Abstract: This paper is based on the study results of two projects: "Rural-Urban Fertility, Differentials in Uganda: The Role of Proximate Determinants" (Nuwagaba, 1993) and "Household Formation Patterns in Uganda" (Nuwagaba, 1994)1. Information was collected form rural and urban households in Mpigi and Kampala districts respectively. The important thread that runs throughout the paper provides a better understanding of the reasons for the persistent high fertility in sub-Saharan Africa contrary to the theory of demographic transition. The analytical framework is illustrated with Uganda data. It is proposed that fertility level in sub-Saharan Africa is a function of the African political economy and changes in fertility levels will have to be preceded by socio-economic progress in real terms.
With the world population projected to increase from 5.4 billion in 1991 to 6.4 billion in 2001 and 8.5 billion in 2025, 96% of this growth is expected to be taking place in the developing world with the fastest growth found in the poorest areas (UNFP, 1991). Between 1950 and 1990, the population of Africa, Asia and Latin America increased by more than three times as compared with that of the developed regions. The African continent, however, is known to have a higher population growth rate than any other region of the world and this rate itself is on the increase.
Uganda's population in particular, with an annual growth rate of 2.7% has increased form 9.5m in 1969 to 12.6m in 1980 and to 16.6 in 1992 (Ministry of Planning and Economic Development, 1991). The population increase in Uganda is, like in other developing countries, attributed to a steep fall in mortality and continuing high fertility. A high Total Fertility Rate (TFR) per woman (7.3) persists, notwithstanding a family planning programme in the country for more than three decades. Modern contraceptive use still remains at only 27% for all women and 8% for married women (UDHS, 1996).
Whether Uganda has a population problem or not appears to remain an academic question. Taking a macro-level perspective, Uganda's population of 17 million people is far from the numbers required to fully utilize her enormous potential in the form of rich agricultural land, water resources, natural forests, minerals as well as to provide an inducing market for industrial production. For instance, Uganda has a large land area - relative to population - of 197,000 square kms, a relatively large percentage of arable land (84%), and a seemingly small proportion of land actually under cultivation (25%) (World Bank, 1993a).
On the other hand, the high fertility and dependency ratios make it difficult for the country's savings rate to be increased sustainably. The rapid population growth makes it more difficult to reduce existing deficits in maternal and child health services and education over the medium to the long term. It is an exacerbating stress on Uganda's environment as manifested by the depletion of biodiversity resources. In the agricultural sector, there is some under-utilzed land, but there are also areas of the country where population has become dense, leading to an increased concentration of very small farms which are not promising for absorbing additional labour.
Data from the 1963/64 census of agriculture reveal that 45% of the population lived on farm holdings less than 5 acres, and that by 1989/90, 85% of rural households with farmland had holdings of less than 5 acres, including 62% of households with holdings of less than 2.5 acres. The increasing concentration of families at the lower end of the distribution of farm sizes suggests land fragmentation arising form population pressure (World Bank, 1993a). Expansion into new virgin land areas is constrained by ethnic ties, human and animal health problems such as malaria and tse tse infections, lack of infrastructure such as roads and water supply.
In the wake of structural economic reforms, a good proportion of the population is getting poorer as unemployment, housing problems and costs for basic services increase, while incomes degenerate.
In the Eastern and Northern part of the country, there have been recent incidents of death due to famine. In addition, the correlation between poverty and population growth in Uganda is vividly clear. The bottom one million people who cannot at least afford to raise children decently have the highest fertility levels, partly due to their desire for many children, but also due to lack of knowledge, choice, motivation and access to family planning.
An analysis of Uganda's population issues brings to the forefront the complex interrelationship between increasing population/high fertility and a number of variables: Gender ideologies which discriminate against women (both as child bearers and victims of adverse consequences of population increases); the AIDS scourge (infected children and uncatered for orphans); rigidities in the growth of major sectors (agriculture and industry); and urban bias (urbanization of poverty and skewed resource distribution). The justification for fertility control in Uganda, is embedded in the above four variables.
In Uganda, population growth/high fertility is a gender question, although it has hardly been addressed as such by demographers. The biological role of women, as child bearers tends to put them at the centre of the blame for continuing population increase. The feeling is that women, through their unchecked pregnancies and child births year by year, are responsible for the population explosion. Yet in Uganda, especially in rural areas where fertility is highest, a pregnancy or a child birth is rarely a women's free choice. On the one hand, there is the socio-cultural values that oblige women to bear children to prove their femininity, and on the other, there is the gender-based household politics which vest the power to control a woman's sexuality and reproductivity in her husband.
