63070 Experiences with Fertility Reduction in Five High-Fertility Countries Synthesis of Case Studies The World Bank May 2010 Experiences with Fertility Reduction in Five High-Fertility Countries Synthesis of Case Studies May 2010 iii Contents Acknowledgements iv Why this Study? 1 Large Fertility Declines in Five Countries 2 Strategies that Have Worked 5 1. Ensure Access to Quality Family Planning Services 5 2. Strengthen Health Systems 6 3. Promote Demand for Family Planning Services 7 4. Create an Enabling Environment 9 How Can We Use this Information? 10 Some Limitations of the Approach 12 Annex 1. Criteria for the Selection of Countries for Case Studies 13 Tables Table 1. Countries with Total Fertility Rate of 6.0 and above in 1980 14 Figures Figure 1. Total Fertility Rates, in Five Countries, 1980–2006 2 Boxes Box 1. A Winning Strategy in Nepal 6 Box 2. Contraceptive Use in Iran: a Mix of Methods 7 Box 3. Thailand’s Winning Strategies 8 iv Acknowledgements T his report was prepared by Shreelata Rao Action International), Daniel Kraushaar (Bill Seshadri of the Health, Nutrition and and Melinda Gates Foundation), Gilda Sedgh Population unit of the South Asia region (Guttmacher Institute), Amy Tsui (Johns Hop- at the World Bank (SASHN), Sadia Chowd- kins University, Bloomberg School of Public hury of the Health, Nutrition, and Population Health), and Wasim Zaman (International unit of the Human Development Network Council on Management of Population Pro- (HDNHE), Naoko Ohno (SASHN), and Pia grammes). The World Bank advisory group Axemo (HDNHE). comprised: Martha Ainsworth (IEGWB), Peter This synthesis paper is based on case Berman (HDNHE), Eduard Bos (HDNHE), studies prepared by the following lead authors: Rodolfo Bulatao (HDNHE), Hugo Diaz Robbyn Lewis (Algeria), Samuel Mills (Bo- Etchevere (HDNVP), Rama Lakshminaray- tswana), Seemeen Saadat (Iran), Usha Vatsia anan (HDNHE), John May (AFTHE), Eliz- (Nicaragua), and Naoko Ohno (Pakistan). The abeth Lule (AFTQK), and Thomas Merrick authors are grateful to the World Bank Library (WBIHS). Research Services for assisting with the litera- Bruce Ross-Larson, Communications De- ture search. Mukesh Chawla, Sector Manager velopment Incorporated, edited the draft re- (HDNHE), and Julian Schweitzer, Sector Di- port and Samuel Mills (HDNHE) reviewed rector (HDNHE), provided overall guidance the final draft. The authors would like to and support. Thanks to Victoriano Arias for thank the government of the Netherlands, providing administrative support. which provided financial support through the This case study was part of a larger World World Bank-Netherlands Partnership Program Bank Economic and Sector Work entitled Ad- (BNPP). dressing the Neglected MDG: World Bank Re- view of Population and High Fertility with an Correspondence Details: external advisory group comprising: Stan Bern- stein (United Nations Population Fund), John Æ Sadia Chowdhury (HDNHE), World Bongaarts (Population Council), John Cast- Bank, Mail Stop G7–701, 1818 H Street erline (Ohio State University), Barbara Crane N.W., Washington, DC 20433, USA, Tel: (IPAS), Adrienne Germain (International 202-458-1984, email: schowdhury3@ Women›s Health Coalition), Jean Pierre Guen- worldbank.org gant (L’Institut de recherché pour le dével- Æ This report is available on the following oppement), Jose Guzman (United Nations website: http://www.worldbank.org/ Population Fund), Karen Hardee (Population hnppublications. Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 1 Why this Study? C ountries with high levels of fertility lag AIDS, tuberculosis, and malaria programs; behind others in development indica- and the complacency that set in as fertility tors and in progress toward the Mil- rates dropped in several developing countries. lennium Development Goals. While several Not until October 2007 was reproductive developing countries have lowered fertility health added to the Millennium Development rates over the last three decades, huge chal- Goal targets. lenges remain. The family planning needs of This shift in focus prompted the Popu- some 137 million married women in devel- lation and Reproductive Health Team in the oping countries are still unmet. About a third Health unit of the Human Development Net- of the approximately 205 million pregnancies work (HDNHE) to undertake a study to each year are unintended, and half of induced better understand how some high-fertility abortions performed globally are unsafe. Some countries managed to dramatically reduce fer- 28 countries, mainly in Sub-Saharan Africa, tility and to draw lessons from their experi- have a total fertility rate greater than 5, and ence. Broad reviews of the literature on fertility the decline in fertility rates has been very slow decline and lessons learned already exist, such or