Decline in Human Fertility:

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1 T E C H N I C A L R E P O R T Decline in Human Fertility: SEPTEMBER 2010 This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and was authored by Luigi Jaramillo of URC. The study was carried out under the USAID Health Care Improvement Project, which is made possible by the generous support of the American people through USAID.

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3 TECHNICAL REPORT Decline in Human Fertility: SEPTEMBER 2010 Luigi Jaramillo, University Research Co., LLC DISCLAIMER This report was prepared by University Research Co., LLC for review by the United States Agency for International Development (USAID) and was authored by Luigi Jaramillo. The USAID Health Care Improvement Project is made possible by the generous support of the American people through USAID.

4 Acknowledgements: The author wishes to acknowledge the Sophia Smith Collection at Smith College for their impressive archives of oral history of the pioneers of family planning around the world. The author would also like to thank Dr. Juan B. Londoño and Dr. Paul Richardson for sharing their vast knowledge of family planning programs across all continents. Special thanks to Dr. Mario Jaramillo for providing valuable documents on family planning program implementation that described in detail the obstacles and challenges encountered during the pioneering family planning work in Latin America. The USAID Health Care Improvement Project is implemented by URC under the terms of Contract Numbers GHN-I and GHN-I URC s subcontractors for the HCI Project include EnCompass LLC, Family Health International, Health Research, Inc., Initiatives Inc., Institute for Healthcare Improvement, Johns Hopkins University Center for Communication Programs, and Management Systems International. For more information on the work of the USAID Health Care Improvement Project, please visit or write hci-info@urc-chs.com. Recommended Citation: Jaramillo L Decline in Human Fertility: Technical Report. Published by the USAID Health Care Improvement Project. Chevy Chase, MD: Universi ty Research Co., LLC (URC).

5 TABLE OF CONTENTS LIST OF TABLES... i ACRONYMS... ii EXECUTIVE SUMMARY... iii I. INTRODUCTION... 1 II. DECLINING WORLD FERTILITY... 2 III. DECLINE OF FERTILITY IN AFRICA... 2 IV. DECLINE OF FERTILITY IN ASIA... 4 V. DECLINE OF FERTILITY IN THE AMERICAS... 6 VI. DECLINE OF FERTILITY IN EUROPE... 8 VII. THE MOST SUCCESSFUL COUNTRIES LIST OF TABLES Table 1: Decline of the Total Fertility Rate from 1950 to 2007 (by region)... 1 Table 2: Decline of the Total Fertility Rate in Subregions of Africa from 1950 to Table 3: Decline of the Total Fertility Rate in North Africa from 1950 to Table 4: Decline of the Total Fertility Rate in Southern Africa from 1950 to Table 5: Decline of the Total Fertlity Rate in West Africa from 1950 to Table 6: Decline of the Total Fertility Rate in East Africa from 1950 to Table 7: Decline of the Total Fertility Rate in Subregions of Asia from 1950 to Table 8: Decline of the Total Fertility Rate in West Asia from 1950 to Table 9: Decline of the Total Fertility Rate in South Asia from 1950 to Table 10: Decline of the Total Fertility Rates in South-Central Asia from 1950 to Table 11: Decline of the Total Fertility Rates in East Asia from 1950 to Table 12: Decline of the Total Fertility in Subregions of America from 1950 to Table 13: Decline of the Total Fertility Rate in Central America and the Caribbean... 7 Table 14: Decline of the Total Fertility Rate in South America from 1950 to Table 15: Decline of the Total Fertility Rate in the Subregions of Europe from 1950 to Table 16: Decline of the Total Fertility Rate in Eastern Europe from 1950 to Table 17: Decline of the Total Fertility in Northern Europe from 1950 to Table 18: Decline of the Total Fertility Rate in Western Europe from 1950 to Table 19: Decline of the Total Fertility in Southern Europe from 1950 to Table 20: The Ten Countries that Have Been Most Successful at Lowering Fertility from 1950 to Decline in Human Fertility: i

6 ACRONYMS HCI Health Care Improvement Project IPPF International Planned Parenthood Federation TFR Total Fertility Rate URC University Research Co., LLC USAID United States Agency for International Development ii Decline in Human Fertility:

