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Potatoes and Pills: An Overview of Innovation-Diffusion Contributions to Explanations of Fertility Decline

JOHN CLELAND

Forks, potatoes, and contraception may not appear at first glance to have much in common but, at different times, all have been innovations that have encountered considerable resistance before becoming accepted as humdrum elements of everyday life. The first mention of a fork as an instrument for carrying food to the mouth describes its use by the wife of the Venetian Doge in the eleventh century (Visser, 1993). The incident aroused the wrath of St. Peter Damian, the cardinal bishop of Ostia, who criticized the whole procedure in a passage entitled “Of the Venetian Doge’s wife, whose body, after her excessive delicacy, entirely rotted away” (Visser, 1993:189). In Northern Italy, it took a further 200 years before forks were commonly used for eating. As usual, England lagged well behind Italy in culinary matters. It was not until the early seventeenth century that Thomas Coryate introduced the fork, following a visit to Italy (Clair, 1965). Once again the instrument was condemned from the pulpit and repudiated by society. One irate preacher declared that “to touch meat with a fork was impiously to declare that God’s creatures were not worthy of being touched by human hands” (Clair, 1965:181).

The initial reaction to the potato in Europe following its introduction at the end of the sixteenth century was similar to that evoked by the fork (Salaman, 1949). Opposition was widespread, partly because of its strange

John Cleland is professor and head of research unit in the Centre for Population Studies at the London School of Hygiene and Tropical Medicine. The author would like to extend appreciation to Ian Timaeus and Brent Wolff who made constructive suggestions for improvement of a first draft of this paper.



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Diffusion Processes and Fertility Transition: Selected Perspectives 2 Potatoes and Pills: An Overview of Innovation-Diffusion Contributions to Explanations of Fertility Decline JOHN CLELAND Forks, potatoes, and contraception may not appear at first glance to have much in common but, at different times, all have been innovations that have encountered considerable resistance before becoming accepted as humdrum elements of everyday life. The first mention of a fork as an instrument for carrying food to the mouth describes its use by the wife of the Venetian Doge in the eleventh century (Visser, 1993). The incident aroused the wrath of St. Peter Damian, the cardinal bishop of Ostia, who criticized the whole procedure in a passage entitled “Of the Venetian Doge’s wife, whose body, after her excessive delicacy, entirely rotted away” (Visser, 1993:189). In Northern Italy, it took a further 200 years before forks were commonly used for eating. As usual, England lagged well behind Italy in culinary matters. It was not until the early seventeenth century that Thomas Coryate introduced the fork, following a visit to Italy (Clair, 1965). Once again the instrument was condemned from the pulpit and repudiated by society. One irate preacher declared that “to touch meat with a fork was impiously to declare that God’s creatures were not worthy of being touched by human hands” (Clair, 1965:181). The initial reaction to the potato in Europe following its introduction at the end of the sixteenth century was similar to that evoked by the fork (Salaman, 1949). Opposition was widespread, partly because of its strange John Cleland is professor and head of research unit in the Centre for Population Studies at the London School of Hygiene and Tropical Medicine. The author would like to extend appreciation to Ian Timaeus and Brent Wolff who made constructive suggestions for improvement of a first draft of this paper.

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Diffusion Processes and Fertility Transition: Selected Perspectives shape and subterranean character. At different times and places, the potato was accused of causing leprosy, scrofula, fever, tuberculosis, and rickets. In 1774 Frederick the Great set out to attack these superstitious beliefs. He sent a wagonload of potatoes to Kolberg to relieve a severe food shortage. After rejection of his gift by the indignant citizens, he dispatched a Swabian gendarme who convinced them that the potato was edible in the most convincing way possible: by eating one (Pyke, 1968). To overcome similar resistance in France, the government adopted a less colorful strategy. It invited the Medical Faculty of Paris to undertake an inquiry into the merits and demerits of the potato and disseminated the favorable verdict. The example of the fork serves to remind us that even a seemingly innocent and trivial innovation may encounter resistance before more widespread (though, in this case, not universal) acceptance and incorporation into everyday life. The case of the potato is perhaps potentially more relevant to contraception because food, sex, and procreation are central concerns of all human societies. Because of this centrality, radically new products or ideas concerning these three topics are likely to arouse particularly strong reactions that often necessitate the intervention of governments or other elites. How useful is it to pursue analogies between the spread of forks, potatoes, and contraception? To what extent can an innovation-diffusion framework help to explain marital fertility declines? These are among the key questions that will be addressed in this paper. Before doing so, however, it may be helpful to present a brief historical sketch of the role of diffusion frameworks in fertility theories. The spread of new products or ideas between societies is such an important feature of human history that it has always formed part of broader theories of social and cultural change. Both archeology and social anthropology have been influenced heavily by diffusionism. Quantitative investigation of the diffusion of innovations also has a relatively long ancestry. It originates in the 1920s in the efforts of the U.S. Department of Agriculture to assist small farmers by encouraging them to adopt new products, such as hybrid seeds, fertilizers, and herbicides. Many of the concepts and assumptions of this early work left a profound imprint on subsequent research. These include the assumption that the new product or practice offered an indisputable benefit; an emphasis on the process of communication and a neglect of possible structural determinants of uptake of the innovation; a focus on the individual as decision maker; a concern with the roles of change agents (in this case, agricultural extension workers); investigation of the characteristics of opinion leaders, early innovators, and late innovators; and an emphasis on applied research rather than on theory building.

