DEMOGRAPHY Volume 7, Number 2 May1970

FAMILY PLANNING AND FERTILITY IN TUNISIA

Robert J. LaphamThe Population Council, 245 ParkAvenue, NewYork, NewYork 10017

Abstract-The crude birth rate for the Tunisian population in 1967-68 isestimated to be about ten percent lower than in 1961-65 although the ratesare subject to a wide margin of error. Unless the birth registration systemis becoming steadily worse or unless the Tunisian population has beendecreasing in size, however, the birth rate has fallen; births registered in1967 or in 1968 were fewer in number than births registered in 1964, 1965,or 1966. The downturn in the crude birth rate occurred shortly after anofficial national family planning program was inaugurated, Estimates ofbirths averted by contraceptive use, however, suggest that only about one­third of the decrease in the rate could be attributed to accomplishmentsof the program. Occurring at the same time were changes in the age struc­ture which led to smaller numbers of women in the peak reproductive agesand changes in the social status of women which included a sharp redue­tion in the proportion married in the age group 15-19.

status of wornen which have resulted in,among other things, a later age at mar­riage.

FAMILY PLANNING IN TUNISIA

Program Deuelopmeni

Following diseussions in 1962and 1963,and a visit by Tunisian offleials to eoun­tries with existing programs, Tunisia be­gan a limited (calIed experimental) offi­cial family planning program in 1964.(On the development of family planningin Tunisia, English readers should seeespecially: Mauldin, Bereison, andHardy, 1963; Daly, 1966; and Poveyand Brown, 1968.) The Ford Foundationend the Population Council arrangedfinancial and personnel assistanee. Bythe time anational program was inaugu­rated in June, 1966, thirty-nine familyplanning centers were in operation inhospitals and clinics. Mobile units pro­vided services in outlying parts of eachof the thirteen provinces in Tunisia, A1964 KAP survey (the sample was

The list of countries evidencing fer­tility declines in the 1960's is not verylong, particularly in the Arab world. In1967 and 1968, the crude birth rate forthe Tunisian population appears to havefallen about ten percent from the levelsobserved in 1961-65. The elements ofthe proeess of fertility change in Tu­nisia warrant careful attention, there­fore. They may indieate necessary de­velopments in other places, as weIl aspoint to further intensified changesrequired within Tunisia, if the goal ofreduced fertility is to be attained.

The downturn in the erude birth rateoceurred shortly after an official nationalfamily planning program was inaugu­rated. Estimates of births averted bycontraceptive use, however, suggest thatat most only about one-third of the de­crease in the birth rate could be attrib­uted to accomplishments of the program.Occurring at the same time were changesin the age structure whieh led to smallernumbers of women in the peak repro­ductive ages, and changes in the social

241

DEMOGRAPHY, volume 7, number 2, May1970

national program began, may have hada little less over-all impact than some­times presumed, although it probablydid retard by a year or so the creationof a Department of Family Planning. InTunisia, there has been a seasonal pat­tern, with more lUD acceptors in theperiod January to June than from Julyto December. Bourguiba's speech cameon August 12, 1966, but there was anincrease in acceptance in the latter halfof 1966, compared to a big decrease inthe latter half of 1965. Total insertionsby six-month periods are shown belowfor 1965 and 1966, as weIl as first inser­tions for 1967.

President Bourguiba's speech also il­lustrates the problems that can arisefrom statistical misinterpretations, i.e.,information given to President Bour­guiba led hirn to understate the averageannual intercensal growth rate. Illustra­tive of the many pro-natalist commentsmade by Bourguiba in his 1966 speechare: "The last Census (1966) has shownan increase rate of 2.2 or 2.3 which doesnot justify our apprehensions. The Tu­nisian population is increasing at a rea­sonable rate"; "... all these coupleshostile to procreation do not fulfill theirduties to the nation"; "We must havechildren to prevent our population frombecoming aged"; "... that a poverty­stricken family should have a crowd ofchildren is a necessary evil: it counter­balances the insufficient birth rate amongpeople who believe they are free to leada pleasure-seeking life without worry­ing about the nation's future" (Studiesin Family Planning, 1967; Povey andBrown, 1968).

In 1968, a renewed national programbegan to take form. A new departmentfor family planning and maternal andchild health services was created. In

242

drawn disproportionately from townsand urbanized areas where family plan­ning services were offered, but excludedthe capital city of Tunis) indicatedfairly widespread approval of familyplanning, but rather poor knowledge andlittle use of contraception. Fifteen per­cent of the respondents had ever usedany method of contraception (Morsa,1966). Particularly in 1965, the Neo­Destourian party (Tunisia has a oneparty government) participated in fam­ily planning educational and promotionalactivities (Studies in Family Planning,1966). This work was carried out on alocal level: women were encouraged touse family planning; President Bour­guiba's support of family planning wasemphasized; in a few cases incentivesof food and clothing from governmentsupplies were offered. In some areas,notably the provinces of Beja and LeKef, government authorities exudedconsiderable enthusiasm and interest inobtaining initial aeceptors. The maincontraceptive method offered has beenthe lUD.