In a society where a man has the right to polygamy, to producing children outside the formal marriage and to decision-making on the sexuality and reproductivity of the wife or wives, men could, more than women, be responsible for a population explosion like the one we are experiencing.
The sexist perception of fertility however, is apparent not only in Uganda but is perhaps, global. It is surprising that even the conventional demographic measures of fertility levels such as Total Fertility Rate (TFR) are calculated with the number of women as the denominator. Whereas no attention is paid to the number of children a man has fathered, unlike a woman, a man's reproductive capacity is unlimited.
Sadly, the relationship between the status of women and high fertility seems to be mutually reinforcing. It is undisputed that low status women are vulnerable to producing many children. It is, however, less popularly recognized that with frequent pregnancy and high fertility, traditionally known to raise the status of women, their status actually degenerates. At a high TFR as 7.3 in Uganda, the average Ugandan woman would spend about 22 years of her life with a child under 6, as compared to only 10 years for the average Thai women (World Bank, 1993b). This long span of child care-taking has adverse implications for the extent of a woman's participation in spheres beyond the boundaries of the home.
Apportioning the responsibility for high fertility among men and women, and referring to the traditional socio-cultural values may, however, be inadequate to explain the current trends of fertility among certain categories of the Ugandan population. We now turn to the probable forces that could be underlying the unaccounted for current patterns of fertility and the attendant population problem.
The changing economic circumstances, largely resulting form structural reform polices, have brought with them new contexts in which fertility is determined. New concepts such as "living together" have come into the marital status vocabulary to refer to a couple neither legally nor culturally married but staying together. This status is common among youthful urban elites especially fresh school leavers unable to secure employment and yet faced with costly survival in the urban economy. Unemployed females may, for example, choose to peg themselves to males who promise economic survival. Such couples end up producing children since contraception is constrained by the expectation that a child will automatically legitmise the cohabitation as marriage. Children born under such arrangements may not be guaranteed of care and upbringing from either parent since the parents do not, in most cases, end up in a long-lasting union.
With great improvements in health services in Uganda beginning from the 1960s, infant and child mortality declined considerably. Renewed public health efforts implemented during the last decade by such organs as the United Nations Expanded Programme on Immunization (UNEPI) brought infant and child deaths to an even smaller scale, only inflated by the neonatal AIDS impact. Infant mortality probably fell by 15% between 1965 and 1985, but since then it is estimated to have risen back to approximately the 1965 level, reflecting the impact of neonatal AIDS (World Bank, 1993b).
The infant mortality rate was estimated at 118 per 1,000 for the period January 1962-July 1966 and 122 per 1,000 for February 1984-June 1988, also reflecting the impact of AIDS (Ministry of Planning and Economic Development, 1993). Estimates of the overall death rates (infant, child and adult mortality) for the periods 1990-95 and 1995-2000 show that AIDS will increase the mortality rate. A comparison of three mortality scenarios, one without AIDS the second with uncontrolled AIDS, and the third with controlled AIDS, presented in Table 1, makes the impact of AIDS evident.
Table 1: The Impact of AIDS on Overall Death Rate (Death Rate per
1000 persons)
|
1990-95 |
1995-2000 |
Without AIDS Uncontrolled AIDS AIDS interventions |
16.9 20.5 20.4 |
15.5 21.7 21.3 |
Source: Uganda, Social Sectors, World Bank Country Study, p. 10.
Whereas it was hoped that declining mortality would be followed by a corresponding decline in fertility levels as people gain confidence in the survival of even fewer children, it is probable that the threat of AIDS, not only to the infants and children but also to grown up offsprings could suddenly reincline parents towards producing many children.
The perception of child-bearing as a woman's responsibility has shaped the direction of population control interventions in Uganda and elsewhere in the world. Health education and family planning messages have almost exclusively been targeted at women. In the context of societies like Uganda where the household level patriarchy denies women control over their reporductivity, this could represent misdirected interventions that have unsurprisingly made the least appeal. Indeed men continue to play a dominant role in matters of reproduction. The 1996 demographic and health survey found that 32% of women including currently married and unmarried women had produced unwanted children by the time of the survey.
The incidence of unsteemed or unwanted pregnancies and births may also point to lack of male support in making contraceptive decisions and their (men's) insistence of high fertility. Thirty per cent of all women would have preferred to wait longer before having their last birth, and 8% reported that they had not wanted the birth at all (Ministry of Planning and Economic Development, 1997). Contraceptive use is constrained to a low level (5%) among women of reproductive age because of generally unfavourable male attitudes (World Bank, 1993b). About 40% of males disapprove the use of contraceptives by their spouses (UDHS, 1988/89), leave alone using it themselves. This suggests that effective family planning should target men as well as women if they are to realise their intended objectives. The former seem to play a more crucial role in fertility decisions and hence the need for programme re-focussing.
