World Fertility Survey Research Articles

Fertility Preferences and Contraceptive Change in Low- and Middle-Income Countries.

The past four decades have witnessed an enormous increase in modern contraception in most low- and middle-income countries. We examine the extent to which this change can be attributed to changes in fertility preferences versus fuller implementation of fertility preferences, a distinction at the heart of intense debates about the returns to investments in family planning services. We analyze national survey data from five major survey programs: World Fertility Surveys, Demographic Health Surveys, Reproductive Health Surveys, Pan-Arab Project for Child Development or Family Health, and Multiple Indicator Cluster Surveys. We perform regression decomposition of change between successive surveys in 59 countries (330 decompositions in total). Change in preferences accounts for little of the change: less than 10 percent in a basic decomposition and about 15 percent under a more elaborate specification. This is a powerful empirical refutation of the view that contraceptive change has been driven principally by reductions in demand for children. We show that this outcome is not surprising given that the distribution of women according to fertility preferences is surprisingly stable over time.

Yoga as the ‘Complementary, Holistic, and Integrative Medicine’ of Infertility

Infertility and conception complications have long been major global health concerns1, and these continue to be significant clinical problems affecting 8% to 10% of couples globally and 7% to 15% of couples in the United States2-6. Infertility has also been common among the Indian population (4-6%, as per the 1981 census)4. In the causation of infertility in a couple, both the male and female factors play vital roles7, 8. According to reviews of infertility conducted worldwide by the World Fertility Survey and others, similar patterns of infertility rates were found in several South Asian countries that include 5% in Pakistan, 6% in Nepal, 4% in Bangladesh, and 4% in Sri Lanka2, 9.

Socioeconomic development predicts a weaker contraceptive effect of breastfeeding

The contraceptive effect of breastfeeding remains essential to controlling fertility in many developing regions of the world. The extent to which this negative effect of breastfeeding on ovarian activity is sensitive to ecological conditions, notably maternal energetic status, has remained controversial. We assess the relationship between breastfeeding duration and postpartum amenorrhea (the absence of menstruation following a birth) in 17 World Fertility Surveys and 284 Demographic Health Surveys conducted between 1975 and 2019 in 84 low- and middle-income countries. We then analyze the resumption of menses in women during unsupplemented lactation. We find that a sharp weakening of the breastfeeding-postpartum amenorrhea relationship has globally occurred over the time period analyzed. The slope of the breastfeeding-postpartum amenorrhea relationship is negatively associated with development: higher values of the Human Development Index, urbanization, access to electricity, easier access to water, and education are predictive of a weaker association between breastfeeding and postpartum amenorrhea. Low parity also predicts shorter postpartum amenorrhea. The association between exclusive breastfeeding and maintenance of amenorrhea in the early postpartum period is also found in rapid decline in Asia and in moderate decline in sub-Saharan Africa. These findings indicate that the effect of breastfeeding on ovarian function is partly mediated by external factors that likely include negative maternal energy balance and support the notion that prolonged breastfeeding significantly helps control fertility only under harsh environmental conditions.

Early pregnancy care in North America: A proposal for high-value care that can level health disparities

In the United States, approximately 40% of pregnancies do not result in a birth, and instead end in induced or spontaneous abortion [ 1 Casterline JB. Collecting data on pregnancy loss: a review of evidence from the World Fertility Survey. Stud Fam Plann. 1989; 20: 81-95 Crossref PubMed Scopus (51) Google Scholar , 2 Jones RK Jerman J. Abortion incidence and service availability in the United States, 2014. Perspect Sex Reprod Health. 2017; 49: 17-27 Crossref PubMed Scopus (209) Google Scholar , 3 Jones RK Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014. Am J Public Health. 2017; 107: 1904-1909 Crossref PubMed Scopus (106) Google Scholar ]. These pregnant patients often present for early pregnancy care before initiation of traditional prenatal care in a variety of clinical venues and are transitional between gynecology and obstetrics [ [4] Miller CA Roe AH McAllister A Meisel ZF Koelper N Schreiber CA. Patient experiences with miscarriage management in the emergency and ambulatory settings. Obstet Gynecol. 2019; 134: 1285-1292 Crossref PubMed Scopus (9) Google Scholar , [5] Wittels KA Pelletier AJ Brown DF Camargo Jr., CA United States emergency department visits for vaginal bleeding during early pregnancy, 1993-2003. Am J Obstet Gynecol. 2008; 198 (e1-6): 523 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar ]. Early pregnancy care encompasses pregnancy options counseling; pregnancy dating; evaluation of common concerns such as bleeding and/or pain; and the assessment and management of early pregnancy loss, pregnancy of unknown location, and ectopic pregnancy, as well as early surveillance for patients at high risk for these outcomes. This commentary will describe early pregnancy care delivery in other countries, and a high-value model emerging from the unification of family planning services with early pregnancy evaluation and management. Combining this care into one setting can save resources, decrease care variability, and improve patient-centered care.