7 EXECUTIVE SUMMARY The desire to control one s own fertility has historical antecedents dating back hundreds and even thousands of years. For example, the first condoms have been documented to the days of the Egyptian empire, and it is known that the Arabs used intrauterine devices to prevent their female camels from getting pregnant and to able to withstand the long desert crossing from the markets in the Red Sea to new affluent cities in the Mediterranean. Organized family planning programs designed to provide services to the population began around the 1950s, starting with a program in India and followed in the 1960s by programs in other Asian and Latin American countries. Since then, family planning has arisen in every country in the world. The success of these programs in terms of helping people control their fertility have varied greatly from one country to another, from one geographic region to another. Some nations have adopted policies aimed at controlling their population growth, particularly in Asia, where programs to promote the use of contraceptives were placed within the reach of all social classes and achieved successful results. It is in the Asian region where the most significant reductions in total fertility are documented, in particular in China, North Korea, Thailand, and Indonesia. In contrast, other nations, despite significant financial and technical assistance from the donor community, have failed to achieve similar reductions in fertility, and in fact, some nations have implemented such mediocre family planning programs that fertility has actually increased. This is the case of some African countries, such as Liberia and Guinea-Bissau. Africa is the region of the world with the most ineffective family planning programs and where the worst results in attaining fertility reduction are documented. This document describes the experience of 50 years of family planning program implementation worldwide and its impact on achieving fertility reduction. It illustrates areas of the world where family planning programs succeeded and where they have failed, while describing the general characteristics that have surrounded family planning programs and that have influenced their ability to obtain significant fertility reductions. These characteristics range from the political will to generate widespread behavior change to adopt contraception, to the belief of many world leaders that great nations are the result of large and increasing populations. Although there has not been much progress in some countries, overall the world has succeeded in reducing its fertility from 5.0 children per woman in 1950 to 2.7 in 2007, an impressive 46% reduction. Furthermore, on average, every region in the world has managed to reduce fertility, no doubt a colossal achievement that should be counted among the greatest human achievements of the 20 th Century. Decline in Human Fertility: iii

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9 I. INTRODUCTION For thousands of years human reproduction and population growth have occurred as it has for other animal and plant species, without a collective effort to reduce fertility or to stop population growth. However, with the advance of medicine and improved standards of living, the 19th and 20th centuries saw a significant reduction in mortality rates and the disparity between deaths and births widened, accelerating population growth. The decline in fertility in developed countries, which almost coincided with the decline in mortality, resulted in a reduction in the population growth rate. On the other hand, the decline in mortality rates in developing countries was not accompanied by a decline in birth rates. Consequently, the population growth rate rose to levels never before seen at first to 1 percent, then to 2 percent at the beginning of the twentieth century, and later to 3 percent and higher around the middle of the century. This means that at first the population doubled every 70 years, then every 35, and around the middle of the century the population doubled in just 25 years. This acceleration of population growth is rightly called the population explosion, which reached the height of its intensity and geographic extension in the middle of the 20th century. While family planning has historical antecedents dating back hundreds of years, only recently have all social classes gained access to contraceptive methods. Around 1950 the first family planning programs began to be organized. The first such program implemented at a national level was in India, where the population explosion had resulted in a tremendous decrease in the quality of life for the vast majority of the population. In the decades that followed other Asian countries also adopted policies aimed at controlling population growth. In the sixties, many other nations on other continents also adopted such policies. They developed programs to promote the use of contraceptives and put these within reach of all social classes, so they were no longer just a privilege of the upper class. Only at the end of the 1950s did these programs begin to be developed in Latin America, first in Chile and Colombia and then, gradually, in other countries in the region. Although great efforts have been made throughout the world to motivate public and private officials to support family planning programs and have been given funds and technical assistance to this end, the progress achieved varies greatly from one country to another. Family planning programs have been very successful in Asia and in most countries in the Americas, but efforts have completely or partially failed in Africa. Table 1 compares total fertility rates (TFR, or the average number of children per woman) in 1950 and 2007 by region; subsequent Tables 2-19 compare TFRs in 1950 and 2007 by subregion and country. They show the magnitude of the decline of the TFR, as well as the percentage of the 1950 TFR that the decline represents. Table 1: Decline of the Total Fertility Rate from 1950 to 2007 (by region) Region Change % WORLD Developed countries Developing countries Asia Latin America and the Caribbean Oceania North America Europe Africa Decline in Human Fertility:

10 II. DECLINING WORLD FERTILITY In little more than 50 years, the world fertility rate has declined by almost half, from an average of 5 children per woman to 2.7. This is clearly a great success that has enormous beneficial consequences for the planet and its inhabitants. This significant change has been achieved in a short period of time and the decline in fertility has been greater in underdeveloped countries than in developed countries, making this achievement much more significant. The TFR declined most by almost 60 percent in Asia. This is due mostly to the population growth control policies decisively adopted and implemented by China, North Korea, Thailand, and Indonesia, as well as the mediocre results obtained in India and Bangladesh, which still carry great weight in the Asian average because of the size of their populations. Latin America and the Caribbean closely follow Asia in terms of declining TFRs. Despite the strong opposition of conservative institutions such as the Catholic Church and socialist leaders, the region experienced a decline in the TFR that almost matched Asia s. Evidently, these populations have mostly freed themselves from political and religious influence on decisions relating to their personal lives and they have been able to put in practice their ideals with regard to fertility. North America and Europe experienced less, though still significant, declines in their TFRs. This is mainly because already low fertility rates are more difficult to decrease. Africa comes in last place. It succeeded in reducing the TFR in the region from 6.6 to 5 in 57 years, which is a decline of just 24 percent. III. DECLINE OF FERTILITY IN AFRICA Worldwide, Africa comes in last in terms of its ability to reduce fertility rates. Only its regions in the far north and south have had good results. Lack of progress along the equator is due to the fact that efforts to promote family planning programs there have been very weak and the population exhibits a lack of sexual discipline. Table 2: Decline of the Total Fertility Rate in Subregions of Africa from 1950 to 2007 Region Change % Southern Africa North Africa East Africa West Africa Central Africa As can be seen in the table above, in the far North and South of the continent, fertility has been reduced by almost half. On the other hand, in the East, it has only been reduced by one-fifth and in the West only by one-tenth. In the Central African countries the TFR has not declined. Instead it has grown on average by 7 percent, the equivalent of almost one-half child per woman. It is very unfortunate that despite substantial economic and technical assistance in the poorest region of the world, results have also been poor. It is very likely that the decline in population growth rates in the Central areas of Africa have not been achieved through family planning but rather through a mechanism that nature has used for thousands of years increased mortality. 2 Decline in Human Fertility:

11 North Africa: In African countries on the Mediterranean coast, fertility has decreased by two-thirds to one-half, so family planning has been remarkably successful. Among the determining factors of this success are French influence and the financial and technical assistance of international organizations. Even countries as behind as Sudan have managed to reduce fertility by one-third. Table 3: Decline of the Total Fertility Rate in North Africa from 1950 to 2007 Tunisia Algeria Morocco Libya Egypt Sudan Southern Africa: This is the other subregion of Africa where fertility rates have been reduced by an acceptable level, but only two countries have reduced fertility to less than half. Table 4: Decline of the Total Fertility Rate in Southern Africa from 1950 to 2007 South Africa Botswana Swaziland Lesotho Namibia West Africa: This is the subregion with the worst results in the world. Fertility rates have declined very little and in two countries the fertility rates have risen. Table 5: Decline of the Total Fertlity Rate in West Africa from 1950 to 2007 Cape Verde Ivory Coast Mauritania Togo Senegal Guinea Benin Burkina Faso Nigeria Niger Sierra Leona Liberia Guinea-Bissau East Africa: Mauritius is a small island which began a family planning program in the sixties that has proven to be successful. Zimbabwe has also made significant efforts to put contraceptives within the Decline in Human Fertility:

12 reach of its populace. In most of the other countries in this region, results have been mediocre or nonexistent, like in Uganda and Burundi. Table 6: Decline of the Total Fertility Rate in East Africa from 1950 to 2007 Mauritius Zimbabwe Djibouti Kenya Ethiopia The Comoros Madagascar Tanzania Zambia Rwanda Mozambique Malawi Somalia Uganda Burundi These figures show how far behind Africa is in terms of controlling its birth rate and how difficult it will be to change that situation of reproductive irresponsibility both among couples and governing leaders. It seems that in this subregion population growth will be controlled by mortality, which is rising in some countries. IV. DECLINE OF FERTILITY IN ASIA Fewer differences exist among the subregions of Asia than in Africa and declines in fertility are rather substantial, greater than 50 percent in three Asian subregions. This decline is due to commitment by political leaders and organizers of family planning programs, who also have not encountered the religious or ideological opposition that has been an obstacle to progress in programs in other regions. Thanks to that, all the Asian subregions have succeeded in reducing by more than three the average number of children per woman. Table 7: Decline of the Total Fertility Rate in Subregions of Asia from 1950 to 2007 Region Change % Southeast Asia East Asia South-Central Asia West Asia West Asia: In this region, predominantly Islam, results have been rather good. Thirteen countries succeeded in lowering their fertility rates by more than 50%. Three countries succeeded in lowering their TFR to one-third and nine others to less than half. 4 Decline in Human Fertility:

13 Table 8: Decline of the Total Fertility Rate in West Asia from 1950 to 2007 Turkey Arab Emirates Kuwait Armenia Azerbaijan Bahrain Libya Qatar Cyprus Jordan Oman Syria Saudi Arabia Israel Iraq South Asia: This region has been very successful in lowering its fertility rate. Singapore lowered its fertility rate to one-fifth and Thailand did so to one-fourth of what they were in The other countries, succeeded in reducing their fertility rates by more than 50% between 1950 and Excellent contraception programs with strong leadership and ample and sincere support from the governments and private organizations have been developed in this region since the sixties. Table 9: Decline of the Total Fertility Rate in South Asia from 1950 to 2007 Singapore Thailand Borneo Vietnam Burma Malaysia Indonesia Philippines Cambodia Laos East Timor South-Central Asia: In this area, more than half of the countries have reduced fertility by more than 50% since In the other countries, with the exception of Afghanistan, intermediate results have been obtained. Pakistan s program is a special case, despite receiving financial support from international organizations and some developed countries; its progress has not been very good. Decline in Human Fertility:

14 Table 10: Decline of the Total Fertility Rates in South-Central Asia from 1950 to 2007 Iran Sri Lanka Bangladesh Uzbekistan India Turkmenistan Bhutan Nepal Kazakhstan Tajikistan Kyrgyzstan Pakistan Afghanistan East Asia: The best family planning programs in the world have been implemented in East Asia. South Korea is first in the world, having reduced its fertility rate during this time by an impressive 80 percent. It is worth noting that the desired and observed fertility rate in Hong Kong is just one child per woman. Table 11: Decline of the Total Fertility Rates in East Asia from 1950 to 2007 South Korea Hong Kong China Mongolia North Korea Japan Although Japan already had a rather low fertility rate in 1950, it still succeeded in lowering it to less than half. Despite being one of the most economically advanced countries, Japan has adopted a small family size (on average 1.4 children). Meanwhile, many poor nations continue to have many children without significant resources. V. DECLINE OF FERTILITY IN THE AMERICAS Of all the subregions in the world, fertility has declined most in Central America, where fertility has declined by almost two-thirds (61 percent). This has happened despite the strong influence of the Catholic Church and the efforts of the United Nations to completely subordinate family planning programs to maternal and child health. It has happened especially because of the financial and technical assistance provided by the United States Agency for International Development (USAID) and the International Planned Parenthood Federation (IPPF). 6 Decline in Human Fertility:

15 Table 12: Decline of the Total Fertility in Subregions of the Americas from 1950 to 2007 Region Change % Central America South America North America Very good results have also been obtained in most countries of South America, with an average decline in TFR of 58 percent. It is also noteworthy that the United States and Canada have lowered their fertility rates almost by half in this 57-year period, even though these rates were already low. Family planning programs have been a success in Latin America and the Caribbean, where fertility rates have been reduced to less than half of what they were in Central America and the Caribbean: Costa Rica is the country that has achieved the greatest progress on this continent with regard to effectively controlling human fertility. Since the sixties it has had an excellent family planning program, which was dedicated solely to putting contraceptives within reach of the population. The program has enjoyed strong leadership both in the public and private sectors, as well as support from the University of Costa Rica on all aspects of the program, including training personnel. Table 13: Decline of the Total Fertility Rate in Central America and the Caribbean from 1950 to 2007 Region Change % Costa Rica Puerto Rico Cuba Dominican Republic Nicaragua Honduras El Salvador Bahamas Belize Jamaica Guatemala Haiti By virtue of all these qualities, Costa Rica has managed to reduce the number of children per family from 6.7 to 1.9. It is the only country in the Central American region that has lowered its fertility rate to less than 2. Not even the US has done that. The situation now in Guatemala and Haiti is unfortunate. Although they began implementing family planning programs more than 50 years ago, both countries are clearly overpopulated and have socioeconomic and cultural characteristics in common with most African nations. South America: Despite the little interest Argentina and Bolivia have shown and the almost complete lack of participation by the government of Brazil, provision of contraceptive services has been made almost completely through the private sector. Opposition by the Catholic Church has also been strong here, but with little effect since people have demonstrated their capacity to decide for themselves how many children to have and when to have them. Decline in Human Fertility:

16 Table 14: Decline of the Total Fertility Rate in South America from 1950 to 2007 Region Change % Colombia Peru Brazil Surinam Chile Guyana Panama Venezuela Ecuador Paraguay Bolivia Argentina VI. DECLINE OF FERTILITY IN EUROPE While Communist ideology rejected birth control in all the underdeveloped regions of the world, claiming that it was a strategy by western imperialists to weaken less developed countries in order to dominate them more easily, communist countries of Eastern Europe had relatively low fertility rates in Furthermore, Eastern Europe strengthened their birth control programs mainly through abortions, thousands of which were performed. Table 15: Decline of the Total Fertility Rate in the Subregions of Europe from 1950 to 2007 Region Change % Eastern Europe Southern Europe Western Europe Northern Europe In the Southern region, where the other adversary of family planning, the Catholic Church, widely dominates, the same phenomenon can be observed: in Catholic countries fertility has dropped more than in the non-catholic countries of Central and Northern Europe. This experience and that of Eastern Europe make one think positively about the future and the possibilities of strengthening control of the birth rate and population growth throughout the world, although this will surely take many decades in Africa. Eastern Europe: All the countries of Eastern Europe had communist governments and despite preaching that birth control was a North American imperialist strategy, and although they had low fertility levels in 1950, they reduced them further. Poland, the most Catholic of these countries, reduced its fertility rate to one-third, more than any other country in the region, and today the average family has is just about one child. 8 Decline in Human Fertility:

17 Table 16: Decline of the Total Fertility Rate in Eastern Europe from 1950 to 2007 Poland Slovakia Romania Belarus Czech Republic Hungary Russia Ukraine Bulgaria Northern Europe: In 1950 the countries of Northern Europe had the lowest fertility rates in the world. Today, 57 years later, they have lowered these rates even more. Lithuania is the Northern European country that has lowered its fertility rate the most. Table 17: Decline of the Total Fertility in Northern Europe from 1950 to 2007 Lithuania Ireland Iceland Finland Latvia Norway Estonia Denmark United Kingdom Sweden Western Europe: Although fertility rates did not decline as much in Western Europe as they did in Eastern Europe from a percentage standpoint, all of these countries succeeded in reducing fertility rates to replacement rates and even lower. Table 18: Decline of the Total Fertility Rate in Western Europe from 1950 to 2007 Holland Germany Switzerland Austria Belgium France Luxembourg Decline in Human Fertility:

18 Southern Europe: It is important to emphasize that in these countries of Southern Europe, many of which are predominantly Catholic and already had a rather low fertility rate in 1950, lowered it even further to just more than one child per family. Table 19: Decline of the Total Fertility in Southern Europe from 1950 to 2007 Bosnia-Herzegovina Albania Malta Serbia Slovenia Portugal Croatia Spain Greece Italy VII. THE MOST SUCCESSFUL COUNTRIES The ten countries that have been most successful at lowering fertility are as follows: Table 20: The Ten Countries that Have Been Most Successful at Lowering Fertility from 1950 to 2007 South Korea Singapore Hong Kong Bosnia and Herzegovina China Thailand Mauritius Costa Rica Iran Tunisia Six of the ten leading countries are Asian, two are African, one is European, and the other is American. This incredible worldwide success achieved in little more than half a century allows us to continue being optimists and to expect that in a few decades the population of most countries will stabilize and we will be able to avoid having death be the main factor that slows population growth. This accomplishment successfully reducing fertility in all regions of the world is so important that it should be counted among the greatest human achievements of the past century. 10 Decline in Human Fertility:

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