Completing theDemographicTransition in

DevelopingCountries

Harry Cross Karen Hardee

John Ross

August 2002

8P O L I C YOCCASIONALP A P E R S

POLICY

POLICY is a five-year project funded by the U.S. Agency for International Development underContract No. HRN-C-00-00-00006-00, beginning July 7, 2000. The project is implemented byThe Futures Group International in collaboration with Research Triangle Institute (RTI) andthe Centre for Development and Population Activities (CEDPA).

POLICY

POLICY Occasional Paper #8

Completing the Demographic Transition

in Developing Countries

Harry Cross Karen Hardee

John Ross

August 2002

ii

Acknowledgments iii

Executive Summary iv

Introduction 1

The Uneven Decline in Fertility 3

What Influences Fertility Decline? 5Economic Development and Fertility 5Child Mortality and Fertility Change 7Social, Cultural, and Religious Norms 8The Diffusion Theory 8Women’s Education 9Use of Contraception 10

Remaining Challenges 13

Conclusion 21

Endnotes/References 23

Contents

iii

POLICY Occasional Papers areintended to promote policy dialogue

on family planning, reproductive health,and HIV/AIDS issues and to presenttimely analysis of issues that will informpolicy decision making. The papers aredisseminated to a variety of audiencesworldwide, including public and privatesector decision makers, technical advisors,researchers, and representatives of donororganizations. An up-to-date listing ofPOLICY publications is available on theweb at www.policyproject.com. Copies ofthese publications are available at nocharge.

This paper is the result of a request fromthe U.S. Agency for InternationalDevelopment (USAID) for information onthe status of the demographic transition indeveloping countries. John Stover andNancy McGirr from the POLICY Projecthave been particularly helpful inpreparing this document. The authorswould also like to thank Terrence H. Hullfrom Australian National University andJill Gay, consultant, for reviewing thepaper. Finally, we would like to thankKaren Cavenaugh, Rose McCullough,Elizabeth Schoenecker, and Ellen Starbirdof USAID for their helpful comments. Theviews expressed in this paper, however, donot necessarily reflect those of USAID.

Acknowledgments

iv

The transition to low fertility in muchof the developing world is

incomplete. To leave it half-finished or toslow its pace would have enormousdemographic, programmatic, and foreignassistance implications. Despiteconsiderable progress over the last 35years, much remains to be done tocomplete the demographic transition. Theworld’s population has not stoppedgrowing, and it is growing fastest in thepoorest countries. To achieve sustainabledevelopment, strong measures bygovernments and donor organizations topromote fertility decline in developingcountries—and to give individuals andcouples the means to do so—need tocontinue for the foreseeable future.

This paper reviews the status of thedemographic transition worldwide,discusses factors associated with fertilitydecline, and highlights challengesassociated with completing the transitionin developing countries. It is intended to

help policymakers both here and abroadto better understand the need forcontinued efforts to reduce fertility andpopulation growth rates, even in the wakeof the HIV/AIDS epidemic.

A reduction in population growth tosustainable levels is not something that willjust occur on its own. Completing thedemographic transition requiresaddressing a number of challenges—andfirst and foremost is maintaining strongsupport for family planning programsfrom governments and donororganizations. Sustaining the demographictransition also requires focused attentionon other proximate, or direct,determinants of fertility, such as increasingthe age at marriage and reducingabortion. In addition, donors andgovernments have an important role toplay in providing continued support forpolicies that indirectly affect fertility, suchas promoting girls’ education and safemotherhood.

Executive Summary

Fertility has declined among women inmany parts of the world, prompting

some to argue that population growth isno longer a matter for internationalconcern1 or foreign assistance funding.Despite the average worldwide fall infertility, many countries have yet tocomplete the demographic transition. Thedemographic transition theory posits that,over time, countries progress from highfertility and high mortality to low fertilityand low mortality in four stages. Stagesone and four are both characterized bylow population growth, the first due tohigh fertility and mortality, and the latterdue to low fertility and mortality. Duringthe middle stages, mortality falls beforefertility, resulting in rapid populationgrowth. Countries have experienced thetransition at different times and differentpaces. In many developing countriestoday, fertility declines have not kept pacewith rapid declines in mortality.

It is true that the rate of global populationgrowth is slowing and that the totalfertility rate (TFR), or the average numberof births per woman, is declining in manycountries worldwide—some to fertilitybelow the replacement level of 2.1children per couple (prompting debateabout the ultimate floor for fertility in thedemographic transition). In thedeveloping world as a whole, the TFR hasfallen from an estimated 5.7 births per

woman in 1970 to 3.0 today (3.5 if Chinais excluded from the analysis).2 Eventhough the global population growth ratehas declined slowly, the base populationkeeps enlarging; as a result, the annualadditions to the world’s population are

huge. The United Nations (UN) projectsthat another 3 billion or more people—three times China’s current population—will be added to the world’s population by2050. While the estimates of populationgrowth are lower than those made adecade ago, and despite declining rates ofpopulation growth, the increase inpopulation size during the next 25 years inthe developing world will equal thepopulation increase of the last 25 years,1.85 billion people. If China is excludedfrom the analysis, the increase in theworld’s population during the next 25years will exceed by 10 percent thecomparison increase of the past 25 years.3

While the annual population growth rateworldwide has fallen from 2.7 to 1.9

1

Introduction

The demographic transition is continuing

because mortality and fertility rates are falling.

But the demographic transition refers to growth

rates and the differences between mortality

and fertility levels—not to the absolute sizes of

countries or to numbers added annually.

percent during the last quarter-century(excluding China), the poorest nations ineach developing region have youngpopulations and are growing rapidly. Thepopulation size in the group of leastdeveloped countries in the UN projectionsis growing at nearly double the annualrate of the other developing countries (2.5percent per year for the least developedcountries compared with 1.3 percent peryear for other developing countries).4

According to the demographer John C.Caldwell, writing for the 2002 UN ExpertGroup Meeting on Completing theFertility Transition, whether the world’spopulation peaks in 2050 at nine or 12billion has vast implications:

“With regard to the long-term stabilityof the world’s ecosystems and our abilityto feed everyone adequately and to givethem a reasonably good life, thatmargin of 3 or 4 billion extra peoplemay be critical. We may well be able toachieve these aims with 12 billionpeople, but we are much more certain ofbeing able to do so with 9 billion, andrisking the additional 3 billion does notseem to be a worthwhile experiment.” 5

The ultimate size of the world’spopulation has implications for the well-being of the earth’s inhabitants. The

National Research Council Board onSustainable Development noted in 2001,“A transition is underway to a world inwhich human populations are morecrowded, more consuming, moreconnected, and in many parts, morediverse, than at any time in history.” Mostof the growth from six billion today to aworld of nine or 10 billion people in 2050will take place in developing countries“…where the need to reduce povertywithout harming the environment will beparticularly acute… If they do persist,many human needs will not be met, lifesupport systems will be dangerouslydegraded, and the numbers of hungryand poor will increase.”6 Furthermore,according to Edward O. Wilson,“…certain current trends of populationand habitation, wealth and consumption,technology and work, connectedness anddiversity, and environmental change arelikely to persist well into the comingcentury and could significantlyundermine the prospects forsustainability.”7 Some countries in thedeveloping world will achieve theirdevelopment goals, while others will failto do so—in part due to demographicpressure.

The fertility transition in much of thedeveloping world is only half-finished. Toleave it half-finished or to slow its pacewould have enormous demographic,programmatic, and foreign assistanceimplications. This paper reviews the statusof the demographic transition, exploresfactors associated with fertility decline,and concludes by discussing the remainingurgent challenges that governments anddonors face in promoting completion ofthe demographic transition.

2

The fertility transition in much of the

developing world is only half-finished. To leave

it half-finished or to slow its pace would have

enormous demographic, programmatic, and

foreign assistance implications.