has stalled. In most countries, national av- as the World Bank (2007) report “The Global erages mask substantial differences in fertility Family Planning Revolution: Three Decades of levels between the well-off and the poor, high- Population Policies and Programs” documenting lighting equity concerns. lessons from family planning in 23 countries. Over the past decade, the focus has shifted The objective of this study is not to repeat from core population and fertility issues in re- those discussions and findings but rather to sponse to several factors. Chief among them provide evidence-based, relevant, and practical have been a broader human rights perspective information on population/family planning is- following the 1994 International Conference sues to stimulate policy dialogue with client on Population and Development; competing countries and influence World Bank lending in demands for resources and attention for HIV/ countries that still have high fertility rates. 2 Large Fertility Declines in Five Countries F ive countries (Algeria, Botswana, Iran, By 2006, Algeria’s annual population Nicaragua, and Pakistan) that succeeded growth rate had fallen by half, to just 1.47 in reducing high fertility rates, during percent, and its total fertility rate had fallen 1980–2006, were chosen for detailed case 40 percent, to 2.4. The contraceptive preva- studies documenting their varied histories in lence rate was 61.4 percent, with a majority fertility reduction (Annex 1). These countries of women using the pill and half of them in- have all had impressive declines in fertility (see dicating that they wanted no more children. figure 1), if mixed performance on the Millen- The transition began in 1965–70, coinciding nium Development Goals overall. with the greater availability of modern con- traceptive methods and the transformation of Algeria is the most populous country in the key reproductive behaviors, including higher Maghreb, with some 33.8 million inhabitants. age at first marriage. Rising rates of female The crude birth rate accelerated from 35 per education also contributed; nearly all Alge- 1,000 population per year in 1911–15 to 48.5 rian girls are enrolled in primary school, and by 1961–65. Between 1966 and 1987, the more than 80 percent complete their primary population grew more than 3 percent a year. education. In 1980, the total fertility rate was 6.76. Figure 1 | Total Fertility Rates, in Five Countries, 1980–2006 8 7 No. of children per woman 6 5 4 3 2 1 0 1980 1982 1985 1987 1990 1992 1995 1997 2000 2002 2005 2006 Algeria Botswana Iran, Islamic Rep. Nicaragua Pakistan Source: Online World Development Indicators. Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 3 Botswana is one of the few upper middle- placement levels. The contraceptive prevalence income countries in Sub-Saharan Africa. rate rose steadily to an estimated 74 percent While population rose more than 2.5-fold in 2000 (77 percent in urban areas and 67per- after 1971, the rate of population growth has cent in rural areas). slowed considerably since the 1980s, following critical actions by the government in reorga- Nicaragua, a largely urban country (56 per- nizing the health system and providing effec- cent of the population lives in urban areas), tive family planning services. is one of the least populous (5.53 million) The impacts of the government’s efforts and poorest countries in Central America. have been substantial: the total fertility rate Following reforms in the 1980s, Nicaragua fell more than half between 1971 and 2001, made remarkable progress in gender equity knowledge of contraceptive methods increased in education and the labor force, while the dramatically to 97 percent in 1996, and use of wide availability of primary health care, in- modern contraceptive methods rose to about cluding family planning services, led to im- 51 percent in 2007. provements in infant and child mortality rates. Iran, with a population of just over 70 mil- The total fertility rate fell dramatically lion in 2006, is one of the most populous between 1980 and 2007, dropping 22 per- countries in the Middle East. After the revo- cent during the 1980s, 31 percent in the lution in 1979, the government focused on 1990s, and 17 percent during 2000–07, three priority areas: reduction of disparities in for a total decline of 55 percent. The fer- food, health, and education. The Constitu- tility rate is lower for urban women than for tion entitles Iranians to basic health care, and rural women, though the reduction has been the country has an extensive primary health greater since 1998 in rural areas (30 percent) care system. Considerable progress has been than in urban areas (24 percent). Fertility made in reducing infant and child mortality. rates have dropped for all age groups, but