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Afghanistan and Pakistan: Demographic Siblings? [Part Two]
›By Elizabeth Leahy Madsen // Wednesday, February 15, 2012Late last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. My first post on the survey focused on the methodology and results, which found that Afghanistan is not as much of a demographic outlier as many observers had assumed. But perhaps the most surprising finding is how the results compare to those of Afghanistan’s neighbor, Pakistan.
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The political future of each country depends largely on the other and, with Afghanistan making progress on reproductive health issues that remain stalled in Pakistan, their demographic trajectories are heading toward closer synchronization as well. In one key measure – use of contraception among married women – Afghanistan is almost identical to Pakistan. The modern contraceptive prevalence rate is 19.9 percent, slightly lower than the rate of 21.7 percent in Pakistan.
While Pakistan faces its own serious political instability, it is widely regarded as more developed than its neighbor. Afghanistan is included in the UN’s grouping of least developed countries, and Pakistan is not. Pakistan’s GDP per capita is almost twice as high. On the surface, this should suggest lower fertility. There is a general negative relationship between economic development and fertility, though demographers are quick to point out its complexities, and David Shapiro and colleagues have found that countries with larger increases in GDP actually experience slower fertility declines.
Pakistan’s fertility rate of 4.1 children per woman is in fact 20 percent lower than Afghanistan’s, but the similarities in contraceptive use, which is one of the direct determinants of fertility, suggest that this gap could be shrinking. If Afghanistan’s median age at marriage (18 compared to 20 in Pakistan) was higher and more women were educated (76 percent of women have never been to school compared to 65 percent in Pakistan), the two fertility rates might be closer.
Pakistan’s Entrenched Challenge
Why are these indicators closer than might be expected? Relative to the other countries in South Asia, Pakistan has had considerably less success in promoting family planning use. Bangladesh has a per capita income about half that of India and one-quarter that of Sri Lanka, yet the three countries’ fertility rates are identical. Nepal has the lowest income in the region – even slightly below Afghanistan – yet more than 40 percent of married women use modern contraception and fertility is three children per woman. And then there is Pakistan. Despite a per capita income 90 percent that of India, only 22 percent of married women use modern contraception and fertility remains persistently high at over four children per woman.
The weaknesses of Pakistan’s family planning program have been well-documented. Government commitment has been lacking and cultural expectations and gender inequities are a powerful force to promote large family size. The country’s most recent DHS report cited disengagement with the program among local agencies, low levels of outreach into communities, and weak health sector support as likely causes for the stagnation of contraceptive use. In summer 2011, the Pakistani government abolished the federal Ministry of Health and empowered provincial governments with all responsibilities for health services. This transfer of authority could pay dividends by increasing local ownership of health care, but some in and outside Pakistan have raised concerns about the loss of regulatory oversight and information sharing entailed in total decentralization.
Compared to the Afghanistan survey, the most recent Pakistan Demographic and Health Survey provides more detail on women’s motivations and preferences regarding fertility and family planning. Overall, 55 percent of married women in Pakistan have a “demand” for family planning; that is, they wish to avoid pregnancy or report that their most recent pregnancy or birth was mistimed or unwanted. More than half of these women are using family planning, while the remaining 25 percent of married women have an “unmet need.”
Unintended pregnancies and births play a major role in shaping Pakistan’s demographic trajectory. The DHS survey finds that 24 percent of births occur earlier than women would like or were not wanted at all. If unwanted births were prevented, Pakistan’s fertility rate would be 3.1 children per woman rather than 4.1. Yet 30 percent of married women are using no contraceptive method and do not intend to in the future. The most common reasons for not intending to use family planning are that fertility is “up to God” and that the woman or her husband is opposed to it.
Linked Destinies
Just as Afghanistan and Pakistan’s political circumstances have become more entwined, their demographic paths are more closely in parallel than we might have expected. For Afghanistan, given the myriad challenges in the socioeconomic, political, cultural, and geographic environments, this is good news; for Pakistan, where efforts to meet family planning needs have fallen short of capacity, it is not. While Afghanistan is doing better than expected, Pakistan should be doing better.
Regardless, both countries are at an important juncture. With very young age structures and the attendant pressures on employment and government stability, each government must reduce unmet need for family planning or face mounting difficulties to providing for their populations in the future. In addition to rolling out health services, turning the share of women without education from a majority into zero would be an excellent way to start.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.
Image Credit: Chart arranged by Elizabeth Leahy Madsen, data from MEASURE DHS. -
Afghanistan’s First Demographic and Health Survey Reveals Surprises [Part One]
›By Elizabeth Leahy Madsen // Tuesday, February 14, 2012Late last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. It shows that Afghan women have an average of five children each, lower than most experts had anticipated, and that their rate of modern contraceptive use is just slightly lower than that of women in neighboring Pakistan.
