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OCR for page R1
P O P U L AT I O ~ D Y FJ A" ~ C S O F S U B - S A H A RA ~ A F R I ~ A
DEMOGRAPHIC CHANGE
N SU B-SAHARAN AF R! CA
DEMOGRAPHIC EFFECTS OF ECONOMIC REVERSAES
IN SUB SAHARAN AFRICA
EFFECTS OF HEAETH PROGRAMS ON CHIED MORTAEITY
IN SUB_SAHARAN AFRICA
FACTORS AFFECTING CONTRACEPTIVE USE
IN SUB_SAHARAN AFRICA
POPUEATION DYNAMICS OF KENYA
POPUEATION DYNAMICS OF SENEGAE
SOCIAE DYNAMICS OF ADOEESCENT FERTIEITY
IN SUB_SAHARAN AFRICA
OCR for page R2
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POPULAT10N DYNAMICS OF SUB-SAHARAbI AFRICA
FACTORS AFFECTING
CONTRACEPTIVE USE
IN SUB_SAHARAN AFRICA
.
Working Group on Factors Affecting Contraceptive Use
Panel on the Population Dynamics of Sub-Saharan Africa
Committee on Population
Commission on Behavioral and Social Sciences and Education
National Research Council
NATIONAL ACADEMY PRESS
Washington, D.C. 1993
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NATIONAL ACADEMY PRESS
.
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The members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
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B168
Copyright 1993 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
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WORKING GROUP ON FACTORS AFFECTING
CONTRACEPTIVE USE
JANE T. BERTRAND (Chair), School of Public Health and Tropical
Medicine, Tulane University
EVASIUS K. BAUNI, Department of Geography, Kenyatta University,
Kenya
RON J. LESTHAEGHE, Faculteit van de Economische, Sociale en
Politieke Wetenschappen, Vrije Universiteit Brussel, Belgium
MARK R. MONTGOMERY, Department of Economics, State University
of New York at Stony Brook
OLEKO TAMBASHE, Faculte d'Economiques, Departement de
Demographie, Universite de Kinshasa, Zaire
MARIA J. WAWER, Center for Population and Family Health, Columbia
University
CAROLE L. JOLLY, Staff Officer
SUSAN M. COKE, Senior Project Assistant
DIANE L. GOLDMAN, Administrative Assistant*
JOAN MONTGOMERY HALFORD, Senior Project Assistant**
PAULA J. MELVILLE, Senior Project Assistant
* through December 1991
**through July 1992
v
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PANEL ON THE
POPULATION DYNAMICS OF SUB-SAHARAN AFRICA
KENNETH H. HILL (Chair), Department of Population Dynamics, Johns
Hopkins University
ADERANTI ADEPOJU, Institut de Developpement Economique et de la
Planification (IDEP), Dakar, Senegal
JANE T. BERTRAND, School of Public Health and Tropical Medicine,
Tulane University
CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern
University
WILLIAM BRASS, Centre for Population Studies, London School of
Hygiene and Tropical Medicine, England
DOUGLAS C. EWBANK, Population Studies Center, University of
Pennsylvania
PHILIPPE FARGUES, Centre d'Etudes et de Documentation Economique,
Sociale et Juridique (CEDEJ), Cairo, Egypt
RON J. LESTHAEGHE, Faculteit van de Economische, Sociale en
Politieke Wetenschappen, Vrije Universiteit Brussel, Belgium
PATRICK O. OHADIKE, Regional Institute for Population Studies
(RIPS), Accra, Ghana
ANNE R. PEBLEY, The RAND Corporation, Santa Monica, California
DANIEL M. SALA-DIAKANDA, Institut de Formation et de Recherche
Demographiques (IFORD), Yaounde, Cameroon
Vl
OCR for page R7
.
COMMITTEE ON POPULATION
SAMUEL H. PRESTON (Chair), Population Studies Center, University of
Pennsylvania
JOSE-LOIS BOBADILLA, World Bank, Washington, D.C.
JOHN B. CASTERLINE, Department of Sociology, Brown University
KENNETH H. HILL, Department of Population Dynamics, Johns Hopkins
University
DEAN T. JAMISON, School of Public Health, University of California,
Los Angeles
ANNE R. PEBLEY, The RAND Corporation, Santa Monica, California
RONALD R. RINDFUSS, Department of Sociology, University of North
Carolina, Chapel Hill
T. PAUL SCHULTZ, Department of Economics, Yale University
SUSAN C.M. SCRIMSHAW, School of Public Health, University of
California, Los Angeles
BETH J. SOLDO, Department of Demography, Georgetown University
MARTA TIENDA, Population Research Center, University of Chicago
BARBARA BOYLE TORREY, Population Reference Bureau, Washington,
D.C.
