assurance that their children
will survive to adulthood, thus reducing the need to have additional children
as insurance against this threat or as compensation for the. actual loss of one
or more children. Such improvements in mortality may prove difficult in
countries experiencing economic difficulties and cuts in the provision of
health services.
In addition to these factors associated with contraceptive use, the strength
of family planning programs is central to the prospects for fertility decline.
Evidence reviewed in Chapter 5 demonstrates that family planning pro-
grams in Botswana, Kenya, and Zimbabwe are the most well developed in
Sub-Saharan Africa. As shown in Chapter 6, certain regions that would be
expected to have a prevalence of modern method use of at least 10 percent
(based on levels of female education) did not, and all these were located in
countries with weak family planning programs. Whereas much of the ear-
lier demographic literature focused on the socioeconomic factors affecting
fertility, there has been a growing awareness during the past decade of the
important role of the family planning supply environment with respect to
meeting the needs of couples motivated to delay or limit births.
OCR for page 214
214
FACTORS AFFECTING CONTRACEPTIVE USE
In the sub-Saharan African countries that have achieved at least moder-
ate success in family planning, the public sector provided the national cov-
erage of services that resulted in increases in national contraceptive use.
However, it is clear from Chapter 5 that private family planning associa-
tions have played a pioneering role in legitimizing the use of family plan-
ning and implementing many of the early services.
Assuming that the use of modern methods continues to increase in the
three higher use countries (and begins to take hold in others), we suspect
that Africa will follow the pattern of other developing countries in terms of
diversification of method mix. The oral pill is the most widely used contra-
ceptive according to the World Fertility Survey (WFS) and Demographic
and Health Survey (DHS) studies conducted in Africa to date (see Chapter
2~. Yet the experience of other developing regions suggests that method
mix will expand as overall prevalence increases.2 Indeed, the 4 to 5 percent
prevalence of female sterilization found in Botswana and Kenya suggests
that even this method once thought to be totally unacceptable in cultures
that placed such a high value on fertility-is gaining in acceptance. Given
anecdotal evidence as to the popularity of Depo-Provera (the three-month
injection) in those countries where it has been introduced, increased ava~l-
ability of this method would be expected to result in greater diversification
of the method mix.
Remarkable as the increases in contraceptive use have been in the coun-
tnes with higlier prevalence, it is important to keep in perspective the fact
that in demographic terms, these three countries represent less than 7 per-
cent of the population of sub-Saharan Africa. Moreover, even these coun-
tries have attained only a moderate level of use in terms of family planning
program evolution. If one excludes Mauritius and South Africa (as we have
done in this report, except in passing, based on their atypical socioeconomic
levels and ethnic compositions), the two African countries (Liberia and
northern Sudan) that follow these three countries in terms of contraceptive
prevalence have a modern use rate of only 5.5 percent.
Our analysis indicates that several factors will be influential in deter-
m~ning future contraceptive prevalence levels. Although impressive progress
was made dunug the decade of the 1980s in terms of population policy and
family planning program implementation, it is our view that the continued
2The majority of developing countries in Asia and Latin America with a contraceptive
prevalence of at least 30 percent are not single-method countries (Rutenberg et al., 1991).
Historically, as prevalence increases, users demand methods for both spacing (satisfied by
reversible methods) and limiting (satisfied by long-term or permanent methods), and method
mix is in turn diversified. Moreover, with the U.S. Food and Drug Administration approval of
Depo-Provera and NORPLANTR, the range of methods available in sub-Saharan Africa should
be greater in the l990s than in the 1980s.
OCR for page 215
CONCLUSIONS
215
development of strong family planning programs will be needed to meet the
demand for family limitation and offer an alternative to high fertility. The
evidence presented in Chapter 5, although qualitative in nature, indicates
that the three countries that have achieved modern prevalence rates of more
than 15 percent have had the best-developed family planning programs.
