To Reduce Births Think About Death: What Fertility Transition Has to Do with Child Mortality
The debate about global health is framed in terms of where money is best channeled to decrease the burden of disease. One of the criteria is what disease offers the best bang for the buck for the money invested. Neglected tropical diseases top this list because fairly cheap interventions are easily available whereas HIV scores low as ARV treatment is expensive and requires life-long support. Following this line of reasoning diseases are pitted against one another so that one can be prioritized. This line of thought has the merit of making the use of the available (scarce) resources more efficient. It has pitfalls too though: it runs the risk of concealing the positive spillovers that tackling one disease can have on another one. The reduction of fertility rates is one example.
When one thinks at ways of reducing the number of births per woman the first thing coming to mind is how to make family planning methods more accessible and socially acceptable for women. Then one would consider that the ability of women to decide when and how many children to have depends on their decisional power within the household and in the society. Education and jobs outside the household, therefore, have a large positive impact on reducing the number of babies per woman. There is, however, another phenomenon which is the underlying driver of fertility rates yet it is often forgotten. And this has to do with the furthest thing from birth: death.
Mortality and fertility: trends across countries. If one looks at relationship between the number of babies per women and child mortality (0-5 years old dying per 1,000 born) across countries (you can build your own map on gapminder.org), one would see a striking and clear trend: as one variable decreases so does the other. This relationship also holds true across time as every country in the world reduces fertility and child mortality rates almost coincidentally. If one asks why Niger has been less successful in reducing fertility rates as compared to Indonesia the answer is that Niger was not able to cut child mortality rates as fast as Indonesia did (this is the point that Hans Rosling makes in his new TED talk). So first thing one ought to keep in mind is that without mortality decline, fertility decline is highly unlikely.
Demographic Transition: mortality drops first. Skeptics could argue that it works the other way around: it is fertility decline which leads to reduction in mortality. If mothers have a large number of babies and if the births are not spaced between each other then it is more likely that both maternal and child mortality remain high. This claim is very persuasive but is not supported by the available evidence: if one looks at the gapminder map one can observe that almost every country experiences a drop in mortality which is accompanied, with a time lag, by a slower drop in fertility rates. If one is not convinced by such data then one could think about another fact: countries which have gone through the demographic transition have experience an increase in population growth rates as compared to pre transitional period. In other words during the demographic transition the population grows much quicker that it did before: this implies that mortality decline occurred before at least a portion of the fertility decline.
From mortality to fertility: how and when does it happen? As the likelihood of a newborn to survive increases, the size of the family swells: this creates an economic stress that the family cannot bear. This is a social phenomenon observed almost everywhere in the world. As a reaction parents act to reduce the family size. One of these reactions is to send children to work in other families or to migrate in urban settings. These strategies are (or were) easily available and they are more socially acceptable than limiting births. This is one of the reasons why fertility rates drop only after child mortality rates. The other reason has to do with psychology and perception. To notice that the chance of every child’s survival are improved takes time. Plus mortality declines for reasons that are beyond the control of mothers: this delays parents’ acknowledgement that the odd of their children to survive have improved. Hence, parents hang on a while before they think about reducing the number of births.
Child mortality plays a big role in tipping people into reducing the number of babies. Yet this fact is often ignored. For example, the United Nations Population Fund Agency (UNFPA), states that its goal is “to ensure an affordable and reliable access to contraceptives to women who would like to avoid or delay a pregnancy”. What it fails to mention is that mortality comes first. To keep the big picture in mind it is necessary that fertility rates consistently decline worldwide.