Fertility Levels, Trends and Key Determinants in Jordan by Issa Almasarweh

1. Fertility Levels, Trends and Key Determinants in Jordan by IssaAlmasarweh Professor – Jordan University

2. Presentation Outlines • Jordan Fertility Trends • Jordan Fertility Goals • Key Factors Affecting Jordan Fertility Levels • State of Knowledge and Perceived Challenges • Relevant Policy Questions

3. Population Growth (%)

4. Current TFR in the Region Source: 2011 PRB WPDS

5. Fertility Trends in Two Decades DHS

6. Jordan Fertility Level is Recently Plateauing DHS

7. Wanted Fertility Increased DHS

8. Early progression to first child 2009 DHS

9. Age Specific Fertility Rates 2002 & 2009 DHS

10. Age Specific Fertility Rates - Urban 2002 & 2009 DHS

11. Fertility – a key component in Jordan future PG 3 million born in the last 20 years 2.3 are expected in the next 10 years RECENT09 Constant

12. Reducing Fertility is a National Priority Goalfor Jordan Births per couple

13. Direct Factors Affecting Fertility 1) % of women 15-49 married 2) Contraceptive use 3) Postpartum insusceptibility 4) Infertility 5) Induced abortion Fertility

14. (1) Marriage - % of Women 15-49 Ever-married DHS

15. % Ever-married Women 15-29 Increased 2002 & 2009 DHS

16. High Growth in Number of First Time Brides (4.3% annually) http://www.dos.gov.jo/sdb_pop/sdb_pop_a/ehsaat/alsokan/marri_divo/Marriages6.pdf

17. Early Marriages<18= 14% of total 1st time brides15-19= 30% of total 1st time brides http://www.dos.gov.jo/sdb_pop/sdb_pop_a/ehsaat/alsokan/marri_divo/Marriages6.pdf

18. (2) Contraceptive use has leveled off DHS

19. Method Prevalence – DHS 2009

20. Sources of Modern Methods 2009

21. (3) Postpartum Insusceptibility DHS

22. (4) Infertility increased - % of women (45-49) who are childless 2002 & 2009 DHS

23. Contraceptive Use needs to increase ! 65 % Fertility Plateauing TotalFertilityRate Contraceptive Prevalence Rate 3.0 FamPlan: File RECENT09

24. Summary – Indexes of direct factors affecting fertility

25. State of Knowledge and Perceived Challenges

26. Challenges to raise contraceptive use and reduce fertility • Shrinking FP Choices / Access • Missed / Lost Opportunities • Churning – Discontinuation • Others

27. 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)

28. 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

29. 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

30. 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)

31. 1st Year Discontinuation Rate (%)

32. Reasons for Discontinuation 42 % Source: Contraceptive Dynamics Study

33. Unmet need for FP use Source : 2009 DHS

34. 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

35. Projected Contraceptive Users (all methods) 42 % 19 % Current Users FamPlan: Files RECENT09 & RECENT09 Constant

36. 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

37. Relevant Policy Questions

38. 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?

39. 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?

40. 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?

41. 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?

42. 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?

43. 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

44. 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 • Communication campaigns

45. 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

46. 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.

47. 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?