This document discusses fertility transitions in sub-Saharan Africa based on data from Demographic and Health Surveys conducted between 1986-2011. It finds that while total fertility rates have declined in many countries, the pace of decline varies significantly between urban and rural areas as well as between different countries. The relationship between contraceptive use and fertility is complex, with some countries seeing their fertility decline offset by decreasing duration of postpartum abstinence, while others have had net fertility declines driven by increased contraceptive use. High levels of unmet need for contraception persist throughout sub-Saharan Africa.

1. The Fertility Transition in Sub-Sahara Africa:
Quo Vadis ?
Ron Lesthaeghe
Em. Prof. Vrije Universiteit Brussels (VUB)
Royal Flemish Academy of Sciences of Belgium.
Centre d’Estudis Demografics, Universitat Autonoma Barcelona.

2. Total Fertility Rates as recorded by the DHS Surveys, 1986-2011
West and Central Africa.
R. Lesthaeghe.
Data source : C. Westoff 2010, and DHS reports after 2008
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
1980 1985 1990 1995 2000 2005 2010 2015
Benin
Burk Faso
Cameroon
Ivory Coast
Chad
Ghana
Guinea Con.
Liberia
Mali
Nigeria
Senegal
Togo
Niger.

3. Total Fertility Rates as recorded by the DHS surveys, 1986-2011.
East and Southern Africa
R. Lesthaeghe
Data source: C. Westoff 2010 and DHS country reports after 2008.
2
3
4
5
6
7
8
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Ethiopia
Kenya
Madagascar
Malawi
Mozambiqu
Namibia
Rwanda
S. Africa
Tanzania
Uganda
Zambia
Zimbabwe
Burundi
Lesotho

4. Sub-Sahara Africa : Urban and Rural Total Fertility Rates.
West and Central Africa
Latest DHS survey in the 21st Century.
• Source: DHS Country Reports
0
1
2
3
4
5
6
7
8
Capital
Urban
Rural
Total

5. • Source: DHS Country Reports
Sub-Sahara Africa : Urban and Rural Total Fertility Rates.
East and Southern Africa
Latest DHS survey in the 21st Century.
0
1
2
3
4
5
6
7
8
Capital
Urban
Rural
Total

6. Total Fertility Rates reported by the latest DHS surveys (up to 2011)
Sub-Sahara Africa.
Map, and cartogram proportional to population size
Total Fertility Rate
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
No Data
Total Fertility Rate
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
No Data
Cartography : Toni Lopez, CED - UABarcelona

7. Latest urban and rural Total Fertility Rates reported by the DHS surveys (up to 2011)
• Cartography: Toni Lopez CED - UABarcelona
Total Fertility Rate
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
No Data
Total Fertility Rate
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
No Data
Urban TFRs Rural TFRs

8. Latest urban and rural TFRs reported by DHS surveys ( up to 2011)
Sub-Sahara Africa
Cartograms with country surface drawn in proportion to population size.
Cartography : Toni Lopez, CED-UABarcelona
Total Fertility Rate
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
No Data
Total Fertility Rate
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
No Data
Urban TFRs Rural TFRs

9. Current use, women 15-49 currently in a union.
Top 10 countries with more than 1% current users, by method.
Latest DHS in 21st Century
PILL Injectables +
inplants
Female
sterilization
IUD
Zimbabwe 41.3%
Cape Verde 21.4
Lesotho 12.5
Zambia 11.0
Namibia 8.6
Kenya 8.6
Rwanda 7.1
Madagascar 6.0
Gabon 4.8
Ghana 4.7
Rwanda 32.6
Malawi 27.3
Ethiopia 24.2
Kenya 23.5
Namibia 22.0
Lesotho 19.4
Madagascar 19.4
Cape Verde 11.3
Zimbabwe 11.0
Burundi 11.0
Cape Verde 14.8
Namibia 10.3
Malawi 9.7
Kenya 4.8
Uganda 2.4
Lesotho 2.4
Zambia 1.9
Ghana 1.6
Zimbabwe 1.1
Madagascar 1.1
Burundi 2.7
Cape Verde 2.2
Lesotho 1.9
Kenya 1.6
Namibia 1.4
Nigeria 1.0
R. Lesthaeghe
data source: DHS country reports.