So far, this overview may appearquite promising, and although some ef­forts were constructive for both theshort-run and Ionger-range developmentof family planning in Tunisia, the re­sults were not overly encouraging, as weshall see shortly. Administrative difficul­ties, lack of personnel, poor (and insome cases non-existent) follow-up careof acceptors, and a shift in position onthe part of President Bourguiba, all be­came problems for the development ofan efficient, respected, and effective fam­ily planning program. (These and othergrowth problems are discussed by Poveyand Brown, 1968.) The lack of adequateIollow-up care continues to be a problemin the Tunisian program. although it isnow at least officially recognized as adifficulty to be overcome. PresidentBourguiba's initial enthusiasm and thenunexpected reversal in 1966 (Studies inFamily Planning, 1967), right after the

196519661967

Firsthalf

809067635714

Second half

518772923903

Famlly Plannlng and Fertllity In Tunlsla

addition to a director and administrativestaff, personnel were hired to staff atraining and education section, a com­munications and information section,and a research and evaluation section.A post-parturn program involving dis­cussion of family planning with mater­nity patients by trained nurses' aides be­gan with about thirty-five "post-partumworkers," and others have been added.A revised system of scheduled and con­sistent weekly visits to each outlyingclinic served by the mobile units wasinitiated. Some educational materials,pamphlets, and posters have appeared,and articles pertaining to family plan­ning provided to newspapers. Week-Iongprovincial campaigns-geared to educa­tion and not special short-term, one­time services-are taking place in 1969in several gouvernorats.

Relaied Social Legislation

A few comments should be made aboutsocial progress among women in Tunisia.Bourguiba has put forth considerableeffort to try to upgrade the status ofwomen. The first law he signed uponindependence abolished polygamy. Farn­ilies have been encouraged to send girlsas weIl as boys to school. Through theUNFT (The Tunisian Women's Na­tional Union), and with government en­couragement, women have been urged toparticipate in society-in the non-agri­cultural labor force of a modernizingsociety, in politics, in local organizations-in short, women have been encouragedto get involved in something beyond thetraditional homemaker, child-rearingrole of most women in Moslem societies.Legal age at marriage has been raisedto seventeen for women and twenty formen. Bourguiba's efforts in these direc­tions warrant much more eareful studyand attention, as they have not beenwithout direct effect on women's roles,and, I think, indirect effect on fertilitybehavior.

Arecent artiole by Amor Daly (1969,

243

pp. 102-113) discusses "legal changes ofthe past ten years, which show the willof the national authorities to fightagainst fatalistic traditions and to pro­mote any measure, including birth con­trol, which will raise the standard ofliving of the people." In addition to ex­tension of voting rights to women, "theend of the use of the veil, and the mixingof the sexes in schools," Daly cites sixlegal foundations of the Family Plan­ning Program:

1. The legal status of the woman, whoacquires the rights of a "completeeitizen."

2. The freedom of information aboutcontraception and of distribution ofcontraceptive products.

3. The limitation of family allowancesto the first four ehildren, to put anend to the pro-natalist policy insti­tuted in the time of the protec­torate.

4. Prohibition of polygamy.5. The raising of the marriage age,

which is set at seventeen years forwomen and twenty years for men.

6. The legalization of abortion, forsocial reasons, in the first threemonths of pregnancy after the fifthchild.

There are few developing societies, andno other Moslem country (with the pos­sible exception of Turkey), that havelegally and aetively instituted all sixof these progressive reforms.

With this brief historieal outline, wenow turn to a review of accomplishmentsto date and subsequently to the rela­tionship of these to fertility in Tunisia.

Program Results

Table 1 is an attempt to estimate thetotal number of users of contraception inthe Tunisian government pro gram, in­cluding sterilized women, at the end ofeach year. As with many programs, theTunisian Family Planning Programstarted off with apparent sueeess, but

244 DEMOGRAPHY, volume 7, number 2, May1970

TABLE l.-Estimll.ted Total Numbers of Users of Contraception in the Tunisia.n GovemmentProgram, December 1964-1968 and June 1969

[Excludes persons using family planning methods obtained private1y]

December JuneMethod 1964 1965 1966 1967 1968 1969

Total, all methods · · · 2,791 13,047 22,332 26,182 34,611 39,240Number receiving supp1ies

during given month:431 2,884 4,212Pi11s. . . . . . · · · · · 0 183 140

Condoms. . . . . · · · · · 1,055 521 310 298 1,295 1,654Other conventiona1 methods 428 164 80 52 147 283

Cumu1ative numbers lessestimated losses:Stesilizationsa• · · · · · 278 604 1,263 1,855 3,200 4,481lUD ••• • • • · · · · · 1,030 11,575 20,539 23,546 27,085 28,610

a-Cumu1ative count less estimated losses of 10 per cent per year due to ad­vancing age, marriage dissolutions, deaths, etc.

b-First insertions only. Assurnes retention rates of .81 at 6 months, .70at 12, .64 at 18, .58 at 24, .53 at; 30, .50 at 36, .42 at 42, .33 at 48,.27 at 54, and .20 at 60 months, which have been estimated on the basiscf 1966 surveys in Le Kef and Tunis, and on experience in other coun­tries. The rates used may be overestimated, but reinsertions have notbeen included in calculating the numbers of users.

