Journal Issue
Finance & Development, December 1980

Family planning programs and fertility decline: A report on family planning programs in 63 developing countries

International Monetary Fund. External Relations Dept.
Published Date:
December 1980
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Roberto Cuca

The developing world, taken as a whole, experienced a consistent increase in the rate of growth of its population from 1945 up to the late 1960s. The rate then stabilized at around 2.4 per cent per annum, and in the mid-1970s it dropped to 2.3 per cent. Although this decline may not appear dramatic, the change of trend it implies is of tremendous importance in the history of population. For the first time in the modern era, the rate of population growth is declining rather than increasing. (Even at this reduced rate, of course, the number of people in the world will continue to grow rapidly, so that a decline in fertility must not be confused with a decline in population.)

The steady increase in the rate of population growth of most developing countries in the post-World War II era took place because of a continuous decline in mortality, while fertility remained constant or even increased somewhat up to about 1960. The data on fertility for the purpose of this article are based on estimates of the total number of live births that each woman would have during her lifetime, if current age-specific fertility rates were to continue unchanged. During the 1960s, fertility began to decrease, but still not as fast as mortality; it was not until the 1970s that fertility decline overtook falling mortality, and the rate of population growth finally began to slow down.

This article is based on a World Bank study of 63 developing countries to determine the conditions that may have brought about the decline in fertility in the developing world during the last two decades. Three principal findings are relevant for policymakers: birthrates fell most in countries that had adopted and implemented family planning policies and programs with specific demographic objectives; they fell less in countries with family planning policies but no demographic objectives; and fell least of all in countries without family planning programs. The analysis also shows that the adoption and implementation of family planning programs, as well as their success, were directly related to each country’s socioeconomic development. (This development was measured by such key indicators as school enrollment; health and nutritional status; income; occupation; sanitation and urbanization; and the status of women.) Although it is difficult to establish the different roles played by the level of development and family planning programs in declining birthrates, the implications of the study for policymaking are that the practice of family planning and the consequent fertility decline depend both on the effective supply of family planning services and on sufficient demand for them. The results also indicate that both socioeconomic development and family planning programs have to be pursued simultaneously if fertility is to decrease in the future.

Critical factors

The 63 countries covered in the analysis have populations of five million or more. They represent approximately 95 per cent of the population of the developing world, or about 67 per cent of the total population of the world. The chart shows the association between the degree of a country’s official commitment to fertility reduction—through a family planning policy and program specifically aimed at reducing birthrates—and the reduction in its birthrate during the period 1960-77. Of the 26 countries with a specific population policy, 20 had a large reduction in the birthrate (10 per cent or more during the period of the analysis); of the 19 countries with a population policy but no specific objective to reduce births, only 6 had a large reduction in the birthrate; and of the 18 countries without any population policy at all, only 2 had a large reduction in the birthrate.

A clear association also emerges between a country’s level of socioeconomic development and the reduction in its birthrate. Eighteen of the 20 countries classified as being relatively developed had large reductions in the birthrate, while only 10 of the 23 middle-level countries and none of the 20 low-level countries had a large drop in rates. There is a similar correlation between low birthrates and relatively high national per capita incomes. Nine out of the 13 countries with high per capita incomes (over US$1,000) in 1977 had large reductions in the birthrate; 16 countries out of the 30 in the middle-income range (between US$250 and US$1,000) had the same success; and only 3 countries out of the 20 in the low-income group (less than US$250) achieved large reductions in the birthrate.

In addition to the relationships shown in the chart, the Bank study also tried to measure the effects of the use of contraception on birthrates. First, the proportion of married women of reproductive age using contraception in a country was estimated. This figure was then related to the degree to which the country’s birthrate fell below a level considered normal if contraception had not been practiced. Two assumptions were made in setting this level: that a rate of about 50 births per 1,000 persons implies natural fertility without contraception; and that for each 2 per cent of women of childbearing age practicing effective contraception, the birthrate would decrease by one point. (This last assumption was made on the basis of experience and implies, of course, that the women practicing contraception are a random sample of all women of childbearing age. This is not always the case and therefore the relevant percentages will vary from country to country.) The analysis found a clear association between the practice of contraception and the reduction of fertility, although the ratio to the decline in the birthrate was not always in the expected relation of two to one.

