Fertility regulation in sub-Saharan Africa: the role of marital sexual inactivity

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Thesis

Reference

Fertility regulation in sub-Saharan Africa: the role of marital sexual inactivity

PEYTRIGNET, Marie-Claire

Abstract

Sub-Saharan Africa is the region with the highest fertility rate and lowest contraceptive prevalence in the World. However, the rate of contraceptive use does not entirely match the levels of expected fertility. Efforts to solve this enigma have led researchers to wonder about hidden means of fertility regulation that were not adequately measured in international surveys. Recent literature has indicated that women in West and Middle Africa have marked preferences for traditional means of birth control (such as the calendar method and withdrawal) but tend to under-declare them. In parallel, sexual inactivity within marriage seems to be a widespread phenomenon in sub-Saharan Africa, and researchers are wondering whether abstinence is a prevalent (but unmeasured) means of birth control. This thesis tries to find out whether abstinence is indeed a common yet hidden means of contraception, and to ascertain the potential contraceptive needs of sexually inactive couples.

PEYTRIGNET, Marie-Claire. Fertility regulation in sub-Saharan Africa: the role of marital sexual inactivity. Thèse de doctorat : Univ. Genève, 2019, no. SdS 110

DOI : 10.13097/archive-ouverte/unige:116024 URN : urn:nbn:ch:unige-1160240

Available at:

http://archive-ouverte.unige.ch/unige:116024

Disclaimer: layout of this document may differ from the published version.

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The Role of Marital Sexual Inactivity

THÈSE

présentée à la Faculté des sciences de la société  de l’Université de Genève

par

Marie Claire Peytrignet

sous la direction de

prof. Clémentine Rossier

pour l’obtention du grade de

Docteur ès sciences de la société mention démographie

Membres du jury de thèse:

M. John CLELAND, Professeur Emeritus, London School of Hygiene and Tropical Medicine Mme. Clémentine ROSSIER, Professeur Assistant Mme. Claudine SAUVAIN-DUGERDIL, Professeur Emeritus

M. Eric WIDMER, Professeur, président du jury Thèse no 110

Genève, 4 février 2019 

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Genève, le 7 février 2019

Le doyen

Bernard DEBARBIEUX

Impression d'après le manuscrit de l'auteur

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Résumé (en français) _______________________________________________________________15 Summary ________________________________________________________________________19 Acknowledgments _________________________________________________________________23 Introduction _______________________________________________________________________1

PART 1 ______________________________________________________7 HISTORICAL CONTEXT AND RATIONALE FOR THIS THESIS _________7

CHAPTER 1_______________________________________________________________8 HISTORICAL CONTEXT AND RATIONALE FOR THIS THESIS______________________8 1.1 THE HISTORY OF FAMILY PLANNING IN THE INTERNATIONAL DEVELOPMENT AGENDA___9 1.1.1 The roots of modern birth control________________________________________________9 1.1.2 The history of the place of birth control in the international development arena after World War II______________________________________________________________________________11

1.2 A RENEWED INTEREST FOR FAMILY PLANNING IN THE INTERNATIONAL DEVELOPMENT ARENA____________________________________________________________________________15

1.2.1 Family Planning 2020: all eyes on sub-Saharan Africa______________________________15 1.2.2 Fears, hopes and current struggles of family planning______________________________17 1.3 THE ACKNOWLEDGMENT OF SEXUALITY IN THE FIRST DEMOGRAPHIC TRANSITION ___19 1.3.1 Sexuality in the early demographic discourse_____________________________________19 1.3.2 The first demographic transition and sexual behavior ______________________________20 1.3.3 The first fertility transition and the causes of fertility decline_________________________23 1.4 THE STUDY OF SEXUAL ACTIVITY IN THE DEMOGRAPHIC FIELD _____________________24 1.4.1 The study of sexual activity in social sciences ____________________________________24 1.4.2 The study of sexual activity in demography_______________________________________25 1.5 THE SECOND DEMOGRAPHIC TRANSITION AND THE TRANSFORMATION OF SEXUALITY 29 1.5.1 Important societal transformations preceding the sexual revolution __________________29 1.5.2 The contraceptive, sexual, and gender revolutions_________________________________29 1.5.3 The contraceptive revolution and female empowerment_____________________________30 1.6 BIRTH CONTROL AND THE DEMOGRAPHIC TRANSITION IN SUB-SAHARAN AFRICA_____31 1.6.1 The demographic transition in sub-Saharan Africa & sub-regional differences__________31 1.6.2 Birth control in sub-Saharan Africa’s demographic transition________________________35

PART 2 _____________________________________________________39 THEORETICAL FRAMEWORKS TO STUDY SEXUAL INACTIVITY IN __39 SUB-SAHARAN AFRICA AND THE HYPOTHESES OF THIS THESIS ___39

CHAPTER 2______________________________________________________________40 THEORETICAL FRAMEWORKS TO STUDY SEXUAL INACTIVITY IN SUB-SAHARAN AFRICA ___________________________________________________________________40

2.1 LEVELS OF SEXUAL ACTIVITY WITHIN MARRIAGE IN SUB-SAHARAN AFRICA __________41 2.2 UNDERSTANDING SEXUAL INACTIVITY IN SUB-SAHARAN AFRICA THROUGH AN