Source: Basic records compiled by Research and Evaluation Section, Depart­ment of Maternal and Child Health and Family Planning, Secretariat ofState for Public Health, Tunisia.

the net gain of users in 1967 slowed toless than four thousand. The trend re­versed in 1968, with a net gain of overeight thousand users or sterilized women,to an estimated total of 34,611. Notethat less than half of this gain is dueto lUD wearers. In the first half of 1969,the program seemed to be gaining eloseto 800 users per month, and while it iseneouraging to see the "use" figures go­ing up, 39,240 users represent only 5.4pereent of the female population ages20 to 44, and the figure of 800 net newusers each month must be compared tothe net gain of approximately 1,100women per month in the age ranges 20to 44. (Figures are based on projeetionsof the 1966 Census population, unad­justed for underenumeration, with mor­tality estimates taken from Coale andDemeny, 1966. The Model South, mor­tality level 14, table-life expectancyof 52.5 with a GRR of 3.o--has beenused.) Also, the program results throughSeptember, 1969, indieate the normalsummer downturn, and disastrous floodsthroughout mueh of Tunisia in the fall

of 1969 have seriously affeeted familyplanning aetivities, notably those of themobileteams.

Thus, although the program is reach­ing more people, the pereentage of esti­mated users of government Iamily plan­ning services in the ehild-bearing agesmay be slightly deelining, or at bestremaining about even. Furthermore, theestimate of 1,100 additional child-bear­ing-age women per month is misleadingfor the near future. The group of womennow ages 15 to 19 inereased by over16,500 women in 1968, or about 1,375per month, and by the time these girlsall turn twenty the net monthly inereasein women ages 20 to 44 will double.Even in 1970, the Tunisian program willhave to have a net inerease of over 1,600users per month, in the age ranges 20to 44, just to maintain the same per­centage of contraceptive use. (Note thatthe age range 15 to 19 has been excludedfrom the above diseussion and figuresof womenin the "child-bearing ages." Aswill be seen in Table 4, the pereentageof married women in the age range 15 to

Famlly P1annlng and Fertlllty In Tunlsla

19 is deereasing rapidly, and very fewprogram users are likely to be attractedfrom among this age group of youngwomen. A more aeeurate appraisal of thenumber of women to be reached in Tu­nisia is obtained by looking at thegroups of women ages 20 and over.)

Tunisia is the only Moslem countryto officially ineorporate both sterilizationand abortion into anational program.Abortions went up in mid-1968, andsince then have remained at a fairlysteady average of 200 plus abortions permonth. It is important to note that bothtubal ligations and abortions are offeredand performed in only a very few urbanhospitals, primarily those in Tunis, Beja,Le Kef, and Bizerte, and the Iacilitiesavailable for such services in these citiesare severely taxed. Social abortionsthrough the services of the governmentfamily planning program have totaledalmest 6,600-2,900 through December1967, and just under 3,700 in the eighteenmonth period January 1968 throughJune 1969.

FERTILITY AND POPULATION GROWTH:

1956-1966

The Growth Rate

An assessment of Tunisia's populationgrowth over the past dozen years re­quires a sceptical review of several pub­lished statements. President Bourguibamay have been inappropriately advisedwhen he said that the average annualintercensal (1956-1966) growth rate was"only 2.2 or 2.3 percent." The Demo­graphie Statistics Service of the Secre­tariat of State for Planning and Na­tional Economy continued in 1968 tomaintain that "if one excludes this cate­gory (foreigners) , the growth rate of theTunisian population was on the avetage2.3 percent per year" (Republique Tu­nisienne, 1968b). My reading of the dataindicates an average intercensal growthrate of 2.5 to 2.6, and it may be helpful

245

to try to reconstruct the thinking andealeulations that led to the 2.3 figure,

Table 2 presents some possible com­parisons of 1956 and 1966 census figures.All of the data, inc1uding numbers addedfor estimated underenumeration, arebased on official Tunisian figures. The3.602 million figure for 1956 is the onemost commonly cited in Tunisia, thecount of Tunlaians only (3.442 million)plus an adjustment for underenumera­tion (160,000). (See Republique Tuni­sienne, 1959, p. 17 for an estimation ofunderenumeration.) For 1966 the figureof 4.533 million, the count of Tunisians(4.463 million) plus foreigners (70,000)with no adjustment for underenumera­tion, is most frequently used and eited.A eomparison based on these figures(Table 2, comparison 1) is probably thesource of the 2.3 figure for average an­nual intercensal population growth citedin the census voIume. The Four-Year­Plan document is more specific on howthey calculated their estimate of 2.3 per­cent as the average intercensal growthrate, but, here also, upward-adjusteddata are used for 1956 and unadjusteddata for 1966. See comparison 2 inTable 2.