It is expected that the immediate impact of contraception use is reduction in fertility. The observed pattern of child-bearing in Uganda however, seem to contradict such an expectation (Nuwagaba, 1994). It is observed that the small proportion of contraceptive users apply modern contraception only after high birth orders have already been achieved and not early enough to influence a reduction in child-bearing. The table below illustrates the point.
Table 2: Proportion Currently Using Modern Contraception According
to Socio-economic and Demographic Characteristics
Variable parity |
% |
S.E. |
Pi/Pref |
X2 |
5 or more 3 - 4 1 - 2 None |
1.30 17.70 10.40 6.90 |
0.0026 0.0313 0.0081 0.0201 |
1.00 13.62 8.00 5.30 |
477.44* |
Note: * denotes P < 0.01
Source: Nuwagaba (1994).
But why do women tend to employ modern contraception at high birth order? One possible explanation is the relationship between contraceptive practice and gender distribution of family composition. Results of the Uganda Demographic and Health Survey (UDHS, 1989) showed that sex composition of children born in a family plays a crucial role in the timing of contraceptive practice. Approximately 7% of the women practised modern contraception after their third or fourth son. On the other hand, some respondents seem to have practised contraception without having a living daughter. This data is not surprising given the apparent gender ideologies obtaining in the country. Most couples prefer having sons even if it means engaging in extra-marital relations. Similarly, it is not uncommon to hear of families which have broken allegedly due to failure of the wife to produce a baby boy. The issue of contraception is that the men always blame the women as the sole cause of the problem. This problem obtains not only among the illiterate but also among the educated elite. This pattern seems to show, that it may not be easy to persuade couples to practice birth control if they do not already have a living son.
Attaining or approximating the desired number of sons appear to be the critical determinant of modern contraceptive practice. In a study on customs and taboos influencing fertility in South-Western Uganda, Ntozi, et al. (1986) observed that the elders recommended a woman should not start practising contraception before she has six to eight children, including at least two sons.
That sons may be seen as determinants of reproductive success is consistent with most of Uganda's traditional values and norms which prescribe various roles that sons play in family life. Sons continue the family name and only sons and not daughters have inheritance rights. Secondly, as has been argued elsewhere (Vlassoff 1990), preference for sons may be prospective as well. Male children are a source of economic security for parents in their old age, especially for the mother who is likely to need financial support in the event that she is widowed, because no social welfare systems exist for the elderly in Uganda.
The current fertility levels in sub-Saharan Africa, and indeed in Uganda in particular, can hardly be understood without recourse to the socio-economic organisation of our productive sectors. Sub-Saharan African countries represent agrarian economies with a small industrial sector. In Uganda the agricultural sector constitutes over 90% of total export earnings and employs over 85% of the total labour force in the country (Ministry of Planning and Economic Development, 1990). Most of these production is performed "on farm" and it is mainly the women and their children who perform the basic tasks. The problem is exacerbated by the fact that the mode of production both in cultivation as well as in rearing of livestock utilizes rudimentary equipment. The hand hoe is still the main equipment used by the majority of households.
This mode of production appears to bear a strong influence on the importance of having sizeable number of children. In a study in Punjab, India, Mamdani (1972) found that most women rarely applied contraception for early termination of child-bearing. It could be argued that, given high infant and child mortality in these countries2, women tend to produce excess children to maximize chances of survival. But the above findings revealed that women in fact need many children. Many children are preferred in order to provide a "hand" on the farm. In industrial societies on the other hand, production is organized along highly capital-intensive techniques which require minimum labour force. Similarly, production is "off farm" and children in a particular household provide little assistance in terms of household labour.
Mamdani's findings could partly explain the failure of demographic transition to take root in least-developed countries, especially in sub-Saharan Africa. According to this transition theory, as propounded by Notesten and Demeny (1972), fertility is presumed to decline following a fall in mortality. However, the sub-Saharan African experience shows that even after a drastic decline in mortality from 140% in 1965 to 50% in 1990, fertility remains high with average TFR of 7.3 in Africa. Of course, there are a number of problems pertaining to this contradiction but the need for children as a source of family labour cannot be over-emphasized.
