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

Fertility Transitions in Ghana and Kenya: Trends, Determinants, and Implications for Policy and Programs IAN ASKEW NDUGGA MAGGWA FRANCIS OBARE As a continent with 54 independent states, Africa s diversity is often highlighted but frequently forgotten when fertility is discussed. Fifty and more years ago, to consider that all African countries and societies had a single fertility pattern (large numbers of children) and single trend (unchanging over time) was a valid characterization. Since the 1960s, however, that uniformity has disappeared, replaced by substantial inter- and intra-country differences in fertility patterns and trends that render previous perceptions of continent-wide homogeneity obsolete. In this chapter we consider two African countries Ghana and Kenya whose fertility patterns and trends, and their determinants, have been well documented (Bongaarts 2008; Garenne 2008; Machiyama 2010; Shapiro and Gebreselassie 2008; Sneeringer 2009). Both countries have benefited from regular World Fertility Surveys (WFS) and Demographic and Health Surveys (DHS) that record trends in fertility, family planning (FP), and other relevant indicators. The recently introduced Performance Monitoring and Accountability 2020 (PMA2020) surveys monitor progress since 2012 for the FP2020 initiative, and occasional Situation Analysis and Service Provision Assessment surveys have also detailed the readiness of the health system in both countries to make quality FP services available. Ghana and Kenya share some common history: both have relatively strong health system legacies from the period of British colonialization; both were among the earliest countries to achieve independence; they were the first two African countries that developed policies to address population growth in the 1960s; and both have received substantial and sustained resources over several decades from many external donors and technical assistance organizations explicitly intended to increase the availability and quality of family planning services. However, they are composed of cultures that are both diverse within each country and markedly different in many 289

290 F ERTILITY T RANSITIONS IN G HANA AND K ENYA ways between the two countries. The two countries demonstrate remarkably different pathways in fertility and family planning patterns and trends from the 1970s to the present. We highlight some of the key differences and similarities, explain why they have occurred, and identify insights that could inform a wider understanding of fertility transitions and the role of family planning in other African countries. Methodology Our analyses draw primarily from three sources. First, DHS datasets from the 1980s to 2014 were analyzed for both countries for sub-group indicators that are not presented in the respective reports. Second, information was obtained from DHS and WFS reports from 1970 to 2014 for nationallevel and some sub-group indicators. Third, selected documents describing population and family planning policies and programs over the past four decades were reviewed to provide insights into the political and social environment in which these transitions have occurred. In addition, all three authors have lived and worked in Kenya for extended periods of time and been involved with the national family planning program and various stakeholders since the early 1990s; over the same period, two authors (Ian Askew and Ndugga Maggwa) have been involved with Ghana s family planning program through multiple research and technical assistance activities. These personal experiences provide valuable insights that complement the evidence from statistical analyses and documentation reviews. Fertility trends in Ghana and Kenya Kenya (in 1967; Ajayi and Kekovole 1998) and Ghana (in 1969; Republic of Ghana 1969) were the first two countries in sub-saharan Africa to develop a national population policy. In Kenya, the policy remained largely dormant until the findings from the first World Fertility Survey in 1977 showed that the country had one of the highest total fertility rates (TFR) in the world at over eight children per woman. This statistic focused both policy and public attention on fertility issues and substantially boosted national and international support for a vigorous and comprehensive national family planning program. Similarly, little progress was made in Ghana during the two decades following the introduction of its population policy. The TFR remained virtually unchanged between 1960 and 1988 at 6.9 and 6.7, respectively, somewhat lower than Kenya during the same period. The main reasons identified at the time were the lack of involvement of key stakeholders and communities in policy development and the absence of a clear strategy for implementation. The policy was revised in 1994 to address these obstacles, leading to a renewed interest and investment in family planning services.

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 291 FIGURE 1 Fertility trends in Ghana and Kenya, 1970 2014 SOURCE: World Fertility Surveys and Demographic and Health Surveys. The revised plan had clear goals of reducing the TFR to 3.0 and increasing the contraceptive prevalence rate (CPR) 1 to 50 percent by the year 2020 (GNPC 1994). Figure 1 compares the trends in TFR for both countries over the past 45 years. Between 1978 and 1988, Kenya s TFR declined from 8.1 to 6.7 children per woman, and then declined by a further two children per woman by 1998. In Ghana, the TFR in 1977 was 1.6 children lower than in Kenya, but in contrast there was virtually no change over the following decade, so that by 1988 the TFRs were similar, at 6.4 and 6.7. Over the decade from 1988 to 1998, both countries experienced a rapid decline of two children per woman. Since these rapid declines, however, the pace of change has not only stalled in both countries, but both have also experienced an increase in TFR at some point. In Ghana, a five-year period of no change was followed by a decrease and then increase, whereas in Kenya the TFR increased and then decreased; by 2008, the TFR in Ghana was more than half a child lower than in Kenya. The past five years have seen surprising changes in the TFR in both countries a decline of 0.7 in Kenya and an increase of 0.2 in Ghana resulting in Kenya now having, for the first time, a TFR that is 0.3 lower than Ghana. In both countries, national TFRs mask major differences according to socioeconomic status and place of residence. Fertility trends among sub-populations Wealth Fertility levels in Ghana and Kenya vary consistently by wealth quintile. Over the period from 1993 to 2014, however, each country shows some surprising differences between quintiles. In 1993, it was the richest quintile in Kenya that was significantly different, with a TFR up to four children

