Coping with fertility decline: tackling the new reproductive challenge.

Our aim in this chapter is to provide an updated and concise description of the diversity of fertility decline patterns among countries1 in sub- Saharan Africa drawing on the latest series of fertility estimates that take into account many different data sources and that are harmonized with other demographic components (United Nations 2015d). We focus on the level of fertility prior to the start of fertility decline the time period of the fertility transition and the estimated pace of decline. We also explore the implications of different fertility decline patterns for future fertility and population projections in the region. We draw on the distinct patterns of fertility decline among countries worldwide that are advanced in (or have completed) their first fertility transition to construct probabilistic fertility and population projections for sub-Saharan African countries. The illustrative comparisons of projections highlight the demographic impact if future fertility decline in sub-Saharan countries were to accelerate and follow the rapid pace of decline already experienced by a diverse group of countries. (excerpt)

Prospects for Fertility Decline in Africa

Important factor related to the conception possibility is women age. The decline in fertility with aging is proven and evident in literature. Infertility is increasing and many couples seek help in advanced techniques such as IVF (in vitro fertilization) in order to overcome the problem caused by aging, but the quality of the oocytes is a significant limiting factor. With the aging the quantity and quality of oocytes decreases, such as the quality of the embryo after fertilization. The accelerated rhythm of life, liberty and women inclusion in all kinds of professions brought many benefits to women, but also increasingly postponing births. Each person is unique individual, and can be more or less fertile compared to the average at same age. Unfortunately, some women has a rapid decline in fertility - accelerate aging, very early, already in the early twenties and when testing them with different methods and exams, the result is very low number of oocytes, low value of anti-Müllerian hormone and also very poor quality of these oocytes, or low ovarian reserve. The problem is that when you have accelerate aging, even IVF techniques can not be of great help in achieving pregnancy. The pregnancy rate (17,65%) and the childbirth rate (5,88%) with the patients older than 40 is very low, although comparable to the data from the scientific literature and speaks in favour of the fact that the success of assisted reproductive techniques is very modest with women older than 44.

In this chapter the author adopts a comparative approach to examining longterm trends in female age at marriage and fertility in sub-Saharan Africa with a focus on continental countries having at least 1 million inhabitants. The author’s database on nuptiality includes over 360 censuses and national surveys conducted in these 39 countries since the 1960s. The author analyzes the association between changes in age at first union and the onset of fertility transition examining whether there is a typical pattern of association followed by most countries in the region.

Study question Are women and healthcare professionals seeking or providing contraception aware of age-related decline in female fertility and information support regarding fertility awareness? Summary answer 89.9% of contraceptive users and 71% of providers stated lack of awareness regarding age and fertility emphasising website as the preferred information resource. What is known already The last 50 years has seen an upward trend in the age at which women are giving birth. The birth rate for women aged 35 to 39 has trebled since 1980 and is now at its highest ever level. Delaying childbearing may mean that some women will inevitably leave it too late and become childless involuntarily. Women are also seeking fertility treatment at older ages, however, success rates decrease dramatically with age. It is not clear whether women who delay their fertility are aware of the decline in fertility with age, and whether healthcare professionals discuss fertility planning with women. Study design, size, duration We conducted two independent anonymous questionnaire surveys of reproductive age women seeking contraception and healthcare professionals(HCP) providing contraception in the UK following research ethics approval, to determine their awareness of the age-related decline in fertility, information resource and potential barriers to provision of information. . This was a prospective study design conducted over a year period using an online questionnaire. A total of 249 participants completed the survey. Participants/materials, setting, methods 138 reproductive age women on contraception consented and participated in the study by completing the online questionnaire. Of these, 96.4% were of white origin,1.4% mixed ethnicity, 1.4% Asian origin and 0.7% Black. 111 HCP providing contraceptive advice in family planning clinics or in General practice completed the survey. Of these, 6 were allied healthcare professionals ie specialist nurses. Data was collated and analysed using percentages and descriptive statistics. Main results and the role of chance Of the total 138 female contraceptive users, 87 were aged 30-39 years whilst 35 were 40-45 years. 51.4% of women indicated no concern about their future fertility, whilst the remainder gave roughly uniformly distributed ratings of concern from unconcerned to highly concerned. However, one third of all women (31.1%) believed that age-related fertility decline occurred after 40 years. 89.9% of women felt fertility awareness and education is important. Of the total 111 HCP, ∼one in 10 HCP (11.7%) misconstrued the female age-related decline to begin from 40 years onwards. The contraceptive providers also were misinformed regarding age related decline in IVF success rate with 45% of them citing 40 years or over to be the age that contributed to decline in IVF success. Despite these figures, majority (71.2%) of HCP agreed there was lack of fertility awareness and 33.3% felt fertility education should be commenced as early as school age. 27% HCP always discussed future fertility whilst 33.3% discussed most of the times. The most commonly-stated barriers to providing information were lack of time, self-perceived lack of knowledge, and women not asking. 73.2% of reproductive age contraceptive users and 85.6% HCPs expressed website to be the most preferred option for information resource. Limitations, reasons for caution To the best of our knowledge, this is one of the first studies seeking fertility awareness amongst those practising family planning. As this was not a qualitative interview based study, the findings are open to interpretation and one must exercise caution. Wider implications of the findings This study highlights clear need for fertility education and awareness amongst contraceptive providers and users. By providing resources to inform, we may increase awareness and confidence amongst both groups thereby empowering women to make informed choices about their future fertility by integrating Fertility planning within Family Planning. Trial registration number Not applicable (IRAS 248991 and R&D Ref 8999)

