The potential role of contraception in reducing abortion.

This study examines the potential role of further increases in contraceptive prevalence and effectiveness in reducing abortion rates. The model used in this analysis links the abortion rate to its direct determinants, including couples' reproductive preferences, the prevalence and effectiveness of contraceptive practice to implement these preferences, and the probability of undergoing an abortion to avoid an unintended birth when a contraceptive fails or is not used. An assessment of the tradeoff between contraception and abortion yields estimates of the decline in the total abortion rate that would result from an illustrative increase of 10 percentage points in prevalence. This effect varies among societies, primarily because the tendency to obtain an abortion after an unintended pregnancy varies. For example, in a population with an abortion probability of 0.5, a 10 percentage-point increase in prevalence would avert approximately 0.45 abortions per woman, assuming contraception is 95 percent effective. If all unintended pregnancies were aborted, this effect would be three times larger. Eliminating all unintended pregnancies and subsequent abortions would require a rise in contraceptive prevalence to the level at which all fecund women who do not wish to become pregnant practice contraception that is 100 percent effective. A procedure is provided for estimating this "perfect" level of contraceptive prevalence.

The fertility impact of changes in the timing of childbearing in the developing world.

This study examines the role of tempo effects in the fertility declines of less developed countries. These effects temporarily inflate the total fertility of a population during periods when the age at childbearing declines and deflate it when childbearing is postponed. An analysis of data from the World Fertility Surveys and the Demographic and Health Surveys demonstrates that fertility trends observed in many less developed countries are likely to be distorted by changes in the timing of childbearing. In most countries women are delaying childbearing, which implies that observed fertility is lower than it would have been without tempo changes. This pattern is most clearly documented in Taiwan, where accurate birth statistics from a vital registration system make it possible to estimate the tempo components of fertility annually from 1978 to 1993. The small but unexpected rise in the total fertility of Colombia in the early 1990s is attributed to a decline in the negative tempo distortion that prevailed in the 1980s. Similar interruptions of ongoing fertility declines may occur in the future in other countries when existing negative tempo effects are removed.

Trends in unwanted childbearing in the developing world.

This study analyzes trends in unwanted fertility in 20 developing countries, based on data from the World Fertility Surveys and the Demographic and Health Surveys. Although wanted childbearing almost invariably declines as countries move through the fertility transition, the trend in unwanted fertility was found to have an inverted U shape. During the first half of the transition, unwanted fertility tends to rise, and it does not decline until near the end of the transition. This pattern is attributed to the combined effects of an increase in the duration of exposure to the risk of unwanted pregnancy and a rise in contraceptive use as desired family size declines. The substantial variation in unwanted fertility among countries at the same transition stage is caused by variation in the degree of implementation of preferences, the effectiveness of contraceptive use, the rate of induced abortion, and other proximate determinants, such as age at marriage, duration of breastfeeding, and frequency of sexual relations. The principal policy implication from this analysis is that vigorous efforts to reduce unwanted pregnancies through family planning programs and other measures are needed early in the fertility transition because, in their absence, unwanted fertility and abortion rates are likely to rise to high levels.

The causes of unmet need for contraception and the social content of services.

Since the 1960s, survey data have indicated that substantial proportions of women who have wanted to stop or delay childbearing have not practiced contraception. This discrepancy is referred to as the "unmet need" for contraception. The traditional interpretation, that these women lack access to contraceptive supplies and services, has led in turn to an emphasis on expanding family planning programs. This study analyzes survey data and related anthropological studies on the causes of unmet need and concludes that the conventional explanation is inadequate. Although for many environments geographic access to services remains a problem, the principal reasons for nonuse are lack of knowledge, fear of side effects, and social and familial disapproval. This finding underscores the need for expanded investment in services that not only provide contraceptives, but also attend to closely related health and social needs of prospective clients. Programs are likely to be most successful when they reach beyond the conventional boundaries of service provision to influence and alter the cultural and familial factors that limit voluntary contraceptive use.