292 F ERTILITY T RANSITIONS IN G HANA AND K ENYA per woman lower than the majority of the population (3.3 vs. 5.3 7.2). By 2014, the poorest quintile was significantly different, with a TFR up to 3.6 children higher than the majority of the population (6.4 vs. 2.8 4.7). Moreover, the TFR of the poorest quintile in 2014 (6.4) is virtually the same as it was in 1998 (6.5). Further, these two extreme quintiles have both shown the smallest decline since 1993 (0.5 for the richest and 0.8 for the poorest), with the middle three quintiles experiencing significantly greater declines of between 1.5 and 2.2 children per woman since 1993. The last five years (2008/9 2014), however, have seen a remarkable catch up among the majority: while the TFR of the top quintile changed little (from 2.9 to 2.8), the TFR of 80 percent of the population declined by 0.6 1.2 children per woman, a pace of change reminiscent of the 1980s. This pattern characterizes what is usual in most behavior change transitions. The wealthiest are usually the early adopters, who are the first to perceive the benefits of lower fertility and, most importantly, have the means and capacity to reduce their fertility. As fertility decreases over time, it is the poorest who are the late adopters because they do not perceive the benefits of lower fertility to be greater than those of high fertility; and a range of inequities means that they usually are not aware of or lack access to effective contraception. Although fertility in Ghana decreased consistently by wealth quintile over time, the poorest and fourth richest quintiles leveled off (at 6.3 6.5 and 3.3 3.5 respectively) over the decade 2003 2014. Conversely, the middle quintile reduced its fertility by one child (from 4.9 to 3.9) and the richest quintile initially decreased by half a child and then increased by half (i.e., 2.8 to 2.3 to 2.8). The overall increase in TFR during the past five years has thus been driven by both the top and bottom 40 percent, with the richest increasing by 0.3 and the poorest by 0.2. By 2014, Kenya and Ghana had transitioned to virtually identical TFRs for the poorest (6.3 and 6.4) and richest quintiles (both 2.8), although through different pathways. Education Level of education in both countries is closely associated with social and economic status in terms of fertility levels and patterns. Since the late 1980s there have been steady and similar declines in fertility among women with formal education, at both primary and secondary levels. Women with secondary or higher education have much lower fertility than those with primary or middle education, particularly in Ghana where highly educated women in 2008 had replacement-level fertility (2.1) while those with primary education were still at almost 5 births. Over the past five years, trends in the two countries reflect the differences in changes in the overall TFR described above. In Kenya, TFR among

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 293 women with secondary or higher education has stabilized at 3.0 and among women with no education at 6.5, whereas for women with completed or incomplete primary education, there have been rapid decreases of 0.7 children to an average of 4.5. In Ghana, the increase in TFR during this period has occurred among all women except those with primary education, for whom it remains constant (4.9); indeed, the most marked change in fertility has been among those with middle or secondary education, with increases of 0.5 0.7 children per woman. In both countries, there are substantial differences in childbearing by education among adolescent girls aged 15 19 years. In Kenya, the age-specific fertility rate (ASFR) in 2014 was 52 for highly educated girls (secondary level and above) and 185 for uneducated girls (those with no education); in Ghana, the rates were 56 for highly educated girls and 183 for uneducated girls. Thus compared to a girl with secondary education, an uneducated girl is three times more likely to have had at least one child. The reasons for this difference are well known (e.g., higher probabilities of early marriage, lower personal autonomy, and poorer access to contraception) and probably similar in both countries, but the scale of this difference and trends over time should be a cause for concern in both countries, albeit for different reasons. In Kenya, while the gap has declined to 3.5-fold from more than four-fold since 1998, this difference has increased substantially since 1989 when it was only 2.5-fold. In Ghana, not only has the ASFR for both uneducated and highly educated girls increased over the past decade, the rates for both education categories is the highest it has been since data were first collected in 1988. To summarize these trends by wealth and education, we have created a simple binary indicator, comprising the richest women with secondary and above education (most advantaged) and the poorest women with no education (most disadvantaged) and tracked these changes over the past two decades (Figure 2). Overall, the TFR declined by 0.9 children among the most advantaged Kenyan women and increased by 0.3 children for the most disadvantaged women. In Ghana, while there was no change among the most advantaged women, the TFR increased by 0.4 children among the most disadvantaged women. These trends suggest that the reductions of about two children per woman observed in both countries over these two decades have occurred among women in the middle categories of wealth and education. We posit that the smaller or non-existent decreases in TFR among the most advantaged may be explained by the fact that they have already achieved TFRs below the average desired family sizes for both countries. The increases in both countries among the most disadvantaged women likely reflect a combination of sustained high-fertility norms and relative inability to obtain and use effective contraceptive services.

