Abstract
Health practitioners, researchers, and donors are stumped about Jordan's stalled fertility rate, which has stagnated between 3.7 and 3.5 children per woman from 2002 to 2012, above the national replacement level of 2.1. This stall paralleled United States Agency for International Development (USAID) funding investments in family planning in Jordan, triggering an assessment of USAID family planning programming in Jordan. This article describes the methods, results, and implications of the programmatic assessment. Methods included an extensive desk review of USAID programs in Jordan and 69 interviews with reproductive health stakeholders. We explored reasons for fertility stagnation in Jordan's total fertility rate (TFR) and assessed the effects of USAID programming on family planning outcomes over the same time period. The assessment results suggest that the increased use of less effective methods, in particular withdrawal and condoms, are contributing to Jordan's TFR stall. Jordan's limited method mix, combined with strong sociocultural determinants around reproduction and fertility desires, have contributed to low contraceptive effectiveness in Jordan. Over the same time period, USAID contributions toward increasing family planning access and use, largely focused on service delivery programs, were extensive. Examples of effective initiatives, among others, include task shifting of IUD insertion services to midwives due to a shortage of female physicians. However, key challenges to improved use of family planning services include limited government investments in family planning programs, influential service provider behaviors and biases that limit informed counseling and choice, pervasive strong social norms of family size and fertility, and limited availability of different contraceptive methods. In contexts where sociocultural norms and a limited method mix are the dominant barriers toward improved family planning use, increased national government investments toward synchronized service delivery and social and behavior change activities may be needed to catalyze national-level improvements in family planning outcomes.
Highlights
Global Health: Science and Practice 2017 | Volume 5 | Number 4 per woman) is usually referred to as a "stall" in fertility
A total fertility rate (TFR) stall is typically accompanied by stalls in multiple parallel measures, including the modern contraceptive prevalence rate, unmet need and demand for family planning, and the desired fertility rate, all of which have stalled in Jordan.[3]
Al-Massarweh[10] applied Bongaarts' classic framework on the proximate determinants of fertility to Jordan,[11] and found that the increase in CPR was not enough to offset the increase in proportion of married women during the same time period, as most of the increase was attributed to use of less Increased use of effective traditional methods.[10]
Summary
Global Health: Science and Practice 2017 | Volume 5 | Number 4 per woman) is usually referred to as a "stall" in fertility. A 2012 analysis of Jordanian fertility patterns found that the stall was not due to data errors, and it was one of the longest-lasting periods of stagnation assessed worldwide.[2]. A TFR stall is typically accompanied by stalls in multiple parallel measures, including the modern contraceptive prevalence rate (mCPR), unmet need and demand for family planning, and the desired fertility rate, all of which have stalled in Jordan.[3] From 2002 to 2012, Jordan's CPR increased from 56% to 61%. The increase was primarily due to use of traditional methods, which rose from 15% to 19%. The mCPR increased only marginally over the same period (41% to 42%).[1,4] Unmet need for family planning is relatively low in Jordan, hovering between 11% and 12% from 2002 to 2012.
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