1 – The highest growth rates in the world in the last 50 years

18Unlike other regions in the world, Africa experienced a steady increase of its population growth between 1950 (2.2%) and 1985 (2.8%), as a result of sustained high fertility and declining mortality. Except for South Africa, where growth remained around 2.4%, and the islands of Reunion and Mauritius, where fertility declined as early as the 1960s, the growth rate went up by 1 percentage point in most of the countries over the period (Table A.3 of the Appendix), to reach close to 3% [7] overall around 1985. With these rates, the population of virtually all of them tripled in 35 to 40 years, and the total population of sub-Saharan Africa grew from 177 million in 1950 to 504 million in 1990 (Table A.2 of the Appendix).

19Since 1990, the whole of sub-Saharan Africa has entered a phase of demographic slowdown, with the growth rate declining from 2.9% a year circa 1985 to 2.3% in 2000. But the slowdown is occurring at various or even divergent paces among the countries (Figure 1). At one extreme, in close to twenty countries from different sub-regions, growth rates have not changed, or have even slightly increased since 1985 (e.g. Niger, Mali, Mozambique, Somalia). At the other extreme, in five Southern African countries plus Zimbabwe and Zambia, growth rates have practically collapsed from 1995 onward, as a result of excess mortality due to AIDS (the topic will be discussed again later). For example, South Africa and Botswana’s growth rates declined from 2.0 and 2.8% respectively in 1990-94, to 0.6 and 0.9% ten years later. This is a unique event in history.

Figure 1

Change in population growth rates from 1980-84 to 2000-04 in 48 countries

Change in population growth rates from 1980-84 to 2000-04 in 48 countries

20Between those extremes, some 25 countries undergo a decline of growth rates, but at different paces (Figure 1) : rather slow in West and Central Africa, slightly more rapid (on average) in East Africa. And there is no clear relation between the pace of decline and the initial level in 1980-84. Finally, between 1990 and 2005, the populations of the various sub-regions and of most of the countries increased by approximately 50%, except in Southern Africa (24%).

2 – Some projections to 2040

21The growth rates are slowing down, or will do so soon, but as they are still very high overall, they will induce significant further increases in the population over the next three or four decades (Table A.2 of the Appendix). The entire region will then rise from 732 million people in 2005 to 992 million in 2020, and to 1,374 million in 2040 according to the medium variant of the United Nations projections (2003b). Three of the four sub-regions, as well as a large majority of the countries, will probably see their population double in 40 years, and in some countries (e.g. Niger, Mali, Burkina Faso) it will increase almost threefold. Even in the countries that are most advanced in the fertility transition today (Ghana, Côte d’Ivoire, Kenya for example), the increase will still amount to 40 to 50%.

22Southern Africa presents a different picture. Still according to the United Nations projections, the growth rates, which have recently collapsed, will soon turn negative and will remain so until 2040 (approximately – 0.30% between 2010 and 2040). The population will significantly decline : between 2005 and 2040, the region will decrease from 52 million people to 47 million, thus recovering its size of 1995. South Africa and Swaziland will lose 10% of their population, and Botswana 19%. The effects of AIDS, as we shall see below, will also cause age structures to be drastically destabilized.

3 – Population density is a relative concept

23Africa, with its fifty countries and their extremely unequal land areas, has for a long time been considered under-populated, and believed to possess huge unoccupied or unexploited areas. True to say, Africa is very unevenly settled, with national population densities currently ranging from less than 10 inhabitants per sq. km. (e.g. Niger, Mauritania, Central African Republic, Gabon, Namibia) to close to 250 in Rwanda and even almost 300 in Burundi [8], for a sub-Saharan average of 27 (Table A.2 of the Appendix).

24These national densities, however, conceal huge inequalities within the countries. In Benin, for example, the Atlantic coastal district where the capital and most economic activities are located accounts for 25% of the population and 3% of the national territory ; rural densities, moreover, range between 10 and 300 inhabitants per sq. km. depending on the region. In Kenya, 90% of the people live on 20% of the land. In Burundi, certain rural communes exceed over 350 inhabitants per sq. km., and some hills exceed 700.

25On the other hand, if calculated in the classic manner (number of inhabitants divided by the total land area), those densities are poor indicators of the relation between population pressure and agricultural resources (Mathieu and Tabutin, 1996). By recalculating the densities, as we did, based on the surfaces of arable land and permanent crops (Table A.2 of the Appendix), the perspective changes completely. For example, densities rise in Mauritania from 3 to 529 inhabitants per sq. km., in Senegal from 48 to 391, in Kenya from 53 to 676, in Somalia from 14 to 817. Africa thus appears to be far from under-populated, in terms of farmed or cultivable land.

1 – General increase in the age at marriage

31In most countries, the median age at first marriage of women is going up, approximately from 18-19 in the late 1970s to 19-20 in the late 1990s, with frequent gains of the order of 1 to 1.5 years. Only a few countries retain an early marriage model today : Niger (16.8 years), Chad (17.7), Uganda (17.5) and Mozambique (17.8). At the other extreme, the countries of Southern Africa and Reunion, which had a late marriage pattern as early as the 1970s, now have an age at first marriage of the order of 28. In between, a majority of countries have an average age around 20 (Figure 3). In short, sub-Saharan Africa has not experienced a marriage revolution comparable to that in North Africa over 25 years, but changes did occur.

Figure 3

Median ages at first marriage of women and men in the late 1990s (36 countries)

Median ages at first marriage of women and men in the late 1990s (36 countries)

32Among men, the ages of entry into union, which were relatively late already in the 1970s, are often also rising, but less so than among women. In a majority of countries, they are now around 25 or 26, except in Southern Africa and Reunion, where they attain 31 (Table A.4).

33As a consequence, age differences at first marriage between men and women, which were very wide in the 1960s and 1970s (usually 6 to 7 years), are now narrowing slightly, though they remain important in a majority of countries (Figure 3).

2 – Marriage remains the rule

34Getting married remains the largely predominant social norm in Africa, for women as well as for men. Except once more for the countries of Southern Africa, where the proportion never married is no longer negligible (about 14% of women at age 45), virtually all men and women eventually contract a union. In 40 countries, the proportion of men who remain single seldom exceeds 4%, and of women 2%. There is, however, a trend in the African capitals or large cities towards extended single life, which may eventually lead to a rise in the proportion never marrying (Antoine, 2003).

3 – A good resistance of polygyny

35Sub-Saharan Africa has always been a fertile ground for this type of marriage, which is one of the essential pillars of family structures in the region. In the 1960s and 1970s its decline or even its demise was predicted, as a result of westernisation, education and socio-economic development, and in more recent times, under the impact of “the crisis”. The most recent data from censuses or surveys show that far from disappearing, polygyny withstands the various contextual changes well.

36However, its prevalence, which is high on average, was and is variable between sub-regions of the continent, between countries within sub-regions, or between ethnic groups and living environments within countries (Sala Diakanda, 1980 ; Klissou, 1995). Polygyny has always been most widespread, and by far, in West Africa and the Sahel (Table 4), with currently 30% to 60% of women aged 35 to 44 living in polygynous marriage, with the exception of Mauritania (Table A.4 of the Appendix). It is only slightly less widespread in Central Africa, but markedly less important and more variable in the 17 East African countries (ranging from 4% in Madagascar to 39% in Uganda), and most of all in Southern Africa (14%).

37However, the beginning of a trend towards widespread decline of polygyny has been observed almost everywhere in recent times, though it mainly affects the cities and the most privileged or educated social classes. For the time being, one out of every three African women aged 40 is in a polygynous marriage (Table 4) ; almost one out of two may still be involved in that regime at one time or another.

4 – Divorce and remarriage are important, but poorly documented

38Polygyny, but also divorce and widowhood remain the major marital “hazards” for an African woman, because of the instability of marriage (quarrels between man and wife, arranged marriages, wife’s infertility) and the age difference between the spouses, which is sometimes quite substantial, particularly in polygynous unions [10]. Frequency and timing of divorce, widowhood and remarriage are among the least well documented facts in African demography, as they require the full marital history of men and women. These are available in the few WFS conducted in the 1970s, but not in the numerous recent DHS [11]. It is therefore difficult to measure changes.

39The few studies of divorce conducted in the 1970s and the 1980s have all demonstrated the importance of the phenomenon as well as its diversity over space. According to R. Lesthaeghe et al. (1989), divorce, generally followed soon after by remarriage, was more frequent in West Africa (45% to 53% of unions dissolved in the different countries) than in East Africa (29% to 34%). Although there are few recent studies, those that are available on West Africa have confirmed the phenomenon’s importance. After 30 years of marriage, 35% of women’s first marriages in Ghana, 38% in Togo, 29% in Mauritania are dissolved by divorce ; in Dakar, one out of every three marriages ends in divorce (Antoine and Dial, 2003). In Burkina Faso (Thiombiano, 2004), a mostly rural country, divorce at the national level is less frequent than elsewhere (16% after 30 years of marriage), but it affects one out of every five women in the cities, with increased risks for early marriages, educated women and the younger generations.

