The Fertility Transition in Sub-Saharan Africa into the 21st Century
Ron Lesthaeghe
Emeritus Professor of Demography, Vrije Universiteit Brussels
([email protected])
Population Studies Center Research Report 14-823
July 2014
This research was conducted during a visiting period at the Centre d'Estudis Demogràfics of the
Universitat Autònoma de Barcelona (UAB).
Fertility Transition in Sub-Saharan Africa into the 21st Century
2
1. Introduction
This paper aims at giving a succinct overview of the most recent data on fertility and contraception
in Sub-Sahara Africa, mostly using the reported results of the Demographic and Health surveys
(DHS) i. In doing so, we have tried to highlight features that are not only striking characteristics for
the situation on that continent but that also provide points of interest for policy interventions. First,
we shall briefly try to sketch the current state of affairs with respect to total fertility and contraceptive
use. Then, we shall address the feature of the “African two stage transition”. We continue with the
issues related to unmet need, and proceed with a four way classification of non-users of
contraception who also do not intend to use it later (not needed, not ready, not willing, not able).
2. Overall fertility trends
Until the turn of the century the fertility transition in Sub-Saharan Africa has been either very
hesitating or stalling after a brief start (Bongaarts 2005, Shapiro and Gebreselassie 2007, Garenne
2008). The overall outcome by 2010 is that, according to the latest Demographic and Health surveys
(DHS), there are only five countries with a total fertility rate (TFR) of less than 4 children. Aside
from Cape Verde (2.9), they are all in Southern Africa: the Republic of South Africa (2.1), Lesotho
(3.3), Namibia (3.6) and Swaziland (3.8). At the other end of the distribution, the fertility transition
has barely started in a number of countries, which all still have TFR’s in excess of 6 children: Niger
(7.1), Mali (6.6), Chad (6.3) and Burkina Faso (6.2) in West Africa, Uganda (6.7) and Burundi (6.4)
in East Africa, and the D.R. Congo (6.3) and Zambia (6.2) in Central Africa. ii Moreover many
countries, particularly in West and Central Africa even experienced a period of rising fertility during
the last decades of the 20th Century (see Garenne 2008), often caused by declining infertility levels
(Frank 1983, Tabutin et al. 1983, Larsen 1989, 2001) and by the eroding of traditional birth-spacing
practices (long periods of breastfeeding and postpartum abstinence) that were not compensated by
rising use of contraception (Romaniuk 1980, Lesthaeghe and Page 1981, Caldwell and Caldwell
1981, Lesthaeghe 1989, Lesthaeghe and Jolly, 1995).
After the turn of the century, it seems that the fertility transition is picking up momentum again in a
select number of countries. Judging from the TFR-levels as measured in the DHS surveys iii, the
downward trend is again in evidence in Liberia, Senegal, Ghana, Uganda, Namibia, Madagascar and
especially in Rwanda (see figures 1 and 2). It should be noted, however, that all results reported here
stem from surveys, and that, despite the care taken to insure optimal quality, numerous biases can
affect survey results. Consequently, apparent trends need to be interpreted with caution.
Fertility Transition in Sub-Saharan Africa into the 21st Century
3
Figure 1: Total fertility rates as recorded by the DHS Surveys, 1986-2011. West and Central Africa
8
7.5
7
Benin
6.5
Burk
Faso
Camero
on
Ivory
Coast
Chad
6
5.5
5
4.5
4
3.5
3
1980
1985
1990
1995
2000
2005
2010
2015
Data source : C. Westoff 2010, and DHS reports after 2008
Figure 2. Total fertility rates as recorded by the DHS-surveys, 1986-2011. East and Southern Africa
8
Ethiopia
7
Kenya
Madagascar
Malawi
6
Mozambiqu
Namibia
5
Rwanda
S. Africa
Tanzania
4
Uganda
Zambia
3
Zimbabwe
Burundi
Lesotho
2
1986198819901992199419961998200020022004200620082010
Data source: C. Westoff 2010 and DHS country reports after 2008.
Fertility Transition in Sub-Saharan Africa into the 21st Century
4
Within all countries, however, marked fertility differentials have emerged between rural and urban
areas and between social classes or levels of education. This undoubtedly reflects differences on both
the demand and supply sides of contraception. Figures 3 and 4 provide an idea of the orders of
magnitude involved in the TFR differentials between the capitals, other urban and rural areas.
Figure 3. Urban and rural total fertility rates: West and Central Africa
8
7
6
5
4
3
2
Capital
Urban
Rural
Total
1
0
Source: Latest DHS survey in the 21st Century
The differences in TFR between the capital cities and the rural areas are commonly of the order of 2
to 3 children, even in countries which, as a whole, have barely started the fertility transition and have
national TFR levels above 6 children. In the D.R. Congo, for instance, the TFR of Kinshasa is
estimated to be in the vicinity of 3.2 children, whereas the rural areas that were sampled had TFRs
close to 7 children. In fact, in a dozen western and central African countries and in four eastern
African ones, rural TFRs are in excess of 6 children according to the latest 21st Century DHS
estimate. The rural-urban gap only diminishes to less than two children in half a dozen eastern and
Southern African countries, who mostly have the lowest overall TFRs of the continent. Hence, the
Fertility Transition in Sub-Saharan Africa into the 21st Century
5
rural-urban gap remains wide and the national levels stay high until contraceptive demand and supply
are reaching the rural areas as well. This has definitely not occurred in a sufficient way so far, and the
reduction of fertility in rural areas needs to be considered as a top priority.