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Diffusion Processes and Fertility Transition: Selected Perspectives During the 1950s and 1960s, innovation-diffusion research blossomed, with scant regard for disciplinary boundaries. In a major synthesis at the end of this era, Rogers and Shoemaker (1971) identified 1,500 studies drawn from agriculture, anthropology, sociology, geography, communications, marketing, and other substantive areas. Not surprisingly, the burgeoning family planning movement participated fully in this enthusiasm. In terms of program design, the early medical clinic-based model gave way to a more diffusionist approach, with an emphasis on communications, incentives, and fieldworkers (i.e., change agents). Major family planning communication groups were created at Johns Hopkins University and the East-West Center. The effect on research into family planning was also considerable. Bogue (1965) defined the field as “the systematic study of the phenomenon of family planning among populations, of the processes by which the practice of family planning diffuses throughout a community or nation and of the forces that retard or facilitate such diffusion and adoption.” Some of the best empirical studies of the role of interpersonal communication in the spread of contraceptive practice date from this era. Palmore (1967) used a diffusion framework to study the discussion of family planning following a mailing of booklets to individuals in low-income, inner-city areas of Chicago. In the famous Taichung experiment, one research question was phrased as follows: “Can direct communication to systematically spaced subgroups of a population indirectly affect a much larger population by diffusion from the initial foci of direct contact?” (Freedman and Takeshita, 1969:110). The answer was emphatically positive. In India, Marshall (1971) compared communication networks for family planning with those for a new wheat variety, while Blaikie (1975) assessed the strengths and limitations of spatial diffusion theory for understanding contraceptive adoption in Northeast Bihar. A diffusionist approach to family planning research was buoyed by numerous Knowledge, Attitudes, and Practice (KAP) surveys that indicated a widespread need for and interest in family planning; by the success of early family planning programs in Taiwan, the Republic of Korea, and Singapore; and perhaps by the illusory success of Ayub Khan’s 1965–1969 program in Pakistan. Subsequently the mood changed as it became clear that adoption of contraception and declines in marital fertility would not sweep across the larger countries of Asia and Africa as fast as they had done in Taiwan, for example. Doubts were expressed about the effectiveness of family planning programs (e.g., Davis, 1969), and the validity of the results of KAP surveys was questioned (Hauser, 1967). Even Rogers (1983:71) had to admit that “contraceptives are one of the most difficult types of innovations to diffuse.” Economic theories of fertility transition, that stressed shifts in the costs and benefits of children, assumed an increasing

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Diffusion Processes and Fertility Transition: Selected Perspectives dominance. And within the favored individual utility maximization model, there was little space for innovation-diffusion ideas. The academic climate of the time is well illustrated by the mammoth National Academy of Sciences volumes on fertility determinants in developing countries. They end with an agenda for future research. Forty topics are described, but only one reflects an interest in diffusion (Bulatao and Lee, 1983). In the mid-1980s, the tide of demographic events and research evidence turned again, and there was a renaissance of interest in diffusion frameworks. By that time, it was clear that fertility declines, largely fueled by increases in birth control, were occurring in most of Asia and Latin America. Within a few more years, indisputable evidence of fertility change in some of the poorest countries in the world (e.g., Bangladesh and Nepal) had accumulated and there were growing signs of the onset of fertility transition in Africa. Both the pace and geographical spread of fertility decline appeared, at least superficially, to be more consistent with an innovation-diffusion style of explanation than one based on structural changes leading to reduced demand for children. The publication of the results of two major research programs greatly strengthened the diffusionist case. The Princeton European Project analyzed aggregate demographic data for the provinces of Europe during the period of the fertility transition (Coale and Watkins, 1986). The analysis of age-specific marital fertility rates suggested that the practice of family limitation, or parity-specific birth control, was largely absent prior to 1880, with the important exception of France. Between 1880 and 1930, the practice spread with remarkable speed throughout most of Western Europe. The timing of the onset of decline was only weakly related to provincial levels of socioeconomic modernization but unmistakably linked to language, a feature most vividly demonstrated by the difference between Flemish- and French-speaking villages in Belgium (Lesthaeghe, 1977). The demographic laggards tended to be communities that were both spatially and linguistically isolated: the Celts in the United Kingdom, the Lapps in Sweden and Finland, and the Frieslanders in the Netherlands (Watkins, 1991). Moreover, there was little evidence that the decline of marital fertility in Europe was propelled by any transformation in the value of children (Knodel and van de Walle, 1986). This Princeton orthodoxy is not without its critics. In an analysis of the Balkans, Hammel (1995) comes to the conclusion that ethnicity is only a proxy for political factors that in turn determine economic motives for childbearing. Kertzer and Hogan (1989) give a plausible economic interpretation to the persistence of high fertility among sharecroppers compared to the other economic strata in Italy. Yet the big picture has not been seriously challenged and the Princeton European Project remains the single most powerful rebuttal of demand theories of decline and pro-

