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Population Reports. Prepared by: Vera M. Zlidar, Robert Gardner, Shea O. Rutstein, Leo Morris, Howard Goldberg, and Kiersten Johnson Series M, Number 17 Spring 2003. New Survey Findings: The Reproductive Revolution Continues. Related Materials Online:.

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    1. Population Reports Prepared by: Vera M. Zlidar, Robert Gardner, Shea O. Rutstein, Leo Morris, Howard Goldberg, and Kiersten Johnson Series M, Number 17 Spring 2003 New Survey Findings: The Reproductive Revolution Continues Related Materials Online: New Survey Findings: The Reproductive Revolution Continues : www.populationreports.org/m17/ Questions & Anwsers: www.populationreports.org/q&as/m17/ Quiz: www.populationreports.org/prquiz/m17/

    2. Which Surveys areCovered in this Report? • Since 1990, 120 surveys of women have taken place in 71 countries (part of the DHS & RHS programs). • Since 1990, 38 countries in developing regions were surveyed more than once, allowing the examination of trends. • Provide information on fertility levels, contraceptive use, fertility desires & other key reproductive health topics.

    3. Regions Where DHS and RHS Surveys are Conducted • Sub-Saharan Africa • Near East & North Africa • Asia • Latin America & Caribbean • Eastern Europe & Central Asia

    4. What Surveys Have Found • Fertility continues to decline. • Contraceptive use is rising. • Ideal family size is decreasing. • Unmet need has fallen. • Unmarried young women face longer years of sexual activity before marriage. • Maternal health often falls short. • Child survival and health have improved, but still far from meeting goals.

    5. Fertility Trends

    6. Current Total Fertility Rates by RegionAmong Women Ages 15-49 *Among 60 developing countries (excludes data from Eastern Europe & Central Asia).

    7. Fertility inSub-Saharan Africa • Fertility is high, but beginning to decline. • In 9 of 16 sub-Saharan African countries, fertility declined by more than 1% per year since 1990. • Projected total fertility rate (TFR) of 2.4 for 2045-2050. • Slow demographic transition due to: • Cultural preference for large families. • High rates of infant and child mortality. • Low levels of economic development. • Lack of government commitment to family planning programs in the past.

    8. Fertility Continuesto Decline • Fertility decline began in developing countries in the 1960s and 1970s, picked up speed in the 1980s, and continued through the 1990s. • TFR fell in almost all 38 developing countries with more than one survey since 1990. • Pace of decline varies widely among countries. • Rate of fertility decline appears to be slowing in many regions.

    9. Biological effects: More deaths to people of reproductive age Reductions in frequency of sex Increased levels of spontaneous abortions & stillbirths Increased amenorrhea Lower fecundity Behavioral effects: Delay in the onset of sex Curtailed extramarital relations Increased condom use Avoid sex entirely How HIV/AIDS CouldAffect Fertility Decline

    10. Fertility Rates Differby Women’s Ages • Age patterns of fertility vary among regions, countries & different groups within countries. • Generally peaks among women ages 20-24. • Falls first among youngest and oldest. • Pattern differs in sub-Saharan Africa: peak extends to age 29 in half of all surveyed countries and women over 40 contribute an average of 0.5 children to the TFR.

    11. In most developing countries surveyed since 1990, fertility is lower and contraceptive use is higher among women with more education. Women’s level of education tends to affect fertility levels at all ages. Education affects fertility via: Social and economic status Status within the household Age at marriage Family size desires Access to and use of family planning Education Affects Fertility and Contraceptive Use

    12. Contraceptive Use

    13. Contraceptive Use Growsin Developing Countries • Use of family planning methods rose by at least 10%: • In 31 of 38 developing countries among married women. • In 18 of 24 developing countries among unmarried women. *Weighted by population size.

    14. Developing Areas Developed Areas Worldwide 100 90 80 70 60 50 Percent Currently Using 40 30 20 10 0 Any Method Any Modern Method Any Traditional Methoda Type of Method Estimate of Contraceptive Use WorldwideAmong Married Women ages 15-49, 2000 Percentages are weighted by population size and use the most recent data from the DHS and RHS and, for countries without these surveys, data from the United Nations, the US Census Bureau’s International Database, and other nationally representative surveys. a Includes periodic abstinence and withdrawal.

    15. Contraceptive Use VariesWidely Among RegionsAmong Married Women Ages 15-49 Percentages are weighted by population size and use the most recent data from the DHS and RHS and, for countries without these surveys, data from the United Nations, the US Census Bureau’s International Database, and other nationally representative surveys.