Figure 4. Urban and rural total fertility rates: East and Southern Africa
8
7
6
5
4
Capital
3
Urban
2
Rural
1
Total
S. Africa 03
Lesotho 09
Namibia 07
Swazil. 07
Zimbabw 11
Rwanda 10
Kenya 09
Madagas 09
Ethiopia 11
Eritrea 02
Tanzania 10
Mozamb 03
Malawi 10
Zambia 07
Burundi 10
Uganda 06
0
Source: Latest DHS survey in the 21st Century
3. Contraceptive use
Limiting ourselves to contraceptive use as measured after the year 1998, the overall impression is
that in the majority of countries only slow progress has been made. Compared to other developing
countries, current use of modern methods of contraception is still low to very low among women 1549 in a sexual union. iv In the period 1998-2005, 12 out of 23 countries with DHS surveys recorded
less than 10 percent of current users of modern methods. Only 9 had more than 20 percent, with
maxima in Namibia (43), Zimbabwe (50) and South Africa (60). In the period 2006 to 2011, the tail
with less than 10 percent comprised 5 countries among 23 countries sampled (Niger, Benin, Sierra
Leone, Guinea, D.R. Congo), and 11 made it above the 20 percent threshold, with maxima above 40
percent in Malawi (42), Rwanda (45), Lesotho (46), Swaziland (48), Namibia (53) and Zimbabwe
(57). Without any doubt, several other West and Central African countries not sampled after 1998
have low levels of usage as well (e.g. Chad, Central African Republic).
Fertility Transition in Sub-Saharan Africa into the 21st Century
6
To give an overview of the disparities by method and by country, we have collapsed the set of
methods into 8 categories, and in each of these, the top 10 countries with more than 1 percent of
current users among women 15-49 in a union are being reported and ranked. This is done in table 1.
In categories with fewer countries, not even 10 cases are recorded exceeding the 1 percent level of
usage of the specified method. The results also pertain to countries with at least one DHS survey
after the turn of the Century.
Table 1: Top 10 countries with more than 1% current users (women 15-49 currently in a union), by method
Male condom
Rhythm and % of users
with correct knowledge
Withdrawal
Namibia
10.6
Congo Braz. 10.4
Lesotho
9.4
Cape Verde 6.1
Zambia
4.7
Congo DR
3.4
Zimbabwe 3.1
Rwanda
2.9
Nigeria
2.4
Ghana
2.4
Congo Braz. 24.9 1.1*
Congo DR
11.0 61.7
Madagascar 9.7 82.5
Benin
6.9 59.4
Ghana
4.7 69.6
Rwanda
2.9 37.8
Uganda
2.8 30.8
Nigeria
2.1 39.3
Burundi
1.9 na
Cape Verde 1.9 22.6
Zambia
Benin
Rwanda
Congo Braz.
Congo DR
Burundi
Cape Verde
Uganda
Nigeria
Ghana
Prolonged lactation
4.8
3.6
3.5
3.5
3.1
2.8
2.2
2.1
2.0
1.4
Niger
4.7
Guinea C. 1.7
Nigeria
1.6
Madagascar 1.0
* Value reported in the Congo Brazzaville DHS country report. Not a printing error, since the text
comments on this extremely low figure.
Latest DHS in 21st Century.
Fertility Transition in Sub-Saharan Africa into the 21st Century
7
The first feature emerging from the data in table 1 is the predilection for hormonal contraception.
There are several reasons for this. Firstly, these methods (pills, injectables, implants) are most suited
as spacing methods. Such methods are indeed appropriate within the African context in which
marked birth-spacing patterns have been stressed traditionally, either through prolonged lactation
alone or in combination with long periods of postpartum abstinence. Secondly, Africa was late in
adopting contraception and could benefit from the latest technology such as injectables and implants.
And thirdly, the method mix reflects also the concentration of use of efficient methods in urban
environments with much easier access to them.
The data in table 1 also reveal marked national idiosyncrasies, which are probably more a reflection
of supply characteristics and Family Planning (FP) program specificities than of the preference
structure underlying demand. Zimbabwe, for instance, is way ahead of all other countries with
respect to current pill use, whereas 7 Eastern and Southern African countries are close to or already
beyond 20 percent usage of injectables and implants. In fact, the recent upsurge in contraceptive use
in Rwanda is largely due to the introduction of the latter methods v. This illustrates that a vigorous FP
program using the most adequate methods can produce a major breakthrough, provided of course that
the supply of such methods remains assured. The latter caveat is of major relevance in Africa given
the economic and political fragility of most countries.
The data for female sterilization and IUDs in table 1 produce two more striking results. Firstly, it is
commonly argued that stopping methods, and particularly those based on sterilization, are almost
taboo in Sub-Saharan Africa. Yet, when available, 10 percent of women in a union can take
advantage of it, as documented by the figures for the Cape Verde islands, Namibia and Malawi.
Female sterilization figures could easily be increased to similar levels in most other Southern and
eastern African countries. The IUD usage, by contrast is universally low. In fact, the maximum usage
figure is for Burundi with 2.7 percent in 2010. This is surprising since IUDs are inexpensive, easily
inserted and removed, do not require frequent visits to health facilities, and are therefore ideally
suited for usage in more remote areas. Again, it may very well be that IUDs were not preferred by FP
providers because of the availability of more modern hormonal alternatives. But, given the marked
urban-rural imbalance in service provision, the low use of IUDs could further accentuate the urbanrural contrast with respect to fertility levels noted in figures 3 and 4. In other words, if services are to
be extended to more remote areas and to poorer populations, the IUDs could again be valuable tools
in stimulating the taking off of a badly needed rural fertility transition.
Fertility Transition in Sub-Saharan Africa into the 21st Century
8
Also the data on current use of the male condom show low usage with about a maximum of 10
percent reported by women 15-49 in a union in Namibia, Congo Brazzaville and Lesotho. The high
prevalence of HIV in Southern Africa may explain the higher figures for Namibia and Lesotho, but it
equally raises the question why other high HIV countries score well below the 5 percent level.
The next column in table 1 not only contains the percentages of current use of the rhythm method,
but also the percentages of users with the correct knowledge of the fecund period. The two countries
at the top of the list are the two Congo’s which underwent a strong Catholic influence during their
colonization, and which, in addition, hardly experience any modernization of contraceptive use after
their independence half a century ago. But even more striking is that in virtually all countries the
correct knowledge is lacking for such high percentages of users. In Congo Brazzaville, virtually
everybody gave the wrong answer to the question about the appropriate period of abstinence vi. Only
in Madagascar could slightly more than two thirds of users give a correct answer. The overall
outcome is a fiasco for the advocates of the rhythm method, and even more so for the women advised
to using it.
