2.3.2 Changes in the Situation of Sexual and Reproductive Health, with an Emphasis on Fertility

Facts/messages: Highlight key aspects of SRH, other than those directly involved in population growth, such as those associated with motherhood (childbirth services, quality of care etc.), the onset of sexuality and other SRH factors. One of the main demographic changes occurring in the world is the decline of fertility. However, to a considerable extent this decline has occurred on account of the reduction of higher order births, to older women; adolescent fertility is declining slowly or even rising in some countries. This results in an increasing proportion of births to adolescent mothers. Early sexuality is a critical concern. Many societies disapprove of premarital sex and consider reproductive health care for young people inappropriate. As a result, parents, educators and health care providers are often unwilling to give young people the information and services needed. Only by receiving reproductive health information and care will adolescents be enabled to make responsible decisions to protect themselves from unwanted pregnancy, sexually transmitted infections (STIs) and HIV/AIDS, maternal mortality and morbidity, sexual violence and rape.

A substantial proportion of fertility continues to be undesired and associated with shorter-than-desired birth spacing intervals. Family planning services, enabling couples and individuals to plan the number and spacing of their children, have been expanded in the last decades, further accelerating the decline in fertility rates. Despite an increased use of modern and traditional methods of contraception, as well as implantable and injectable contraception, the female condom and emergency contraceptives, there are still barriers with regard to access and availability of modern methods.

There are a number of costing models that exist which reflect the dynamics between investments in family planning and the resulting impacts on fertility including the SPECTRUM tools (Futures Institute), Reproductive Health (RH) Costing Tool by UNFPA, Marginal Budgeting for Bottlenecks (MBB) by the UNICEF and Unified Health Model by the Inter-Agency Working Group on Costing (IAWG Costing). All of these tools make use of Bongaart’s formula to predict age-specific fertility rates based on inputs such as the method mix and contraceptive prevalence rates. This consistency in methodology was driven by efforts of the IAWG Costing. More generally, costing tools are being harmonized through the work of this working group in its development of the Unified Health Model, a tool for costing, budgeting, financing and strategic planning which pulls together the strengths of each of the different costing methods in one single, user-friendly tool.

Methodology: The following indicators are proposed: percentage of contraceptive use by type, unmet need for contraception, patterns of sexual behaviour measured by the age of first sexual intercourse, sexually protected relationships, etc., Total Fertility Rate, age-specific fertility rates (with the indicator for adolescent motherhood in censuses—assign zero fertility or no response), percentage of adolescent mothers, distribution of birth-spacing intervals, unwanted fertility by age group. To compute the latter, different criteria can be combined. The Bongaarts method, which is the most rigorous, can only be applied at the level of the total population. In the disaggregations by age, one can combine the criterion of preferred family size with the criterion of the extent to which children born during the past 3 or 5 years were wanted or not. Emphasize the gap between actual and desired fertility as a key indicator of the exercise of reproductive rights.

Primary Sources:

  • For adolescent motherhood, unwanted fertility and unmet need for contraception, use Demographic and Health Surveys (DHS) (www.measuredhs.com, percentage of adolescents that are mothers or pregnant for the first time, broken down by simple age);
  • Censuses (online processing of data for some countries through REDATAM. Available at: http://www.eclac.cl/);
  • Fertility and Family Surveys (FFS);
  • Vital statistics, administrative registers, MICS.

Secondary Sources:


  • UNFPA (2010). A Guide to Tools for Assessments in Sexual and Reproductive Health;
  • UNFPA (2009). Rapid Assessment Tool for Sexual & Reproductive Health and HIV;
  • UNFPA. Reproductive Health (RH) Costing Tool;
  • African Development Bank and UNFPA (2005). Training Module on Integration of Population Issues into African Development Bank programmes and projects. Section 2 on Status of Population Dynamics and Socioeconomic Development in Regional Member Countries (RMCs) and Session 1 on Levels and trends in Population Size, Fertility, Mortality and Migration;
  • Futures Institute: SPECTRUM tools:
  • UNICEF. Marginal Budgeting for Bottlenecks (MBB);
  • InterAgency Working Group on Costing (IAWG Costing). Unified Health Model (UHM);
  • http://www.who.int/pmnch/topics/economics/costing_tools/en/index4.html;
  • A general review of costing tools is available at:
    http://www.who.int/pmnch/topics/economics/costing_tools/en/index.html, which includes descriptions of each tool and how to access them. Included in this link is a review of the costing tools by an external group;
  • Lamlenn B. Samson (2008). Guidance note for the in-depth analysis of data from a Population and Housing Census. Dakar, CST: section on Analysis of Fertility and Nuptiality.

32  Bongaarts, J. (1978). “A framework for analyzing the proximate determinants of fertility”. Population and Development Review 4(1): 105-132.
33  Bongaarts, John. 1990. “The measurement of wanted fertility.” Population and Development Review 16(3): 487–506.