40Widowhood is obviously another major cause of marriage dissolution in Africa, in contexts where mortality is still high, particularly among men, and age differences between spouses are often important. In Burkina Faso for instance (Thiombiano, 2004), one out of every ten first marriages is dissolved by the man’s death before 20 years have elapsed, and one out of every five before 30 years have. The cumulative impact of divorce and widowhood results in particularly high probabilities of dissolution of their union for women, even before the end of their fecund life.

41To the extent that marriage remains a quasi-universal social norm in Africa, these marriage dissolutions by divorce or widowhood are often followed by remarriage, particularly when the women are still comparatively young and fecund. Again, the phenomenon varies throughout the continent, and remarriage is on the whole more frequent and rapid in West Africa than in the eastern or southern parts of the continent, with relatively marked differences between cities and countryside and among social groups.

5 – General regional marriage patterns

42Africa is culturally and ethnically very diversified, and this is true with regard to nuptiality as well as to family structures and social or gender relations. Marked differences prevail even among neighbouring countries.

43For the 1970s and the 1980s, R. Lesthaeghe et al. (1989) and V. Hertrich (2001) have distinguished between several main regional patterns of nuptiality. These include the Sahel and the western and central savannah regions, where marriage occurs at a very early age, polygyny is widespread and the age differences between spouses are large ; East Africa, where polygyny is less frequent and marriage occurs at a later age ; and Southern Africa with little polygyny, a fairly late age at marriage, and large proportions of never married individuals, in part because of labour migration.

44Approximately the same regional patterns still prevail in the late 1990s, twenty years later, with slightly different results (Table 4), but still with two extreme situations. On the one hand, West Africa, the most polygynous region in the world, has significant age differences between spouses ; on the other hand, Southern Africa has a very different pattern, with late marriage, a significant proportion of never married, little polygyny, and small age differences between spouses.

45Those significant spatial and cultural disparities in marriage patterns should be kept in mind as we examine the levels and trends of overall fertility.

1 – Diversity in the pace of decline

47Figure 4, which compares the total fertility rates of all 48 countries in 1960-1964 and in 2000-2004 [12], clearly shows how different the current situation is from the homogeneity of the 1960s, when virtually all the countries had 6 to 7.5 children per woman [13]. Since then, very fast declines have been observed in Southern Africa (South Africa, Zimbabwe, Botswana), in Ghana and Kenya, and in the island-states (Mauritius, Cape Verde) and Reunion, and much slower declines in some twenty countries (where fertility has approximately decreased by one child per woman in 30 years), but also stagnation or even slight increases in about fifteen countries. The latter, where the TFR is still around 7 children per woman, are mostly located in Central and West Africa, with Niger holding the world record of fertility (8 children per woman). Fertility in Africa, which ranged from 6 to 8 children in the 1960s, currently varies from 2.6 to 8.0 among countries.

Figure 4

Total fertility rates (TFR) from 1960-64 to 2000-04 in 48 countries

Total fertility rates (TFR) from 1960-64 to 2000-04 in 48 countries

2 – Still a generally early onset of fertility

48Fertility in sub-Saharan Africa was traditionally characterized by an early onset. Three indicators may be used to measure the earliness in the 30 countries where at least one DHS has been conducted since 1994 (Table A.6 of the Appendix) : the median age at first birth, the proportion of adolescent girls (15 to 19 years) who had a child or were pregnant at the time of the survey, and the proportion of total fertility achieved before age 25.

49The median age at first childbirth, which is partly related to age at first union [14], is 19.7 (i.e. every other African woman has her first child before 20) for sub-Saharan Africa as a whole, with regional averages ranging from 18.9 in Central Africa to 20.9 in Southern Africa. In a majority of countries, women have their first birth in their nineteenth or twentieth year (Table 5) and only in four countries above age 21 : the Comoros, Eritrea, Namibia and Rwanda where, along with Burundi, age at first marriage has always occurred later, and extramarital conceptions are rare. Excluding a few small countries such as Mauritius, or Reunion, fertility still begins at an early age in Africa, and no important changes have occurred.

Table 5

Number of countries by sub-region according to the median age at first birth and the proportion of adolescent girls (15 to 19) who have started childbearing

Sub-region Median age at first birth % of adolescent girls having started childbearing(a) Total number of countries < 19 19-20 21 < 15% 15-24% ? 25% West Africa 3 9 – 1 5 6 12 Central Africa 2 2 – – – 4 4 East Africa 2 7 3 3 3 6 12 Southern Africa – 1 1 – 2 – 2 Total sub-Saharan Africa 7 19 4 4 10 16 30 (a) Defined as the proportion of women aged 15-19 who already had a child or were pregnant at the time of the survey. Source : Table A.6 of the Appendix. Most recent DHS since 1994.

Number of countries by sub-region according to the median age at first birth and the proportion of adolescent girls (15 to 19) who have started childbearing

50The high level of adolescent fertility confirms this clearly. The proportion of girls aged 15-19 (with an average age of 17.5) who either have had a child or are pregnant is 25% for the whole of the region, ranging from 19% in Southern Africa to 34% in Central Africa. In a majority of countries it is over 25% (Table 5), with some Sahelian countries (Mali, Niger, Chad), and also Madagascar and Mozambique close to 40%. Countries like Ghana (14%), the Comoros (9%) and Rwanda (7%) occupy the other extreme.

51As for the proportion of total fertility achieved before 25 years [15], it is around 35% in a large majority of countries (Table A.6 in the Appendix), with Namibia (20%) at one extreme and Mozambique (40%) at the other.

52Early timing of fertility (whether in or out of wedlock) and high levels of adolescent fertility remain two major characteristics of African fertility.

3 – The demand for children is dropping but remains high

53In a vast majority of countries and societies, children are as much in demand as ever, and the large family norm is still valued, though on the whole the number of children wanted has been declining in the last fifteen years. For example, in very different contexts, the ideal family size among women aged 15-49 has declined in roughly ten years from 6.8 to 5.3 in Senegal, from 6.9 to 6.2 in Mali, from 5.3 to 4.3 in Ghana and from 4.4 to 3.8 in Kenya [16]. However, when calculated for the women aged 25-34 (in their peak reproductive years) in the 30 countries that had a DHS recently (between 1995 and 2002), it still amounts to 5.4 children for the whole of Africa. This is a large number when compared with the “ideal” 2.8 children in Asia and Latin America, and the 3.0 children in North Africa. Ideal family size of the younger women (25-34) is at the same level as current total fertility, but is definitely lower than the number of children actually born to women aged 45 (6.4 children).

54The demand for children naturally varies from one sub-region to the other (ranging from 3.9 in Southern Africa to 5.6 in West Africa) and from one country to the other. In 12 out of 30 countries (Table A.6 of the Appendix), desired fertility is still higher than actual fertility (TFR) ; in the remaining 18 countries it is either the same, or markedly lower.

55Changes are undoubtedly occurring. The demand for children is lower than it used to be, the proportion of women of a given age or parity who declare that they do not want any more children is increasing, and social and regional differentials (for example, between educational levels) are well established, in conformity with the geography of fertility. As we wrote as early as 1997 (Tabutin, 1997) :

56

“This reflects some ideological changes, but no radical and irreversible transformation of opinions and norms yet, such as other regions of the world have known in the last fifteen years. Rural, impoverished Africa, in particular, remains still very pro-natalist”.

4 – Social and regional diversification of reproductive patterns in the various countries

57All societies and regions of the world are going or have gone through a phase of growing regional and social disparities in their demographic history. In any dynamics of social change or of crisis, there are always social groups (or regions) that are ahead of the others, groups that are culturally more open or less resistant, groups that are economically more affected by crises or by progress, groups that are more influential than others. As a result, different models of adaptation or response to crisis and to progress are emerging ; in other words, life (or survival) strategies, in fertility as in other areas, are becoming diversified. To varying degrees in the different countries, Africa has now entered that phase of growing internal heterogeneity or inequality. And as in many other societies in the world, fertility transitions are channelled through the city, education and the social group. By way of illustration, Table 6 presents differential fertility by type of residence and by educational level in six countries now in different stages of transition.

Table 6

Total fertility rates by type of residence and women’s educational level in six countries at various stages of transition

Country and dates of DHS Type of residence Educational level Capital Other cities Rural Illiterate Primary Secondary and over Total Mali 1987 5.4 6.4 7.0 6.8 6.2 – 6.7 2001 4.9 6.3 7.3 7.1 6.6 4.1 6.8 Côte d’Ivoire 1994 4.1 5.5 6.4 6.2 5.3 3.8 5.7 1999 3.4 4.9 6.0 6.1 4.7 2.3 5.2 Cameroon 1991 4.4(a) 5.6 6.3 6.2 6.4 4.5 5.8 1998 3.1(a) 4.5 5.8 6.6 5.3 3.6 5.2 Ghana 1988 4.5 5.6 6.6 6.7 6.0 3.6 6.4 1998 2.7 3.4 5.4 5.8 4.4 2.8 4.6 Kenya 1989 4.2 5.0 7.1 7.5 6.9 4.8 6.7 1998 2.6 3.5 5.2 5.8 5.0 3.5 4.7 Zimbabwe 1988 3.9 6.1 6.7 5.7 3.7 5.3 1999 2.9 4.6 5.2 4.5 2.8 3.9 (a) Average for Yaoundé and Douala. Source : DHS Country Reports.