294 F ERTILITY T RANSITIONS IN G HANA AND K ENYA FIGURE 2 Total fertility rate by wealth quintile and education level: Ghana and Kenya, 1993 2014 NOTE: Based on a binary variable combining bottom quintile and no education as one category and top quintile and secondary and above education as another category. SOURCE: Demographic and Health Surveys. Place of residence TFRs continue to be substantially higher among rural than urban dwellers in both countries. 2 There are some important differences between the two countries, however, especially over the past decade. In Kenya, the urban TFR of 3.1 in 2014 represents an increase of 0.2 births in the last five years. Conversely, the rural TFR has continued to decline rapidly, decreasing from 5.2 to 4.5 over the last five years. The urban rural gap is now 1.4 children, compared with 2.3 in 1989. In Ghana, the urban TFR increased by 0.3 over the past five years, reaching 3.4 in 2014. Unlike in Kenya, however, the rural TFR also increased by 0.3 in the past five years, and is now 5.2. The urban rural gap is currently 1.8 children, compared with 1.5 in 1988. Thus, the stall and increase in national fertility levels in Ghana over the last five years have been evenly distributed among urban and rural dwellers. Similarly, the increase in urban areas has been evenly distributed among the poorest and richest wealth quintiles. In particular, TFR increased by 0.5 births among the urban poor and by 0.4 births among the urban rich in Ghana in the past five years (Figure 3). However, the TFR of urban rich in 2014 is now lower than 20 years ago (by 0.6 births), while fertility among the urban poor is now higher by 0.6 births. Conversely, the recent fertility decline in Kenya has been entirely within the rural population. In urban areas, the TFR increase over the past five years has been greater among the richest quintile (0.7 births) than among the poorest (0.2 births). In contrast to Ghana, the TFR of the urban rich in Kenya is now higher than it was 20 years ago (by 0.3 births), while the TFR of the urban poor is lower by 0.4 births. However, the poorest

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 295 FIGURE 3 Total fertility rate among poorest and richest wealth quintiles in urban areas: Ghana and Kenya, 1993 2014 SOURCE: Demographic and Health Surveys. quintiles in urban areas of both countries continue to have much higher fertility than the richest quintiles, with fertility levels that are comparable to those of rural populations. It is important to consider the patterns and trends for 15 19-year-olds by residence, because the context within which urban and rural girls grow up has changed rapidly over the past three decades. The gap in ASFR between rural and urban girls in both countries has increased since 2008, and is now 25 births per 1,000 girls higher in rural than urban Kenya, and 47 per 1,000 girls higher in rural than urban Ghana. In Kenya, this increase is due primarily to a reduction in the ASFR among urban girls (from 92 to 81) but little change among rural girls (from 107 and 106); conversely, in Ghana the ASFR has increased among both urban (from 49 to 54) and rural girls (from 82 to 101), with a much greater rate of increase among the latter. Trends in wanted and unwanted fertility Wanted fertility Examining trends in wanted fertility rates provides insight into both individual desires and social norms. As Figure 4 indicates, an important element of the stalled fertility transition in Kenya from 1993 to 2008 was the unchanging wanted total fertility rate (WTFR) over the 15-year period. In Ghana, the WTFR declined in the late 1990s and leveled off at about the same level as in Kenya for the following decade (1998 2008), with the gap widening by 2014 because of the rapid decrease in Kenya over the past five years.

296 F ERTILITY T RANSITIONS IN G HANA AND K ENYA FIGURE 4 Trends in wanted fertility in Ghana and Kenya, 1993 2014 SOURCE: Demographic and Health Surveys. Wanted fertility rates are higher in rural than urban areas in both countries, but there are marked differences between sub-populations in the two countries. In Ghana, the WTFR decreased over time in rural areas and increased slightly in urban areas. Conversely, the rate remained constant in urban areas of Kenya (between 2.5 and 2.6), while in rural areas it declined from 3.9 in 2003 to 3.4 in 2014. The two countries show wide ranges subnationally, with WTFRs in both ranging between 2 and 6 children, indicating that differential fertility preferences across regions are likely to sustain high fertility in some areas, even if fertility rates decline in most parts of the country. Wanted fertility in both countries is also much higher among women with no education and the poorest quintile than in the general population. Moreover, when compared with the most advantaged, wanted fertility is approximately three children per woman higher among the most disadvantaged women. In Ghana, the WTFR for women with no education has risen steadily from 5.1 in 1993 to reach an all-time high of 5.5 in 2014. Among the most educated, the WTFR was fairly constant at 2.3 2.5 since 1993, dropped to 1.8 in 2008, but rose sharply by half a child over the past five years. In Kenya, the WTFR steadily increased among those with no education, from 4.2 in 1993 to 6.1 in 2014, but remained fairly stable among the most educated over the past decade (2003 2014) at between 2.3 and 2.4, having declined from a high of 2.8 in the previous decade. Unwanted fertility Unwanted fertility, as measured by the DHS, is the proportion of women who have more children than they say they desire or consider ideal; high

