Birth control in sub-Saharan Africa’s demographic transition

Although it is clear that active family planning programs can promote the use of contraceptives, the relationship between contraceptive prevalence and fertility decline is not a straightforward one. In the Western World, fertility declined completely through rudimentary contraceptive methods, before the arrival of highly effective modern family planning. In pioneer South Africa, the situation was somewhat similar: its fertility was already declining by the 1960s, before the establishment of family planning programs in the mid-1970s (Moultrie & Timæus 2003). Kenya and Ghana were among the first countries to put in place family planning programs and to formulate population policies, by the second half of the 1960s (Belcher et al. 1978; National Research Council 1993a;

Heisel 2007). Zimbabwe was also a pioneer even before its independence: while the authorities did not formulate population policies in the late 1960s, they did support private family planning projects. Interestingly, although such programs have led to significant increases in contraceptive use and fertility decline (National Research Council 1993a), they did not prevent countries from going through critical fertility stagnation phases. As stated before, Kenya is a well-studied case of fertility stalls (Ezeh et al. 2009; Garenne 2011). In Ghana also, despite being on the forefront of Western Africa’s demographic transition (Agyei-Mensah 2006), fertility decline witnessed significant stalls, especially in urban areas (Garenne 2011).

The above mentioned programs were at the vanguard of family planning in sub-Saharan Africa. However, post-colonial Africa was overall very reticent to consider the need for family planning (National Research Council 1993a). Beside some exceptions such as Liberia and Ethiopia , the majority of the region was under occupation from around the ³⁵ 1880s. The first country to gain independence was South Africa, in 1910, while all others gained theirs during a process which lasted from the 1960s until the 1970s.

Zimbabwe was among the exceptions of gaining late independence from Great Britain in the early 1980s, as well as Namibia that was subordinated to South Africa until the 1990s. As stated in the previous chapter, the delay in getting free from colonial rule can explain the fact that, during the first World Population Conference at Bucharest (1974), newly independent African States were more concerned with development issues and North/South relations than about fertility.

Liberia is a nation created by the United States in 1847 in an effort to resettle freed slaves and free-born

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blacks (Falkner 1910), and Ethiopia which was occupied for half a decade by the Italians until 1941 (Tibebu 1996).

In the 1970s, sub-Saharan Africa witnessed a remarkable progress in data collection.

Censuses held in the 1960s under the colonies’ status were weak, and vital registration systems malfunctioned. However, newly independent countries made considerable efforts to improve censuses and launched a series of surveys. Statistical institutions were developed, and the World Fertility Surveys and their successor, the Demographic and Health Survey started gathering high-quality data (UNECA 1994; Tabutin &

Schoumaker 2004). Improved demographic knowledge allowed to create projections regarding population growth. Prospects of fast population increase by the end of the XX^th century pushed African States to address population issues in the late 1970s. In the Kilimanjaro Programme of Action (1984), the main principles explicitly state that

"population should be considered as a central issue in development strategies" and that

"population and development are interrelated" (United Nations Economic Commission for Africa 1994). A change of heart that was also reflected at the Mexico City World Population Conference (1984), and the importance to commit to family planning was renewed at the Cairo Conference (1994), and more strongly so at the London Summit (FP2020) in 2012. While the Kilimanjaro and the Mexico City meetings were taking place, only about one in ten women resorted to contraception in sub-Saharan Africa. By 1994, on the eve of the Cairo Conference, family planning had reached one in seven women. In 2012 during the London Summit, more than one woman out of four was using contraception in sub-Saharan Africa, and today, it nearly reaches one in three (UNDESA 2017a).

As already stated, just as the setting up of family planning programs does not necessarily induce a straightforward effect on contraceptive prevalence, the effect of contraceptive prevalence on fertility is not always clear-cut, either. It is important to remind that factors such as long-term breastfeeding and postpartum abstinence were key characteristics of the sub-Saharan African fertility regime, that allowed to historically space childbearing. However, socioeconomic development and urbanization contributed to the shortening of the duration of breastfeeding and of the postpartum abstinence tradition; it also increased access to healthcare and allowed to reduce sub-fertility or infertility in the region. In this sense, socioeconomic progress combined with low levels of contraceptive intake can sometimes lead to an increase in fertility rates. We can therefore observe cases where rises in contraceptive prevalence did not bring about the expected fertility impact (Westoff & Bankole 1991; National Research Council 1993;

Bongaarts 2017b). This scenario could also reflect the fact that the sub-Saharan fertility transition has been operating in part through the spacing of childbearing throughout women’s reproductive life-course, unlike in Asia and in Latin America, where couples opted for highly effective means of contraception after having reached the desired number of children (i.e., limitation). Regulating childbearing through spacing can typically lead to higher rates of contraceptive discontinuation, and of course, to virtually non-existing use of irreversible methods (i.e., sterilization) (Westoff & Bankole 1991).

At the same time, literature has pointed to cases where drops in fertility levels did not seem to match the levels of contraceptive use. This case could be due to the effect of underreported traditional means of contraception (Westoff & Bankole 1991; Askew et

al. 2017; Rossier & Corker 2017), as well as to the largely uncaptured impact of marital sexual inactivity on fertility (Stover 1998; Blanc & Grey 2002; Machiyama 2011).

PART 2

THEORETICAL FRAMEWORKS TO