If we accept as reasonably aecuratepopulation comparison 3 from Table 2,i.e., Tunisians only in 1956 and 1966,with adjustments made for underenu­meration in both censuses, an averageannual growth rate on the order of 2.5 to2.6 is implied. (For the 1966 Census, theDepartment of Demographie Statisticsstates that no post-census control waspossible, but estimates that "the rate ofomission is 4 to 5 percent." See Röpub­lique Tunisienne, 1968b, p. viii. Thelower figure-4 percent-e-has been usedin the calculations presented in Table 2.)Incidentally, since in percentage termsthe adjustment for underenumeration isof the same size in 1956 and 1966, acomparison based on unadiusted countsof Tunisians also implies an avetageannual growth rate of about 2.6.·

246 DEMOGRAPHY, volume 7, number 2, May 1970

TABLE 2.-Selected Comparisons of 1956and 1966Populations in Tunisia, with Implied AverageAnnual Growth Rates

Comparison

Population (OOO's) Implied1n- Per cent average annual

1956 1966 crease increase growth rate

928 .25.8

1956, Tunisians only, adjustedfor underenumeration, ~nd 1966:

1. Tunisians plus foreigners,unadjusted •••••••••• 3,602 4,533

2. Tunisians only,' unadjusted,plus Tunisians who emigrated a1956-66•••••••••••• 3,601 4,529

3. Tunisians only~ adjusted for .underenumeration ••••••• 3,602 4,642

931

1,040

25.8

2B.9

2.3

2.3

2.5 - 2.6

a-Adjusted figure used in Four-Year Plan, 1969-72, document.b-~or the 1956 Census, underenumeration was estimated to be 160,000 fema1es

(Republique Tunisienne, 1959, p. 17). For the 1966 Census, the Depart­ment of Demographie Statistics states that no post-census contr01 waspossib1e, but estimates that "the rate of omission is 4 to 5 per cent"(Repub1ique Tunisienne, 196B, p. viii). The 10wer figure (4 per cent)has been used in the calculations presented in comparison 3.

~ources: Repub1ique Tunisienne, 1968b; 1959, vol. 11; and 1969b, p. 28.

Crude Birth Rates

Numerous estimates are necessary, dueto the lack of "hard" data, to constructa time series of crude birth rates. First,annual estimates of the mid-year Tu­nisian population must be made. Second,the annual number of registered birthsto Tunisians must be estimated. Third,the extent of birth underregistration eachyear must be estimated

The adjusted census counts of 3.602million Tunisians for 1 February, 1956,and 4.642 million for 3 May, 1966, areaccepted as base figures for estimatingthe mid-year populations. Alternativesets of estimated annual growth ratesconsistent with these base figures can beformed; the set used is displayed in col­umn 2 of Table 3. An increasing rate isassumed because considerable emphasiswas given to development and improve­ment of the health infrastructure inTunisia following independence in 1956,which probably caused the death rateto drop faster than the birth rate, es­pecially in the early 1960's. The esti­mated mid-year populations appear incolumn 3 of Table 3. No account istaken here of emigrants. If migration

were to be considered, it should be netin- and out-migration. Presumably therewere some Tunisians who came back toTunisia following independence in 1956.

The numbers of births registered inthe Tunisian registration system areshown in columns 4 and 5 of Table 3.For 1960-1964 and 1966-1968, onlytotals including births to foreigners arecurrently available, and estimates mustbe made of births to the declining for­eign population for these years. In 1959,7,276 births were registered to foreign­ers; 176,933 were registered to Tunisians(Republique Tunisienne, 1959, p. 19). In1965, only 2,312 births were registeredto foreigners (including 707 cases of un­declared nationality); 190,908 birthswere registered to Tunisians (Repub­lique Tunisienne, 1968a, p. 5). Using1959 and 1965 as base points, births toforeigners for each year have been esti­mated. The series shown assume thatbirths to ioreigners have accounted for aregularly decliningshare of all registeredbirths, and in the most recent years ae­count for only about one percent.

Only for the years since 1961 are esti­mates of the extent of birth underregis-

Family Plannlng andFertility in Tunisia 247

TABLE 3.-Crude Birth Rate in Tunisia Computed from Births Registered in RegistrationSystem (Etat-Civil), and Estimated Mid-year Populations, for 1955-1968.