Total fertility rates by type of residence and women’s educational level in six countries at various stages of transition

58Today, the city and the countryside are distinct worlds. On the whole fertility rates in the different types of environment are no longer similar, as they used to be in the 1970s. In every country, urban fertility is noticeably lower (Shapiro and Tambashe, 2003a) [17], with between 3 and 4 children, as against 5 to 6 children in rural environments (Table 6). In the capitals and large cities in particular, fertility is markedly lower than elsewhere, the ideal family size is smaller, marriage is later and polygyny less common ; as we shall see below, breastfeeding and postpartum abstinence periods are shorter, and contraception of course is more widespread. Even in countries well advanced in the fertility transition (Ghana, Kenya and Zimbabwe in Table 6), the capital and the rural world still differ by 1 to 2 children.

59Similarly, education is playing an increasingly important role everywhere, as in other regions of the world. Except for a very few countries that are in a pre-transition phase (Niger, Chad or Mali), primary education is sufficient to change norms and behaviour significantly, though for the time being it is mostly access to secondary (and higher) education that induces a sharp fall in fertility (to around 3 children in many countries). Education, as we shall see, fundamentally changes the role of intermediate variables such as breastfeeding, abstinence and contraception.

60Similarly, almost everywhere regional diversity in fertility is increasing in the countries, as a consequence of frequent serious inequalities in cultural, economic, educational or health development. For example, excluding the capital regions, fertility currently ranges, in the different regions, from 5.0 to 6.9 children per woman in Benin, from 4.4 to 6.6 in Cameroon and from 3.7 to 5.7 in Kenya. The comparative spatial homogeneity observed during the 1970s and the 1980s is definitely a thing of the past.

5 – Human development and child mortality : close correlates of fertility

61Various studies on the early 1990s [18] have shown a close relationship in Africa between the fertility of a country and its human development index [19], as well as between fertility and child mortality [20]. Those synchronic relations around 2002 are presented in Figures 5 and 6, based on the United Nations’ most recent estimates of fertility and infant mortality in all 48 African countries (Tables A.5 and A.8 of the Appendix).

Figure 5

Relationship between the total fertility rate and the human development index in 48 countries around 2002

Relationship between the total fertility rate and the human development index in 48 countries around 2002

Figure 6

Relationship between the total fertility rate and infant mortality in 48 countries around 2002

Relationship between the total fertility rate and infant mortality in 48 countries around 2002

62There have been no major changes in the last ten years, and the correlations are of the same order, and significant (R²= 0.62 for human development, R²= 0.70 for infant mortality). In general, the higher a country’s human development level, the lower its fertility ; the more infant mortality is under control, the lower the fertility level. In other words, no fertility transition took place without a drop of infant mortality or without socioeconomic and health progress. In that sense, Africa seems to be conforming to the classic path of the demographic transition theory. But only the extreme situations stand out clearly. The ten poorest countries in the region all have more than 6 children per woman, whereas the six or seven most “developed” ones have between 2.2 and 3.9 children. In between, there is uncertainty and diversity [21]. In Africa as elsewhere, there will probably be multiple paths leading from high to low levels of fertility.

1 – Extended breastfeeding remains universal

65On the whole, sub-Saharan Africa has retained the practice of universal and lengthy breastfeeding. All women breastfeed and most of them do so for as long as possible. In 23 out of 30 countries (Table A.7 of the Appendix) the median duration of breastfeeding exceeded 20 months in the late 1990s [23]. In South Africa and Namibia, it is still 16 and 17 months respectively. In our estimates, the African average (21 months, Table 7) is far longer than in Latin America (13 months) or North Africa (12 months).

Table 7

Breastfeeding, postpartum sexual abstinence, contraception and sterility by major sub-region around 2002

Sub-region Median duration of breastfeeding (in months) Median duration of sexual abstinence (in months) Modern contraceptive prevalence (in %)(a) % of married women aged 40-49 with no live birth West Africa [11] 21.9 10.0 7 2 Central Africa [4] 18.2 8.9 6 6 East Africa [11] 23.0 4.1 13 2 Southern Africa [3] 17.5 4.5 44 3 Total sub-Saharan Africa [29] 21.4 7.0 13 3 (a) All women 15-49 in union. Source : Table A.7 of the Appendix (30 countries). The data by sub-region and for the whole are non-weighted averages based on national results. Cape Verde, where breastfeeding is much shorter and contraception very high, was excluded from West Africa, whereas Zimbabwe was included in the Southern African sub-region. The figures between brackets represent the number of countries by sub-region.

Breastfeeding, postpartum sexual abstinence, contraception and sterility by major sub-region around 2002

66Comparing the results of the 1980s, 1990s or 2000s DHS, it appears that breastfeeding periods have remained virtually unchanged at the national level. However, they are usually shorter in the cities than in the countryside, and among literate than among illiterate women. This may foreshadow future changes, though not abrupt ones. Meanwhile breastfeeding still contributes largely to lengthening birth intervals.

2 – Different durations of sexual abstinence, and a declining prevalence

67Sexual abstinence among spouses after a birth has always been a common practice, but its duration varies between cultures, ethnic groups and religions. Except for Rwanda and Burundi, where they have always been very short, postpartum abstinence periods currently last between 2 and 4 months in ten countries (including the Moslem Sahel region), between 9 and 12 months in seven others, and between 19 and 22 months in Burkina Faso and Guinea (Table A.7 of the Appendix). Just as in the 1970s and 1980s, they are longer on the whole in the western and central than in the eastern and southern parts of the continent (Table 7). With an average duration of the order of 7 months, abstinence is much longer in sub-Saharan Africa than in the other developing regions, where it is between 2 and 3 months.

68Whereas breastfeeding is keeping up, abstinence is undergoing more fluctuations, with the duration decreasing in many countries during the last 15 years : it went down from 14 to 8 months in Ghana, from 7 to 2 in Mali, from 6 to 3 in Kenya, from 4 to 3 in Zimbabwe. This is probably the behaviour that is most susceptible to contextual changes. Everywhere, its duration is curtailed most in the large cities, among literate couples or in the more privileged social classes. For example, in Benin in 2001 (Table 8), though the country is poor and at the very beginning of the transition, abstinence now lasts only 5 months in Cotonou (the largest city) and 4 months among well-educated women, as against 10 months in the rural area and 13 months among the illiterate.

Table 8

Age at first marriage, breastfeeding, postpartum abstinence, modern contraception and fertility in benin (2001) by type of residence and women’s educational level

Variable Type of residence Educational level Secondary and over Total Cotonou Other cities Rural Illiterate Primary Median age at first union 22.4 19.0 18.0 18.1 19.6 23.6 18.8 Median duration of breastfeeding (months) 19 22 23 23 21 20 22.0 Median duration of abstinence (months) 5 13 10 13 6 4 9.0 Contraceptive prevalence (%)(a) 12 9 6 5 9 20 7.0 Total fertility rate 3.4 4.9 6.4 6.3 4.9 3.5 5.6 Relative weight (%) of each group 15 26 59 64 22 14 100.0 (a) All women 15-49 in union. Source : DHS report for Benin (2002).

Age at first marriage, breastfeeding, postpartum abstinence, modern contraception and fertility in benin (2001) by type of residence and women’s educational level

69While they are evolving, these postpartum breastfeeding and sexual abstinence practices remain markedly more intense and more widespread in Africa than in the rest of the world. They still induce long periods of postpartum non-susceptibility [24] (12 months in Kenya, between 14 and 16 months in Ghana, Mali and Benin, 19 months in Côte d’Ivoire). In a vast majority of countries, they are still the main fertility regulator in the absence of widespread contraception [25].

3 – The slow progress of modern contraception

70The situation in Africa is now different from what it was in the 1970s or 1980s, when except for a few countries (Mauritius, Cape Verde, South Africa, Zimbabwe), contraception was negligible, with prevalence ranging from 1 to 5% among married women. Since then there has been real progress, though on the whole it was slow and often limited to the large cities and the most educated or privileged social groups.

71Around 2000, modern contraceptive prevalence among married women aged 15-49 is still under 8% in 15 countries (out of the 30 in Table A.7 of the Appendix), between 8 and 15% in six countries, between 15 and 30% in five countries. Only three countries (Cape Verde, South Africa and Zimbabwe) [26] come close to or exceed 50%. Changes are occurring almost everywhere, though usually on a small scale. In 10 years, for example, contraceptive prevalence in Mali rose from 1 to 6%, in Benin from 2 to 7%, in Ghana from 5 to 13%, in Cameroon and Côte d’Ivoire from 4 to 7%.

72Except for seven or eight countries, the contraceptive revolution is still a long way off in Africa, though it has started in the large cities and the capitals. Some have only reached a contraceptive prevalence around 15% (e.g. Cotonou, Yaoundé, Abidjan, Libreville), but others verge on 25% (Ouagadougou, Dakar) or have even exceded 35% (e.g. Addis Ababa, Nairobi). Highly literate couples, who are a minority in every country, are everywhere between 30 and 50%. Although health centres do not yet diffuse contraception effectively among unmarried women, it is also gradually reaching that population, but at a different pace from one country to another.

