Family Planning Effort Research Articles

The National Composite Index for Family Planning (NCIFP): Results and Methodological Issues.

Background: The " FP2020 Global Partnership" signaled a shift to broader, rights-based approaches to family planning programs, and the National Composite Index for Family Planning was developed as part of related measurement efforts. Methods: In each country 10-15 experts on the family planning program completed a 35-item questionnaire, first in 2014 in 89 countries, and in 2017 in 84 countries. Data were entered in Excel, with checks for consistency and data quality. The total score, and scores for each of 5 dimensions of effort are averages across the 35 indicators. Analytic techniques included cross-tabulations, graphical and correlation approaches. Results: The average total score for all countries in 2017 was 64 of the maximum of 100 of effort. Sub-regions differed: Anglophone and Francophone sub-Saharan Africa (SSA) scored highest in the total score and across all 5 dimensions. Next in order came Latin America and the Caribbean, Asia, the Middle East and North Africa, and Eastern Europe and Central Asia. Despite large differences in scores, the sub-regions followed similar profiles across the 35 indicators. The long term rise in the basic family planning effort scores continued, extending the series from surveys approximately every five years beginning in the 1980s. The highest score reached was for the strategy dimension, but the others were close.Their relative levels remained essentially the same as in the 2014 survey. NCIFP scores correlated positively with modern contraceptive use in both the sub-Saharan Africa (SSA) and non-sub-Saharan Africa (non-SSA) countries, but the relationships were stronger for SSA. Access to long-acting and permanent methods (LAPMs) was accompanied by greater LAPM use and modern method use. Conclusion: Repeated surveys in most developing countries show improvements in family planning effort, though unevenly, by 35 indicators and across regions.

A Review of Unintended Pregnancy in Opioid-Using Women: Implications for Nursing.

Opioid use among reproductive-age women has greatly increased, resulting in high rates of opioid-exposed pregnancies, which are associated with negative outcomes, such as neonatal abstinence syndrome. Prevention of unintended pregnancy among opioid users is a critical pathway to reducing opioid-exposed pregnancies; however, little is known about pregnancy intention in this group. This article estimates the prevalence of unintended pregnancy among opioid-using women, thereby supporting efforts to develop interventions to reduce unintended pregnancy. A systematic literature search was conducted in PubMed, Web of Science, PsycINFO, and CINAHL, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses framework. Reference lists of articles were searched. Eligibility criteria included reported unintended pregnancy rates within a population of opioid-using women of reproductive age. The search was completed in July 2018 and updated in October 2019. We identified 115 citations, screened 64 titles/abstracts, reviewed 31 full-text articles, and included 12 articles for this review. Rates of unintended pregnancy in opioid users were estimated in two ways, across the lifetime and for a current pregnancy, depending on study samples. Rates for both groups were high, with rates among currently pregnant opioid-using women (85%) compared with 45% among the general population. Unintended pregnancy rates in opioid-using women were strikingly high, indicating a critical need for intervention. Routine inclusion of pregnancy planning in opioid treatment care is indicated. Education regarding contraception and opioid treatment services is essential for nurses in these settings. Family planning and opioid treatment efforts can be optimized by care coordination, with focus on nurse training for screening and patient education.

Trends and Contributing Factors to Contraceptive Use in Kenya: A Large Population-Based Survey 1989 to 2014.

Kenya is among the leading nations in family planning in Africa, having the first official nationwide family planning program in sub-Saharan Africa. However, Kenya is still one of the most highly populated countries in Africa with a population of more than 52 million. The objective of this study was to assess the trends and contributing factors of contraceptive use. We conducted a multi-wave cross-sectional study using both the demographic health survey (DHS) and family planning effort index (FPE) datasets, analyzing five-year waves from 1989 to 2014. This study indicates that contraceptive use increased from 24.0% to 42.6%, with a change % of 77.5%. Despite changes in women’s characteristics, these characteristics posed little on the time trend of contraceptive use in Kenya. In addition, the policy component of FPE scores had a positive association with contraceptive use with negligible change after adjusting for social and demographic factors 1.055 (1.046–1.065). There was a fluctuating trend of the additional FPE components throughout the years. Women with lower education, those married to husbands with lower education, unmarried, and rural women remain behind in family planning service utilization. Targeted programs are still needed for these special groups. Policy adherence is vital for continued progress.

