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P O P U L AT I O ~ D Y FJ A" ~ C S O F S U B - S A H A RA ~ A F R I ~ A DEMOGRAPHIC CHANGE N SU B-SAHARAN AF R! CA DEMOGRAPHIC EFFECTS OF ECONOMIC REVERSAES IN SUB SAHARAN AFRICA EFFECTS OF HEAETH PROGRAMS ON CHIED MORTAEITY IN SUB_SAHARAN AFRICA FACTORS AFFECTING CONTRACEPTIVE USE IN SUB_SAHARAN AFRICA POPUEATION DYNAMICS OF KENYA POPUEATION DYNAMICS OF SENEGAE SOCIAE DYNAMICS OF ADOEESCENT FERTIEITY IN SUB_SAHARAN AFRICA

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POPULAT10N DYNAMICS OF SUB-SAHARAbI AFRICA FACTORS AFFECTING CONTRACEPTIVE USE IN SUB_SAHARAN AFRICA . Working Group on Factors Affecting Contraceptive Use Panel on the Population Dynamics of Sub-Saharan Africa Committee on Population Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1993

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NATIONAL ACADEMY PRESS . - 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the further- ance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Robert M. White is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's pur- poses of furthering knowledge and advising the federal government. Functioning in accor- dance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engi- neering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council. Library of Congress Catalog Card No. 93-85134 International Standard Book Number 0-309-04944-X Additional copies of this report are available from: National Academy Press, 2101 Constitu- tion Avenue, N.W., Box 285, Washington, D.C. 20418. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). B168 Copyright 1993 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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WORKING GROUP ON FACTORS AFFECTING CONTRACEPTIVE USE JANE T. BERTRAND (Chair), School of Public Health and Tropical Medicine, Tulane University EVASIUS K. BAUNI, Department of Geography, Kenyatta University, Kenya RON J. LESTHAEGHE, Faculteit van de Economische, Sociale en Politieke Wetenschappen, Vrije Universiteit Brussel, Belgium MARK R. MONTGOMERY, Department of Economics, State University of New York at Stony Brook OLEKO TAMBASHE, Faculte d'Economiques, Departement de Demographie, Universite de Kinshasa, Zaire MARIA J. WAWER, Center for Population and Family Health, Columbia University CAROLE L. JOLLY, Staff Officer SUSAN M. COKE, Senior Project Assistant DIANE L. GOLDMAN, Administrative Assistant* JOAN MONTGOMERY HALFORD, Senior Project Assistant** PAULA J. MELVILLE, Senior Project Assistant * through December 1991 **through July 1992 v

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PANEL ON THE POPULATION DYNAMICS OF SUB-SAHARAN AFRICA KENNETH H. HILL (Chair), Department of Population Dynamics, Johns Hopkins University ADERANTI ADEPOJU, Institut de Developpement Economique et de la Planification (IDEP), Dakar, Senegal JANE T. BERTRAND, School of Public Health and Tropical Medicine, Tulane University CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern University WILLIAM BRASS, Centre for Population Studies, London School of Hygiene and Tropical Medicine, England DOUGLAS C. EWBANK, Population Studies Center, University of Pennsylvania PHILIPPE FARGUES, Centre d'Etudes et de Documentation Economique, Sociale et Juridique (CEDEJ), Cairo, Egypt RON J. LESTHAEGHE, Faculteit van de Economische, Sociale en Politieke Wetenschappen, Vrije Universiteit Brussel, Belgium PATRICK O. OHADIKE, Regional Institute for Population Studies (RIPS), Accra, Ghana ANNE R. PEBLEY, The RAND Corporation, Santa Monica, California DANIEL M. SALA-DIAKANDA, Institut de Formation et de Recherche Demographiques (IFORD), Yaounde, Cameroon Vl

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. COMMITTEE ON POPULATION SAMUEL H. PRESTON (Chair), Population Studies Center, University of Pennsylvania JOSE-LOIS BOBADILLA, World Bank, Washington, D.C. JOHN B. CASTERLINE, Department of Sociology, Brown University KENNETH H. HILL, Department of Population Dynamics, Johns Hopkins University DEAN T. JAMISON, School of Public Health, University of California, Los Angeles ANNE R. PEBLEY, The RAND Corporation, Santa Monica, California RONALD R. RINDFUSS, Department of Sociology, University of North Carolina, Chapel Hill T. PAUL SCHULTZ, Department of Economics, Yale University SUSAN C.M. SCRIMSHAW, School of Public Health, University of California, Los Angeles BETH J. SOLDO, Department of Demography, Georgetown University MARTA TIENDA, Population Research Center, University of Chicago BARBARA BOYLE TORREY, Population Reference Bureau, Washington, D.C. JAMES TRUSSELL, Office of Population Research, Princeton University AMY O. TSUI, Carolina Population Center, University of North Carolina, Chapel Hill LINDA G. MARTIN, Director BARNEY COHEN, Research Associate SUSAN M. COKE, Senior Project Assistant KAREN A. FOOTE, Research Associate DIANE L. GOLDMAN, Administrative Assistant* JAMES N. GRIBBLE, Program Officer JOAN MONTGOMERY HALFORD, Senior Project Assistant** CAROLE L. JOLLY, Program Officer DOMINIQUE MEEKERS, Research Associate* PAULA J. MELVILLE, Senior Project Assistant * through December 1991 ** through July 1992 . . V11