es- Comprehensive family planning services were pecially for young women ages 20–24. Ni- incorporated into the health care delivery caragua’s contraceptive prevalence rate rose system in 1989. Young couples are required dramatically as well, from 27 percent in 1981 by law to take family planning counseling to 72 percent in 2007 among women ages classes before they can obtain a marriage li- 15–49. cense. The fertility decline in Iran began in the Pakistan is the world’s sixth most populous late 1980s and continued throughout the country and has the second largest Muslim 1990s. Following the war with Iraq, the gov- population after Indonesia. Since indepen- ernment of Iran reintroduced family planning dence in 1947, Pakistan’s turbulent political programs, largely in response to resource limi- situation has frequently disrupted govern- tations and the impending youth bulge. Ac- ment development policies. Health status cording to the most recent census of 2006, has improved since 1990, but the pace of the total fertility rate now stands at below re- improvement has been slow and perfor- 4 mance lags behind other South Asian coun- 1990s, the fertility rate started to decline rap- tries. Large gender disparities persist in idly until 2000, when the decline seems to education and health status, as well as in ac- have slowed. Estimates of the current total fer- cess to education, health, employment, as- tility rate vary from 3.8 to 4.1, roughly a 40 sets, and justice. percent decline since the 1980s. Contraceptive The total fertility rate in Pakistan stood prevalence also rose, from 12 percent in 1990 at an estimated 6.8 from the 1960s to the to 30 percent in 2006. late1980s. Then, in the late 1980s to early Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 5 Strategies that Have Worked So how did these countries succeed in re- areas, have made family planning services ducing fertility so dramatically? The case widely available. studies reveal some common themes: Æ In Iran, the government set up an exten- sive primary health care network, with 1. Ensure Access to Quality Family “health houses” serving a central village Planning Services and several surrounding villages in rural Make family planning and maternal and areas and “health centers” in urban areas. child health services readily available. Bo- In 1991, Iran had nearly 12,000 health tswana, Iran and Algeria, countries that sub- houses and 4,000 health centers, and 75 stantially reduced fertility, had a widespread percent of the rural population had cov- network of service outlets that integrated erage. By 2002, 95 percent of the rural family planning services with an existing population had coverage. When the gov- government-funded primary health care net- ernment decided to offer family planning work. The integrated approach ensures that services, this public health network was primary care doctors and other professionals pressed into service. provide family planning counseling and ser- Æ In Algeria, where family planning was vices as part of their core services, even to controversial and government commit- people who come to the health care system ment was weak, the government increased for unrelated health needs. access by establishing “birth spacing” cen- ters, which were more politically and cul- Æ In Botswana, the government integrated turally acceptable than family planning services for family planning and maternal centers. and child health and sexually transmitted infections from the outset in 1973. When Provide outreach services to complement women visit health facilities for maternal static services. In many regions, geographic and child health services (antenatal care, and sociocultural barriers, such as difficult postnatal care, immunizations) and sexu- terrain and cultural taboos against women ally transmitted infections, they are also traveling alone, reduce access to family plan- offered family planning services. With the ning services. In such cases, trained outreach advent of the HIV epidemic in the 1990s, workers can increase women’s access to family HIV/AIDS services were also integrated. planning services. These integrated services, offered daily through a vast network of primary health Æ In Pakistan, when services provided in care facilities in both rural and urban fixed facilities were found to be under- 6 of Health, which distributes family plan- Box 1 | A Winning Strategy in Nepal ning supplies through departmental and Following an expansion of the family planning regional health offices and facilities, is the program in Nepal, the wide availability of a range of contraceptive methods, free of cost, main source of free modern family plan- led to an increase in contraceptive use among ning methods. The private sector and ever-married women—from 29 percent in 1996 NGOs supply