10. Current use of contraception, women 15-49 currently in a union.
Top 10 countries with use larger than 1 %. By method.
Latest DHS in 21st Century
Male condom Rhythm + % of users
with correct knowledge
Withdrawal Prolonged lactation
Namibia 10.6
Congo Braz. 10.4
Lesotho 9.4
Cape Verde 6.1
Zambia 4.7
Congo DR 3.4
Zimbabwe 3.1
Rwanda 2.9
Nigeria 2.4
Ghana 2.4
Congo Braz. 24.9 1.1*
Congo DR 11.0 61.7
Madagascar 9.7 82.5
Benin 6.9 59.4
Ghana 4.7 69.6
Rwanda 2.9 37.8
Uganda 2.8 30.8
Nigeria 2.1 39.3
Burundi 1.9 na
Cape Verde 1.9 22.6
Zambia 4.8
Benin 3.6
Rwanda 3.5
Congo Braz. 3.5
Congo DR 3.1
Burundi 2.8
Cape Verde 2.2
Uganda 2.1
Nigeria 2.0
Ghana 1.4
Niger 4.7
Guinea C. 1.7
Nigeria 1.6
Madagascar 1.0
•Value reported in the Congo Brazzaville DHS country report. Not a printing error, since the text
comments on this extremely low figure.
R. Lesthaeghe. Data source : DHS country reports

11. Sub-Sahara African countries: Relationship between the TFR and the percentage of women 15-49
in a union using a modern method of contraception. Latest DHS survey data.
• Ron Lesthaeghe,
• Data source: Westoff 2010 and DHS country reports
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
0 10 20 30 40 50 60 70
Latest TFR
Latest TFR
Expon. (Latest TFR)
% Current Users
Modern Method

12. Reminder : the Bongaarts model of intermediate fertility variables:
Successive reductions in specific order.
(impact is low if fraction closer to unity)
Total Fecundity Rate TF ( about 14 to 16 children per woman)
* Ci or index of postpartum non-susceptibility (fraction)
= Total Natural Fertility Rate TNFR
* Cc *Ca or indices of contraceptive use-effectiveness and of induced
abortion (fractions)
= Total Marital (Union) Fertility Rate TMFR
* Cm or index on non-marriage or proportions outside union
(fraction)
= Total Fertility Rate TFR
TFR= TF * Ci * Cc *Ca *Cm
=> Counterbalancing changes in Ci and Cc are important
especially in sub-Sahara Africa

13. Durations of postpartum abstinence reported by ethnographic studies
(mostly 1st half 20th Century)
Source : Schoenmaeckers et al.

14. The abstinence bonus:
Number of months of extra protection beyond lactational amenorrhoea
depending on the extra length of postpartum abstinence
Source : Lesthaeghe et al.
Data : WFS surveys.

15. The “two-phase transition”: counteracting effects of declining durations of
postpartum non-susceptibility and increased use-effectiveness of
contraception.
A. Countries with a shortfall of contraception or just breaking even (Cc > or = Cc*)
Country Years
compared
(DHS)
Median duration
postpartum
Non-susceptible
period (nsp)(mths)
Bongaarts Index
fertility reducing
effect of
postpartum nsp
Ci
Bongaarts
Index
fertility reducing
effect of
contraception
Cc
Overall
Effect
Pp nsp and
contra-
ception
Ci.Cc
Cc required
for neutralizing
decline in length
nsp
Cc*
Family
Planning Effort
Score
(FPES)
Burk. Faso 1993
2003
22.2
19.9
.49
.52
.82
.87
.40
.45 .77
46
46
Rwanda 1992
2005
17.1
15.3
.56
.59
.81
.86
.45
.51 .76
43
36
Benin 1996
2006
18.9
14.4
.53
.61
.86
.84
.46
.51 .75
30
35
Senegal 1986
2005
16.2
12.6
.58
.64
.92
.89
.53
.57 .83
51
46
Cameroon 1991
2004
16.0
13.7
.57
.62
.85
.76
.48
.47 .77
36
41
Ron Lesthaeghe. Data source : K Johnson et al 2011 and DHS country reports