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Diffusion Processes and Fertility Transition: Selected Perspectives vides the most convincing, albeit indirect, evidence to support an innovation-diffusion style of explanation. The second major research program to reach completion in the mid-1980s was the World Fertility Survey. The raw data, cross-sectional interview surveys of women were very different from those available to the Princeton Project. Nevertheless, there were striking parallels in some of the findings. Once again, there was evidence of a rapid spread of birth control practices from urban to rural strata and evidence that language or other cultural factors (denoted, for example, by religious affiliation) influenced the onset and speed of decline (Cleland, 1985). With the clear exception of Sub-Saharan Africa, differences in the level of contraceptive practice or marital fertility at national or subnational levels appeared to reflect variations in the propensity to act on family size preferences rather than variations in the nature of preferences themselves (Lightbourne, 1985). And once again, evidence of the impact of economic factors on reproduction was largely absent. For example, women’s labor force participation was not a predictor of fertility in most countries (United Nations, 1985) nor did the shift from familial to nonfamilial modes of production have the expected effect on family size (Rodriguez and Cleland, 1981). This evidence, together with that from historical Europe, constituted a major attack on the dominant economic paradigm of the previous decade and a boost to diffusion frameworks (Cleland and Wilson, 1987). Since the 1980s, empirical work that bears directly on innovation-diffusion explanations of fertility decline has taken two very different pathways. Watkins and collaborators have investigated the content and nature of interpersonal discussions about family size and family planning in the United States and in Kenya, thereby beginning to remedy a glaring gap in the research evidence (Watkins and Danzi, 1995; Watkins et al., 1997; Rutenberg and Watkins, 1997), and Valente and collaborators have applied network theory (a rapidly growing field) to family planning in Cameroon (Valente et al., 1997). Meanwhile, Caster line, Montgomery, and Rosero-Bixby have modeled fertility trends in Taiwan and Costa Rica to test expectations derived from the diffusion framework (Montgomery and Casterline, 1993; Rosero-Bixby and Casterline, 1993, 1994). These contributions will be discussed later. SPECIFICATION OF THE INNOVATION-DIFFUSION FRAMEWORK AND ITS APPLICABILITY TO FERTILITY TRANSITION THEORY Thus far in the paper, no specification of the innovation-diffusion framework has been given. It is appropriate now to remedy this defect. The third edition of Diffusion of Innovations serves as an appropriate basis

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Diffusion Processes and Fertility Transition: Selected Perspectives for the account that follows (Rogers, 1983). According to Rogers (1983:10), diffusion has four main elements. It is “the process by which (1) an innovation (2) is communicated through certain channels (3) over time (4) among members of a social system.” The characteristics of the innovation (new product, procedure, idea, or some combination of these) partly determine its rate of adoption. These include its perceived relative advantage, compatibility with norms and values, complexity, trialability, and observability. The last two features have potentially interesting implications for family planning diffusion. Reversible methods can be subjected to trial but not sterilization, for example. Observability is likely to differ between supply methods and other methods, such as withdrawal, with possible consequences for the speed of diffusion. In contrast the concepts of relative advantage and compatibility relate to familiar themes in fertility theorizing and have nothing distinctive to offer. Relative advantage simply echoes child-utility theories while compatibility corresponds to cultural theories of fertility change. The innovation-diffusion approach is thus at its weakest in helping to understand why some innovations spread and others do not. As the vast majority of new ideas or products fail to gain acceptance, this is a damaging weakness and helps to explain why the concept of diffusion remains at the margins of mainstream theories of change. The framework offers potentially more useful concepts to examine the process of communication. It draws heavily on sociological theories of learning, influence, and networks. Although the role of mass media and specially trained “change agents” is recognized, the importance of interpersonal communication is stressed as the most powerful channel of influence. In contrast to theories that model behavior as the outcome of isolated individual decision making or of internalized norms and values, the major concern of network theory is the ties that link people, both strong ties between close friends and weak ties with mere acquaintances (Granovetter, 1973). Such interpersonal contacts act not only as conduits for information flow but as powerful constraints on behavior. To put it at its most simple, the behavior of individuals is heavily influenced by the behavior or perceived behavior of others with whom they interact. These concepts lend themselves readily to the study of innovations. Because innovations, almost by definition, carry an element of uncertainty, risk, and perhaps even fear, uptake is initially slow. The incidence of adoption then accelerates because of the social influence of peer groups on individuals. This self-reinforcing process is also fueled by reductions in risk and uncertainty as the innovative item becomes more common and familiar. Rogers (1983:234) call this the “diffusion effect.” The term preferred in later work by Caster line and others is “endogenous feedback.” In terms of Easterlin’s framework, the spread of contraception reduces