Withdrawal and prolonged lactation both score less than 5 percent users in African countries, and
there is a clear overrepresentation of populations with an overall low contraceptive prevalence. This
once more highlights the state of neglect of Family Planning in these countries.
On the whole, even taking levels of development or literacy into account, most African countries
score low on contraceptive use. Moreover, in countries with the lowest overall levels, the method
mix is the most inefficient. Much of Central and West Africa falls into this category. And among
these countries there are very populous ones such as Nigeria, the D.R. Congo, the whole of the
Guinea Coast from Senegal to the Benin, and the entire Sahel. Only Ghana has continued to be a
noteworthy exception in the region.
4. The African “two-phase fertility transition”
Already during the 1970s and 1980s it had become evident that a two phase transition was in the
making in much of Sub-Saharan Africa. Such a fertility transition is characterized by an initial
fertility increase and only a later fertility decline (Lesthaeghe et al. 1981, Jolly and Lesthaeghe
1993). The mechanism is as follows: the initial effects of rising schooling levels and of rapid
urbanization are a gradual erosion of two props of the traditional African birth-spacing pattern,
Fertility Transition in Sub-Saharan Africa into the 21st Century
9
namely long lactation and a concomitant postpartum taboo on sexual intercourse. During that first
phase, this fertility increasing effect of shortened postpartum non-susceptibility is not yet corrected
by a sufficient increase in contraceptive use-effectiveness, and a marital fertility bulge comes into
existence. Only during the second phase is there a slowing down of the erosion of postpartum nonsusceptibility and also a further and accelerating adoption of contraception, so that, in the balance,
marital fertility can start a decisive downward transition. Another variant produced by the same
mechanism is that contraceptive use-effectiveness increases without any noticeable fertility decline.
In such instances, the downward effect of contraception on fertility is neutralized by the upward
effect of earlier weaning and an earlier resumption of sexual intercourse. Hence, in both variants,
forces of structural modernization (e.g. education, urbanization) have a double and opposite effect
via two different intermediate fertility variables (i.e. postpartum non-susceptibility and contraceptive
use-effectiveness), and depending on the elasticities between each of these and the different forces of
structural social change, more intricate patterns of fertility transitions have emerged.
As with the earlier analyses of the respective effects of the various “intermediate fertility variables”,
use can still be made of the Bongaarts’ model and its operationalization (Bongaarts 1976, 1981,
Bongaarts and Potter 1983). In what follows, we shall use the index of postpartum non-susceptibility
Ci which captures the joint effects of lactational amenorrhea and postpartum abstinence, and of the
index of contraception Cc which also takes the effectiveness of the various methods into account. vii
In the Bongaarts model both Ci and Cc are fractions, and these are multipliers to be applied to the
Total Fecundity Rate (TF) in order to get to the Total Natural Fertility Rate (TNFR) first and to the
Total Marital Fertility Rate subsequently (TMFR):
TNFR= TF.Ci
TMFR=TNFR.Cc
Or, TMFR=TF.Ci.Cc
The product Ci.Cc gives the joint fertility reducing effect of both intermediate fertility variables
combined. In table 2 we calculated for each country the value of Ci.Cc at two dates. If that product
increases, then the joint fertility reducing effect has diminished over time. The cause of such an
outcome is typically a further shortening of breastfeeding and abstinence between the two dates.
Another way of bringing this out is to calculate the value of Cc* at time 2 that would be needed to at
least maintain the value of Ci.Cc at time 1. For instance, in table 1 Burkina Faso had a combined
Fertility Transition in Sub-Saharan Africa into the 21st Century
10
value of Ci.Cc of 0.40 in 1993, which means that the TMFR was reduced to 40 percent of the TF. In
2003 that combined value was 0.45, which implies a weaker joined fertility reducing effect than
before. Given the Ci-value in 2003 of 0.52, Cc had to diminish to 0.77 in order to maintain the status
quo with respect to the 1993 level of Ci.Cc. Hence, Cc* = Ci.Cc (t=1)/Ci (t=2) or in Burkina Faso
0.40/0.52=0.77. The actual value of Cc in 2003 in Burkina Faso was 0.87 which means that
improvements in contraceptive use effectiveness fell substantially short from neutralizing the fertility
increasing effect of less breastfeeding and shorter postpartum abstinence. Burkina Faso is therefore
still a country in phase 1.
Table 2: The “two phase transition”: Counteracting effects of declining durations of postpartum
non-susceptibility and increasing use-effectiveness of contraception
A. Countries with a shortfall of contraception or just breaking even ( Cc (t=2) > or = Cc*)
Country
Years
Median
compared duration
(DHS)
postpartum
Nonsusceptible
period
(nsp)(mths)
Bongaarts
Index
fertility
reducing
effect of
postpartum
nsp
Ci
Bongaarts
Index
fertility
reducing
effect of
contraception
Cc
Overall
Effect
Pp nsp and
contraception
Ci.Cc
Cc required
for
neutralizing
decline in
length nsp
Cc*
Family
Planning Effort
Score
(FPES)
Burk. Faso
1993
2003
22.2
19.9
.49
.52
.82
.87
.40
.45
.77
46
46
Rwanda
1992
2005
17.1
15.3
.56
.59
.81
.86
.45
.51
.76
43
36
Benin
1996
2006
18.9
14.4
.53
.61
.86
.84
.46
.51
.75
30
35
Senegal
1986
2005
16.2
12.6
.58
.64
.92
.89
.53
.57
.83
51
46
Cameroon
1991
2004
16.0
13.7
.57
.62
.85
.76
.48
.47
.77
36
41
Similar calculations are given in table 2 for all the countries for which we had two points of
comparison, with the most recent one located in the 21st Century. In this fashion we can update our
earlier work on the “two phase transition”. The data are all taken from the DHS surveys and are
reported in Johnson et al. (2011) or calculated by ourselves on the basis of the DHS values for the
median duration of the overall non-susceptible period. viii
Fertility Transition in Sub-Saharan Africa into the 21st Century
11
B. Countries with net gains in fertility reduction through contraception ( Cc (t=2) < Cc* )
Country
Years
Me nsp Ci
Compared
Cc
Ci.Cc
Cc*
FPES
Ghana
1988
2008
14.0
12.4
.62
.64
.88
.79
.55
.51
.86
53
46
Tanzania
1991-92
2004-05
15.6
13.0
.59
.63
.90
.76
.53
.48
.84
42
45
Kenya
1989
2009
11.1
10.3
.68
.69
.76
.57
.52
.39
.75
56
49
Zambia
1992
2007
14.1
12.5
.61
.65
.87
.64
.53
.42
.82
40
45
Malawi
1992
2004
(13,7)
12.9
.62
.63
.88
.68
.55
.43
.87
44
48
Zimbabwe
1988
2005-06
14.1
15.6
.61
.59
.62
.44
.38
.26
.64
49
60
Madagascar 1992
2008-09
12.0
10.7
.66
.68
.85
.60
.56
.41
.82
34
64
Namibia
12.8
13.1
.64
.63
.73
.49
.47
.31
.75
40
45
1992
2006-07
Data Source: K. Johnson, N. Abderrahim, S. Rutstein, 2011, and own calculations of Ci.