On average, fertility has declined indeveloping countries. However,

decline has taken place at different rates—even within the same country. In India,fertility is near replacement level (definedas 2.1 children per couple)8 in manysouthern states but remains at levelsresembling those of sub–Saharan Africa innorthern states—close to five children perwoman. Fertility in Egypt is near replace-ment level in many urban and northernareas but remains high in the south.

In many countries, the fertility transition hashardly started. In those countries, mortalityrates may have started their decline yearsago. Fertility, however, is stillapproximately five children per woman ormore in most of west, central, and eastAfrica. TFR exceeds five children inseveral of the world’s most populouscountries, such as Pakistan (5.3), Nigeria(5.9), and Ethiopia (6.7).9

Although the onset of fertility declinestarted in several sub–Saharan Africancountries during the 1990s, themagnitude, pace, and durability of thedeclines are yet not well established. Inaddition, the fertility transition has noteven started in 14 countries in the region(i.e., in one of three countries).10

The fertility transition in Kenya may takeanother 30 years. Even in Kenya, which has

experienced a decline in fertility in recentyears, the fertility transition may takeanother 30 years. With a moderncontraceptive prevalence rate slightly over30 percent and a fertility rate that hasbeen dropping for two decades, Kenya hasbegun the fertility transition. However, inKenya, as in other sub–Saharan Africancountries, opportunities abound toaccelerate the process of fertilitytransition.11

The fertility rate has also begun to reach aplateau in some countries that had untilrecently experienced a more rapid decline infertility. In Bangladesh, the TFR stagnatedabove three during the 1990s. Similarly,the fertility decline has apparently stalledin Egypt and the Philippines, among othercountries. The plateau is partlyattributable to the “tempo” effect onfertility. Rapid fertility decline can occurwhen women delay marriage andpostpone childbearing to a later age. Theresult is a temporary deflation in the TFR.For example, the TFR in Taiwan would

3

The Uneven Decline in Fertility

While the TFR in many countries is falling, time

counts. That is, the slower the decline in TFR,

the higher the ultimate population size when

the world’s population ultimately stops

growing.

have been about 19 percent higher duringone five-year period except for the tempoeffect.12 After cessation of the interimeffects of delayed marriage and postponedchildbearing, fertility rates can rise again.However, the factors associated with therise in age at marriage also tend to reducedesired family sizes, which may help tooffset any increase in fertility rates.

The world’s populations will continue to growin the face of AIDS. According to the UN’s2000 projections,13 HIV/AIDS will resultin 15.5 million more deaths than wouldotherwise be expected in the 45 mostaffected countries in the next five years.However, even in a country such asZimbabwe, the UN projections show apositive growth rate in every five-yearperiod until 2050 (although alternativeprojections by the U.S. Bureau of theCensus show negative growth in a fewAfrican countries).14 Moreover, mostwomen live in countries with a lowHIV/AIDS prevalence.

The seriousness of the AIDS problemcannot be overstated; however, it must bekept in geographic perspective for rationalprogram planning. Only 19 percent ofreproductive-age women in the developingworld (outside of China) live in countrieswhere HIV/AIDS prevalence is 1 percent

or higher.15 Most of the 46 countries withHIV/AIDS prevalence over 1 percent havesmall population sizes, but they accountfor 79 percent of all HIV/AIDS cases.Among these, the 10 countries with thehighest HIV rates account for over half(56 percent) of all cases. In India,HIV/AIDS prevalence is below 1 percent,but due to its sheer population size, itaccounts for 14 percent of all HIV/AIDScases. All the other countries (with verylow prevalence) claim the remaining 7percent of cases.

Strenuous efforts must continue to beapplied to HIV/AIDS while not forgettingthat most countries, including countrieswith large HIV/AIDS epidemics, requirecontinuing provision of family planning iffertility rates are to continue their decline.Measures are urgently needed to ensurethat HIV-positive women can choosewhether to have children. Access tomodern methods of contraception iscentral to ensuring that women can makeinformed choices. One study in Kigali,Rwanda found that providing easy access tocontraceptives resulted in a 50 percentincrease in their use by HIV-positivewomen and a corresponding decrease inpregnancy incidence among women.16

Indeed, simply providing low-cost,accessible family planning to HIV-positivewomen who do not want more, or any,children can reduce the huge numbers ofAIDS orphans. Furthermore, the key tosafe sex is a method of contraception—thecondom—and the institutional structuresneeded to promote control of HIV are thesame as those needed to promote access tothe technologies and information neededto give women control over their fertility.

4

Worldwide, AIDS will not offset population

growth. Each year, five million people tragically

succumb to AIDS. At the same time, 80 million

people are added to the world’s population

each year.

Since Malthus in the late 18th century,scholars have postulated a number of

explanations for historical trends infertility and mortality. In the last third ofthe 20th century, major research effortsexplored the relationships between a widevariety of possible fertility determinantsand their impacts on birth rates.

Distal determinants—social and economicfactors. The basic theory of why couplesdecide to have fewer children is complex.The decision to bear fewer childrenrequires a change in values, which in turnmust be translated into changes in fertilitybehavior. The broadest investigations intofertility decline have focused on thepossible factors that change people’s valuesand how those factors may or may notaffect fertility. Factors affecting couples’values are mostly related to socioeconomicenvironment and include possibledeterminants such as children’s schoolingand health status, child survival, economicconditions, urbanization, status of women,religion, socioeconomic organization, andthe diffusion of ideas, among others.17

Proximate determinants. Four main factors,called proximate determinants of fertility,have a direct effect on fertility. All otherfactors, such as those listed above, operatethrough the proximate determinants toaffect fertility. The four main proximatedeterminants are marriage (age at

marriage and proportion of womenmarried); contraception (proportionusing contraception and effectiveness ofmethod); abortion (proportion ofpregnancies that are terminated); andinfecundity (lactational amennorhoea andsterility).18

The mechanisms of how proximatedeterminants of fertility affect birth ratesare well understood because they can bestudied relatively easily in a scientificallysound manner. The evidence is global innature and holds across all countries andpeoples. Because the connection tofertility decline is so direct and theimpacts are so dramatic, public policies onpopulation (and donor programs) havefocused, first, on providing informationand contraceptives to couples wanting tocontrol their fertility and, to a lesserextent, on raising the age at marriage.

Understanding how the more distalsocioeconomic determinants affect couples’decisions to delay sexual debut andmarriage, use contraception, breastfeed, orseek an abortion is more complex.

Economic Development andFertility

Generally, as countries improve theireconomic performance, higher incomes

5

What Influences Fertility Decline?

translate into better education and healthbehaviors. As a result, costs associated withhaving children rise and an increasingnumber of couples have fewer children.Declines in mortality may or may notprecede fertility declines.19 Mainlythrough the consideration of othervariables affecting fertility, this theory hasbeen the subject of considerable debateand revision since its introduction in the1960s.

In Europe and the United States, wheredemographic transitions took place overperiods of 100 years or longer, therelationship between rising incomes anddecreasing fertility is clear. However, incountries in which the demographictransition has occurred over a period ofjust a few decades, the relationshipbetween economic growth and fertility ismuch less clear. Table 1 shows someexamples of recent economic growth and

fertility trends. While lower-incomecountries experienced significant annualdeclines in economic health in the 1980sand 1990s, their fertility rates still felldramatically.