To evaluate the effect of age on pregnancy success rates in functionally agonadal women undergoing oocyte donation. A prospective study of 100 consecutive patients using oocyte donation for the treatment of infertility. Women aged 40 years and above requesting oocyte donation (N = 104) were required to undergo medical, reproductive, and psychological screening. Suitable candidates (n = 65) were matched with an oocyte donor whose cycle was synchronized with that of the potential recipient, prior to the donor's undertaking ovarian hyperstimulation and transvaginal ultrasound-directed follicle aspiration. Outcomes were compared with those of two groups undergoing therapy at the same time: (1) women below 40 years of age undergoing oocyte donation for premature ovarian failure (n = 35) and (2) women 40 years of age and above undergoing standard in vitro fertilization and embryo transfer using their own oocytes (n = 57). Embryo implantation and pregnancy rates. The in vitro fertilization program of the University of Southern California and the California Medical Center, Los Angeles. Improved outcomes were observed with regard to fertilization rates in vitro, number of embryos transferred, embryo implantation rate, clinical pregnancy rates, and ongoing or successfully completed pregnancy rates when women undergoing oocyte donation regardless of age were compared with women 40 years of age and above using their own oocytes. No age-related decline in fertility was demonstrable when oocyte donation was used, with a mean age of 44.3 +/- 3.1 years for those successfully conceiving (range, 40 to 52 years). Perinatal outcomes (n = 27) were generally uncomplicated, with a mean gestational age at delivery of 38.4 +/- 2.1 weeks (range, 34 to 42 weeks), although multiple births occurred in 24.1% of cases. The age-related decline in female fertility may be reversed in couples electing to use donated oocytes from a younger woman, and women of advanced reproductive age may conceive, carry, and give birth to infants with success rates similar to those of their younger counterparts using assisted reproductive methods.

The remarkable global decline in human fertility has coincided with a move away from institutional religion. Church attendance is a strong predictor of future childbearing.1 Thus, one possible explanation for that coincidence is that secularization contributed to the decline in fertility. Previous research suggests that family formation may lead to increased religious service attendance.2 Thus, the decline in religious service attendance could also be the result of the decline in fertility. In this interesting book, Jenkins explores the second possibility. His is not the first book to do so. However, it is the first to explore the linkage on a global scale (18). It draws a convincing picture of a world in which “faith is so often bound up with fertility” (181).Social scientists will search the book in vain for empirical evidence of the contribution of family formation to the decline in institutional religion. Britain is one of the few places for which an estimate of such a contribution is available. The British data, however, do not support the claims that family formation is the main driver of the decline in church attendance. Family-formation effects there were relatively small, though they may be larger elsewhere.3 Chapter 3 presents a rare case in which trends in church attendance were reversed, as fertility rose. The “years of the mid-twentieth century baby boom were a flourishing era for religion across non-Communist Europe” (49). However, in Britain the brief postwar peak in church attendance was still a long way below percentages recorded for the 1920s and 1930s, when fertility was lower.4Additional theories in the book shy away from empirical evidence. Chapter 2, for example, includes a section about the “First Baby Bust” in the late 1920s and 1930s, offering the following explanation: “One reason for that was the strong presence of death and death rituals as a consequence of the First World War” (61). Jenkins admits that other factors were also at work. The Netherlands, for instance, was a noncombatant in World War I, but it still noted a fertility dip. Previous research has shown that prosperity explains the dip of the 1920s in the Netherlands. Without a rise in prosperity, a dip in fertility would not have occurred.5 There also was a rise in prosperity elsewhere in Europe. Thus, the strong presence of death and death rituals may have played only a marginal role in the “First Baby Bust.”The book also discusses the contribution of mortality and morbidity to institutional religion, especially in Africa. “Without the promise of healing…, the growth of African Christianity is incomprehensible” (127). Low infant mortality in combination with high fertility is responsible for the demographic growth of the Christian and Muslim populations in Africa (128–130).In the last chapter, Jenkins asks, “If in fact faith and fertility are bound together so tightly, does that mean that a world of very low fertility will also be one of low or sharply diminished religiosity?” (186). Some social scientists believe that there is a decline in actual belief rather than in just institutional structures (189). Jenkins disagrees, however, arguing that “the changes we have seen in Europe portend grim times for organized institutional faith, but not necessarily for faith itself. Religious and spiritual attitudes remain alive and even vigorous, even if they seek nontraditional channels for expression” (186).

