Reasons for high birth rate in stage I: children need for farming, children die at early age, No family planning, Social and cultural encouragementReasons for high death rate in stage II: famine, diseases, poor medical knowledge
Reasons for changes in Birth and Death rates in Stage III: Improved medical care and diet, use of family planning methods, improved water supply and sanitation, fewer children die
Reasons for changes in Birth and Death rates in stage IV: family planning, later marriages, improved women status, good health, longer life expectancy, reliable food supply
Reasons for decline in birth and death rates in Stage V: family planning, high standard of living, highly advanced medical services, food supply, longer life expectancy, improved women status, later marriages etc.
Though fertility declined in western but the condition under which it declined were diverse.
There has been a decline in the use of female sterilization and injectables, while the use of male sterilization has increased slightly. It is also notable that the long-term use of temporary methods such as implants and IUDs has been increasing over the past few years, providing options for women to drift away from permanent methods such as sterilization. Use of traditional methods has also increased over the years.
Tetanus toxoid (TT) vaccine is given to women during pregnancy to prevent infant deaths caused by neonataltetanus, which can occur when sterile procedures are not followed in cutting the umbilical cord after delivery.
Shraddha Acharya_Demographic transition theory n NDHS
Maharajgunj Medical Campus, IOM (BPH 26th Batch)
DEMOGRAPHIC TRANSITION THEORY
NEPAL DEMOGRAPHIC AND HEALTH SURVEY (NDHS)
& ITS MAJOR INDICATORS
Ravindra Bhandari (451)
Ramsagar Thakur (454)
Sanjay Sah (457)
Shraddha Acharya (460)
Yograj Karki (466)
The Demographic Transition Theory refers to the
transition from a condition of high mortality and high
fertility with consequent slow growth of population
to conditions of low mortality and low fertility, once
again leading to a slow growth of population; as the
country develops from pre-industrial to industrialized
Unlike other population theories, it is based on the
actual demographic experience of Western
Earlier demographers such as Landry (in 1909) and
Warren Thompson (in 1929) had attempted to construct
a typology to describe the transition from conditions of
high mortality and high fertility to conditions of low
mortality and low fertility.
In 1945, Frank W. Notestein presented the theory of
demographic transition in mature form, with explanation
for the changes in fertility so he may be credited with
expounding the theory of Demographic Transition.
However, in 1947, C.P. Blacker attempted to identify the
following five phases of the demographic transition:
5 PHASES OF DEMOGRAPHIC
1. THE HIGH STATIONARY STAGE
2. THE EARLY EXPANDING STAGE
3. THE LATE EXPANDING STAGE
4. THE LOW STATIONARY STAGE
5. THE DECLINING STAGE
1. HIGH STATIONARY STAGE
Characterized by high birth rates and death rates
which are in balance which causes population
All human populations are believed to have
experienced this balance until the late 18th
Mostly in pre-industrialized countries.
Because both rates are approximately in
balance, population growth is typically very slow
in this stage.
2. EARLY EXPANDING STAGE
Death rate begins to decline while the birth
rate remains same.
Developing countries like countries of South
Asia and Africa are in this phase.
The death rates drop rapidly as a result of
improved health conditions.
Example: Egypt, Kenya, India
The decline in the death rate is due initially to two factors:
1. Improvements in the food supply brought about by
advancements in agricultural practices and better
transportation prevent death due to starvation and lack of
water. Agricultural improvements included crop
rotation, selective breeding, and seed drill technology.
2. Significant improvements in public health, reduced
mortality, particularly in childhood. Improvements in
water supply, sewerage, food handling, and general
personal hygiene and knowledge about disease causation.
During the second half of the 20th century less-developed
countries entered Stage-2 i.e. Early Expanding
Stage, creating the worldwide population explosion.
3. Late expanding stage
The death rate declines still further and the birth
rate tends to fall.
wages, urbanization, an increase in the status and
education of women etc.
Due to decline in child death rate and increase in
incomes, parents realize that they do not need
more child for their comfortable old age.
Population growth begins to level off.
Example: Brazil, Singapore, China
4. LOW STATIONARY STAGE
There is low birth and low death rate which
results in stationary population.
Population is stable or very slow increase in
Many industrialized countries are in this stage.
This is all due to development in socio economic
condition, education and all services and facilities
concerning well being and quality life of every
Example: USA, Japan, France, UK, Denmark,
5. Declining stage
The population begins to decline because
death rate exceeds birth rate.