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Preface This report is one in a series of studies that have been carried out under the auspices of the Panel on the Population Dynamics of Sub-Saharan Af- rica of the National Research Council's Committee on Population. The Research Council has a long history of examining population issues in de- veloping countries. In 1971 it issued the report Rapid Population Growth: Consequences and Policy Implications. In 1977, the predecessor Commit- tee on Population and Demography began a major study of levels and trends of fertility and mortality in the developing world that resulted in 13 country reports and 6 reports on demographic methods. Then, in the early 1980s, it undertook a study of the determinants of fertility in the developing world, which resulted in 10 reports. In the mid- and late-1980s, the Committee on Population assessed the economic consequences of population growth and the health consequences of contraceptive use and controlled fertility, among many other activities. No publication on the demography of sub-Saharan Africa emerged from the early work of the committee, largely because of the paucity of data and the poor quality of what was available. However, censuses, ethnographic studies, and surveys of recent years, such as those under the auspices of the World Fertility Survey and the Demographic and Health Survey Programs, have made available data on the demography of sub-Saharan Africa. The data collection has no doubt been stimulated by the increasing interest of both scholars and policymakers in the demographic development of Africa and the relations between demographic change and socioeconomic develop IX

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x PREFACE meets. In response to this interest, the Committee on Population held a meeting in 1989 to ascertain the feasibility and desirability of a major study of the demography of Africa, and decided to set up a Panel on the Popula- tion Dynamics of Sub-Saharan Africa. The panel, which is chaired by Kenneth Hill and includes members from Africa, Europe, and the United States, met for the first time in Febru- ary 1990 in Washington, D.C. At that meeting the panel decided to set up six working groups, composed of its own members and other experts on the demography of Africa, to carry out specific studies. Four working groups focused on cross-national studies of substantive issues: the social dynamics of adolescent fertility, factors affecting contraceptive use, the effects on mortality of child survival and general health programs, and the demo- graphic effects of economic reversals. The two other working groups were charged with in-depth studies of Kenya and Senegal, with the objective of studying linkages between demographic variables and between those vari- ables and socioeconomic changes. The panel also decided to publish a volume of papers reviewing levels and trends of fertility, nuptiality, the proximate determinants of fertility, child mortality, adult mortality, internal migration, and international migration, as well as the demographic conse- quences of the AIDS epidemic. This report, one of the four cross-national studies, analyzes the factors affecting contraceptive use. The study was initiated because of interest in recent survey results that indicated increases in contraceptive use in several sub-Saharan African countries. Because of historically high fertility levels and low contraceptive use in the region, it was debated whether these chancres heralded a new era for Africa or were anomalies. This report examines the literature on the socioeconomic, social organi- zational, and family planning program factors that are related to contracep- tive use. Multivariate analysis is employed to assess the relative impor- tance of those factors that can be measured and for which data are available from surveys. In Chapter 7, the relative importance of contraceptive use versus postpartum practices in inhibiting fertility in Africa is assessed. As is the case for all of the panel's work, this report would not have been possible without the cooperation and assistance of the Demographic and Health Survey (DHS) Program of the Institute for Resource Develop- ment/Macro Systems. We are grateful to the DHS staff for responding to our inquiries and facilitating our early access to the survey data. We are also grateful to the organizations that provided financial support for the work of the panel: the Office of Population and the Africa Bureau of the Agency for International Development, the Andrew W. Mellon Foun- dation, the William and Flora Hewlett Foundation, and the Rockefeller Foundation. Besides providing funding, the representatives of these organizations were a