Several factors mediate the relationshipbetween population growth and economicgrowth. A recent analysis found that, inthe long term, countries with higher ratesof population growth have tended todemonstrate lower rates of economicgrowth (see Box 1).20

Countries that have had the “right”political, economic, social, and educationalenvironment, such as the Asian Tigers, havebeen able to capitalize on their rapiddemographic transitions. In those countries,the “demographic bonus” created by ashifting age structure that increased thenumber of workers per capita wasaccompanied by faster growth in gross

6

Table 1. Growth in Per Capita Gross Domestic Product and Decline inTFR, for Selected Countries: 1980 to 1995

GDP per capita Percent decline growth in percent in TFR

Country 1985–1995 1980–1995Bahamas –1.0 43Cameroon –7.0 12Côte d’Ivoire –4.3 28Guatemala 0.3 24Iran 0.5 26Jordan –2.8 29Madagascar –2.0 11Mexico 0.1 33Nicaragua –5.8 34Peru –1.6 31Senegal –1.2 15Zimbabwe –0.6 44Low-income countries (excluding China and India) –1.4 21Lower and middle-income countries –1.3 19Source: Data from Soubbotina, Tatyana P. and Katherine Sheram. 2000. Beyond Economic Growth: Meeting theChallenges of Global Development. Washington, D.C.: World Bank.

domestic product per capita. Other regionsof the world, however, such as parts of LatinAmerica and the rest of Asia, have not beenable to capitalize on the demographicbonus to promote economic growth. Forexample, South Korea increased netsecondary school enrollment from 38 to 84percent between 1970 and 1990 and morethan tripled expenditure per secondaryschool student. South America failed to takeadvantage of a similar opportunity to makesuch an investment.21

Child Mortality and FertilityChange

Scholars have attempted to identify avariety of other correlations to explainfertility decline. Researchers have spentconsiderable efforts over the past 30 yearsstudying the relationships betweenmortality (especially infant and childmortality) and fertility changes. Agenerally accepted view holds that lowerinfant mortality is a contributing factor tocouples’ decisions to have fewer births.22

The exact nature of the relationship,however, is still not well understood, andseveral different views on the topic prevail.

After noting that most developing countrieshave experienced or are experiencingsome type of simultaneous decline inmortality and fertility, Cohen, Barney, andMontgomery conclude the following:

“Their fertility declines are a product ofdiverse social, economic, political, andcultural changes, and are shaped aswell by a response to programs andmortality change. The precisecontribution of each of these factorsvaries from one society to another. Thus,

at the macro level, a search for a simpleand universal rule linking the timingof mortality and fertility declines wouldseem to be futile.”

They underline the point as follows:

“…[T]here can be nothing automaticor self-sustaining about the effects ofmortality decline on fertility. Thisdiversity should also put to rest thenotion that mortality decline can belinked to fertility decline by way ofsimple necessary or sufficientconditions. It may seem that aparticular configuration of social,political, and economic forces may berequired for any given country toembark on transition, but the outlinesof that configuration may be difficult todiscern in advance.” 23

In other words, recent research suggeststhat the completion of the fertility portionof demographic transition in developingcountries does not depend directly ontrends in infant and child mortality.

The onset of HIV/AIDS epidemics isconfusing the mortality-fertility linkages,

7

Box 1. The Economic Consequences ofPopulation Growth

◗ Rapid population growth has exercised a negativeimpact on the pace of economic growth in developingcountries.

◗ Rapid fertility decline contributes to reducing theincidence and severity of poverty.

◗ High fertility in poor countries has been a partialcause of the persistence of poverty—poverty thataffects both small and large families.

however. In some African countries,fertility has dropped rapidly while recentchild mortality has jumped. In Kenya, forexample, fertility declined by about 30percent between 1989 and 1998 whilechild mortality jumped by 32 percent overthe same period. Similar trends occurredin Zambia.24

Social, Cultural, andReligious Norms

Few trends are clearly discernible in theliterature on the relationship betweensocial, cultural, and religious norms andfertility. For example, in Europe in the17th and 18th centuries, socioeconomicnorms stipulated that newly marriedcouples had to set up their ownindependent households. Few couplescould afford to get married at an earlyage. As a result, the mean age at marriagein much of Europe in the 18th centurywas 25 years, with 15 to 20 percent ofwomen never marrying. In 20th-centuryUttar Pradesh, India, socioeconomicnorms stipulate that newlywedsimmediately live with the groom’s family;such an arrangement guarantees thecouple shelter and provisions. Aningrained dowry system creates furtherpressure for early marriage and forchildbearing to begin soon thereafter. As aresult, the mean age at marriage forwomen in Uttar Pradesh is 16 years, withalmost universal marriage. Earlymarriages, in addition to influencing TFR,lead to higher rates of maternal mortalityand lower levels of education for girls andwomen, with a concomitant effect oneconomic growth. In the case of 18th-century Europe, socioeconomic normsheld fertility low while, in 20th-century

Uttar Pradesh, norms have had theopposite effect and have stimulated highfertility.25

Observing these events, the sociologistNorman Ryder has argued that culturaland normative views may overcome arational assessment of the consequences ofchildbearing.26 Caldwell has theorized thata shift away from the extended familystructure to a child-centered nuclearfamily had the effect of stimulating theflow of wealth from parents to children,thereby reducing the demand forchildren.27,28 The impact of suchinstitutional structures on the proximatebehavioral determinants of fertility can, ofcourse, vary among societies.

The Diffusion Theory

If the socioeconomic variables discussedabove are not consistent triggers forfertility decline, what other mechanismsare at work to expedite the decline? Socialscientists have sought to explain the“diffusion of innovative attitudes andbehaviors” as an important means ofchanging couples’ fertility values andbehaviors.29 The diffusion process, bywhich certain individuals change theirattitudes and behavior, becomes a socialdynamic that spreads new ideas andbehavior related to reduced fertilitythroughout the population. Bongaarts andWatkins argue that fertility transitions tendto start in leader countries wheredevelopment is relatively high and thenspread to other countries within a region,generally before the other countries havereached the same level of development.30

However, while the diffusion process islinked to other socioeconomic changes,

8

the diffusion of ideas around fertilitycontrol and family planning has in factgreatly accelerated in countries or regionswhere good quality family planningservices and information are readilyavailable.31,32

Women’s Education

Female education has consistently beenassociated with lower fertility (with theeffects mediated by the presence orabsence of mass education, the strength ofthe family planning program, andemployment opportunities for women).33

Economist Paul Schultz concludes that

“…expansion of women’s schoolingclosely parallels the decline in fertilityacross high and low income countriessince 1960…Educated women couldhave lower fertility for many reasons, inaddition to the greater opportunity costof their time in childrearing. The socialand intellectual advantages thateducated women enjoy help them indeciphering, adopting, and usingeffectively, new and old forms of birthcontrol, and thereby avoidingunwanted births.” 34

Although gender inequities in educationduring the last 50 years are of legendaryproportions, a number of developingcountries made considerable progress inthe 1970s, 1980s, and 1990s—a span thatcorresponds with marked fertility declinesin many places. During the 1975–1995period, for example, the combined primaryand secondary enrollment ratio for girls (toboys) in developing countries increasedfrom 38 to 78 percent.35 In the 1980s and1990s, girls made significant gains in the

proportion attending secondary schools,with many low-income countries increasingschool enrollment for girls by 30 percent ormore in a 10-year period.36

While female primary education iscertainly important from an overalldevelopment and gender perspective,secondary education has a greater effecton fertility behavior (see Figure 1). A 1995study from Zimbabwe, which cut its TFRby nearly 50 percent between 1980 and1995, showed that after six years ofschooling, the negative correlationbetween education level and fertilitybehavior is significant, especially at thehighest levels of education (10+ years of

9

Number of children

0

1

2

3

4

5

6

7

8

Guate

mala

Colom

bia

Philip

pines

Nepal

ZambiaMali

NonePrimary Secondary

Source: Demographic and Health Surveys 1995–1999. Calverton, MD: Macro International, Inc.Note: For Mali, Zambia, and Nepal, data include secondary-level education and higher. The other three countries show secondary-level education only.

7.1

6.5

4.1

6.8 6.7

4.5

5.1

3.8

2.5

5.0 5.0

3.6

5.0

3.8

2.6

7.1

5.1

2.7

Figure 1. Average Number of Children perWoman by Education Level

schooling).37 Clearly, completion of thedemographic transition in developingcountries will indirectly depend on theextent to which young women receivesecondary schooling.

Use of Contraception

Figure 2 shows a clear relationshipbetween the total fertility rate andcontraceptive prevalence, one of the fourproximate determinants of fertility.