The development of programs in Africa will be helped undoubtably by
sustained government commitment. Recent statements from more than 50
African ministers at the Third African Population Conference in Dakar,
Senegal, attest to the growing support for family planning (United Nations
Population Fund, 1992~.
The mechanisms used to deliver family planning services in Africa in
the coming years are likely to resemble those now in use both in Africa and
in other regions of the developing world: clinic-based facilities, commu-
nity-based distribution, and social marketing. However, the patterns of
social organization in Africa may provide a unique opportunity to involve
local organizations and community networks (women's groups, networks of
traders, etc.) in legitimizing the concept of family planning and disseminat-
ing information on the methods. In addition, given that men have a domi-
nant role in fertility decision making, programs in Africa may derive par-
ticular benefit from targeting interventions to this subgroup.
In view of economic difficulties in some African countries, donor sup-
port for family planning is likely to remain crucial in the coming years.
Even where the political will exists, governments stretched thin with pro-
viding basic services to growing populations will find it difficult to imple-
ment effective family planning programs without continued donor support.
Whereas in the past, Africa had been somewhat neglected (relative to Asia
and Latin America) by international donors to population activities, this
situation shifted dramatically during the 1980s, when Africa became a pri-
ority for numerous organizations. The external investment in family plan-
ning in the 1980s contributed to the increases in contraceptive use in Botswana,
Kenya, and Zimbabwe, and it may begin to affect prevalence rates in the
l990s in other countries that have intensified their program efforts (e.g.,
Niger, Rwanda).
Changes in African social structure will certainly affect the future de-
mand for children. As shown in Chapter 4, social factors at the community
and household levels (particularly the value attached to perpetuation of the
lineage, which has served as an organizing cultural principle in many areas
of Africa) have exerted pressure on couples to have large families. In many
ways, these factors explain "why Africa is different" with regard to the
fertility transition. Yet these social structures are not immutable, and changes
in the nature of kinship support and of spousal relations would be expected
to influence attitudes toward the value of family planning.
There is consensus in the literature that pro-natalist social factors are
OCR for page 216
216
FACTORS AFFECTING CONTRACEPTIVE USE
being undermined progressively by economic development and perhaps, in
some areas, by economic crisis. Thus, the degree to which African social
organization will limit fertility decline in the future is unclear. For ex-
ample, there are indications of growing conjugal closeness and shared deci-
sion making, possibly resulting from changes in childrearing costs and edu-
cational aspirations. Land scarcity due to high population density and rising
educational costs in some areas may increase the perceived benefits of fewer
children. As discussed in Chapter 3, deteriorating economic conditions in
some countries may decrease the prevalence of child fostering as families
seek to care for their immediate kin and avoid the costs associated with
caring for children of relatives. These same conditions may also increase
the likelihood of resource pooling and joint decision making as families
strive to meet the sustenance and educational needs of their children.
What is clear from our review of African social structure is that there is
great variation in how it affects the demand for children. Although scat-
tered qualitative evidence indicates that social factors are changing in such
a way that might lead to lower fertility desires, there is an insufficient body
of knowledge to predict the direction of change for most of Africa. Many
of the changing factors we have emphasized are more important in urban
areas and among the educated populations that have expressed a desire for
family limitation. Although the high-fertility rationale persists in many
areas, the examples of Zimbabwe, Botswana, and Kenya demonstrate that
parts of sub-Saharan Africa are receptive to contraceptive use. However,
dramatic increases in prevalence may not be imminent for other areas, al-
though we believe that contraceptive use will take hold eventually. Be-
cause of the variation in cultural and socioeconomic structures across Af-
rica, we expect increases in contraceptive use to be uneven; increase is
initially more likely in areas that are urban, with educated populations, and
with access to social services.
