High Fertility in Sub-Saharan Africa

The African continent is home to approximately 1.34 billion people, and that number is about to get much larger. Because of high fertility rates in many African countries, the continent has the highest rate of population growth in the world: 2.5% per year.

Though fertility rates are high throughout the continent, they’re highest in the sub-Saharan region, where the population is projected to double by 2050. Although the total fertility rate has declined in sub-Saharan Africa over the past 30 years, from 6.5 to 4.7 births per woman, it remains much higher than in any other world region, and far higher than replacement rate (2.1 births per woman in low-mortality settings).

What drives high fertility rates in sub-Saharan Africa?

First, low contraceptive prevalence. Contraceptive use in sub-Saharan Africa increased from 13% in 1990 to 29% in 2019 (although only 88% of contraceptive users in 2019 were using modern methods). However, this region still has one of the lowest contraceptive prevalence rates in the world. According to a 2016 Guttmacher Institute study, a survey of 20 countries in sub-Saharan Africa found that at least 25% of married women have an unmet need for modern contraception. This unmet need was higher for women with less education, for those living in rural areas, and for those whose households had lower socioeconomic status.

Myths and misinformation keep many women from using contraception in sub-Saharan Africa. A 2015 study looking at data from Kenya’s Demographic and Health Surveys (DHS) found that fear of side effects and infertility were major barriers to use. Effective family planning programs address these myths and misinformation, but they are woefully underfunded—there’s a huge need for expanding family planning programs into the poorer, more rural parts of most sub-Saharan African countries.

There’s reason for hope though: Between 2010 and 2019, the 10 countries with the largest increases in the use of modern contraception were all in sub-Saharan Africa. One of these countries is Senegal. Through mass media campaigns and community leader engagement, the Initiative Sénégalaise de Santé Urbaine, or Senegal Urban Reproductive Health Initiative, educated women about the benefits of contraceptives. Radio shows included content around family planning methods, and Muslim religious leaders led conversations centered around family planning. The country’s urban rate of contraceptive use increased from 20% in 2010 to 30% in 2015. The initiative demonstrated that introducing more women to family planning in safe, familiar environments can address their fears.

Second, cultural and religious preferences. Both play a pivotal role in shaping behaviors. There is often a perceived economic advantage to having large families in rural areas. There are existing attitudes that God(s) and ancestors play a significant role in determining when each child is born and how many children each couple will ultimately have. Barrenness can be viewed as a punishment for sins. Polygyny and beliefs that women must prove their worth in marriage through childbearing can lead women to have more children than they would necessarily like to have. A 2017 study found that in half of the countries in sub-Saharan Africa for which the researchers had data, men had an average of more than 8.5 children each.

Third, high rates of adolescent childbearing. In 2018, West and Central Africa had a birth rate of 115 births per 1,000 girls between the ages of 15 and 19—the highest regional rate in the world. Early childbearing extends the length of women’s reproductive lives, often ensuring that they have larger families over their lifetimes than if they had started having children later.

Often, adolescent childbearing is a result of child marriage. One study of 34 sub-Saharan African countries found that 54% of women ages 20–24 were married as children. Child marriage is disproportionately experienced by girls who live in disadvantaged households, lack formal education, and reside in rural areas. This causes a repeating generational cycle, as child marriage and early childbearing often stifle any economic opportunities girls might eventually have, as they are typically forced to drop out of school when they begin having children. Early marriage is associated with an increased risk of multiple health consequences, including sexually transmitted diseases, domestic violence, obstetric fistula, and even death. In fact, pregnancy-related complications are the leading cause of death in girls ages 15-19 in the developing world.

In order to reduce unmet need for contraception and allow women in sub-Saharan Africa to have only the children they wish to have, these important initiatives must be prioritized:

• Eliminate child marriage
• Promote girls education
• Ensure universal access to an array of safe and affordable contraceptive methods
• Increase participation of men in family planning
• Eliminate all forms of violence and discrimination against women
• Ensure equal access to the labor market and political processes

The best way the United States can help countries in sub-Saharan Africa reduce their fertility rates is through foreign aid. We spend about $600 million a year funding international family planning programs throughout the developing world, at the request of country governments and foreign NGOs. The U.S. is the largest donor to international family planning programs in the world, and yet, we should still be doing more.

Our calculated “fair share” to meet the gaps in family planning and reproductive health funding is $1.74 billion* a year—a billion more dollars than we’re presently spending. Currently, all U.S. international family planning assistance is given bilaterally, through the U.S. Agency for International Development (USAID). USAID works to increase access to family planning in over 30 countries. The U.S. typically also provides assistance through an annual contribution to the United Nations Population Fund (UNFPA), which works in 150 countries. For the past three years, however, the U.S. has withheld support to UNFPA, and has become the only country to refuse funding for non-budgetary reasons.

It’s time for the United States to step up its investment in international family planning. Women’s lives across sub-Saharan Africa, and the developing world, depend on it.

* This figure was updated on March 11, 2021.