ANTHROPOLOGICAL LENS___________________________________________________________42 2.2.1 Postpartum abstinence in sub-Saharan Africa_____________________________________42 2.2.2 A social system engineered to control conjugal bonds______________________________43

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2.2.3 A high plasticity of the family forms_____________________________________________46 2.3 OTHER FACTORS ASSOCIATED WITH SEXUAL INACTIVITY __________________________46 2.3.1 Factors associated with higher levels of sexual activity_____________________________46 2.3.2 Factors associated with lower levels of sexual activity______________________________48 2.4 THE EASTERLIN FRAMEWORK: ASSESSING THE COSTS AND BENEFITS OF MODERN AND TRADITIONAL CONTRACEPTIVE USE __________________________________________________50

2.4.1 The costs and benefits of modern contraceptive use_______________________________50 2.4.2 The costs and benefits of traditional birth control__________________________________53 2.4.3 Including sexual inactivity and abstinence in the Easterlin framework_________________54 2.5 MULTIPLE MODERNITIES AND GENDER EMPOWERMENT FRAMEWORKS:

UNDERSTANDING THE "MODERNITY" BEHIND TRADITIONAL METHOD USE _________________56 2.6 SEXUAL INACTIVITY IN THE UNMET NEED INDICATOR______________________________59 CHAPTER 3______________________________________________________________64 GOALS, RESEARCH QUESTIONS AND HYPOTHESES __________________________64 3.1 INVESTIGATING WHETHER MARITAL SEXUAL INACTIVITY COULD CONSTITUTE A MEANS OF CONTRACEPTION IN SUB-SAHARAN AFRICA ________________________________________65

3.2 EXPLORING THE MODERNITY OF ABSTINENCE AS BIRTH CONTROL IN A PRE-

TRANSITIONAL SOCIETY_____________________________________________________________68 3.3 EXAMINING THE UNMET NEEDS FOR BIRTH CONTROL OF THE SEXUALLY INACTIVE FEMALES__________________________________________________________________________69

PART 3 _____________________________________________________71 METHODS AND RESULTS _____________________________________71

CHAPTER 4______________________________________________________________72 IS SEXUAL INACTIVITY USED AS A MEANS OF FERTILITY CONTROL IN SUB-

SAHARAN AFRICA? A STUDY OF THE FACTORS ASSOCIATED WITH SEXUAL

INACTIVITY AND WITH CONTRACEPTIVE USE __________________________________72 4.1 INTRODUCTION _______________________________________________________________73 4.2 DATA: CHILDREN & FEMALE DATA IN THE DEMOGRAPHIC AND HEALTH SURVEYS______80 4.2.1 A short history of the Demographic and Health Surveys ____________________________80 4.2.2 Countries and regions selected to study sexual inactivity and its associated factors ____80 4.2.3 Children data to measure the median time spent in postpartum abstinence ____________82 4.2.4 Individual female data to measure the prevalence of sexual inactivity and to study its associated factors___________________________________________________________________82

4.2.5 Weights & clustering of the Demographic and Health Surveys _______________________83 4.3 METHODS____________________________________________________________________86 4.3.1 Distinguishing sexual inactivity, infrequent sex and abstinence______________________86 4.3.2 Factors to include in our research and dependent variable__________________________87 4.3.3 Calculation of the median time spent in postpartum abstinence______________________93 4.3.4 Bivariate analysis & the chi-square test__________________________________________95 4.3.5 The logistic regression________________________________________________________97 4.4 RESULTS____________________________________________________________________100 4.4.1 Studying the extent to which sexual inactivity is imposed to couples by external

circumstance or through codified tradition _____________________________________________100 4.4.2 Profile of the different kinds of sexually inactive women in sub-Saharan Africa________103 4.4.3 Exploring what distinguishes sexual inactivity as a lifestyle from contraceptive users __107 4.4.4 Multivariate results: sexually inactive women are not using abstinence as a means of family planning __________________________________________________________________________111

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4.5 DISCUSSION_________________________________________________________________117 CHAPTER 5_____________________________________________________________124 FEMALE DECISION-MAKING POWER & ABSTINENCE AS A MEANS OF FERTILITY REGULATION IN NIGER: A MODERN TAKE ON AN ANCIENT METHOD?_____________124

5.1 INTRODUCTION ______________________________________________________________125 5.2 DEFINITIONS, THEORY AND HYPOTHESES_______________________________________127 5.3 DATA & METHODS: CAMBER COLLECTIVE SURVEY ABOUT CONTRACEPTIVE USE IN NIGER 2014 _______________________________________________________________________132

5.3.1 The construction of Niger’s Camber Collective survey sample (2014) and our variables of interest___________________________________________________________________________132

5.3.2 Key differences between the Camber Collective survey sample (2014) and Niger’s

Demographic and Health Survey sample (2012) _________________________________________135 5.3.3 Methods ___________________________________________________________________138 5.4 RESULTS____________________________________________________________________139 5.4.1 Abstinence and periodic abstinence in the Camber Collective survey sample (2014) ___139 5.4.2 Abstinence as a means of fertility regulation_____________________________________140 5.4.3 Contraception and gender empowerment in our sample ___________________________142 5.5 DISCUSSION_________________________________________________________________147 CHAPTER 6_____________________________________________________________150 SEXUAL INACTIVITY IN SUB-SAHARAN AFRICA AND THE UNMET NEED INDICATOR:

TAKING A CLOSE LOOK AT THE USE OF CONTRACEPTION AT LAST SEXUAL

INTERCOURSE____________________________________________________________150 6.1 INTRODUCTION ______________________________________________________________151 6.2 DATA: COUPLES’ DATA IN THE DEMOGRAPHIC AND HEALTH SURVEYS ______________152 6.2.1 Couples’ data to study contraceptive use at last sexual intercourse _________________153 6.2.2 Weighting couples’ data______________________________________________________160 6.3 METHODS: CONSTRUCTING OUR REVISED UNMET NEED AND EVALUATING ITS

RELIABILITY ______________________________________________________________________161 6.3.1 Variables used to study contraceptive use at last sexual intercourse for a revised unmet need indicator _____________________________________________________________________161

6.3.2 Kappa index and data reliability assessment_____________________________________165 6.3.3 The calculation of the unmet need and how to take sexual inactivity into account in the indicator__________________________________________________________________________166

6.4 RESULTS ___________________________________________________________________171 6.4.1 Kappa concordance estimates ________________________________________________171 6.4.2 Comparing males’ and females’ contraceptive prevalence__________________________177 6.4.3 Contraceptive use at last sexual intercourse among sexually inactive women _________178 6.4.4 The revised unmet need indicator (taking sexual inactivity into account) _____________179 6.4.5 Wider considerations on contraceptive measurement _____________________________181 6.5 DISCUSSION_________________________________________________________________184 Conclusions ______________________________________________________________________187 Bibliography ____________________________________________________________________195 APPENDIX CHAPTER 4 ___________________________________________________________245 APPENDIX CHAPTER 5 ___________________________________________________________273 APPENDIX CHAPTER 6 ___________________________________________________________279 APPENDIX FORMULAS & CODES __________________________________________________301

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List of Tables & Figures

Table 1. Stratum with only one primary sample unit and new stratum in DHS complex survey design. Women individual DHS files, latest surveys (DHS 2006-17). ____________________________________________________85

Table 2. Extract from the relative and cumulative frequencies of the months spent in postpartum abstinence among married women. Children DHS file, Benin (2006). ______________________________________________________95

Table 3. Median length of postpartum abstinence (in months), among married women whose last child is aged three years or younger and who did not resume sex after their last birth. Children DHS file, earliest (1990-08) and latest surveys (2008-16), 29 countries, by sub-regions. _____________________________________________________101

Table 4. Relative distributions of marital sexual activity. Women individual DHS file, earliest (1990-08) and latest surveys (2008-16), 29 countries, by sub-regions. _____________________________________________________102

Table 5. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to the socioeconomic status (education, residency and wealth quintiles). Women individual DHS file, sub-Saharan Africa, 33 countries, latest surveys (2006-17).______________________________________104

Table 6. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 33 countries, latest surveys (2006-17). ________105

Table 7. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to fertility intentions/fertility status and age. Women individual DHS file, 33 countries, latest surveys (2006-17)._____________________________________________________________________________106

Table 8. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to the socioeconomic status (education, residency and wealth quintiles). Women individual DHS file, 33 countries, latest surveys (2006-17). Postpartum abstainers, sexually inactive and pregnant /amenorrheic, sexually inactive and non cohabiting with their partners are not part of this analysis._________________________________108

Table 9. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 33 countries, latest surveys (2006-17). Postpartum abstainers, sexually inactive and pregnant /amenorrheic, sexually inactive and non cohabiting with their partners are not part of this analysis. _____________________________________________________________________________________110

Table 10. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern

contraceptive use according to fertility intentions/fertility status and age. Women individual DHS file, 33 countries, latest surveys (2006-17). Postpartum abstainers, sexually inactive and pregnant /amenorrheic, sexually inactive and non cohabiting with their partners are not part of this analysis._______________________________________________111

Table 11. Relative risk ratios from multinomial logistic regression to identify the factors associated with sexual inactivity and with contraceptive use. Women individual DHS file, 33 countries, latest surveys (2006-17). Postpartum abstainers, sexually inactive and pregnant /amenorrheic, sexually inactive and non cohabiting with their partners are not part of this analysis. ____________________________________________________________________________116

Table 12. Distributions and relative distributions of married women, according to the area of residency, education, contraceptive use, type of contraceptive method used, and polygyny status. Women individual DHS file, Niger (2012) and CC survey, Niger (2014)._____________________________________________________________________137

Table 13. Multiple method mix by method type among married women. Camber Collective data, Niger (2014).___140 Table 14. Relative distributions of contraceptive use, by cohabitation, date of last period, breastfeeding, taking care of children younger than one year, date of last sexual intercourse, among married women. Camber Collective data, Niger (2014). ______________________________________________________________________________________141

Table 15. Relative distributions of contraceptive use, by problem if found out about pregnancy, age of the respondent, parity, among married women. Camber Collective data, Niger (2014). _____________________________________143

Table 16. Relative distributions of contraceptive use, by area of residency, education, work in last year and wealth quintiles, among married women. Camber Collective data, Niger (2014).___________________________________144

Table 17. Relative distributions of contraceptive use, by decision-making power in the couple (household purchases, respondent’s health, contraceptive use, right to refuse intercourse), among married women. Camber Collective data, Niger (2014).__________________________________________________________________________________146

Table 18. Most recent Demographic and Health Survey (2010-17) in sub-Saharan Africa used in the analysis:Women individual file, men individual file and couples file._____________________________________________________153

Table 19. Total number of couples, of monogamous couples, and of monogamous and sexually exclusive couples.