73Nowadays it is no longer only a question of knowledge of contraceptive methods (there has been great progress in that area) [27], but at the same time a problem of demand on the part of a large majority of the population (as stated previously, the demand for children is still high among women, and still more so among men) and of availability of services (in terms of geographical or cultural accessibility as well as of quality).

74In the area of contraception, the situation in Africa differs from what is happening or has happened in Asia or Latin America in two major ways : 1) when contraception is practised in marriage, it is still mainly with a view to spacing births, more or less as a substitute for abstinence ; 2) therefore it relies on reversible methods (e.g. pill, IUD, rhythm), with very little female sterilization and no vasectomy at all. Outside of Southern Africa or Kenya, few countries practice stopping behaviour. The vast majority of African cultures still abhor sterility, sub-fecundity and early infertility. Everywhere the proportion of women who say that they do not want any more children increases substantially with age, but a wide gap still persists between stated desires, real expectations and behavioural change.

75Overall, as expected, modern contraceptive practice is negatively associated with fertility [28], even though the general level of the former is still low (13%). But the relationship is neither as clear nor as linear as in other parts of the world (Figure 7).

Figure 7

Relationship between total fertility rates and prevalence of modern contraception in 30 countries around 2000

Relationship between total fertility rates and prevalence of modern contraception in 30 countries around 2000

76A great variety of situations are observed. For a total fertility of 6 children, prevalence ranges from 5 to 25%. With low prevalence, national fertility rates range from 4 to 6. Countries like Ghana, Mauritania or Eritrea achieved a first fertility transition (from 6 to 4.5 children) without great diffusion of contraception. Even better, cities like Lomé, Yaoundé-Douala, Accra or Abidjan went down to 3 children with little contraception (10 to 15% only among married women), whereas others have achieved the same fertility rates with more common prevalence rates of 30 to 40%. Outside of Southern Africa or countries like Kenya, Cape Verde or Reunion, this confirms the fact that contraception plays an extremely variable and sometimes very small role as a fertility regulator.

4 – Induced abortion

77Probably even more so than in other regions of the world, abortion is a taboo subject in Africa that is little known and rarely addressed in the classic surveys. Its prevalence can only be inferred from declining fertility rates, particularly in the cities, but very few studies have been able to take it into account. According to a recent comprehensive review of the literature on Africa (Guillaume, 2003a), abortion would appear not to be only practised by young, unmarried women, but also to be a non-negligible means to control the number of children for women in unions, “more a method to space births than to limit family size”.

78On the basis of a special survey conducted in 1998 on 2,400 women in Abidjan, A. Guillaume (2003b) was able to measure the impact of abortion on fertility. In 1998 it reduced the total fertility rate (for women 15-44) by 12%, or by 0.6 children per woman. The effect on age-specific fertility rates was variable (22% at 15-19, 16% at 20-24, and 9% at 25-39). Abortion had virtually the same weight in the decline of fertility in that city between 1994 and 1999 as the postponement of first marriage and the rise of contraception.

79Resort to abortion, which is related to various economic, cultural and social reasons in the different countries, is probably on the rise in many African cities. It has — and will have — consequences not only on fertility, but also on maternal morbidity and mortality, in the absence of legalization and of adequate health structures.

1 – Progress between 1950 and 1990

81Starting from life expectancy figures that were particularly low in the 1950s (37 years for the region as a whole), all African countries achieved significant progress during the 1960s, 1970s and 1980s, with average annual gains of about 0.30 year (Table 9). Yet, over these four decades, Africa did not catch up with other regions of the world. Even the most rapid progress achieved on the continent, in Southern Africa (an annual gain of 0.42 year) or in Botswana (0.48 year), still lagged behind that recorded in other developing regions — 0.52 in North Africa, 0.66 in East Asia, 0.56 in Southeast Asia — from levels of life expectancy that were almost as low at the outset.

Table 9

Life expectancy levels in 1952, 1972, 1992 and 2002, maternal mortality and HIV prevalence around 2001 by sub-region

Sub-region Life expectancy Maternal mortality rate in 2000(a) HIV prevalence (%) in 2002(b) 1950-1954 1970-1974 1990-1994 2000-2004 West Africa 35.5 43.0 50.0 49.6 940 4.4 Central Africa 36.1 44.1 45.3 42.7 930 7.0 East Africa 36.3 45.0 46.0 43.1 960 10.1 Southern Africa 44.5 53.2 61.3 46.4 310 29.2 Total sub-Saharan Africa 36.7 44.7 48.6 45.7 870 10.4 North Africa 41.9 51.2 62.7 66.3 130 0.1 East Asia 42.9 64.2 69.4 72.1 60 0.1 Southeast Asia 41.0 52.0 63.3 66.7 260 0.6 South America 52.0 60.5 67.5 70.1 170 0.5 (a) Number of maternal deaths per 100,000 live births. (b) Both sexes together, ages 15-49. The HIV prevalence rate measures the proportion infected by HIV, whether or not they have AIDS. Sources : Tables A.8 and A.10 of the Appendix. The calculated sub-regional averages are non-weighted figures derived from national results. Cape Verde, Reunion and Mauritius are excluded from the averages because of their exceptionally good situation.

Life expectancy levels in 1952, 1972, 1992 and 2002, maternal mortality and HIV prevalence around 2001 by sub-region

82Obviously, the progress achieved up to the late 1980s was not uniform between countries, and this led to growing inequalities in health and mortality in the region. Around 1950, life expectancy (Table A.8 in the Appendix) ranged from 30 (Angola, Sierra Leone, the Gambia) to 51 years in Mauritius and almost 53 in Reunion. Around 1990, it ranged from less than 40 years (in war-torn countries such as Sierra Leone, Burundi, Angola) to 66 years (Cape Verde, Sao Tome and Principe), and even 70 years in Mauritius and 73.5 in Reunion, while it remained at the time between 45 and 53 years in many countries.

83Because of AIDS, wars and economic recession, these health transitions, which on the whole were already less rapid than elsewhere, slowed down or stopped abruptly during the 1990s.

2 – Stagnation and dramatic reversals since 1990

84From 1990-94 to 2000-2004, still according to United Nations estimates (Table A.8 in the Appendix), regional life expectancy stagnated in West Africa (at 50 years), went down by 3 years in Central and East Africa (43 years in 2002), and lost 15 years in Southern Africa where current life expectancy — 46 years — is the same as it was in 1955 ! Out of a total of 48 countries, 20 (including some 10 in West Africa) are still experiencing a slight decline of mortality, but more slowly than before. Life expectancy is stagnating in seven countries (e.g. Benin, Nigeria, Ethiopia), seven more have lost between 1 and 5 years of life expectancy since 1990 (e.g. Togo, Mozambique, Tanzania), five have lost between 5 and 12 years (e.g. Côte d’Ivoire, Cameroon, Kenya), and close to ten countries (mostly in Southern Africa) have lost between 12 and… 25 years [30]. The evolution can be characterized as a health crisis or even a catastrophe, but also as a paradox since the countries most severely affected are precisely the economically emerging countries of Southern Africa.

85In sum, the African countries have experienced diversified health and mortality evolutions in the last 15 years, as illustrated in Figure 8, where we distinguish between five types depending on the recent evolution of life expectancy : a) steadily progressing countries, b) recently stagnating countries, c) countries in marked regression, d) countries with complete reversal and e) war-torn countries [31].

Figure 8

The different health (life expectancy) transition patterns in sub-Saharan Africa from 1950 to 2005

The different health (life expectancy) transition patterns in sub-Saharan Africa from 1950 to 2005

86The irruption of AIDS in the 1980s and its rapid expansion in some countries during the 1990s is of course the cause of a number of these reversals, which were often spectacular and almost without precedent in the history of mankind. As mentioned above, about 15 countries are most severely affected. But in all the countries where mortality has stagnated in recent times, the effects of the economic crisis, of structural adjustment programmes that have disrupted the health and education sectors, and of poverty, have combined to cause a fresh upsurge of infectious diseases that had been “under control” until then (e.g. tuberculosis). There is also a group of countries (Figure 8) that in the last 15 years have been through bloody and sometimes protracted civil wars, culminating in genocide in Rwanda. All those conflicts obviously have direct, but also indirect, effects on the health and mortality of the population, through the dismantling of land tenure and agricultural systems, the slowing down or interruption of international assistance, population displacements, etc.

3 – AIDS : a general threat

87The latest overview of the situation by UNAIDS (2003) has confirmed the seriousness of the pandemic in sub-Saharan Africa. It is by far the most severely affected region in the world, with close to 27 million people living with HIV/AIDS in 2003 (out of a total of 40 million in the world), 3.2 million new cases of infection (out of a total of 5 million) and 2.3 million deaths (out of 3 million in the world) [32]. The prevalence of HIV/AIDS attains approximately 10% for the entire sub-Saharan Africa, as against less than 1% everywhere else (Table 9).

