**4. Case studies on fertility decline**

This section presents some well documented and contrasting specific cases: cases of completed fertility transition, cases of rapid decline in fertility in urban areas, and cases of no significant decline in rural areas, in order to show the great diversity of situations among African countries.

#### **4.1. Completed fertility transitions (national level)**

According to United Nations recent estimates, only five countries or territories in Africa have completed their fertility transition at national level [6]. Only one is located on the continent: South Africa, a country which benefited from an excellent family planning program since 1974, and which is much more economically and socially advanced than other African countries [28–30]. It should be noted, however, that the case of South Africa is complex: marital fertility (after the first marriage) is now very low (of the order of 1.5 children per woman), and this applies to all racial and ethnic groups, but there are still significant pockets of premarital fertility, especially among adolescent girls and disadvantaged groups (Black/African, Colored), indicating incomplete fertility control and a deficiency in the family planning program [31, 32].

The other countries that have completed their fertility transition are islands, which have profiles distinctly different from other African countries: Mauritius, which has been the pioneer in this field among African countries and has fertility below replacement level since 1994; Reunion, which benefits from the French public health system; the Seychelles islands, and the Cabo Verde Islands. All have benefited from excellent family planning programs, excellent health services and a level of development well above the African average (**Figure 4**).

#### **4.2. Rapid fertility decline in urban areas**

**Figure 3.** Trends in the intensity of family planning programs in Africa. Source: Futures Group: average calculated on

by an apparent stagnation, which however has not translated into a decline in contraceptive prevalence (**Figure 3**). Ideally, one would have hoped to reach 90% in 2009, but the indicator remained at about half (45.6%). This national indicator corresponds to half of women covered by contraception, which can be compared to half of the fertility transition in urban areas, but

Most of the numerous studies on the socioeconomic correlates of fertility and contraceptive prevalence are carried out in cross-sectional analyses, that is to say, with data applicable at the time of the survey. They consistently show a correlation, at household level and at any given point in time, between socio-economic status (measured by level of wealth, or by level

In contrast, longitudinal studies show different results at aggregate level, when the transition from natural fertility to the adoption of modern contraception is studied in response to changes in income, wealth and education over time. For example, an analysis of African countries between 1977 and 1999 shows that changes in per capita income and in level of education do not explain changes in fertility levels: most of the variations can be explained by changes in contraceptive use, age at first marriage, and urbanization, which follow other

Finally, it should be noted that in African countries, at national level, the relationship between prevalence of contraception and level of fertility is surprising. Indeed, one would expect higher

hides the significant backwardness of the rural environment.

of education), contraceptive use and fertility level [25].

**3.6. Contraception and fertility in Africa**

**3.5. Socio-economic correlates**

128 Family Planning

dynamics [21, 26].

37 countries (some years are missing).

In some countries, the fertility transition in urban areas is almost complete: three southern African countries: Botswana, Lesotho, and Swaziland, which are geographically and culturally close to South Africa, and who adopted family planning programs similar to that of their big neighbor; and two East-African countries: Kenya (discussed in more detail below) and Ethiopia. The decline in fertility in urban areas of the latter country, particularly poor and isolated, surprised many observers and was the subject of several publications [33]. These five cases are illustrated in **Figure 5**.

**Figure 4.** African countries which have completed their fertility transition. Source: United Nations, 2015.

areas, as a percentage of the transition, ranged from 19% (Congo-Brazza) to 96% (Lesotho) with an average of 60%, and in rural areas it ranges from 0% (Angola, Mozambique, Congo-Brazza, Congo-Kinshasa) to 76% (Botswana), with an average of 29%. These large differences between countries are mainly due to differences between family planning policies and pro-

**Figure 6.** Selected African countries which have not yet begun the fertility transition in rural areas. Source: reconstruction

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This section presents striking contrasts between countries with fairly similar characteristics but very different demographic dynamics in rural areas due to differences in family planning policies and programs. These case studies cover various regions of Africa: Central Africa (Rwanda/Burundi), East-Africa (Kenya/Uganda), West-Africa (Ghana/Nigeria), Southern Africa (Zimbabwe/Zambia) and South-Eastern Africa (Madagascar/Mozambique). The aim of this section is to show the differential impact of family planning programs on fertility decline in rural areas, by comparing cases (successful country) with controls (country failing to con-

Rwanda and Burundi are two neighboring countries located in Central Africa, with similar sizes (10.6 and 9.2 million inhabitants in 2010), very high population densities (403 and 332

levels of income (1262 and 725 US \$ in 2011), and a similar level of ethnic composition (with two rival ethnic groups: Hutus and Tutsis). These two countries share the same colonial history

in 2010), low urbanization (18.8 per cent and 10.6 per cent in 2010), low

grams, as illustrated in the next section.

from demographic surveys.

**5.1. Rwanda and Burundi (rural areas)**

trol its fertility).

inhabitants per km2

**5. Contrasts between countries (rural areas)**

**Figure 5.** Selection of African countries having nearly completed their fertility transition in urban areas. Source: reconstruction from demographic surveys.

#### **4.3. No decline in rural areas**

At the other end of the spectrum are countries that have not yet begun their fertility transition in rural areas: these are two former Portuguese colonies that have gone through a period of difficult decolonization: Angola and Mozambique (discussed below), and three Central-African countries: Congo-Kinshasa (former Zaire, or DRC), Congo-Brazza (former RPC), and Cameroon (**Figure 6**). These five countries did not have effective family planning programs, and four of them (apart from Cameroon) experienced long periods of civil war, which severely disrupted the rural health system.

#### **4.4. Other cases**

These extreme cases should not hide the other cases, and the great diversity of situations in African countries in terms of fertility transition. **Table A1** shows that fertility declines in urban

**Figure 6.** Selected African countries which have not yet begun the fertility transition in rural areas. Source: reconstruction from demographic surveys.

areas, as a percentage of the transition, ranged from 19% (Congo-Brazza) to 96% (Lesotho) with an average of 60%, and in rural areas it ranges from 0% (Angola, Mozambique, Congo-Brazza, Congo-Kinshasa) to 76% (Botswana), with an average of 29%. These large differences between countries are mainly due to differences between family planning policies and programs, as illustrated in the next section.