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 297 FIGURE 5 Trends in unwanted fertility in Ghana and Kenya, 1993 2014 SOURCE: Demographic and Health Surveys. levels of unwanted fertility indicate a potential unmet need for contraceptive services. As seen in Figure 5, Kenya had double the level of unwanted fertility of Ghana over a 15-year period (1993 2008), although the gap was halved in the last five years. The two countries display similar trends, however: a virtual halving of unwanted fertility in the late 1990s, with little or no change over the next decade, although the last five years in Kenya show a substantial decline. The most educated in both countries have the lowest unwanted fertility, while those with primary education have the highest levels. In Kenya, while uneducated women have the second lowest level of unwanted fertility and the steepest decline over time, they also have the highest level of wanted fertility; this combination explains why fertility has remained high among uneducated women. Although unwanted fertility has been between two and four times higher among the poorest compared to the richest women over time, it steadily declined among the poorest quintiles (from 2.3 in 2003 to 1.4 in 2014) but remained stable among the richest quintiles (at between 0.4 and 0.6 over the same period). Unwanted fertility among the richest and poorest quintiles in Ghana has been consistently lower than that of similar sub-groups in Kenya. In contrast to Kenya, unwanted fertility among the poorest women in Ghana remained stable at around 0.7 0.8 between 2003 and 2014, but declined among the richest over the same period (from 0.4 to 0.2). Unwanted fertility among the most educated in Ghana steadily decreased between 1998 and 2003 (from 0.6 to 0.2) but then leveled off at 0.3 in 2008 and 2014. In contrast, there was a rapid decline in unwanted fertility among women with no education between 1993 and 1998 (from 1.6 to 0.9), but this slowed and stabilized thereafter (at between 0.8 in 2003 and 0.7 in 2014).

298 F ERTILITY T RANSITIONS IN G HANA AND K ENYA In both countries, unwanted fertility is higher in rural areas. Unwanted fertility steadily declined in urban Ghana from 1.1 in 1993 to 0.3 in 2014. Although a similar trend was noted in rural areas between 1993 and 2008 (from 1.5 to 0.7), it increased in 2014 to around the level recorded in 1993 (1.4). There was no consistent change in unwanted fertility in urban areas of Kenya, with the lowest and highest levels of 0.4 and 0.9 being recorded in 2008 09 and 1993 respectively. In contrast, unwanted fertility in rural areas of Kenya declined from 2.1 in 1993 to 1.4 in 1998 and remained stable at 1.4 1.5 over the next decade before declining further in 2014. Trends in provision and use of contraceptive services Source and method mix Formal family planning programs have existed in both countries for several decades, and provision of contraceptive services preceded the population policies by several years. A brief history of family planning policies and programs in Ghana and Kenya is given in the Annex. 3 In Kenya, the public sector continues to be the predominant source of family planning services; in 2014, 60 percent of clients used the public sector, down from a high of 71 percent in 1989. The private sector increased its share steadily over the past 15 years to 34 percent (from 26 percent in 1989), with 5 percent getting their method from a shop, market, community volunteer, friend, or relative. There are wide variations by wealth, with 82 percent of the poorest women and 35 percent of the richest using the public sector (PMA2020 and ICRHK 2014). In Ghana, the market share has historically been more evenly distributed, with the private sector marginally larger than the public sector; however, there was a rapid shift between 2008 and 2014, with the proportion using the public sector increasing from 39 percent to 64 percent and the private sector share declining from 51 percent to 33 percent. During the period of stalled fertility decline experienced by both countries in the late 1990s, the proportions of women using the private sector increased (from 25 percent to 41 percent in Kenya between 1993 and 2003; from 45 percent to 54 percent in Ghana between 1998 and 2003) and public-sector use decreased (from 68 percent to 53 percent in Kenya; from 47 percent to 41 percent in Ghana over the same periods), possibly reflecting reduced investments. An important trend in the provision and use of family planning services in both countries over the past 25 years has been the rapidly increasing dominance of injectables as the most widely used method and the concomitant reductions in all other methods, especially intrauterine devices (IUDs), pills, and sterilization. In Kenya, injectables accounted for 50 percent of modern methods used by currently married women in 2014,