Modern contraceptive use, unmet need, and demand satisfied among women of reproductive age who are married or in a union in the focus countries of the Family Planning 2020 initiative: a systematic analysis using the Family Planning Estimation Tool

SummaryBackgroundThe London Summit on Family Planning in 2012 inspired the Family Planning 2020 (FP2020) initiative and the 120×20 goal of having an additional 120 million women and adolescent girls become users of modern contraceptives in 69 of the world's poorest countries by the year 2020. Working towards achieving 120 × 20 is crucial for ultimately achieving the Sustainable Development Goals of universal access and satisfying demand for reproductive health. Thus, a performance assessment is required to determine countries' progress.MethodsAn updated version of the Family Planning Estimation Tool (FPET) was used to construct estimates and projections of the modern contraceptive prevalence rate (mCPR), unmet need for, and demand satisfied with modern methods of contraception among women of reproductive age who are married or in a union in the focus countries of the FP2020 initiative. We assessed current levels of family planning indicators and changes between 2012 and 2017. A counterfactual analysis was used to assess if recent levels of mCPR exceeded pre-FP2020 expectations.FindingsIn 2017, the mCPR among women of reproductive age who are married or in a union in the FP2020 focus countries was 45·7% (95% uncertainty interval [UI] 42·4–49·1), unmet need for modern methods was 21·6% (19·7–23·9), and the demand satisfied with modern methods was 67·9% (64·4–71·1). Between 2012 and 2017 the number of women of reproductive age who are married or in a union who use modern methods increased by 28·8 million (95% UI 5·8–52·5). At the regional level, Asia has seen the mCPR among women of reproductive age who are married or in a union grow from 51·0% (95% UI 48·5–53·4) to 51·8% (47·3–56·5) between 2012 and 2017, which is slow growth, particularly when compared with a change from 23·9% (22·9–25·0) to 28·5% (26·8–30·2) across Africa. At the country level, based on a counterfactual analysis, we found that 61% of the countries that have made a commitment to FP2020 exceeded pre-FP2020 expectations for modern contraceptive use. Country success stories include rapid increases in Kenya, Mozambique, Malawi, Lesotho, Sierra Leone, Liberia, and Chad relative to what was expected in 2012.InterpretationWhereas the estimate of additional users up to 2017 for women of reproductive age who are married or in a union would suggest that the 120 × 20 goal for all women is overly ambitious, the aggregate outcomes mask the diversity in progress at the country level. We identified countries with accelerated progress, that provide inspiration and guidance on how to increase the use of family planning and inform future efforts, especially in countries where progress has been poor.FundingThe Bill & Melinda Gates Foundation, through grant support to the University of Massachusetts Amherst and Avenir Health.

Measuring Access to Family Planning: Conceptual Frameworks and DHS Data.

Expanding access to family planning (FP) is a driving aim of global and national FP efforts. The definition and measurement of access, however, remain nebulous, largely due to complexity. This article aims to bring clarity to the measurement of FP access. First, we synthesize key access elements for measurement by reviewing three well-known frameworks. We then assess the extent to which the Demographic and Health Surveys (DHS)-a widely used data source for FP programs and research-has information to measure these elements. We finally examine barriers to access by element, using the latest DHS data from four countries in sub-Saharan Africa. We discuss opportunities and limitations in the measurement of access, the importance of careful interpretation of data from population-based surveys, and recommendations for collecting and using data to better measure access.

“알맞게 낳아서 훌륭하게 기르자!” (Let’s Have the Proper Number of Children and Raise Them Well!): Family Planning and Nation-Building in South Korea, 1961–1968

