Letter: Effect of Contraceptive Access on Birth Rate

Letter in response to the Perspective “REPRODUCING IN CITIES” by Mace published in Science February 2008 in Science

In her Perspective “Reproducing in cities” (8 February, p. 764), R. Mace assumes that differences in birth rates between rural and urban areas largely represent the wishes of parents. Human beings in all societies have sexual intercourse hundreds or even thousands of times more often than is needed to conceive the number of children they want. Once individuals have access to the means and information to separate sex from childbearing, family size often falls rapidly (1). For rural women there are an astonishing number of barriers to access to modern contraception (2), while urban women are often better placed to overcome these barriers.

We suggest that birth rates fall in cities primarily because contraception and safe abortion are easier to obtain than in the countryside. For example, in rural Ethiopia only doctors and nurses are permitted to give contraceptive injections, so this popular method is denied to rural women. The total fertility rate (TFR) in Ethiopia as a whole is 5.4, while in Addis Ababa it is now thought to be below 2.0 children. Addis is unusual among African capitals in that safe abortion was available for several years before the recent liberalization of the abortion law. Tens of thousands of operations were performed annually and linked to effective post-abortion contraceptive advice.

We posit that fertility will fall in rural Ethiopia as contraception and safe abortion become more easily available. In Bangladesh, where many women now have access to modern contraception and reasonably safe abortion, two large predominantly rural areas (Khulna and Rajhashi) now have replacement-level fertility (3).

Published in Science, May 16 2008, 874