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 299 FIGURE 6 Trends in all-method contraceptive use among currently married women in Ghana and Kenya, 1988 2014 SOURCE: Demographic and Health Surveys. up from 19 percent in 1989, while the share of IUDs declined from 21 percent to 7 percent, pills from 26 percent to 15 percent, and tubal ligation from 29 percent to 16 percent over the same period. As Kenya s contraceptive prevalence rate (CPR) did not increase between 1998 and 2003, most of the increase in injectable use during this period represented either switching from methods such as pills, IUDs, and condoms, or new users starting with injectables. In Ghana, injectables increased from 3 percent to 36 percent while IUDs declined from 10 percent to 3 percent, pills from 36 percent to 21 percent, and tubal ligation from 19 percent to 9 percent between 1988 and 2014. Notable in both countries has been the rapid increase in implant use over the past five years, from 0.9 percent to 5.2 percent of married women in Ghana and from 1.9 percent to 9.9 percent in Kenya. This is likely due to an increased emphasis on informing women about this option and increasing its availability within FP programs; the past three years have also seen a substantial reduction in the cost of implant commodities to FP family planning programs following negotiations with the manufacturers through the global Implant Access Program (CHAI 2015). Trends in use of contraception The CPR among married women has more than doubled in both countries over the past 25 years, but since the early 1990s the trajectories in the two countries are notably different (Figure 6). Kenya sustained its rapid growth in the CPR until 1998 and leveled off for five years, after which the rate of

300 F ERTILITY T RANSITIONS IN G HANA AND K ENYA increase through 2014 returned to its previous levels of almost 2 percentage points per year. In Ghana, the rate of increase has slowed during the past two decades, after increasing by 7 percentage points in 20 years; indeed, CPR decreased between 2003 and 2008. As with national fertility trends, insights can be gained through analyzing trends in contraceptive use within sub-populations. In Kenya, CPR has always been higher among urban than rural dwellers, but over the past decade the difference has been substantially reduced, from 11 percentage points (37 percent in rural and 48 percent in urban) in 2003 to 6 percentage points (56 percent rural, 62 percent urban) in 2014. Within the urban population, there is great disparity by education, with 21 percent of urban uneducated women using a modern method compared with 61 percent of women with secondary education in 2014. Conversely, in Ghana the proportion of rural women using modern contraception (24 percent) has surpassed that of urban women (20 percent). Use of modern contraception among women with primary education in Kenya (complete or incomplete) has increased rapidly (to 56 percent) so that there is now little difference from those with secondary education (60 percent). A major challenge remains, however, among women with no education; although use of modern methods has increased since 2003, it is still only 15 percent among this sub-group. In Ghana, although modern contraceptive use is higher among women with higher levels of education, since 1993 use of these methods has increased from 4 percent to 17 percent among uneducated women, but remained constant at 24 25 percent among women with secondary or higher education; indeed, women with primary education now have the highest modern contraceptive prevalence rate (mcpr). Over the decade 2003 2014, the differences in mcpr between wealth quintiles in Kenya declined sharply, with a range of only 7 percentage points (54 percent 61 percent) between the top four quintiles. Despite an increase of 12 percentage points over the past five years in the poorest quintile to 29 percent, they remain 25 percentage points below the next poorest quintile. Conversely, in Ghana, the past five years have seen substantial increases in modern contraceptive use within the lowest three wealth quintiles, stagnation within the fourth quintile, and a decline of 5 percentage points in the highest quintile between 2008 and 2014. Women in the richest quintile in Ghana now have the lowest mcpr in the country. The past decade has also been characterized by steep increases in contraceptive use among women aged 15 19, rising from 8 percent to 19 percent in Ghana and from 16 percent to 40 percent in Kenya. Moreover, median age at first sex increased significantly between 1993 and 2014 in both countries, from 17.1 to 18.4 years in Ghana and from 16.8 to 18.0 years in Kenya among women aged 25 49 years. Similarly, the median age at first marriage increased from 18.1 to 20.7 in Ghana and from 18.8 to 20.2 in