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The Afghanistan Mortality Survey 2010 is based on interviews with nearly 48,000 Afghan women, ages 12 to 49, conducted over eight months in 2010. Due to conditions of extreme insecurity, 13 percent of the population, mostly living in the southern provinces of Helmand, Kandahar, and Zabul, had to be excluded from the survey. Although officially titled a mortality survey, it includes the topics most commonly addressed in other USAID-sponsored Demographic and Health Surveys (DHS), such as fertility, family planning, and maternal health. The survey objectives were to provide a knowledge base of health needs as the country continues to rebuild from constant conflict, as well as to demonstrate how international humanitarian and development investments have affected population well-being.
Afghanistan’s last census was conducted in 1979, the year of the Soviet invasion, which ushered in a decade of war followed by more insecurity. The population then was estimated at 15.6 million; in 2010, the UN Population Division estimated it had reached 31.4 million.
Contraceptive Use Higher Than Sub-Saharan AfricaFertility in Afghanistan is estimated at an average of 5.1 children per woman. While still quite high – growing at 2.6 percent per year, the population is on pace to double every 26 years – this is significantly lower than estimates generated before the survey was conducted. Afghanistan was often grouped among countries with the highest fertility rates in the world. The most recent fertility estimates from the U.S. Census Bureau, UN Population Division, and Population Reference Bureau range from 5.8 to 6.6 children per woman. Even these estimates are lower than those for the 1990s, when the UN pegged the fertility rate at eight children per woman.
In 2009, demographers Richard Cincotta and Carl Haub noticed indications of demographic change in Afghanistan, with Haub suggesting that the national Basic Package of Health Services, introduced in 2003, was succeeding in bringing health care, including family planning, to rural areas. The Mortality Survey itself proposes that fertility rates may be falling due to urbanization and “exposure to modern means of communication,” as well as access to family planning.
Although women in Afghanistan are often restricted in their mobility outside the home, knowledge of effective family planning methods is, as in most countries, almost universal. However, current use of contraception remains relatively low: One-fifth of married women of reproductive age are using a modern contraceptive method, most commonly injectables or the pill. Following the typical pattern, contraceptive prevalence is higher among women who are educated, wealthier, and those who live in urban areas. Still, family planning use among rural women has more than tripled since 2003 and the overall rate is four points higher than the average for sub-Saharan Africa.
Household Indicators
Women in Afghanistan face conditions of widespread inequity, and this is reflected in the survey results. Seventy-six percent of women surveyed have never been to school, making education for girls and women a clear priority for government intervention. In a positive step, Afghanistan’s 2004 constitution promised that the government will provide them with education.The median age of marriage is 18, and half of women surveyed gave birth while still teenagers. Age at marriage directly affects fertility patterns, and another sign that fertility is falling is reflected in the fact that age at marriage is rising among younger women.
Two-thirds of births occur at home, the vast majority of these without the assistance of a skilled provider. Still, the survey also reports much lower estimates of maternal mortality than those prepared by international agencies.
The survey also provides a snapshot of the housing circumstances and economic quality of life for Afghans. About 40 percent get their water from unprotected wells, surface water, and other non-improved sources. Households are large, averaging eight people each, and only five percent of homes have their own flush toilet. Nearly 60 percent of the population lives without electricity and in homes with mud or earthen floors. Although only eight percent of the population has a refrigerator, three-quarters have a mobile phone.
Per capita GDP is estimated at less than $600 annually. More than one-third of the population is unemployed, and agriculture remains the primary industry and source of income, even though most of the country’s land is not arable.
Moving Closer to Pakistan
Despite these dire statistics, given the rapid rise in contraceptive use, the health system has clearly succeeded in improving health care access among some Afghan women. For the demographic picture moving forward, the question is whether rapid jumps in contraceptive use will continue. Several developing countries have experienced an initial decline in fertility that has subsequently stalled. These stalls have been linked to slower improvements in female education, infant and child mortality, and contraceptive prevalence, compared to countries that are experiencing steadier fertility declines. Unfortunately, the Afghanistan survey does not include data on women’s and men’s fertility preferences, sources of contraception, and reasons for not using family planning, which would provide clues in planning priorities for future services and outreach.
The most important general finding of the new survey is that Afghanistan is not as much of a demographic outlier as many observers had assumed, given the challenging conditions of geographic remoteness, violence, poverty, and low status of women. While the sustainability of these improvements can’t be taken for granted in such fragile conditions, the public health system in Afghanistan is making strides against the odds and reaching closer to parity with neighboring Pakistan.
Update: In the second paragraph we originally stated that “nine percent of the population, living in the southern provinces of Helmand, Kandahar, and Zabul, had to be excluded from the survey.” However, there were several “enumeration areas” (units selected to be included in the survey sample), constituting another four percent, that were not surveyed during implementation, also primarily due to insecurity. The total non-covered portion of the population, therefore, is 13 percent.
Part two of Elizabeth Leahy Madsen’s look at the Afghanistan Mortality Survey 2010, compares the survey’s surprising results with those of Pakistan and others in South Asia.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Guttmacher Institute, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.
Photo Credit: “View inside Afghan Apartment Block,” courtesy of United Nations Photo; charts courtesy of MEASURE DHS.
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