PIP: Since the 1960s, survey data have indicated that substantial proportions of women who have wanted to stop or delay childbearing have not practiced contraception. This discrepancy is referred to as the unmet need for contraception. The traditional interpretation, that these women lack access to contraceptive supplies and services, has led to an emphasis on expanding family planning programs. Recent estimates put the total number of women with an unmet need in the developing world at about 120 million. This study analyzes national Demographic and Health Survey data and related anthropological studies on the causes of unmet need and concludes that the conventional explanation is inadequate. Sub-Saharan Africa stands out as the region with the lowest potential demand and contraceptive prevalence and having the highest unmet need. The unmet need in Asian countries is only 14%. The proportion of women not currently seeking to become pregnant and those who do not want children rises from 29% to 73% between the lowest and the highest levels of development. The prevalence of contraceptive use also increases sharply between the lowest and highest development group: from 4% to 16% for spacing, from 3% to 43% for limiting, and from 7% to 59% for total use. Although for many environments geographic access to services remains a problem, the principal reasons for nonuse are lack of knowledge (25%), especially in Sub-Saharan countries, fear of side effects both life-threatening and non-life-threatening (20%), and social and familial/husband disapproval (9%), even when the women have never discussed family planning with their husbands or families. This finding underscores the need for expanded investment in services that not only provide contraceptives, but also attend to closely related health and social needs of prospective clients. Programs are likely to be most successful when they reach beyond the conventional boundaries of service provision to influence and alter the cultural and familial factors that limit voluntary contraceptive use.

Population policy options in the developing world.

The population of the developing world is currently expanding at the unprecedented rate of more than 800 million per decade, and despite anticipated reductions in growth during the 21st century, its size is expected to increase from 4.3 billion today to 10.2 billion in 2100. Past efforts to curb this growth have almost exclusively focused on the implementation of family planning programs to provide contraceptive information, services, and supplies. These programs have been partially successful in reducing birth rates. Further investments in them will have an additional but limited impact on population growth; therefore, other policy options, in particular measures to reduce high demand for births and limit population momentum, are needed.

[Fertility preferences in Latin America: trends and differentials in seven countries]. / Fecundidad deseada en America Latina: tendencias y diferenciales en siete paises.

The authors use Bongaarts's fertility preference measurement methodology to examine and compare changes in fertility preferences in Colombia, Costa Rica, the Dominican Republic, Ecuador, Jamaica, Peru, and Trinidad and Tobago over the period 1975-1989. "The trends of observed and desired fertility are examined at the national level and by level of education and rural-urban place of residence. The data used comes from fertility surveys....such as the World Fertility Survey (WFS) and the Demographic and Health Survey (DHS). The analysis suggests that the changes in fertility between the dates of the two surveys...are not due to changes in desired fertility, but mainly to differences in the degree to which fertility is controlled to coincide with desired levels.... Both the WFS and the DHS show that unwanted fertility was significant in all countries, specially in the lower socioeconomic strata." (SUMMARY IN ENG)

Behavioural and biological determinants of fertility transition in sub-Saharan Africa.

In the transition from high to low fertility, different biological and behavioural proximate determinants play roles of varying importance in mediating the change. In most regions of the world, the practice of contraception has come to play the major role, so much so that there is a close relationship worldwide between the level of practice of contraception and the level of fertility. In sub-Saharan Africa, the prevalence of contraceptive practice is low, and fertility levels are exceptionally high for recorded levels of contraceptive practice, even where levels of contraceptive practice are comparable to other regions. The discrepancies are explained to a very large extent by differences between Africa and other regions in other proximate determinants--notably exposure to the risk of pregnancy, and abstinence after delivery. It would seem that transition in African countries will follow one of two patterns that are different to the pattern of transition observed in all other regions. First, fertility may rise before it declines, due to abandonment of traditional fertility regulation for some time prior to the eventual adoption of contraceptive practice. Second, the prevalence of contraceptive practice may rise for a time before there is an observable decline in fertility, because at the same time that contraception is adopted, traditional regulation of fertility is being abandoned, offsetting any effect on fertility. Kenya is an example of the first pattern, while Botswana, Ghana, and Zimbabwe are probably examples of the second.

The demographic impact of family planning programs.

In response to concerns about the adverse consequences of rapid population growth, family planning programs have been implemented in many developing countries. The aim of the present study is to assess the impact of this programmatic approach on long-range population growth. The result of a new and hypothetical population projection indicates that in the absence of family planning programs the population of the developing world could be expected to reach 14.6 billion in the year 2100 instead of the 10 billion that is currently projected by the World Bank. Despite the apparent success of existing interventions, fertility control is far from complete, as many women continue to bear unwanted births. To assess the impact of this unintended childbearing a second hypothetical projection is made. With perfect implementation of reproductive preferences, the population size of the developing world in 2100 would be reduced by an estimated 2.2 billion below the current projection. Further strengthening of family planning programs and improvements in birth control technology are therefore likely to provide important demographic benefits.

The relationship between male circumcision and HIV infection in African populations.