European and many East Asian countries now
have higher death rates than birth rates.
Example: Germany, Hungary
Corresponding Population Pyramid of the Phases of Demographic Transition
Notestein characterized 3 types of populations
according to their stage of demographic evolution:
• Where fertility have fallen below the
replacement level. Example:
USA, Australia, New Zealand
• Where birth and death rates are still high
and growth is rapid, but the decline of the
birth rate is well established. Example:
Soviet Union, Japan, some countries of
3. HIGH GROWTH
• Where mortality is high and variable and is chief
determinant of growth, while fertility is high
and has thus far shown no evidence of a
• Rapid growth is expected as soon as technical
developments make possible decline in
mortality. Example: Asia, Africa, Latin America
CRITICISM OF DEMOGRAPHIC
1. The critics of this theory point out that the
experiences of the various European countries
were not uniform, in the sense that the
sequences of the stages as described in the
theory were not the same.
2. In Spain and in some eastern and southern
Europe countries, fertility decline occurred even
when mortality was very high.
3. In some countries like USA, the growth rate in
the post-transition stage was probably higher
than in Stage-II and Stage-III.
4. Notestein’s claim that fertility declined initially in
urban areas is not true for some countries.
France, Sweden, Finland, Bulgaria with
predominantly rural populations, experienced
declines in birth rate to the same extent as did
some highly urbanized countries like England and
5. This theory cannot also explain the phenomenon
of “baby boom” in Western countries after
economic recovery and Second World War.
6. It does not provide a theoretical explanation of the forces that
caused demographic changes, especially fertility which brought
7. Further it took European countries 150 to 200 years to reduce their
death rate below 15 but this was done by some developing
countries in 15 or 20 years. Thus, it could also not be used to
predict the sequences through which the developing countries
8. It cannot be called a “theory” because it does not also identify
crucial variables involved in fertility decline therefore, it also
doesn’t fulfill the criterion of a theory.
* However, its greatest strength is the prediction that the transition will
occur in every society which is experiencing modernization. So, the
objections, qualifications, and doubts about the demographic
APPLICATION IN DEVELOPING NATIONS
As we see later, mortality in Nepal started to decline since the late fifties
and the pace of mortality decline has become faster since the 1990s. If one
looks at the fertility transition in Nepal one would find that fertility started to
decline much later and at much slower speed than mortality. For example,
fertility in Nepal was more or less constant till early eighties and started to
decline thereafter. Thus it can be argued that Nepal is in the third phase of
Demographic transition where both the fertility and mortality are declining.
The developing countries have recently experienced a phenomenal reduction in death
rates, as a result of which there has been tremendous increase in rates of population
growth. This rapidly increasing population is an obstacle in the path of development
programmes for economic developments, industrialization and modernization.
According to this theory, the reduction in the birth rate is an outcome of
industrialization and modernization. However, in rapidly growing population, it is not
possible to wait for industrialization and modernization to bring about reduction in
fertility. Many developing countries have, therefore, adopted family planning
programmes directly to influence fertility negatively. Therefore, it is difficult to trust
that the Demographic Transition Theory is also applicable to developing countries like
Nepal and that what happened in West, in respect to population growth, would be
duplicated in developing countries.
AND HEALTH SURVEY
(NDHS) & ITS MAJOR
Population censuses have been carried out in Nepal since 1911 at
decennial intervals. However, detailed information about the size and
structure of the population was provided only since the 1952/54 census.
The 2011 Nepal Demographic and Health Survey (NDHS) is the fourth
nationally representative comprehensive survey conducted as part of the
worldwide Demographic and Health Surveys (DHS) project in the country.
It was conducted under the aegis of the Ministry of Health and Population
The survey was implemented by New ERA, a private research firm in
Nepal. ICF Macro provided technical assistance through its MEASURE DHS
project. Funding for the survey came from the United States Agency for
International Development (USAID).
Long-term objective of the survey is to strengthen the technical capacity
of local organizations to plan, conduct, process, and analyze data from
complex national population and health surveys in Nepal.
• Samples were selected independently in every stratum, through a
two-stage selection process. In the first stage, Enumeration Areas
(EAs) were selected using a probability proportional-to-size. In
order to achieve the target sample size in each domain, the ratio of
urban EAs over rural EAs in each domain was roughly 1 to
2, resulting in 93 urban and 196 rural EAs, for a total of 289 EAs.