    16. Fertility Levels Closely Correspondto Levels of Contraceptive Use

    17. Contraceptive Use is HigherAmong Unmarried, Sexually Active Women than Married Women • Sub-Saharan Africa: Use is at least twice as high on average among unmarried sexually active women than among married women, mostly due to higher levels of condom use. • In 14 of 17 countries in Latin America and Caribbean, use is equal to or higher than that of married women. • Differences are less than in sub-Saharan Africa because use among married women in this region is more widespread.

    18. Contraceptive Use Varies Among Groups of Women • Age and number of children • Contraceptive use peaks at ages 30-39. • Contraceptive use tends to rise with parity. • Women’s education • Better educated women are more likely to use contraception. • Rural or urban residence • Generally lower in rural areas than urban areas.

    19. Reasons for Not Intendingto Use Contraception Vary • Percentage who intend to use contraception varies from 41% in the Near East & North Africa to 57% in Latin America & Caribbean. • Main reasons for not intending to use: • Outside sub-Saharan Africa: At little risk of becoming pregnant. • Sub-Saharan Africa: Currently pregnant or want to have more children. • Other reasons for not intending to use: • Concerns with contraceptive side effects, religious or other opposition to family planning.

    20. Contraceptive Method Mix • Four most widely used methods among married women in surveyed developing countries in rank order: • Female sterilization • Oral contraceptives • Injectables • Intrauterine device • Together these methods account for almost 75% of total contraceptive use.

    21. Male Condom Use Varies • Among married women in developing countries, reliance on male condoms for family planning is rare. • Average of 3% of married women in 60 developing countries rely on condoms. • Levels have not changed much in recent years. • Unmarried sexually active women are more likely to report using condoms. • Levels at least 20% in 11 developing countries. • Since 1990, condom use rose an average of 7 percentage points.

    22. Few Women Use Other Modern Methods of Contraception • Vaginal method use averages <1% of total contraceptive use. • Male sterilization use generally less than 1%. • Implant use highest in Indonesia (6%) and Haiti (1%). • Female condom use <1%.

    23. Use of Traditional Family Planning Methods Varies Widely • Levels of use of traditional contraceptive methods are generally much lower than that of modern methods. • Periodic abstinence: Low levels of use overall, but most widely used in Bolivia (20% of married women). • Withdrawal: Variable use ranges from 18% average in Eastern Europe and Central Asia to 2% average in sub-Saharan Africa.

    24. Lactational Amenorrhea Method (LAM) is Used Frequently,but Often Incorrectly • Most breastfeeding women said they relied on breastfeeding to avoid pregnancy. • Ranges from 50% in Peru to 94% in Mali. • Studies show correct use of LAM is limited. • In 12 countries, few women met the LAM criteria, from 3% in Haiti to 20% in Mali. • 3 criteria must be met for correct use of LAM: • Fully or nearly fully breastfeeding • Less than six months postpartum • Not menstruating

    25. Other Factors Besides Contraceptive Use CanAffect Fertility Levels • Direct factors: Age at first marriage, induced abortion, postpartum insusceptibility, infertility • Indirect factors: Social, economic and cultural factors, family planning program effort • These factors help explain fertility levels and declines where access to and use of family planning is poor.

    26. Awareness and Availability of Contraception

    27. Awareness of Contraception is High, but Varies Among Countries • Awareness of contraception is nearly universal among married women in developing countries. • In 37 of 60 countries, at least 95% know of at least one contraceptive method. • Average number of methods known varies among countries. • Lowest: Average of 1.4 methods in Chad. • Highest: Average of 9 methods in Bangladesh, Colombia, Dominican Republic, Jordan and Peru.

    28. Most Married Women Approve of Family Planning • Sub-Saharan Africa: 74% • Near East and North Africa: 76% • Latin America and the Caribbean: 88% • In 27 of 50 countries, more than half of married women say that they approve of family planning and think that their husbands also approve.

    29. Mass Media is a Key Source of Family Planning Information • The most far-reaching medium varies among regions: • Radio: Sub-Saharan Africa • Television: In 20 of 32 other countries, especially in Eastern Europe and Central Asia • The reach of family planning messages broadcast through the mass media has grown since 1990.

    30. Knowledge of Family Planning Sources Varies Widely • Most women say they know where to obtain contraceptive methods. • In 9 of 11 countries outside sub-Saharan Africa, 90% of married women know where to obtain at least one modern method. • In sub-Saharan Africa, knowledge is more variable. • Large gap between awareness of a method & knowledge of its source in some countries. • In Burkina Faso, 63% of married women know of a modern method, but only 28% know of its source.

    31. Fertility Preferences

    32. Desired Family Size • Married women want an average of 4.7 children (among 50 developing countries surveyed since 1990). • Outside sub-Saharan Africa: Desired family size is 3.3 • Sub-Saharan Africa: Desired family size is 5.7

    33. Fertility Preferences are Changing in Many Developing Countries • Percent of married women who want to end childbearing rose at least 10% in 13 of 37 developing countries. • Half of such countries are in sub-Saharan Africa. • On average, desired family size fell about 0.2 children in 32 developing countries. • Changes in desired family size in the 1990s reflect a continued long-term trend of wanting smaller families.