condoms procured inter- to 48 percent in 2006. More than 90 percent of these women and their husbands used modern nationally and repackaged for sale at low methods, including sterilization, injectables, oral cost locally. They operate their own clinics contraceptives, condoms, and IUDs. The propor- tion of contraceptive users practicing child spac- and network of agents for distributing ing methods rose from 30 percent in 1996 to 41 contraceptives. percent in 2006. Æ In Pakistan, private sector involvement started in the 1980s, with a U.S. Agency for International Development–sup- utilized because of geographic and socio- ported condom social marketing cam- cultural constraints (women had to be paign. Greenstar provides 30 percent of accompanied by a male family member modern contraceptives used in Pakistan, when going outside the home), the govern- the second largest family planning service ment introduced the Lady Health Worker provider after the government. Program. The program delivered family planning services to women in their homes, 2. Strengthen Health Systems boosting use of family planning services. Focus on improved quality of care. Inte- Æ In Botswana, services at fixed facilities are grating family planning with all other health complemented by outreach services using programs boosts commitment to family plan- mobile units and home visits to reach ning—it becomes the responsibility of the people who do not use the fixed services. entire health ministry, rather than a separate (vertical) program. Strengthening the man- Make a wide range of contraceptive agement and quality of care of the health methods available. An extensive and efficient ministry, through training and stringent mon- contraceptive logistics and distribution system itoring, positively affects such factors related that coordinates activities of the government, to family planning as infant mortality and international donors, the private sector, and child survival, reducing the desire for addi- nongovernmental organizations (NGOs) tional children. can bridge gaps in the delivery system. Some countries have used innovative programs such Æ Botswana has taken the most systematic as social marketing of condoms to increase ac- approach to strengthening health system cess to contraceptives and services by drawing capacity and quality of care. The Min- in private sector providers. istry of Health embarked on an intensive training program for health personnel, Æ In Nicaragua, contraceptives are avail- nursing students, and tutors. Addition- able from multiple sources. The Ministry ally, several family welfare educators were Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 7 Box 2 | Contraceptive Use in Iran: a Mix of Methods Modern methods were introduced in Iran in the 1960s, when the government allowed imports of oral contraceptives. Early efforts focused mainly on providing oral contraceptives, which may have slowed the program’s growth. Traditional contraceptive methods had been used in Iran for centuries and may also have contributed to fertility decline in the 1970s, especially in urban areas. However, as early as 1989, data show a growing preference for modern contraceptive methods, which have steadily replaced traditional methods (see figures). Contraceptive Prevalence in Iran, 1989–2000 Urban contraceptive prevalence Rural contraceptive prevalence 6 8 prevalence rate (%) prevalence rate (%) 5 Contraceptive Contraceptive 6 4 3 4 2 2 1 0 0 1989 1992 1996 2000 1989 1992 1996 2000 Modern Traditional Modern Traditional While oral contraceptives remain the most popular contraceptive method, female sterilization has gained steady acceptance and popularity, especially among women ages 33–34 from more religiously conserva- tive provinces and with an average of five children. These women appear to use sterilization as a last resort when they have achieved their desired family size. Still unclear is whether these women had used any other form of contraceptive before sterilization. Source: Abbasi-Shavazi 1998; Mehryar 2001; World Bank 2007. trained for home visits and community Æ Guide service delivery approaches and de- outreach activities at mobile stops. These sign programs with a greater likelihood of measures contributed to improved child success. survival: infant mortality rates fell dra- Æ Motivate program managers to higher matically, from 97.1 deaths per 1,000 live levels of performance by sharing informa- births in 1971 to 37.4 in 1998, contrib- tion with them on strategies and interven- uting to the transition from high to low tions that have worked elsewhere. fertility. Æ Introduce mid-course corrections in pro- gram implementation. Collect and use health sector data regularly. Effective use of information can have an enor- 3. Promote Demand for Family mous impact. Information