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PREFACE Xl source of information and advice in the development of the panel's overall work plan. This report results from the joint efforts of the working group members and staff, and represents a consensus of the members' views on the issues addressed. The Committee on Population and the Panel on the Population Dynamics of Sub-Saharan Africa appreciate the time and energy that all the working group members devoted to the study. The following people de- serve recognition for their special contributions: Mark Montgomery ana- lyzed the socioeconomic and social organizational factors affecting contra- ceptive use and wrote the first drafts of Chapters 3 and 4. He also developed the framework of the factors affecting contraceptive use (described in Chapter 1 and Appendix A), which guided the working group's research, and carried out the individual-level bivariate analysis of contraceptive use discussed in Chapter 2. Maria Wawer explored the development of family planning policies and programs, and their effect on contraceptive use. Her research is the basis for Chapter 5, which she first drafted. Ron Lesthaeghe performed the re- gional multivariate analysis of contraceptive use based on a data set devel- oped by Carole Jolly. Chapters 6 and 7 reflect this effort. Ron Lesthaeghe was also instrumental in documenting the historical context of contraceptive use in sub-Saharan Africa and graciously hosted the second of the three meetings of the working group in Brussels. Oleko Tambashe pulled to- gether the evidence on levels, trends, and differentials in contraceptive use to write, with Jane Bertrand, the first draft of Chapter 2. Evasius Bauni contributed to the sections on knowledge of contraceptive use. Both Oleko Tambashe and Evasius Bauni played important roles in promoting the work- ing group's understanding of the experiences of their respective countries. Jane Bertrand, as the working group's chair, was instrumental in direct- ing the research of the group during the last two years and wrote the first drafts of Chapters 1 and 8. She and Carole Jolly served as the principal editors and coordinators for the report. Linda Martin provided substantive comments on numerous drafts of the report, as well as participating in all the group's meetings and contributing substantially to the review process. Jay Gribble took care of innumerable details in the final drafting stages. As noted above, however, this report reflects the views of the working group as a whole, and considerable effort by all the members and staff has gone into its production. The working group was assisted in its efforts by several commissioned background papers. Lisa Brecker and Regina McNamara coauthored a pa- per on family planning programs in Africa. Therese Locoh wrote a paper on the socioeconomic context of contraceptive use. Maria Messina authored a paper on household decision making, reproductive roles, and local social

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. . Xll PREFACE organization as they affect contraceptive use and fertility. G. Verleye as- sisted in the regional analysis of contraceptive use. Special thanks are also due Susan Coke, Joan Montgomery Halford, Diane Goldman, and Paula Melville for providing superb administrative and logistical support to the working group, to Florence Poillon for her skillful editing of the report, and to Elaine McGarraugh for meticulous production assistance. Joan Montgomery Halford and Paulette Valliere Korazemo pro- vided excellent French to English translation of a draft chapter and a back- ground paper. Eugenia Grohman and Elaine McGarraugh were instrumental in guiding the report through the review and production processes. SAMUEL H. PRESTON, Chair Committee on Population

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Contents EXECUTIVE SUMMARY INTRODUCTION The Contraceptive Revolution in the Developing World, 5 Contraceptive Use in Sub-Saharan Africa, 6 Levels of Socioeconomic Organization Affecting Contraceptive Use, 12 Organization of Report, 18 2 LEVELS AND TRENDS IN CONTRACEPTIVE USE Sources of Data on Contraceptive Use, 19 Definition of Contraceptive Use, 20 Prevalence of Current Contraceptive Use in Selected Countries, 23 Other Indicators Related to Contraceptive Practice, 38 Results From Male Surveys, 48 Conclusion, 48 THE SOCIOECONOMIC CONTEXT Socioeconomic Differentials of Fertility, 54 Evidence on Changes in Child Mortality, 70 . . . x~' 1 s 19 52

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XIV CONTENTS Evidence on Changes in the Quantity-Quality Trade-Off, 72 Economic Stagnation and Adjustment: Effects on Fertility, 77 Conclusion, 83 4 THE HOUSEHOLD, KINSHIP, AND COMMUNITY CONTEXT 85 The High-Fertility Rationale: An Overview, 87 Lineage and Descent, 91 Kin Networks and Child Fostering, 98 The Conjugal Bond, 104 Prospects for Change, 1 15 Local Social Organization and the Diffusion of Family Planning, 122 Conclusion, 127 FAMILY PLANNING PROGRAMS AND POLICIES The African Context for Population and Family Planning Programs, 129 International and Regional Influences on Population Policy Development, 133 Historical Evolution of Family Planning Programs, 135 Program Development in Selected Countries, 140 Major Donors for Population Activities, 153 Lessons Learned from Programs and Projects, 158 Private Versus Public Service Delivery, Including Social Marketing, 165 The Impact of AIDS on Family Planning Program Activity, 168 Conclusion, 169 REGIONAL ANALYSIS OF CONTRACEPTIVE USE Female Education and Contraceptive Practice, 173 Multivariate Analysis of Modern Contraceptive Use, 179 CONTRIBUTION OF MODERN CONTRACEPTIVE USE RELATIVE TO POSTPARTUM PRACTICES TO FERTILITY DECLINE The Two-Phased Fertility Transition, 198 Contraception, Nonsusceptibility, and Fertility Decline, 205 The Uncertain Future, 209 Conclusion, 210 128 170 197

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CONTENTS 8 CONCLUSIONS Findings, 212 Research Gaps, 217 xv 212 APPENDIX A: ADAPTING THE EASTERLIN-CRIMMINS SYNTHESIS MODEL TO SUB-SAHARAN CONDITIONS 221 Demand for Births, 223 Supply of Births, 224 APPENDIX B: SAMPLE SIZES FOR THE WFS AND DHS REGIONAL FILES REFERENCES 230 233

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