**3. Trends in fertility and family planning in Africa**

This section revisits previous studies and provides a general overview of fertility trends in African countries, separating urban and rural areas, because their population dynamics are different. There are even countries in Africa where fertility continued to increase in rural areas, while it was declining in urban areas for decades, such as Congo-Kinshasa.

#### **3.1. Data and methods**

It should first be recalled that no country in sub-Saharan Africa maintains a complete civil registration of births and deaths necessary for monitoring precisely changes in birth and death rates. For the purpose of estimating fertility levels and trends, sample demographic surveys, based on representative household samples, were used, in particular the well-known Demographic and Health surveys (DHS), which collect maternity histories of women in their reproductive ages. These surveys are conducted approximately every 5 years, but are sometimes separated by 10 years or more, and data available in 2017 essentially cover the period before 2010.

DHS surveys and related data have been used to reconstruct levels and trends in fertility since 1950, separating urban and rural areas. The technical details of this reconstruction are presented in other documents [20–22]. In brief, annual fertility rates can be calculated for the 10 years prior to each survey, which allows long-term trends to be reconstructed, despite the large random fluctuations due to small samples (5000–15,000 women in general). This reconstruction has been done separately for urban and rural areas for 35 African countries, which comprise more than 90% of the continent's population.

DHS surveys also permit to reconstruct levels and trends in the use of modern contraception. The technique is somewhat different: trends were reconstructed by cohort (year of birth), which allowed reconstructing the trends by period (calendar year), again since 1950, and separately for urban and rural for 35 countries. The technical details of the calculations are presented in another document [21].

**3.3. Trends in contraceptive use**

Reconstruction of trends in contraceptive use, as measured by the proportion of women who have used modern contraceptives, shows a fairly consistent pattern. In urban areas, contraception appeared in the 1960s, but remained infrequent in the first decades, reaching the 10% threshold in 1974, and covered approximately half of women in 2005 (49.3%). In rural areas, modern contraceptive use started later and its increase was slower: the 10% threshold was

**Figure 1.** Trends in fertility in sub-Saharan Africa. Source: reconstruction from demographic surveys in 35 countries.

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

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

127

The evolution of the indicator of family planning programs, which measures both the efforts made and the program's operations, revealed a rather rapid rise between 1972 and 1999, followed

**Figure 2.** Trends in contraceptive use in Africa (proportion of women who have ever-used modern contraception).

reached in 1989, and it covered only 28.4% of women in 2005 (**Figure 2**).

**3.4. Intensity of family planning programs (Effort index)**

Source: reconstruction from demographic surveys in 35 countries.

The Futures Group, a USAID sponsored consulting group, produced an indicator of the intensity of family planning programs, called the "Effort index," which is expressed as the percentage completed by the program in relation to an ideal of 100%. The indicator measures several parameters with 30 variables in three chapters: official policy, service activity, and program monitoring. This study is available at intervals of 5–10 years: 1972, 1982, 1989, 1994, 1999, 2004, 2009, which makes it possible to reconstruct the dynamics of the program efforts over a long period of time. The indicator is available for 37 African countries, but with some missing data [23].

This study also refers to other sources of data, in particular to data on Gross Domestic Product (GDP) per capita gathered by Angus Maddison and colleagues, expressed in constant dollars (1990 International Geary-Khamis dollars) and converted to 2011 dollars [24].

#### **3.2. Fertility trends in urban and rural areas**

The reconstruction of fertility trends from demographic surveys shows firstly a marked increase in fertility in rural areas from 1950 to 1980, followed by a decline, from 7.05 to 6.08 children per woman between 1980 and 2010, that is 19.2% of the fertility transition from the maximum level to the level of 2 children per woman, considered as the end of the transition. The increase in the years 1950–1980 is due to the improvement of sanitary conditions and especially to the control of tropical and sexually transmitted diseases causing primary and secondary infertility. In urban areas, the increase in the first years is markedly lower, and the decline in fertility begins in 1976 (5.90 children per woman), reaching 3.96 in 2010, almost half the transition (49.7%). It should be noted that fertility control in urban areas probably started before 1976, and that without modern contraception, which was already noticeable at that time (10% prevalence), there would probably be an increase in fertility in urban areas as well (**Figure 1**).