This paper looks at the formation of a South Korean national health network by focusing on the introduction of an ambitious National Family Planning (FP) Program under President Park Chung Hee (1961–1968). The program, influenced in part by the model of its neighbor, Taiwan (Taichung), saw two pilot studies carried out in Koyang (rural, beginning in 1963) and Sundong-gu (Seoul metropolitan area, 1964–1966), before being carried to rural areas nationwide. If the program began with numerous echoes of Japanese colonial practice, it was mobilized specifically in terms of the emerging “modern” South Korean story and the state’s relationship to the welfare of the individual family unit. Using a range of Korean and English-language sources, the paper illustrates how the FP effort took: (1) the Koyang study of the effects of mass communication in rural areas as a tentative blueprint for expanding its national agenda; (2) subsequently enlisted mobile transportation (1966) to expand the scope of its reach; and finally, mobilized “Mothers’ Clubs” (1968) to penetrate the very fabric of rural society, making women both the target as well as the primary means of distribution. Ultimately, this strategy of enlisting the active participation of South Korean women on behalf of the program asked rural women in particular to submit their bodies to the state’s scrutiny, even as they formed the core of the distribution network. In this respect, FP anticipated the mass mobilization of rural South Korea in the New Village movement of the 1970s and leaves behind an ambiguous legacy of state control that is only just beginning to be re-examined.

(Let's Have the Proper Number of Children and Raise Them Well!): Family Planning and Nation-Building in South Korea, 1961–1968

This paper looks at the formation of a South Korean national health network by focusing on the introduction of an ambitious National Family Planning (FP) Program under President Park Chung Hee (1961–1968). The program, influenced in part by the model of its neighbor, Taiwan (Taichung), saw two pilot studies carried out in Koyang (rural, beginning in 1963) and Sundong-gu (Seoul metropolitan area, 1964–1966), before being carried to rural areas nationwide. If the program began with numerous echoes of Japanese colonial practice, it was mobilized specifically in terms of the emerging “modern” South Korean story and the state's relationship to the welfare of the individual family unit. Using a range of Korean and English-language sources, the paper illustrates how the FP effort took: (1) the Koyang study of the effects of mass communication in rural areas as a tentative blueprint for expanding its national agenda; (2) subsequently enlisted mobile transportation (1966) to expand the scope of its reach; and finally, mobilized “Mothers' Clubs” (1968) to penetrate the very fabric of rural society, making women both the target as well as the primary means of distribution. Ultimately, this strategy of enlisting the active participation of South Korean women on behalf of the program asked rural women in particular to submit their bodies to the state's scrutiny, even as they formed the core of the distribution network. In this respect, FP anticipated the mass mobilization of rural South Korea in the New Village movement of the 1970s and leaves behind an ambiguous legacy of state control that is only just beginning to be re-examined.

Opportunities and pitfalls in integration of family planning and HIV prevention efforts in developing countries.

Recognizing that HIV/AIDS is a paramount health priority for virtually all the developing world “integrating” HIV with existing services such as family planning is highly attractive. At first blush it would seem that the same reproductive health arena that both interventions share should provide opportunities for integration. But the reality is far more complex. Our central proposition is that in the developing world the family planning clinic arena—with its emphasis on providing contraceptive methods—is a weak platform to promote the behavior change so essential to HIV prevention. On the other hand other elements of family planning programming that operate outside the clinic (though they support clinical services) often provide a strong platform for HIV prevention. At the same time growing areas of HIV programming such as Voluntary Counseling and Testing (VCT) Mother-to-Child Transmission (MTCT) and long-term Antiretroviral Therapy (ART) offer strong programmatic opportunities to fulfill the unmet need for family planning. (excerpt)

China's family planning policy: an overview of its past and future.

This article provides a broad overview of China's family planning policy during the last three decades, highlighting key trends and goals of the program at national and provincial levels. It focuses on the administrative, economic, cultural, and other factors that have helped or hindered the family planning effort and reviews the impact of the program on the provincial population. A key question is whether the policy of strict fertility control will remain relevant and enforceable as population growth slows, as controlling private life becomes increasingly problematic for the government, and as new demographic problems (for example, aging) emerge.

Family Planning Programs, Socioeconomic Characteristics, and Contraceptive Use in Malawi

In this paper, micro-level data from a survey of 4,849 women in Malawi are linked to information from a service availability questionnaire to assess the relative importance of socioeconomic background and various aspects of family planning provision on contraceptive use in one country in sub-Saharan Africa. Maximum-likelihood probit is used to assess the independent influence of four distinct dimensions of family planning effort on contraceptive use: mass media exposure, i.e., promotion of family planning through radio and print messages; contraceptive choice; accessibility of contraceptive services; and service quality. Results indicate that all four components of family planning effort contribute to the use of modern contraceptives in Malawi, although their relative importance varies significantly across different segments of the population.