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Diffusion Processes and Fertility Transition: Selected Perspectives the psychic and social “costs” of fertility regulation (Easterlin, 1975). The incidence of adoption then falls as saturation is approached, giving an S-shaped cumulative adoption distribution over time. Early adopters tend to be of high social status and education, partly because of exposure to a wider range of communication networks. The speed of diffusion thus depends to some extent on interpersonal links between these individuals and others: hence the importance of heterophilous contacts (Rogers’ term) or weak ties (Granovetter’s term). The potential applicability of this model to contraception is obvious. From this brief description, both blended and pure versions of innovation-diffusion explanations of marital fertility decline may be derived. Blended versions are essentially a fusion of classical demand theories and elements of the diffusion model. The fundamental cause of fertility decline is reduced demand for children (and/or increased supply through improved child survival) that stems from modernization in its various forms. Once the structural conditions are right, fertility decline is inevitable but its timing may be lagged. The onset of decline can be advanced by skillful government deployment of mass media and change agents or delayed by inappropriate official efforts to promote contraception. Diffusion processes subsequently condition the speed and mechanisms of change. Couples do not make reproductive decisions in isolation from one another. Although the idea of birth control within marriage may or may not be new, the modern array of methods certainly is. The spread of knowledge and use of these methods accords with the diffusion model described above. Early adopters tend to be more cosmopolitan, urban, and educated, but adoption, and reduced fertility, spreads to other sectors, largely through interpersonal communication networks. Formal expositions of such a blended theory may be found in Retherford (1985) and Kohler (1997). Under the blended theory, the engine of demographic change is the structural transformation of societies, and diffusion is the lubricant. A pure version of innovation-diffusion explanations of fertility decline accords a much more central explanatory role to marital birth control as an innovation. It is an exogenous theory of change whereas the blended version is essentially an endogenous theory. Not only are modern methods of contraception recent inventions, but the very idea of deliberate pregnancy regulation within marriage has been absent in most societies for most of human history. This absence of pregnancy regulation for so much of human history remains a puzzle because, as our knowledge of historical demography increases, it is becoming clear that all societies have developed ways of suppressing average fertility and family size to remarkably low levels. Total fertility rates of between four and six births appear to have been the norm (Wilson and Airey, 1999). A latent demand

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Diffusion Processes and Fertility Transition: Selected Perspectives for pregnancy regulation exists in all societies. The “invention” of contraception offers huge advantages over previous ways of mitigating the perennial human problem of controlling numbers: celibacy; methods of abortion that were dangerous, partially effective, or both; infanticide; child abandonment; fostering; or adoption (Mason, 1997). The “invention” is largely a moral one in historical Europe: forms of behavior previously considered repugnant and fit only for illicit relationships became respectable. In the developing world, the invention was both moral and technological. Like the wheel, once invented, its global spread is inevitable and unstoppable. The nexus between sexual intercourse and conception, once broken, cannot be restored. But like the potato, both the idea of marital birth control and its material manifestations encounter resistance of a largely cultural or religious nature that condition the timing and speed of adoption. New Frederick the Greats arise at international and national levels, and cohorts of Swabian gendarmes in the modern uniform of grey suits, are dispatched from New York and Washington, D.C., to convince suspicious or fearful communities of the merits of the new idea and its products. Partly because of the effectiveness of their efforts but also because of the proliferation of communication networks, universal diffusion of contraception is achieved more quickly than the diffusion of the potato in Europe: 150 years if Europe is included and a mere 50 or so years for other major regions. The spread of contraception has no logical, inevitable link to the level of fertility but, like other radical innovations, it has profound implications. By releasing women from the burden of frequent childbearing, it paves the way for a revolution in gender relations. More importantly for fertility theory, it allows couples to reassess the number of children they want, and this reassessment inevitably leads to a downward revision. New means make possible new motives and new attitudes toward children. This drop in the desired number of births is undoubtedly influenced by improvements in child survival that accompany or precede the spread of birth control. Whether or not this reassessment leads inexorably to replacement-level fertility or below remains to be seen, but the indications, thus far, are that it will. These sketches of blended and pure versions of innovation-diffusion explanations of course do not imply that stark choices have to be made between rejection of both or endorsement of one. There are many possible variations on the central themes. However, the distinction is worth making for the following reason. As I shall argue below, the evidence that contraceptive practice spreads by interpersonal communication and that the reproductive habits of couples are influenced by the behavior of those around them is overwhelmingly strong and indeed blindingly obvious to anyone with first-hand experience in family planning in developing coun-