#### **5. Contrasts between countries (rural areas)**

This section presents striking contrasts between countries with fairly similar characteristics but very different demographic dynamics in rural areas due to differences in family planning policies and programs. These case studies cover various regions of Africa: Central Africa (Rwanda/Burundi), East-Africa (Kenya/Uganda), West-Africa (Ghana/Nigeria), Southern Africa (Zimbabwe/Zambia) and South-Eastern Africa (Madagascar/Mozambique). The aim of this section is to show the differential impact of family planning programs on fertility decline in rural areas, by comparing cases (successful country) with controls (country failing to control its fertility).

#### **5.1. Rwanda and Burundi (rural areas)**

**4.3. No decline in rural areas**

reconstruction from demographic surveys.

disrupted the rural health system.

**4.4. Other cases**

130 Family Planning

At the other end of the spectrum are countries that have not yet begun their fertility transition in rural areas: these are two former Portuguese colonies that have gone through a period of difficult decolonization: Angola and Mozambique (discussed below), and three Central-African countries: Congo-Kinshasa (former Zaire, or DRC), Congo-Brazza (former RPC), and Cameroon (**Figure 6**). These five countries did not have effective family planning programs, and four of them (apart from Cameroon) experienced long periods of civil war, which severely

**Figure 5.** Selection of African countries having nearly completed their fertility transition in urban areas. Source:

**Figure 4.** African countries which have completed their fertility transition. Source: United Nations, 2015.

These extreme cases should not hide the other cases, and the great diversity of situations in African countries in terms of fertility transition. **Table A1** shows that fertility declines in urban Rwanda and Burundi are two neighboring countries located in Central Africa, with similar sizes (10.6 and 9.2 million inhabitants in 2010), very high population densities (403 and 332 inhabitants per km2 in 2010), low urbanization (18.8 per cent and 10.6 per cent in 2010), low levels of income (1262 and 725 US \$ in 2011), and a similar level of ethnic composition (with two rival ethnic groups: Hutus and Tutsis). These two countries share the same colonial history and were parts of the same Belgian colony, known as Rwanda-Urundi, until independence (1962). Their economic histories diverge somewhat: Rwanda experienced a period of growth from 1964 to 1986, followed by a severe recession from 1986 to 1997, then by a rapid recovery with strong growth from 1997 to 2013. Burundi experienced a period of growth after independence until 1991, but this was followed by a long recession, lasting until 2013. Both countries experienced a long period of political strife, economic downturns and civil wars.

The stories of population policies and family planning programs also diverge very markedly between the two countries. In Rwanda, modern contraception appeared in 1962. A first family planning program was launched in 1977, which resulted in a first decline in fertility (from 7.9 in 1977 to 6.4 children per woman in 1991 in rural areas). A new phase was launched in 1990 as part of a pro-active population policy, but its implementation was hampered by the period of civil war which culminated in the 1994 genocide and was followed by a period of recovery with an increase in marriages and births, so that fertility remained virtually unchanged during the 1991–2002 period. In 2003, the family planning program took on a new development, a well-organized and well-funded program, with home visits, and even a target of a maximum of 4 children per family. This program resulted in a dramatic decline in fertility, from 6.0 children per woman in 2003 to 4.1 children per woman in 2013 in rural areas [34, 35].

In Burundi, the developments were slower and later, and provoked more reticence and negative reactions. Awareness about the population problem did not appear until the early 1980s, following the 1979 census and the first RAPID population projection studies. The first official political position in favor of family planning and the first pilot project date back to 1983, but faced a frontal opposition from the Church, which in 1986 created a movement hostile to modern contraception (*L'Action Familiale*). This movement considerably hampered the first attempts to promote family planning at the national level (1987–1988). Moreover, family planning programs were severely disrupted by the civil war (1993–2000) and the subsequent political turmoil. A new impetus was given in 2011–2012, including the creation of "Family and Community Development Centers," with strong support from UNFPA, but it is too early to see their effects since the last DHS survey was conducted in 2010 [36, 37].

**Table 1** summarizes the contrast between the two countries: the effort index of the family planning program was always higher in Rwanda than in Burundi since 1982, home visits were more frequent, and therefore the prevalence of contraception, and the fertility decline was larger. Regarding the rural environment, between 1980 and 2010, Rwanda achieved 56.3% of its fertility transition, while Burundi realized only 5.6%, a huge difference with multiple consequences (**Figure 7**).

period of civil unrest and civil war which followed the seizure of power by Idi Amin Dada: severe recession between 1971 and 1986, then stagnation until 1991, followed by economic

Family planning Effort index, 1982 23.0 10.5 (national) Effort index, 1999 62.1 40.2 Contraception Last survey (2014) (2010) (rural areas) Prevalence 46.7% 16.7%

Fertility TFR, 1980 8.03 6.94 (rural areas) TFR, 2010 4.64 6.67

**Table 1.** Comparison of fertility and family planning indicators: Rwanda and Burundi.

Home visit 21.5% 4.1%

% Transition 56.3% 5.6%

**Rwanda Burundi**

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Family Planning and Fertility Decline in Africa: From 1950 to 2010

**Figure 7.** Comparison of fertility trends in rural areas: Rwanda and Burundi.

TFR, Total Fertility Rate (number of children per woman).

Kenya held the world record in fertility at the time of independence, and was a pioneer for family planning in Africa. Modern contraception was introduced in Kenya in 1957 and the first clinics distributing modern contraceptives began in 1960. The Kenyan Family Planning Association (FPAK) was created in 1962 and the national family planning program was launched in 1967, the first national program in sub-Saharan Africa, then expanded in 1975. An official population policy was declared in 1984 and subsequently updated (1996,

growth up to 2013.