Prevention First: A Three-Pronged Strategy to Integrate Family Planning Program Efforts Against HIV and Sexually Transmitted Infections

This article presents a three-pronged strategy for prevention of HIV/AIDS and sexually transmitted infections (STIs). The enormous misfortune caused by HIV/AIDS and STIs provides compelling grounds for enlisting the support of family planning and related health program efforts against these diseases. The dynamics of STI transmission support a three-pronged prevention strategy aimed at high transmitters at men and at the general population. While ultimate success will require support from a number of other segments of the health community and from the broader society family planning and related health efforts can contribute much especially by building ongoing prevention activities. Reducing STIs and HIV/AIDS on a broad scale even a global one will not be easy. But it can happen if there is a primary preventative strategy.

The Impact of Population Policies: Reply

Specific critiques were made by James Knowles John Akin David Guilkey and John Bongaarts of the authors article Fertility and the Impact of Population Policies. In response the author makes 6 points: 1) Empirically nearly all the differences across countries in actual fertility are explained by cross-country differences in womens desired fertility. Desired fertility plus a constant is an excellent prediction of actual fertility. 2) The 2 most potent objections to the use of desired fertility as an explanatory variable can be overcome by using both retrospective and prospective data on desired fertility together with the statistical estimation technique of instrumental variables. Neither ex-post rationalization of prior births nor the influence of contraceptive costs on reported fertility desires determines the empirical results. 3) In explaining differences in fertility such measures as contraceptive use unmet need and family planning effort have an empirically small impact and explain very little of fertility variation once differences in desired fertility are accounted for. These 3 facts were consistent with economic common sense consistent with much of the literature and not refuted by arguments commonly adduced in support of the presumed importance of family planning programs. 4) A small effect of family planning programs is plausible when the cost of avoiding a child is compared with the cost of having a child. Contraceptive costs do not strongly affect the decision to have a child. 5) The small effect of family planning programs on fertility is consistent with historical experience which shows that modern contraceptive technology is not a precondition for fertility decline. 6) Arguments based on the existence of unmet need for contraception the speed of the demographic transition or experimental family planning programs do not provide contradictory evidence to an empirically small family planning program impact.

Beyond the Numbers: A Reader on Population, Consumption, and the Environment.

Beyond the Numbers presents a thought-provoking series of essays by leading authorities on issues of population and consumption. The essays both define the poles of debate and explore common ground beyond the polarized rhetoric.Specific chapters consider each of the broad topics addressed at the International Conference on Population and Development held in September 1994 in Cairo, Egypt. The essays are supplemented by sidebars and short articles featuring more-impassioned voices that highlight issues of interest not fully explored in the overviews.As well as providing a sense of the difficulties involved in dealing with these issues, the essays make clear that constructive action is possible.Topics covered include: the interrelationships between population, economic growth, consumption, and development the history of population and family planning efforts gender equality and the empowerment of women reproductive rights, reproductive health, family planning, health and mortality

Family Planning Program Effort Has Increased During the 1980s, with East Asia Ranked Highest

A capsule of family planning (FP) program activity in East Asia South Asia sub-Saharan Africa Middle East/north Africa and Latin America in 1982 and 1989 is presented based on a cross sectional study conducted by Mauldin and Ross. Activity increased >50% over 7 years. East Asia ranked the highest at 64% followed by South Asia at 52% Latin America at 54% sub-Saharan Africa at 36% and Middle East at 33%. Africa increased from 15% but was still low in program effort. Program effort was scored (0-4) on policy and stage setting activities service and service-related activities record keeping and availability of contraceptives. Scores were converted to a 100-point scale. Response rate was 433 respondents (FP government officials donor agency staff knowledgeable citizens and foreigners) out of 100 countries in 1982 and 359 out of 98 countries in 1989. Countries included those developing ones with a population of >1 million. Specific country analysis showed China with the highest program effort score of 84 or 101 out of 120. Gabon Kuwait Libya and Saudi Arabia had scores of 0. Scores were high for Tunisia (68) and Egypt (65) even though the region was very low. The average score among countries was 29 in 1982 and 44 in 1989. Effort was further grouped into strong (67+) moderate (46-66) weak (21-45) or very weak (0-20). Countries with strong scores in 1989 increased from 23 to 42 those with weak scores decreased from 65 to 46. Strong scoring countries constitute 64% of developing country populations (14 countries including China India and Mexico). Moderate scores of 29 countries (including Ghana Lebanon and the Philippines) contribute 15% of the developing worlds population. 38 weak scoring countries (most sub-Saharan countries) contain 17% of the population. 17 countries had weak or no programs and contain 4% of the population including Iraq Kuwait Laos and Malawi. Gains were made in all 4 categories but sub-Saharan Africa had the lowest score on availability. Social setting was also ranked and compared to FP effort. Only Bangladesh had a low social setting score and strong FP effort. FP effort and the effect on fertility and social setting are also discussed. For example total fertility rates (TFRs) declined by 6% in countries with weak programs 24% with moderate programs and 34% with strong programs. TFR declined the most in countries with the highest social setting. It is concluded from statistical analysis that modern contraceptive method are a necessary condition for fertility decline.