Urbanization in most developing countries started with the advance of colonization. In Uganda, urban growth started in the first half of the present century with the establishment of economic and administrative centres all over the country (Nuwagaba, 1993). This triggered the influx of people to the urban nuclei for commerce, employment and education. With time, the nuclei developed into full grown district urban centres. The influx, however, later over-ran the urban facilities due to increased rural poverty and deprivation and neglect of urban public facilities. This bred pressure on housing, utilities, land and other infrastructure, a phenomenon which still obtains. The table below depicts the magnitude of urbanization since 1969.
Table 3: Population of Major Urban Centres (1969 - 1991)
Urban Centre |
1969 |
1980 |
1991 |
Kampala Jinja Mbale Masaka Gulu Entebbe Soroti Mbarara |
330,700 47,872 23,546 12,987 18,170 21,096 12,398 16,028 |
458,503 45,060 28,039 29,123 14,958 21,289 15,048 23,255 |
773,463 60,929 53,636 49,070 42,841 41,638 40,602 40,383 |
Total |
482,845 |
609,075 |
1,062,008 |
Source: MPED (1991).
The eight urban centres comprise 57% of the total urban population in the country. As can be seen from the table, the population of these urban centres has doubled over the past two decades, with most of the growth recorded in the 1980s. Although the level of urbanization is low compared with the global average, it has been characterized by a high rate of growth and haphazard (unplanned) development, which has unleashed tremendous pressure on urban facilities.
One important aspect associated with urbanization is the reduction in fertility. Theories on the relationship, as first propounded by Demographic Transition Theorists, assert that increased urbanization poses tremendous costs in terms of social services such as housing, education and health. Other costs constitute food, energy, transport and water supply. Cross-section studies (Caldwell and Caldwell 1977; Tsui, 1981; Jones, 1984) have argued that accessibility of family planning services in urban areas play a crucial role in high contraceptive prevalence usually observed in urban areas. In line with these studies, Nuwagaba (1993) established that women in rural areas in Uganda had an average TFR of 7.2 while the TFR for urban areas stood at 5.4. Similarly, the contraceptive prevalence level for rural women was 12.2% while that of urban women was 35% (UDHS, 1996), as indicated in Table 4.
Table 4: Current Use of Contraception by Place of Residence
|
Any modern method |
Any traditional method |
Total |
Urban Rural |
34.5% 12.2% |
28.1% 5.1% |
45.4% 17.8% |
Source: UDHS (1996:76).
The other intermediate fertility variables that determine fertility levels in rural and urban areas include: young age at first marriage in the former and a higher age in the latter. Also urban women tend to be more educated and enlightened and therefore more likely to respond to new ideas such as contraceptive use.
In the current development thinking, one cannot avoid the issue of empowerment among urban women which implies that women become more assertive and therefore are more capable of influencing decisions including those concerning fertility.
Education and health provisions, communication facilities, electricity and water supply are more concerns in urban than rural areas. The rural areas seem to have been neglected, a phenomenon which seem to have triggered off the prevailing rural-urban influx. This problem has been exacerbated by political turmoil characterized by civil strife, political intrigue, social unrest culminating in economic disequilibria and devastation. In Uganda's case, the above mentioned problems are clearly documented during 1971 to 1986.
Despite the economic mismanagement and decay that characterised the Ugandan economy for almost two decades beginning in early 1970s, demographic dynamics remained on course. By 1980, the Ugandan population had increased to 13.6 million from 7 million in 1970 with unprecedented urban growth as already shown in table 3. This was out of proportion with the declining trend of the health services, educational facilities, public utilities and shelter provisions. Rural-urban migration intensified in the period causing pressure on the urban environment.
The practice of controlling child bearing is not a new phenomenon. Contraceptive use has a long history dating back to pre-industrial Europe and pre-modern societies in Australia and Africa (Tsui, 1980; Caldwell, 1977). Evidence exists of traditional methods notably coitus interrupts-withdrawal, a method that was widely used in Europe and probably the oldest method known to man. The use of vaginal sponges was recorded as early as 1900 BC in Etype (Himmes, 1936). In Africa, the practice of birth control has until recently been overwhelmingly dominated by traditional methods of sexual abstinence. Ntozi, et al. (1991) held a similar view and asserted that in Ankole in Western Uganda, in spite of the universal knowledge of modern contraception, most women preferred traditional methods of contraception which involve tying the belt around the stomach, using umuloto and herbs like agashi (kind of grass).
In sub-Saharan Africa, the level of use of modern contraception lags behind that of the world. The cause is partly related to the issue of `unmet needs" like ideal or target family size, child spacing and sex preference. Ignorance of modern contraception also partly explains the current contraceptive prevalence level (Westoff, et al., 1991; Nuwagaba, 1994). For example, it is feared in some societies that modern contraceptive use leads to permanent sterility.
