Transcript Threats to Fertility Reduction Efforts in Jordan

Fertility Levels, Trends and Key
Determinants in Jordan
by
Issa Almasarweh
Professor – Jordan University
Presentation Outlines
1) Jordan Fertility Trends
2) Jordan Fertility Goals
3) Key Factors Affecting Jordan Fertility Levels
4) State of Knowledge and Perceived Challenges
5) Relevant Policy Questions
Population Growth (%)
Current TFR in the Region
Source: 2011 PRB WPDS
Fertility Trends in Two Decades
9
8
8.3
7.2
Births per Woman
7
6
7.1
6.1
5.9
3.6
3.8
5.6
5
4.4
4
3.7
3
2
1
0
1990
DHS
Completed
1997
2002
2007
2009
TFR
Jordan Fertility Level is Recently
Plateauing
5
Births per Woman
4
3.7
3.6
3.8
3
2
1
0
2002
DHS
2007
2009
TFR
Wanted Fertility Increased
4
Births per Woman
3
2.6
2.8
3.0
2
1
0
2002
DHS
2007
2009
Early progression to first child
100%
Have Their 1st Child
80%
60%
40%
20%
0%
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Months Since Marriage
2009 DHS
Age Specific Fertility Rates
Births per 1000 Women
250
238
200
182
152
150
126
100
50
37
3
0
0
-
-
-
-
-
-
-
2002 & 2009 DHS
Age Specific Fertility Rates - Urban
245
Births per 1000 Women
250
200
177
150
150
122
100
50
35
34
3
0
-
-
-
-
-
-
2002 & 2009 DHS
Fertility – a key component in Jordan
future PG
240,000
226,000
Births
220,000
3 million born in the last 20 years
2.3 are expected in the next 10
years
200,000
190,000
180,000
160,000
140,000
2010
RECENT09 Constant
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Reducing Fertility is a National Priority
Goal for Jordan
4
3
3.8
3.5
3.0
Births per
couple
2.5
2
2.1
1
0
2009 2012 2017 2025 2030
Direct Factors Affecting Fertility
1) % of women 15-49 married
2) Contraceptive use
3) Postpartum insusceptibility
4) Infertility
5) Induced abortion
Fertility
(1) Marriage - % of Women 15-49
Ever-married
DHS
% Ever-married Women 15-29
Increased
71.5
75
60
45
37
30
15
6.8
0
-
-
2002 & 2009 DHS
High Growth in Number of First Time
Brides (4.3% annually)
60000
50000
40000
30000
20000
10000
2002
http://www.dos.gov.jo/sdb_pop/sdb_pop_a/ehsaat/alsokan/marri_divo/Marriages6.pdf
2009
Early Marriages
<18= 14% of total 1st time brides
15-19= 30% of total 1st time brides
< 18
15-19
18000
15000
12000
9000
6000
3000
0
2002
2009
http://www.dos.gov.jo/sdb_pop/sdb_pop_a/ehsaat/alsokan/marri_divo/Marriages6.pdf
(2) Contraceptive use has leveled off
DHS
15
Fo
lk
al
2
ith
dr
aw
6
W
0
P.
A
8
LA
M
1
Co
nd
om
pl
an
t
3
Im
25
In
je
cta
bl
es
D
5
IU
10
Pi
ll
F.
S
Method Prevalence – DHS 2009
23
20
13
4
1
0
Sources of Modern Methods 2009
Private Hospitals; 8
UNRWA; 8
JAFPP; 12
Private Doctors; 13
Pharmacies; 13
Public Sector; 46
(3) Postpartum Insusceptibility
DHS
(4) Infertility increased - % of
women (45-49) who are childless
2002 & 2009 DHS
Contraceptive Use needs to increase !
70
65 %
7.5
6.0
50
40
5.6
4.5
40
Fertility Plateauing
30
3.0
3.0
20
1.5
10
0
0.0
1990
FamPlan: File RECENT09
1997
2002
2007
2009
2017
Total Fertility Rate
Contraceptive Prevalence Rate
60
Summary – Indexes of direct factors
affecting fertility
2002
2009
1.0
0.8
0.6
0.4
0.2
0.0
Contraceptive Use
Marriage
PPI
Infertility
State of Knowledge and
Perceived Challenges
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 (%)
50
42
45
40
30
20
10
0
2002
2009
Reasons for Discontinuation
42 %
Method Failure
10 %
Stopped Using
8%
Switched to
Traditional 5 %
Switched to
Modern 10 %
Source: Contraceptive Dynamics Study
To Become
Pregnant 9 %
Unmet need for FP use
Not using but
want no more
children or delay
next child
11 %
Not Using
30 %
Using
59 %
Source : 2009 DHS
4) Other Challenges