    34. Married Women (Ages 15-49) Have About One Child MoreThan They Want, 1990-2001

    35. Percent with Unmet Needfor Family Planning Among Married Women Ages 15-49, 1990-2001

    36. Unmet Need forFamily Planning • 2000 estimates: 105 million married women and 8 million unmarried women worldwide have an unmet need for family planning. • Among 37 countries surveyed more than once since 1990, unmet need fell an average of 14%. • Percentage with unmet need has fallen since 1990, but the number of women with unmet need changed little because populations grew.

    37. Young Women

    38. Unmarried Women 20-24 More Likely Than 15-19-Year-Olds To Have Had Premarital Sex

    39. Levels of Premarital Sex Largely Unchanged • Levels of premarital sex among 15-19-year-old women remained about the same among 30 developing countries with more than one survey since 1990. • Among women ages 20-24: • Increased only slightly in 16 sub-Saharan African countries. • Increased about 8 percentage points during the 1990s in Latin America & Caribbean.

    40. Time Between Onset of Sex and Marriage Increasing • Sub-Saharan Africa: Average time is 1.7 years. • Increased by 3 months since 1990, largely because women are delaying marriage. • Latin America & Caribbean: Average time is 1.4 years. • Increased by 8 months since 1990, largely because women are starting sex younger. • Eastern Europe: Average time is 2-3 years.

    41. Young Adult Contraceptive Use is Increasing • Highest levels of contraceptive use: • Among unmarried sexually active women 20-24. • Lowest levels of contraceptive use: • Among adolescent married women 15-19. • Contraceptive use among unmarried women 15-19 increased by average of 5 percentage points in sub-Saharan Africa & by 21 points in Latin America & the Caribbean. • Greater condom use is responsible for most of the increase.

    42. Adolescent Childbearing • About 15 million births take place worldwide among women ages 15-19. • Among 50 developing countries, an average of 23% of adolescent women have given birth or are pregnant. • In most countries with multiple surveys since 1990, average levels of childbearing remain unchanged. • However, substantial declines have occurred in Ghana, Mozambique, and Uganda.

    43. Maternal andChild Health

    44. Maternal Health Practices Often Fall Short • Among women surveyed in developing countries: • One-fourth received no antenatal care from a skilled attendant during their most recent pregnancy within the past 5 years. • Over one-third did not obtain tetanus toxoid injections. • Nearly one-half had no skilled attendant at delivery. • Only a few countries have made substantial improvement in these indicators since 1990.

    45. Child Survival has Improved, but Still Far From the Goal • 30 of 56 countries achieved the World Summit goal for infant mortality. • 19 of 56 countries achieved the World Summit goal for child mortality. • Sub-Saharan Africa: Deaths to children under 5 have increased. • 1950s: 2.3 million/year • 1990s: 4.5 million/year

    46. Infant and Under-Five Mortality Rates Vary by Region, 1990-2001

    47. HIV/AIDS Influences Infant and Child Mortality Rates • In many countries child mortality rates are higher than they would be in the absence of AIDS. • Further reductions are unlikely as AIDS deaths overwhelm advances made against other causes of death. • 3.7 million children will die before age five in Africa between 1990 and 2015 (UN estimate).

    48. Breastfeeding PracticesHave Improved in Most Developing Countries • In 35 countries with more than one survey since 1990, level of exclusive breastfeeding among infants to 3 months of age increased an average of 10 percentage points. • Mainly because many mothers stopped introducing non-milk foods to children too early.

    49. Now Available...The New Survey Findings CD-ROM • Includes: • PDF files of all six Population Reports survey issues. • POPLINE abstracts of many of the most useful bibliographic items in these six issues. • Excel files of all tables and figures used in preparing the 2003 and 2004 Population Reports surveys issues. • PowerPoint presentations, “Question and Answer” compilations, and quizzes of the 2003 and 2004 Population Reports issues. • To order your copy, send your name and address to: • Orders@jhuccp.org, or • Orders Department (New Survey Findings CD-ROM), 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA

    50. Photo Credits • Slide 1: Uttara Bharath/CCP • Slide 5: CCP • Slide 12: El Salvador Ministerio de Salud Pública y Asistencia Social; Asociacion Demografica Salvadorena (ADS); Program for International Training in Health (INTRAH), PRIME Project;USAID; Instituto Salvadoreño del Seguro Social (ISSS) • Slide 26: H. Kakande/DISH II Project • Slide 31: Andrea Fisch • Slide 37: Harvey Nelson • Slide 43: Harvey Nelson