Listed as the first priority in the 2001report of National Research Council’sBoard on Sustainable Development is theacceleration of current trends in fertilityreduction by

“…meeting the large unmet need forcontraceptives worldwide, by postponinghaving children through education andjob opportunities, and by reducingdesired family size while increasing thecare and education of smaller numbersof children. Moreover, the lack of accessto family planning contributessignificantly to maternal and infantmortality, an additional burden onhuman well-being. Allowing families toavoid unwanted births, enhancing thestatus of women to delay childbearingand nurturing children, would resultin a billion fewer people [assuming a10 percent reduction in the projectedpopulation in 2050] and substantiallyease the transition towardsustainability.” 38

The last 30 years have seen substantialprogress in the area of family planningand reproductive health as demonstratedby a number of national success stories:

◗ In Latin America, Colombia, Brazil, andMexico have succeeded in providingmost citizens with high-quality familyplanning and no longer receivesignificant international assistance.

◗ In Asia, Thailand, Sri Lanka, Korea, andSingapore—and perhaps most recentlyIndonesia—have all made a successfultransition to lower fertility rates.

◗ In the Middle East, the fertility rates inIran, Tunisia, and Turkey have fallen tolow levels, and some family planningprograms in the region are nowpurchasing their own contraceptives.

By providing an enabling environmentand expanding access to family planning,national policies and programs canincrease contraceptive use. Thailand, Iran,

10

Contraceptive prevalence

Source: Ross, J., J. Stover, and A. Willard. 1999. Profiles for Family Planning and Reproductive Health Programs: 116 Countries. Washington,D.C.: The Futures Group International.

Total fertility rate

0 1 2 3 4 5 6 7 80

20

40

60

80

100

Figure 2. Contraceptive Prevalence andTotal Fertility Rate

Pakistan, and Bangladesh provideevidence of the importance of policies andprograms in promoting and facilitatingcontraceptive use.

Thailand. Thailand is a developmentsuccess story, particularly in regards to itsfamily planning program. Fertilitydeclined by nearly half between 1960 and1980. An economic analysis of thecontributions to fertility decline between1960 and 1980 found that “a major factorin facilitating fertility decline has been theThai government’s family planningprograms.”39 Both the public sectorprogram and the government-subsidized,nonprofit, private family planningassociation were effective in reachingThailand’s urban and rural population. Inaddition, the rapid increase in femaleeducation played a role in fertilitydecline.40

Iran. When governments lose focus onfamily planning, fertility can rise. Despitepromulgation of a population policy in1967, when Iran diverted attention fromfamily planning to other issues after the1979 revolution, the nation’s rate ofpopulation increase grew from 2.7 percentin 1976 to 3.4 percent in 1986. The TFRincreased from 6.3 in 1976 to 7.0 in1986.41 “As a result, the government facedgreat demands for food, health care,education, and employment. In February1988, for the first time, the prime ministerissued a statement on population tomembers of the cabinet, requesting thatthey consider population size and growthwhen setting policy.”42 With renewedgovernment focus on family planning,average annual growth fell from 3.4percent to roughly 2.5 percent in just afew years by 1991.

Pakistan versus Bangladesh. Divergent pathscan have marked fertility consequences.Since 1971, when Pakistan andBangladesh (formerly East Pakistan) split,the two nations have taken dramaticallydivergent approaches to populationgrowth. Bangladesh, still one of theworld’s poorest countries, made familyplanning a priority; in response, donorsprovided the country with significantfunding. Pakistan paid lip service to familyplanning, and donor funding was far lesssignificant. The differences of the past 30years are striking. From a common TFR ofaround seven in the early 1970s, Pakistan’scurrent TFR is 5.3 compared withBangladesh’s 3.3. Between 2001 and 2050,Pakistan’s population is projected to growby 144 percent to almost 350 million whileBangladesh’s population is expected to

11

Population (millions)

Source: United Nations. 2000. World Population Prospects: The 2000 Revision. New York: United Nations Population Division.

50

100

150

200

250

300

350

20502040203020202010200019901980

Figure 3. Populations of Bangladesh andPakistan, 1970 to 2050 (projected)

grow by 93 percent (see Figure 3).43

Pakistan has begun to focus on familyplanning, with the result that moderncontraceptive prevalence is now 24percent compared with less than 10percent at the beginning of the 1990s.44

12

Despite considerable progress over the last35 years, much remains to be done tocomplete the demographic transition inthe developing world. The data aboveshow that, in many countries with largepopulations, the fertility transition is onlypartially underway. In other countries, thetransition has not yet started. Over thenext 25 to 50 years, nations and donorswill face many challenges in stimulatingand maintaining demographic transitions,particularly the following:

◗ Continuing to manage the fertilitytransition in developing countries. Unlikethe long-term demographic transitions inEurope and the United States, whichhardly involved any governmentintervention, the transitions in 20th-century developing countries have beenactively “managed.” That is, governmentsand donors have specifically organizedand invested heavily in spurringdemographic transitions and providingthe inputs that otherwise would not havebeen available (e.g., contraceptives,training, supportive policy environments)and, in addition, have supported policiessuch as promoting female education thathave indirectly affected fertility rates.Given that the current majordemographic transitions are activelymanaged, any government and donorreduction in the management of thetransition is likely to result in a dramatic

reduction in the pace of the transition andperhaps stall it altogether in somecountries. As Caldwell put it, “Theimmediate challenge is to maintain someof the attitudes, policies, and expenditurepatterns that have so far sustained thedeveloping world’s fertility decline.”45

Caldwell has also noted that the need forfertility decline was kept on theinternational and national policy agendasthrough the conferences, workshops, andacademic inputs that convincedgovernments to invest in contraception.

◗ Reducing unintended births. One-thirdof births (32 percent) in the developingworld are ill-timed or unwanted, asdocumented in the latest DHS estimatesfor 51 developing countries.46 Thisstatistic is consistent with an earlierestimate from 1995 for 28 countries.47

◗ Meeting unmet need. About 114 millionwomen—over one in six—in thedeveloping world have an unmet needfor contraception. None of these womenis using a modern method; in addition,millions of couples rely on high-failuretraditional methods, often for lack ofaccess to a choice of modern methods.48

Many others are using a modern methodthat is unsuitable to their circumstances,leading to high discontinuation rates.They would benefit from access to better,more secure contraceptive methods.

13

Remaining Challenges

◗ Assisting couples wanting to usecontraception. One-third of marriedwomen in developing countries who arenot currently using contraceptives saythey intend to use a method within thenext year.49 Even more wish to use amethod later on, for example, afterbreastfeeding, but many of these womenlack knowledge of methods and servicesand/or access to family planning.Strengthened programs would helpeliminate barriers associated with lack ofknowledge and access, therebyexpanding contraceptive use andreducing unwanted fertility.

◗ Improving access to contraception.Many couples still cannot obtain amodern contraceptive method close tohome. A 1999 survey of the experienceof 88 developing countries showed thatonly about half (57 percent) of coupleshad reasonable access to five moderncontraceptive methods (pills, IUDs,condoms, and male and femalesterilization).50 The closest correlate tofertility decline is contraceptive use, asrecorded in more than three decades ofnational surveys. Clearly, if familyplanning programs could improve theirdistribution networks for contraceptivemethods and more couples in thepoorest countries had ready access to achoice among the main contraceptionoptions, the use of contraception wouldincrease and fertility would tend to fallfaster.51 Currently, the lack of access toservices or supplies is one of the brakeson faster fertility decline.

◗ Reducing failure and discontinuationrates. Much work remains to improvethe reliability of contraceptive use. Astudy of 15 countries concluded that

“…the total fertility rate (TFR) wouldbe between 4 and 29 percent lower inthe absence of contraceptive failure,”52

which averaged 14 percent. “Withoutother types of contraceptivediscontinuation, the TFR would bereduced by between 20 percent(Indonesia) and 48 percent (Jordan).More than half of recent unwantedfertility was due to either acontraceptive failure or a contraceptivediscontinuation in all countries exceptGuatemala.”53 Further, discontinuationwas negatively associated with thestrength of the family planningprogram. In countries with strongerprograms, discontinuation rates werelower. Discontinuation rates are highpartly because couples lack a full rangeof choice of contraceptives. No singlemethod works for all couples, and anarrow mix of contraception optionsleads many couples to stop use offamily planning unnecessarily.Strengthened programs and furtherstimulation of private sectordistribution are needed to addressthese challenges.