• A complete household listing and mapping was carried out in all
selected clusters. In the second stage, 35 households in each urban
EA and 40 households in each rural EA were randomly selected. The
2011 NDHS collected demographic and health information from a
nationally representative sample of 10,826 households, which
yielded completed interviews with 12,674 women age 15-49 in all
selected households and with 4,121 men age 15-49 in every second
Here, is Comparison of selected Demographic Indicators:
LIFE EXPECTANCY :
The Kathmandu district has the highest population density (4,408) and
Manang (3) the lowest.
The decennial population growth has been highest in Kathmandu (61
percent) and lowest in Manang (-31 percent) .
Currently, 4.5 million people (17 percent) reside in urban areas.
The largest percentage of the population is in the Central development
region (36 percent) and the smallest in the Far-western region (10 percent).
The sex ratio (number of males per 100 females) is estimated at 94.4 in the
current census, as compared to 99.8 in the previous census in 2001.
Average household size has decreased in 2011 (i.e. 4.7) as compared to 2001
According to the results of the 2011 NDHS, the Total Fertility Rate(TFR) calculated for the
three years preceding the survey is 2.6 births per woman age 15-49. The other fertility
indicators are as shown below according to NDHS,2011.
Trends in TFR
Age Specific Fertility Rate (ASFR)
5 * (min)
Family planning use has remained essentially the same since 2006. Use of
female sterilization has dropped slightly, from 18% in 2006 to 15.2% in 2011,
while male sterilization has increased, from 6.3% in 2006 to 7.8% in 2011.
One in two currently married women is using a method of contraception,
with most women using a modern method (43.2 percent).
Use of traditional methods has also increased, from 4% in 2006 to 7% in
2011, mostly due to an increase in the use of withdrawal.
The 2011 NDHS also reveals that 27% of married women have an unmet
need for family planning – 10% for birth spacing and 17% for limiting.
INFANT AND CHILD MORTALITY
Neonatal mortality (NN): the probability of dying within the first month of life.
Post-neonatal mortality (PNN): the difference between infant and neonatal
Infant mortality (1q0): the probability of dying between birth and the first birthday.
Child mortality (4q1): the probability of dying between exact ages one and five.
Under-five mortality (5q0): the probability of dying between birth and the fifth
Rates of childhood mortality are expressed as deaths per 1,000 live births, except
in the case of child mortality, which is expressed as deaths per 1,000 children
surviving to age one.
• Neonatal Mortality Rate (NMR/1000 live births)
• Post-Neonatal Mortality Rate (PNMR/1000 live births)
• Infant Mortality Rate (IMR/1000 live births)
• Child Mortality Rate (CMR/1000 children surviving to
• Under 5 Mortality Rate( U5 MR/1000 live births)
• Perinatal Mortality Rate (PMR/1000 live births)
* Perinatal Mortality rate: death of child from 28 weeks of gestation to 7th day
• Antenatal Care (ANC)
% ANC by skilled providers
(Doctors, nurses, and midwife)
% of ANC by Trained Health
ANC 1st Coverage
ANC 4th Coverage
• Tetanus Toxoid (TT) vaccination coverage
TT 2+ coverage
Delivery in Health
Delivery assisted by
Delivery assisted by
• Site of Delivery
• Postnatal Care (PNC) Coverage
Women receiving PNC
PNC within 4 hours of
1 in 5 women
1 in 3 women
PNC within 4-23 hours of
PNC within 1-2 days
• Overall Immunization among children(12-23 months)
•Coverage of individual vaccine among children(12-23 months)
didn’t receive any
• Malnutrition among Women
Anemia among 6-59
Anemia among women of
• Breast Feeding
Duration of BF
Mean duration of
• Mistakes made in implementing data collection and data processing, such
as failure to locate and interview the correct household, misunderstanding
of the questions on the part of either the interviewer or the respondent,
and data entry errors result in the non-sampling errors in NDHS.
• Also the data collected through questionnaires, debriefing are not very
• Moreover, it doesn’t use analytical statistical methods to ascertain the
significance of change and causative association between variables.
• However, information provided in this report will help to assess the
current health- and population-related policies and programs. It will also
be useful in planning, implementing, re-focusing, monitoring, and
evaluating health programs related to these issues in Nepal.
Nepal Demographic and Health Survey (NDHS) report
2001,2006 and 2011
Population and studies :Challenges and Opportunities-J.C.
Demographic Transition Theory-DUDLEY KIRKT
Principles of Population Studies- Asha A. Bhende and Tara
Kanitkar (21st Edition)
Park’s Textbook of Preventive and Social Medicine(21st