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Diffusion Processes and Fertility Transition: Selected Perspectives tries. Only a bigot or a theoretician who never strays from the comforts of algebraic models could attempt to explain what has happened to human fertility without invoking elements of the diffusion framework. Interest should focus therefore on the pure version of the innovation-diffusion framework, which is more controversial, more problematic, and by no means blindingly obvious. The pure version of innovation-diffusion explanations rests on key assumptions and leads to a large number of empirical expectations, some of which can be addressed by evidence. Many are also relevant to the blended version. These are listed below. Fertility regulation within marriage is an innovation. The idea of fertility regulation within marriage and many of the methods to achieve this initially evoke feelings of uncertainty, ambivalence, and fear. The evidence concerning the timing of fertility transitions across societies is more consistent with expectations derived from the innovation-diffusion framework than with those derived from economic theories. Once a certain threshold of cumulative adoption is reached, contraception spreads rapidly throughout socially and linguistically homogeneous systems, regardless of the position of groups within the economic structure. Contraception, and related topics, are the subject of interpersonal communication. The decision of individuals to adopt contraception and the methods they choose are influenced by their perceptions of behavior of others within their communication networks. Declines in desired family size accompany or follow the diffusion of contraception rather than precede it. Contraception supercedes earlier methods of managing family size and composition. THE EVIDENCE Is Fertility Regulation an Innovation? In view of universal understanding of the causal link between sexual intercourse and pregnancy, it may seem fanciful to claim that deliberate control of conception within marriage can be an innovation. Indeed it has often been claimed that coitus interruptus, nonvaginal intercourse, and prolonged abstinence are always available when the motive arises. But as Pollack and Watkins (1993) point out, the innovatory element of preg-

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Diffusion Processes and Fertility Transition: Selected Perspectives nancy regulation within marriage may not take the form of new information about the biology of procreation but a more moral one of thinking (and then doing) the hitherto unthinkable. This concept of “unthinkability” is a familiar one and appears under a number of terms: Coale’s (1973) “calculus of conscious choice”; Rotter’s (1966) “locus of control”; and “active agency,” as used, for example by Carter (1995). What then is the evidence that pregnancy prevention was a cognitive or an ideational innovation? For historical Europe, the evidence is largely indirect. The literary material is generally positive (van de Walle, 1992). Analysis of marital age-specific fertility rates certainly demonstrates that parity-specific control became very much more common in Europe between 1880 and 1930, though this evidence does not rule out the possibility that minority groups may have practiced family limitation long before the fertility transition itself nor that deliberate regulation of birth spacing may have been common. The single most telling piece of evidence to support the view that pregnancy prevention was indeed an innovation is the fact that illegitimate fertility fell in parallel with marital fertility (Knodel and van de Walle, 1986). It requires considerable sophistry to explain this trend without coming to the conclusion that individuals in Europe were putting to effective use new forms of behavior that were previously denied to them. Evidence with regard to developing countries comes mainly in the form of the direct testimony of the actors themselves, gathered in structured interview surveys or by ethnographic techniques. The results of early fertility and family planning surveys strongly suggest that there are indeed societies where almost no one attempts to prevent or delay pregnancy within marriage (or, alternatively, is prepared to report such behavior). If, as some have claimed, traditional methods are always available when needed, this is an astonishing finding that is compatible only with extreme forms of pronatalism or the existence of more attractive methods of control. As mentioned earlier, it is implausible to characterize historical societies as strongly pronatalist, nor do most of the alternative control mechanisms appear to be intrinsically superior. Reported awareness of methods of contraception—either traditional or modern—can also be very low. Majorities of women canvassed in the World Fertility Survey reported ignorance of all methods in Yemen, Cameroon, Benin, and Nepal, for example. There is little evidence that coitus interruptus was widely known, let alone practiced. Qualitative or ethnographic evidence, on occasion, has raised serious questions about the validity of standardized survey results with regard to contraceptive knowledge and use (e.g., Stone and Campbell, 1984; Bleek, 1987). There also is no doubt that women are reluctant to admit their

