Does Contraception Use Always Lead to Lower Fertility? The Case of Malawi
Publication date: 2015
HEALTH POL ICY P R O J E C T Does Contraception Use Always Lead to Lower Fertility? The Case of MalawiHEALTH POL ICY P R O J E C T CONTACT US Health Policy Project 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 www.healthpolicyproject.com email: firstname.lastname@example.org Tel: +1.202.775.9680 Fax: +1.202.775.9684 PRESENTED BY Aparna Jain1 John Ross2 Erin K. McGinn2 Jay Gribble2 1 Population Council 2 Health Policy Project, Futures Group Population Association of America 2015 Annual Meeting April 30–May 2, 2014 San Diego, CA Rural/Urban Differences When HPP applied the Proximate Determinants model calculations to rural/urban areas, the estimated TFR was higher than the DHS reported TFR. Urban Rural 2000 2004 2010 2000 2004 2010 Estimated TFR 6.2 6.4 5.5 6.6 6.8 5.9 Observed TFR 4.5 4.2 4.0 6.7 6.4 6.1 CONCLUSIONS Differences between the estimated and observed TFRs are less than half a child, which falls into a reasonable realm of variation. This does not conclusively suggest that Malawi’s DHS fertility rates are higher than the true fertility rates. In urban areas, the estimates were found to be vastly different than the observed fertility rates, but methodology provides no explanation. ■ Measurement error? (only 20% of population lives in urban areas) ■ HIV acquisition influencing desire for children? (not accounted for in Proximate Determinants model) ■ Untreated sexually transmitted infections? (which may cause sterility) Additional qualitative and quantitative research to supplement understanding of these issues may address the following questions: ■ Does discontinuation of contraceptive methods play a role in why TFR is not lower than expected? What is the duration of non-permanent method use? ■ Why did sexual debut and age at marriage remain virtually unchanged from 2000 to 2010? Have early marriage beliefs evolved over time? ■ Given the observed urban/rural TFR differences, are migratory patterns of urban men affecting fertility? ■ What are client preferences and health system factors that result in a method mix skewed toward injectables? For more information: Jain, Aparna, John Ross, Erin McGinn, and Jay Gribble. 2014. Inconsistencies in the Total Fertility Rate and Contraceptive Prevalence Rate in Malawi. Washington, DC: Futures Group, Health Policy Project. 2000 2004 2010 Pushes TFR Sexual activity (Cm) 0.938 0.934 0.932 Contraception (Cc) 0.754 0.745 0.644 Postpartum infecundability (Ci) 0.578 0.597 0.599 Abortion (Ca) 0.955 0.949 0.938 Total fecundity 15.3 15.3 15.3 - Estimated TFR 6.0 6.0 5.2 - Observed TFR 6.3 6.0 5.7 - RESULTS The authors estimated TFR as 6.0 in 2000, which is lower than the reported DHS TFR. The estimated TFR for 2004 was also 6.0, likely due to an increase in the index of postpartum insusceptibility offset by small increases in the use of contraception and abortion. This estimate corresponded with the reported DHS TFR. The rise in contraceptive use in 2010, coupled with unchanged postpartum infecundability began to drive the TFR downward between 2004 and 2010. This resulted in an estimated TFR of 5.2, lower than the observed TFR of 5.7. METHODOLOGY The authors used Bongaarts’ Proximate Determinants (PD) of Fertility Model to estimate TFR and compare it to the observed TFR reported in the Demographic and Health Surveys (DHS). HPP generated values for these indices using Malawi’s DHS data from 2000, 2004, and 2010. PD Formula TFR = Cm × Cc × Ca × Ci × TF ■ Cm = index of marriage ■ Cc = index of contraception ■ Ca = index of induced abortion ■ Ci = index of postpartum infecundability ■ TF = total fecundability * Since 5.6% of Malawian women have never been married but have been sexually active, sexually active was used as the measure for Cm. ^ Abortion data are unavailable in Malawi. An estimate was used to calculate Ca (see below). MALAWI’S RECENT SUCCESSES IN FP In the past two decades, use of contraception among married women rose from 13% in 1992 to 46% in 2010, and unmet need declined from 36% in 1992 to 26% in 2010. Malawi is often highlighted as a family planning (FP) success story. Yet the total fertility rate (TFR) decreased from 6.7 births per woman in 1992 to only 5.7 in 2010. CPR TFR 1992 DHS 2000 DHS 2004 DHS 2010 