◗ Reaching adolescents. The fertilitytransition in historical Europe took placeover about a 150-year period. Europeancountries and the United States did notface rapid mortality declines as part ofthe transition and thus did not have toabsorb a huge increase in the number ofyounger people and couples cominginto young adulthood. In contrast,developing countries have experiencedfar greater population growth, requiringabsorption of disproportionate numbersof youth for care during childhood,investment in education, and jobcreation. Policies that slow the growth of

14

new cohorts will decrease pressures onthose governments that are strained tocapacity from increasing numbers ofyoung adults. Even in the few developingcountries that are at or nearreplacement, the numbers reachingemployment age will tend to outrun jobopenings for some years to come.Slowing the growth of the youngercohorts in the near future will greatlydecrease potential pressure ongovernments already strained to capacitywith increasing current numbers ofyoung adults.

As a result of recent high fertility inthe last four decades of the twentiethcentury, there are more young people inthe world than ever before—over onebillion young women and men betweenages 15 and 24. These young people arereaching their peak childbearing yearsand thus are the key to the world’sdemographic destiny. While youth as aproportion of the world’s populationpeaked in 1985 at 21 percent and isprojected to decline to 14 percent by2050, the actual number of youngpeople will grow from 859 million in1995 to 1.1 billion or more by 2050.54

This increase will occur unless fertilitybehaviors change and family planningprograms become more effective inreaching adolescents.

Even in Thailand, where fertility hasfallen dramatically, 30 percent of thepopulation is under age 15, and thepopulation is projected to grow by 15percent between 1999 and 2025, eventhough the average couple now hasfewer than two children. Raising theaverage age at which women have theirfirst child from 18 to 23 would reducethe population momentum by 40percent.55 In many parts of the

developing world, the percentage oftotal births to young women under age20 is high (see Figure 4), makingpostponement of early childbearingextremely important, which can bepromoted through increased schoolingand access to contraception, andthrough changing gender norms thatcontribute to early marriage.

◗ Raising the age at which women havetheir first child. Policies andprogrammatic approaches can raise theage at marriage and the age at first birth.For example, USAID has workedsuccessfully in India to stimulateenforcement of the legal age (18) atmarriage law and registration ofmarriages.56 Ensuring that young womenand men have access to contraceptives to

15

Source: United Nations Population Division. 2000. World Population Monitoring, 2000: Populations, Gender and Development. New York: United Nations Population Division.

0 5 10 15 20

Oceania

Other Europe

Eastern Europe

Northern America

Latin America and the Caribbean

Other Asia

South Central Asia

Northern Africa

Sub-Saharan Africa 18.1

9.6

18.6

5.1

16.5

13.5

14.7

4.1

5.9

Figure 4. Percentage of All Births toWomen under Age 20, by Region/Subregion

delay the first pregnancy and to spacesubsequent pregnancies is also crucial.

In addition, early childbearingamong young women interrupts youngwomen’s schooling, reduces theirworkforce involvement, and constrainsimprovements in the status of women. A1998 study in Cameroon showed howfamily planning programs are likely tohave raised school enrollments.Quantitative data from 8,000 schoolhistories showed that unplannedpregnancies accounted for an estimatedone of every five school dropouts. Theelimination of unplanned pregnancieshelps increase enrollment retention andnarrow the gender gap in secondaryschooling.57

◗ Increasing educational opportunities,including opportunities for girls. Thediscussion above on the strongrelationship between schooling for girlsand decreased fertility rates points to theneed to continue to expand access toschooling for girls—and for boys.Schooling establishes alternativestructures of authority that weaken thecontrol of parents, particularly for girlswho are educated beyond the primaryschool level. Educated women are alsomore empowered to participate in thelabor force and in decision makingwithin the family.

◗ Reducing abortion. Many abortionsoccur for lack of good contraceptiveavailability and services.58 Developingcountries account for 35 millionabortions annually; of these, 19 milliontake place in countries where abortion isillegal and generally unsafe. “Every year,70,000 women die of complications ofabortion performed by unqualifiedpeople in unhygienic conditions, orboth; many suffer serious, oftenpermanent disabilities.”59 ExcludingChina, 79 percent of abortions occur incountries where abortion is illegal orsharply restricted.

By the best estimates, about one ineight pregnancies in Africa ends inabortion (12.9 percent); in LatinAmerica, the figure is two in five (39.7percent); and in Asia (including Chinaand Japan, where abortion is legal), overone in four (28.9 percent).

◗ Reducing the availability ofcontraceptives will drive women to useabortion, even in countries with lowfertility. Moreover, abortion can increaseif reductions in the desired number of

16

Abortions per 100 pregnancies

Source: Rahman, M., J. DaVanzo, and A. Razzaque. 2001. “Do Family Planning Services Reduce Abortion in Bangladesh?” The Lancet 358(9287): 1051.

0

1

2

3

4

5

6

199819941990198619821979

Comparison

Treatment

Figure 5. Abortion in an Area with WideAccess to Family Planning (FP) and aComparison Area with Poor Access to FP,Bangladesh: Selected Years, 1979 to 1998

children outpace the availability ofcontraceptive methods and services tomeet the growing needs of thepopulation. High levels of unintendedpregnancies, which can occur whenwomen do not have access tocontraception, tend to result in highlevels of abortion.

Compelling evidence comes from astudy in the Matlab area of Bangladesh,comparing a control area, in whichfamily planning was less available, withan area in which family planningservices have been widely accessible overthe years.60 Providing women with accessto high-quality family planning servicesnot only helps individuals and coupleshave the number of children they wantbut also reduces the incidence ofabortion. In the Matlab area, womenhave fewer abortions (see Figure 5)because they have fewer pregnancies andtherefore fewer unintended pregnancies.In the comparison area, women havemore unintended pregnancies andhigher rates of abortion.

A 1997 study in three Central AsianRepublics (Kazakhstan, Kyrgyzstan, andUzbekistan) documented thereplacement of abortion bycontraception as a means of birthcontrol. The study provides ampleevidence that reliance on abortion isdiminishing in these countries ascontraception is substituted.Contraceptive prevalence (modern andtraditional methods) ranges between 56and 59 percent and increased by one-third to one-half between 1991 and1996. In contrast, abortion ratesdeclined by as much as one-half duringthe same period.61

Improved use of moderncontraception reduces the need for

abortions by reducing mistimed andunwanted pregnancies and by replacinghigh-failure traditional methods.

◗ Contributing to safe motherhood. In thelatest (1995) estimate, approximately511,000 maternal deaths occur annuallyin the developing world.62 The risk issmallest in countries that include strongfamily planning services in their healthservices.63 Contraception, offered at thetime of abortion or birth as well asroutinely at health centers, reducespregnancies and therefore deaths.Moreover, high-risk women (e.g., highparity, older women) are especially likelyto use a contraceptive method if it ismade available to them. Countries withthe highest maternal mortality rates aregenerally those in need of the greatestlevel of donor assistance; they are amongthe poorest and therefore lack theinfrastructure necessary for caring foremergency obstetric cases, trainingperipheral staff, and maintaining securesupply lines. Family planning is a lowcost way of contributing to safemotherhood outcomes, yet, as Figure 6shows, countries in Africa with thehighest maternal mortality tend to bethose with the lowest contraceptiveprevalence.

◗ Meeting the growing need for resources.Resources will be needed not only tomaintain contraceptive use at currentlevels but also to meet ever-growingdemands for family planning and tosupport new and ongoing fertilitytransitions. For the foreseeable future,family planning programs must continueto address unmet need in order toreduce mistimed and unwanted fertility.Even if contraceptive prevalence were

17

not to increase at all between 2000 and2015, developing countries would stillhave to serve 125 million additionalusers (see Figure 7). Expected increasesin new demand for lower fertility willadd another 92 million new users;accordingly, over the next 15 years, anestimated 217 million additional usersare expected worldwide, that is, 55,000additional users per working day.Meanwhile, overall government anddonor funding seems to be declining.