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 301 Kenya over the same period. This indicates that adolescents are not only starting to become sexually active later, but are also more likely to marry later and to use contraception when they are sexually active. These averages mask large differences between sub-populations. For example, in both countries adolescent girls and women in the lowest wealth quintiles and with no education start sex and marry much earlier than those in the wealthiest quintiles. In Ghana, the poorest start having sex, on average, 2.1 years earlier than the wealthiest, and women with no education start sex 3.1 years earlier than those with secondary or higher education. A similar scenario exists in Kenya, where the wealthiest and most educated start sex and enter marriage three years later than the poorest and uneducated. In both countries, contraceptive use among sexually active never-married women is higher than among currently married women (46 percent and 33 percent in Ghana; 70 percent and 64 percent in Kenya) (PMA2020 2013). Women in both countries, including those wanting no more children, still rely heavily on injectables (primarily Depo Provera). The use of longacting reversible and permanent contraception remains low. While there has been a recent increase in the availability and use of implants in both countries, there has also been a significant decline in the use of IUDs and sterilization. The global Implant Access Program has ensured lower prices for implants through negotiations with manufacturers, enabling donors and governments to increase their availability (CHAI 2015). The program has recently been extended, but it is unclear what would happen if it ends and a low-cost implant product does not become available. Recent studies raise concerns about the contraceptive efficacy and future role of implants when used in combination with antiretroviral drugs like Efavirenz (currently the first-line drug for HIV treatment in most of sub-saharan Africa). Moreover, the ongoing controversies concerning the use of Depo Provera by women with a high risk of HIV infection and the use of implants among women on antiretroviral therapy have the potential to derail both options for women (Heffron et al. 2011; WHO 2012; Womack, Novick, and Goulet 2015). There is, therefore, a need for both governments and their partners to prepare alternative strategies for expanding the method mix of their programs to account for any changes in access that might arise. Need for contraception Family planning programs can be measured in terms of their effect in reducing unmet need and satisfying demand. Given the trends in mcpr described earlier, it is not surprising that while unmet need in Ghana has been reduced from 36 percent in 2008 to 30 percent in 2014, it is now only 7 percentage points lower than it was in 1993. In Kenya, conversely, unmet need was

302 F ERTILITY T RANSITIONS IN G HANA AND K ENYA halved between 1993 and 2014, from 35 percent to 18 percent. There is little difference in unmet need by age in Kenya (low of 15 percent at ages 25 29, high of 23 percent at ages 15 19), and it continues to be lower in urban (13 percent) than rural areas (20 percent). In Ghana, however, unmet need is very high at ages 15 19 (51 percent) and low at ages 45 49 (14 percent), yet virtually the same in urban and rural areas (29 percent and 31 percent). Overall, the proportion of women with satisfied demand in Kenya has continued to increase, reaching 77 percent in 2014 a substantial improvement over 64 percent in 2008 and exceeds 80 percent among urban, welleducated, and well-to-do women. It remains much lower, however, among the poorest (52 percent) and the uneducated (41 percent). Satisfied demand remains below 50 percent in Ghana overall, and is particularly low among adolescents (27 percent) and the uneducated (38 percent). Despite high satisfied demand, the proportion of births that are unintended (mistimed or unwanted) remains high in both countries: 36 percent in Kenya, 31 percent in Ghana. Unintended births are by far the highest at ages 15 19: 74 percent in Ghana, 59 percent in Kenya. The proportion of unintended pregnancies that are terminated through induced abortion is difficult to determine. Estimates show that 50 percent of unintended pregnancies globally result in induced abortion, with the proportion being higher in developed than developing countries (54 percent and 49 percent), while across Africa the proportion varies from 22 percent to 39 percent (Sedgh and Hussain 2014). The largest surveys to date in Ghana (Ghana Statistical Service et al. 2009) and Kenya (Republic of Kenya/Ministry of Health 2013) indicate abortion incidence rates (number of abortions per 1,000 women aged 15 49) of 15 in Ghana and 48 in Kenya. The rate for Ghana is far lower than for Kenya because it includes only induced abortions while the rate for Kenya includes both spontaneous and induced abortions. In addition, access to legal abortion is less restricted in Ghana than in Kenya. Recent evidence further indicates that there has been no major decline in the rate of induced abortion in developing countries since the 1990s, while significant declines have been recorded in developed countries (Sedgh et al. 2016). In Kenya, the rate increased slightly from the figure of 45 per 1,000 recorded in 2002 in spite of the increase in the CPR (Republic of Kenya/Ministry of Health 2013). Parallel increases in contraception and abortion have mainly been found in countries with rapid fertility declines and have been associated with the inability of contraceptive use alone to meet the growing demand for fertility regulation; while in countries where fertility has stalled, increased contraceptive use is associated with a decline in induced abortion (Marston and Cleland 2003). In both Ghana and Kenya, rates of abortion are high among women with low, declining, or stalled contraceptive use.