88But HIV prevalence varies considerably through the continent (Table 9), ranging at the sub-regional level from 4.5% in West Africa to almost 30% in Southern Africa. It is less than 2% in only six countries out of the 38 for which data are available (Table A.10 of the Appendix), between 2 and 10% in 20 countries, and more than 20% in seven countries, of which all the Southern African ones. A large proportion of African countries and societies are thus fully concerned by this unprecedented epidemic, which in general is far from being under control. Although HIV prevalence is decreasing in a few countries such as Uganda, where the fight against AIDS became a national priority, or in a few capitals (e.g. Addis Ababa in Ethiopia), the worst is yet to come in countries where prevalence shows no sign of levelling off (e.g. South Africa, Botswana, Lesotho) (UNAIDS, 2003).

89The major characteristics and the present or foreseeable consequences of AIDS in Africa are quite well documented. A few words will suffice for a simple summary. Unlike in developed countries, in Africa HIV transmission is mostly heterosexual, and the majority of seropositive women were in fact infected by their husband (Cohen and Reid, 1999). Mother-to-child HIV transmission during pregnancy, delivery or breastfeeding represents the other major mode of transmission of the virus in the region. Breastfeeding is responsible for about one third of the cases of vertical HIV transmission, and this risk constitutes a genuine public health issue. Prevention is quite complex, and there is no simple solution. The use of substitutes for mother’s milk also presents high nutritional and infectious risks, which may be even higher than those from HIV. The dilemma is all the more acute as the risk of transmission from an HIV-positive mother to her child is not absolute, and amounts to 20 to 40% (Desclaux and Taverne, 2000). Another characteristic of the epidemic in sub-Saharan Africa is that women are in proportion substantially more affected than men, by at least 20% (UNAIDS, 2003), because they become sexually active at a younger age, with older sexual partners, and because the risk of HIV transmission from men to women is higher than the other way around.

90The demographic consequences of AIDS have been discussed on several occasions. The most obvious consequence is the rise of mortality at adult ages (Timæus, 1999), and AIDS today is sometimes considered as the first cause of adult mortality in sub-Saharan Africa. For example, a study on Zimbabwe has shown that the probability of dying between ages 15 and 50 has increased almost threefold in 15 years, rising from close to 150‰ in the early 1980s to more than 400‰ in the late 1990s (Feeney, 2001). Child mortality, as we shall see below, rose also significantly in the more seriously concerned countries.

91The slowdown in population increase, and even the emergence of negative growth in the most severely affected countries that we mentioned, is a consequence of the increases in mortality. The slowdown, which is obvious but moderate at the level of the continent, is extremely serious in the Southern African countries. For example, the natural growth rate of Botswana is likely to be slightly negative during the 2000-2015 period, whereas it would have been about 2.2% but for AIDS. The population of Lesotho too will be decreasing slightly, whereas a 1.6% growth rate would have been observed if there had been no AIDS (United Nations, 2003b). Age structures, as we shall see in the instance of Zimbabwe, will also be disturbed by the sudden increase in mortality [33].

92Beyond its demographic effects, the AIDS epidemic naturally also has huge economic, social and health consequences. The population of working age is the most seriously affected by HIV/AIDS, and this results in a loss of human capital because of the rising mortality and a decrease in productivity among people suffering from AIDS. Health systems are also being greatly weakened by the epidemic, which absorbs a growing part of the available resources. Educational systems too are affected, particularly through the rise of mortality among teachers. Another important consequence of the epidemic is the rapid growth of the number of orphans, both in absolute and in relative terms. In Zimbabwe in 2001 there were already about 18% orphans among the under-15s, three-fourths of whom were orphaned as a result of AIDS.

4 – Maternal mortality still very high

93National maternal mortality estimates should probably be used with even greater caution than those on AIDS, in Africa as elsewhere. In the absence of data on causes of death, indirect estimations using the different possible definitions and methods of computation provide no more than plausible orders of magnitude [34]. The mortality of women during pregnancy, at delivery or in the next 42 days (in the WHO definition of maternal mortality) is very high on the whole in sub-Saharan Africa. With a regional average estimated at 870 deaths for 100,000 births (almost 1 woman for every 100 births), it is three times higher than in Southeast Asia, five times higher than in Latin America, seven times higher than in North Africa, and fifteen times higher than in East Asia (Table 9). In practical terms, 11% of the world population (sub-Saharan Africa) accounts for 47% of maternal deaths on the planet, which were estimated at 529,000 in 2000. One African woman out of 16 will incur maternal death during her reproductive life, as against one East Asian woman out of 840 and one European woman out of 2,400 (WHO, 2003). Those few figures illustrate the huge risks that mothers in Africa still run during their fecund life.

94When this is said, maternal mortality varies in Africa as do other phenomena (Table A.10 in the Appendix). It is very high on average (around 950 for 100,000 births) in West, Central and East Africa. At 310 in Southern Africa, it is still three times higher than in North Africa. Excepting Mauritius and Reunion where it is low, it ranges from 100 (Botswana) to 2,000 (Sierra Leone), with many countries between 700 and 1,200. Maternal mortality is clearly a major public health issue for the entire region. Without going into further details, maternal mortality is related both to the supply of health care (the quantity and quality of services) and to the demand of the population for antenatal care, conditions of delivery (place and type of assistance) and post-natal follow-up of mothers. It is also related to fertility (e.g. number of children, age at delivery) and to mothers’ health condition. Some of these aspects will be examined in the next section.

1 – Substantial progress since 1950, though slower than elsewhere

97In the 1950s, in all developing countries child mortality rates were extremely high. Close to one out of every six children died before they got to be one year old, and around one out of four died before age 5. Moreover, the differences between major world regions were not large (Table 10). Sub-Saharan Africa was then virtually at the same level as North Africa, South Asia or East Asia [36]. In 50 years, there has been substantial progress, though it was achieved at different paces.

Table 10

Infant mortality from 1952 to 2002 by sub-region

Sub-region Infant mortality rate (‰) Change (%) 1952 1972 1992 2002 1952-72 1972-92 1992-2002 West Africa 192 143 104 90 – 26 – 27 – 13 Central Africa 186 137 118 116 – 26 – 14 – 2 East Africa 182 134 109 97 – 26 – 19 – 11 Southern Africa 105 82 52 52 – 21 – 37 0 Total sub-Saharan Africa 180 134 105 95 – 26 – 22 – 9 North Africa 188 132 67 49 – 30 – 49 – 27 East Asia 181 56 43 34 – 69 – 23 – 21 Southeast Asia 168 108 55 41 – 36 – 49 – 25 South America 126 84 42 32 – 33 – 50 – 24 Source : Table A.8 of the Appendix.

Infant mortality from 1952 to 2002 by sub-region

98From 1952 to 1972 infant mortality in Africa declined almost as fast as elsewhere. Between 1972 and 1992 the decline was already not as rapid, but it is mostly since the early 1990s that the signs of its slowing down or stalling have multiplied. The decline amounted to 10% between 1992 and 2002 for the whole of sub-Saharan Africa, as against approximately 25% for all other regions (Table 10). As we shall see below, there has even been a recent upsurge of mortality in some countries.

99Today, with a current infant mortality rate of the order of 95‰, Africa is far behind the other regions, where rates range from 30 to 50‰. Since mortality between ages 1 and 5 is also very high at around 75‰ (Table 11), currently one African child out of every seven dies before age 5. And yet there has been some progress, though slower than elsewhere and slower than was expected in the 1980s, and variable from one sub-region and from one country to another. Southern Africa is still well ahead (with an infant mortality rate of 52‰), but has been making no further gains since AIDS (which involves mother-to-child transmission) began to spread. At the other extreme, Central Africa, riddled with conflicts and poverty, has the highest infant mortality rates (116‰), and here too no progress is taking place. East and West Africa are still making progress, but rather slowly. Now, let us to take a closer look at the changes.

Table 11

Mortality under 5 by age, conditions of delivery, vaccination and malnutrition by sub-region around 2000 (29 countries)

Sub-region Probability of dying (‰) % of deliveries unattended by trained staff % of children mal-nourished % of children vaccinated Neonatal < 1 year old 1-5 0-5 West Africa [11] 40 90 90 172 51 33 36 Central Africa [4] 38 84 70 148 44 31 25 East Africa [11] 38 92 66 152 58 42 55 Southern Africa [3] 27 56 26 81 26 28 65 Total sub-Saharan Africa [29] 37 86 72 152 50 36 45 Source and definitions of indicators : Table A.9 of the Appendix. The number of countries by sub-region is between parentheses. Sub-regional figures are non-weighted averages from national results. Cape Verde is not included because of its exceptionally good situation in West Africa. Zimbabwe is included in the Southern African sub-region.

Mortality under 5 by age, conditions of delivery, vaccination and malnutrition by sub-region around 2000 (29 countries)

2 – Increasing heterogeneity among the countries

100Figure 9 illustrates the diversity of the situations as well as of the progress achieved during the last forty years through the comparison between infant mortality in 48 African countries in 1960-64 and in 2000-04. Geographical inequalities in infant mortality widened considerably from the 1950s to the 2000s. In 1950-54, the rates ranged already from approximately 100‰ (South Africa, Mauritius) to 240‰ (Mali, Gambia, Angola). Nowadays they range from 30‰ (Cape Verde, Sao Tome and Principe) [37]to close to 180‰ (Sierra Leone), with rates between 90 and 110‰ in many countries (Table A.8 of the Appendix). The probability of dying between 0 and 5 varies currently from around 40‰ to almost 300‰ (Niger), for a ratio of about 1 to 7.