Malawi value of nsp in parentheses is reversely calculated on the basis of the Ci value reported by
Johnson et al., 2011.
In part A of table 1 we find countries for which Cc* is smaller or about equal to the most recent value
of Cc. These are countries where effects of further reductions in breastfeeding and postpartum
abstinence during the given period were not neutralized by better contraception, and are therefore
still in that first phase of the transition. In Burkina Faso and Rwanda (till 2005) there was even a
weakening of the effect of contraception (rising values of Cc) in addition to declines in lengths of
postpartum non-susceptibility. In Benin and Senegal, the improvements in contraceptive useeffectiveness were too modest to neutralize the effect of shortened postpartum non-susceptibility, and
in Cameroon there was just a near perfect equilibrium between the two opposing forces (Cc*= 0.77
and Cc 2004 = 0.76). However, it should be noted that the DHS recorded a spectacular increase in
contraceptive use-effectiveness in Rwanda after 2005, so that this country has now definitely made it
to the second phase of the transition, along with the countries reported in panel B of table 1.
Fertility Transition in Sub-Saharan Africa into the 21st Century
12
The countries for which the declining fractions of Cc could compensate for the increasing ones of Ci
are all Eastern and Southern African countries, which have now made it to phase two of the
transition. In several of them (e.g. Namibia and Zimbabwe) the erosion of breastfeeding may have
stopped and postpartum abstinence was already at a low duration to start with, so that the effect of
improving contraception is now fully converted into a net fertility decline. In Ghana the reduction in
Ci.Cc over two decades is still modest, and this is at least a partial explanation for earlier stalling
fertility in that country. The change in Tanzania over one decade is in the right direction as well, but
still modest in comparison with several other eastern and Southern African countries. In the latter
clear progress has been made along the path of the second phase, and in these cases one can indeed
argue that all gains in contraceptive use-effectiveness are almost completely translated into net
marital fertility reductions.
5. Unmet need and reasons for non-use
The notion of unmet need refers to the percentage of women 15-49 in a sexual union who are not
using a method of contraception but who want either to delay further childbearing for at least two
years (unmet need for spacing) or who want to stop altogether (unmet need stopping)(Khan et al.
2007). In most Asian and Latin American countries, total unmet need has typically dropped below 20
percent, and in several instances even below 10 percent. However, these countries are in the more
decisive phase of their demographic transition when contraceptive use is catching up with declining
desired family size and equally declining unwanted or unplanned fertility. In Sub-Saharan Africa,
however, unmet need can be low at both extremes: it is either low because the desire for children is
still very high and the need for contraception low, or, conversely, because rising contraceptive use is
catching up with declining desired fertility. Obviously, only in the latter instance are Sub-Saharan
countries falling in a similar category as their Asian or Latin American counterparts.
Examples of low unmet need due to a high demand for children are Niger in 2006 (total unmet need
= 16), Congo Brazzaville in 2005 (16), Nigeria in 2008 (20) or Guinea in 2008 (21). At a first glance
these countries with such fairly low levels would be statistically classified together with the much
further advanced Asian of Latin American countries. Obviously, this would be an erroneous decision.
By contrast, examples of countries which have similar low levels of unmet need, but in tandem with
significantly higher usage levels of contraception, are typically located in Southern Africa : the
Fertility Transition in Sub-Saharan Africa into the 21st Century
13
Republic of South Africa in 2003 (14), Swaziland in 2006/07 (14), Namibia in 2006/07 (7), and
Zimbabwe in 2010 (13)(Kahn et al. 2007: p. 48 for data up to 2006; Rutstein 2011: pp. 33-35 and
DHS country reports for later dates).
In between these extreme types with low levels are cases with levels well in excess of 20 percent of
unmet need. These higher levels are symptomatic of situations where desired fertility sizes or spacing
intervals are diminishing, but in an insufficiently responsive context with respect to the supply of
contraception. We shall refer to this as a structural supply lag. High levels of unmet need reaching
30 percent or more can then be produced as an indicator of a starting fertility transition in such a
structural lag context. Examples are: Uganda in 2006 (41), Ghana in 2008 (36), Liberia in 2007 (36),
Mali in 2006 (31), Senegal in 2010 (30), and Benin in 2006 (30) (ibidem).
There are also examples of both major increases and major reductions of total unmet need. Uganda is
the example of the former: unmet need rose steadily from 27 percent in 1988 to 29 in 1995, to 35 in
2000 and to a record high of 41 in 2006. Uganda’s neighbor, Rwanda, is the counterexample (cf.
Westoff 2012). This very densely populated country had similarly high levels to start with: 39 in
1992, 36 in 2001, and still 38 in 2005. However, the vigorous Family Planning effort after 2005
reduced the level of unmet need to just 19, so that Rwanda now joins the Southern African group
with much smaller structural supply lags. Nothing of the sort happened in Rwanda’s neighbor
Burundi, which is almost Rwanda’s twin in terms of ethnic composition and socio-economic
structure. This clearly illustrates that the supply side of contraception is of major importance as well.