has been used to: Planning Services Bring about behavior change. Effective and Æ Raise awareness of the need for family extensive information campaigns, both through planning and focus political and technical interpersonal communication and mass media, attention on the issue. can greatly increase awareness of contraceptive 8 Box 3 | Thailand’s Winning Strategies Thailand reduced fertility dramatically, from 5.5 births per woman in 1970 to 1.8 births per woman in 2007. How? By building a strong national program. The Thai program was established early and, along with other health programs, performed strongly. Capacity building of the health system was a priority. Improvements in a range of health indicators showed that the health system was capable of delivering services effectively. By giving people a choice. The Thai family planning program is noted for providing a wide array of contra- ceptive methods, either free of cost or highly subsidized. By rapidly building up services in rural areas. Family planning services tend to take off well in urban areas, but usually falter in rural settings. Thailand addressed this problem by using an established grassroots network to distribute modern contraceptives. Paramedical personnel were used to distribute oral contracep- tives in rural areas. By building on cultural values to reinforce change. Paramedics not only supplied the contraceptives, but also disseminated information on the need for family planning and the availability of different family plan- ning methods. This legitimized people’s concerns about having a large number of children and reinforced their desire for small families. methods. Information campaigns for health they disseminated information on con- and family planning programs can be inte- traception. grated, to make the most of limited budgets. Promote prolonged breastfeeding. Pro- Æ In Botswana, the Condom Social Mar- longed breastfeeding can help to reduce the keting program generated demand for number of children and increase child spacing. condoms for dual protection against HIV and pregnancy. Æ In Botswana, cultural norms supporting Æ In Iran, family planning counseling classes prolonged breastfeeding and postpartum are a prerequisite for obtaining a marriage abstinence might have contributed to the license. The classes inform couples of their fertility decline. The 2000 Multiple Indi- family planning choices, encourage birth cator Survey reported that more than half spacing, and provide samples of accepted of children ages 12–15 months were still contraceptives. In addition, compulsory being breastfed. In addition, the 1988 Bo- population education is included in school tswana Family Health Survey found that and university curricula. half of women abstained from sex in the Æ In Nicaragua, a literacy brigade of first year after delivery, and nearly half 100,000 young people went into rural had not resumed menstruation one year areas to teach elementary health princi- postpartum. The prolonged breastfeeding ples. Along with health education—on coupled with postpartum abstinence has sanitation, vaccination, and nutrition— contributed to longer birth intervals. Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 9 4. Create an Enabling Environment vices. Educated women are more able to make Support governments and other stake- independent choices about delaying mar- holders in providing consistent support for riage and childbirth, limiting family size, and family planning. Government backing for adopting contraception. Educated women are family planning needs to be maintained over a also better able to negotiate with their spouses, long period to affect fertility rates strongly and even in highly patriarchal societies. lastingly. This requires steady, strategic gov- ernment and donor support to sustain family Æ In Iran, the government reintroduced planning services. Almost all the programs adult literacy programs as part of its ef- studied had 20 or more years of consistent forts to educate people about family plan- support; where support was not consistent and ning. The main beneficiaries were rural long standing (as in Pakistan), the impact on women. Although the relationship be- outcomes has been weakened. It is possible tween female education and fertility is to provide steady support to family planning complex, it is clear that empowerment in- even where there is religious opposition. creases women’s sense of control over their bodies and their lives. Æ In Algeria, the government was able Æ In Algeria, fertility declined despite the to win the broad support of religious government’s ambivalence toward the leaders through a process of consulta- family planning program, largely be- tion. Algeria’s experience challenges the cause of broad gains in female educa- widely held