In Uganda, family planning activities were introduced as early as 1957 (Obbock, 1980). However, despite the existence of family planning service in the country for more than three decades, the estimated proportion of sexually unmarried women of child-bearing age currently using a modern method of contraception was recorded at only 27% (UDHS, 1996). In a study on modern contraceptive use and their determinants in Uganda, it was found that:
Most women irrespective of their educational level have knowledge of modern contraception. Approximately 71% of non-educated women in Uganda knew a modern method while approximately 96% of those with 8 years or more of schooling knew a modern method (Nuwagaba, 1992:24).
The above findings indicate a very high level of knowledge of modern contraception in highly traditional and illiterate society, a finding that concurs with the assertion that there seems to be increasing spread of knowledge and modern ideas even among the uneducated.
The most pertinent question raised by the findings is "why then is there such a big contradiction between knowledge and practice?" It seems that knowledge of a method of birth control may not necessarily translate into practice given the multitude of factors as already documented elsewhere (Ntozi, et al., 1991; Caldwell and Caldwell, 1977; Tsui, et al., 1981; Jones, 1984).
Although the existence of a family planning clinic in a locality is one of the crucial factors that could influence motivation to practice birth control (Westoff, et al., 1991), it is to be noted that the Ugandan society is pronatalistic with heavily entrenched value for children which mainly derives ammunition from the utility of children especially as sources of labour. Drawing on the above suppositions, it may be possible to explain the relatively low prevalence level of contraception among the urban women even when they have enough knowledge and accessibility to family planning services.
We have endeavoured to examine the magnitude of the population problem and the trends of fertility in sub-Saharan African countries in general and in Uganda in particular. What seems to emerge is that the population problem results from high fertility which is a culmination of a complexity of factors, ranging from discriminatory gender ideologies through HIV/AIDS to production modes that require substantial labour force. The bottom line is that children are highly valued as potential resources and assets in the agriculture-dominated economy.
It seems that any effort directed at fertility control must recognise the following:
- Producing many children must be perceived as disadvantageous.
- Techniques for fertility control must be morally acceptable, socially approved and health friendly.
- The means to control child bearing must be available and affordable.
- Women need to be empowered in terms of decision making over sexual matters and reproduction.
The question of women empowerment is fundamental as women constitute the most crucial component in the fertility equation. Yet women have been at the losing end for centuries.
This was perpetrated by age-old traditional institutions cultivated and preserved over the years by carefully interwoven multitude of cultural values, norms, taboos and practices. While they appear to have survived the test of time, their nucleus and source of maintenance have in the recent past had to contend with formidable progressive forces.
The cost of rearing and brining up children is rapidly rising, especially as urbanization progresses. The cost of food, clothes, education, housing are increasingly becoming unmanageable and it may not be far-fetched to propose that households may very soon begin considering the socio-economic cost of producing big numbers of children. This has been exacerbated by the current wind of change in the area of economic restructuring where the government has started divesting most of the social service provisions. Even health services which have for far too long been a domain of central government is under privatization. This process generally leads to rising costs thereby increasing the cost of rearing children tremendously.
Even in the area of women empowerment, a lot of water has flowed under the bridge. Since 1975, the United Nations International Women's Year Conference in Mexico and the declaration of the UN Decade for Women running up to 1985, academicians, politicians, researchers and policy makers have increasingly acknowledged the need to address the plight of the African woman. Though much of what has come out of these quarters is no more than rhetoric, it has served the invaluable purpose of sensitizing other sections of society on the need to address women's problems. The message is getting across, the recently concluded United Nations Conference on Population and Development in Cairo, Egypt discussed the strategies for controlling the galloping rate of population growth and the major issue of contention was reproductive health. Similarly, the recently concluded 4th United Nations Conference on Women in Beijing, China underscored the need for empowerment of women as a benchmark for national development among different countries.
This paper has not been concerned with the proposing lines of action. We have been primarily concerned with setting a framework for a clear understanding of the dimensions that have influenced fertility in Uganda.
Clearly, the writing is on the wall and the tide of progress is well on its way. The bottom line is that economic development is the best contraception. As sure as day follows night, economic progress will lead to low fertility.
1. The first project was funded by, and the report is available at, OSSREA. The report on the second project can be obtained from Makerere University.
2. Average Infant Mortality Rate (IMR) is 17.7% while Child Mortality Rate (CMR) is 18.5%.
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