Timing and determinants of age at menarche in low-income and middle-income countries

IntroductionUnderstanding the timing and determinants of age at menarche is key to determining potential linkages between onset of puberty and health outcomes from a life-course perspective. Yet, we have little...

Trends in age at menarche and adult height in selected African countries (1950–1980)

Background: The mean age at menarche remains poorly documented in Africa.Aim: To document levels, trends, and determinants of mean age at menarche in selected African populations.Subjects and methods: The World Fertility Surveys recorded the age at menarche in 12 African countries. These surveys were conducted from 1977 to 1983 and were based on large representative samples of national populations. Demographic and Health Surveys provided trends in adult height for the same cohorts.Results: The mean age at menarche was higher in sub-Saharan Africa (14.5 years) than in North-Africa (13.5 years). Age at menarche was declining significantly in all sub-Saharan African countries, but only in one North-African country. The speed of decline in sub-Saharan Africa averaged 0.47 years for a 30-year period, comparable to the speed of decline in Europe. Sub-Saharan African countries with higher increase in female adult height also had larger declines in mean age at menarche. In multivariate analysis, trends in age at menarche were correlated with trends in adult height and child survival.Conclusion: In sub-Saharan Africa, age at menarche was undergoing a transition similar to that of European countries in the nineteenth century and was associated with improving health of young women. North-African countries were more advanced.

Extracting and reshaping World Fertility Survey data in Stata

Background: The Demographic and Health Surveys (DHS) program has made available online a large number of public use files from its predecessor, the World Fertility Survey (WFS) program, see wfs.dhsprogram.com. Contribution: To encourage and facilitate the use of these data we provide a Stata command that can be used to extract and reshape the data, using local copies or directly from the DHS data archive pages.

Fertility Desires and the Course of Fertility Decline in sub‐Saharan Africa

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).

Has Child Marriage Declined in sub‐Saharan Africa? An Analysis of Trends in 31 Countries

Age at marriage is rising throughout sub-Saharan Africa. The singulate mean age at marriage is now greater than 18 in the vast majority of countries in the region and in all of the countries included in our analysis (United Nations Department of Economic and Social Affairs Population Division 2015). Even so sub-Saharan Africa has the highest rates of child marriage in the world and previous studies have estimated that more than half of girls marry before age 18 in many countries in the region (Singh and Samara 1996; Mensch Singh and Casterline 2006). Measuring trends in the prevalence of child marriage over time is important for understanding where the practice is most common and for evaluating the effectiveness of efforts to eliminate it. However measuring age at marriage in sub-Saharan Africa is difficult. Unlike Western marriages which are often unambiguously dated by a ceremony the signing of legal documents and civil registration marriage in sub-Saharan Africa is often described as a process consisting of multiple stages including legitimized sexual relations cohabitation and ceremonies. The process can be lengthy and the various stages occur in different sequences across ethnic and social groups (van de Walle and Meekers 1994; Locoh 1994; Arnaldo 2004). If several events are required to solidify a union it may be unclear when the union was formalized. (excerpt)

Fertility Transitions in Ghana and Kenya: Trends, Determinants, and Implications for Policy and Programs