#### **5.2. Kenya and Uganda (rural areas)**

Kenya and Uganda share a common colonial history, as parts of the British Empire, until independence (1963 and 1964 respectively). At this date, per capita income was equivalent in both countries. From an economic point of view, Kenya had first a favorable period with steady growth until 1990, followed by a period of recession (1990–2003) and then a new period of growth until 2013. Uganda followed a more tortuous path, disrupted in particular by the


**Table 1.** Comparison of fertility and family planning indicators: Rwanda and Burundi.

and were parts of the same Belgian colony, known as Rwanda-Urundi, until independence (1962). Their economic histories diverge somewhat: Rwanda experienced a period of growth from 1964 to 1986, followed by a severe recession from 1986 to 1997, then by a rapid recovery with strong growth from 1997 to 2013. Burundi experienced a period of growth after independence until 1991, but this was followed by a long recession, lasting until 2013. Both countries

The stories of population policies and family planning programs also diverge very markedly between the two countries. In Rwanda, modern contraception appeared in 1962. A first family planning program was launched in 1977, which resulted in a first decline in fertility (from 7.9 in 1977 to 6.4 children per woman in 1991 in rural areas). A new phase was launched in 1990 as part of a pro-active population policy, but its implementation was hampered by the period of civil war which culminated in the 1994 genocide and was followed by a period of recovery with an increase in marriages and births, so that fertility remained virtually unchanged during the 1991–2002 period. In 2003, the family planning program took on a new development, a well-organized and well-funded program, with home visits, and even a target of a maximum of 4 children per family. This program resulted in a dramatic decline in fertility, from 6.0 chil-

experienced a long period of political strife, economic downturns and civil wars.

dren per woman in 2003 to 4.1 children per woman in 2013 in rural areas [34, 35].

to see their effects since the last DHS survey was conducted in 2010 [36, 37].

consequences (**Figure 7**).

132 Family Planning

**5.2. Kenya and Uganda (rural areas)**

In Burundi, the developments were slower and later, and provoked more reticence and negative reactions. Awareness about the population problem did not appear until the early 1980s, following the 1979 census and the first RAPID population projection studies. The first official political position in favor of family planning and the first pilot project date back to 1983, but faced a frontal opposition from the Church, which in 1986 created a movement hostile to modern contraception (*L'Action Familiale*). This movement considerably hampered the first attempts to promote family planning at the national level (1987–1988). Moreover, family planning programs were severely disrupted by the civil war (1993–2000) and the subsequent political turmoil. A new impetus was given in 2011–2012, including the creation of "Family and Community Development Centers," with strong support from UNFPA, but it is too early

**Table 1** summarizes the contrast between the two countries: the effort index of the family planning program was always higher in Rwanda than in Burundi since 1982, home visits were more frequent, and therefore the prevalence of contraception, and the fertility decline was larger. Regarding the rural environment, between 1980 and 2010, Rwanda achieved 56.3% of its fertility transition, while Burundi realized only 5.6%, a huge difference with multiple

Kenya and Uganda share a common colonial history, as parts of the British Empire, until independence (1963 and 1964 respectively). At this date, per capita income was equivalent in both countries. From an economic point of view, Kenya had first a favorable period with steady growth until 1990, followed by a period of recession (1990–2003) and then a new period of growth until 2013. Uganda followed a more tortuous path, disrupted in particular by the

**Figure 7.** Comparison of fertility trends in rural areas: Rwanda and Burundi.

period of civil unrest and civil war which followed the seizure of power by Idi Amin Dada: severe recession between 1971 and 1986, then stagnation until 1991, followed by economic growth up to 2013.

Kenya held the world record in fertility at the time of independence, and was a pioneer for family planning in Africa. Modern contraception was introduced in Kenya in 1957 and the first clinics distributing modern contraceptives began in 1960. The Kenyan Family Planning Association (FPAK) was created in 1962 and the national family planning program was launched in 1967, the first national program in sub-Saharan Africa, then expanded in 1975. An official population policy was declared in 1984 and subsequently updated (1996, 2007, 2012). These policies and programs had virtually no opposition, neither from political authorities nor from religious authorities. Since the 1960s, family planning has grown steadily, first in public and private clinics and NGOs, and then through community-based health workers, outreach programs (Community-based distribution), improved communication (Information, Education, Communication program), and integrated reproductive health programs. All these programs have been generously financed by the Kenyan government and various international actors (bilateral aid, multilateral aid, international organizations, NGOs, etc.), in particular British and American, and have benefited from the advice of many international experts. The various contraceptive methods have remained essentially free, and are widely distributed and available to the general population [38, 39].

The development of family planning in Uganda was very different, and was considerably delayed by the political turmoil of the 1971–1986 period. Although modern contraception came very early (1957), as in Kenya, that the Ugandan association has officially existed since 1963, that the first family planning clinic was opened in the same year, and modern contraception was available in public hospitals as early as 1968, many obstacles impaired its development: opposition from traditional, political and religious leaders, and very strong restrictions on access (married women with at least 3 children and with the husband's permission). Then, shortly after his coming to power, Idi Amin banned family planning in 1972, and drove out people of Indian origin, many of whom were doctors. It took about 10 years for the program to restart timidly: contraception became again available in public hospitals and clinics in 1983, adoption of a population policy in 1995, and especially a new start in 2004–2005 with the development of a major awareness campaign (IEC), followed by new actions in 2008 and 2015 [40].

10 years before resuming after 2004. This phenomenon of stagnation (fertility stall), which corresponds to the period of economic recession, was the focus of numerous academic debates

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Ghana and Nigeria, both located on the coast of the Gulf of Guinea in West-Africa, share a similar colonial history, as parts of the British Empire. The two countries had a fairly strong economy and a serious potential at time of independence (1957 and 1960 respectively). Both countries have a fairly high level of education and similar population structures with north/south opposition (savanna/forest and coast) which corresponds roughly to a cleavage between Muslims and Christians. But the divide between ethnic groups and religions is very strong in Nigeria, leading to fierce struggles and even civil wars (Biafra, Boko-Haram), while inter-ethnic or inter-religious tensions are very low in Ghana. The economy of Ghana had a favorable period until 1974, followed by a long recession of about 10 years, due to political instability and corruption of the "kalabule" years, followed by a period of steady and sustained growth (1983–2013), combined with political stability and sound economic policies. Nigeria's economy, dominated by oil exports, has fluctuated greatly in response to fluctuations in international oil prices and to political instability of the country: growth up to 1965, recession at the time of the Biafra war, growth from 1968 to 1977, strong recession until 1984,

The history of family planning in Ghana is quite similar to that of Kenya, with an early start, sustained and steady development, and little resistance or barriers. Interest in family planning began shortly after independence, and in 1961 there was a Family Advice Center in Accra, the capital city. Apart from a short period (1964–1966), when President Nkrumah banned contraception,

but remains largely unexplained [41–44].