Couples DHS files, latest surveys (2010-17)._________________________________________________________155 Table 20. Female interview dates for Benin 2011-12 survey. __________________________________________156

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Figure 1. Fictitious timeline of last sex & interview date: when male data cannot be included to assess the

concordance of data collected about the last sexual intercourse. _________________________________________156 Table 21. Number of monogamous and sexually exclusive couples, and number and share of couples excluded because the date of the last sexual intercourse of one partner falls after the interview of the other. Couples DHS files, latest surveys (2010-17). ________________________________________________________________________158

Table 22. Total number of original couples, number of couples in our final sample, and relative size of the final sample in comparison to original one. Couples DHS file, latest surveys (2010-17).__________________________________159

Table 23. Relative distributions of couples by area of residency, wealth quintiles and education in DHS’s original couples file and in our reduced sample, by region. Couples DHS file, latest surveys (2010-17). _________________160

Table 24. Categorization of the contraceptive methods in our research.__________________________________164 Table 25. Construction of the different unmet need indicators._________________________________________170 Table 26. The levels of reliability of the Kappa agreement index._______________________________________171 Table 27. Concordance of the age of last male sexual partner (for wives), by region. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________172

Table 28. Concordance of the age of last female sexual partner (for husbands), by region. Couples DHS file, latest surveys (2010-17)._____________________________________________________________________________172

Table 29. Couples’ concordance in their responses about the month of their last sexual intercourse, by region.

Couples DHS file, latest surveys (2010-17).__________________________________________________________173 Table 30. Couples’ concordance in responses about contraceptive use (all methods) by region. Couples DHS file, latest surveys (2010-17)._____________________________________________________________________175

Table 31. Couples’ concordance in responses to the question on condom at last sex, by region. Couples DHS file, latest surveys (2010-17)._____________________________________________________________________176

Table 32. Relative frequencies of wives and husbands’ contraceptive declaration, by region (monogamous and cohabiting couples). Couples DHS file, latest surveys (2010-17)._________________________________________178

Table 33. Distributions of current contraceptive use and contraceptive use at last sexual intercourse for sexually active and sexually inactive women, by region. Couples DHS file, latest surveys (2010-17).____________________179

Table 34. Different unmet need for contraception indicators in sub-Saharan Africa, all methods and modern methods, for a sample of monogamous and cohabiting women, couples DHS file, latest surveys (2010-17). _______________180

Table 35. Distributions of contraceptive declaration at last sexual intercourse among sexually active women who declared they were not currently using contraception, monogamous and cohabiting couples, Couples DHS file, latest survey in Benin, Côte d’Ivoire, Ghana, Comoros, Rwanda, Uganda, Zambia, Angola and Namibia._______________182

APPENDIX CHAPTER 4 ___________________________________________________________245 Table 4.1. Total population (both sexes combined) by sub-region and country. United Nations Population Division, World Population Prospects: the 2017 revision. Population for years 2000 and 2010 (in thousands), and proportion of the survey country population within each sub-region.__________________________________________________245

Table 4.2. Procedure by Schoumaker to calculate the country-specific weights. Female 15-49 population by country.

United Nations Population Division, World Population Prospects: the 2017 revision. Population estimates for each country according to the survey year, and total sample for each country. Women individual DHS files, earliest (1990-08) and latest surveys (2006-17)._____________________________________________________________________246

Table 4.3. Variables to weight according to the Demographic and Health Surveys’ complex survey design. Women individual DHS files, earliest (1990-08) and latest surveys (2006-17).______________________________________247

Table 4.4. Missing values from the variable "Time since last sex" (v527). Women individual DHS files, latest surveys (2006-17).____________________________________________________________________________________248

Table 4.5 Median length of postpartum abstinence (in months), among married women whose last child is aged three years or younger and who did not resume sex after their last birth. Children DHS file, earliest (1990-08) and latest surveys (2006-17)._____________________________________________________________________________249

Table 4.6. Relative distributions of marital sexual activity. Women individual DHS file, earliest (1990-08), 29 countries, by countries.__________________________________________________________________________________250

Table 4.7. Relative distributions of marital sexual activity. Women individual DHS file, latest surveys (2008-16), 29 countries, by countries.__________________________________________________________________________251

Table 4.8. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 12 countries, West Africa, latest surveys (2010-16). __252

Table 4.9. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 11 countries, East Africa, latest surveys (2011-17). ___253

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Table 4.10. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 7 countries, Middle Africa, latest surveys (2008-16).

254 ____________________________________________________________________________________________

Table 4.11. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 3 countries, Southern Africa, latest surveys (2006-14). 255

Table 4.12. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 12 countries, West Africa, latest surveys (2010-16).____________________________________________________________________________________256

Table 4.13. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 11 countries, East Africa, latest surveys (2011-17).____________________________________________________________________________________257

Table 4.14. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 7 countries, Middle Africa, latest surveys (2008-16).____________________________________________________________________________________258

Table 4.15. Relative distributions of marital sexual activity, lifestyle sexual inactivity, and socially or externally imposed sexual inactivity according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 3 countries, Southern Africa, latest surveys (2006-14).____________________________________________________________________________________259

Table 4.16. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 12 countries, West Africa, latest surveys (2010-16).