As Figure 8 shows, despite theinexorable growth in the number of

couples and the number ofcontraceptive users, donor contributionsfor contraceptives have fallen from the1996 peak and have reached a plateau.Developing country governmentsalready cover roughly three-fourths of allprogram costs in their own nations, butthey generally lack foreign currency tobuy contraceptive supplies frominternational sources. For many of thosecountries, donors have historically beenthe mainstay for contraceptives, apartfrom partial exceptions such asIndonesia, India, and, most recently,

18

Percent (CPR)

Source: Demographic and Health Surveys and Hill, K., Carla AbouZahr, and Tessa Wardlaw. 2001. “Estimates of Maternal Mortality for 1995.” Bulletin of the World Health Organization 79(3): 182–193.

Maternal deaths per 100,000 live births

0

10

20

30

40

50

60

Mali, 1

996

Ethio

pia, 2

000

Côte

d'Iv

oire, 1

999

Sene

gal, 19

99

Nigeria

, 199

9

Ghana

, 199

8

Zambia

, 199

6

Tanz

ania,

199

9

Ugand

a, 2

000–

01

Malawi,

2000

Keny

a, 1

999

Zimba

bwe, 1

999

Sout

h Af

rica, 1

998

0

500

1,000

1,500

2,00055.1

341

50.4

609

1,339

32.0

26.1

576

18.2

1,056 1,059

16.914.4 13.4

8.6 8.2 7.36.3

4.5

867

583

1,1291,198 1,183

1,841

630

Figure 6. Contraceptive Prevalence Rate (CPR) and Maternal MortalityRatio by Country

Turkey. USAID has been the leadingdonor in providing contraceptives overthe past 35 years. In 1999, USAID wasresponsible for 37 percent of all donorassistance for contraceptive supplies,with the World Bank providing 16percent, the UNFPA 11 percent, DFID(British government) 10 percent, andthe European Community 10 percent.64

Between 1997 and 1999, shortfalls incontributions to the UNFPA necessitateda full two-thirds cut in commoditypurchases, shortfalls that were barelymade up by last minute contributions.65

◗ Continued donor assistance for familyplanning. A number of donororganizations, including USAID, whichhas been the largest donor by far in

supporting family planning programs,UNFPA, the World Bank, and Europeanand Japanese donors, have contributedsignificantly to the fertility transition.Donor assistance has been especiallycrucial in policy development, researchand data collection, training, commoditysupply, program management, socialmarketing, and quality improvements.Donors have played a key leadership roleby supporting national governments inplacing a higher priority on improvingreproductive health, pioneeringinnovative approaches, fostering thereplication of proven programs, fundingcontraceptive procurement and servicedelivery (both directly and bystimulating governments to do so), and

19

125 million (population growth)

525(current use)

Source: UNFPA. 2002. Reproductive Health Essentials— Securing the Supply: Global Strategy for Reproductive Health Commodity Security. New York: United Nations.

92 million(demand increase)

Contraceptive users (millions)

0

100

200

300

400

500

600

700

800

20152000

525525

650

742

Figure 7. Projected Increase inContraceptive Users inDeveloping Countries(217 million additional users)

$US (millions)

Source: Interim Working Group on Reproductive Health Commodity Security. 2001. “Donor Funding for Reproductive Health Supplies: A Crisis in the Making.” Washington, D.C.: Population Action International.

50

100

150

200

1999

1998

1997

1996

1995

1994

1993

1992

1991

1990

Figure 8. Donor Contributions forContraceptive Commodities

encouraging other donors to contributeto this effort.

By one estimate, USAID assistancein 2000 was directly responsible forproviding modern contraception to 27million couples in developingcountries.66 As a result, 10 million womenwere able to avoid an unintendedpregnancy that year, leading to

◗ 3.4 million fewer unintendedbirths;

◗ 5.0 million fewer abortions; and◗ 1.1 million fewer miscarriages.

◗ By preventing these unintendedpregnancies, 34,000 mothers’ lives weresaved: 16,000 from pregnancy-relatedcauses other than induced abortion, and18,000 from unsafe abortions. Inaddition, 210,000 infant lives weresaved.

By 1990, organized family planningprograms had been responsible forabout half of the recorded fertility

decline since the 1950s. The average netimpact in the developing world in thelate 1980s was estimated at 1.4 births perwomen.67 Through 1990, FP programshad already produced a populationreduction of about 412 million personsand were projected to add considerablyto that figure.68

Donor leadership will continue tobe needed for the foreseeable future inwork with governments of the leastdeveloped countries to ensure access toa range of contraceptives (in addition toproviding other reproductive health andHIV/AIDS services), especially in Africaand parts of South Asia and the NearEast. Donor assistance is also criticallyneeded to promote expandededucational opportunities, particularlyfor girls. Donor funds have sustained thesupply of contraceptives—the use ofwhich remains a crucial proximatedeterminant of fertility.

20

Two types of consequences areassociated with a sluggish fertility

transition in the developing world—socioeconomic and programmatic.

Socioeconomic consequences. Much of theworld is suffering from economic crises—more so in the weakest developingcountries, with no relief on the horizon.Global economic cycles do not explaincurrent conditions. Between 1985 and1995, food production lagged behindpopulation growth in 64 of 105developing countries, with Africa faringthe worst.69 Population and food securityis a key component of the United NationsFood and Agriculture Organization(FAO) Sustainable DevelopmentDepartment’s strategy to meet the goals ofthe 1996 World Food Summit Plan ofAction.70 While global food productioncan probably be increased somewhat,particularly if countries improve farmingtechniques and land management, largerpopulations require greater quantities offood to overcome current malnutritionand to achieve better living standards.Satisfying such needs will prove costly aspeople are forced to rely on marginalland. The better land is already used;irrigation systems have been built onmore favorable sites; and water isbecoming scarcer.71 Troublesomeenvironmental effects related toadditional deforestation, soil erosion,

pollution from pesticides, and loss ofspecies all demand attention. All theseconsequences, observes John Bongaarts inthe January 2002 issue of ScientificAmerican (and echoed by renownedscientist Edward Wilson in his February2002 article in the same journal), couldbe mitigated by slower populationgrowth.72 While some would argue thatinequalities between nations have fueledthe economic crises, broad agreementholds that denying women access to safe,affordable contraception results inunwanted births and can only aggravatethe current economic crises confrontingmany countries.

At the same time, in 68 developingcountries, more than 40 percent of thetotal population is under 15 years of age.As Professor Wilson points out,

“A country poor to start with andcomposed largely of young children andadolescents is strained to provide evenminimal health services and educationfor its people. Its superabundance ofcheap, unskilled labor can be turned tosome economic advantage, butunfortunately also provides cannonfodder for ethnic strife and war…theindustrial countries will feel theirpressure in the form of many moredesperate immigrants and the risk ofspreading international terrorism.”

21

Conclusion

All of the adolescents referred to byProfessor Wilson will have moved into thereproductive stage of life in the next 15years. Given the advances in women’seducation and the nearly universal desireof couples for smaller family sizes, pooraccess to family planning today will onlyincrease the future ranks of theunemployed, poorly educated, andpolitically radicalized.

Programmatic consequences. A slower fertilitydecline translates into greater numbers ofcouples and potential contraceptive usersin the future. There is a time penalty onweak action, especially in the face ofdemonstrable demand for services;whatever is not done now is harder to dolater. Rising contraceptive prevalence is apositive development, but, due topopulation momentum through which ever-larger base populations will continue togrow, ever-larger numbers ofcontraceptives will be needed to meet thedemand. While a few still adhere to thenotion that population growth does nothave negative global consequences,73 in

the context of a rapidly modernizingworld, current evidence based onlongitudinal analysis suggests that asmaller ultimate population size willgreatly increase prospects for a sustainableworld in which all citizens can enjoy a lifefree of poverty while satisfying basichuman needs.74

The world’s population has not stoppedgrowing and is growing fastest in thepoorest countries. To achieve sustainabledevelopment, strong measures bygovernments and donors to promotefertility decline in developing countries—and to give individuals and couples themeans to do so—need to continue for theforeseeable future.