**Figure 8.** Comparison of fertility trends in rural areas: Kenya and Uganda.

**5.3. Ghana and Nigeria (rural areas)**

followed by rapid growth until 2013.

The consequences of these different stories are impressive (**Table 2**, **Figure 8**). In rural Kenya, fertility declined considerably between 1980 and 2010 (53.3% of the transition), while it stagnated at high levels in rural Uganda, declining only in recent years (2003–2011). It should be noted, however, that in Kenya, the decline in fertility has not been steady: first slow between 1964 and 1981, then rapid until 1994, and then halted or even slightly increased for some


**Table 2.** Comparison of fertility and family planning indicators: Kenya and Uganda.

**Figure 8.** Comparison of fertility trends in rural areas: Kenya and Uganda.

10 years before resuming after 2004. This phenomenon of stagnation (fertility stall), which corresponds to the period of economic recession, was the focus of numerous academic debates but remains largely unexplained [41–44].

#### **5.3. Ghana and Nigeria (rural areas)**

2007, 2012). These policies and programs had virtually no opposition, neither from political authorities nor from religious authorities. Since the 1960s, family planning has grown steadily, first in public and private clinics and NGOs, and then through community-based health workers, outreach programs (Community-based distribution), improved communication (Information, Education, Communication program), and integrated reproductive health programs. All these programs have been generously financed by the Kenyan government and various international actors (bilateral aid, multilateral aid, international organizations, NGOs, etc.), in particular British and American, and have benefited from the advice of many international experts. The various contraceptive methods have remained essentially free, and

The development of family planning in Uganda was very different, and was considerably delayed by the political turmoil of the 1971–1986 period. Although modern contraception came very early (1957), as in Kenya, that the Ugandan association has officially existed since 1963, that the first family planning clinic was opened in the same year, and modern contraception was available in public hospitals as early as 1968, many obstacles impaired its development: opposition from traditional, political and religious leaders, and very strong restrictions on access (married women with at least 3 children and with the husband's permission). Then, shortly after his coming to power, Idi Amin banned family planning in 1972, and drove out people of Indian origin, many of whom were doctors. It took about 10 years for the program to restart timidly: contraception became again available in public hospitals and clinics in 1983, adoption of a population policy in 1995, and especially a new start in 2004–2005 with the development of a major awareness campaign (IEC), followed by new actions in 2008 and 2015 [40]. The consequences of these different stories are impressive (**Table 2**, **Figure 8**). In rural Kenya, fertility declined considerably between 1980 and 2010 (53.3% of the transition), while it stagnated at high levels in rural Uganda, declining only in recent years (2003–2011). It should be noted, however, that in Kenya, the decline in fertility has not been steady: first slow between 1964 and 1981, then rapid until 1994, and then halted or even slightly increased for some

Family planning Effort index, 1982 28.1 17.1 (national) Effort index, 1999 48.7 50.4 Contraception Last survey (2014) (2011) (rural areas) Prevalence 50.9 23.4

Fertility TFR, 1980 8.81 7.92 (rural areas) TFR, 2010 5.18 6.80

TFR: Total Fertility Rate (number of children per woman).

**Table 2.** Comparison of fertility and family planning indicators: Kenya and Uganda.

Home visit 6.8 8.7

% Transition 53.3% 18.9%

**Kenya Uganda**

are widely distributed and available to the general population [38, 39].

134 Family Planning

Ghana and Nigeria, both located on the coast of the Gulf of Guinea in West-Africa, share a similar colonial history, as parts of the British Empire. The two countries had a fairly strong economy and a serious potential at time of independence (1957 and 1960 respectively). Both countries have a fairly high level of education and similar population structures with north/south opposition (savanna/forest and coast) which corresponds roughly to a cleavage between Muslims and Christians. But the divide between ethnic groups and religions is very strong in Nigeria, leading to fierce struggles and even civil wars (Biafra, Boko-Haram), while inter-ethnic or inter-religious tensions are very low in Ghana. The economy of Ghana had a favorable period until 1974, followed by a long recession of about 10 years, due to political instability and corruption of the "kalabule" years, followed by a period of steady and sustained growth (1983–2013), combined with political stability and sound economic policies. Nigeria's economy, dominated by oil exports, has fluctuated greatly in response to fluctuations in international oil prices and to political instability of the country: growth up to 1965, recession at the time of the Biafra war, growth from 1968 to 1977, strong recession until 1984, followed by rapid growth until 2013.

The history of family planning in Ghana is quite similar to that of Kenya, with an early start, sustained and steady development, and little resistance or barriers. Interest in family planning began shortly after independence, and in 1961 there was a Family Advice Center in Accra, the capital city. Apart from a short period (1964–1966), when President Nkrumah banned contraception, the country committed itself early on to a voluntary population policy and was the first African state to sign an international convention on the subject in 1967 (World Leaders Declaration on Population). A national population policy was established in 1969, and in 1970 family planning structures were set up in hospitals and public health centers, as well as in private family planning centers. The family planning program developed regularly thereafter, with extensive awareness campaigns (1986) and regular updates such as integration into reproductive health (1994, 2006) [45, 46].

The history of family planning in Nigeria is different and has been marked by several major handicaps: lack of political commitment and recurrent political instability; on social grounds, strong resistance from traditional and religious authorities, especially Muslims in the north and Catholics in the south, as well as sexual taboos, rumors and frontal opposition to certain methods of contraception from selected groups; at organizational level, poor organization and mismanagement of the program, and in particular low reliance on community activities. However, family planning had started early, in 1962, with the creation of an association (Family Planning Council of Nigeria). As in Ghana, but later, a population policy was adopted in 1989 (National Population Policy for Development, Unity, Progress, and Self-Reliance), followed by an awareness campaign (1992), but they were not successful and did not have an impact as in Ghana, although an ambitious goal of four children per woman has been recently adopted. The family planning program was reactivated in 2004, then in 2012, but so far had only modest effects in rural areas [47–49].

children per woman in 2010), while it remained abnormally high in Nigeria (4.9 children per woman in 2010), given the level of development and the level of education of the country.