The study shows that a country cannot be successful in significantly reducing fertility unless it has a relatively medium to high level of per capita income and social development and, as a minimum, a favorable official attitude toward family planning, if not a positive commitment to reducing the birthrate. The few exceptions to this rule found in the analysis only serve to confirm it. India, Sri Lanka, and Viet Nam have low per capita incomes but fall within the middle to high range of social development and are fully committed to fertility decline. Although Argentina and North Korea have no commitment to birth reduction, they are highly developed socially and are middle-income or high-income countries.

On the other hand, countries—such as Ghana and Kenya—with a clear official commitment to reducing birthrates have failed to affect them significantly because they have not developed effective programs. The other countries with low per capita incomes and low socioeconomic development were unsuccessful primarily because their socioeconomic environment was not conducive to the practice of family planning. In some cases—such as Iraq and the Syrian Arab Republic—unspecific or relatively weak commitment to fertility decline led to a low reduction in birthrates in spite of a relatively developed social environment.

Chart 1.Developing countries with a reduction in the crude birthrate of 10 per cent or more (in black), or less (in color), 1960-771

Sources. World Sank. World Development Report. 1978 and 1979. Dorothy L. Nortman and Ellen Hofstatter. Population and Family Planning Programs (The Population Council. New York. 1978); W. Parker Maudlin and Bernard Berelson. “Conditions of Fertility Decline in Developing Countries, 1965-1 975.”‘ in Studies in Family Planning, Vol. 9 (May 1978).

1 Includes only countries with a population of al least five million in 1977; includes low-income and middle-income countries, capital surplus oil exporters, and centrally planned economies outside Europe with per capita gross national product (GNP) of less than $1,000.

2 The index of social setting is obtained by dividing the countries into three groups containing about the same numbers of countries, on the basis of the index developed by Maudlin and Berelson (see source reference). Their index includes measures of adult literacy and school enrollment, life expectancy and infant mortality, men in nonagricultural activities. GNP per capita, and urbanization.

Implementing policies

Another relationship observed was that between the level of socioeconomic development and the adoption of a family planning policy. Of the 20 countries classified as high in socioeconomic development, 17 had favorable family planning policies; of the 23 countries classified as having middle-level socioeconomic development, 18 had adopted favorable family planning policies; and only 10 of the 20 countries classified as low in socioeconomic development had favorable family planning policies. The reasons for this are clear. In order to adopt a policy, a country has to be aware, first, that it has a population problem and, second, that a family planning program can help to solve it. For this awareness to exist, countries must have had some tradition of census taking and have experienced the typical discussions and debates that take place anywhere on the need to establish family planning programs.

Developing countries, particularly the poorest, seem to suffer most from these debates. These circumstances at least partly explain why they are the least willing to adopt policies to control population growth, and why they are less successful than other countries in their efforts both to generate demand for family planning services and to supply them. The difficulties of implementing family planning programs in the poorer developing countries are compounded by their lack of capacity to implement them, since a certain level of administrative efficiency is necessary to make a family planning program work. While these services may be initially met by private supply, the experience of most developing countries shows that only organized public programs have the means to supply these services to large numbers of people effectively in the long term. In countries with relatively low socioeconomic development, the public provision of services does not appear to be effective.

These propositions do not imply that, in general, countries with low per capita incomes cannot be successful in reducing birthrates. Other factors, such as the social environment, play an important part in this process. India, Sri Lanka, and Viet Nam have low per capita incomes but not the lowest social development, and, with strong official commitment to planning programs, they have substantially reduced their birthrates. For policymakers, the message is clear: modernization and social development can increase the demand for family planning services, and well organized programs can ensure the supply of such services. Both supply and demand working simultaneously tend to increase contraceptive practice and, in turn, to lower birthrates.