Postpartum abstainers, sexually inactive and pregnant /amenorrheic, sexually inactive and non cohabiting with their partners are not part of this analysis._______________________________________________________________260

Table 4.17. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 11 countries, East Africa, latest surveys (2011-17).

Table 4.18. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 7 countries, Middle Africa, latest surveys (2008-16).

Table 4.19. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to the socioeconomic status (education, residency and wealth quintiles) and to fertility intentions/fertility status and age. Women individual DHS file, 3 countries, Southern Africa, latest surveys (2006-14).

Table 4.20. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 12 countries, West Africa, latest surveys (2010-16).

Table 4.21. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 11 countries, East Africa, latest surveys (2011-17).

Table 4.22. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 7 countries, Middle Africa, latest surveys (2008-16).

Table 4.23. Relative distributions of marital sexual activity, lifestyle sexual inactivity, traditional and modern contraceptive use according to parity, ideal family size, polygyny status, age differences within husband, and couples decision-making within the household. Women individual DHS file, 3 countries, Southern Africa, latest surveys (2006-14). Postpartum abstainers, sexually inactive and pregnant /amenorrheic, sexually inactive and non cohabiting

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with their partners are not part of this analysis. _______________________________________________________267 Table 4.24. Relative risk ratios from multinomial logistic regression to identify the factors associated with sexual inactivity and with contraceptive use. Women individual DHS file, 12 countries, West Africa, latest surveys (2010-16).

Table 4.25. Relative risk ratios from multinomial logistic regression to identify the factors associated with sexual inactivity and with contraceptive use. Women individual DHS file, 11 countries, East Africa, latest surveys (2011-17).

Table 4.26. Relative risk ratios from multinomial logistic regression to identify the factors associated with sexual inactivity and with contraceptive use. Women individual DHS file, 7 countries, Middle Africa, latest surveys (2008-16).

Table 4.27. Relative risk ratios from multinomial logistic regression to identify the factors associated with sexual inactivity and with contraceptive use. Women individual DHS file, 3 countries, Southern Africa, latest surveys (2006-14).

APPENDIX CHAPTER 5 ___________________________________________________________273 Table 5.1. Relative distributions of contraceptive use in sub-Saharan Africa among married women (within the rare surveys that include abstinence as a country-specific method). Women individual DHS files. ___________________273

Table 5.2. Proportions of women not postpartum abstaining and women postpartum abstaining, among those who declare using abstinence as a means of contraception in sub-Saharan Africa, among married women (within the rare surveys that include abstinence as a country-specific method). Women individual DHS files. ___________________273

Table 5.3. Relative distributions of contraceptive use by education level, among married couples with the same level of education. Camber Collective (2014) & Demographic and Health Survey data (2012), Women individual DHS files, Niger. _______________________________________________________________________________________274

Table 5.4. Relative distributions of contraceptive use by decision-making power regarding household purchases, among married couples with the same level of education. Camber Collective (2014) & Demographic and Health Survey data (2012), Women individual DHS files, Niger.______________________________________________________275

Table 5.5. Relative distributions of contraceptive use by decision-making power regarding the health of the respondent, among married couples with the same level of education. Camber Collective (2014) & Demographic and Health Survey data (2012), Women individual DHS files, Niger.__________________________________________276

Table 5.6. Relative distributions of contraceptive use by decision-making power regarding the right to refuse sexual intercourse, among married couples with the same level of education. Camber Collective (2014) & Demographic and Health Survey data (2012), Women individual DHS files, Niger.__________________________________________277

APPENDIX CHAPTER 6 ___________________________________________________________279 Table 6.1. Relative distributions of couples by area of residency in DHS’s original couples file and in our reduced sample, by country. Couples DHS file, latest surveys (2010-17).__________________________________________279

Table 6.2. Relative distributions of couples by wealth quintiles in DHS’s original couples file and in our reduced sample, by country. Couples DHS file, latest surveys (2010-17).__________________________________________280

Table 6.3. Relative distributions of couples by education in DHS’s original couples file and in our reduced sample, by country. Couples DHS file, latest surveys (2010-17).___________________________________________________281

Table 6.4. Concordance of the age of last male sexual partner (for wives), by country. Couples DHS file, latest surveys (2010-17)._____________________________________________________________________________282

Table 6.5. Concordance of the age of last female sexual partner (for husbands), by country. Couples DHS file, latest surveys (2010-17)._____________________________________________________________________________283

Table 6.6. Couples’ monthly sexual intercourse concordance, by country. Couples DHS file, latest surveys (2010-17).

284

Table 6.7. Couples’ last sexual intercourse concordance (in last 28 days), by country. Couples DHS file, latest surveys (2010-17)._____________________________________________________________________________285

Table 6.8. Couples’ last sexual intercourse concordance (in last 7 days), by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________286 Table 6.9. Couples’ overall contraceptive use concordance, by country. Couples DHS file, latest surveys (2010-17). _ 287

Table 6.10. Couples’ contraceptive use concordance (in last 28 days), by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________288

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Table 6.11. Couples’ contraceptive use concordance (in last 7 days), by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________289

Table 6.12. Couples’ overall condom at last sex concordance, by country. Couples DHS file, latest surveys (2010-17).