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Zimbabwe and Zambia, two neighboring countries in Southern Africa, also share a common British colonial heritage, as Southern Rhodesia and Northern Rhodesia. However, their postcolonial stories diverge, like their economic performance and their family planning programs. Zimbabwe became independent late (1980), following a disturbing period of civil war. Power was taken by a very marked left-wing government, a single party (ZANU), and a highly controversial leader (Robert Mugabe). While economic growth was strong in the 1960s, it stopped during the period of struggle for independence and in the years that followed (1973–1998), before collapsing for about 10 years, a consequence of deleterious economic policies and social disasters. Growth has only recovered since 2010, but by 2013 GDP per capita was barely equal to that of 1960. In a very different situation, Zambia became independent in 1964, with no particular hardship at the time of decolonization. Its economic history is marked by a long recession since 1975, which followed the fall in copper prices on international markets, copper ore being its main export good. Growth did not resume until year 2000, and has been sustained since. The period of acute economic crisis (1975–1995) had many consequences: cuts in social budgets, departures of doctors (especially expatriates), and increased mortality of children [50]. In Zimbabwe, despite repeated political and economic crises, the family planning program has been a notable success, often cited as an example in Africa. It should first be noted that modern contraception has been available since 1953, although initially restricted to urban elites and expatriates. Family planning in Zimbabwe has not met with any marked opposition, even if some anti-colonial elites initially doubted its interest. Family planning began in

**5.4. Zimbabwe and Zambia (rural areas)**

**Figure 9.** Comparison of fertility trends in rural areas: Ghana and Nigeria.

As a result, the 2010 indicators differ widely between the two countries: rural Ghana achieved already almost half of its transition (43.3%), while rural Nigeria is still in its early stage (13.0%). In Ghana, all indicators are better: the program effort index, the prevalence of modern contraception, and home visits (**Table 3**). In Ghana, rural fertility declined steadily since 1980, while in Nigeria it has been irregular, fluctuating, and declining only since 2002 (**Figure 9**). In addition, it should be noted that demographic data in Nigeria are problematic, while they are of much better quality in Ghana. Furthermore, in urban areas fertility is low in Ghana (3.2


**Table 3.** Comparison of fertility and family planning indicators: Ghana and Nigeria.

**Figure 9.** Comparison of fertility trends in rural areas: Ghana and Nigeria.

children per woman in 2010), while it remained abnormally high in Nigeria (4.9 children per woman in 2010), given the level of development and the level of education of the country.

#### **5.4. Zimbabwe and Zambia (rural areas)**

the country committed itself early on to a voluntary population policy and was the first African state to sign an international convention on the subject in 1967 (World Leaders Declaration on Population). A national population policy was established in 1969, and in 1970 family planning structures were set up in hospitals and public health centers, as well as in private family planning centers. The family planning program developed regularly thereafter, with extensive awareness campaigns (1986) and regular updates such as integration into reproductive

The history of family planning in Nigeria is different and has been marked by several major handicaps: lack of political commitment and recurrent political instability; on social grounds, strong resistance from traditional and religious authorities, especially Muslims in the north and Catholics in the south, as well as sexual taboos, rumors and frontal opposition to certain methods of contraception from selected groups; at organizational level, poor organization and mismanagement of the program, and in particular low reliance on community activities. However, family planning had started early, in 1962, with the creation of an association (Family Planning Council of Nigeria). As in Ghana, but later, a population policy was adopted in 1989 (National Population Policy for Development, Unity, Progress, and Self-Reliance), followed by an awareness campaign (1992), but they were not successful and did not have an impact as in Ghana, although an ambitious goal of four children per woman has been recently adopted. The family planning program was reactivated in 2004, then in 2012, but so far had

As a result, the 2010 indicators differ widely between the two countries: rural Ghana achieved already almost half of its transition (43.3%), while rural Nigeria is still in its early stage (13.0%). In Ghana, all indicators are better: the program effort index, the prevalence of modern contraception, and home visits (**Table 3**). In Ghana, rural fertility declined steadily since 1980, while in Nigeria it has been irregular, fluctuating, and declining only since 2002 (**Figure 9**). In addition, it should be noted that demographic data in Nigeria are problematic, while they are of much better quality in Ghana. Furthermore, in urban areas fertility is low in Ghana (3.2

Family planning Effort index, 1982 17.8 12.8 (national) Effort index, 1999 46.4 33.6 Contraception Last survey (2014) (2013) (rural areas) Prevalence 24.6 5.7

Fertility TFR, 1980 6.95 7.25 (rural areas) TFR, 2010 4.80 6.57

Home visit 12.2 5.3

% Transition 43.3% 13.0%

**Ghana Nigeria**

health (1994, 2006) [45, 46].

136 Family Planning

only modest effects in rural areas [47–49].

TFR: Total Fertility Rate (number of children per woman).

**Table 3.** Comparison of fertility and family planning indicators: Ghana and Nigeria.

Zimbabwe and Zambia, two neighboring countries in Southern Africa, also share a common British colonial heritage, as Southern Rhodesia and Northern Rhodesia. However, their postcolonial stories diverge, like their economic performance and their family planning programs. Zimbabwe became independent late (1980), following a disturbing period of civil war. Power was taken by a very marked left-wing government, a single party (ZANU), and a highly controversial leader (Robert Mugabe). While economic growth was strong in the 1960s, it stopped during the period of struggle for independence and in the years that followed (1973–1998), before collapsing for about 10 years, a consequence of deleterious economic policies and social disasters. Growth has only recovered since 2010, but by 2013 GDP per capita was barely equal to that of 1960. In a very different situation, Zambia became independent in 1964, with no particular hardship at the time of decolonization. Its economic history is marked by a long recession since 1975, which followed the fall in copper prices on international markets, copper ore being its main export good. Growth did not resume until year 2000, and has been sustained since. The period of acute economic crisis (1975–1995) had many consequences: cuts in social budgets, departures of doctors (especially expatriates), and increased mortality of children [50].