When it comes to the distinction between unmet need for spacing and for stopping respectively, then
there is a major contrast between Sub-Saharan African and the other developing countries. As is well
known, African countries have a strong birth-spacing tradition, and this is also reflected in the
preponderance of unmet need for spacing over stopping. However, there is again a clear pattern
exhibiting a shift in favor of stopping as the use of modern methods of contraception increases. This
is depicted in figure 5 in which a scatterplot is given for the difference in percentage points of unmet
need for spacing over that for limiting fertility on the vertical axis and the use of modern
contraception, equally for women 15-49 in a sexual union.
Fertility Transition in Sub-Saharan Africa into the 21st Century
14
Figure 5: Relationship between (Y) the difference in percentages of non-users with an unmet need for
spacing and an unmet need for stopping, and (X) the percentage of use of a modern contraceptive method
Percentage points difference
UN spacing minus UN stopping
20
15
10
5
0
-5
-10
0
20
40
60
80
% current users
modern method
contraception
Source: S. Kahn et al. 2007, and latest DHS data for Sub-Saharan African countries.
Countries with a usage of modern contraception below 20 percent essentially exhibit a strong surplus
of unmet need for spacing purposes comprised between 5 and 16 percentage points. Those with a use
of modern contraception between 20 and 40 percent, have a surplus of 0 to 8 percent, and those with
more than 40 percent of modern contraception use, that surplus declines to merely 3 percentage
points, or changes into a modest surplus of an unmet need for stopping. Also over time (not shown
here) countries with large increases in usage of modern contraception (e.g. Rwanda, Malawi, Kenya)
there is a clear shift away from the surplus of unmet need for spacing purposes. This suggests that
indeed at the onset of the fertility transition the unmet need is mainly for contraception suited for
spacing purposes, but also that, as the transition advances, that the unmet need for limiting fertility
should be addressed as well, and probably more so than in the past. In other words, the proverbial
focus on spacing in Sub-Saharan Africa should not be turned into a self-fulfilling prophecy, with
contraception suited for stopping (sterilization, IUDs) being neglected. In this context, we refer back
to our earlier point about the neglect of the use of IUDs in virtually all of Sub-Saharan Africa.
Fertility Transition in Sub-Saharan Africa into the 21st Century
15
For the examination of the reasons for non-use of contraception, we make use of our earlier work
(Lesthaeghe and Vanderhoeft 2001) where a distinction was made in non-use because of a lack of
interest (“not ready”), because of social or religious pressures or because of fears for health (“not
willing”) or because of a lack of access or of resources (“not able”). In what follows, a similar
typology is attempted on the basis of a reclassification of the original alternatives used in a
standardized way by all DHS-surveys. An overview of the classification scheme is given in figure 6.
Figure 6: Reasons for non-use of contraception (nu ni) among women 15-49 currently in a union
A. % nu ni because of sterilization, infecundity, infrequent sex No Need
B. All other nu ni, i.e., fecund and exposed, but
B1.
B2.
B3.
B4.
B5.
% wants as many children as possible Not Ready
% opposed to contraception (self, husband, other, religion) Not Willing 1
% health reasons & fears, inconvenient use Not Willing 2
% no knowledge, no access, too expensive Not Able
% other, unknown, missing
In the DHS surveys women currently in a union and not using contraception are also asked why they
are not using it and about their intensions for future use. In what follows, we have taken such women
who stated no current use (nu) and no intention for later use (ni). In a first step we then identified all
women who apparently have no need to adopt contraception because of sterilization, infecundity or
infrequent sexual relations (category A). The remaining women (B) were further classified depending
on the reasons given for not using and not intending to use (categories B.1 through B.5). These were:
(B.1) Wanting as many children as possible, and hence this is the not ready category;
(B.2) Opposed to contraception, either the respondent herself or her husband or others, for social
or ideological reasons. This is the not willing type 1 category
(B.3) Opposed to contraception because of fears for side effects, for other health reasons, or
because of inconvenience of use. This is the not willing type 2 category.
(B.4) No use and no intention to use because of a lack of knowledge about contraception, a lack
of access to it, or lack of ability to pay for it. This is the not able category.
(B.5) All others that were unspecified, plus the unknowns and missing answers.
The results for the latest DHS survey are given in the subsections of table 3. Also note that the
denominator for the five B categories are the nu ni respondents without those in category A – that is,
the denominator for the B categories is the subset of fecund and exposed women only.
Fertility Transition in Sub-Saharan Africa into the 21st Century
16
Table 3: Percentage of women 15-49 currently in a union not using contraception and not intending to
(nu ni). Overall percentage and percentage by reason (no need, not ready, not willing, not able) in the
respective high incidence countries
Denominator: Women 15-49 in
union
West & Central Africa (N=12)
East & Southern Africa
(N=11)
% Not using and not intending (nu
ni). Countries with 40% or more.
Senegal 2005
Niger 06
Guinea C. 05
Mali 06
Nigeria 08
Sierra Leone 08
Liberia 07
Cameroon 04
Ghana 08
Congo Brazza 05
Benin 05
(11/12)*
Mozambique 2003 48%
Ethiopia 05
44
Kenya 05
40
(3/11)
Denominator: Women 15-49 in
union.
West and Central Africa
N=12
East and Southern Africa
N=11
Pct of nu ni because of sterilization,
infecundity, or infrequent sex
( = “no need” )
Category A in chart.
Countries with 30% or more
Congo Brazza 05
Burkina Faso 03
Benin 05
3/12
Swaziland 06-07
Zimbabwe 05-06
Zambia 07
Namibia 06-07
Rwanda 05
(but Rwanda 07-08
Malawi 07
6/11
Denominator: Women 15-49 in
union, nu ni for reasons other than
sterilization, infecundity or
infrequent sex.