There are several factors that may curtail the spread of contraceptive
use in Africa. First, although there are few hard data to substantiate the
point, preliminary reports from countries ravaged by acquired immune defi-
ciency syndrome (AIDS) suggest that this epidemic may change perceptions
regarding mortality. In an effort to ensure the survival of sufficient num-
bers of children and to maintain continuity of the lineage, women may seek
to have as many children as soon as possible. Under such circumstances,
contraceptive use would be counterproductive. However, educational pro-
grams to increase condom use to prevent the spread of AIDS may have the
opposite effect on use.
Second, a few African countries are experiencing extreme political and
social unrest. Civil war and famine have devastated regions of Angola,
Ethiopia, Liberia, Mozambique, Somalia, Sudan, Uganda, and Zaire. Under
conditions that threaten survival on a daily basis and severely disrupt access
OCR for page 217
CONCLUSIONS
217
to health, family planning, and other services, there is no reason to expect
more widespread use of contraception.
Third, further increases in contraceptive use are dependent on contin-
ued improvements in female education and the returns to schooling. As
discussed in Chapter 3, the willingness of parents to accept the quantity-
quality trade-off (having fewer children but investing more heavily in their
schooling) is dependent on their perceptions that increased schooling will in
fact result in greater economic benefits to both the child and the family in
later life. However, studies in selected countries demonstrate that the qual-
ity of education has deteriorated, which decreases the return that can be
expected on such an investment. The return is also heavily dependent on
the supply and demand for labor by educational level. Thus, the evidence
for a quantity-quality demographic transition is decidedly mixed, and con-
tinued progress in terms of female education cannot be taken for granted.
RESEARCH GAPS
There are a number of areas in which further research would greatly
assist in understanding of the dynamics of contraceptive use in sub-Saharan
Africa. We present these topics in an order that mirrors the chapters in this
volume.
Levels and Trends in Contraceptive Use-
Contraceptive Discontinuation
There is little reliable information on the average duration of contracep-
tive use (i.e., once an acceptor begins a period of contraceptive use, how
long does she use the original method or, if switching occurs, any method).
As mentioned in Chapter 2, such information can be obtained from two
different sources: program records or population-based surveys. In many
countries, service statistics if collected at all are unreliable. Even if
carefully recorded, data based on service statistics suffer from the problems
of sample selectivity and loss to follow-up. Because of these limitations,
there is a preference for obtaining continuation data from population-based
surveys. The DHS questionnaire for high-prevalence countries contains an
instrument for obtaining retrospective data with which to calculate continu-
ation rates. But to date, none of the African DHS have employed this
questionnaire, given their relatively low levels of prevalence. A more
widespread use of these questions in African countries that have at least 15
to 20 percent prevalence of modern contraceptive methods would provide
some needed information on discontinuation.
OCR for page 218
218
Effects of Economic Downturns
FACTORS AFFECTING CONTRACEPTIVE USE
Socioeconomic Context
There are competing hypotheses as to the effects of economic hardship
on contraceptive use. On one hand, it has been argued that low levels of
socioeconomic development (which are generally accompanied by low lev-
els of female education, high infant mortality, and large percentages of the
population living in rural areas) work to sustain the demand for a large
number of children. On the other, it has been hypothesized that the current
economic crisis in many parts of Africa may cause Africans to respond by
altering their attitudes regarding family size and increasing their receptivity
to family planning. The theories underlying these competing positions are
discussed in detail in Chapter 3, but there has been very little empirical
work on the effects of economic downturns.3
Effects of Child Mortality and AIDS on Demand for Children and
Attitudes Toward Family Planning
It is generally accepted that high levels of child mortality tend to sus-
tain the demand for a large number of children among parents seeking to
insure themselves against possible future loss or compensation for deaths
that have already occurred. The populations of countries ravaged by the
AIDS epidemic are now painfully aware that children born to mothers in-
fected with the human immunodef~ciency virus ~V) may be infected themselves.