The relationship between HIV seroprevalence and the proportion of uncircumcised males in African countries is examined to determine whether circumcision practices play a role in explaining the large existing variation in the sizes of African HIV epidemics. A review of the anthropological literature yielded estimates of circumcision practices for 409 African ethnic groups from which corresponding national estimates were derived. HIV seroprevalence rates in the capital cities were used as indicators of the relative level of HIV infection of countries. The correlation between these two variables in 37 African countries was high (R = 0.9; P less than 0.001). This finding is consistent with existing clinic-based studies that indicate a lower risk of HIV infection among circumcised males.

PIP: Wide variations in the HIV epidemic exist among the different countries in Africa. The relationship between HIV seroprevalence and the proportion of uncircumcised males is examined to determine whether circumcision practices play a role in explaining the variation in the sizes of the African HIV epidemics. Circumcision practices for 409 African ethnic groups were corresponded with national estimates of HIV infection levels. Although age at circumcision and other ethnic group identity characteristics were known, this information was not considered in this study. HIV seroprevalence rates in the capital cities were used to indicate the relative level of HIV infection in the countries. In 5 countries where more than 3 quarters of males were estimated to be uncircumcised, the average HIV prevalence was 16.4%. In none of the capital cities of these 5 countries was the seroprevalence less than 9.5%. Among the 20 countries where more than 90% of males were circumcised, the average seroprevalence was 0.9% and in no case did it exceed 4%. The correlation between these 2 variables was high (R=0.9%;P 0.001). Although strong population level correlation between circumcision and HIV seroprevalence exists, it does not prove a cause and effect relationship. However, the results are consistent with existing clinic-based studies that indicate a lower risk of HIV infection among circumcised males and suggest that male circumcision is a cofactor in HIV infection.

A model of the spread of HIV infection and the demographic impact of AIDS.

The objective of the computer simulation model described here is to project, for periods up to one or more decades, the annual incidence and prevalence of HIV infection and AIDS in a population with given epidemiological, behavioural and demorgraphic characteristics. In addition, the epidemic's impact on a range of demographic variables is calculated. The epidemiological components of the model use a compartmental approach and they are described with sets of linear differential equations. The demographic framework in which the epidemiological components are integrated, is based on a standard cohort component method of population projection. The simulated population is stratified by age, gender, sexual behaviour, marital status and infection/disease status. The concluding section provides an illustrative application of the model to a Central African population. In this hypothetical simulation covering the period from 1975 to 2000, HIV prevalence in the adult population rises from 0 to 21 per cent. By the end of the projection period mortality is about double the level that would have prevailed in the absence of the epidemic, but, owing to the very high birth rates that prevail in most of Africa, the growth rate of the population remains substantially positive.

Fertility policy in China: future options.

A wide range of social, economic, and demographic criteria are used to evaluate China's present one-child policy and five alternative fertility policies that might guide China's population control efforts until the end of the century when the one-child policy is scheduled to be abandoned. These criteria include the policies' macrodemographic impact on total population size and population aging; their microdemographic effects on the family's ability to support the elderly, its economic capabilities, and the position of women; and their cultural acceptability to the majority Han Chinese population. The results suggest that the least desirable strategy is to retain the present policy; all the two-child alternatives perform better than the current one-child policy in achieving the policy goals considered.

Contraceptive use and annual acceptors required for fertility transition: results of a projection model.

Major fertility declines in developing countries are invariably accompanied by large increases in contraceptive prevalence and in the annual number of new acceptors. This article applies a target-setting model to make hypothetical projections of trends in prevalence and number of acceptors over the course of a full fertility transition. The sensitivity of these trends to variations in proximate determinants such as the marriage pattern and the duration of lactational amenorrhea, as well as in the discontinuation rate and the method mix, are examined. It is concluded that a contraceptive prevalence of around 75 percent is needed to achieve replacement-level fertility and that variations in proximate determinants other than contraceptive prevalence have only a modest effect on this result. On the other hand, trends in new acceptors are demonstrated to be very sensitive to discontinuation rate changes. As a consequence, it is generally difficult to draw conclusions about trends in fertility from trends in acceptors.

[Introduction of Goldstein therapies for disadvantaged clients in the Netherlands]. / Zur Einführung der Goldsteintherapien für chancenarme Klienten in den Niederlanden.

In Limburg, Netherlands, a project is going on aiming to implement lower class-linked skill-therapies into the regional mental health services. This article elucidates: the poor relationship that exists between contemporary psychotherapy and the lower class clients; various efforts that have been attempted to solve this problem; the basic elements of Goldstein's 'structured learning therapy'; activities and results of the Dutch 'Goldsteinproject'.

A simple method for estimating the contraceptive prevalence required to reach a fertility target.