Figure 9

Infant mortality between 1960-64 and 2000-04 in 48 countries

Infant mortality between 1960-64 and 2000-04 in 48 countries

101Such growing heterogeneity is a result of the diversity in the pace of progress, which incidentally has little relation to initial levels. It is related to social policies (health, education, family planning), political history, the environment, and the degree of economic development in each country. In Africa, the mortality of children is closely related to the human development index [38]. And there are neighbouring countries that on the whole have the same climatic and cultural environment, and yet experience different situations. For example, the probability of dying between 0 and 5 is 108‰ in Ghana, while it is 146‰, 181‰ and 160‰ respectively for its neighbours, Togo, Côte d’Ivoire and Benin. A set of factors contributes to this lower mortality in Ghana. Though not much richer than its three neighbours (Table A.13 of the Appendix), Ghana is one of the sub-Saharan countries ranking highest in terms of human development (8th out of 47 countries), with a comparatively high level of adult literacy (72%), a slightly more effective infant and child health policy (Table A.9 of the Appendix), a higher prevalence of modern contraception (13% as against 7% in the neighbouring countries) and a somewhat lower fertility level (4.6 children per woman in 1998, as against 5.2 to 5.6 among the others).

102In all the countries, there is great spatial and social inequality in the mortality from 0 to 1 as well as from 1 to 5, often with threefold differences between the cities and the countryside or between social groups. We shall come back to this point later.

3 – Progress slowing down and mortality going up again in recent times

103The decade of the1990s was not favourable for children in large parts of Africa. Mortality is still declining in certain countries (e.g. Senegal, Benin, Tanzania), but progress is slowing down or halted altogether in many other countries. Worse, mortality has been rising to various degrees in the last decade for about ten countries (e.g. Zambia, Zimbabwe, Uganda, Kenya, Côte d’Ivoire, Cameroon). Figure 10 illustrates the diversity of the trends. It is based on the results of the latest two DHS in six countries that are representative of that diversity — Burkina Faso, Tanzania, Ghana, Côte d’Ivoire, Cameroon and Zimbabwe — over the years 1975 to 1998 [39]. It shows the evolution of the probabilities of dying from 0 to 5 and from 1 to 5, which have always been more sensitive to “shocks” and to progress than infant mortality.

Figure 10

A few examples of stagnation, slowing down of progress, and recent upsurge in the mortality of children

A few examples of stagnation, slowing down of progress, and recent upsurge in the mortality of children

104Along with Malawi, Guinea, Eritrea or Ethiopia, Tanzania and Ghana (which are both included in Figure 10) have on the whole made progress in the last 25 years, even if there was a slowdown in Ghana recently at ages 1 to 5. In Burkina Faso, where there seems to be more inconsistency between the two surveys, progress has halted and mortality is stagnating, as it is also in Mali and Gabon among others. Worse, mortality is rising again in Cameroon and Côte d’Ivoire, with consistent results between the two surveys ; as in Togo, Zambia, Nigeria or Kenya, the rise affects children aged 1 to 5 most of all, who are more susceptible to infectious diseases. Finally, Zimbabwe exemplifies the negative impact of AIDS on the mortality of children, which is also observed in Zambia, Botswana and, to a lesser degree, South Africa. In sum, as of 2000 many countries find themselves once again with the infant and child mortality rates of the 1980s.

105Those different or even diverging trends between countries, which are not related to the level of health development reached in 1990, must be attributed to a set of intertwined factors whose weight varies from one country to another : AIDS, of course, particularly in those countries most heavily affected, but also the deteriorating living standards and purchasing power in many countries, the dismantling of public health systems, the universal rise in health costs, which in Cameroon (Beninguisse, 2003) for example has caused notable changes in the behaviour and practices of the population (among the poor as well as among the middle classes) in such areas as antenatal care, delivery care or vaccination.

4 – A few examples of medical failings

106To illustrate the health situation in Africa and better understand those high rates of infant and child mortality, let us examine three practices that are essential to maternal and child health : antenatal visits, assistance at delivery, and vaccination.

107Table A.9 of the Appendix presents, for 30 countries with recent DHS, the proportion of births occurring without antenatal visits, the proportion of deliveries unassisted by medical or trained personnel, the proportion of children who receive the complete set of vaccinations (BCG, DPT, polio and measles), and the proportion of children in a state of medium or severe malnutrition. In Table 11 three of these indicators are given as regional average figures [40], along with the corresponding neonatal mortality, mortality under 1, from 1 to 5, and from 0 to 5.

108The proportion of women who have at least one antenatal visit varies considerably in the region, and sometimes even between neighbouring countries — from over 92% (in Cape Verde, South Africa, Kenya, Gabon, Uganda) to less than 40% in countries of the Sahel such as Niger and Chad or in Ethiopia (the most disadvantaged country by far in terms of child health) ; between the two extreme groups, it is around 70% in many countries. Everywhere, pregnancy is best monitored, and by far, in urban environments, and among educated and economically more privileged women (or couples).

109Similarly, Africa is still very far from supplying good medical assistance at delivery : 50% of all births in the region occur in the absence of a doctor, a midwife, a nurse or the equivalent (Table 11) ; most take place at home [41]. But it comes as no surprise that here too, wide inequalities are observed between countries. Less than 16% of deliveries are unassisted in Cape Verde, Gabon and South Africa, and almost 70% in countries like Burkina Faso, Chad and Rwanda, and even 90% in Ethiopia (Table A.9 of the Appendix). Without going into the details, there is no clear relation between the extent of medical assistance and the level of neonatal mortality by country.

110The diversity of situations is equally wide in terms of vaccination— one child out of three in West Africa, only one out of four in Central Africa, every other child in East Africa and two out of three in Southern Africa had all four basic vaccinations. Chad, Ethiopia, Niger and Nigeria (where fewer than 20% of children are vaccinated) stand at one extreme, and Tanzania, Zambia and Zimbabwe at the other (over 70%). Overall, less than one African child out of two was adequately protected around 2000.

111The living conditions, low purchasing power, poverty and at times extreme destitution make Africa a region where malnutrition is frequent and widespread. The successive surveys of the last 15 years register no gains in this area. Except for the small island countries (Cape Verde, Reunion, Sao Tome and Principe) where it is very low, malnutrition affects the whole of Africa, with the proportions of (moderately or severely) malnourished children ranging from 20% in Gabon and Togo to near 50% in Ethiopia, Madagascar, Zambia and once again, Nigeria (Table A.9 of the Appendix). Even Southern Africa, the richest sub-region, is not unaffected. Considering the close relationship between malnutrition and morbidity and mortality from infectious diseases, it is not surprising that mortality levels are high at ages 1, 2 or 3.

5 – Strong social and spatial inequalities within the countries

112Despite an economic and health situation that is more precarious and difficult than elsewhere, Africa is not spared growing social and spatial disparities in the area of child health and mortality. Without dwelling on this important issue, we take only the example of Nigeria, the country with the largest population (120 million). Table 12 shows the variability of mortality and health indicators by type of residence and mothers’ level of education. As everywhere else in Africa and the world, the urban sector of Nigeria is clearly advantaged compared with the rural world, even though the situation in the cities is far from perfect. All the mortality or health indicators are definitely better there, except for child malnutrition that is almost as high in urban (42%) as in rural (47%) areas.

Table 12

Mortality of children, conditions of delivery, vaccination and malnutrition in Nigeria (1999) by mothers’ educational level and type of residence

Variable Type of residence Educational level Total Urban Rural None Primary Secondary Higher Probability of dying from birth to age 1(a) 59 75 77 71 59 40 71 Probability of dying from 1 to 5(a) 52 74 87 55 39 13 67 Probability of dying from 0 to 5(a ) 108 143 157 122 96 53 133 % of childbirths with antenatal consultations 84 56 38 82 91 95 64 % of childbirths with trained assistance 58 35 15 55 74 89 42 % of vaccinated children (complete vaccination) 32 11 6 18 33 53 17 % of malnourished children(b) 42 47 56 40 38 37 46 Relative weight (%) of each group 31 69 41 23 30 6 100 (a) Per 1,000. These probabilities are slightly different from those in Appendix Table A.9 since the reference periods used for the calculations are not the same. (b) Height-for-age as a measure of chronic malnutrition (medium and severe). Source : 1999 DHS Country Report.

Mortality of children, conditions of delivery, vaccination and malnutrition in Nigeria (1999) by mothers’ educational level and type of residence

113Similarly, in Nigeria as elsewhere, the education of mothers (or couples) and their living standards (which are not presented here) play a considerable role in behaviour and health practices. Mortality at ages 0 to 5 varies in a ratio of one to three between extreme educational levels, and at ages 1 to 5 (which are more sensitive to health interventions) in a ratio of one to seven (Table 12). Inequalities are just as wide for the other health indicators, except again for malnutrition, which in Nigeria also severely affects the children of highly educated women (37%, a rather surprising result). Uneducated women (41% of the population), who are often in situations of poverty, are mostly excluded from the modern health system, particularly for deliveries and vaccination.

