Foreword
This article is part of the PDR supplement Contraceptive Transitions: Explanations and Evidence.
This collection of papers is a product of the International Union for the Scientific Study of Population [IUSSP] Panel “Contraceptive Transition Theories”, with members John Casterline (Chair), Ann Biddlecom, Irene Casique, Suzana Cavenaghi, Jamaica Corker, Allen Kabagenyi, Nathalie Sawadogo, and Chander Shekhar. The panel’s work was supported by a grant to the IUSSP from the Bill & Melinda Gates Foundation.
The charge to the panel was to assemble and synthesize theories of contraceptive change that have been developed by scholars over the past five decades, with specific reference to low- and middle-income countries [LMICs]. The background, and motivation, for this effort was the substantial increase in the use of contraception, especially “modern” methods, in the decades since 1960. We term this “contraceptive transition”, which the panel defined as the historical process in which contraceptive prevalence rises from low levels — around 10% — to about 60% among women of reproductive age. This shift represents a transition from a rare practice to one adopted by the majority of women of reproductive age. Note that this is an aggregate-level definition; the panel’s brief was to interrogate theory that strives to explain societal trends, not differentials among women. This rather elementary definition was deliberatively chosen to be encompassing of the existing scholarship on contraception; the panel feared that more complex and restrictive definitions would have the unintended consequence of excluding valuable historical experience. It should be added that, while developing an understanding of the determinants of trends in the prevalence of contraception is a demanding endeavor, the panel has also recognized the growing demand for multidimensional definitions of contraception that recognize factors beyond prevalence alone (e.g. women’s reproductive agency/autonomy).
“Contraceptive transition” constitutes a revolutionary change in reproductive behavior, and as such, begs for explanation. The explanatory challenge is to identify underlying causal forces, balancing the extraction of commonalities with a recognition of differences. Indeed, the latter was itself a principal goal of the panel’s work: the amount of change in contraception and the pace of change are known to vary across societies. What accounts for this variation? Is there a universality of contraceptive transitions, similar to the fertility transition, with variations in rates and timing, or does the empirical evidence suggest a wider range of distinct pathways for contraceptive transitions? Some contemporary societies have experienced less change in contraceptive use over the past half century, notably many countries in sub-Saharan Africa. Why?
To this end, the panel organized a succession of activities in the period from late-2020 to late-2022. In addition to regular virtual internal brainstorming, an expert group meeting (virtual) was held in October 2020. Following this, the panel developed a set of topics for papers along with proposed authors for these papers. Invitations to authors followed during the first half of 2021. Meetings (virtual) with the authors were held in August 2021 and January 2022. First drafts of the papers were presented at a “mini conference” in Madeira (Portugal) in July 2022. The Panel also held an internal side meeting and organized a special session during the November 2022 International Conference on Family Planning in Pattaya City (Thailand). Submission of revised papers to Population and Development Review followed in 2023, with anonymized external review and revision extending into 2024.
At its inception, the panel had the goal of producing a relatively unified explanatory framework incorporating insights from the multiple scientific disciplines that have grappled with contraception as a phenomenon. The framework would aspire to be comprehensive, informed by the enormous accumulation of empirical evidence during the past five decades. Few demographic phenomena have been as extensively analyzed as contraception.
Early on, however, the panel realized that this ambition – constructing a unified explanatory framework – was neither feasible nor a wise use of the available time and effort of the panel and the other scholars recruited for this endeavor. Over the decades there have been several such ambitious efforts, most notably the new economics approach pioneered by Gary Becker; the National Academy of Sciences early 1980s two-volume Determinants of Fertility in Developing Countries, which relied on and elaborated on the Easterlin Synthesis Framework; and more recently Johnson-Hanks et al. Understanding Family Change and Variation: A Theory of Conjunctural Action. During its first years of discussion, the panel decided it would be more fruitful at this juncture to invite scholars to explore new directions theoretically – to venture off the beaten track – with no compulsion to fit into the strictures of a unified framework.
The outcome is a set of essays distinguished by theoretical creativity that one could view as surprising given the decades of intense scientific, and policy, focus on the practice of contraception. A first essay (Kantorová & Bongaarts) provides an empirical backdrop, a description of contraceptive change in LMICs since 1970 and its association with fertility decline. This essay draws on the comprehensive estimates produced by the United Nations Population Division. The essay goes beyond summary presentation of the estimates per se, adopting a more analytical approach in describing trends and regional patterns.