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Diffusion Processes and Fertility Transition: Selected Perspectives familiarity with male methods such as coitus interruptus and condoms, presumably because of shyness or shame. Yet much of the ethnographic evidence is entirely consistent with the impression given by survey results. In North India (Jeffery et el., 1989), Bangladesh (Maloney et al., 1981), Thailand (Knodel et al., 1984), Mali (van de Walle and van de Walle, 1991), and early twentieth-century Prussia (Lee et al., 1994), to cite but a few examples, there is convincing testimony that the idea of fertility regulation was unthinkable and/or the means to achieve it unknown. A few quotations give the flavor of responses. “Truly the number I wanted was four, but going on to ten was God’s work.” (Mali) “We didn’t think about how many (children] we should have. [My husband] felt sorry for me when I had lots of children but no one knew what to do.” (Thailand) “In the old days, no one used medicines to stop having children. They would say it was bad to stick out your leg to trip up God in his work. However many children were in a person’s fate, that many would certainly be born.” (India) “It is very hard with more than two children, but if they are given by dear God, one must be satisfied.” (Prussia) “The number of children to be born is indicated in the woman’s childbearing tube. Only God knows this, and no one can foretell it.” (Bangladesh) The constant reference to religion need not be interpreted literally. In my interpretation, these statements reflect a distrust of an alien idea that appears unnatural, rather than a carefully considered rejection on the basis of religious doctrine. In societies where religious sentiments permeate every aspect of life, the easiest way to express this distrust is to resort to familiar religious terminology. To sum up, the case that the idea of marital fertility regulation was a true innovation both in Europe and elsewhere remains robust despite widespread skepticism. Does the Idea of Fertility Regulation and Methods Initially Evoke Feelings of Uncertainty, Ambivalence, and Fear? In some developing countries the advent of modern contraceptive methods was greeted enthusiastically. In the 1960s, many Taiwanese and Thai women, for example, traveled long distances to have Intrauterine Devices (IUD) fitted. In other settings it is clear that marital birth control and its methods is initially greeted with suspicion, ambivalence, and fear. Both surveys and more indepth investigation in many parts of

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Diffusion Processes and Fertility Transition: Selected Perspectives decision making within families, is subject to social control and social pressures that constrain other forms of behavior. What exactly do individuals talk about? What exactly is it that diffuses? One of the very few detailed accounts comes from the work of Watkins and collaborators in South Nyanza. Not surprisingly, perhaps, discussions of contraception among women are embedded in more general debates about family size and modern life. Everyday conversation makes no distinction between motives and means. Information exchange goes hand in hand with assessment and evaluation. The experiences of close friends, neighbors, and relatives appear to be of particular importance. What matters most is the direct testimony of those who have actually tried a method. The deep ambivalence about family planning methods lends credence to disquieting stories about babies born with disease or deformity as result of their mother’s contraceptive habits. There was little evidence that women explicitly seek information and advice from high-status or highly educated individuals. Formal health care providers are valued sources of technical information but they are socially distanced in a way that erodes complete trust (Rutenberg and Watkins, 1997). The metaphor used by Watkins et al. (1995:51) aptly sums up the general impression from their work: “Women in these areas are not navigating the domain of uncertainty alone, but rather in flotillas, convoys in which the topics of conversation are relevant, the debates widespread and sometimes intense.” And the substance of the diffusion is a bundle of interrelated topics: the idea of birth control, characteristics of particular methods, and ideas about family size. Are the Decisions of Individuals to Adopt Contraception and the Method Chosen Influenced by the Behavior of Those Around Them? The evidence reviewed in the previous section suggests: that contraception is part of everyday conversation in many settings; that in some societies at least, it is regarded with ambivalence, uncertainty, and fear; and that the use of modern methods of contraception by individuals tends to be a socially observable form of behavior. It is but a small leap to postulate that the reproductive behavior of individuals is influenced by the behavior, or perceived behavior, of those with whom they interact daily. Indeed it would be astonishing if the social learning that clearly takes place partly though communication networks is not accompanied by a degree of social influence. The illusion of rational decision making is a powerful influence on self-presentation in all societies. Whatever the topic of inquiry, the response “I behave in this way because every one/no one that I know behaves in that way” is never heard. In noncontracepting communities,

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Diffusion Processes and Fertility Transition: Selected Perspectives women may explain their own nonuse in terms of lack of knowledge or husband’s disapproval but rarely in terms of the behavior or example of others in the same community. It appears difficult for individuals to accept that their beliefs and decisions may be influenced by those of immediate others. Moreover such influences are often subtle, indirect, quickly internalized, and thus impossible to identify and articulate. For these reasons, the evidence for social influence in the reproductive domain rarely takes the form of direct testimony but has to be inferred indirectly from observed patterns of behavior. Each strand of evidence, taken in isolation, is inconclusive. Taken together, however, they represent a powerful case in favor of social influence. One of the weaker strands of evidence is the finding that a woman’s perception that others in the community or village approve of family planning and/or are using family planning is predictive of her own contraceptive use (see Retherford and Palmore, 1983, and Beckman, 1993, for discussions of the evidence; and Valente et al., 1997, as an empirical case study). The evidence is relatively weak because it is usually impossible to ascertain whether contraception adoption of an individual preceded and then influenced her reported perception of others (following the principle of cognitive dissonance) or vice versa. This simple approach can be extended to a formal network analysis, where individuals are asked to specify by name those with whom they interact most (in general or on particular topics). Perceived use status and attitudes of these network members can be gathered and in certain circumstances, it may be possible to contact and gather parallel information from these named friends. Such data were obtained in a remarkable 1973 Korean study, initially analyzed by Rogers and Kincaird (1981) and reanalyzed more recently by Montgomery and Chung (1999). The results of the latter analysis suggest that the extent of perceived use of contraception, advice giving, and perceived favorable attitude among network contacts were predictive of use. However, the estimates of the effect of actual contraceptive use among network contacts were ambiguous and, as the authors accept, the cross-sectional of the inquiry further erodes confidence. Prospective studies are clearly needed to demonstrate beyond doubt the effect of interpersonal influences at the micro level. In view of the general lack of data to test diffusion, or social influence, at the micro level, the search has switched to the aggregate level: 361 townships in Taiwan and 100 counties in Costa Rica (Montgomery and Casterline, 1993; Rosero-Bixby and Casterline, 1993, 1994). The general approach in both these studies is to identify spatial-temporal patterns of fertility decline that are suggestive of social influence. Specifically, they assess evidence of endogenous feedback, whereby the fertility decline in a