West and Central Africa
N=12
East and Southern Africa
N=11
% wants as many children as
possible or opposed to
contraception (self, husband, other,
religion)
(Not Ready + Not Willing type 1 = B1
+ B2 in chart)
Countries with 50 % or more.
Guinea C. 05
Cameroon 04
Senegal 05
Nigeria 08
Mali 06
Niger 06
Sierra Leone 08
Congo Brazza 05
Burkina Faso 07
9/12
Mozambique 03
Ethiopia 05
2/11
66%
63
58
55
55
48
48
46
46
41
40
42%
33
32
81%
73
66
64
62
61
58
57
52
51%
48
44
35
34
67 !)
30
81%
51
Fertility Transition in Sub-Saharan Africa into the 21st Century
% for reasons of health, fears about
side effects, and use contraception
or method inconvenient.
Not willing type 2
(Category B3 in chart)
Countries with 30% or more.
Ghana 08
Liberia 07
Benin 05
Congo Brazza
4/12
% no knowledge, no access, too
expensive
NOT ABLE
(Category B4 in chart)
Countries with 10 % or more
Niger 06
Mali 06
Liberia 07
Burkina Faso 03
Nigeria 08
5/12
% Other reasons, don’t know,
missing.
(Category B5 in chart)
Countries with 10% or more
Burkina Faso 03
1/12
53
41
37
31
17
Malawi 07
Kenya 08-09
Swaziland 06-07
Zambia 07
Lesotho 04
Zimbabwe 05-06
Tanzania 04-05
Rwanda 07-08
(Rwanda 05
Namibia 06-07
9/11
54
49
48
47
47
45
38
38
33)
36
19
15
15
14
10
Ethiopia 05
1/11
14
12
Namibia 06-07
Ethiopia 05
Rwanda 05
(Rwanda 07-08
Zambia 07
Swaziland 06-07
Zimbabwe 05-06
6/11
24
18
16
16)
12
12
10
Source: R. Lesthaeghe. Raw data : DHS country reports. *The only missing West African country here is
Burkina Faso 2007 with 29 %, but with a large number of missing responses (12%).
The first panel of table 3 contains the overall percentages of women 15-49 in a union who are nonusers and who do not intend any use either for the high incidence countries with more than 40
percent. In this respect there is a major concentration of West and Central African countries. In fact
of the 12 countries in that region for which we have recent information no less than 11 have more
than 40 % non-use and no intension (overall nuni) . The 12th country is Burkina Faso, and it is only
an exception because of the higher proportion of missing responses. By contrast, only three of the 11
East and Southern African countries have more than 40 % nuni respondents: Ethiopia, Kenya and
Mozambique. This highlights once more the cleavage that has emerged between the two parts of
Africa during the last 2 or 3 decades.
Fertility Transition in Sub-Saharan Africa into the 21st Century
18
The second panel of table 3 contains the high incidence cases of category A in the chart, i.e. the
percentage who has no need for contraception for biological reasons or because of infrequent sex.
Here, high incidence is defined as 30% of the nuni respondents. Only three West and Central
African countries out of the 12 have figures above 30%, but the DHS reports many more Eastern and
Southern African countries as having a high or even higher incidence in the category “no need”. For
instance, the figures exceed half of the nuni respondents in both Swaziland 2006-07 and Rwanda
2007-08.
The third panel of table 3 contains the fecund and exposed nuni respondents ( i.e. without those in
category Ain the denominator) that are not ready and are not willing for social or ideological reasons
(B.1 + B.2), and high incidence in this regard is defined as 50 percent. The majority of all such nuni
respondents fall in these two categories in 11 of the 23 countries, with again a clear
overrepresentation of West and Central African ones (9 of the 12 countries). In East Africa, only
Ethiopia and especially Mozambique have such high levels of opposition to contraception.
The fourth panel of table 3 gives the category of “not willing” but for personal reasons dealing with
health related fears and inconvenience of use (B.3). This is a very distinct type of motivation
compared to the previous two which capture the persistence of unchecked fertility and the social and
ideological barriers to contraceptive use. In contrast to panel 3, panel 4, with 30 percent or more of
“not willing” for personal health reasons, contains the majority of Eastern and Southern African
countries and only 4 West and Central African ones. In fact, among the latter, Ghana is in the lead
with over half of the fecund and exposed nuni respondents being of the second type of “no
willingness”.
The last two panels, finally, specify the countries with high percentages of fecund and exposed nu ni
respondents in the category “not able” (B.4) and in the residual categories (B.5) respectively. Again,
knowledge, access and affordability seem to be an obstacle in the 5 West African countries, where
evidently the hard core of nuni respondents is located. Only Ethiopia on the other side of the
“African divide” has more than 10 percent in the “not able” category. Finally, uncertainty and
reluctance to answer seems to be more of an Eastern and Southern trait, with 6 of the 11 countries
having more than 10 % answers that are unspecified or missing. The very high figure for Namibia
2006-07 with a quarter of all nuni respondents in this category is surprising and calls for extra
caution in interpreting the other figures as well.
Fertility Transition in Sub-Saharan Africa into the 21st Century
19
The results of the 21st Century DHS surveys confirm what was reported for the Sub-Saharan African
countries on the basis of the earlier DHS data (Lesthaeghe and Vanderhoeft 2001: 260-261): as the
fertility transition progresses, there is a shift away from “not ready” to “not willing”, and within the
latter from “not willing” type 1 (social and religious barriers prevailing) to “not willing” type 2
(personal health and convenience concerns). This has policy implications since very different
motivations and bottlenecks have to be addressed depending on the “ready, willing and able” profiles
of the nuni and unmet need public in each of the countries.
6. Conclusions
1. It seems that substantial parts of Sub-Saharan Africa have resumed their fertility transition during
the first decade of the 21st Century. However, there is now a sharper divide between East and
Southern Africa, where most of the change has occurred, and West and Central Africa, where change
is either negligible or modest. This divide also shows up in contraceptive use, the method mix, the
type of unmet need (spacing versus stopping), the effect of reduced postpartum non-susceptibility,
and the types of barriers and bottlenecks in the demand for contraception. In all these aspects West
and Central African countries are at a disadvantage. This is not only true for the poorer Sahelian
countries, but also for the richer ones (e.g. Nigeria, Cameroon).