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 303 Discussion and conclusions Until the late 1970s, women in Kenya had a TFR of more than 8, one child more than women in Ghana. Although Ghana s fertility had leveled off at that time, Kenya s TFR continued to decline; by 1988 the TFR was 6.4 in Ghana and 6.7 in Kenya. For the next ten years, Ghana and Kenya experienced similarly rapid declines, reaching TFRs of 4.4 and 4.7 respectively in 1998. In the following decade, fertility leveled off in both countries, although Ghana experienced a slight decline so that by 2008 its TFR had decreased to 4.0 while in Kenya it was still at 4.6. What has happened in the last five years is a remarkable change. Ghana s TFR increased by 0.2 and Kenya s decreased by 0.7, so that for the first time Kenya s TFR is below Ghana s. Our discussion will address three aspects of these fertility transitions: Why did the declines in fertility stall in both countries when they reached about four children? Why has a fertility decline apparently resumed in Kenya while fertility remained stalled, and indeed increased slightly, in Ghana? And although Kenya s CPR is nearly twice that of Ghana, how has Ghana been able to reach a TFR virtually as low as Kenya s? Since 2003 both countries have had a WTFR of 3.0 to 3.7, with the levels for Kenya being slightly lower than for Ghana. Over the same period, Kenya s unwanted total fertility rate (0.9 1.3) has been higher than Ghana s (0.5 0.7). This suggests that women and couples in Kenya may have been more motivated to use family planning, and particularly modern contraceptives, given their higher levels of unwanted fertility. It is important to highlight the complete stall in CPR in Kenya (at 39 percent) during 1998 2003, which can now be seen as an anomaly given the consistent increases before and after this period (see Figure 6). As discussed elsewhere (Askew, Bongaarts, and Townsend 2009), the stall most likely reflected a combination of several factors, predominantly the Kenya Government s shift to prioritize resources and attention to the national disaster of the HIV/AIDS pandemic; the donor community s decreased financial and technical support for family planning because of a transfer of funding to HIV/AIDS; and a perception that the family planning program was well established, given the remarkable increase in CPR seen over the previous decade. Both countries have been exemplary in their development of a full range of policies, norms, standards, and guidelines, particularly over the past two decades, thus creating a highly supportive environment for program implementation (see Annex). However, continued reliance on donor funding for commodity security, in-service training, and other system strengthening and community engagement interventions has left both countries highly vulnerable to resource gaps and sudden disruptions when donors change commitments and priorities. The experience

304 F ERTILITY T RANSITIONS IN G HANA AND K ENYA of Kenya during the period 1998 2003 illustrates what can happen when government-controlled financing becomes uncertain. These vulnerabilities have increased with the recent devolution of governmental responsibility for family planning to sub-national levels in Kenya. The rapid and sustained increase in mcpr in Kenya over the past decade suggests that strong government-led planning and implementation, together with coordinated and sustained funding from donors, can lead to significant achievements over short periods of time. The largest donorsupported programs in Kenya have been USAID s AIDS, Population and Health Integrated Assistance (APHIA) and APHIAPlus investments. Their integrated design, which focused on both health systems strengthening and community engagement, enabled the national family planning program to optimize both community platforms and facility-level resources that had not been supported in previous initiatives that primarily focused on expanding service delivery. Innovative approaches have also been tested within the APHIA programs for example, the combination of a task-shifting intervention that supported community health workers (CHWs) in providing injectable contraceptives, together with expanded implementation of the government s community health strategy that supported CHWs in providing contraceptive information and commodities to largely rural populations. The rapid increases in mcpr (primarily in injectable use) were greatest in the provinces where the government s community health strategy was most thoroughly implemented. Although Ghana has also instituted a large-scale community health strategy that increases access to injectables and other contraceptive services namely, the Community-based Health Planning and Services (CHPS) program a lower degree of integration within a broader health systems strengthening approach appears to have lessened its reach and impact. The increase in age at first sex and marriage observed in both countries presents both an opportunity and a challenge for national family planning programs. Both trends are likely to reduce fertility over time, but they also mean that programs have to be restructured to better meet the needs of this increasingly large number of unmarried new clients. Both countries have also seen a rapid increase in use of modern contraceptives among young women aged 15 19. This trend suggests an improvement in the capacity of programs to reach these often marginalized populations. The poorest quintile and the least educated, in Kenya particularly, are becoming increasingly distinct from the rest of the population, with much higher fertility preferences, higher TFR, and lower contraceptive prevalence. These differences within this sizable population are distorting the national aggregates, and steps should be taken to reduce disparities in access to effective contraception between these groups and better-off segments of the population. Moreover, both countries have geographically distinct populations that are socio-culturally diverse, including some that are very