Is development really the best contraceptive?: A 20-year trial in Comilla District, Bangladesh

"This article examines which public programmes and which socio-economic development indicators have had an impact on contraceptive practices and fertility in a selected group of villages in Comilla district of Bangladesh. It finds that equitable, even-handed development may be a good 'contraceptive', but is not a realistic alternative to family planning effort.... This research, undertaken in 1985, replicates a similar knowledge, attitudes and practice (KAP) type study undertaken in these same villages some 20 years earlier, in 1967/68....Thus, the two studies provide a unique look at demographic behavioural characteristics when these agricultural development programmes were in an early stage and then 20 years later."

Health is a sustainable state

This commentary by Maurice King questions the viability of current public health strategies. He advocates for an ecological approach that seeks to improve the health of the entire planet. He discusses the concept of the demographic trap. Being demographically trapped refers to a population being stuck in an "unsustainable state with a high birth rate and death rate, with an ever increasing pressure on its resources, and with a rapidly deteriorating environment". King points out that the possible outcomes are limited for a population that becomes trapped. Some of the possible outcomes include dying from starvation and disease; fleeing as ecological refugees; being destroyed by war or genocide; or being supported by food and other resources from elsewhere, first as emergency relief and then perhaps indefinitely. King believes that ecological collapse has already taken place in parts of Ethiopia and the process may have begun on a wider scale elsewhere. According to King, this ecological predicament can be found in both rural and urban areas in the developing world. This article also discusses the problem of high fertility. King believes that the widely held belief that the necessary and sufficient condition for reducing the birth rate is to reduce the child death rate is erroneous. He states that a causal relationship between the 2 rates is untenable, instead, it is more reasonable to say that both rates respond to other common factors. The author suggests that a fall in the birth rate requires the harnessing of social and economic gains to reduce poverty and promote socio-economic development. He also believes that the continued growth in the size of the world's population is due to declining efforts in family planning and declining child mortality not having its alleged effects on fertility. King also brings forth an ethical dilemma. He asks, "are there some programs which, although they are technically feasible, should not be initiated because of there long-term population-increasing consequences?" He suggests that other factors such as ecological deterioration, integrity of the ecosystem, and the welfare of future communities need to be taken into consideration. King presents a new global strategy based on the concept of "sustainability". He says that "sustainability should be the maintenance of the capacity of the ecosystem to support life in quantity and variety". Specifically, he advocates for consumption control in the industrial North with intensive energy conservation and recycling. In the South, he calls for renewed vigor in family planning efforts. Public health measures need to be understood in terms of their demographic and ecological implications. If measures are found to be desustaining, King says that complementary ecologically sustaining measures should be introduced with them. He also believes that desustaining measures, such as oral rehydration, should not be introduced on a public health scale if no adequately sustaining complementary measures are possible. He asserts that desustaining measures, without complementary interventions, can ultimately increase the man-years of human misery.

The effects of family planning effort and development on fertility: an intervening variables framework.