290 ____________________________________________________________________________________________

Table 6.13. Couples’ condom at last sex concordance (in last 28 days), by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________291

Table 6.14. Couples’ condom at last sex concordance (in last 7 days), by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________292

Table 6.15. Relative frequencies of wives contraceptive declaration, by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________293

Table 6.16. Relative frequencies of husband’s contraceptive declaration, by country. Couples DHS file, latest surveys (2010-17).____________________________________________________________________________________294

Table 6.17. Different unmet need for contraception indicators in West Africa, all methods and modern methods.

Couples DHS file, latest surveys (2010-16).__________________________________________________________295 Table 6.18. Different unmet need for contraception indicators in East Africa, all methods and modern methods.

Couples DHS file, latest surveys (2011-17).__________________________________________________________296 Table 6.19. Different unmet need for contraception indicators in Middle Africa, all methods and modern methods.

Couples DHS file, latest surveys (2013-16).__________________________________________________________297 Table 6.20. Different unmet need for contraception indicators in Southern Africa, all methods and modern methods.

Couples DHS file, latest surveys (2013-14).__________________________________________________________298 Table 6.21. Relative distributions of current contraceptive use and contraceptive use at last sexual intercourse for sexually active and sexually inactive women, by country. Couples DHS file, latest surveys (2010-17). ____________299

APPENDIX FORMULAS & CODES __________________________________________________301 Formula 1. Formula to calculate expected frequencies.______________________________________________301 Formula 2. Formula to calculate the odds ratio. ____________________________________________________301 Code 1. Syntax to calculate the revised unmet need. _______________________________________________301

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Résumé (en français)

L’Afrique subsaharienne est la région avec le taux de fécondité le plus élevé au monde et la prévalence contraceptive la plus basse (UNDESA 2017a, 2017b). Les chercheurs ont commencé à remarquer, depuis les années 1990 (lorsque la région attestait ses premiers signes de déclin de fécondité), une divergence entre les niveaux d’utilisation contraceptive et la fécondité attendue (Westoff & Bankole 2001; Blanc & Grey 2002;

Askew et al. 2017). Les efforts menés pour résoudre cette énigme ont poussé les chercheurs à s’interroger sur la diversité des méthodes utilisées en Afrique subsaharienne, et à se demander si elles étaient adéquatement mesurées. D’une part, les chercheurs ont remarqué qu’une partie importante de femmes dans la région sous- déclarait l’utilisation de méthodes traditionnelles (i.e., le calendrier et le coït interrompu, souvent en combinaison avec le recours à l’avortement et à la contraception d’urgence) (Mathe et al. 2011; Adanu et al. 2012; Rossier et al. 2014; Staveteig 2016; Marston et al. 2017); d’autre part, ils ont aussi noté que les couples mariés en Afrique subsaharienne déclaraient des niveaux relativement bas d’activité sexuelle à travers la région (Caraël 1995; Brown 2000; Ubillos et al. 2000; Wellings et al. 2006;

Schneidewind-Skibbe et al. 2008). Ainsi, l’inactivité sexuelle maritale semblerait jouer un rôle inattendu dans la baisse de fécondité, en tant que variable intermédiaire (Blanc

& Grey 2002; Machiyama 2011).

Au cours des années 1990-2000, environ une femme sur trois en Afrique subsaharienne déclarait ne pas avoir eu de rapport sexuel au cours du dernier mois. Aujourd’hui, de par l’érosion de la tradition de l’abstinence postpartum, la proportion de femmes sexuellement inactives correspond à une femme sur quatre (36%) (chapitre 4). On observe aussi qu’une des premières causes de non-utilisation contraceptive en Afrique subsaharienne est l’inactivité sexuelle ou la basse fréquence de rapports sexuels (Sedgh

& Hussain 2014; Sedgh et al. 2016). Par ailleurs, le fait d’être sexuellement inactif est fortement associé au fait de ne pas vouloir avoir d’enfants, à la non-utilisation contraceptive (Machiyama & Cleland 2013a, 2013b, 2014) et au fait d’avoir un besoin non-satisfait en matière de contraception (Bell & Bishai 2017). Ainsi, bien que ¹ l’abstinence ne soit pas considérée comme une méthode de planification familiale dans les Enquêtes démographiques et de santé (EDS) (Curtis & Neitzel 1996; Rustein &

Rojas 2006), les chercheurs s’interrogent actuellement sur l’hypothèse selon laquelle les femmes aient volontairement recours à l’abstinence pour réguler leur fécondité.

Le premier objectif de cette thèse (chapitre 4) était donc d’examiner si l’inactivité sexuelle était réellement utilisée comme une méthode consciente de régulation des naissances dans la région; mais nos résultats semblent indiquer le contraire. Grâce aux

L’indicateur des besoins non-satisfaits en matière de contraception mesure la part des femmes qui ne

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désirent pas avoir d’enfants mais n’ont pas recours à la contraception. C’est un indicateur clef pour suivre l’avancement des Objectifs du millénaire pour le développement (OMD) et il est aussi actuellement utilisé pour évaluer le progrès des Objectifs de développement durable (ODD) n°3 (i.e., bonne santé et bien-être) ainsi que celui des objectifs du projet/programme Planning Familial 2020 (PF2020).