Estimated Estimated crude birthMid-year Registered births rate for Tunisians

Annua1 Tunisian (OOO's) Regis- Adjustedgrowth population Total Number to tration for under-

Year rate (OOO's) number Tunisians sts t em registration(1) (2) (3) (4) (5) 6) (7)

1955. · 2.3 3,555 125.3d 35.2 ?(1 Feb. 1956) (3,602)a

d1956. · 2.4 .3,638 132.1d 36.3 ?1957. · · 2.4 3,724 150.2d 40.3 ?1958. · · 2.4 3,813 174.9d 45.9 f1959. · 2.4 3,905 184.2b 176.ge 45.3 f1960. 2.5 3,998 182.2 175.8e 44.0 f1961. · 2.5 4,098 184.4 178.ge 43.7 49.6Q1962. · 2.6 4,201 181.9 177.2e 42.2 47.9g1963. 2.6 4,310 187.4 183.5e 42.6 48 4g

• g1964. · 2.7 4,422 206.0c 202.913

45.9 50.4g1965. · . . · 2.7 4,542 193.2 190.9 42.0 47.8(3 May 1966). (4,642)a e 47.0Q1966. · · · · 2.8 4,664 201.8 199.6e 42.81967. · · · · 2.7 4,794 187.3 185.2e 38.6 43.9g1968. · · · · 2.6 4,923 188.3 186.2 37.8 43.0g

a-From Table 2. Foreigners are excluded from this figure.b-Does not include births to an estimated 170,000 Algerian refugees present

in Tunisia in 1960. See United Nations, 1966.c-Final figure; for all othef years 1960-69 the figures were provisional.

The Provisiona1 figure for 1965 was 191.7. Sources are Republique Tuni­sienne, 1968a and 1969a•.

d-Source is Repub1ique Tunisienne, 1959, p. 21.e-Estimated.f-Estimates of underregistration are extreme1y difficu1t for these years.

As the tab1e implies, registration was rapid1y improving, and the regis­tration figures for the years 1958-1960 probably include a disproportion­ate1y large group of births which actua1ly occurred from one to severalyears ear1ier.

g-Twe1ve per cent is estimated as the rate of underregistration, i.e., thenumber of Tunisian births registered each year is estimated as 88 per centof the actual number of births, except for 1964 and 1966 when underregis­tration is estimated at 9 per cent. See exp1anations in text.

tration attempted. National underregis­tration is estimated at 12 pereent onthe basis of some preliminary data fromthose few rural areas of the reeent Tu­nisian Demographie Survey wherematehing was done (Vallin and Paulet,1969), and on the delays (not infre­quently up to several months) in regis­tering some vital events in Tunisia,whieh probably eause a number of birthsfollowed by early death to never getregistered. For 1964 and 1966, however,underregistration is estimated at 9 per­cent, beeause the marriage-age law of1964 and the eensus of 1966 probablystimulated both registrees and registrars.

For 1960 and earlier years, no basisexists for estimating underregistration.Registration is known to have been im­proving rapidly in the late 1950's, andthe registration figures for the years1958-1960 probably inelude a dispro­portionately large group of births whiehaetually oeeurred from one to severalyears earlier. Annual erude birth rates,without and with adjustment for under­registration, are shown in eolumns 6and 7 of Table 3.

The unadjusted erude birth rate rosefrom 35-36 per thousand in 1955-56 to45-46 in 1958-59 as the registration sys­tem was improved. Whether any real

248

inerease in the erude birth rate oeeurredis open to question; and the 1958-59rates may be inflated by the inelusionof delayed registrations, Through1965-66, the unadjusted erude birth ratefluetuated in the low 40's (with the ex­eeption of 1964). After adjustment forunderregistration, the rates were in thehigh 40's. For 1964 the higher level mayrefleet in part change in the legal age atmarriage. In 1963 the pending ehangespurred additional marriages whieh pro­dueed an upturn in the number of birthsthe fo11owing year. A study of marriagereeords indieates an "exeess" of approxi­mately 7,500marriages in 1963and early1964, whieh aecount for part, but nota11, of the additional births reeorded in1964 (Vallin and Lapham, 1969).

For 1967 and 1968,unless the registra­tion system is beeoming steadily worseor unless the Tunisian population hasdecreased in numbers, there is adefinitedeeline in the erude birth rate. The num­ber of registered births in 1967or in 1968was smaller than in any year sinee 1963.The unadjusted erude birth rates hadfallen to the high 30's; the adjusted rateswere in the low 40's.

The effeet of the assumption of asmooth growth rate eurve on the impliederude death rate should be noted. Forthe years 1962 through 1968, the implieddeath rate in Table 3 drops somewhatirregularly from the low 20's to about 17.Probably the erude death rate deelinedin a more regular pattern during this pe­riod, with the annual growth rate mov­ing more erratically, espeeia11y in thepeak birth years of 1964 and 1966.How­ever, the net effeet on the birth rate es­timates is small, i.e., a smoothly-declin­ing death rate with a more erratiogrowth rate, or the reverse pattern,makes little differenoe on the birth-rateestimates in Table 3, sinoe the numera­tors for the birth estimates remain thesame while the denominators ehangeonly slightly.