6 – Excess female child mortality in nearly one country out of two

114The differences in mortality between male and female children depend on both biological and socio-cultural factors. On the biological side, the facts are relatively clear and universal : boys are less resistant than girls from the outset, and hence more vulnerable to many infectious or congenital diseases. This causes — or should cause — excess male mortality in the early years of life. But the history of Europe as well as of the developing countries in the last 40 years has often belied that “law”. Two out of every three developing countries in the 1970s and 1980s, and still one out of two in the 1990s, experienced a clear excess mortality of little girls, particularly between 1 and 5 (Tabutin and Willems, 1995 ; United Nations, 1998). The biological and “natural” excess male child mortality has often been compensated by socially determined excess female child mortality, which is usually attributed to differences in the behaviour (e.g. attention and care) of communities, families or couples when confronted with a boy’s or a girl’s health or sickness.

115Sub-Saharan Africa was long believed to be free of that problem, which is particularly acute in North Africa, the Middle East, or South and East Asia. But more recent studies (Tabutin et al., 2001 ; United Nations, 1998), based on better statistical material, confirm that excess female child mortality is a fact in many African countries.

116On average for the continent, mortality rates are generally equal for both sexes [42] between ages 1 and 5, but this conceals very diversified situations. When there is excess mortality of girls at those ages, it is not as intense (about 7%) or widespread as in North Africa (15%), or in West and South Asia (15 to 20%), and has probably even declined between 1970-85 and 1986-98 ; yet it does still exist in half of the countries (Tabutin et al., 2001). It is geographically undetermined (as it is observed virtually everywhere, except in Southern Africa, from where it has disappeared) and bears no relation to religion (it is observed in Islamic as well as non-Islamic societies) nor to the wealth of the country or the social and health status of its population (it is found in such different countries as Mauritius and Niger). The city does not appear to be systematically more favourable to girls. As for mothers’ education, which usually has a very positive impact on the children’s mortality and health, it plays an ambiguous role in the inequalities between the sexes.

117Vaccination, which is usually carried out in the course of large campaigns, does not discriminate particularly against little girls. On the other hand, in many countries, particularly the poorest ones, girls are disadvan-taged in terms of medical visits and care when they are sick.

118Considering the heterogeneity of the situations in the region, sometimes even between neighbouring countries, the sexual inequality with regard to mortality is not explained easily, occurring as it does in societies which, however diversified, usually consider that girls as well as boys represent a potential source of prosperity for the family group or the lineage.

1 – The heterogeneous character of urbanization among countries

126In this respect too, there is great diversity in urbanization levels among sub-regions and among African countries (Table 14 and Table A.13 of the Appendix). Southern Africa, today as in the early 1950s, is far more urbanized than the other regions of the continent. Over half of its population lives already in cities, particularly as a result of South Africa’s relatively high proportion urban (58%). On the contrary, barely a quarter of the population of East Africa is urban, with extremely low levels in Rwanda (6%) and Burundi (9%) and a majority of countries around 30% (e.g. the Comoros, Kenya, Madagascar, Mozambique). The proportion of city dwellers is 39% in West Africa, and ranges from 17% in Burkina Faso to more than 60% in Cape Verde, with around 40% in about half the countries of the sub-region (e.g. Benin, Nigeria, Côte d’Ivoire). Finally Central Africa, with its population a little more than one third (35%) urban, is close to the continental average, but includes some of the most urbanized countries in Africa : Gabon (82%) and Congo (66%).

127On the whole, however, the heterogeneity in the degree of urbanization between sub-regions has lessened since the 1950s, as the least urbanized regions 50 years ago have experienced the highest urban growth. East Africa, for example, where the level was very low in 1950, underwent a particularly rapid growth of its urban population (an average annual growth of 5.9%) that was practically multiplied by 20 between 1950 and 2000, while the proportion urban was multiplied by 5. Urban growth has also been very rapid in West Africa (population multiplied by 15 in 50 years, annual growth of 5.4%, proportion urban multiplied by 4). In contrast, it has been more moderate in Central Africa (urban population multiplied by 9, growth rate of 4.4%) and relatively low in Southern Africa (multiplied by 4, growth of 2.8%) which, as previously mentioned, had started from a higher level. Finally, for the whole of sub-Saharan Africa, the urban population has grown at an average annual pace close to 4.8% over fifty years. This average conceals, however, a slight tapering of urban growth, which was slower during the 1980s and 1990s (when the annual growth rate was 4.6%) than during the 1960s and 1970s (5.0%).

2 – The emergence of the megalopolis

128The rapid growth of the urban population occurred concurrently with the emergence of large cities, and even a few megalopolises across the continent (Table 15) [46]. In 2000 Africa numbers 27 cities with more than 1 million inhabitants (including 19 capital cities), whereas there were only four (Lagos, Kinshasa, Capetown, Johannesburg) 25 years earlier, and none in 1950. The population of Lagos, the largest urban cluster in sub-Saharan Africa, approaches 9 million, or five times its size in 1975, and 30 times that in 1950 ! Kinshasa currently reaches 5 million, also 30 times larger than fifty years ago, and three times larger than in 1975. Abidjan is close to 4 million, and several other cities exceed 2 million people (e.g. Luanda, Addis Ababa, Khartoum). In some countries, over 20% of the total population and over half the urban population (Table 15) live in these large cities (Abidjan) or capitals (Dakar, Luanda, Brazzaville). In others, a much smaller proportion live in the capital, though the latter is sometimes quite a large city. A diversity of urban systems are thus to be found in Africa, and not a single macrocephalous model (Dubresson, 2003).

Table 15

Population of selected capitals between 1950 and 2000, and projection to 2015

City Country Population (in thousands) 2000/1950 ratio 2000/1975 ratio % of the total population of the country in 2000 % of the urban population of the country in 2000 1950 1975 2000 2015 Abidjan(a) Côte d’Ivoire 59 960 3,790 6,076 64.2 3.9 24 54 Addis-Ababa Ethiopia 392 926 2,645 4,932 6.7 2.9 4 27 Bamako Mali 62 377 1,114 2,143 18.0 3.0 10 32 Brazzaville Congo 216 340 1,306 2,259 6.0 3.8 43 66 Dakar Senegal 223 768 2,078 3,481 9.3 2.7 22 46 Dar-es-Salaam Tanzania 78 638 2,115 4,080 27.1 3.3 6 19 Harare Zimbabwe 84 529 1,791 3,013 21.3 3.4 14 40 Khartoum Sudan 182 896 2,742 4,687 15.1 3.1 9 24 Kinshasa DR Congo 173 1,735 5,054 9,883 29.2 2.9 10 33 Lagos Nigeria 288 1,890 8,665 15,966 30.1 4.6 8 17 Luanda Angola 138 669 2,697 5,144 19.5 4.0 20 60 Yaoundé Cameroon 50 276 1,420 2,281 28.4 5.1 9 19 (a) Formerly the capital (until 1983). Source : United Nations (2002d).

Population of selected capitals between 1950 and 2000, and projection to 2015

129These large cities will go on growing in number and their size will increase in the coming decades. They will absorb a growing proportion of the African urban population (Dubresson, 2003) [47]. However, the pace of growth is likely to decrease, in line with the slowdown that is already taking place. Thus, for the 12 cities in Table 15, the annual growth rate, which was an average 6.7% during the period 1950-1975, was 5.0% between 1975 and 2000, and is expected to be a mere 3.8% between 2000 and 2015, according to United Nations projections.

3 – A slowdown in urban growth

130The slowdown is observed not only in the major cities, but often also in the rest of the urban world. Although the extent of the slowdown is a matter of debate, depending on the sources of data used, several recent studies suggest that the pace of urban growth in Africa has abated (Potts, 1995), or even that certain countries such as Côte d’Ivoire or Zambia are undergoing de-urbanization (Beauchemin et al., 2004). The slowdown varies between regions and countries, and reflects both a decline of the rate of natural increase in cities and, most of all, a slowing down of migration to the urban areas and sometimes an intensification of return migration to the countryside (Beauchemin and Bocquier, 2003 ; Potts, 1995 ; Potts, 2000). The part played by migration in urban growth in Africa has thus significantly diminished since the 1960s (Bocquier, 2003 ; Chen et al., 1998), among other reasons because of the effects of economic crises and of the structural adjustment programmes initiated from the 1980s onwards (Beauchemin and Bocquier, 2003 ; Becker et al., 1994). This put a brake on recruitment into the civil service and increased unemployment, particularly among young people.

1 – From the 1960s to the 1980s

138Since the early 1960s, i.e. the period of decolonisation, migratory flows from sub-Saharan Africa to the developed countries have been increasing [55]. In the early 1960s about 17,000 individuals migrated yearly from sub-Saharan Africa to Western Europe, North America and Oceania taken together, as against nearly 80,000 in the late 1980s (Table 16) [56]. Europe witnessed a period of large increase first between the 1960s and the 1970s, with annual numbers rising from under 14,000 to over 50,000 migrants. This was followed by a slowdown in the late 1970s and the early 1980s, and by a new spurt until the numbers reached 51,000 migrants around 1990. The increase of the flow to North America and Oceania was more steady, rising from 4,000 migrants annually to approximately 26,000 in the late 1980s. Thus, around 1990, the United States, Canada, Australia and New Zealand received a larger proportion of African migrants than in the early 1960s (34% as against about 20%). Europe, with two-thirds of the total, remained by far the primary destination among the developed regions.