#### **3.3. Trends in contraceptive use**

based on representative household samples, were used, in particular the well-known Demographic and Health surveys (DHS), which collect maternity histories of women in their reproductive ages. These surveys are conducted approximately every 5 years, but are sometimes separated by 10 years or more, and data available in 2017 essentially cover the period

DHS surveys and related data have been used to reconstruct levels and trends in fertility since 1950, separating urban and rural areas. The technical details of this reconstruction are presented in other documents [20–22]. In brief, annual fertility rates can be calculated for the 10 years prior to each survey, which allows long-term trends to be reconstructed, despite the large random fluctuations due to small samples (5000–15,000 women in general). This reconstruction has been done separately for urban and rural areas for 35 African countries, which

DHS surveys also permit to reconstruct levels and trends in the use of modern contraception. The technique is somewhat different: trends were reconstructed by cohort (year of birth), which allowed reconstructing the trends by period (calendar year), again since 1950, and separately for urban and rural for 35 countries. The technical details of the calculations are

The Futures Group, a USAID sponsored consulting group, produced an indicator of the intensity of family planning programs, called the "Effort index," which is expressed as the percentage completed by the program in relation to an ideal of 100%. The indicator measures several parameters with 30 variables in three chapters: official policy, service activity, and program monitoring. This study is available at intervals of 5–10 years: 1972, 1982, 1989, 1994, 1999, 2004, 2009, which makes it possible to reconstruct the dynamics of the program efforts over a long period of time. The indicator is available for 37 African countries, but with some

This study also refers to other sources of data, in particular to data on Gross Domestic Product (GDP) per capita gathered by Angus Maddison and colleagues, expressed in constant dollars

The reconstruction of fertility trends from demographic surveys shows firstly a marked increase in fertility in rural areas from 1950 to 1980, followed by a decline, from 7.05 to 6.08 children per woman between 1980 and 2010, that is 19.2% of the fertility transition from the maximum level to the level of 2 children per woman, considered as the end of the transition. The increase in the years 1950–1980 is due to the improvement of sanitary conditions and especially to the control of tropical and sexually transmitted diseases causing primary and secondary infertility. In urban areas, the increase in the first years is markedly lower, and the decline in fertility begins in 1976 (5.90 children per woman), reaching 3.96 in 2010, almost half the transition (49.7%). It should be noted that fertility control in urban areas probably started before 1976, and that without modern contraception, which was already noticeable at that time (10% prevalence), there would probably be an increase in fertility in urban areas

(1990 International Geary-Khamis dollars) and converted to 2011 dollars [24].

comprise more than 90% of the continent's population.

presented in another document [21].

**3.2. Fertility trends in urban and rural areas**

missing data [23].

as well (**Figure 1**).

before 2010.

126 Family Planning

Reconstruction of trends in contraceptive use, as measured by the proportion of women who have used modern contraceptives, shows a fairly consistent pattern. In urban areas, contraception appeared in the 1960s, but remained infrequent in the first decades, reaching the 10% threshold in 1974, and covered approximately half of women in 2005 (49.3%). In rural areas, modern contraceptive use started later and its increase was slower: the 10% threshold was reached in 1989, and it covered only 28.4% of women in 2005 (**Figure 2**).

#### **3.4. Intensity of family planning programs (Effort index)**

The evolution of the indicator of family planning programs, which measures both the efforts made and the program's operations, revealed a rather rapid rise between 1972 and 1999, followed

**Figure 2.** Trends in contraceptive use in Africa (proportion of women who have ever-used modern contraception). Source: reconstruction from demographic surveys in 35 countries.

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 hides the significant backwardness of the rural environment.

fertility levels if one considers only the prevalence of contraception. At the global level, it is estimated that without contraception some 7 children per woman are expected, and that 80% of contraception is needed to ensure complete control of fertility, or 2 children per woman. In Africa, however, fertility levels are well below the level expected from contraceptive prevalence, indicating that other phenomena, in addition to contraception, are not adequately measured by demographic surveys (induced abortion, separation of couples, traditional contraception, incomplete declarations, etc.). A detailed analysis of 32 African countries showed that the increase in modern contraception explains only about half of the decline in fertility

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

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

129

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.

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 pro-

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

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

health services and a level of development well above the African average (**Figure 4**).

(50.9% in urban and 41.4% in rural), the remainder being unexplained [27].

**4. Case studies on fertility decline**

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

cases are illustrated in **Figure 5**.

gram [31, 32].

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

#### **3.5. Socio-economic correlates**

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

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 dynamics [21, 26].

#### **3.6. Contraception and fertility in Africa**

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

**Figure 3.** Trends in the intensity of family planning programs in Africa. Source: Futures Group: average calculated on 37 countries (some years are missing).

fertility levels if one considers only the prevalence of contraception. At the global level, it is estimated that without contraception some 7 children per woman are expected, and that 80% of contraception is needed to ensure complete control of fertility, or 2 children per woman. In Africa, however, fertility levels are well below the level expected from contraceptive prevalence, indicating that other phenomena, in addition to contraception, are not adequately measured by demographic surveys (induced abortion, separation of couples, traditional contraception, incomplete declarations, etc.). A detailed analysis of 32 African countries showed that the increase in modern contraception explains only about half of the decline in fertility (50.9% in urban and 41.4% in rural), the remainder being unexplained [27].
