CONTEXT: In many developing countries, fertility has declined steadily in recent decades, while the average strength of family planning programs has increased and social conditions have improved. However, it is unclear whether the synergistic effect of family planning programs and social settings on fertility, first identified in the 19705, still holds.
METHODS: Data from 40 developing countries in which Demographic and Health Surveys were conducted in 2003-2070 were used to examine associations among socioeconomic conditions, family planning program effort strength and fertility. Cross-tabulations and multiple regression analyses were conducted.
RESULTS: Variation among countries in scores on the Family Planning Program Effort Index, but not on the Human Development Index, has diminished since the 1970s. On average, fertility levels were lower among countries with better social settings or stronger family planning programs than among those with poorer settings or weaker programs; they were lowest in the presence of both good social settings and strong programs. In addition, fertility was positively associated with infant mortality and negatively associated with female education, but not associated with poverty. About half of the 2.3-birth difference in fertility between countries in Sub-Saharan Africa and those elsewhere can be attributed to differences in program efforts and social settings.
CONCLUSIONS: Policies focused on improving levels of female education, reducing infant mortality and improving family planning services can be expected to have mutually reinforcing effects on fertility decline.
International Perspectives on Sexual and Reproductive Health, 2012, 38(1):15-22, doi: 10.1363/3801512
National family planning programs, which emerged during the 1960s and 1970s, were greeted skeptically by some, who doubted that they would affect fertility behavior. However, extensive evidence subsequently suggested that these programs do reduce fertility, especially when socioeconomic conditions are relatively favorable and sufficient infrastructure (including administrative, staff and logistical support) for the implementation of mass programs exists. (1-6)
In the years since, family planning programs have come under scrutiny, notably at the 1994 Cairo International Conference on Population and Development, where leaders strongly advocated that programs be broadened to embrace aspects of reproductive health beyond contraceptive use. The conference's impact is hard to gauge, but some countries may have modified programs that were narrowly focused on fertility change. Furthermore, the organization of family planning and related programs in some countries has been sharply modified through decentralization of the health ministry or to address the massive demands of HIV/ AIDS programs. Nonetheless, average global scores on the Family Planning Program Effort. Index--a survey-based assessment that measures national program strength--have risen steadily since 1972, albeit more slowly in the last decade than previously. (7) During these same years, fertility has declined substantially and contraceptive use has risen in many countries. (8)
Given these changes, as well as the passage of time, the relationship of national fertility levels to the strength of family planning programs and to socioeconomic context warrants reexamination. In the long term, economic development is expected to lead to fertility decline, as it did in North America and Western Europe. At the same time, it seems clear that a good family planning program can reduce fertility, even in very poor countries, as in Bangladesh and Northern Ghana. (9-11) Nonetheless, studies conducted prior to the 1994 Cairo meeting found that family planning programs are most effective when a strong program is implemented in a good social setting (e.g., one in which literacy, life expectancy and income are high). (1-6) These results were consistent with the Cairo conference's program of action, (12) which called for countries to reduce gender inequality in health, education and economic opportunities and to provide contraceptive services within the context of reproductive health. …