2. African populations in West and Central Africa are by no means immune to fertility control, as is
evident from the lower urban levels of the Total Fertility Rate. But many of these countries as a
whole have retained national TFR levels above 5 and even 6 children because of a lack of any
fertility control in rural areas. On the whole, in much of Sub-Saharan Africa a decisive fertility
transition at the national level will not occur for as long as the rural areas fail to get their share of
attention.
3. In much of West and Central Africa, a substantial if not the entire gain in contraceptive useeffectiveness is neutralized by further declines in postpartum non-susceptibility (i.e. the period of
lactational amenorrhoa + postpartum abstinence combined). Only in Ghana is the effect of increased
contraceptive use more pronounced. By contrast, in most Eastern and Southern African countries
much of the fertility reducing capacity of increased use-effectiveness of contraception is being
realized since the non-susceptibility factor is not shrinking much further from its already lower level.
4. There is a clear preference for hormonal contraception, and especially for injectables. This is
normal given that these methods are the most modern ones and, in addition, are ideally suited for
Fertility Transition in Sub-Saharan Africa into the 21st Century
20
spacing purposes. By contrast, the IUDs are heavily underutilized, despite the fact that they would be
suited for use in more remote rural areas where clinics, other than ambulatory, are not in easy reach.
5. The continued stressing of Africa’s predilection for spacing should not become a self-fulfilling
prophecy leading to the neglect of stopping needs. As the transition advances, unmet need for
stopping clearly takes over from unmet need for spacing. This is particularly evident in Eastern and
Southern Africa. Contraceptive methods suitable for stopping should therefore get more attention in
all countries where unmet need exceeds 15 to 20 percent and/or where unmet need for stopping
exceeds 10 % of all women 15-49 currently in a union.
6. Several countries provide remarkable lessons. For instance, the improvement of Family Planning
services and the policy focus on fertility control since 2003 in Rwanda has produced a major increase
in contraceptive use and a sudden acceleration of the decline of the TFR. ix The Cape Verde
experience shows that female sterilization as a stopping method is not per definition taboo. The same
holds for Malawi, which furthermore experienced a significant increase in the use of injectables and
implants as well. All of this indicates that adequate FP services can indeed go a long way in Africa,
and that there is no room for negative fatalism among local policy formulators or among foreign
donors.
7. The “ready, willing, and able” profiles of exposed women who are not current users of
contraception exhibit clear distinctions between countries (with again an East+South versus a
West+Central divide). As the transition advances, barriers to contraceptive use change in nature.
Generally, barriers related to high (and partially fatalistic) fertility expectations and to social and
religious pressures yield to more individual concerns about health effects and ease of use.
8. A continued monitoring using the DHS or similar survey instruments is needed, particularly in
those countries where information for the last decade is missing. But, by the same token, detailed
studies of what happens on the supply side are even more needed. In fact there is still a dire need of
information about the spread and quality of the service providing facilities, the method mix offered,
the organization of the FP programs by states and private agents, the connections with other aspects
of reproductive health, all aspects with respect to the training of FP personnel, etc. x
9. The bottom line of all this is that a renewed effort in stimulating the take-off and further
advancement of the African fertility transition is badly needed, most importantly by local
governments first, particularly in West and Central Africa (!), and furthermore by private
organizations and by international and bilateral donors.
Fertility Transition in Sub-Saharan Africa into the 21st Century
21
7. References
J. Bongaarts 1978: “A framework for analyzing the proximate determinants of fertility.” Population and
Development Review 4(1): 105-132.
J. Bongaarts 1981: “The impact on fertility of traditional and changing child-spacing practices.” In R.
Lesthaeghe and H.J. Page (eds): Child-spacing in tropical Africa – Traditions and Change. London:
Academic Press, 111-129.
J. Bongaarts, R. Potter 1983: Fertility, biology and behavior – An analysis of the proximate determinants.
New York: Academic Press.
J. Bongaarts 2005: “The causes of stalling fertility”. New York: Population Council Working Paper ,nr
204.
J.C. Caldwell, P. Caldwell 1981: “The function of child-spacing in traditional societies and the direction
of change.” In R. Lesthaeghe, H.J. Page (eds): Child-spacing in tropical Africa – Traditions and
change. London: Academic Press. Chapter 3: 73-92.
T. Dyson 1988: “Decline of traditional fertility restraints – Demographic effects in developing countries.
IPPF Medical Bulletin 22(6): 1-3
M. Garenne 2008: Fertility Changes in Sub-Saharan Africa. DHS Comparative Reports nr. 18. Calverton
MD: Macro International Inc.
O. Frank 1983: “Infertility in Sub-Saharan Africa – Estimates and implications.” Population and
Development Research 9: 137-145.
S. Kahn, V. Mishra, F. Arnold, N. Abderrahim 2007: Contraceptive trends in developing countries. DHS
Comparative Reports nr. 16. Calverton MD: Macro International Inc.
U. Larsen 1989: “A comparative study of the levels and the differentials of sterility in Cameroon, Kenya
and Sudan.” In R. Lesthaeghe (ed): Reproduction and social organization in Sub-Saharan Africa.
Berkeley and Los Angeles: University of California Press. 167-211.
U. Larsen, H. Raggars 2001: “Levels and trends in infertility in Sub-Saharan” In J.T. Boersma, Z. Mgalla
(eds): Women and infertility in Sub-Saharan Africa – A multidisciplinary perspective. Amsterdam:
Royal Tropical Institute, KIT publishers: 25-69.
R. Lesthaeghe, H.J. Page 1981(eds): Child-Spacing in tropical Africa – Traditions and Change. London:
Academic Press.
R. Lesthaeghe, H.J. Page, P.O. Ohadike, J. Kocher 1981: “Child-spacing and fertility in Sub-Saharan
Africa – An overview of issues. In R. Lesthaeghe and H.J. Page (eds): Child-spacing in tropical
Africa – Traditions and change. London: Academic Press. 3-23.