In Zimbabwe, despite repeated political and economic crises, the family planning program has been a notable success, often cited as an example in Africa. It should first be noted that modern contraception has been available since 1953, although initially restricted to urban elites and expatriates. Family planning in Zimbabwe has not met with any marked opposition, even if some anti-colonial elites initially doubted its interest. Family planning began in 1965 with the creation of a National Association of Rhodesia and the establishment of the first specialized clinics (1967). It is important to note that the program relied very early on mobile teams (1973), on the distribution of modern contraceptives to families by specialized agents (Community-based distributors), and on information campaigns in schools (Youth Advisory Services). The new government set up at independence continued, unified and developed this pioneering work. The Family Planning Association was incorporated into the Zimbabwe National Family Planning Council in 1985 and became an important element in public health policy. Infrastructure was expanded, staff increased, and resources were sufficient, from national and international sources, to ensure a good geographical coverage. The system continued to function during the crisis years, despite the financial difficulties of the country, despite the departure of some medical staff, and despite the difficulties of supply and management [51, 52].

The case of Zambia is strikingly contrasting, while the country has benefited from a better economic and political situation than Zimbabwe. First, the position of political powers at independence was resolutely pro-natalist, as well as that of the main religious and traditional leaders. The government even went as far as to prohibit modern contraception and related literature in the first years after independence. Even women's associations (the Women's league) opposed it at the time. A first family planning association was founded in 1972 (Family Planning and Welfare Association of Zambia), but again faced a frontal opposition from the Family Life Movement of Zambia. The situation changed only after the Mexico Conference (1984), after which the government changed its position, adopted the Kilimanjaro resolution, and founded a new National Commission for Development Planning to coordinate efforts. A population policy was adopted shortly thereafter in 1989 (National Population Policy), integrated into the development plan and from there family planning spread throughout the country. Planning centers are set up in public hospitals and clinics, guides were developed in 1992 (Family Planning Policy Guidelines and Standards), and an awareness program was set up in 1994 (IEC). This program was updated several times (1996, 2006–2007, 2013), and integrates home distribution by specialized agents in the recent period. Although it has clearly stated goals (families with four children or less, 58% contraceptive prevalence) and if opposition from hostile groups diminished over time, the program has been slow to take off in rural areas [53, 54].

The contrast between the two countries is again striking: by year 2010, Zimbabwe achieved almost half of its transition in rural areas (45.6%), while Zambia experienced only a small decline (16.4% of the transition). Zimbabwe has better indicators in terms of efforts in family planning, and in the prevalence of contraception (**Table 4**). While Zambia made a serious effort to promote home visits, this effort is too recent to have had a significant impact. It should also be noted that fertility fluctuated in Zambia, following the economic crisis and recovery, while the decline has been steady in Zimbabwe, except for the recent period when it has stagnated since 2003: fertility trends showed even a surprising peak during the worst years of the economic crisis, probably due to a shortage in imported supplies of contraceptives, in particular pills and injectables, the most widely used methods in this country (**Figure 10**).

**5.5. Madagascar and Mozambique (rural areas)**

**Figure 10.** Comparison of fertility trends in rural areas: Zimbabwe and Zambia.

TFR: Total Fertility Rate (number of children per woman).

Madagascar and Mozambique occupy a special place because they are two countries located in the extreme south-east of the continent, on both sides of the Straits of Mozambique, geographically isolated and having a common characteristic of extreme poverty (GDP per capita of \$ 1390 and \$ 933 respectively in 2010). Their colonial history is different, the large island having been colonized by France (independence in 1960) while Mozambique was colonized by Portugal and became independent later (1975). The two countries faced a serious political and economic crisis shortly after independence (1973–1983 in Madagascar,

Family planning Effort index, 1982 27.3 16.4 (national) Effort index, 1999 59.9 44.6 Contraception Last survey (2015) (2014) (rural areas) Prevalence 63.2 39.0

Fertility TFR, 1980 7.52 8.11 (rural areas) TFR, 2010 5.01 7.11

**Table 4.** Comparison of fertility and family planning indicators: Zimbabwe and Zambia.

Home visit 13.0 11.6

% Transition 45.6% 16.4%

**Zimbabwe Zambia**

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**Table 4.** Comparison of fertility and family planning indicators: Zimbabwe and Zambia.

1965 with the creation of a National Association of Rhodesia and the establishment of the first specialized clinics (1967). It is important to note that the program relied very early on mobile teams (1973), on the distribution of modern contraceptives to families by specialized agents (Community-based distributors), and on information campaigns in schools (Youth Advisory Services). The new government set up at independence continued, unified and developed this pioneering work. The Family Planning Association was incorporated into the Zimbabwe National Family Planning Council in 1985 and became an important element in public health policy. Infrastructure was expanded, staff increased, and resources were sufficient, from national and international sources, to ensure a good geographical coverage. The system continued to function during the crisis years, despite the financial difficulties of the country, despite the departure of some medical staff, and despite the difficulties of supply

The case of Zambia is strikingly contrasting, while the country has benefited from a better economic and political situation than Zimbabwe. First, the position of political powers at independence was resolutely pro-natalist, as well as that of the main religious and traditional leaders. The government even went as far as to prohibit modern contraception and related literature in the first years after independence. Even women's associations (the Women's league) opposed it at the time. A first family planning association was founded in 1972 (Family Planning and Welfare Association of Zambia), but again faced a frontal opposition from the Family Life Movement of Zambia. The situation changed only after the Mexico Conference (1984), after which the government changed its position, adopted the Kilimanjaro resolution, and founded a new National Commission for Development Planning to coordinate efforts. A population policy was adopted shortly thereafter in 1989 (National Population Policy), integrated into the development plan and from there family planning spread throughout the country. Planning centers are set up in public hospitals and clinics, guides were developed in 1992 (Family Planning Policy Guidelines and Standards), and an awareness program was set up in 1994 (IEC). This program was updated several times (1996, 2006–2007, 2013), and integrates home distribution by specialized agents in the recent period. Although it has clearly stated goals (families with four children or less, 58% contraceptive prevalence) and if opposition from hostile groups diminished over time, the program