DHS 8 1 2 3 4 5 6 7 0 0 50 40 30 20 1013 30.6 32.5 46.1 TF R CPR With CPR at 46%, shouldn’t TFR be lower? Globally, several studies suggest a linear relationship between TFR and the contraceptive prevalence rate (CPR). Tsui (2001) estimated for every 15-point increase in CPR, TFR should decline by 1. With the dramatic increase in CPR over the past two decades, we might expect Malawi’s TFR to be closer to 4.4 than 5.7. RESEARCH QUESTIONS & HYPOTHESES Question 1: Why has the rise in CPR not translated into significant reductions in TFR? Hypothesis 1: Malawi’s DHS fertility rates may be higher than the true fertility rates. Question 2: Are there notable differences in CPR and TFR estimates in urban and rural areas? Hypothesis 2: Urban or rural fertility is weighting the national fertility rates. Proximate Determinants of Fertility Distal Determinants Social: Female education, income, status of women Cultural: Marriage practices, religious beliefs about contraception, divorce, ideal family size Health: Prevalence of STIs, malaria, HIV, under-5 mortality Political: Government policies regarding family planning Programmatic: Availability of a range of contraceptive information and services, demand generation for contraceptive methods Proximate Determinants Fertility Sexual Activity Postpartum Breastfeeding/ Abstinence Contraceptive Use Abortion TRENDS Abortion Two data sources were used to calculate the abortion rates: ■ Levandowski et al., (2013), who estimated 23 abortions per 1,000 women ages 15–44 in 2009 ■ WHO’s East Africa estimate of 31 abortions per 1,000 in 2000 and 36 per 1,000 in 2008 The authors first calculated the yearly amount of change in abortions from 2000 to 2008 using WHO regional estimates. This yearly change was applied to the Levandowski abortion estimate to calculate values for 2000, 2005, and 2010. This calculation yielded abortion estimates of 19.8 in 2000, 21.6 in 2004, and 23.4 in 2010. Mean Duration (months) 2000 2004 2010 Postpartum amenorrhea 14.1 13.1 12.7 Postpartum abstinence 9.0 8.4 8.2 Postpartum insusceptibility 16.1 15.0 14.9 Postpartum Infecundability Is Declining Breastfeeding and abstinence between births provide natural contraception and reduce fertility. Between 2000 and 2010, women in Malawi reduced the number of months they breastfed, and also returned to sexual activity earlier (shortened period of postpartum abstinence). The proportion of women who were using contraception during the postpartum period (dual protection) also declined. Percentage Married by Exact Age 18 and Sexual Activity by Exact Age 18 Among Women Ages 20–49, 2000–2010 Malawi 2000 Malawi 2004 Malawi 2010 80 70 60 50 40 30 20 10 0 Married by exact age 18 Sexual activity by exact age 18 Pe rc en t 50.7 50.5 51.6 65.2 67.1 65.1 Sexual Debut and Marriage Sexual debut is slowly shifting toward older ages, however Malawians are still getting married at a young age. Of those women who wish to limit births, 58% are using less- effective short-acting methods (pills, injectables, and condoms) and traditional/folkloric (withdrawal, abstinence, and lactational amenorrhea method, among others). 58% The CPR increase in Malawi has been uneven. While use of almost all methods increased over this period, injectables and female sterilization accounted for the majority of the rise in contraceptive use. 10.5% 1992 24.9% 2000 25.7% 2004 35.4% 2010 CPR and Method Mix Pill IUD Injectable Male Condom Female Sterilization Periodic Abstinence Withdrawal Implant Female Condom Other Malawi FP Method Mix, 1992 (CPR = 13%) Malawi FP Method Mix, 2010 (CPR = 46%) 15.1 17.0 11.3 2.8 13.2 14.2 16.0 10.4 7.6 54.2 21.2 0.65.4 2.53.1 3.4 1.7 0.3 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID- OAA-A-10-00067, beginning September 30, 2010. HPP is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. References Levandowski, B. A., C. Mhango, E. Kuchingale, J. Lunguzi, H. Katengeza, et al. 2013. “The Incidence of Induced Abortion in Malawi.” International Perspectives on Sexual and Reproductive Health, 39(2): 88–96. World Health Organization. 2011. Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality in 2008. Geneva: World Health Organization. World Health Organization (Ed.). 2004. Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality in 2000. Geneva: World Health Organization.