R. Lesthaeghe (ed) 1989: Reproduction and social organization in Sub-Saharan Africa. Berkeley and Los
Angeles: University of California Press.
R. Lesthaeghe, C. Jolly 1993: “Contribution of modern contraceptive use relative to postpartum practices
to fertility decline.” In National Research Council: Factors affecting contraceptive use in SubSaharan Africa. Washington DC: National Academy Press. Chapter 7: 197-211.
R. Lesthaeghe, C. Vanderhoeft 2001: “Ready, Willing and Able – A conceptualization of transitions to
new behavioral forms. In J. Casterline (ed): Diffusion Processes and fertility transition – Selected
perspectives. Washington DC: National Research Council, National Academy Press. Chapter 8: 240264.
A. Romaniuk 1980: “Increase in natural fertility during the early stages of modernization – Evidence from
an African case study: Zaïre.” Population Studies 34(2): 293-310.
Fertility Transition in Sub-Saharan Africa into the 21st Century
22
S.O. Rutstein 2011: Trends in birth-spacing. DHS Comparative Reports nr. 28. Calverton MD, Macro
International Inc.
R. Schoenmaeckers, I.H. Shah, R. Lesthaeghe, O. Tambashe 1981: “The child-spacing tradition and the
postpartum taboo in tropical Africa – Anthropological evidence.” In R. Lesthaeghe and H.J. Page
(eds): Child-spacing in tropical Africa – Traditions and change. London: Academic Press. Chapter
2: 25-72.
D. Shapiro, T. Gebreselassie 2007: “Fertility transition in Sub-Saharan Africa – Falling and stalling.”
Paper presented at the 2007 Annual conference of the Population Association of America, New
York.
D. Shapiro, T. Gebreselassie 2012: “Marriage in Sub-Saharan Africa – Trends, determinants and
consequences.” Paper presented at the seminar of the International Union for the Scientific Study of
Population (IUSSP) on First union patterns around the world. Madrid, Consejo Superior de
Investigaciones Cientificas – Centro de Ciencias Humanas y Sociales, June 20-22, 2012.
D. Tabutin, M. Sala-Diakanda, Ngondo a Pitshendenge, E. Vilquin 1983: Fertility and child-spacing in
Western Zaïre. In R. Lesthaeghe and H.J. Page (eds): Child-spacing in tropical Africa – traditions
and change. Chapter 14: 287-302.
C. Westoff 2011: Desired number of children, 2000-2008. DHS Comparative reports nr. 25. Calverton
MD: Macro International Inc.
C. Westoff 2012: “The making of the demographic transition in Rwanda.” Unpublished manuscript, draft
version July 24, 2012.
ENDNOTES
i
In this article we will not focus on the role of later marriage or later entry into a sexual union, since
other authors (Shapiro and Gebreselassie, 2012) have paid ample attention to this factor, inter alia also
using the Bongaarts index Cm of proportions in a sexual union in their update.
ii
It should be noted that there are no data later than 2000 for Angola, Botswana, Central African
Republic, Eritrea, Gabon, Equatorial Guinea, Gambia, Somalia.
iii
An extensive comparison of all sources, both surveys and censuses, is given in the report by M.
Garenne (2008)
iv
Modern methods, as defined by the DHS reports( e.g. Khan et al. 2007, p.29), include male and female
sterilization, all hormonal contraception (pill, injectables, implants), both male and female condoms,
diaphragm an cervical caps, jellies and spermicides, “emergency contraception”, and lactational
amenorrhea (LAM). Since breastfeeding is so common in Africa, and since we doubt that a clear
distinction can be made between consciously prolonging lactation and regular lactation we feel that
LAM should not be included in the set of modern methods, but still belongs to the traditional methods,
along with periodic abstinence and withdrawal (and other folk forms of “contraception”). In this article
we have followed the DHS definition of modern contraception, which is more likely to be biased
upwardly than downwardly.
v
The DHS survey for Rwanda in 2010 indicated a usage of injectables of no less than 26.3 percent among
women 15-49 in a union, and of a record 6.3 percent for inplants. Malawi in 2010 had 25.8 percent
usage on injectables, Namibia 2006-07 had 21.8 percent, Kenya 21.6, and Ethiopia 20.8.
Fertility Transition in Sub-Saharan Africa into the 21st Century
23
vi
Initially we thought that the 1.1 percent with the correct answer in Congo Brazzaville was just a
printing error, but the DHS country report itself comments more extensively on this very low level. It is
still possible of course that there were coding errors or other biases in the data processing which have
gone unnoticed, but, if true, such a low figure would indeed be alarming.
vii
The index Ci is defined as 20/(18.5+i) where i is the duration of the overall postpartum nonsusceptibility in months(i.e. whichever is longest, the duration of lactational amenorrhea or the duration
of postpartum abstinence). If there is no breastfeeding and no abstinence, the non-susceptible period i
is about 1.5 months, and in this instance Ci=1. Hence, the lower the fraction of Ci, the stronger the
fertility reducing effect of prolonged lactation and abstinence. The index Cc is defined as 1-(1.08ue)
where u is the proportion of users among women 15-49 in a sexually active union and e is the methodspecific effectiveness (typically 0.60 for less efficient methods and 0.97 for the efficient ones). Again,
the lower the fraction of Cc the stronger the fertility reducing capacity of contraception.
The Bongaarts model also contains an index Cm of “non-marriage” to capture the fertility reducing
effect of not being in a sexual union. Then TFR=TMFR.Cm. Later entry into sexual unions is not the
subject of study of this article, but an update is provided by Shapiro and Gebreselassie 2012.
viii
The Cc values are all from Johnson et al 2011 (p.49) and the Ci values are recalculated on the basis of
the median number of months of postpartum infecundity (col. 6, p.51) or as reported in the DHS
Country Reports.
ix
The decline in TFR has also been helped by an increase in the proportions not married. See Shapiro and
Gebreselassie, 2012.
x
The DHS Analytical Study nr 26 by Wenjuan Wang et al. 2012 covering the FP programs and facilities in
4 East African countries provides a good example of supply-side evaluations.