Sustaining the demographic transitionrequires focused attention on theproximate determinants of fertility. Theevidence points to significant unmet needfor fertility control, and providing good-quality family planning services is theeasiest and least expensive way to satisfythat unmet need.

22

1. Crossette, Barbara. 2002. “PopulationEstimates Fall as Poor Women AssertControl.” The New York Times, March10.

2. United Nations. 2000. World PopulationProspects: The 2000 Revision. New York:United Nations Population Division.

3. United Nations. 2000. World PopulationProspects: The 2000 Revision. New York:United Nations Population Division.

4. United Nations. 2000. World PopulationProspects: The 2000 Revision. New York:United Nations Population Division.

5. Caldwell, John C.. 2002. “TheContemporary Population Challenge.”Paper presented at the Expert GroupMeeting on Completing the FertilityTransition. UN/POP/CFT/2002/BP/1. United Nations PopulationDivision. Department of Economicand Social Affairs. United NationsSecretariat. New York, March 11–14.New York: United Nations.

6. National Research Council, PolicyDivision, Board on SustainableDevelopment. 2001. Our CommonJourney: A Transition towardSustainability. Washington, D.C.:National Academy Press, p. 1.

7. Wilson, Edward O. 2002. “TheBottleneck.” Scientific American(February): 82–91.

8. The notion of replacement level being2.1 children per couple may need tobe revised particularly in countrieswhere HIV and associated infectionsare raising the mortality rates even asfertility is declining.

9. United Nations. 2000. World PopulationProspects: The 2000 Revision. New York:United Nations Population Division.

10. Guengant, Jean-Pierre and John F.May. 2001. “Impact of the ProximateDeterminants on the Future Course ofFertility in Sub–Saharan Africa.” Paperpresented at a workshop on Prospectsfor Fertility Decline in High FertilityCountries. New York, July 9–11. NewYork: United Nations PopulationDivision.

11. Guengant, Jean-Pierre and John F.May. 2001. “Impact of the ProximateDeterminants on the Future Course ofFertility in Sub–Saharan Africa.” Paperpresented at a workshop on Prospectsfor Fertility Decline in High FertilityCountries. New York, July 9–11. NewYork: United Nations PopulationDivision.

23

Endnotes/References

12. Bongaarts, J. 1999. “The FertilityImpact of Changes in the Timing ofChildbearing in the DevelopingWorld.” New York: Population CouncilWorking Paper No. 120, p. 28.

13. United Nations. 2000. World PopulationProspects: The 2000 Revision. New York:United Nations Population Division.

14. U.S. Bureau of the Census. Data fromthe International Database (IDB).http://www.census.gov/cgi-bin/ipc/idbsum?cty=BC. Assessed July 10, 2002.

15. UNAIDS. 2000. Report on the GlobalHIV/AIDS Epidemic. New York: JointUnited Nations Programme onHIV/AIDS. United Nations. 2000.World Population Prospects: The 2000Revision. New York: United NationsPopulation Division.

16. King, R., J. Estey, S. Allen, S. Kegeles,W. Wolf, C. Valentine, and A.Serufilira. 1995. “A Family PlanningIntervention to Reduce VerticalTransmission of HIV in Rwanda.”AIDS 9: S45–S51. Cited in S. Allen, E.Karita, N. N’Gandu, and A. Tichacek,“The Evolution of Voluntary Testingand Counseling as an HIV PreventionStrategy.” In L. Gibney, R.DiClemente, and S. Vermund, eds.Preventing HIV in Developing Countries:Biomedical and Behavioral Approaches.New York: Kluwer Academic/PlenumPublishers.

17. Casterline, John B., ed. 2001. DiffusionProcesses and Fertility Transition.Washington, D.C.: National AcademyPress.

18. Bongaarts, John. 1978. “A Frameworkfor Analyzing the ProximateDeterminants of Fertility.” Populationand Development Review 4(11): 104–132.

19. World Bank. 1984. World DevelopmentReport 1984. Washington, D.C.: OxfordUniversity Press.

20. Birdsall, Nancy, Allen C. Kelly, andSteven W. Sinding. 2001. PopulationMatters: Demographic Change, EconomicGrowth, and Poverty in the DevelopingWorld. London: Oxford UniversityPress.

21. UNFPA. 1998. State of the WorldPopulation. New York: UNFPA.http://www.unfpa.org/swp/1998/newsfeature1.htm

22. O’Neill, Brian and Deborah Balk.2001. “World Population Futures.”Population Bulletin 56(3). Birdsall,Nancy, Allen C. Kelly, and Steven W.Sinding. 2001. Population Matters:Demographic Change, Economic Growth,and Poverty in the Developing World.London: Oxford University Press.

23. Cohen, Barney and Mark R.Montgomery. 1998. “Introduction.” InMark R. Montgomery and BarneyCohen, eds. From Death to Birth:Mortality Decline and ReproductiveChange. Washington, D.C.: NationalAcademy Press.

24. MEASURE DHS. 2002. Stat Compiler.Calverton, MD: ORC Macro.http://www.measuredhs.com.

25. International Institute for PopulationSciences (IIPS) and ORC Macro. 2000.

24

National Family Health Survey (NFHS-2),1998–99: India. Mumbai: IIPS. WorldBank. 1984. World Development Report1984. Washington, D.C.: OxfordUniversity Press.

26. Ryder, Norman B. 1983. “Fertility andFamily Structure.” Population Bulletinof the United Nations 15: 15–33.

27. Caldwell, J.C. 1982. “The Wealth FlowsTheory of Fertility Decline.” In C.Horn and R. Mackensen, eds.Determinants of Fertility Trends: TheoriesRe-examined. Liege, Belgium: OrdinaEditions.

28. Caldwell, J.C. 1994. “The Course andCauses of Fertility Decline.”Distinguished Lecture Series onPopulation and Development. For theInternational Conference onPopulation and Development. Liege,Belgium: The International Union forthe Scientific Study of Population(IUSSP).

29. Casterline, John B., ed. 2001. DiffusionProcesses and Fertility Transition. Wash-ington, D.C.: National Academy Press.

30. Bongaarts, John and Susan Watkins.1996. “Social Interactions andContemporary Fertility Transitions.”Population and Development Review22(4): 639–682.

31. Casterline, John B., ed. 2001. DiffusionProcesses and Fertility Transition.Washington, D.C.: National AcademyPress.

32. Caldwell, J.C. 1994. “The Course andCauses of Fertility Decline.”

Distinguished Lecture Series onPopulation and Development. For theInternational Conference onPopulation and Development. Liege,Belgium: The International Union forthe Scientific Study of Population(IUSSP).

33. Bledsoe, Caroline H., John B.Casterline, Jennifer Johnson-Kuhn,and John G. Haaga. eds. 1998. CriticalPerspectives on Schooling and Fertility inthe Developing World. Washington, D.C.:National Academy Press.

34. Schultz, T. Paul. “The FertilityTransition: Economic Explanations.”In N.J. Smelser and P.B. Baltes, eds.International Encyclopedia of the SocialSciences. Amsterdam: Elsevier Science,Ltd., pp. 14–15.

35. United Nations. 1996. Economic andSocial Information: Women at a Glance.New York: United Nations. http://www.un.org/ecosocdev/geninfo.

36. World Bank. 2002. World Bank Research.Washington, D.C. http://www.worldbank.org/data/wdi2001/pdfs/tab2_12.pdf.

37. Thomas, Duncan and John Maluccio.1996. “Fertility, Contraceptive Choice,and Public Policy in Zimbabwe.” WorldBank Economic Review 10(1): 189–222.

38. National Research Council, PolicyDivision, Board on SustainableDevelopment. 2001. Our CommonJourney: A Transition towardSustainability. Washington, D.C.:National Academy Press, p. 12.