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dernières Enquêtes démographique et de santé (2006-17, enquêtes individuelles de femmes), nous nous sommes rendues compte que la grande majorité (75%) des couples sexuellement inactifs n’étaient vraisemblablement pas en train de pratiquer l’abstinence dans le but de réguler leur fécondité — car cette inactivité sexuelle leur était imposée par des forces externes (i.e., par la non-cohabitation liée à la migration, ou par des pratiques culturelles telles que l’abstinence postpartum) (Easterlin 1975). Nous avons aussi remarqué que le restant des femmes sexuellement inactives (qui cohabitaient avec leur mari et qui n’étaient ni enceintes ni en période postpartum) étaient en réalité peu ou pas exposées au risque d’avoir une grossesse (i.e., car âgées entre 40 et 49 ans et infécondes). Par ailleurs, nous nous sommes rendues comptes que le fait de vivre en ville et d’être dans une union polygame s’avérait aussi hautement associé avec le fait d’être sexuellement inactif. Ce dernier résultat semble indiquer que la possibilité même d’avoir des relations extra-conjugales pourraient faciliter la non-sexualité dans le mariage. Rappelons par ailleurs que ces couples ayant un mode de vie sexuellement inactif ont souvent plus de 20 ans de vie commune. Nous sommes donc arrivées à la conclusion que l’association statistique entre l’inactivité sexuelle et les intentions de fécondité ne montrait pas que l’abstinence était une méthode répandue de planification des naissances, mais plutôt que cette corrélation était le fait d’une causalité inverse. Pour beaucoup de couples en Afrique au sud du Sahara, la sexualité est probablement vue comme la voie directe vers la reproduction, plus que l’abstinence comme étant une méthode de contraception. Les couples sembleraient donc avoir moins de rapports sexuels lorsqu’ils ne veulent pas se reproduire.

Il est important de souligner que bien que la grande majorité des couples sexuellement inactifs ne s’abstiendraient pas dans le but de réguler leur fécondité, cela n’empêche pas qu’il puisse exister une minorité de couples qui pratiquent l’abstinence comme mode de régulation des naissances. Nous avons donc supposé que, tel que dans la première transition démographique en Occident, l’abstinence constitue probablement une méthode de régulation des naissances parmi d’autres, même si celle-ci n’est pas mesurée dans les Enquêtes démographiques et de santé. Dans ce sens, il nous semblait important d’examiner si les pionnières de la transition démographique en Afrique subsaharienne avaient recours à cette méthode de contraception, et notamment au Niger (un pays pré- transitionnel avec le taux de fécondité le plus élevé du monde). Nous avions par ailleurs aussi eu la chance d’avoir accès à des données nigériennes qui ont interrogé les femmes au sujet de cette méthode de planification familiale. En parallèle, la littérature démographique a récemment noté un phénomène paradoxal en Afrique subsaharienne:

les femmes appartenant à l’élite (particulièrement en Afrique de l’Ouest et en Afrique Centrale) préfèrent avoir recours aux méthodes de contraception traditionnelles (Machiyama & Cleland 2014; Rossier & Corker 2017; Marston et al. 2017). Dans ces cas, la capacité à négocier les rapports sexuels serait indispensable à l’utilisation adéquate des méthodes de contraception traditionnelles. Le deuxième objectif de cette thèse était donc de vérifier si le profil des femmes qui ont recours à l’abstinence au Niger est celui d’un groupe de femmes avec suffisamment d’autonomie et de ressources pour réguler leur fécondité de telle sorte (Kabeer 1999; Richardson 2018) (chapitre 5).

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Pour ce faire, nous avons utilisé des données du groupe de conseil Camber Collective (2015), qui ont interrogé les femmes au Niger au sujet de l’utilisation d’une série de méthodes traditionnelles, dont l’abstinence. Les femmes ont aussi été relancées pour chaque méthode afin de limiter la sous-déclaration de méthodes traditionnelles. Nous avons trouvé trois résultats clef: premièrement, l’abstinence est effectivement utilisée comme une méthode de contraception au Niger, mais uniquement par une minorité de femmes (i.e., 10% des utilisatrices de la contraception, et moins de 2% de la population féminine nigérienne en âge de procréer); deuxièmement, nous avons remarqué que l’abstinence au Niger semblait être utilisée essentiellement comme un moyen de réduire les risques de grossesses plutôt que comme une méthode à part entière, et la majorité des femmes qui ont recours à l’abstinence utilisent aussi d’autres méthodes et n’excluent pas des rapports sexuels occasionnels (i.e., faible fréquence de rapports sexuels combinée avec d’autres moyens de contraception) (David & Sanderson 1986; Marston et al.

2017); finalement, nous avons confirmé que les femmes qui ont recours à l’abstinence constituent une élite avec un certain pouvoir d’autonomie — bien qu’elles ne représentent qu’une minorité de la population.

Notre troisième objectif (chapitre 6) était de déterminer si les femmes sexuellement inactives en Afrique subsaharienne devraient être considérées comme ayant un besoin non-satisfait en matière de planification familiale. La grande majorité de la littérature qui s’intéresse à cette question est arrivée à la conclusion que les femmes sexuellement inactives devraient être considérées comme ayant des besoins en matière de contraception car elles courent le risque de ne pas se protéger lors de leur prochain rapport sexuel (DeGraff & de Silva 1991; DeGraff & Siddhisena 2015; Bradley &

Casterline 2014). Toutefois, les chercheurs ont négligé l’existence de variables qui informent sur l’utilisation contraceptive au cours du dernier rapport sexuel, et nous avons estimé que ces dernières variables pouvaient nous fournir des pistes sur la propension de ces femmes à se protéger de grossesses non-désirées lors du prochain rapport sexuel. Notre approche a donc été de tenter de déduire l’utilisation de la contraception au cours du dernier rapport sexuel parmi les femmes sexuellement inactives, en faisant recours à la déclaration contraceptive de leur mari.