As a continent with 54 independent states Africa’s diversity is often highlighted but frequently forgotten when fertility is discussed. Fifty and more years ago to consider that all African countries and societies had a single fertility pattern (large numbers of children) and single trend (unchanging over time) was a valid characterization. Since the 1960s however that uniformity has disappeared replaced by substantial inter- and intra-country differences in fertility patterns and trends that render previous perceptions of continent-wide homogeneity obsolete. In this chapter we consider two African countries—Ghana and Kenya—whose fertility patterns and trends and their determinants have been well documented (Bongaarts 2008; Garenne 2008; Machiyama 2010; Shapiro and Gebreselassie 2008; Sneeringer 2009). Both countries have benefited from regularWorld Fertility Surveys (WFS) and Demographic and Health Surveys (DHS) that record trends in fertility family planning (FP) and other relevant indicators. The recently introduced Performance Monitoring and Accountability 2020 (PMA2020) surveys monitor progress since 2012 for the FP2020 initiative and occasional Situation Analysis and Service Provision Assessment surveys have also detailed the readiness of the health system in both countries to make quality FP services available. Ghana and Kenya share some common history: both have relatively strong health system legacies from the period of British colonialization; both were among the earliest countries to achieve independence; they were the first two African countries that developed policies to address population growth in the 1960s; and both have received substantial and sustained resources over several decades from many external donors and technical assistance organizations explicitly intended to increase the availability and quality of family planning services. However they are composed of cultures that are both diverse within each country and markedly different in many ways between the two countries. The two countries demonstrate remarkably different pathways in fertility and family planning patterns and trends from the 1970s to the present. We highlight some of the key differences and similarities explain why they have occurred and identify insights that could inform a wider understanding of fertility transitions and the role of family planning in other African countries. (excerpt)

Africa's Unique Fertility Transition

Africa's Unique Fertility Transition

Espaciamiento de los nacimientos y el descenso de la fecundidad en Costa Rica

Este trabajo utiliza datos de las Encuestas Comparativas de Fecundidad de América Latina, así como de la Encuesta Mundial de Fecundidad para estudiar las tendencias y diferenciales en el espaciamiento de los nacimientos entre las mujeres alguna vez casadas en Costa Rica durante el período 1945-1974. Una buena parte de la atención se pone en el ritmo de la fecundidad en las etapas umbral, temprana y tardía de la disminución de la fecundidad que este país experimentó durante los años sesenta y principios de los setenta. Los resultados muestran bastante similitud en el tempo de la reproducción en los diferentes niveles paridez y áreas geográficas. Sin embargo, un análisis de las variables del entorno que afectan espaciamiento de los nacimientos muestra diferencias entre las zonas urbanas y rurales. Por último, se postula que el reciente estancamiento en las tasas de período puede ser una consecuencia de los cambios en el tempo de construcción de la familia, con mujeres de baja paridez que postergan los nacimientos, lo que contrarresta las tendencias de descenso que generan las mujeres de mayor paridez quienes aún pueden estar restringiendo su reproducción.

Introduction to Use of health impact metrics for programmatic decision making in global health

Over the past twenty years, the international landscape for health programming in developing countries has changed dramatically, and global awareness of the consequences of poor health has grown. One result is the international commitment to the Millennium Development Goals (MDGs) that has put poverty reduction and health at the forefront of the global agenda. And, as new funding agencies and mechanisms (e.g., GFATM, GAVI, PEPFAR, PMI) appeared, attention focused more closely on the impact of their expenditures. Major donors - multilateral, bilateral and private - have embraced ‘results-based programming’. They ask whether they are getting ‘value for money’. And the commitment of national leaders to the MDGs confirms that they, as well as the donors, expect accountability for the significant expenditures now being made on health programs. Ultimately, what the global health community wants to know is which programs of service delivery can most efficiently improve health. Without strong evaluations designed to measure impact, decision-makers lack sufficient evidence to fund expansion of service delivery or behavior change programs, and doing so without data on impact might even be considered unethical [1]. But there are many constraints to measuring the impact of large, complex programs, and studies to evaluate impact are expensive and take time [2]. The global health community has instead relied almost exclusively on measurements of intervention coverage, behaviors, and levels of mortality and fertility from household surveys to assess progress. This approach has a long tradition, starting in the 1970s with the World Fertility and Contraceptive Prevalence Surveys, and continues today with the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys, which are the main vehicle for measuring progress toward many of the MDGs. But from the point of implementing organizations, surveys do not provide timely information, and rarely report below regional or provincial level, when more specific data are often needed for program management. Surveys are also expensive and they leave a large gap - a black box - between program inputs and their outcomes and impact. Many implementing organizations are looking for new approaches to express the impact, equity and breadth of their programs. The papers in this Supplement provide a middle ground solution. They give us the opportunity to examine how two organizations that implement global health programs are addressing the need to assess performance, make strategic decisions about their programmatic priorities based on performance and goals, and at the same time be accountable to funders and national stakeholders. The papers provide details about how these program implementers are translating routinely-collected data on program outputs - either commodities distributed or services provided - into estimates of impact on health status, as expressed in disability-adjusted life years (DALYs) averted and on outcomes as expressed in changes in contraceptive prevalence and contribution to national indicators. The papers describe a range of organizational uses for data on impact, as well as analytic methods for examining equity in health status and program exposure that may be used to guide program development.