Female Population Momentum - one million girl child
exists now
– Number of women 15-49 years will increase from 1.6
to 2.0 million by 2020
Projected Contraceptive Users
(all methods)
MWRA Growth
NPS
750,000
42 %
19 %
500,000
Current Users
250,000
FamPlan: Files RECENT09 & RECENT09 Constant
2010
2020
4) Other Challenges

Local price of contraceptive commodities is higher than
UNFPA price

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
Relevant Policy Questions
Policy Questions





Is there a competition between RH pillars/elements (FP, breast
cancer awareness and detection, family violence, antenatal
care, STDs/HIV/AIDS) that has resulted in less focus on FP?
Why FP is not a priority at major SDPs with great potential
for more quality services (RMS and universities hospital
based clinics)?
Why FP services are not covered by commercial self-insured
firms and health insurance benefits package?
Why poor a/o inadequate FP counseling? Is it an infrastructure
or policy issue? Is counseling recognized as a profession in
the human resources policy? Are there full time counselors at
SDPs with high work load?
What is the reason behind the increase in urban fertility? Is it
a result of refugees camps in urban centers?
Policy Questions






State commitment to FP: Are NPS/FP and small family goal
and slogan promulgated?
Why FP and population issues are absent in parliamentarian
election campaigns?
How to seize the many lost opportunities?
What are the barriers to enforcing the law/policy governing
child marriage?
Politicalization of FP issues by conservative and
fundamentalist political forces
Do we know the attitudes of civil society organizations
(political parties for example) towards FP? Is it on their
agenda or an issue imposed by external forces?
Policy Questions






Was the extended maternity leave optimally spent?
To what extent child bearing was a reason behind women
withdrawal from work?
Are postnatal post-miscarriage services supportive to
FP? Is FP counseling provided before discharge from
delivery sites? Is IUD inserted immediately after
delivery? If not why?
Is there an appointment system at FP SDPs that ensures
quality services?
Is CBP necessary in the country: home visit, phone
communication, workplace?
Is there a daily bookkeeping and recording of
information on FP services at SDPs?
Policy Questions





Do we have enough information on men knowledge and
attitudes towards FP and family size?
Do we know what religious leaders and preachers
actually do in Friday speeches (52 weeks * number of
mosques) and daily lessons? Do they actually speak in
support of FP? What proportion of these activities are
devoted to FP, breastfeeding, birth spacing or other RH
components?
How service providers are dealing with rumors and side
effects of FP methods?
Why the prevalence of F.S has declined?
Do we know how teachers at all levels are currently
dealing with RH/FP topics in school curricula?
Policy Questions






Is there a providers' bias towards certain FP methods?
Is there an early transition to the first child after
marriage? What is the contribution of first child to the
overall period fertility rate?
How friendly is the breastfeeding environment at
maternal wards especially in the commercial sector?
Is fertility stalling a result of population momentum?
Can we measure the impact of son preference on fertility
stalling?
Do we have enough number of preferred FP service
providers?
RH-FP Symposium Recommendation
(September 19-20,2011)

-
-
Maintaining the Momentum for
Fertility Decline:
Quality improvement
Address the issue of unmet need
Civil status in Jordan
Promoting FP concepts
RH-FP Symposium Recommendation
(September 19-20,2011)

-
-
Access to long acting contraceptive
methods:
Contraceptive security
Provision of IUD by midwifes
Method mix(provide at least four FP
methods)
Counseling about contraceptive side effects
Health insurance
Availability of well trained service providers
RH-FP Symposium Recommendation
(September 19-20,2011)

-
-
Public privet partnerships
Health insurance planes
Expanded method mix
Provision of IUDs by midwives
Training for general and family medicine
practitioners
Demand generation interventions
RH-FP Symposium Recommendation
(September 19-20,2011)

-
-
-
Research topics:
Conduct further research on the attitudes and
opinions about FP and the different family
planning methods among service providers.
Conduct an assessment of the family planning
counseling services.
Collect and analyzes information on implanon
discontinuation rate ,side effects, and
acceptance.
RH-FP Symposium Recommendation
(September 19-20,2011)
-
-
Conduct an assessment of the feasibility and
effectiveness of introducing new brands and
varieties of pills to Jordan FP logistics system
Conduct further detailed analysis to
understand the reasons behind plateau for
different sub-groups and geographic areas.
why urban areas did not complete their
transition?