One reading of these series is that

DEMOGRAPHY, volume 7, number 2, May 1970

over the five years 1963-1968 the erudebirth rate in Tunisia declined by 10 per­cent or more, from about 48 to about 43.For a Moslem eountry, this is a substan­tial drop. A number of estimates andassumptions have entered the ealcula­tion of these rates, but unless the 1967­1968 populations are substantia11y over­estimated or births to Tunisians in theseyears substantia11y underestimated, thecrude birth rate was lower in 1967-1968than in any one of the ten precedingyears.

We must be careful, however, to dis­tinguish a declining erude birth ratefrom a true decline in fertility. Struc­tural factors may cause temporary fluc­tuations in the crude rate, while leavingfertility unchanged.

PossmLE (ExPLANATIONS OF THE

DECLINING CRUDE BIRTH RATE

Analysis suggests that three factors­marriage-age patterns, eontraeeptive use,and age strueture-probably eontributeto the reeent deeline in the erude birthrate, and undoubtedly involved also isa fourth, more intangible, element, i.e.,the upgrading of the position of womenin Tunisia.

M orriaqe-aqe Patterns

Perhaps the most striking factor is thechange in marriage-age patterns amongwomen. In 1956, 40 percent of thewomen in the age range 15 to 19 weremarried, but by 1966 only 18 percentof the women in this age group weremarried (Table 4). This rather strikingevidence of social change is indicative ofthe general improvement in the status ofwomen in Tunisia, improvement due inlarge part, I think, to the encouragementand policies of President Bourguiba. Thesmaller percentage of married 15-to-19­year-old females in 1966 is not due di­reotly to girls staying in school longer.Aside from a small elite, education forTunisians began after independenee in1956, and the number of girls who could

Family Plannlng and Fertllity In Tunisia

have entered school and reached age 15by 1966is minimal, but the push towardthe education of girls as well as boyshas had effects on parents and older sis­ters, Nor can this change in marriage agebe attributed to the 1964 change in thelaw. While postponing some potentialmarriages, or causing them to oceursomewhat sooner in 1963 (most prob­ably some of the excess marriages whichcoeurred in 1963 were to girls 17 or over,but knowing that a law was coming andlacking adequate proof of age, parentsand couples hastened marriages in orderto avoid possible complications later on)the law seems, in fact, to have fol1owedan already existing trend. PresidentBourguiba, and other Tunisians follow­ing his lead, built pressure for changingage at marriage and then had the lawchanged as a reinforcing measure.

Table 4 also shows a six percentage­point decrease in the proportion of mar­ried warnen in the age range 20 to 24.From about age thirty and up, the trendreverses, with percentages of marriedwomen increasing from 1956 to 1966.Part of this change ean be accounted forby differential male-female mortality, aslife expectancy increased. Using theCoale/Demeny model life tables (1966,pp. 666 and 668) it can be noted, forexarnple, that as eo goes from 45 to 50,and looking at males age 60 and fernalesage 50 (due to age differences betweenhushands and wives in Tunisia), thenumber of female survivors increases by12.8 percent, (150 from .546 to .616),and the number of male survivors by15.2 percent, (160 from .421 to .485).Thus, somewhat fewer women approaeh­ing age 50 were widows in 1966 than in1956. But this accounts for only about afourth of the increase in the percentageof married females ages 45 to 49.The in­creases in percentages of married womenover thirty are consistent with the hy­pothesis concerning the changing role ofwomen in Tunisian society. Polygamy isdiscredited, both legally and socially,

249

TABLE 4.-Percentages of Wornen Married, asReported in the 1956 and 1966 Tunisian Cen­

suses, Classified by Age, for Tunisia

Age 1956 1966 Change

15-19 · · . . . 39.8 18.5 -21.320-24 • · 76.8 71.1 - 5.725-29 89.1 88.5 - 0.630-34 • · 90.6 92.4 + 1.835-39 · · . . . 88.0 91.8 + 3.840-44 • · 82.9 87.9 + 5.045-49 · 72.2 81.8 + 9.650-54 · 62.3 70.4 + 8.1

Sources: Repub1ique Tunisienne, n.d.and 1968b.

and while divorce is still permissible,women have and exereise more rights,This might suggest to some that divorcewould inerease as women obtain morefreedom, but in Tunisia, as in otherMoslem countries, economic security, es­pecially for illiterate women, is stillbound up in a family maintained by asenior male. Table 4 indicates, therefore,Iater age at marriage, and it also sug­gests greater marital stability.

Table 5 demonstrates that this socialchange in Tunisia is not uniformthroughout the country. The northernand central, more urbanized, gouvernor­ats (Tunis, Bizerte, Sousse) have smallerpercentages of rnarried wornen under age25 than the southern, highly rural, gouv­ernorats of Kasserine and Gafsa, and therelative changes from 1956 to 1966 arelarger in the Iormer. The Gouvernorat of

TABLE 5.-Percentages of Wornen Ages 15-19and 20-24 Married, as Reported in the 1966

Tunisian Census, for Selected Gouvernorats

Ages 15-19 Aqes 20-24Gouvernorat 1956 a 1966 1956a 1966

Tunis. . · · 33 13 69 62Bizerte. · · 33 15 72 67Sousse • · · 32 11 72 63Le Kef • · · 55 24 84 79Kasserine. · 52 28 85 84Gafsa. . · · 43 29 80 81

a-Based on a ten per cent sample ofcensus data.