This report describes and applies a procedure for estimating the increase in contraceptive prevalence that would have to occur to achieve specified future reductions in a population's fertility. This target-setting methodology is based on a previously developed analytic model for the relationship between fertility and its proximate determinants. The basic aggregate version of the estimation procedure, which is described in detail, requires relatively few input data, but it allows changes in the mix of contraceptive methods in future years. In extended versions of the model, age specificity and adjustments for given trends in the proximate determinants other than contraceptive use are introduced.

PIP: A procedure for estimating the increase in contraceptive prevalence that would have to occur to achieve specified future reductions in a population's fertility is described and applied. This target-setting methodology is based on a previously developed analytic model for the relationship between fertility and its proximate determinants. The basic aggregate version of the estimation procedure requires few input data, but allows changes in the mix of contraceptive methods in future years. 7 proximate determinants of fertility can be identified: 1) marriage pattern; 2) contraceptive prevalence and effectiveness; 3) induced abortion; 4) postpartum infecundability; 5) frequency of intercourse; 6) spontaneous abortion; and 7) sterility. A change in any of these will cause a change in fertility; however, the 1st 4 are the most important. To quantify the relationship between fertility and its proximate determinants, a multiplicative model has been developed. The fertility-inhibiting effect of each of the principal proximate determinants is measured by an "index." This is the proximate determinants model. In Equation 1 the total fertility rate of a population is reduced from its maximum total fecundity rate by the multiplicative reductions of the 4 indexes. Equation 2, although aggregate, takes into account changes in all principal proximal determinants between the base and target years. The basic version of the model is described in detail. 2 general applications are summarized: 1 assumes that use-effectiveness will remain constant between the base and target years and the other allows a trend in effectiveness. The basic version of the model can be extened to a more general 1 that makes it possible to take into account the effects of trends in all proximate determinants (Appendix 1). An age-specific version is also available (Appendix 2).

Building a family: unplanned events.

Couples in developed societies are often unsuccessful in achieving precise family building goals despite the widespread use of birth control. Unplanned events that frustrate reproductive intentions to varying degrees include contraceptive failure, sterility, miscarriage, prolonged conception delay, undesired sex combination of offspring, divorce, and the death of a spouse or a child. This paper reviews the probability of the occurrence of these events using US data. It is concluded that the large majority of newlyweds will experience at least one unplanned event during the family building phase of the life cycle.

PIP: Couples in developed societies are often unsuccessful in achieving precise family building goals despite the widespread use of birth control. Based on US data, this paper reviews the probablility of the occurrence of 9 unplanned events that may frustrate reproductive intentions to varying degrees. 1) Contraceptive method-specific failure rates over 2 years, range from 3.8 for the pill to 32.4 for foam/jelly/cream. The average failure rate for all methods combined is 7.3% after 1 year and 12.1% after 2 years. 2) The risk of experiencing primary sterility ranges from a few % in the early 20s to about 20% between ages 35-40. The proportion of couples experiencing secondary sterility is lower at all ages. 3) Prolonged conception delay is yet another unexpected outcome for many fecund couples. The probability of conceiving in a month is 20% for noncontracepting couples engaging in intercourse at a rate of twice a week. 4) Approximately 1/5 conceptions fails to end in a live birth. The risk of intrauterine death varies significantly with the age of the mother. 5) Congenital malformations range widely in severity; yet, around 2% of newborns have serious defects resulting in early death or requiring intensive medical care and supervision. Congenital disease risk increases with maternal age. 6) 50% of couples who desire at least 1 boy and 1 girl can achieve this sex composition with 2 births; 25% require 3 births and the rest 4 or more births to reach it. 7) Analysis of US divorce rates shows that 1/2 of all 1st marriages end in divorce. 8) The probability of child or spouse death is small, but it adds up to significant cumulative levels over 1 or more decades of family life. 9) The projected proportion of couples with an unwanted birth 15 years after the last wanted child was 11% in 1973-76. It is concluded that 93.8% of newlyweds will experience at least 1 unplanned event during the family building phase of the life cycle.

The formal demography of families and households: an overview.

"The objective of the present paper is to give a brief overview of the subject matter of the formal demography of the family. Selected references are included, but no attempt is made to be exhaustive. No discussion of socio-economic determinants or consequences is included, because this overview is limited to the formal aspects of the field. "The...paper is divided into five parts. The first deals with the descriptive analysis of family and household size and composition, from both a cross-sectional and a longitudinal perspective. The next two sections discuss, in order, demographic determinants and consequences. This is followed by a brief section on projection methods and the conclusion."