Achievement of replacement fertility among educated ... · Achievement of replacement fertility...
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Achievement of replacement fertility among educated Ghanaian women:
A conundrum
Improving health worldwide www.lshtm.ac.uk
Kazuyo Machiyama and John Cleland
London School of Hygiene & Tropical Medicine (LSTHM)
ESRC Seminar Series
Post-Transitional Fertility in Developing Countries:
Causes and Implications
16 July 2013, Oxford, UK
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• Historical Europe:
Widespread use of withdrawal and postponement of marriage since the 18th century (Coale and Watkins 1986, McLauren 1990, Van de Walle and De Luca 2006)
• Fertility transition is usually led by wider use of modern method after the advent of modern contraception in the 1960s.
Introduction
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Role of traditional and short-term methods in fertility transition
• Former Soviet Union and Turkey: widespread of withdrawal with abortion as back-up
• Albania - fertility transition driven by withdrawal without legal abortion (Falkingham and Gjonca 2001, Institute of Statistics et al. 2010).
• Japan: fertility transition is driven by induced abortion and condom use (Coleman 1983)
• India – higher use of sterlisation among the poor and higher use of traditional method among the educated (Basu 2005)
• Iran: Use of withdrawal was positively associated with level of education in Iran, but not Turkey (Erfani and Yüksel-Kaptanoğlu 2012)
Introduction
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Eastern Africa
Middle Africa
NorthernAfricaSouthernAfricaWestern Africa
Eastern Asia
South-CentralAsia
Trends of TFR in Africa and Asia
Source: UN. World Population Prospect: The 2012 Revision
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SSA: Trends of contraceptive
prevalence (traditional & modern)
Source: UN World Contraceptive Use 2012Among married or in-union women aged 15-49
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10.0
20.0
30.0
40.0
50.0
60.0
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Western Africa Middle Africa Eastern Africa Southern Africa
Modern
Traditional
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SSA: Ratio of traditional users among all users by level of education
Source: DHS STAT CompilerAmong married or in-union women aged 15-49
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Perc
ent
(%)
Noeducation
Primary
Secondaryor higher
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Ghana: TFR
Source: ICF Macro 2010
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23
45
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TF
R(1
5-3
9)
1980 1985 1990 1995 2000year
partial TFR(no education) partial TFR(primary education) partial TFR(secondary+ education)
lowess noeductfr year lowess primarytfr year lowess seceductfr year
Ghana, 1978-2007
Ghana: TFR
Source: Machiyama 2011TFR among women aged 15-39
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No education Primary Middle/JSS Secondary/SSS+
1988
1993
1998
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2008
Source: GDHS
Mean ideal family size among women aged 20-29
Ghana: fertility intention
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Ghana: fertility intention
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No education Primary Middle/JSS Secondary+
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1993
1998
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% of currently married women who have 2 children want no more children by level of education
Source: GDHS
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Source: ICF Macro 2010
Ghana: CPR
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% of married women currently using a contraceptive method, by
level of education and method
Source: GDHS
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10
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No education Primary Middle/JSS Secondary+
Ghana: CPR
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• Assess determinants of use of traditional methods in Ghana
• Investigate reasons for non-use of family planning
Objectives
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Methods
• DHS Ghana 1988, 1993, 1998, 2003 & 2008
• Women in union who were exposed to risk of pregnancy
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Adjusted odds ratios for currently using traditional or folkloric method vs non-
users Adjusted OR 95% CI
Residence (ref. urban)
Rural 1.05 0.70 1.57
Area (ref. Southern)
Greater Accra 1.63 0.94 2.85
Middle 1.31 0.82 2.07
Northern 0.09 0.03 0.31 ***
Education (ref. no education)
Primary 2.22 1.16 4.25 *
Middle/JSS 1.80 0.97 3.35
Secondary/SSS+ 2.45 1.14 5.26 *
Religion (ref. Protestant)
Catholic 0.95 0.50 1.77
Other Christian 0.85 0.49 1.48
Moslem 0.69 0.33 1.42
Traditional/spiritualist 2.25 0.74 6.85
Other 1.15 0.38 3.47
N=1046
Traditional methods
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Trends of reasons for non-use, 1988-2008
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50.0
Health concerns/side effect/
interfere with body
Infrequentor no sex
Breastfeeding Lack ofknowledge/access/cost
Respondent's/partner's/
other's opposition
Others/don't know
1988
1998
2003
2008
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0% 10% 20% 30% 40% 50%
Total
Secondary/SSS+
Middle/JSS
Primary
Noeducation
Healthconcerns
infrequent sex
Respondent'sopposition
Breastfeeding
Other'sopposition
Lack ofknowledge oraccess/cost
Reasons for non-use by level of education
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Infrequent sex:
Recency of last sex
Reason for non-use:
Infrequent sex
TotalNo Yes
in last 4 weeks 71.3 32.6 64.8
in last 3 months 19.8 28.9 21.3
4 or more months ago 6.2 34.0 10.8
before last birth 0.0 1.6 0.3
Missing 2.7 2.9 2.8
Total 100.0 100.0 100.0
N=479
Recency of last sex by whether infrequent sex was given as a reason for non-use, 2008
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Infrequent sex
Adjusted for education, parity, postpartum status, age group, polygyny
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Od
ds
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Adjusted odds ratios for not having sex in the last 4 weeks versus having sex in the last 4 weeks, 2008
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• An enduring resistance to hormonal methods may lead many Ghanaian women to use non-hormonal methods, i.e. male condom, periodic abstinence or reduced coital frequency as an alternative means of reducing pregnancy-risk.
Implications
The elite group use less effective method, but the TFR has continuously declined.
Is Ghanaian fertility transition powered by less effective methods with medical abortion as back-up? (Osei 2009)
“modern” women prefer natural methods to modern methods? (Basu 2005)
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Implications
Further research is needed to understand fertility regulation strategies and strong resistance to FP in Ghana, taking into account living arrangement.
Re-visit role of traditional methods.
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The STEP UP (Strengthening Evidence for Programming on Unintended Pregnancy) Research Programme Consortium generates policy-relevant research to promote an evidence-based approach for improving access to family planning and safe abortion. STEP UP focuses its activities in five countries: Bangladesh, Ghana, India, Kenya, and Senegal. STEP UP is funded by UK aid from the UK Government.
www.stepup.popcouncil.org