I AN A SKEW /NDUGGA M AGGWA /FRANCIS O BARE 305 different in terms of fertility and family planning use from the rest of the country. Although the TFR has remained higher among rural, poor, and less educated women in Ghana, the recent increase in TFR and wanted fertility, and a stalling in the mcpr among the urban, wealthy, and educated populations in the country, present an unusual situation. These trends may represent a combination of achievement of desired family size in this population and dissatisfaction with hormonal contraceptives as a preferred means for fertility control. A recent study by Machiyama and Cleland (2014: 221) concluded that Many urban elite couples appear to be rejecting highly effective hormonal methods, primarily for health reasons. They resort instead to various means of restricting coitus, and to abortion, to achieve small family size. It remains to be seen whether this trend will emerge among urban elites in other African countries. In addition, evidence suggests that use of less effective traditional methods could actually be higher in Ghana than is reported in surveys, mostly as a result of under-reporting associated with misunderstanding of the questions (Blanc and Grey 2002; Staveteig 2016). Besides reporting biases, studies show that discrepancies between TFR and CPR are influenced by the degree of overlap between contraceptive use and postpartum amenorrhea (Adamchak and Mbidzo 1990; Jain et al. 2014; Thomas and Mercer 1995). In addition, the estimates might be affected by DHS sampling errors such that very small differences over time or between sub-groups could be a reflection of sampling variability rather than genuine change. In spite of the limitations in the estimates, the fertility trends identified above have important implications for policy and programs in both countries, including a need for: Sustained efforts to reduce high fertility levels and norms among the most disadvantaged sub-populations, for example, through sustained behavior change communications and improved access to contraception, Concerted programmatic action to reverse the decline or stall in contraceptive use by expanding the method mix and providing a wider range of options to meet various needs, and Innovative financing strategies to ensure sustained contraceptive commodity security, health systems strengthening, and community engagement in order to reduce resource gaps in public financing that might be occasioned by fluctuations in donor funding. Notes Analysis for this chapter was supported by UKaid from the Department for International Development (DfID) through the STEP UP (Strengthening Evidence for

306 F ERTILITY T RANSITIONS IN G HANA AND K ENYA Programming on Unintended Pregnancy) Research Programme Consortium. The data used are publicly available from the MEA- SURE DHS program at ICF International (http://dhsprogram.com/). The DHS program is funded by the United States Agency for International Development (USAID) to carry out population and health surveys in developing countries. 1 The contraceptive prevalence rate (CPR) is the proportion of currently married women using any method of contraception; mcpr refers to the proportion of such women using a modern method. 2 The two countries have different definitions of urban areas. In Ghana, the sampling frame used for the 2014 GDHS is the frame of the Ghana 2010 Population and Housing Census (PHC) provided by the Ghana Statistical Service (GSS). This frame uses a locality as the geographic area, with all localities of 5,000 or more persons classified as urban. In Kenya, urban areas and cities were previously categorized as city councils, municipal councils, county councils, and town councils based on population sizes as per the Local Government Act of 1963. This has, however, changed based on the Urban Areas and Cities Act of 2011, which classifies urban areas as city counties, cities, municipalities, and towns, largely based on population sizes but partly on capacity to provide certain services. The Act defines an urban area as a settlement with at least 2,000 people but sets a minimum population size of 500,000 for cities and city counties, 250,000 for municipalities, and 10,000 for towns. 3 Annex is available at the supporting information tab at wileyonlinelibrary.com/journal/pdr. References Adamchak, D.J. and M. Mbidzo. 1990. The relationship between fertility and contraceptive use in Zimbabwe, International Family Planning Perspectives 16(3): 103 106 & 111. Ajayi, A. and J. Kekovole. 1998. Kenya s population policy: From apathy to effectiveness, in A. Jain (ed.), Do Population Policies Matter? Fertility and Politics in Egypt, India, Kenya and Mexico. New York: Population Council, pp. 113 156. Askew, I., A. Ezeh, J. Bongaarts, and J. Townsend. 2009. Kenya s Fertility Transition: Trends, Determinants and Implications for Policy and Programmes. Nairobi: Population Council. Blanc, A.K. and S. Grey. 2002. Greater than expected fertility decline in Ghana: Untangling a puzzle, Journal of Biosocial Science 34: 475 495. Bongaarts, J. 2008. Fertility transitions in developing countries: Progress or stagnation?, Studies in Family Planning 39(2): 105 110. CHAI (Clinton Health Access Initiative). 2015. Case Study: Expanding Global Access to Contraceptive Implants. http://www.clintonhealthaccess.org/content/uploads/2015/08/case- Study_LARC.pdf. Accessed on January 20, 2016. Chege, J. and I. Askew. 1997. An Assessment of Community-Based Family Planning Programs in Kenya. Nairobi: Population Council. Crichton, J. 2008. Changing fortunes: Analysis of fluctuating policy space for family planning in Kenya, Health Policy and Planning 23(5): 339 350. Garenne, M. 2008. Situations of fertility stall in sub-saharan Africa, African Population Studies 23(2): 173 188. Ghana National Population Council (GNPC). 1994. National Population Policy. Revised edition. Accra, Ghana. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and Macro International. 2009. Ghana Maternal Health Survey 2007. Calverton, MD: GSS, GHS, and Macro International. Heffron, R. et al., for the Partners in Prevention HSV/HIV Transmission Study Team. 2011. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study, Lancet 3099(11): 70254 70257. Jain, A., J. Ross, E. McGinn, and J. Gribble. 2014. Inconsistencies in the Total Fertility Rate and Contraceptive Prevalence Rate in Malawi. Washington, DC: Futures Group, Health Policy Project.

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