Sources: Repub1ique Tunisienne, n.d.and 1968b; and Picouet, 1969.

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Le Kef is mostly rural, but located inthe central part of Tunisia. The 1966percentages of married females in theGouvernorat of Sousse (which is 60 per­cent urban versus 87 percent urban forthe Gouvernorat of Tunis) may be af­fected downward by a lack of males age20 to 29. The 1966 Census (RepubliqueTunisienne, 1968b) shows the followingpopulation for the Gouvernorat ofSousse, for the age groups listed:

Age group Male Female

15-19 21,668 21,33720-24 12,341 17,34625-29 12,679 16,863

Unless the Census missed a high pro­portion of young males, it would seemthat a good many young men have mi­grated out of this gouvernorat, but thepercentage of young married females isstill very low.

The effect of this reduction in the per­centage of married 15-to-19-year-old fe­males on the crude birth rate is signifi­cant, There were an estimated 220,513females ages 15 to 19 in 1968. Applyingthe different percentages married in 1956and 1966 to the marital fertility rate of1966 makes a difference of 9,300 fewerbirths in 1968. (The estimated numberof females in 1968 is the sum of 2/5 ofthe 271,455 females ages 10 to 14 on the1966 census date plus 3/5 of the 188,751females ages 15 to 19 on that date minusan estimated 1,320 deaths occurring tothese women between 1966 and 1968.One estimate of the 1966-67 marital fer­tility rate for 15-to-19-year-old femalesis 198 per 1,000 (ValIin and Lapham,1969, p. 396). If 39.8 percent (the 1956level) of the females 15 to 19 in 1968 hadbeen married and their fertility ratebeen 198, there would have been 17,377births. If only 18.5 percent (1966 level)were married and their fertility rate was198, there would have been only 8,077births.) The effects of the changes inpercentages married in all other agegroups very nearly cancel each other

DEMOGRAPHY, volume 7, number 2, May1970

out, and need not be considered here, i.e.,applying the same techniques, the netdifference for all age groups 20 to 49is 310 fewer births in 1966.

Contraceptive US8

The second factor affecting the erudebirth rate is the increasing use of con­traception, We have reviewed the Fam­ily Planning Program in some detail, andprepared estimates of the numbers ofbirths possibly averted by the use of con­traception and sterilization. Some ac­count has been taken of contraceptivesales in the private sector, but abortionshave not been included. The total num­ber of abortions performed in govern­ment facilities is smalI, and it is difficultto guess how many of these abortionswould have occurred (under much moredifficult circumstances) anyway, andhow many would have been allowed toproceed to term in the absence of thegovernment program.

By mid-1967, an estimated 24,257women were using contraception or weresterilized under the government pro­gram. An additional 4,000 women are es­timated to be using contraceptives sup­plied by the private sector. (The averagewholesale sales of pills, ereams andfoams by the Central Pharmacy toretail outlets is used as the basis for esti­mating the additional number of non­government-program users. For exam­ple, for the period April to September,1968, average wholesale sales were 7,953cycles of pills per month and 225 unitsof creams and foam. Estimating thatahout half of these sales are to Tunisiansgives a figure of just over 4,000 users.Unfortunately, data on wholesale con­dom sales are unavailable.)

It is difficult to determine whether ornot these women would have had a babyin the absence of contraception. We lackdata on their previous fertility histories,and some women might have used othermeasures of avoiding or voiding preg­nancies. Assuming that all users were

Family Plannlng and Fertlllty In Tunlsla

distributed by age proportional to lUDwearers, whose age distribution has beenreported by VaIlin (1968), and that sge­specific marital fertility rates for usersin the absence of contraception wouldhave been identical with the rates for1966-1967 reported by VaIlin and Lap­ham (1969, p. 396), 31 percent of theusers would have had a baby in the ab­sence of contraception.

For 1968, approximately 8,800 birthsmay have been prevented by the use ofcontraception; that is, 31 percent of theestimated 28,257 couples using contra­ception in mid-1967 would have had ababy. Estimating births prevented byfamily planning programs is difficult,even when good data on lUD retentions,pill continuation rates, previous fertilityof users, etc., are available. Hence, theestimate of 8,800 averted births in 1968is subject to a wide range of error.