PIP: To pinpoint the intervening variable that transmit the impacts of development and family planning effort on fertility, a modified proximate determinants model was applied to data from 59 developing countries. The intermediate variable included level of exposure to sexual intercourse (the percentage of women 20-24 years old in a union), deliberate marital fertility control (the percentage of married women of reproductive age who were using contraception), and natural marital fertility (operationalized as average per capita calorie consumption). The regression equations indicated that both social development and family planning effort can influence fertility levels substantially through their association with higher levels of contraceptive use. Interestingly, the direct effects of family planning and social development on the crude birth rate became insignificant when the intermediate variables were included in the same equation. Path analysis revealed that social development has an indirect effect of -0.083 via its influence on marriage patterns and of -0.316 due to its effect on contraceptive usage. Family planning has a lesser indirect impact on fertility (-0.487), and -0.111 of this effect reflects program effort's dependence on the level of social development. Economic development is positively linked to fertility, and future research should assess whether this factor is partially counterbalancing the fertility-reducing impact of social development and family planning programs. Although this analysis confirms that delayed marriage and widespread adoption of contraception are key intervening variables, they cannot influence fertility in societies where there are social or cultural impediments to such changes.

Dependence, Distorted Development, and Fertility Trends in Noncore Nations: A Structural Analysis of Cross-National Data

To evaluate the hypothesis that dependence on developed nations distorts demographic development in less developed countries (LDCs) a researcher used panel regression analysis to study variables from 62 nations. Multinational corporate penetration an estimate of the shares of both a nations capital and its labor that are controlled by developed country based transnational corporations was used as a measure of the level of dependence. The analysis demonstrated that school enrollment was highly correlated with level of development social insurance program history and both family planning effort (FPE) measures. In addition countries that underwent the most economic growth the most concerted FPEs etc. had the most rapid decline in fertility rates. Conversely those with high levels of multinational corporate penetration/dependency experienced either an increase in fertility or a slow decline. For example South Koreas 1965 CBR was 36 below the population mean of 45. In 1984 the CBR dropped to 20 even further below the population mean of 39 a dramatic absolute and relative fertility decline. South Korea also had the highest rate of economic growth and its increase in family planning program effort was dramatic: from no measurable effect in 1972 to the nation with the highest FPE score in 1982. In addition the level of multinational penetration was modest. In conclusion this research supports the view that intranational economic phenomena such as rate of economic growth and concerted FPEs contribute significantly to fertility decline. On the other hand multinational corporate penetration distorts development and impedes fertility reduction.

The Fertility Revolution: A Supply-Demand Analysis

Easterlin and Crimmins present and test a supply-demand theory of fertility determination that integrates both economic and sociologic approaches. According to this theory a couples use of fertility control varies directly with the excess of their supply of children over demand (motivation for family planning) and inversely with the perceived costs (both objective and subjective) of regulating fertility. This model is tested with household data from Sri Lanka and Colombia aggregative population data from Taiwan and the Indian state of Karnataka and macro data from 10 Indian states. In all data sets examined motivation for fertility control was consistently and significantly related to use of control. Changes in the supply of and demand for children that increase motivation appear to be most important in generating family planning adoption whereas changes in regulation costs appear less significant. Interestingly supply is as important as demand and perhaps more so. This approach to the fertility transition asserts that with the onset of modernization the number of children that would result from unregulated fertility comes to exceed desired family size and incentives to limit family size develop. The growing excess of the potential supply of children over demand appears to be due to increases in parents potential supply in turn due both to declining infant and child mortality and increasing natural fertility. Once use of fertility control has spread to 50% of married women 35-44 years of age a fertility decline can be expected. By raising the supply of children and lowering demand socioeconomic modernization is both increasing motivation for fertility control and lowering the costs of fertility regulation. The data suggest that family planning programs should be formulated with careful attention to the populations state of motivation and perceived costs of regulation. Early in the modernization process before motivation for family planning has emerged socioeconomic development programs should be prioritized. The targeting of populations for a family planning effort should be based on their motivation not their actual fertility levels and methods that are perceived as entailing low regulation costs should be promoted.

Political Capacity and the Decline of Fertility in India

With data from 15 Indian states, in this study I demonstrate that political capacity, defined as the ability of government to penetrate society and extract resources, has a more significant—though indirect—effect on fertility behavior than does level of economic development. A path-analysis model with six variables—crude birth rate (the dependent variable), family-planning-program effort, mean female age at marriage, physical-quality-of-life index (PQLI), income per capita, and political capacity—showed a strong indirect effect by the political-capacity measure on fertility decline through both the PQLI and family-planning effort. Within the model, income per capita had little effect on birth rate or any of the intervening variables. The conclusion drawn is that under conditions of economic backwardness as exist in India, it is politics, not economics, that is the primary determinant of fertility patterns.