A Stata module for computing fertility rates and TFRs from birth histories: tfr2

Since the 1970s, birth history data have become widely available, thanks to the World Fertility survey and the Demographic and Health Surveys programs. Despite their wide availability, these data remain under-exploited. Computation, even of simple indicato

Demographic and health surveys: a profile

Demographic and Health Surveys (DHS) are comparable nationally representative household surveys that have been conducted in more than 85 countries worldwide since 1984. The DHS were initially designed to expand on demographic, fertility and family planning data collected in the World Fertility Surveys and Contraceptive Prevalence Surveys, and continue to provide an important resource for the monitoring of vital statistics and population health indicators in low- and middle-income countries. The DHS collect a wide range of objective and self-reported data with a strong focus on indicators of fertility, reproductive health, maternal and child health, mortality, nutrition and self-reported health behaviours among adults. Key advantages of the DHS include high response rates, national coverage, high quality interviewer training, standardized data collection procedures across countries and consistent content over time, allowing comparability across populations cross-sectionally and over time. Data from DHS facilitate epidemiological research focused on monitoring of prevalence, trends and inequalities. A variety of robust observational data analysis methods have been used, including cross-sectional designs, repeated cross-sectional designs, spatial and multilevel analyses, intra-household designs and cross-comparative analyses. In this profile, we present an overview of the DHS along with an introduction to the potential scope for these data in contributing to the field of micro- and macro-epidemiology. DHS datasets are available for researchers through MEASURE DHS at www.measuredhs.com.

Child Mortality Estimation: A Global Overview of Infant and Child Mortality Age Patterns in Light of New Empirical Data

The under-five mortality rate (the probability of dying between birth and age 5 y, also denoted in the literature as U5MR and (5)q(0)) is a key indicator of child health, but it conceals important information about how this mortality is distributed by age. One important distinction is what amount of the under-five mortality occurs below age 1 y ((1)q(0)) versus at age 1 y and above ((4)q(1)). However, in many country settings, this distinction is often difficult to establish because of various types of data errors. As a result, it is common practice to resort to model age patterns to estimate (1)q(0) and (4)q(1) on the basis of an observed value of (5)q(0). The most commonly used model age patterns for this purpose are the Coale and Demeny and the United Nations systems. Since the development of these models, many additional sources of data for under-five mortality have become available, making possible a general evaluation of age patterns of infant and child mortality. In this paper, we do a systematic comparison of empirical values of (1)q(0) and (4)q(1) against model age patterns, and discuss whether observed deviations are due to data errors, or whether they reflect true epidemiological patterns not addressed in existing model life tables. We used vital registration data from the Human Mortality Database, sample survey data from the World Fertility Survey and Demographic and Health Surveys programs, and data from Demographic Surveillance Systems. For each of these data sources, we compared empirical combinations of (1)q(0) and (4)q(1) against combinations provided by Coale and Demeny and United Nations model age patterns. We found that, on the whole, empirical values fall relatively well within the range provided by these models, but we also found important exceptions. Sub-Saharan African countries have a tendency to exhibit high values of (4)q(1) relative to (1)q(0), a pattern that appears to arise for the most part from true epidemiological causes. While this pattern is well known in the case of western Africa, we observed that it is more widespread than commonly thought. We also found that the emergence of HIV/AIDS, while perhaps contributing to high relative values of (4)q(1), does not appear to have substantially modified preexisting patterns. We also identified a small number of countries scattered in different parts of the world that exhibit unusually low values of (4)q(1) relative to (1)q(0), a pattern that is not likely to arise merely from data errors. Finally, we illustrate that it is relatively common for populations to experience changes in age patterns of infant and child mortality as they experience a decline in mortality. Existing models do not appear to cover the entire range of epidemiological situations and trajectories. Therefore, model life tables should be used with caution for estimating (1)q(0) and (4)q(1) on the basis of (5)q(0). Moreover, this model-based estimation procedure assumes that the input value of (5)q(0) is correct, which may not always be warranted, especially in the case of survey data. A systematic evaluation of data errors in sample surveys and their impact on age patterns of (1)q(0) and (4)q(1) is urgently needed, along with the development of model age patterns of under-five mortality that would cover a wider range of epidemiological situations and trajectories. Please see later in the article for the Editors' Summary.