JAMES TRUSSELL, Office of Population Research, Princeton University
AMY O. TSUI, Carolina Population Center, University of North Carolina,
Chapel Hill
LINDA G. MARTIN, Director
BARNEY COHEN, Research Associate
SUSAN M. COKE, Senior Project Assistant
KAREN A. FOOTE, Research Associate
DIANE L. GOLDMAN, Administrative Assistant*
JAMES N. GRIBBLE, Program Officer
JOAN MONTGOMERY HALFORD, Senior Project Assistant**
CAROLE L. JOLLY, Program Officer
DOMINIQUE MEEKERS, Research Associate*
PAULA J. MELVILLE, Senior Project Assistant
* through December 1991
** through July 1992
. .
V11
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Preface
This report is one in a series of studies that have been carried out under
the auspices of the Panel on the Population Dynamics of Sub-Saharan Af-
rica of the National Research Council's Committee on Population. The
Research Council has a long history of examining population issues in de-
veloping countries. In 1971 it issued the report Rapid Population Growth:
Consequences and Policy Implications. In 1977, the predecessor Commit-
tee on Population and Demography began a major study of levels and trends
of fertility and mortality in the developing world that resulted in 13 country
reports and 6 reports on demographic methods. Then, in the early 1980s, it
undertook a study of the determinants of fertility in the developing world,
which resulted in 10 reports. In the mid- and late-1980s, the Committee on
Population assessed the economic consequences of population growth and
the health consequences of contraceptive use and controlled fertility, among
many other activities.
No publication on the demography of sub-Saharan Africa emerged from
the early work of the committee, largely because of the paucity of data and
the poor quality of what was available. However, censuses, ethnographic
studies, and surveys of recent years, such as those under the auspices of the
World Fertility Survey and the Demographic and Health Survey Programs,
have made available data on the demography of sub-Saharan Africa. The
data collection has no doubt been stimulated by the increasing interest of
both scholars and policymakers in the demographic development of Africa
and the relations between demographic change and socioeconomic develop
IX
OCR for page R10
x
PREFACE
meets. In response to this interest, the Committee on Population held a
meeting in 1989 to ascertain the feasibility and desirability of a major study
of the demography of Africa, and decided to set up a Panel on the Popula-
tion Dynamics of Sub-Saharan Africa.
The panel, which is chaired by Kenneth Hill and includes members
from Africa, Europe, and the United States, met for the first time in Febru-
ary 1990 in Washington, D.C. At that meeting the panel decided to set up
six working groups, composed of its own members and other experts on the
demography of Africa, to carry out specific studies. Four working groups
focused on cross-national studies of substantive issues: the social dynamics
of adolescent fertility, factors affecting contraceptive use, the effects on
mortality of child survival and general health programs, and the demo-
graphic effects of economic reversals. The two other working groups were
charged with in-depth studies of Kenya and Senegal, with the objective of
studying linkages between demographic variables and between those vari-
ables and socioeconomic changes. The panel also decided to publish a
volume of papers reviewing levels and trends of fertility, nuptiality, the
proximate determinants of fertility, child mortality, adult mortality, internal
migration, and international migration, as well as the demographic conse-
quences of the AIDS epidemic.
This report, one of the four cross-national studies, analyzes the factors
affecting contraceptive use. The study was initiated because of interest in
recent survey results that indicated increases in contraceptive use in several
sub-Saharan African countries. Because of historically high fertility levels
and low contraceptive use in the region, it was debated whether these chancres
heralded a new era for Africa or were anomalies.
This report examines the literature on the socioeconomic, social organi-
zational, and family planning program factors that are related to contracep-
tive use. Multivariate analysis is employed to assess the relative impor-
tance of those factors that can be measured and for which data are available
from surveys. In Chapter 7, the relative importance of contraceptive use
versus postpartum practices in inhibiting fertility in Africa is assessed.
As is the case for all of the panel's work, this report would not have
been possible without the cooperation and assistance of the Demographic
and Health Survey (DHS) Program of the Institute for Resource Develop-
ment/Macro Systems. We are grateful to the DHS staff for responding to
our inquiries and facilitating our early access to the survey data.
We are also grateful to the organizations that provided financial support
for the work of the panel: the Office of Population and the Africa Bureau
of the Agency for International Development, the Andrew W. Mellon Foun-
dation, the William and Flora Hewlett Foundation, and the Rockefeller Foundation.
Besides providing funding, the representatives of these organizations were a
OCR for page R11
PREFACE
Xl
source of information and advice in the development of the panel's overall
work plan.
This report results from the joint efforts of the working group members
and staff, and represents a consensus of the members' views on the issues
addressed. The Committee on Population and the Panel on the Population
Dynamics of Sub-Saharan Africa appreciate the time and energy that all the
working group members devoted to the study. The following people de-
serve recognition for their special contributions: Mark Montgomery ana-
lyzed the socioeconomic and social organizational factors affecting contra-
ceptive use and wrote the first drafts of Chapters 3 and 4. He also developed
the framework of the factors affecting contraceptive use (described in Chapter
1 and Appendix A), which guided the working group's research, and carried
out the individual-level bivariate analysis of contraceptive use discussed in
Chapter 2.