SummaryAn analysis of Maori fertility shows that a transition from a high to a low level has begun. The crude birth rate has declined by nearly 28% during the period 1961–72; only a small part of this decline can be attributed to changes in the age–sex and marital status composition.A substantial decline in the fertility of older women has been observed and there are indications of the beginning of a major decline in the fertility of younger women. Since women aged 30–49 still account for 30% of total fertility there is enough potential for a further fertility decline in the later child-bearing years.Age patterns of fertility decline suggest that inter-marriage between Pakehas and Maoris is not a prime cause of the recent fertility decline. The factors which are thought to be responsible for this change in Maori fertility are rapid urbanization, a low level of infant mortality and an increase in the overall level of education.A further decline in Maori fertility will depend on the continuation of the tendency in fertility among the younger women.

During 2010–20, period fertility in England and Wales fell to its lowest recorded level. The aim of this paper is to improve our understanding of the decline in period fertility in two dimensions: differentials by the education of a woman's parents (family background) and by a woman's education in relation to that of her parents (intergenerational educational mobility). The analysis finds a substantial decline in fertility in each education group, whether defined by a woman's parents’ education alone or by a woman's own education relative to her parents’ education. Considering parents’ and women's own education together helps differentiate fertility further than analysing either generation's education in isolation. Using these educational mobility groups more clearly shows a narrowing of TFR differentials over the decade, but timing differences persist.

Developed countries have experienced both some population growth and unprecedented declines in fertility rates during the last half of the twentieth century. Couples now have fewer than two children on average in most European countries and they tend to postpone these births until a later age. A decline in male fertility has been suggested by some studies of semen quality, but there is contrasting evidence of shorter times to pregnancy for couples trying to conceive. An important economic factor is the income of young men relative to their parents' incomes, which determines how they rate the ability of their own earnings to support a family. Lower relative income in the 1970s was associated with a lower fertility rate. The decline in fertility in the USA may have been attenuated by the sharp rise in female income during the late 1960s and early 1970s, allowing women to take advantage of purchased child care, thus maintaining the relative family income. The level of demand for children does not appear to be set by known psychological factors, although explanations for the desire to reproduce have been sought in biological, psychoanalytical and socio-cultural research. Recent studies indicate that adults with secure attachment relationships are more interested in being parents. Possible epidemiological factors include age at first marriage, but in Eastern Europe, where age at first marriage is as low as 22 years, fecundity rates do not exceed 1.5. When mothers' age cohorts are analysed, the mean fecundity rate has been falling since the 1920s. Health factors affecting population trends include the change in contraceptive prevalence over the last 40 years. The prevalence of sub-fertility remains close to 10%, and studies from a number of countries indicate that approximately 50% of infertile couples make use of infertility services including IVF and intracytoplasmic sperm injection which are available in 45 countries covering 78% of the world's population. It is estimated that the level of service is sufficient for less than one-third of the need.

Objective. —To evaluate the effect of age on pregnancy success rates in functionally agonadal women undergoing oocyte donation. Design. —A prospective study of 100 consecutive patients using oocyte donation for the treatment of infertility. Patients. —Women aged 40 years and above requesting oocyte donation (N=104) were required to undergo medical, reproductive, and psychological screening. Suitable candidates (n=65) were matched with an oocyte donor whose cycle was synchronized with that of the potential recipient, prior to the donor's undertaking ovarian hyperstimulation and transvaginal ultrasound—directed follicle aspiration. Outcomes were compared with those of two groups undergoing therapy at the same time: (1) women below 40 years of age undergoing oocyte donation for premature ovarian failure (n=35) and (2) women 40 years of age and above undergoing standard in vitro fertilization and embryo transfer using their own oocytes (n=57). Main Outcome Measures. —Embryo implantation and pregnancy rates. Setting. —The in vitro fertilization program of the University of Southern California and the California Medical Center, Los Angeles. Results. —Improved outcomes were observed with regard to fertilization rates in vitro, number of embryos transferred, embryo implantation rate, clinical pregnancy rates, and ongoing or successfully completed pregnancy rates when women undergoing oocyte donation regardless of age were compared with women 40 years of age and above using their own oocytes. No age-related decline in fertility was demonstrable when oocyte donation was used, with a mean age of 44.3±3.1 years for those successfully conceiving (range, 40 to 52 years). Perinatal outcomes (n=27) were generally uncomplicated, with a mean gestational age at delivery of 38.4±2.1 weeks (range, 34 to 42 weeks), although multiple births occurred in 24.1% of cases. Conclusions. —The age-related decline in female fertility may be reversed in couples electing to use donated oocytes from a younger woman, and women of advanced reproductive age may conceive, carry, and give birth to infants with success rates similar to those of their younger counterparts using assisted reproductive methods. ( JAMA . 1992;268:1275-1279)