Age Structure

The age structure of Tunisia is thethird factor affecting the crude birthrate in recent years. The 1966 Censusshowed:

PopulationAgegroup in thousands

15-19 188.820-24 151.025-29 154.430-34 147.8

At least part of this flattening in the ageranges 20 to 34 is real and not due togreater underenumeration of females inthese age ranges. Picouet (1969) hasshown that a cohort dent in unadjustedcensus data appears in the last threecensuses (1946, 1956, 1966) and un­doubtedly results from lower fertilityand/or higher infant and child mortalityduring the Second World War. Childrenborn in 1942-1944 were ages 19 to 26 inthe period 1964-1968, and there appearto be about 15,000 fewer women ages 20to 24 in 1966 than would be the ease witha more smooth age curve. This may be

251

an underestimate. Most of the modellifetables (Coale and Demeny, 1966) thatcome close to resembIing the Tunisianpopulation show over 8 percent of thefemale population in the age range 20to 24. Eight percent would indicate eloseto 180,000 in the age range 20 to 24 in1966, so the estimate of an "indentation"of 15,000may be eonservative. One effectof this indentation in the age structureis that about 4,150 fewer births wereprodueed by this age group than wouldbe expeeted from a smoother age struc­ture. This assumes that 71 percent ofthe "missing" women would have beenmarried and that their marital fertilityrate would have been 389.5.

ASummary

If the crude birth rate had been 48in 1968, there would have been approxi­mately 236,500 births, but the aetualnumber is estimated at 212,500, and thethree Iactors affecting the erude birthrate very closely approximate this dif­ference.

Births that did not occur. . . . . . . 24,000

Estimated numbers of "missing"0'1' "averted" births accountedfür by:

1. Change in marriage-agepatterns. . . . . . . . . . . . . . . . 9,300

2. Use of contraception. . . ... 8,8003. Age structure effect. . . . . . . 4,200

Total. . . . . . . . . . . .. . . . . .. . . . 22,300

A different "accounting" system is alsopossible, concentrating on the rather no­ticeable downturn in the most recent pe­riod 1965 to 1968, and looking separatelyat age structure and fertility compo­nents. Here we have:

a, the age effect: (expected births toTunisians in 1968 using the 1965 unad­justed crude birth rate) - (expectedbirths to Tunisians in 1968 using 1965age-specifie fertility rates)

b. the fertility effect (age at marriage

252

+ contraception): (expected births toTunisians in 1968 using 1965 age-specifiefertility rates) - (actual births to Tu­nisians 1968)

c. total effect: (expected births toTunisians using the 1965 unadjustedcrude birth rate) - (actual births toTunisians 1968).

The calculations are listed below. Age­specific fertility rates for 1965 comefrom Tunisian Government vital statis­tics data (Vallin and Lapham, 1969);1968 five-year-age-group populationscome from 1966 census data (Govern­ment of Tunisia, 1968b) projected for­ward with survival rates based on theCoale and Demeny (1966) Model South,level 13, life table values (e.g. ages 13to 17 in 1966 become ages 15 to 19 in1968) ; and total Tunisian population es­timates and crude birth rates come fromTable 3. Unadjusted data are used be­cause the age-specific rates for 1965 arebased on vital statistics data which werenot adjusted for underenumeration, butforeigners and estimated births (2100 in1968) to foreigners have been excluded.No account is taken of net migration.

a, Age effect: 206,800 - 203,200 = 3,600b. Fertility effect (age

at marriage + contraception):203,200 - 186,200 = 17,000

c. Total effect: 206,800 - 186,200 = 20,600

This result is quite similar to the to­tal of 22,300 above, and the age-struc­ture component makes comparable con­tributions in both cases. However, thesecond set of figures can lead to a dif­ferent interpretation of the relative im­portance of the age-at-marriage andcontraceptive-use components within thefertility effect. Unless there was a con­tinued and marked decline in the percentof women married in the age range 15 to24, this second set of calculations im­plies a larger contribution by "use ofcontraception" to the decrease in thecrude birth rate in the period 1965-1968.

DEMOGRAPHY, volume 7, number 2, May1970

One hypothesis consistent with this in­terpretation would be that the crudebirth rate was most probably around 50ten to fifteen years ago and that the ef­fect of increasing age at marriage hasbeen gradual over the past ten or twelveyears, with fertility declines in the mostrecent years due more to the use of con­traception.

Much more work is required. Partien­larly called for are better assessments ofthe Tunisian registration system. Whatis the true level of underregistration, andis the level changing? Further analysesof structural effects are indicated, espe­cially in view of the very Iarge, by com­parison, groups of females soon to enterthe marriage and prime child-bearingages. The effects of the family planningprogram and the use of contraception inTunisia need to be more adequatelymeasured and analyzed. And, as notedearlier, the study of fertility, distinctfrom the crude birth rate, should be con­tinued. The evidence and materials pre­sented here are best considered as aprovocative first step toward our under­standing of the declining crude birth ratein Tunisia.

ACKNOWLEDGMENTS

The author would like to thank theResearch and Evaluation Section of theTunisian Family Planning Department(Ministry of State for Health) and theDivision of Demographie and Social Sta­tistics (Secretariat of State for Plan andNational Economy) for the basie dataand documents utilized in this article.

Helpful comments have been receivedfrom W. Parker Mauldin, Joseph A.Grinblat, Dorothy Nortman, and DonaldHeisel of the Population Council, andfrom an anonymous editorial consultant.

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