25

39. Schultz, T. Paul. 1997. “Returns toScale in Family PlanningExpenditures: Thailand, 1976–1981.”Unpublished paper, Yale University.

40. Knodel, John, AphichatChamratrithirong, and NibhonDebavalya. 1987. Thailand’sReproductive Revolution: RapidFertility Decline in a Third-WorldSetting. Madison: The University ofWisconsin Press.

41. Abbasi-Shavazi, Jalal. 2002. “RecentChanges and the Future of Fertility inIran.” Paper presented at the ExpertGroup Meeting on Completing theFertility Transition. PopulationDivision, Department of Economicand Social Affairs, United NationsSecretariat. New York, March 11–14.

42. Aghajanian, Akbar. 1995. “A NewDirection in Population Policy andFamily Planning in the IslamicRepublic of Iran.” Asia PacificPopulation Journal 10(1): 3–20.Aghajanian, Akbar and Amir H.Merhyar. 1999. “Fertility,Contraceptive Use and FamilyPlanning Program Activity in theIslamic Republic of Iran.” InternationalFamily Planning Perspectives 25(2):98–102.

43. Calculated from Population ReferenceBureau World Population Data Sheet2001.

44. Pakistan Demographic and HealthSurvey 1997.

45. Caldwell, John C. 2002. “TheContemporary Population Challenge.”

Paper presented at the Expert GroupMeeting on Completing the FertilityTransition. UN/POP/CFT/2002/BP/1. United Nations PopulationDivision. Department of Economicand Social Affairs. United NationsSecretariat. New York, March 11–14.New York: United Nations.

46. Westoff, Charles F. 2001. Unmet Needat the End of the Century.Demographic and Health SurveysComparative Reports No. 1, Calverton,MD: ORC Macro.

47. Bankole, Akinrinola and Charles F.Westoff. 1995. “Childbearing Attitudesand Intentions.” DHS ComparativeStudies, No. 19. Calverton, MD: MacroInternational, Inc.

48. Ross, J. and W. Winfrey. 2001. “UnmetNeed in the Developing World andthe Former USSR: An UpdatedEstimate.” Washington, D.C.: FuturesGroup, POLICY Project. Submitted forpublication.

49. Ross, John A and William L. Winfrey.2001. “Contraceptive Use, Intention toUse, and Unmet Need During theExtended Postpartum Period.”International Family Planning Perspectives27(1):20–27.

50. Ross, J.A. and J. Stover. 2001. “TheFamily Planning Program EffortIndex: 1999 Cycle.” Studies in FamilyPlanning 27(3): 119–129.

51. Ross, John, Karen Hardee, ElizabethMumford, and Sherine Eid. 2002.“Contraceptive Method Choice inDeveloping Countries.” International

26

Family Planning Perspectives 28(1):32–40.

52. Blanc, Ann K., Sian Curtis, and TrevorCroft. 1999. “Does ContraceptiveDiscontinuation Matter? Quality ofCare and Fertility Consequences.”Working Paper WP-99-14. Chapel Hill:University of North Carolina,MEASURE EVALUATION.

53. Blanc, Ann K., Sian Curtis, and TrevorCroft. 1999. “Does ContraceptiveDiscontinuation Matter?: Quality ofCare and Fertility Consequences.”Working Paper WP-99-14. Chapel Hill:University of North Carolina,MEASURE EVALUATION.

54. United Nations Population Fund(UNFPA). 1999. State of the WorldPopulation. New York: United Nations.

55. United Nations Population Fund(UNFPA). 1999. State of the WorldPopulation. New York: United Nations.

56. Government of Uttar Pradesh. 2000.Population Policy of Uttar Pradesh.Lucknow: Department of Health andFamily Welfare.

57. Elonddou-Enyegue, Parfait, JulieDaVanzo, Simon Yana, and F. Tchala-Abina. 2000. “The Effects of HighFertility on Human Capital underStructural Adjustment in Africa.”Santa Monica, CA: RAND.

58. Henshaw, Stanley K., Susheela Singh,and Taylor Haas. 1999. “TheIncidence of Abortion Worldwide.”International Family Planning Perspectives25 (Supplement): S30–S38. Presented

also in Alan Guttmacher Institute.1999. Sharing Responsibilities: Women,Society and Abortion Worldwide. NewYork: Alan Guttmacher Institute.Appendix Table 3, p. 53.

59. IPAS. 2001. http://www.ipas.org.

60. Rahman, M., J. DaVanzo, and A.Razzaque. 2001. “Do Family PlanningServices Reduce Abortion inBangladesh?” The Lancet 358(9287):1051.

61. Westoff, Charles F., Almaz T.Sharmanov, Jeremiah Sullivan, andTrevor Croft. 1998. “Replacement ofAbortion by Contraception in ThreeCentral Asian Republics.” Calverton,MD: POLICY Project and MacroInternational, Inc.

62. Hill, Kenneth, Carla AbouZahr, andTessa Wardlaw. 2001. “Estimates ofMaternal Mortality for 1995.” Bulletinof the World Health Organization 79(3):182–193.

63. Ross, J.A., O.M.R. Campbell, and R.A.Bulatao. 2001. “The Maternal andNeonatal Programme Effort Index(MNPI).” Tropical Medicine andInternational Health 6(10): 1–12.

64. United Nations Population Fund(UNFPA). 2000. “Donor Support forContraceptives and Logistics 1999.”New York: UNFPA, p. 3–4.

65. United Nations Population Fund(UNFPA). 2000. “Donor Support forContraceptives and Logistics 1999.”New York: UNFPA. See also InterimWorking Group on Reproductive

27

Health Commodity Security (IWG).2001. “Meeting the Challenge.”Prepared for Seminar in Istanbul,Turkey, 2001.

66. These figures are based on an analysiscontained in “Potential Impact ofIncreased Family Planning Fundingon the Lives of Women and TheirFamilies Overseas” (June 2000, AlanGuttmacher Institute, PopulationReference Bureau, Futures Group,and Population Action International),which estimated the benefits of a $169million increase in the USAIDpopulation budget. These figures werescaled up to represent the impact ofthe full USAID population budget in2000.

67. Bongaarts, J. 1993. “The FertilityImpact of Family Planning Programs.”New York: Population CouncilWorking Paper No. 47.

68. Bongaarts, J., W. P. Mauldin, and J.E.Phillips. 1990. “The DemographicImpact of Family Planning Programs.”Studies in Family Planning 21(6):299–310.

69. United Nations Population Fund(UNFPA). 2001. State of the WorldPopulation. New York: United Nations.

70. FAO. SD Dimensions. People:Population. http://www.fao.org/sd/

PE3_en.htm. Assessed on July 10,2002.

71. See analysis of China’s foodproduction prospects in EdwardWilson’s 2002 article in ScientificAmerican, “The Bottleneck.” Wilson’sdetailed analysis of carrying capacityof China’s grain production (with themost favorable assumptions aboutproductivity), supported by a host ofinternational studies, estimates that in23 years (2025) China will beimporting 175 million tons of grainper year to sustain its population. Thisamount equals the entire amount ofgrain currently exported by the world.

72. Bongaarts, J. 2002. “Population:Ignoring Its Impact.” ScientificAmerican (January): 67–69.

73. Wattenberg, Ben. 1997. “ThePopulation Explosion Is Over.” NewYork Times Magazine, November 23.

74. Wilson, Edward O. 2002. “TheBottleneck.” Scientific American(February): 82–91. Bongaarts, J. 2002.“Population: Ignoring Its Impact.”Scientific American (January): 67–69.Birdsall, Nancy, Allen C. Kelly, andSteven W. Sinding. 2001. PopulationMatters: Demographic Change, EconomicGrowth, and Poverty in the DevelopingWorld. London: Oxford UniversityPress.

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Director, POLICY ProjectThe Futures Group International1050 17th Street, NWSuite 1000Washington, DC 20036Tel: 202-775-9680Fax: 202-775-9694E-mail: policyinfo@tfgi.comInternet: www.policyproject.com