**6. Conclusions**

In Sub-Saharan Africa, there is a wide range of situations in population policies, family planning programs and fertility control that reflect the diversity of ideological, political, economic and social situations, and even to a certain extend a diversity of epidemiological situations: some countries had higher natural fertility levels than others, and therefore had more problems to solve, which could take a longer time.

The case studies presented here provide guidance for defining the conditions for successful family planning and fertility control:


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 This law has been revoked in most countries, but this has taken a long time in some cases.

**5.6. Socio-economic correlates**

142 Family Planning

uted to socio-economic differences.

lems to solve, which could take a longer time.

through continued support from international aid.

family planning and fertility control:

**6. Conclusions**

**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 attrib-

In Sub-Saharan Africa, there is a wide range of situations in population policies, family planning programs and fertility control that reflect the diversity of ideological, political, economic and social situations, and even to a certain extend a diversity of epidemiological situations: some countries had higher natural fertility levels than others, and therefore had more prob-

The case studies presented here provide guidance for defining the conditions for successful

**1.** *On the political standpoint*: political will and commitment of the state to establish, operate and develop family planning programs is the first condition for success. If the state does not support the program at national level, or if it puts obstacles to the operation of private associations, the program has little chances of success. This political will is first of all ideological: the government must be convinced of the desirability of family planning (at least as a right to reproductive choices), and of a neo-Malthusian policy. The government needs to have the necessary charisma to get the message across to the different actors of public health and social action. In the event that the government is still pro-natalist, whatever its motivation, it will be reluctant to make efforts in family planning. However, these attitudes have changed over time, and by 2010 very few African governments still assert pro-natalist positions, while these were predominant in 1960. Another condition for the smooth functioning of programs is political stability, economic growth, and continuity in population policy during the inevitable changes of political regime. When the country is in a period of political turmoil, civil war or severe economic recession, progress in family planning can be halted or even reversed. However, it should be noted that some countries (such as Zimbabwe and Madagascar) have managed to survive periods of political unrest and economic recession by continuing to make the family planning program work, notably

**2.** *On the social standpoint*: in some countries, the first programs have been subjected to strong reticence, or even frontal oppositions, by various social, religious, traditional or family groups.


World Bank, UNICEF, European Union, etc.), bilateral aid (United States, European countries, Japan, etc.), international federations, American foundations (Ford, Rockefeller, Gates, etc.), and many intermediary actors. This international aid has made it possible not only to provide free contraceptives, but also to finance a significant part of the operation of the programs on the ground.

Finally, population pressure in general, and competition for land in rural areas in particular, may have played a role in the more or less rapid adoption of birth control. This is probably the case in Kenya, Rwanda and Madagascar where population pressure is high, but probably not in Ghana or Zimbabwe where it is moderate. Moreover, the contrast between Rwanda and Burundi shows that population pressure is not decisive in itself, while population policies

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

http://dx.doi.org/10.5772/intechopen.71029

145

The demographic outlook for sub-Saharan Africa is therefore not as bleak as it is often presented. It is likely that populations will increase considerably in most countries by 2100, creating unsustainable situations of overpopulation in many cases. However, the analysis presented above shows that this evolution can be modulated, if family planning efforts continue, if countries lagging behind are targeted, if enough financial resources are mobilized, if all actors are actively involved (state structures and NGOs), and if family planning programs are well-organized and well-managed and affect all population strata. The line drawn by the 2012 London Summit seems to be the right one, and should be followed with diligence. If the declared goal of universal access to contraception by 2020 is achieved, the decline in fertility could be faster than that currently foreseen by the United Nations for

This work benefited from a grant from the French National Research Agency under the "Investments for the Future" program bearing the reference "ANR-10-LABX-1401." The author thanks in particular FERDI (the French Foundation for Research on International Development) for its support and interest in the subject, as well as Mr. Charles Becker (historian, CNRS, France) and Dr. Monica Das Gupta (demographer, The World Bank, USA), for

**Country Urban (% of transition) Rural (% of transition)**

their careful reading of the manuscript, their comments and suggestions

Angola 53.2 0.0 Benin 41.6 34.6 Botswana 93.9 75.7 Burkina-Faso 65.5 20.6 Burundi 28.4 5.6 Cameroon 52.7 4.2 Central-African Rep. 36.9 9.8 Chad 24.4 6.2 Comoros 53.7 45.0

and family planning programs explain the differences between the two countries.

African countries.

**A. Annex**

**Acknowledgements**


This study gave little consideration to the different epidemiological situations. In particular, the HIV/AIDS epidemic has several possible interactions with contraception and fertility. On the one hand, the virus itself induces a decrease in fertility by a biological effect. On the other hand, the fight against AIDS has led to an increase in condom use in many countries. In the case studies presented above, it appears that these interactions had no impact on the fertility transition: in three cases (Rwanda/Burundi, Kenya/Uganda, Ghana/Nigeria) the epidemiological situation of HIV was comparable in the case and control countries. In the case of the comparison between Madagascar and Mozambique, the situation was rather the opposite of what one would have expected, because HIV was rare in Madagascar but frequent in Mozambique. Even in the Zimbabwe/Zambia comparison, there was slightly less condom use in Zimbabwe (3.2% women) than in Zambia (4.2% women), while the first country was slightly more affected by HIV than the second (prevalence of 15.2% and 13.3% respectively). The impact of epidemiological situations seems therefore negligible compared to the functioning of family planning programs.

Finally, population pressure in general, and competition for land in rural areas in particular, may have played a role in the more or less rapid adoption of birth control. This is probably the case in Kenya, Rwanda and Madagascar where population pressure is high, but probably not in Ghana or Zimbabwe where it is moderate. Moreover, the contrast between Rwanda and Burundi shows that population pressure is not decisive in itself, while population policies and family planning programs explain the differences between the two countries.

The demographic outlook for sub-Saharan Africa is therefore not as bleak as it is often presented. It is likely that populations will increase considerably in most countries by 2100, creating unsustainable situations of overpopulation in many cases. However, the analysis presented above shows that this evolution can be modulated, if family planning efforts continue, if countries lagging behind are targeted, if enough financial resources are mobilized, if all actors are actively involved (state structures and NGOs), and if family planning programs are well-organized and well-managed and affect all population strata. The line drawn by the 2012 London Summit seems to be the right one, and should be followed with diligence. If the declared goal of universal access to contraception by 2020 is achieved, the decline in fertility could be faster than that currently foreseen by the United Nations for African countries.