16. B. Countries with net gains in fertility reduction through contraception.
Cc<Cc*
Me nsp Ci Cc Ci.Cc Cc* FPES
Ghana 1988
2008
14.0
12.4
.62
.64
.88
.79
.55
.51 .86
53
46
Tanzania 1991-92
2004-05
15.6
13.0
.59
.63
.90
.76
.53
.48 .84
42
45
Kenya 1989
2009
11.1
10.3
.68
.69
.76
.57
.52
.39 .75
56
49
Zambia 1992
2007
14.1
12.5
.61
.65
.87
.64
.53
.42 .82
40
45
Malawi 1992
2004
(13,7)
12.9
.62
.63
.88
.68
.55
.43 .87
44
48
Zimbabwe 1988
2005-06
14.1
15.6
.61
.59
.62
.44
.38
.26 .64
49
60
Madagascar 1992
2008-09
12.0
10.7
.66
.68
.85
.60
.56
.41 .82
34
64
Namibia 1992
2006-07
12.8
13.1
.64
.63
.73
.49
.47
.31 .75
40
45
R. Lesthaeghe. Data Source: K. Johnson, N. Abderrahim, S. Rutstein, 2011, and own calculations of Ci
Malawi value in parentheses is reversely calculated on the basis of the Ci value reported by Johnson et al., 2011

17. Sub- Sahara African countries: Relationship between (Y) the unwanted part of the TFR,
and (X) the percentage current use of a modern method of contraception
(women 15-49 in a union). Latest DHS survey.
• R. Lesthaeghe
• Data Source: C. Westoff 2010 and DHS country reports
0
5
10
15
20
25
30
35
40
45
50
0 10 20 30 40 50 60 70
% of TFR unwanted
Fertility
goals reached
Lower fertility wanted
but not yet realized
High fertility wanted
Percentage current use
modern contraception
Lesotho outlier

18. “Unmet need” (UN)
• 1. % of women 15-49, currently in a union &
exposed, not using contraception but do not
want a birth in the next 2 years = UN SPACING
• 2. % of women 15-49, currently in a union &
exposed, not using contraception and not
wanting any more children = UN STOPPING
• 1+2=Total unmet need
S. Rutstein, 2011, p. 2

19. Sub-Sahara African countries : Relationship between the unmet need for spacing
among non-users and the percentage use of modern methods of contraception
(women 15-49 in union)
R. Lesthaeghe
Data source: Westoff 2010 and DHS country reports
0
5
10
15
20
25
30
0 10 20 30 40 50 60 70
Latest % unmet need spacing
Latest UN sp
Expon. (Latest UN sp)
Latest % current
users modern

20. Sub-Sahara African countries: Relationship between (Y) the difference in percentages of
non-users with an unmet need for spacing and an unmet need for stopping, and
(X) the percentage of use of a method of modern contraception.
Latest DHS data.
• R. Lesthaeghe
• Data source : C. Westoff 2010 and DHS country reports
-10
-5
0
5
10
15
20
0 10 20 30 40 50 60 70
Percentage points difference
UN spacing minus UN stopping
Dif UN sp-st
Linear (Dif UN sp-st)
% current users
modern method
contraception

21. Chart for the reasons of non use of contraception,
women 15-49 currently in a union.
No need ? Not Ready ? Not Willing ? Not Able ?
Source : R. Lesthaeghe
W. 15-49
in union
% Not using &
not intending
(nu ni)
A. % nu ni because
of sterilization,
infecundity,
infrequent sex
No need
B. All other
nu ni
B1. % wants as many children
as possible Not Ready
B2. % Opposed to contraception
(self, husband, other, religion)
Not Willing 1
B3. % Health reasons & fears,
inconvenient use. Not Willing 2
B4. % No knowledge, no access,
too expensive. Not Able
B5. % Other, unknown, missing

22. Percentage of women 15-49 in union
not using any contraception and not intending to.
“ nu ni ”
Countries reporting 40 % or more
Women 15-49 in union West & Central Africa
(N=12)
East & Southern Africa
(N=11)
% Not using and not
intending (nu ni)
(Category A in chart)
40 % or more.
Senegal 2005 66%
Niger 06 63
Guinea C. 05 58
Mali 06 55
Nigeria 08 55
Sierra Leone 08 48
Liberia 07 48
Cameroon 04 46
Ghana 08 46
Congo Brazza 05 41
Benin 05 40
(11/12)*
Mozambique 2003 48
Ethiopia 05 44
Kenya 05 40
(3/11)
•The only missing country here is Burkina Faso 2007 with 29 %, but with a large number of missing responses
(12%)
•Source: R. Lesthaeghe. Data : DHS country Reports