belief that Islam inhibits fer- tion. The median age at first marriage tility reduction. Fertility declined in Al- and first childbirth also rises with wom- geria and women’s age at marriage rose en’s education, another important con- during the 1990s, at the height of the Is- tributor to reducing fertility. And by lamist movement. enabling more Algerian women to enter the labor force, gains in women’s edu- Support government efforts to enact laws cation further contributed to lower fer- increasing age at marriage and empow- tility: the 1970 national fertility survey ering women. All the case studies demon- (ENSP) found that employed urban strate the impact of women’s empowerment women had fewer children. on increased demand for family planning ser- 10 How Can We Use this Information? S ome common strategies, applicable in fertility reduction. The World Bank, in varied sociopolitical settings, underlie its programs in high-fertility countries, the large fertility reductions in the case can encourage a multisectoral approach study countries. Some of the strategies re- that promotes synergies across programs late to macroeconomic policies and programs influencing fertility decisions, including (overall economic development, increased op- education and poverty reduction. Main- portunities for employment). Others call for streaming the population and reproduc- intersectoral coordination (women’s empower- tive health agenda into the core strategies ment through education and labor force par- of both the Bank’s Human Development ticipation). and Poverty Reduction and Economic Management Networks could promote Æ Dialogue with governments. There is such a holistic approach. strong evidence that sustained govern- Æ Encouraging health systems reforms. ment commitment to family planning These case studies provide a good basis programming is positively related to sig- for promoting health systems reform nificant declines in fertility. This evidence in several areas: integrating and main- could be used to prompt commitment streaming family planning services into from senior levels of government. the primary health care network rather Æ Advocacy. Even conservative countries than treating them as a separate pro- have been able to gain support for contra- gram; promoting synergies within the ception and family planning among re- health sector, for example, by encour- ligious leaders and other opponents by aging condom use as a priority for both using economic and other data (for ex- family planning and HIV/AIDS and ample, on high levels of youth unemploy- other sexually transmitted illness control ment and poor prospects for employment programs; improving the quality of care growth). Governments can often persuade and service delivery for all services, which religious leaders to support birth spacing can improve maternal and child health efforts, if not a full family planning pro- outcomes overall; and focusing on moni- gram. toring and supervision to maintain close Æ Promoting intersectoral coordination. oversight and strengthen management of Evidence shows that supporting invest- health programs. ment in women’s empowerment through Æ Promoting opportunities for public– female education and greater labor force private partnerships. Using as wide a participation can contribute directly to network as possible to distribute and pro- Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 11 mote modern contraceptive products in- vate sector in primary health care and creases access and thus the likelihood of family planning services can increase ac- their adoption. Partnering with the pri- cess in underserved rural areas. 12 Some Limitations of the Approach T he study has identified policies, interven- not covered in the literature. Finally, this study tions, and environments that may have relied primarily on English-language sources been associated with substantial fertility and likely missed important work available reduction in the selected case study countries. only in national languages. No attempt was made to attribute causality between interventions and fertility reduction. Second, the study is a desk review of the lit- Full case studies and references erature; no new research was conducted. Thus, are available at the HNP web- it is possible that some determinants of fer- site: http://www.worldbank. tility reduction were missed because they were org/hnppublications. Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 13 Annex 1. Criteria for the Selection of Countries for Case Studies T he cases studies covered 5 countries that tries which have experienced “signifi- have demonstrated significant total fer- cant” fertility reduction (defined as 40% tility reduction during 1980–2006 com- or more during 1980–2006) were further pared with other countries in the respective chosen. region. The following criteria were established Æ Medium to large scale countries. Con- to select 5 countries globally: sidering the applicability of good exam- ples to other countries with continuing Æ High total fertility rate as of 1980. Total high fertility, countries with popula- fertility rate trend data from 1980 to 2006 tion size with less than 1 million were (the latest year with available data for most excluded. Accordingly, five countries— countries) in the World Development In- Bhutan, Maldives, Cape Verde, Comoros, dicators database was used to initially se- and Solomon Islands—were excluded lect high fertility countries as of 1980 from the list of 22 countries. (defined in this instance as total fertility Æ Preliminary review of the literature. Of rate more than 6.0). As a result, 61 coun- the remaining 17 countries, preliminary tries were initially selected. The reference review of the literature was conducted to point of year 1980 seems appropriate, as obtain a general idea of (a) what factors/ many countries adopted population/family interventions have been discussed in the planning policies and started implemen- literature and (b) whether the amount and tation of these policies through the 1980s quality of information for the country is and beyond after the World Population sufficient to conduct an in-depth country Conference in Bucharest in 1974. case study. This brought the number Æ Significant fertility reduction during down to the 5 countries finally selected: 1980–2006. Of the 61 countries with Algeria, Botswana, Iran, Nicaragua and high total fertility rate in 1980, 22 coun- Pakistan. 14 Table 1 | Countries with Total Fertility Rate of 6.0 and above in 1980 Absolute reduction Difference in TFR (%) between ‘80 between ‘80 Population Country Name Region1 1980 2006 and ‘06 and ‘06 size (2006) Iran, Islamic Republic MENA 6.58 2.06 4.52 69% 70,097,913 Algeria MENA 6.76 2.41 4.35 64% 33,351,137 Bhutan EAP 6.52 2.34 4.19 64% 648,766 Libya MENA 7.26 2.79 4.47 62% 6,038,643 Maldives SAR 6.88 2.67 4.21 61% 300,292 Syrian Arab Republic MENA 7.30 3.16 4.14 57% 19,407,558 Oman MENA 7.20 3.14 4.06 56% 2,546,325 Jordan MENA 7.01 3.21 3.80 54% 5,537,600 Nicaragua LAC 6.05 2.80 3.25 54% 5,532,364 Saudi Arabia MENA 7.14 3.44 3.70 52% 23,678,849 Botswana AFR 6.13 2.95 3.17 52% 1,858,163 Namibia AFR 6.51 3.27 3.24 50% 2,046,555 Lao PDR EAP 6.41 3.29 3.12 49% 5,759,402 Cape Verde AFR 6.57 3.45 3.12 48% 518,562 Honduras LAC 6.24 3.39 2.85 46% 6,968,687 Zimbabwe AFR 6.96 3.80 3.16 45% 13,228,191 Comoros AFR 7.20 4.03 3.17 44% 613,606 Pakistan SAR 7.00 3.92 3.08 44% 159,002,039 Swaziland AFR 6.22 3.54 2.68 43% 1,137,915 Solomon Islands EAP 6.68 3.96 2.71 41% 484,022 Haiti LAC 6.05 3.64 2.41 40% 9,445,947 Ghana AFR 6.56 3.95 2.61 40% 23,008,443 Djibouti MENA 6.68 4.06 2.62 39% Micronesia, Fed. Sts. EAP 6.16 3.81 2.35 38% Cote d’Ivoire AFR 7.41 4.58 2.83 38% Sao Tome and Principe AFR 6.34 3.95 2.39 38% Yemen, Republic MENA 8.70 5.61 3.09 36% Kenya AFR 7.36 4.97 2.39 33% Sudan AFR 6.41 4.35 2.06 32% Guatemala LAC 6.14 4.24 1.90 31% Cameroon AFR 6.40 4.43 1.97 31% Rwanda AFR 8.50 5.94 2.56 30% Togo AFR 6.98 4.91 2.07 30% Mauritania AFR 6.28 4.46 1.81 29% (continued on next page) Experiences with Fertility Reduction in Five High-Fertility Countries | Synthesis of Case Studies 15 Table 1 | Countries with Total Fertility Rate of 6.0 and above in 1980 (continued) Absolute reduction Difference in TFR (%) between ‘80 between ‘80 Population Country Name Region1 1980 2006 and ‘06 and ‘06 size (2006) Gambia, The AFR 6.52 4.79 1.73 27% Zambia AFR 7.12 5.27 1.85 26% Congo, Republic AFR 6.11 4.55 1.56 26% Madagascar AFR 6.48 4.88 1.60 25% Malawi AFR 7.53 5.68 1.85 25% Senegal AFR 7.00 5.30 1.70 24% Benin AFR 7.12 5.51 1.62 23% Ethiopia AFR 6.82 5.33 1.50 22% Nigeria AFR 6.90 5.43 1.47 21% Burkina Faso AFR 7.71 6.08 1.63 21% Guinea AFR 7.00 5.52 1.48 21% Eritrea AFR 6.50 5.14 1.36 21% Tanzania AFR 6.62 5.26 1.36 21% Mozambique AFR 6.48 5.19 1.28 20% Somalia AFR 7.22 6.12 1.10 15% Niger AFR 8.11 7.00 1.11 14% Mali AFR 7.56 6.55 1.00 13% Angola AFR 7.20 6.50 0.70 10% Chad AFR 6.75 6.26 0.48 7% Uganda AFR 7.10 6.70 0.40 6% Congo, Dem. Rep. AFR 6.66 6.30 0.36 5% Liberia AFR 6.90 6.78 0.12 2% Sierra Leone AFR 6.50 6.48 0.02 0% Guinea-Bissau AFR 7.10 7.08 0.02 0% Burundi AFR 6.80 6.80 0.00 0% Afghanistan* SAR 7.76 — — — Iraq* MENA 6.53 — — — Source: World Development Indicators. 1 AFR= Africa; EAP= East Asia and Pacific; LAC= Latin America and Caribbean; MENA = Middle East and North Africa; SAR= South Asia. Note*: The recent TFR data for Afghanistan and Iraq is not available in the World Development Indicators; the latest data for Afghanistan is 1987 (7.9 per woman) and 1997 for Iraq (5.37 per woman). THE WORLD BANK 1818 H Street, N.W. Washington, DC 20433