Welcome to the programmatic area on fertility within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. Fertility is one of the subareas found in the family planning section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications.
- Fertility is the natural ability to conceive offspring, and is central to population health. High fertility has profound effects on the health and well-being of women, their families, and communities, as well as on socioeconomic development from national to local levels, on supplies of food and other resources, and on environmental sustainability (UNFPA, 2009).
- The core fertility indicators in this database include higher-level indicators for tracking trends in total fertility and age-specific fertility rates, as well as indicators that influence fertility and the use of family planning and related services.
High fertility has profound effects on the health and well-being of women, their families, and communities, as well as on socioeconomic development from national to local levels, on supplies of food and other resources, and on environmental sustainability (UNFPA, 2009). Fertility above the replacement level (about 2.1 births per woman) is a key contributing factor to world population growth, in conjunction with reduced mortality and young age structure. While the average total fertility rate has fallen from more than 6 children per woman in the 1960s to less than 3 by the early 2000s (UNFPA, 2002), according to the 2007 UN medium projection, world population will continue to grow at least until 2050, adding 3.7 billion to the 2005 population of 6.5 billion (Bruce and Bongaarts, 2009). High fertility in women is associated with early marriage, high adolescent birth rates, higher risk of complications from pregnancy and child birth, maternal and infant morbidity and mortality, lower educational attainment and reduced capacity to earn income (UN, 2011). The ability of women and couples to achieve desired levels of fertility and to space or limit births through effective use of family planning (FP) is directly related to Millennium Development Goal (MDG) #5. improve maternal health and indirectly to #1. reduce poverty and hunger and #4. reduce child mortality.
Conversely, the incidence of infertility in a population has important demographic and health implications. However, despite infertility being a serious public health problem, it has received low priority in many developing countries – particularly in the context of policies on fertility control – because of continued donor focus on reduced family size (Inhorn and van Balen, 2002). Because high infertility has a dampening effect on overall fertility and the rate of population growth, improvements in the ability to bear children actually can impede efforts to lower the fertility rate in areas of low contraceptive prevalence. At the individual and family level, the inability to bear children for many couples can lead to a sense of loss, failure, and exclusion. Rutstein and Shah (2004) estimate that in 2002, more than 186 million ever-married women of reproductive age (15 to 49 years) in developing countries (excluding China) were infertile because of primary or secondary infertility. This number represents more than one-fourth of the ever-married women of reproductive age in these countries.
Primary infertility (also called primary sterility) is defined as the inability to bear any children, either due to the inability to conceive or the inability to carry a pregnancy to a live birth (Rutstein and Shah, 2004). Secondary infertility is the inability to bear a child after having an earlier birth and is associated with sexually transmitted infections (STIs), unsafe abortion, postpartum infections, and female genital cutting (Ombelet et al., 2008). The burden of infertility in most societies is placed more heavily on women and childlessness may lead to divorce, separation, the man taking another wife, and the social and economic isolation of women. Programs addressing infertility in developing countries focus primarily on prevention through reducing the incidence of and improving treatment for STIs and other causes (Ombelet et al., 2008). Assisted reproductive technology is being offered in some higher income urban settings, although the costs are prohibitive for widespread access to these services. For more information on primary and secondary infertility and prevention and treatment in developing countries, see Rutstein and Shah (2004) and Ombelet et al., (2008).
In 1978, John Bongaarts (1978) developed a framework for analyzing the proximate determinants of fertility that explained the effects of four key direct determinants: (1) age-specific proportions of women married; (2) contraceptive prevalence adjusted for method effectiveness; (3) induced abortion rate; and (4) average duration of postpartum amenorrhea (See Stover  for a review of the framework after twenty years of application). In a response to critics of FP programs, Bongaarts and Sinding (2009) have laid out rationales for the success of and need for continuing these efforts, and among these are: (1) FP programs have had a major and unambiguous impact on reducing fertility rates in many countries; (2) despite this success, there are regions in which high fertility remains a challenge that imposes significant risks on health, socioeconomic development, and the environment; and (3) FP is highly cost-effective and few public health interventions are more important or less expensive than FP in reducing the morbidity and mortality of mothers, infants and young children. The authors call for renewed focus and funding for FP programs.
In keeping with the current focus on FP and fertility with the MDGs, the Global Health Initiative, and international and country-level partners working to increase integration of FP services with maternal and child health and related programs, continued systematic monitoring and evaluation of FP programs and their impacts on fertility are required. The core indicators selected for this database include the higher-level indicators for tracking trends in total fertility and age-specific fertility rates, as well as indicators that influence fertility and use of FP and related services, including wanted versus unwanted fertility, age at first birth, and infertility.
Bongaarts J., “A Framework for Analyzing the Proximate Determinants of Fertility,” Population and Development Review, Vol. 4, No. 1 (Mar., 1978), pp. 105-132
Bongaarts J. and Sinding S., 2009, ‘A Response to Critics of Family Planning Programs,’ International Perspectives on Sexual and Reproductive Health. Vol 35:(1)Mar; 39-44
Bruce, J. and Bongaarts J. ‘The New Population Challenge’, From Laurie Mazur (ed.), A Pivotal Moment: Population, Justice, and the Environmental Challenge. Washington, DC: Island Press. http://www.popcouncil.org/pdfs/2009PGY_NewPopChallenge.pdf
Inhorn M. and van Balen F, Infertility around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies (University of California Press, 2002).
Ombelet W, Cooke I, Dyer S, Serour G, Devroey P, Infertility and the provision of infertility medical services in developing countries. Human Reproductive Update. 2008 Nov–Dec; 14(6): 605–621. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569858/
Rutstein, Shea O. and Iqbal H. Shah. 2004. Infecundity, Infertility, and Childlessness in DevelopingCountries. DHS Comparative Reports No. 9. Calverton, Maryland, USA: ORC Macro and the World Health Organization. http://www.measuredhs.com/pubs/pdf/CR9/CR9.pdf
Stover, J. “Revising the Proximate Determinants of Fertility Framework: What Have We Learned in the past 20 Years?” Studies in Family Planning, Vol. 29, No. 3 (Sep., 1998), pp. 255-267
United Nations (UN), Background Release, April 11, 2011, Economic and Social Council (POP/990), New York: UN. https://www.un.org/press/en/2011/pop990.doc.htm
UNFPA, State of the World Population 2002: People, poverty, and possibilities, New York: UNFPA. http://www.unfpa.org/swp/2002/english/ch1/page2.htm
UNFPA, State of World Population 2009: Facing a changing world: women, population and climate, New York: UNFPA. http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/state_of_world_population_2009.pdf
USAID, 2004, Health and Family Planning Indicators: A Tool for Results Frameworks, Washington, DC; USAID Bureau for Africa.
World Health Organization. 2001. Reproductive health indicators for global monitoring: Report of the second interagency meeting, 2001. Geneva: World Health Organization.