This report tracks changes in fertility and its determinants in 13 sub-Saharan countries that have had three
or more DHS surveys and show at least some evidence of beginning a fertility transition. The countries
included are Benin, Burkina Faso, Cameroon, Ghana, Kenya, Madagascar, Malawi, Namibia, Rwanda,
Senegal, Tanzania, Zambia, and Zimbabwe. In some of these countries, notably Namibia, there
... [Show full abstract] has been a
consistent downward trajectory in the total fertility rate (TFR). In most countries, however, there was little
change from approximately 1995-1999 to approximately 2005-2009, a pattern often described as a
“stalled” fertility decline.
The goal of the study is to inform fertility-related population policies, largely from the perspective of
women’s ability to implement their fertility preferences and to avoid risks associated with births that are
too early, too late, or too close. In most of these countries, women have high levels of unplanned births,
with less use of contraception than their preferences would imply.
The determinants of fertility are of two types. The “direct” or “proximate” determinants are behavioral
mechanisms that act to reduce fertility to less than its theoretical or biological maximum. These are
primarily of three types: non-marriage, or reduced exposure to the risk of conception; post-partum
amenorrhea, which can be substantially extended by prolonged breastfeeding; and contraceptive use.
These three proximate determinants are measured well by DHS surveys. A fourth proximate determinant
in the decomposition originally developed by John Bongaarts is induced abortion, which has its effect
after conception. Most DHS surveys do not provide estimates of the use of abortion, but there is evidence
that it may be significant in some countries.
The “indirect” determinants, sometimes simply labeled “background variables”, are socio-economic or
contextual characteristics that influence fertility through changes in the proximate determinants, that is,
indirectly. In this study, these are assessed nationally at, or near to, the date of each survey. They include
the desired number of children, national family planning effort, under-five mortality, level of education,
female participation in the workforce, and type of place of residence. Each of these factors has well-established
associations with fertility. In addition, this study tracks four indicators of whether women’s
fertility preferences are being satisfied or whether public health messages related to fertility are being
effective, specifically the percentage of births that are wanted; the percentage of births that are to women
under 18; the percentage of births that are to women over 34; and the median length of the birth interval.
In most countries, it is found that contraceptive use has been increasing, if only modestly, during the
entire series of surveys. Benin and Ghana were the only countries where the fertility-reducing effect of
contraception actually reversed between 2000-2004 and 2005-2009. However, fertility decline sometimes
stalled, despite an increase in contraception, because of a countervailing trend in non-marriage or postpartum
infecundity, predominantly the latter. For example, in all countries observed in 2000-2004 and
again in 2005-2009, other than Ghana and Malawi, a reduction in breast-feeding resulted in a shorter
period of post-partum amenorrhea and more exposure to the risk of childbearing, tending to neutralize the
small increases in contraception.
The analysis is not multivariate, in the sense of statistically articulating the roles of the direct and indirect
determinants, and identifying precise pathways that connect them. Moreover, changes in the direct
determinants were not consistent or monotonic, either between or across countries. Nevertheless, a
description of the patterns within each country helps to clarify how socio-economic development may or
may not translate easily into fertility decline.