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Diffusion Processes and Fertility Transition: Selected Perspectives community is in part a function of past fertility decline in that community and adjacent communities. Although the idea is relatively straightforward, specification of an appropriate model to test the central hypothesis is a formidable undertaking, and a degree of faith in the methodology is required. In both countries, evidence of strong feedback mechanisms is found. In Taiwan, within-township diffusion effects were stronger than across-township effects and there was no evidence of an influence of lagged fertility in nearby larger towns. In Costa Rica, intercounty effects are estimated to be stronger than intracounty ones, which is surprising and remains unexplained. These results are entirely consistent with the fact that fertility decline, and levels of overall or method-specific contraceptive use vary sharply between otherwise similar rural communities. This feature has been observed for German villages by Knodel (1986), for Korea by Rogers and Kincaird (1981), and for Thailand by Entwistle et al. (1996). There is more than one possible explanation for such disparities, but the obvious one, mentioned by analysts in all three studies, hinges on the role of social influence. At national levels, there is also evidence of social influence or social imitation in the choice of modern contraceptive method. In the average country (developed and developing), 50 percent of modern method use is accounted for by one type of method (Ambegaokar, 1996). One obvious explanation concerns biases in contraceptive provision; this factor is certainly important in some settings. However, there is no relationship between the skewness of method mixes in developing countries and method-access scores derived by Ross and Mauldin (1996). It seems unlikely, therefore, that supply factors can offer a convincing explanation and correspondingly likely that strong social influences operate to tilt individual choices. As mentioned at the start, most of the direct evidence concerning social influences on reproductive behavior is fragmentary and indirect. A heavy penalty has been paid by excessive reliance on World Fertility Survey/Demographic and Health Survey (WFS/DHS) data in fertility research, because the sampling strategy used by these programs is ill suited for analysis of the spread of new reproductive habits within communities. The most powerful argument in favor of the view that individual decisions and behavior are indeed influenced by the behavior of friends, relatives, and neighbors remains the simple and obvious one of the speed with which behavior can change. It is unconvincing to explain rapid marital fertility transition solely in terms of the spread of knowledge. Knowledge of contraceptives and supply source is often well established long before changes in behavior. Nor is it plausible to conclude that couples, independently of each other, perform the same calculations and

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Diffusion Processes and Fertility Transition: Selected Perspectives come to the same conclusion about family size and fertility regulation within a short span of time. The principle of Occam’s razor should apply: give the simplest explanation that is consistent with the evidence. The simplest explanation for rapid rises in contraception and declines in fertility is that people are influenced by one another. Not only is it the simplest explanation, it is also the most compelling. Copying is a far more common influence on human behavior than calculation. The latter is fine for choices of minor significance, but individuals rarely make big decisions on the basis of cost-benefit calculations. Do Falls in Demand for Children Precede, Accompany, or Follow Widespread Adoption of Contraception? One strong expectation derived from economic theories is that falls in parental demand for children will precede widespread changes in reproductive behavior. Conversely the innovation-diffusion framework allows for the possibility that the advent of new means of regulating fertility may bring about radical reappraisals of desired family size. Apart from Sub-Saharan Africa, and to a lesser extent the Arab states, demand for children, as indicated by survey responses, typically have been modest. The very earliest surveys suggest that three or four children were considered sufficient by large majorities of women surveyed (Mauldin, 1965). It is, of course, possible that substantial declines in desired family sizes took place before the era of survey research, but our growing knowledge of pretransitional reproductive regimes makes this proposition unlikely. There are rather few countries where fertility preferences have been monitored reliably over a prolonged period of time, but in many, if not most, of these cases, declines in fertility preceded drops in desired fertility. This holds true, for example, in Taiwan, Republic of Korea, Thailand, and Costa Rica. In these and many other settings, the early stages of fertility decline took the form of reductions in unwanted births rather than in declining demand for children. For Sub-Saharan Africa, the indications are rather different. Desired family sizes are generally high, ranging from 6 to 8.3 children in WFS enquiries, with substantial numbers of respondents giving nonnumerical responses. More recent DHSs show a widespread downward drift in preferences: from 8.3 to 6.2 or 6.3 in Senegal and Nigeria; from 6 to 4.7 in Ghana; from 6.5 to 5.6 in Uganda. Thus it is fair to conclude that, in this region, falling demand for children will precede rather than accompany or follow actual changes in reproductive behavior. An intriguing exception is Kenya, where on the eve of fertility transition, fertility aspirations remained extremely pronatalist. In this country, the drop in desired family size from 7.2 to 3.9 accompanied the spread of fertility regulation.