The contrast between the two countries is again striking: by year 2010, Zimbabwe achieved almost half of its transition in rural areas (45.6%), while Zambia experienced only a small decline (16.4% of the transition). Zimbabwe has better indicators in terms of efforts in family planning, and in the prevalence of contraception (**Table 4**). While Zambia made a serious effort to promote home visits, this effort is too recent to have had a significant impact. It should also be noted that fertility fluctuated in Zambia, following the economic crisis and recovery, while the decline has been steady in Zimbabwe, except for the recent period when it has stagnated since 2003: fertility trends showed even a surprising peak during the worst years of the economic crisis, probably due to a shortage in imported supplies of contraceptives, in particular pills and injectables, the most widely used methods in this

and management [51, 52].

138 Family Planning

has been slow to take off in rural areas [53, 54].

country (**Figure 10**).

**Figure 10.** Comparison of fertility trends in rural areas: Zimbabwe and Zambia.

#### **5.5. Madagascar and Mozambique (rural areas)**

Madagascar and Mozambique occupy a special place because they are two countries located in the extreme south-east of the continent, on both sides of the Straits of Mozambique, geographically isolated and having a common characteristic of extreme poverty (GDP per capita of \$ 1390 and \$ 933 respectively in 2010). Their colonial history is different, the large island having been colonized by France (independence in 1960) while Mozambique was colonized by Portugal and became independent later (1975). The two countries faced a serious political and economic crisis shortly after independence (1973–1983 in Madagascar, 1975–1992 in Mozambique), although the crisis in Mozambique was longer and marked by a civil war. Both countries have seen their per capita income drop seriously over a long period of time (1972–2002 in Madagascar, 1973–1995 in Mozambique), and recovered with difficulty.

**Madagascar Mozambique**

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Family planning Effort index, 1982 8.6 16.4 (national) Effort index, 1999 64.0 39.2 Contraception Last survey (2009) (2011) (rural areas) Prevalence 28.0 7.2

Fertility TFR, 1980 7.55 6.76 (rural areas) TFR, 2010 4.96 6.76

**Table 5.** Comparison of fertility and family planning indicators: Madagascar and Mozambique.

**Figure 11.** Comparison of fertility trends in rural areas: Madagascar and Mozambique.

**Indicator Cases (5 countries in progress)**

Growth rate −0.1% +1.0% Level of education AYS, 1975 2.20 1.28 1.71

Changes +2.99 +2.29

**Table 6.** Comparison of income and level of education between cases and controls countries.

Income per capita

women aged 15–49, rural areas.

(GDP)

TFR: Total Fertility Rate (number of children per woman).

Home visit 7.5 8.1

% Transition 46.7% 0.0%

**Controls (5 countries late in the transition)**

GDP, 1980 1985 \$ 1723 \$ 1.15 GDP, 2010 1941 \$ 2303 \$ 0.84

AYS, 2005 5.19 3.58 1.45

Note: Income: GDP per capita in 2011 dollars, national data; Level of education: in average years of schooling (AYS),

**Relative difference**

In Madagascar, family planning began fairly early, was not subject to any particular reluctance, except occasionally by the Catholic Church, and has always been supported by successive governments, despite repeated political crises. A family planning association (FISA or Fianakaviana Sambatra) was set up and active since 1967, and the program was supported from the very beginning by UNFPA. In 1987, the public sector became involved and, in 1987, family planning centers were set up in health facilities. A National Population Policy for Economic and Social Development (PNPDES) was adopted in 1990 and from that date progress were rapid. In addition to fixed structures, the country promoted mobile teams since the 1990s, and it allowed the distribution of contraceptives by mobile teams. The country followed major global developments and updated its program on several occasions: National Policy on Reproductive Health (2000), awareness programs (2003), social marketing (Strategic Pathway to Achieving Reproductive Health Commodity Security), Action Plan for Madagascar (2006), sexual education in secondary schools, clubs for adolescent reproductive health (peer education), etc. Over the years, the country received technical and financial assistance from many agencies and donors, particularly from USAID [55, 56].

The situation is quite different in Mozambique. From the outset, the FRELIMO government, of Marxist obedience, was hostile to birth control, and did not include family planning in its maternal and child health policy defined shortly after independence (1980). There was also considerable reluctance among the population. A first program was announced in 1978, and the first trials were carried out under the aegis of UNFPA in the 1980s, but they remained timid and affected only a small fraction of the population. Large parts of the country were at civil war, and in particular public health was no longer functioning in rural areas in the central part of the country. Following the 1992 peace agreement, a new impetus was given in 1999 when defining a "Population Policy for Mozambique" and the adoption of the Millennium Development Goals (MDGs), but this effort was hampered by a large-scale HIV/AIDS epidemic, which captured a big chunk of public health resources. New programs were implemented in 2010, as part of a new family planning policy, which involved home visits (*Agente Polivalente Elementar*) and campaigns with volunteers. But until then, family planning has remained the poorest part of public health in Mozambique, and as a result, the prevalence of modern contraception has hardly increased between 1997 and 2011, and even seems to have declined between 2003 and 2011.

The contrast between the two countries is therefore very clear (**Table 5**, **Figure 11**). Madagascar achieved almost half of its transition in rural areas (46.7%), while in Mozambique fertility remained at a natural level, with no significant decline. The efforts made by Madagascar were much more important, and the prevalence of contraception was almost four times higher in 2010. While home visits have developed in Mozambique, this occurred only recently, within the framework of the new programs, which is very different from the situation in Madagascar where home visits have been practiced for nearly 25 years.