Grâce aux dernières Enquêtes démographiques et de santé des couples en Afrique subsaharienne (2010-17), nous avons trouvé — avec un degré de fiabilité faible à modéré — qu’environ 99% des femmes fécondes et sexuellement inactives qui ne désiraient pas avoir d’enfants ne s’étaient pas protégées contre une grossesse lors de leur dernier rapport. En somme, nous avons confirmé que les femmes sexuellement inactives qui ne veulent pas avoir d’enfants devraient être considérées comme ayant un besoin non-satisfait en matière de contraception — même si elles ne courraient pas le risque de tomber enceintes au moment de l’enquête. Toutefois, nous avons suggéré que les besoins de ces femmes étaient probablement différents de ceux des femmes sexuellement actives. Les femmes qui n’ont pas de rapports sexuels auraient probablement des besoins marqués en matière d’information et de négociation contraceptive, afin de ne pas être prises en dépourvu lors de leur prochain rapport. Dans

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ce chapitre, nous avons aussi confirmé une importante sous-déclaration des méthodes liées au coït (modernes et traditionnelles) parmi les femmes sexuellement actives; nous avons ainsi proposé un nouveau questionnaire, d’une part, pour mieux mesurer l’utilisation contraceptive, et d’autre part, afin de capturer la combinaison de différentes méthodes contraceptives en parallèle, ce que Marston et al. (2017) appellent: la contraception en mosaïque.

L’inactivité sexuelle au sein du mariage a constitué pendant trop longtemps une zone inexplorée de la démographie. Le fait que la littérature récente ait commencé à révéler les hauts niveaux d’inactivité sexuelle maritale en Afrique subsaharienne a poussé les chercheurs à s’interroger davantage sur l’influence de plusieurs facteurs: le rôle de l’inactivité sexuelle comme mode de planification des naissances; le profil des femmes abstinentes; et sur les besoins futurs en matière de contraception des femmes sexuellement inactives. Nous espérons que cette thèse a pu permettre de fournir des réponses à ces questionnements, qui contiennent des implications programmatiques importantes sur le terrain.

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Summary

Sub-Saharan Africa is the region with the highest fertility rate and the lowest levels of contraceptive prevalence in the world (UNDESA 2017a, 2017b). Since the 1990s (when signs of fertility decline were visible throughout the region) researchers started to notice a mismatch between expected fertility and the levels of birth control use (Westoff &

Bankole 2001; Blanc & Grey 2002; Askew et al. 2017). The efforts put into resolving this conundrum led some researchers to inquire about the prevailing composition of the fertility regulation mix in sub-Saharan Africa. On the one hand, there is increasing evidence that many women in this region are underreporting the use of traditional means of family planning (i.e., the calendar method and withdrawal, likely used in combination with abortion and emergency contraception) (Mathe et al. 2011; Adanu et al. 2012;

Rossier et al. 2014; Staveteig 2016; Marston et al. 2017); on the other hand, the literature is pointing to high levels of sexual inactivity within marriage throughout the region (Caraël 1995; Brown 2000; Ubillos et al. 2000; Wellings et al. 2006;

Schneidewind-Skibbe et al. 2008), while showing that low levels of sexual intercourse seem to be playing an unexpected role as an intermediate fertility variable (Blanc &

Grey 2002; Machiyama 2011).

In the 1990s and 2000s, roughly one in three women in sub-Saharan Africa reported no coitus in the previous month. Because of the erosion of postpartum abstinence, this proportion has decreased over the last decades, but about one in four (26%) married women are still sexually inactive today (chapter 4). Although abstinence is not considered as a means of family planning by the international Demographic and Health Surveys (Curtis & Neitzel 1996; Rustein & Rojas 2006), researchers are currently inquiring as to whether married couples could nevertheless be resorting to sexual inactivity as an alternative to birth control (i.e., abstinence as a means of contraception) (Machiyama & Cleland 2013a, 2013b, 2014; Bell & Bishai 2017); indeed, many elements seem to favor this hypothesis. Infrequent sex and sexual inactivity are one of the main reasons of contraceptive non-use in sub-Saharan Africa (Sedgh & Hussain 2014; Sedgh et al. 2016). As a matter of fact, the literature has shown that sexual inactivity is associated with the desire to not have a child, with contraceptive non-use (Machiyama & Cleland 2013a, 2013b, 2014) and with having an unmet need for contraception (Bell & Bishai 2017). ²

The first goal of our research (chapter 4) was, therefore, to examine whether sexual inactivity could indeed, as suggested by previous research, constitute a major means of voluntary fertility regulation in the region; but our results seemed to suggest quite the contrary. Using the latest Demographic and Health Surveys (2006-17, female individual

The unmet need for contraception is an indicator that measures the share of women who wish to avoid

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childbearing but are not using contraception. It constituted one of the key indicators to monitor the

advancement of the Millennium Development Goals (MDGs) and it is also currently being used to evaluate the progress of the Sustainable Development Goal n°3 (i.e., good health and wellbeing) and of the targets set by Family Planning 2020.

Fertility regulation in sub-Saharan Africa: the role of marital sexual inactivity

Thesis

Reference