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Diffusion Processes and Fertility Transition: Selected Perspectives Does Contraception Supercede Previous Methods of Managing Fertility and Family Size? One reasonable, though not strong, expectation of innovation-diffusion theories is that contraception will supercede or displace prior ways in which the problems of human numbers were managed or mitigated. The evidence is, on the whole, negative. In developing countries, at least, there has been no increase in nuptiality. Breastfeeding durations remain surprisingly resilient. In West Africa, postpartum abstinence has actually increased in length. The incidence of induced abortion appears to increase, at least in the earlier phases of transition. To be sure, infanticide has declined but there are many obvious reasons for this trend and, in any case, rises in sex-selective abortion in East Asia may be seen as a modern equivalent of infanticide. In short, the advent of fertility regulation within marriage coexists with older ways of fertility or family size moderation rather than replacing them. CONCLUSIONS To sum up briefly, there is extremely strong evidence that fertility declines of the past 200 years have been conditioned by diffusion processes. The spread of new ideas about fertility regulation and new information about methods must form part of any convincing overall explanation. Moreover, the indirect evidence is very strong that changes in reproductive habits, like most other changes in human behavior, are a social transformation, heavily influenced by the climate of opinion and perceptions of how others are behaving. The transition from high to low fertility is not characterized by a shift from societal mechanisms of control to individualistic control. Social influences are just as strong in transitional and posttransitional societies as in pretransitional ones. Rejection of both blended and pure variants of the innovation-diffusion explanations, as outlined earlier, is thus to ignore both common sense and a large body of evidence. However, the pure variant is rather implausible in the case of the developing world. I find it impossible to believe that the fertility transitions of the past 50 years would have occurred without the massive prior declines in mortality. These improvements in survival make a fertility response inevitable because no society can sustain for long a doubling in numbers every 25 to 30 years. The international family planning movement was one part of the response. Government efforts to popularize fertility regulation also stem directly from mortality decline. Fertility decline in the developing countries is essentially a lagged response to improved survival, but the length of the lag probably depends on cultural and political factors that condition the ease with which, and the speed with

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Diffusion Processes and Fertility Transition: Selected Perspectives which, new methods of regulating fertility are incorporated. Transformations in the economic value of children are of secondary importance to the sheer increase in the numbers that have to be nurtured. The causal role of prior mortality decline is an element of most classical statements of fertility transition and was asserted most emphatically by Davis (1963) in his theory of the multiphasic response. In his view, mortality decline constitutes both a necessary and a sufficient stimulus for fertility decline because, for the family, improved survival represents severe disadvantages, both in agrarian and industrial settings. The costs of child bearing rise steeply because more survive beyond infancy and early childhood. Inheritance of family resources is fragmented and delayed because of longer parental survival. These pressures on families invoke an inevitable response: out-migration, marriage postponement, and/or fertility control within marriage. It is inappropriate in this chapter to review all the evidence that supports Davis’s view of fertility to transition. This may be found elsewhere (Macunovich, 2000; Cleland, in press). Suffice it to say that the relatively rapid spread of fertility decline throughout Asia, Latin America, and Africa in the past 50 years surely implies that there is some common underlying cause; improved survival is the most plausible candidate as this common cause. The absence of any straightforward mechanical relationship between mortality and fertility simply reflects the complexity of the real world. A host of factors—social, political, cultural, and economic—mediate the inevitable fertility response to radically improved survival. This scenario offers a less convincing explanation for the European transition. If new forms of parity-specific control had originated in countries with pronounced prior declines in mortality and subsequently spread to other countries within Europe, it could be argued that, in this part of the world, fertility decline was also essentially a response to improved survival. But of course it did not. It originated in France in the eighteenth century. Chesnais (1992:142), determined to assert the general principle that mortality decline must be temporally prior to fertility decline, notes that infant mortality in France fell “appreciably” from 296 per 1,000 births in the 1740s to 278 in the 1780s. Few other demographers would attach much significance to such a modest change. Moreover the subsequent spread of marital fertility control from France throughout the rest of Europe does not appear to be linked to mortality conditions. The pure version of the innovation-diffusion explanation remains compelling for this region of the world.

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