Sir Maurice Kendall (1907–1983)

Maurice George Kendall was an extraordinarily versatile and influential leader in statistics. He distinguished himself as a prolific and effective expositor of statistical theory, and also made important contributions to nonparametric statistics, time series, symmetric functions, and the history of statistics. An innovative organizer, he launched a Dictionary of Statistical Terms and a Bibliography of the Statistical Literature, and served as Director of the World Fertility Survey.

Health transitions in sub-Saharan Africa: overview of mortality trends in children under 5 years old (1950-2000)

To reconstruct and analyse mortality trends in children younger than 5 years in sub-Saharan Africa between 1950 and 2000. We selected 66 Demographic and Health Surveys and World Fertility Surveys from 32 African countries for analysis. Death rates were calculated by yearly periods for each survey. When several surveys were available for the same country, overlapping years were combined. Country-specific time series were analysed to identify periods of monotonic trends, whether declining, steady or increasing. We tested changes in trends using a linear logistic model. A quarter of the countries studied had monotonic declining mortality trends: i.e. a smooth health transition. Another quarter had long-term declines with some minor rises over short periods of time. Eight countries had periods of major increases in mortality due to political or economic crises, and in seven countries mortality stopped declining for several years. In eight other countries mortality has risen in recent years as a result of paediatric AIDS. Reconstructed levels and trends were compared with other estimates made by international organizations, usually based on indirect methods. Overall, major progress in child survival was achieved in sub-Saharan Africa during the second half of the twentieth century. However, transition has occurred more slowly than expected, with an average decline of 1.8% per year. Additionally, transition was chaotic in many countries. The main causes of mortality increase were political instability, serious economic downturns, and emerging diseases.

A Person-Period Approach to Analysing Birth Histories

The reconstitution of birth histories - or maternity histories - is a widely used approach for collecting data on fertility in developing countries. Since the 1970s with the World Fertility Survey (WFS), and even more so since the mid-1980s with the program of Demographic and Health Surveys (DHS), birth histories have become an indispensable source of data for studying fertility levels, trends, and determinants. The principle is well-known: a sample of women are asked about their reproductive history, and the birth dates of each of their children, from the first birth until the time of the survey, are recorded. These birth histories are mainly used to calculate the classic indicators of fertility, in particular fertility rates and total fertility rates, and to reconstitute fertility trends over the past ten to fifteen years. When combined with socio-economic data collected by fertility surveys, they can also be used for explicative analyses of fertility behaviour. Finally, although these data are most often used to study recent fertility, occasionally researchers carry out explanatory analyses that exploit their longitudinal nature. (excerpt)

Cultural and Socioeconomic Influences on Divorce During Modernization: Southeast Asia, 1940s to 1960s

The conventional model of a rising divorce rate during the process of modernization is a staple element of the sociological theory of the family. This generalization is challenged, however, by traditional high‐divorce societies, primarily in Islamic Southeast Asia, which have experienced a decline in divorce with modernization. In this study, based on micro‐level survey data, the authors explore the social roots of marital disruption in Indonesia and Malaysia and in another Southeast Asian society, Thailand, which has not been identified as a high‐divorce society. Comparable survey data from the 1970s (from the World Fertility Survey) allow for an in‐depth analysis of traditional patterns of divorce before the rapid modernization of recent decades. Two major findings emerge from the multivariate analysis. First, there is a common pattern across all three societies of higher levels of divorce among “traditional” women—those who live in rural areas, marry at young ages, and have lower levels of education. Second, the authors find significant sociocultural (ethnic, regional, religious) differentials in divorce within each country that cannot be explained by demographic and socioeconomic composition. They present an interpretation of how moderately high levels of divorce were accommodated in traditional Southeast Asian societies.