Maria Wawer explored the development of family planning policies and
programs, and their effect on contraceptive use. Her research is the basis
for Chapter 5, which she first drafted. Ron Lesthaeghe performed the re-
gional multivariate analysis of contraceptive use based on a data set devel-
oped by Carole Jolly. Chapters 6 and 7 reflect this effort. Ron Lesthaeghe
was also instrumental in documenting the historical context of contraceptive
use in sub-Saharan Africa and graciously hosted the second of the three
meetings of the working group in Brussels. Oleko Tambashe pulled to-
gether the evidence on levels, trends, and differentials in contraceptive use
to write, with Jane Bertrand, the first draft of Chapter 2. Evasius Bauni
contributed to the sections on knowledge of contraceptive use. Both Oleko
Tambashe and Evasius Bauni played important roles in promoting the work-
ing group's understanding of the experiences of their respective countries.
Jane Bertrand, as the working group's chair, was instrumental in direct-
ing the research of the group during the last two years and wrote the first
drafts of Chapters 1 and 8. She and Carole Jolly served as the principal
editors and coordinators for the report. Linda Martin provided substantive
comments on numerous drafts of the report, as well as participating in all
the group's meetings and contributing substantially to the review process.
Jay Gribble took care of innumerable details in the final drafting stages. As
noted above, however, this report reflects the views of the working group as
a whole, and considerable effort by all the members and staff has gone into
its production.
The working group was assisted in its efforts by several commissioned
background papers. Lisa Brecker and Regina McNamara coauthored a pa-
per on family planning programs in Africa. Therese Locoh wrote a paper
on the socioeconomic context of contraceptive use. Maria Messina authored
a paper on household decision making, reproductive roles, and local social
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. .
Xll
PREFACE
organization as they affect contraceptive use and fertility. G. Verleye as-
sisted in the regional analysis of contraceptive use.
Special thanks are also due Susan Coke, Joan Montgomery Halford,
Diane Goldman, and Paula Melville for providing superb administrative and
logistical support to the working group, to Florence Poillon for her skillful
editing of the report, and to Elaine McGarraugh for meticulous production
assistance. Joan Montgomery Halford and Paulette Valliere Korazemo pro-
vided excellent French to English translation of a draft chapter and a back-
ground paper. Eugenia Grohman and Elaine McGarraugh were instrumental
in guiding the report through the review and production processes.
SAMUEL H. PRESTON, Chair
Committee on Population
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Contents
EXECUTIVE SUMMARY
INTRODUCTION
The Contraceptive Revolution in the Developing World, 5
Contraceptive Use in Sub-Saharan Africa, 6
Levels of Socioeconomic Organization Affecting
Contraceptive Use, 12
Organization of Report, 18
2 LEVELS AND TRENDS IN CONTRACEPTIVE USE
Sources of Data on Contraceptive Use, 19
Definition of Contraceptive Use, 20
Prevalence of Current Contraceptive Use in Selected Countries, 23
Other Indicators Related to Contraceptive Practice, 38
Results From Male Surveys, 48
Conclusion, 48
THE SOCIOECONOMIC CONTEXT
Socioeconomic Differentials of Fertility, 54
Evidence on Changes in Child Mortality, 70
. . .
x~'
1
s
19
52
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XIV
CONTENTS
Evidence on Changes in the Quantity-Quality Trade-Off, 72
Economic Stagnation and Adjustment: Effects on Fertility, 77
Conclusion, 83
4 THE HOUSEHOLD, KINSHIP, AND COMMUNITY CONTEXT 85
The High-Fertility Rationale: An Overview, 87
Lineage and Descent, 91
Kin Networks and Child Fostering, 98
The Conjugal Bond, 104
Prospects for Change, 1 15
Local Social Organization and the Diffusion of Family Planning, 122
Conclusion, 127
FAMILY PLANNING PROGRAMS AND POLICIES
The African Context for Population and Family
Planning Programs, 129
International and Regional Influences on Population
Policy Development, 133
Historical Evolution of Family Planning Programs, 135
Program Development in Selected Countries, 140
Major Donors for Population Activities, 153
Lessons Learned from Programs and Projects, 158
Private Versus Public Service Delivery, Including
Social Marketing, 165
The Impact of AIDS on Family Planning Program Activity, 168
Conclusion, 169
REGIONAL ANALYSIS OF CONTRACEPTIVE USE
Female Education and Contraceptive Practice, 173
Multivariate Analysis of Modern Contraceptive Use, 179
CONTRIBUTION OF MODERN CONTRACEPTIVE USE
RELATIVE TO POSTPARTUM PRACTICES
TO FERTILITY DECLINE
The Two-Phased Fertility Transition, 198
Contraception, Nonsusceptibility, and Fertility Decline, 205
The Uncertain Future, 209
Conclusion, 210
128
170
197
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CONTENTS
8 CONCLUSIONS
Findings, 212
Research Gaps, 217
xv
212
APPENDIX A: ADAPTING THE EASTERLIN-CRIMMINS
SYNTHESIS MODEL TO SUB-SAHARAN CONDITIONS 221
Demand for Births, 223
Supply of Births, 224
APPENDIX B: SAMPLE SIZES FOR THE WFS AND
DHS REGIONAL FILES
REFERENCES
230
233
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