Table 16

Average annual numbers of immigrants from sub-Saharan Africa to the developed countries from 1960 to 1991

Destination 1960-64 1965-69 1970-74 1975-79 1980-84 1985-89 1990-91 North America 1,900 4,105 10,094 15,817 17,506 20,942 16,191 Oceania 2,072 2,722 3,832 3,124 4,454 5,708 3,960 Western Europe 13,287 37,688 50,998 42,254 37,368 51,644 – Total 17,259 44,515 64,924 61,195 59,328 78,294 – Europe as % of the total 77.0% 84.7% 78.5% 69.0% 63.0% 66.0% – Note : North America includes the United States and Canada, Oceania includes Australia and New Zealand, and Western Europe includes Germany, Belgium, France, the Netherlands, the United Kingdom and Sweden. Source : Zlotnik (1993).

Average annual numbers of immigrants from sub-Saharan Africa to the developed countries from 1960 to 1991

139The increase in the flows to the United States, Canada and Australia is a sign that the destinations of African migrants are diversifying, as they are within Europe too. Whereas in the 1960s and 1970s the main migration flows went mainly from the former colonies to the former colonial powers (France, Britain, Portugal, Belgium), the symmetry no longer applies, with the growing importance of migration to such countries as Italy, the Netherlands or Germany (Hamilton, 1997 ; Zlotnik, 1996). The Gulf countries also seem to be an increasingly popular destination for African migrants, particularly the more educated ones (Adepoju, 2000).

2 – Since the early 1990s

140Despite what might have been expected with the increasingly strict migration policies enforced in the rich countries, migration to those countries continued to increase during the 1990s (Hamilton, 1997). For example, in France, the annual number of migrants from sub-Saharan Africa has more than doubled from 1994 to 2001, rising from 11,000 to 26,000 migrants, a much faster increase than that of migrants from other regions except North Africa (Table 17) [57]. On the whole, the former colonies are still the main countries of emigration — in 2001 Senegal ranked first, before Cameroon and Côte d’Ivoire. However, the Democratic Republic of the Congo is an exception, as the main country of origin of migrants from sub-Saharan Africa in 1994 and 1997. The share of sub-Saharan Africa in the migration to France rose from 9% in 1994 to more than 14% in 2001, and that of North Africa from 20 to 29%.

Table 17

Long-term immigration by year of admission as regular residents in France, 1994-2001

Origin 1994 1995 1996 1997 1998 1999 2000 2001 Sub-Saharan Africa 11,316 9,852 10,179 18,652 27,880 19,776 22,427 26,325 Including : Senegal 1249 1,282 1,257 2,023 3,175 2,678 3,422 3,694 Cameroon 675 668 768 1239 1798 1499 2,039 2,672 Côte d’Ivoire 812 831 958 1,402 2,020 1,688 2,187 2,648 Mali 441 416 491 1,533 3,962 2,051 1,856 2,124 Congo (D.R.) 1293 767 785 2,784 3,620 1,623 1,369 1,620 North Africa 23,432 18,758 19,164 27,963 37,004 34,230 41,754 52,428 Europe (incl. Turkey) 61,216 55,680 54,212 54,232 59,322 61,195 61,912 64,010 Asia 13,123 11,177 11,447 14,972 19,668 17,759 21,001 25,234 Americas 9,797 9,216 9,352 10,256 11,255 11,498 12,776 14,083 Other 679 1,497 1,632 1,356 750 662 558 614 Total 119,563 106,180 105,986 127,431 155,879 145,120 160,428 182,694 Source : Data kindly supplied by X. Thierry, with an update of his 2001 article (Thierry, 2001).

Long-term immigration by year of admission as regular residents in France, 1994-2001

141We shall not consider the various factors behind the migration from sub-Saharan Africa. Suffice it to say that motivations for coming to Europe, particularly to France, have changed noticeably. Whereas up to the mid-1980s, migration was mainly related to employment, it is now related more to family reunification, education and requests for asylum (Thierry, 2001).

1 – Illiteracy remains a real problem, particularly among women

145In the last 30 or 40 years, considerable progress has been achieved in the matter of education across the world. The phrase “schooling explosion” has even been used to describe the joint population growth and expansion of school systems (UNESCO, 2003 ; United Nations, 2003a). But despite such substantial progress, illiteracy remains very widespread, affecting 40% of adults in the Arab world and sub-Saharan Africa, and 45% in South and West Asia. Much lower levels — about 12% (Table 18) — are found in Latin America and East Asia. In Africa, the number of illiterate individuals continues to grow as a consequence of population increase.

146Everywhere in the world, women are most affected by far, with illiteracy rates that are 1.2 to 2.4 times higher than those of men. For similar levels, on average the differences between men and women are slightly smaller in sub-Saharan Africa than in South or West Asia or the Arab world.

147In this area too, there are currently wide inequalities in Africa, with proportions of individuals who can read and write that are on average [60]45% in West Africa, 64 to 68% in Central and East Africa and 81% in Southern Africa, and national levels only around 20% in Sahel countries such as Niger, Mali or Burkina Faso, and at the other end of the spectrum over 80% in all the countries of Southern Africa (Figure 12).

Figure 12

Literacy rates (in %) for men and women in 38 countries in 2000

Literacy rates (in %) for men and women in 38 countries in 2000

148Except for those few countries where the vast majority of the population can read and write, all the other African countries present strong disparities between men and women ; the lower the educational level, the wider the disparities (Figure 12). The fight against illiteracy and gender disparities is far from over. Let us now look at schooling among young people.

2 – Insufficient school enrolment and a great variety of situations in Africa

149While there is hardly any difference between Africa and some other regions in the world (North Africa, South and West Asia) in terms of illiteracy, there are differences in primary schooling (Table 18). In 2000, with a rate of 64% (for both sexes together), the region was far behind the Arab world (81%), South and West Asia (81%) and of course East Asia (93%). On the other hand, with girls’ school enrolment lower by 10% on average, inequality by sex, though real, is not greater than in North Africa or South Asia.

150As in the case of illiteracy, the disparities between countries are still wide (Figure 13). On the one hand, in the Southern African nations and in Gabon and Cape Verde, over 80% of the children are enrolled in primary schools ; on the other hand, in such countries as Niger, Burkina Faso, Angola and Djibouti, the rates are as low as 30%.

Figure 13

Net rates (%) of primary school enrolment by sex in 32 countries in 2000

Net rates (%) of primary school enrolment by sex in 32 countries in 2000

151Inequality between the sexes is on the whole less important than for adult illiteracy. It is true that for the entire region, school enrolment rates for girls are 11% lower than for boys [61], but in 13 countries with markedly different overall levels of education, equality between the sexes is virtually a fact. On the other hand, in countries like Benin, Côte d’Ivoire, Chad or the Central African Republic, girls’ school enrolment rates are lower by approximately 30%. In the last 30 years, much progress has been achieved, without resulting in an important decline of discrimination against girls. In addition, the question is now raised, and legitimately, of the effects of economic recession, the recurring decline of purchasing power and the increasing cost of education (because, for example, of the privatisation of parts of the educational system) on the demand for schooling on the part of the parents, and its effect on the disparities between boys and girls. The various historical, economic and cultural factors underlying this persisting inequality will not be discussed here [62].

3 – Education in relation to fertility and infant mortality in the various countries

152For all the developing countries together, the classic observation is that fertility or infant mortality and the countries’ educational level are fairly closely related. What is the situation in sub-Saharan Africa in 2000, with respect to the women’s literacy levels ?

153The correlation with fertility is relatively strong, explaining 45% of the variance (R²), and negative as expected (Figure 14). Overall, the higher the proportion of literate women, the lower the fertility in a country. The correlation is higher than with men’s literacy (R² = 0.31) (not presented here). It is also quite close to the relation obtained (R² = 0.39) among 152 regions of Africa, using the proportion of women aged 15-49 with no education (Tabutin and Schoumaker, 2001). The correlation between fertility and education is slightly lower in Africa, however, than elsewhere, where the R² may be as high as 0.60. The relation is present, but it is far from perfect (Figure 14). This is not surprising : in particular, fertility is quite variable among countries where literacy rates exceed 60%.

Figure 14

Relationship between fertility and adult women’s literacy in 38 countries in 2000

Relationship between fertility and adult women’s literacy in 38 countries in 2000

154The correlation with infant mortality (Figure 15) is weaker (R² = 0.31), though still quite significant. Of course it is negative overall, but with greater variability at low levels of literacy (around 30%) as well as at higher levels (over 60%). When calculated with male literacy, the coefficient drops to 0.20.

Figure 15

Relationship between infant mortality and adult women’s literacy in 38 countries in 2000

Relationship between infant mortality and adult women’s literacy in 38 countries in 2000

155Such brief synchronic analysis at the aggregate level simply confirms the non-negligible role of educational development, and more particularly that of woman’s education.