**Table 5.** Comparison of fertility and family planning indicators: Madagascar and Mozambique.

1975–1992 in Mozambique), although the crisis in Mozambique was longer and marked by a civil war. Both countries have seen their per capita income drop seriously over a long period of time (1972–2002 in Madagascar, 1973–1995 in Mozambique), and recovered with

In Madagascar, family planning began fairly early, was not subject to any particular reluctance, except occasionally by the Catholic Church, and has always been supported by successive governments, despite repeated political crises. A family planning association (FISA or Fianakaviana Sambatra) was set up and active since 1967, and the program was supported from the very beginning by UNFPA. In 1987, the public sector became involved and, in 1987, family planning centers were set up in health facilities. A National Population Policy for Economic and Social Development (PNPDES) was adopted in 1990 and from that date progress were rapid. In addition to fixed structures, the country promoted mobile teams since the 1990s, and it allowed the distribution of contraceptives by mobile teams. The country followed major global developments and updated its program on several occasions: National Policy on Reproductive Health (2000), awareness programs (2003), social marketing (Strategic Pathway to Achieving Reproductive Health Commodity Security), Action Plan for Madagascar (2006), sexual education in secondary schools, clubs for adolescent reproductive health (peer education), etc. Over the years, the country received technical and financial assistance from many agencies and donors, particularly

The situation is quite different in Mozambique. From the outset, the FRELIMO government, of Marxist obedience, was hostile to birth control, and did not include family planning in its maternal and child health policy defined shortly after independence (1980). There was also considerable reluctance among the population. A first program was announced in 1978, and the first trials were carried out under the aegis of UNFPA in the 1980s, but they remained timid and affected only a small fraction of the population. Large parts of the country were at civil war, and in particular public health was no longer functioning in rural areas in the central part of the country. Following the 1992 peace agreement, a new impetus was given in 1999 when defining a "Population Policy for Mozambique" and the adoption of the Millennium Development Goals (MDGs), but this effort was hampered by a large-scale HIV/AIDS epidemic, which captured a big chunk of public health resources. New programs were implemented in 2010, as part of a new family planning policy, which involved home visits (*Agente Polivalente Elementar*) and campaigns with volunteers. But until then, family planning has remained the poorest part of public health in Mozambique, and as a result, the prevalence of modern contraception has hardly increased between 1997 and 2011, and even seems to have

The contrast between the two countries is therefore very clear (**Table 5**, **Figure 11**). Madagascar achieved almost half of its transition in rural areas (46.7%), while in Mozambique fertility remained at a natural level, with no significant decline. The efforts made by Madagascar were much more important, and the prevalence of contraception was almost four times higher in 2010. While home visits have developed in Mozambique, this occurred only recently, within the framework of the new programs, which is very different from the situation in Madagascar

difficulty.

140 Family Planning

from USAID [55, 56].

declined between 2003 and 2011.

where home visits have been practiced for nearly 25 years.

**Figure 11.** Comparison of fertility trends in rural areas: Madagascar and Mozambique.


Note: Income: GDP per capita in 2011 dollars, national data; Level of education: in average years of schooling (AYS), women aged 15–49, rural areas.

**Table 6.** Comparison of income and level of education between cases and controls countries.

#### **5.6. Socio-economic correlates**

**Table 6** shows socio-economic correlates, women's per capita income and level of education, associated with cases (countries in progress) and controls (countries late in the transition). Both groups had equivalent income levels in both 1980 and 2010, with a small advantage for cases in 1980 and for controls in 2010, which ironically means that the control countries (lagging behind schedule) had better economic development between 1980 and 2010. For adult women's educational attainment, case countries had a small advantage in 1975, which they maintained over the years and even increased, but the differences remained small in relation to the large differences in fertility decline highlighted above. Therefore, these cannot be attributed to socio-economic differences.

In other countries, on the contrary, the transition from a traditional regime (without birth control) to a modern regime (with contraception) has been smooth and with the consent of all social actors. These dynamics are complex, and often specific to each country. Thus, in some cases, Muslim or Catholic religious groups opposed family planning, while in other countries they let things evolve without intervening. It should be noted at the global level that no religion has been an insurmountable obstacle to the development of family planning and birth control, and that some Muslim countries (such as Iran, Bangladesh, Indonesia, Tunisia) as well as some Catholic countries (in Latin American countries, or the Philippines) are considered to be models of rapid transition. In some countries, rumors about the side effects of some contraceptives have hampered their spread. Again, these are groups of activists who developed for different reasons in some countries, but not in others. In most cases, information campaigns can help to narrow down these problems, but this may take a long time. In addition, some forms of contraception, well accepted in other countries, are problematic in many African countries, especially sterilization and induced abortions. These ethically legitimate oppositions should not be a brake on birth control if alternatives exist, that is if the supply of contraceptive methods is abundant, diversified and adapted to the needs of couples. Finally, certain legal provisions have been problematic in some countries, notably the 1920 law prohibiting the promotion of contraception that was in force in the countries of French colonization at the time of independence. This law has been revoked in most countries, but this has taken a long time in some cases.

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**3.** *On the organizational standpoint*: organizing the family planning program is important, and some programs have been poorly designed, poorly implemented, and poorly monitored. The programs that have worked best are those that have targeted the entire population through fixed posts and mobile teams, through public centers and private centers, and which have provided a continuous supply of contraceptives, free products, and which ensured a diversity of contraceptive methods. To the technical questions of management, one could add the question of the relationship with the population, very important in the case of mobile teams (client centered approach). Especially in the extension phase of the program it is important that new clients are welcomed properly, that the information given is simple and precise, that the rights of women are respected, especially confidentiality. This is especially the case for adolescent girls, for whom efforts have been insufficient, even in advanced countries such as South Africa. Moreover, it seems important that the program be stimulated regularly by new multiform actions. The programs that have worked best have been updated regularly, approximately every 10 years, with awareness campaigns, health education, sex education in schools, distribution of new products, and so on. Finally, an important element to obtain a large demographic impact is to cover the entire population, including women who do not come spontaneously in medical consultation. As such, the programs that seem to have had the greatest impact are those that included home visits, motivation visits (information, awareness), and home delivery of contraceptives [57]. In some new programs, the distribution of injectable contraceptives is done through home visits by trained personnel [58].

**4.** *Funding*: funding family planning programs has rarely been a problem in the past 50 years. Indeed, abundant international resources were available and distributed generously to all countries that requested it. These sources come from international organizations (UNFPA,