Korea’s level of population aging remains lower than the OECD average. However, the pace of population aging in Korea is faster than that of many other member countries, as its total fertility rate is the lowest among OECD countries while its life expectancy exceeds the OECD average. Using panel data from OECD member countries, this paper divides the common causes of population aging in OECD countries into declining fertility rate and increasing life expectancy, and analyzes these causes of aging mainly in terms of factors influencing the declining fertility rate. According to the results of the analysis, declines in fertility rate are attributable mainly to socioeconomic factors, including wedding and childcare expenses and labor market conditions that limit the division of housework, and sociocultural factors, such as changes in education levels and gender equality values. Increases in life expectancy are found to be positively correlated to welfare policies and income levels. This paper also compares descriptively the characteristics of population aging in Korea with those in major countries. As Korea industrialized rapidly, the aging of its population has progressed rapidly as well. The factors driving this rapid aging include: historical characteristics, such as the decline in potential fertility, caused in part by Korea’s birth control policy; sociocultural characteristics, such as the decline in the fertility rate due to high wedding and childcare expenses, emergence of an environment in which it is difficult to achieve work-family balance, and gender inequality in the division of housework; and demographic characteristics, such as the surge in the proportion of elderly people as the baby boomers age. To cope with this aging, policies are urgently needed to help ease the burdens of wedding and childcare expenses, for example by stabilizing the housing market and, reducing private education expenses, and create working conditions that ensure work-family balance and gender equality in the division of housework. More fundamentally, it is necessary to establish social consensus on the need for a gender-equal society and develop legal and institutional frameworks that will help make such a society a reality. We must also seek comprehensive measures to address poverty among the elderly, caused by the fast pace of aging, and to support the post-retirement pension and welfare systems.

There is a substantial body of literature on the subject of fertility decline in Europe during the first demographic transition. Historical demographic research on this topic started in Western Europe, but, as a result of the discussion of the Hajnal line thesis, the decline in fertility has been more thoroughly explored for Eastern Europe (especially Poland and Hungary) than for areas in between, like Austria. This project and this working paper will seek to close this gap by addressing the question of whether the Austrian Crown lands in the southeast represented not just an administrative, but also a demographic border. Using aggregated data from the political districts, this paper will review the classic research about, as well as the methods and definitions of, fertility decline. Our results show that, even the Crown land level, which was used in the Princeton Fertility Project, is much too high for studying significant regional and systemic differences and patterns of fertility changes and decline. This process is interpreted as a result of economic and social modernization, which brought new challenges, as well as new options. Thus, fertility decline should not be seen as a linear and sequential process, but rather as a process driven by the sometimes paradoxical interdependencies of problems and opportunities faced by families and social groups.

This research has two main goals: (i) to examine fertility desires (number of children) in sub-Saharan Africa: levels as compared to other major regions and recent trends; and (ii) to assess the extent to which fertility decline in sub-Saharan Africa is contingent on decline in fertility desires (singly and in combination with other reproductive changes).

Part 1 The debate about European fertility decline: theories of fertility decline - a non-specialist's guide to the current debate, George Alter. Part 2 Family and gender: gender and fertility decline among the British middle classes, John Gillis mothers and the state in Britain, 1904-1914, Ellen Ross men's marital rights and women's wifely duties - changing conjugal relations in the fertility decline, Wally Secombe the sexual politics of reproduction, Angus McLaren the contours of childhood - demography, strategy and mythology of childhood in French and German lower class autobiographies, Mary Jo Maynes. Part 3 Community and class: population, change, labour markets and working class militancy - the regions around Birmingham and St Etienne, 1840-1880, Michael Hanagan going forward in reverse gear - culture, economy and political economy in the demographic transition of a Sicilian rural town, Jane Schneider and Peter Schneider the history of migration and fertility decline - the view from the road, Leslie Page Moch occupation and social class during fertility decline - historical perspectives, Michael Haines exploring a case of late French fertility decline - two contrasted Breton examples, Martine Segalen. Part 4 State and politics: constructing families, shaping women's lives - the making of Italian families between market economy and state interventions, Chiare Saraceno demographic nationalism in Western Europe, 1870-1960, Susan Cotts Watkins war, family and fertility in 20th century Europe, Jay Winter safety in numbers - social welfare legislation and fertility decline in Western Europe, Lynn Lees. Part 5 Postscript: movements in time - an historian's context of declining fertility, David Levine.