The seven essays that follow Kantorová & Bongaarts examine a range of perspectives on contraceptive transitions and population-level contraceptive change. These essays synthesize and critique existing scholarship:
- Sawadogo et al. note that current theory about contraceptive transition is predominantly grounded in either economic theory or cultural theory. They submit that more reliance on demographic concepts and models would advance our understanding. In particular, the authors discuss the rich possibilities for better understanding of contraceptive change offered by three basic demographic concepts: life-course (individual-level), generation (meso-level), and demographic structure (macro-level). They also make the case for analytical payoffs from employment of the relatively simple tool of demographic decomposition.
- Yeatman & Sennott offer a synthesis and critique of the rich research literature on how change in fertility desires bears on contraceptive change. They offer a micro-level conceptual model to explain misalignments between desires and contraceptive behaviors that are standardly summarized in country-level indicators (such as “unmet need for contraception”). They call for a more nuanced understanding and measurement of fertility desires. They also stress that fertility desires should not be treated in isolation, instead theory must also acknowledge “contraceptive costs” that may block the implementation of desires in contraceptive behavior.
- Karra & Wilde provide a concise exposition of major strands of economic theory of contraceptive change. Their essay begins by summarizing the channels posited in economic theory through which economic development might drive contraceptive transition. A review of empirical evidence follows. The authors identify mechanisms through which economic development might affect contraceptive per se rather than fertility more generally. The essay contains an extended discussion of “contraceptive demand” as defined in the economics literature; setting this discussion against Yeatman & Sennott’s essay that draws largely on the social demographic literature, important conceptual differences between these major research traditions are clarified.
- Corker et al. extend theory on reproductive change and contraceptive transition to encompass the impact of multiple facets of health transition, with a featuring of the decline in child mortality rates and the expansion of health care services. The evidence indicates that both have the effect of increasing contraceptive prevalence. They also highlight the role of health systems in influencing which contraceptive methods predominate in the population. Specific country experiences are reviewed at some length.
- Jejeebhoy & Sathar argue for a central place for gender systems and gender roles in theory of contraceptive transition. Based on a review of eighty empirical studies, the authors conclude that women’s agency has a substantial influence on contraception, and that both community-level structures (gender systems) and individual-level attributes (gender roles) are determinative. The authors argue that not only does women’s empowerment enhance the likelihood of the adoption of contraception, but also women’s ability to make contraceptive choices – including choice of method – should be included in scientific assessments of the status of the contraceptive transition.
- Lerch tackles the intriguing question of how societal traumas such as civil conflict, natural disasters, and infectious disease pandemic might affect contraceptive transition. His review of existing empirical studies suggests that barriers to contraceptive use become more salient during societal upheavals, with the consequence that more often than not such upheavals reduce contraceptive prevalence. Interestingly, these barriers often consist of the re-emergence of barriers that had already been successfully surmounted.
- Finlay reviews the empirical evidence on the net impact of family planning programs on contraceptive change, the subject of many debates over the decades among scholars because of its direct relevance to significant public policy decisions. The author considers what types of program designs have proved most effective in shaping contraceptive use, and how program efficacy is conditioned by socioeconomic and reproductive context. The experience of three countries (Peru, Rwanda, and Vietnam) is reviewed. Standing back, the author summarizes the case for investment of public funds in family planning programs.
These essays provides a refreshing and invigorating contribution to the scholarly understanding of “contraceptive transition”. They synthesize existing scholarship and offer new perspectives on this significant reproductive change. Our hope is that this collection paves the way for future scholarship that might presume to attempt a unified theory of this historic transformation in the lives of men and women globally.
As Co-Editors, we express our thanks to all those who have contributed time and effort to this endeavor. This includes, first of all, the six other members of the IUSSP panel. The October 2020 workshop and the 2022 mini conference benefited from the input of scholars other than the panel members and the authors of the eight essays. Finally, every one of the essays was substantially improved by the critique of anonymous external reviewers, and we are grateful for this essential contribution to the production of this PDR supplement.
John Casterline
Suzana Cavenaghi
Co-Editors