Factors Behind Recent Fertility Plateauing in Jordan

&Challenges to Maintaining Future Fertility

Decline

byIssa Almasarweh

Professor – Jordan University

Presentation Outlines

1) Jordan Fertility Trends

2) Jordan Fertility Goals

3) Factors Affecting Fertility Rates

4) Challenges to Sustained Decline in Jordan Fertility

Current TFR in the Region

3.8

3.3 3.2

2.11.9

2.9

2.2 2.1

3.0

0

1

2

3

4

Jordan Oman Syria Israel Turkey Iran Egypt Morocco Tunisia

Bir

ths

per

wom

an

Source: 2011 PRB WPDSSource: 2011 PRB WPDS

Jordan Fertility Level is Plateauing

5.96.6

6.1

3.83.73.6

0

1

2

3

4

5

6

7

2002 2007 2009

Birt

hs p

er W

oman

Completed

TFR

DHSDHS

Wanted Fertility Increased

3.0

2.6 2.8

0

1

2

3

4

2002 2007 2009

Birt

hs p

er W

oman WTFR

DHSDHS

Early progression to first child

0%

20%

40%

60%

80%

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Months Since Marriage

Hav

e T

hei

r 1s

t C

hil

d

2009 DHS

Fertility – a key component in Jordan future PG

226,000

190,000

140,000

160,000

180,000

200,000

220,000

240,000

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Birth

s

3 million born in the last 20 years

2.3 are expected in the next 10 years

RECENT09 ConstantRECENT09 Constant

Reducing Fertility is a National Priority Goal for Jordan

3.83.5

3.0

2.5

2.1

0

1

2

3

4

2009 2012 2017 2025 2030

Births per couple

RHAP2RHAP2

Direct Factors Affecting Fertility Rate

1) % of women 15-49 married

2) Contraceptive use

3) Postpartum insusceptibility

4) Induced abortion 5) Infertility

Fertility

(1 )Marriage - % of Women 15-49 Ever-married

59

54

57

40

45

50

55

60

2002 2007 2009

DHSDHS

% Ever-married below the age of 30 years

0

15

30

45

60

75

15-19 20-24 25-29

2002 2009

2002 & 2009 DHS

High Growth in Number of First Time Brides )4.3% annually(

10000

20000

30000

40000

50000

60000

2002 2009

http://www.dos.gov.jo/sdb_pop/sdb_pop_a/ehsaat/alsokan/marri_divo/Marriages6.pdf

Early Marriages<18= 14% of total 1st time brides

15-19= 30% of total 1st time brides

0

3000

6000

9000

12000

15000

18000

2002 2003 2008 2009

< 18 15- 19

http://www.dos.gov.jo/sdb_pop/sdb_pop_a/ehsaat/alsokan/marri_divo/Marriages6.pdf

Age Specific Fertility Rates

0

50

100

150

200

250

15-19 20-24 25-29 30-34 35-39 40-44 45-49

2002 2009

2002 & 2009 DHS

Age Specific Fertility Rates - Urban

0

50

100

150

200

250

15-19 20-24 25-29 30-34 35-39 40-44 45-49

2002 2009

2002 & 2009 DHS

(2 )Contraceptive use has leveled off

10

20

30

40

50

60

2002 2007 2009

%

All Methods

Modern

DHSDHS

Modern CPR by Sector -JCLS

0

5

10

15

20

25

%

GOV. NGOs Total

2002 2010

Based on JCLS

Infertility increased = % of women 45-49 who are childless

0

3

6

9

12

15

%

2002 2009

Ever- married Currently married

Based on JCLS

40

5.6

0

10

20

30

40

50

60

70

1990 1997 2002 2007 2009 2017

0.0

1.5

3.0

4.5

6.0

7.5

Con

trac

epti

ve P

reva

lenc

e R

ate

Total F

ertility Rate

65 %65 %

3.03.0

Contraceptive Use needs to increase!

FertilityFertility PlateauingPlateauing

FamPlan: File RECENT09FamPlan: File RECENT09

Summary – Indexes of direct factors affecting fertility

0.0

0.2

0.4

0.6

0.8

1.0

Contraceptive Use Marriage PPI Infertility

2002 2009

Challenges to raise contraceptive use and reduce fertility

1) Shrinking FP Choices / Access

2) Missed / Lost Opportunities

3) Churning – Discontinuation

4) Others

1( Shrinking Choices / Access

Limited access to permanent & long-acting methods : Female Sterilization, Injectables, Implanon

Dominance of one and provider-based method )IUD(

Unmet preference for female providers )87%(

Disappearance of low-price OCs in the commercial sector

Uncertain role of major FP providers )JAFPP, RMS, Universities Hospitals(

2( Missed Opportunities

At premarital exam At time of signing marriage contract At delivery and postnatal period

• low postnatal return• low postnatal counseling• no immediate IUDs insertion after delivery )providers

fear of expulsion or lack training( At child health care visits At Schools and Colleges At youth centers, clubs, camps At Mosques At Workplace At pharmacies

2( Missing Opportunities

Low demand on available services at SDPs

High downtime at SDPs due to lack of appointment system

Exclusion of FP in private health insurance

Exclusion of important groups: men, newly married, unmarried youth

Unfriendly breastfeeding environment at private hospitals

3( Churning – Discontinuation

High FP discontinuation and failure rates

– Quality of services - informed choice )poor treatment of side effects; inadequate and poor FP counseling(

– High use of traditional methods

– Unsatisfied users )20% want another method(

– Son Preference

– Family pressure )63% - 2007 DHS(

1st Year Discontinuation Rate )%(

4245

0

10

20

30

40

50

2002 2009

Reasons for Discontinuation

Method Failure 10 %

To Become Pregnant 9 %

Switched to Modern 10 %

Switched to Traditional 5 %

Stopped Using 8%

42 %42 %

Source: Contraceptive Dynamics Study

Unmet need for FP use

Using59%

Not Using30%

Not using but want no more

children or delay next child

11%

Source : 2009 DHS

TFR and Unmet Need and Discontinuation

3.10

3.80

3.39

0

1

2

3

4

Current 50% Reduction in UnmetNeed

50% Reduction in UnmetNeed and Failure Rate

Birt

hs p

er W

oman

HPC, 2011, Reducing Discontinuation of Contraceptive Use and Unmet Need for FP, policy BriefsHPC, 2011, Reducing Discontinuation of Contraceptive Use and Unmet Need for FP, policy Briefs

4( Other Challenges

Population Momentum – more than one million girl child exists now

• Number of women 15-49 years will increase from 1.6 to 2.0 million by 2020

• The impact of this is shown in the next slide

Projected Contraceptive Users )all methods(

250,000

500,000

750,000

2010 2020

MWRA Growth NPS

Current Users

19 %

FamPlan: Files RECENT09 & RECENT09 ConstantFamPlan: Files RECENT09 & RECENT09 Constant

42 %

4( Other Challenges

Divided civil society- politicalization of issues

Distortion of market forces through subsidies may delay the rationalization of childbearing decision by parents

Abuse of maternity leave by public sector servants