Establishing causality

The data in the chart show the relationship between declining birthrates, official commitment to family planning, and the socioeconomic environment. Is it the existence of a family planning program or a good socioeconomic environment that reduces birthrates? The most difficult task is to isolate the different causes of decreased fertility in order to find out how much of the decline is due to the practice of contraception or induced abortion, and how much is caused by socioeconomic factors. This exercise is complicated by the fact that socioeconomic factors affect fertility in different ways. For instance, socioeconomic development may raise the average age of marriage—which would be expected to reduce fertility—but may cause an increase in premarital sexual intercourse—which, in the absence of contraception or abortion, tends to increase fertility. Again, socioeconomic development appears to increase the number of live births and therefore to decrease fertility, since the occurrence of one birth delays the time of a new pregnancy. The development process may also increase rather than reduce fertility by decreasing the prevalence of sterility and the practice of lactation (which tends to delay conception for some months after the birth of an infant).

Little work has been done to explain the influence of these factors on fertility. Some studies, such as one in the Republic of Korea, have identified the contribution of the increase in the age of marriage and the change in the relative proportions of persons of each age group in the total population to declines in the birthrate. Evaluations of family planning programs in different countries have also estimated the number of births averted as a consequence of contraceptive practice, but these efforts may have been vitiated by defective data and by the assumptions made and are often, therefore, not fully convincing.

These problems have been complicated rather than clarified, oddly enough, by research efforts into the determinants of fertility. The main reason is that such efforts have concentrated on finding the correlation between indicators of socioeconomic development and those of changing fertility levels, but without considering the intermediate variables—such as age of marriage or the proportion of married women—that are affected by socioeconomic factors, and that in turn affect fertility. Another weakness of this research is that, with few exceptions, the studies have not considered the availability of family planning services. This is surprising considering that much of the research has been undertaken by economists who would be expected to use the same approach used in studying the market for other goods and services, which would look into both supply and demand functions.

Demographic data

Reliable evaluation assumes the availability of reliable data. Lack of data on population explains why in many cases trends in fertility cannot be ascertained. By the early 1960s many countries had not even taken a population census, and statistics on vital rates were either unavailable or so unreliable that observed changes could not be accepted with confidence. Lack of data to estimate changes in fertility gave rise to the use of statistics from family planning program services to evaluate the programs. The emphasis on the achievement of targets for family planning programs, however, produced falsification of data in some countries. This raised questions about their reliability.

There have been several efforts since then to improve the situation. The United Nations has established a census program; national programs now exist to improve birth registration; sample surveys are more widely used than before; and techniques of estimation based on incomplete data have been developed.

The lack of reliable data has been one of the principal problems in assessing changes in fertility in the past. The most important problem, however, has been that of attributing the identified reductions in fertility to either socioeconomic development or to the action of family planning programs. But since birthrates mostly fall when both the supply of family planning services and the demand for them are matched, substantial reductions in fertility will only be achieved when both are affected. Thus, it is advisable to invest in fields which accelerate development—in order to increase the demand for family planning services—and to invest in family planning programs to increase the supply of services. Development, of course, takes time. But it is reassuring that even at low levels of development there appears to be a demand for services that can be met with strong family planning programs, which, if effective, may accelerate development by reducing the problems of overpopulation.

The question for researchers is not whether they can discover the socioeconomic determinants of fertility, but whether they can identify the effects of social and economic factors that directly affect the desire for low fertility and the factors that affect the supply of acceptable family planning services. The answer is not to abandon the efforts but to redirect them.

Related reading

Roberto Cuca, Family Planning Programs: An Evaluation of Experience, a background study for the World Development Report, 1979, World Bank (July 1979).

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