Whereas medical specialists advise against pregnancy for women who are
infected with HIV (to avoid hastening the onset of symptoms), this advice
may be meaningless to women who measure their own personal worth by
their contribution to continuing the lineage. More data of a qualitative
nature are needed to understand the motives of women in this situation and
how AIDS affects their attitudes toward family planning.
Costs of Investments in Children, Including Education
Given the importance of the quantity-quality trade-off to the question
of impending fertility decline in Africa, it is surprising that there are not
more data on the actual costs of investments in children in the African
context. The few studies presented in this report suggest that in certain
3An exception is the report of the Working Group on the Effects of Economic and Social
Reversals (1993), which estimates the effects of economic reversals on child mortality, mar-
riage, and fertility, with special attention to first and second births, in seven African countries.
OCR for page 219
CONCLUSIONS
219
settings (e.g., Kenya), men have begun to entertain the prospect of fewer
children because of the increased costs of schooling. However, these stud-
ies have tended to be qualitative in nature, such that the results are limited
in geographical scope and do not produce quantitative estimates of invest-
ment per child. To investigate this issue more rigorously, it is essential to
have better data on the actual costs of schooling in different countries, as
well as the perceptions of the costs and benefits of investing in children's
education.
Female Education, Income, and Contraceptive Use
Although improvements in female education are associated with in-
creased contraceptive use, the research that has led to this finding generally
lacks controls for income, which may distort the relationship. Because
increases in female education most likely result in higher incomes (and both
are associated with lower fertility), it is important to distinguish which of
these changes is primary in driving lower fertility. Income has not been
included in most studies because of the difficulty of measuring it. The one
study we found that does control for income suggests that female education
is significantly associated with decreased fertility regardless of the effect of
income on fertility (see Chapter 3~. Further work in this area would be
most useful if it included such information.
Community/Kinship/Household
Extent of Nucleation of the Family and Child Fostering
There is need for further research on the extent of joint decision making
between spouses. The premise of the weak conjugal bond needs to be
revisited in light of urban life-styles, exposure to western ideas via the mass
media, and changing economic circumstances. Because of the heterogene-
ity of sub-Saharan Africa, these factors may result in different responses.
In some areas there may be greater pooling of resources and conjugal close-
ness (see Chapter 4) and in other areas the family structure may not depart
from a lineage orientation. Moreover, the effects of these factors on child
fostering may be mixed. Such varied responses will have a profound effect
on the future fertility desires of different African populations.
Quantification of Kinship Factors
Given the importance of kinship in influencing the demand for children,
it would be useful to devise means for integrating kinship factors into quan
OCR for page 220
220
titative data analysis.
FACTORS AFFECTING CONTRACEPTIVE USE
Such efforts would clarify the relative effects of
social organization and socioeconomic factors on the demand for births.
Local Social Organization and the Diffusion of Family Planning
Chapter 4 highlighted the potential role of local social networks in the
provision of information and the legitimization of contraception. There is a
need for further research on the possible contributions of these organiza-
tions.
Population Policies and Program Implementation-
Service Availability at the Regional Level
Not only in Africa but also in other parts of the developing world,
attempts to evaluate and quantify the family planning supply environment
have been limited to date. Although some information is available on the
national level, there is a need for subnational data that indicate not only the
quantitative but also the qualitative aspects of service delivery. Without
these data, it is impossible to assess the effect of family planning programs
on changes in contraceptive use.
This list of research gaps is by no means exhaustive. However, it
includes those items that would have been most beneficial to improving our
analysis of the factors affecting contraceptive use in sub-Saharan Africa.
Regardless of the limitations of our study, a central conclusion remains:
We believe that although the social supports for high fertility have not
disappeared, Zimbabwe, Botswana, and Kenya demonstrate that increases in
contraceptive use can occur in sub-Saharan Africa. We believe that future
fertility decline is likely in these three and other countries assuming provi-
sion of family planning services, improvements in child mortality, and progress
in female education.
Representative terms from entire chapter:
female education