23. Percentage of women 15-49 currently in union, not using contraception and not
intending to, who give as reason : sterilization, infecund or infrequent sex.
Countries reporting 30% or more.
“NO NEED”
Women 15-49 in union West and Central Africa
N=12
East and Southern Africa
N=11
Pct of nu ni because of
sterilization, infecundity,
or infrequent sex
( = “no need” )
Category A in chart.
30% or more
Congo Brazza 05 42%
Burkina Faso 03 33
Benin 05 32
3/12
Swaziland 06-07 51%
Zimbabwe 05-06 48
Zambia 07 44
Namibia 06-07 35
Rwanda 05 34
(but Rwanda 07-08 67 !)
Malawi 07 30
6/11
R. Lesthaeghe. Data source: DHS country reports

24. NOT READY + NOT WILLING type 1
wants as many children as possible + opposed to contraception (self, husband, other
persons, religion)
Countries reporting 50% or more.
Women 15-49 in union,
Nu ni for reasons other
than sterilization,
infecundity or infrequent
sex
West and Central Africa
N=12
East and Southern Africa
N=11
% wants as many children
as possible or opposed to
contraception (self,
husband, other, religion)
(Not Ready + Not Willing
type 1 = B1 + B2 in chart)
50 % or more.
Guinea C. 05 81%
Cameroon 04 73
Senegal 05 66
Nigeria 08 64
Mali 06 62
Niger 06 61
Sierra Leone 08 58
Congo Brazza 05 57
Burkina Faso 07 52
9/12
Mozambique 03 81%
Ethiopia 05 51
2/11
R. Lesthaeghe; data: DHS Country Reports

25. NOT WILLING Type 2
Countries reporting 30% or more
West and Central Africa
N=12
East and Southern Africa
N=11
% for reasons of health,
fears about side effects,
and use contraception or
method inconvenient.
Not willing type 2
(Category B3 in chart)
30% or more
Ghana 08 53
Liberia 07 41
Benin 05 37
Congo Brazza 31
4/12
Malawi 07 54
Kenya 08-09 49
Swaziland 06-07 48
Zambia 07 47
Lesotho 04 47
Zimbabwe 05-06 45
Tanzania 04-05 38
Rwanda 07-08 38
(Rwanda 05 33)
Namibia 06-07 36
9/11
Women 15-49 in union,
Nu ni for reasons other
than sterilization,
infecundity or
infrequent sex.

26. NOT ABLE, OTHER + DOES NOT KNOW + MISSING
Countries reporting 10% or more
Women 15-49 in union,
Nu ni for reasons other
than sterilization,
infecundity, infrequent sex
West & Central Africa
N=12
East and Southern Africa
N=11
% no knowledge, no
access, too expensive
NOT ABLE
(Category B4 in chart)
10 % or more
Niger 06 19
Mali 06 15
Liberia 07 15
Burkina Faso 03 14
Nigeria 08 10
5/12
Ethiopia 05 14
1/11
% Other reasons, don’t
know, missing.
(Category B5 in chart)
10% or more
Burkina Faso 03 12
1/12
Namibia 06-07 24
Ethiopia 05 18
Rwanda 05 16
(Rwanda 07-08 16)
Zambia 07 12
Swaziland 06-07 12
Zimbabwe 05-06 10
6/11
R. Lesthaeghe. Data : DHS country reports

27. The 10 “take home messages” on the Sub-Saharan fertility transition
1. Dominant pattern : slow with periods of “stalled transitions”.
2. Generally, more progress in Eastern and Southern Africa.
3. Wide scatter of TFR-levels for given level of contraceptive
use, pointing at effects of other crucial “intermediate fertility
variables”.
4. “Two phase transition”: parts of the gains realized via
increased contraceptive use is lost through shortening of the
periods of lactational amennorrhea and postpartum
abstinence. This “neutralizing” effect is strongest in West
Africa.
5. Large urban-rural differences, reflecting both motivation
differences and contrasts in service supply and quality.

28. 10 take home messages -- continued
6. Initial phase of transition characterized by rise of the
“unplanned” and “unwanted” part of the TFR.
7. Unmet need for spacing much larger than for stopping. Only
reversal at advanced phase of the transition.
8. Hormonal contraception ( pill, injection, and also inplants
when available) are by far the most used and prefered
methods of modern contraception. Remarkably little use of
IUDs (FP program bias ?)
9. Low condom use in West and Central Africa; rythm method
mostly misunderstood, even by users.
10. MAJOR FP DRIVE ABSOLUTELY NECESSARY WITH PRIORITY
FOR RURAL AREAS.