Traditional supports and contemporary disrupters of high fertility desires in sub-Saharan Africa: a scoping review

In terms of geographic coverage of the 258 relevant pieces, most countries (91%) in SSA are represented, with West Africa having the largest concentration. Figure 2 shows the number of studies from each country.

Fig. 2figure 2

Included studies by country

Most pieces were published after the year 2000. Quantitative studies were overrepresented, constituting 154 of the 258 pieces. There were 64 qualitative studies and 36 mixed methods studies. Table 2 presents each determinant in terms of how many studies examined it and its role as a traditional/historical support or contemporary disrupter of high fertility. We have categorized the determinants from Table 2 into six overarching themes: economy and costs; marriage; mortality and health; the influence of others; education and status;  and demographic predictors. Within each of these six themes, we review the evidence on both traditional supports and contemporary disrupters of high fertility desires.

Economy and costs

Children have long been viewed as economic resources for families and as providing security for parents in old age in SSA. Most studies (n = 63) found that viewing children as economic resources and children providing security for their parents in old age (n = 51) increased desired fertility. Having many children provides families with additional labor, and this economic value of children is especially high in agricultural societies, rural areas, and for poorer families. Amongst these groups, having many children can help with farming and trading. In the absence of governmental social support programs for the elderly in SSA, support and care from children remains important and not easily replaceable. Thus, having children to take care of elderly parents is important, and this is particularly true for women, especially if their spouse dies [24,25,26,27]. Having daughters is important for this reason, as most people expected that their daughters would be more likely to support them in old age than their sons [28]. One study found that having too many children can backfire, because one can only reap the benefits of old-age support if the children are raised properly. Thus, there may be quantity/quality tradeoffs where having too many children might render parents unable to invest enough effort into any one child and help secure their future success [29].

Increasing urbanization and changing economic conditions have altered the value of children. Almost all included studies on economy and costs (n = 60) found that recent economic changes, which have had the effect of increasing the cost of children, have decreased desired fertility. While children are still considered a source of wealth in more rural parts of SSA, they are increasingly seen as expensive burdens in urban areas where the cost of raising children and a higher overall cost of living outweighs potential economic returns. Widespread unemployment and increases in the cost of living have shaped the perceived value of children for urban residents of SSA. Among urban residents, education is perceived as improving future prospects for their children, a perception less prevalent in rural areas where farming and other agricultural occupations are still very common and require little, if any, formal schooling. Furthermore, many urban residents choose to have fewer children due to high schooling fees, so they can afford to invest more heavily in each child [30,31,32,33].

Several studies (n = 10) found that environmental factors—natural disasters, droughts, long-term climate change—have decreased desired fertility. Several mechanisms account for this. First is food shortages, leading to a recognition that fewer children can be supported [34,35,36]. Second, a decrease in cash crops and agricultural yield reduces the economic value of children [37,38,39,40]. Importantly, in many studies respondents indicated that while they continue to desire a large number of children, they had come to the conclusion that this was ill-advised under current conditions [15, 39, 41,42,43]. As a respondent in Agadjanian’s (2005) study states, “Now it seems that people don’t want to have many children, but it is not so. We want more children, but because of the [economic] situation we can’t” [15]. One can infer that improvements in economic conditions might lead to increased fertility rates.

Economic downturns often lead to increased migration for work and other opportunities. Migration is in turn associated with fertility desires, but this literature is limited (n = 4). Women married to successful migrants (e.g., those who found steady employment) were less likely to want to stop childbearing compared to women married to unsuccessful migrants [44,45,46]. Spousal migration may be important to consider in its influence on women’s fertility desires. In Rwanda, residents in high-migration areas were less likely to want a/another child than residents of low-migration areas, but this was likely driven by the proportion of refugees in high-migration areas [47].

Marriage

Several pieces (n = 74) investigate fertility desires in relation to type of marital union (monogamous vs. polygynous). This collection of studies shows that polygyny both encourages higher fertility desires as well as serves as a mechanism for realizing high fertility desires. The bulk of studies (n = 47) found that polygyny was associated with higher fertility desires. Men can acquire additional wives with the purpose of achieving their desired family sizes and compositions. A small number (n = 6) found no significant difference in fertility desires between monogamous and polygynous unions. Additionally, preferences for male children may motivate entrance into polygynous unions, and high aggregate fertility desires have been found to be significantly associated with the presence and prevalence of polygyny in a community [90]. Qualitative studies provided more detailed insight into the structure and expectations of polygynous marriages and found that women expect and want to have many children because increased childbearing wins favor in competition between co-wives [50, 61, 62, 91]. The rank and placement of co-wives moderates individual women’s fertility desires with senior wives being more likely to desire no more children than junior ones, and this is shaped by age and parity [92]. In some cases, as they age and/or attain their desired fertility, senior wives may welcome a junior wife who can take on further childbearing responsibilities.

Apart from the matter of union type, several studies (n = 29) indicate that women's efforts to promote marital stability and secure spousal rights  were common reasons women wanted more children, with the caveat that too many children can also strain a marriage. A break-up of the union would place extra burden on the women for feeding, educating, and generally caring for their children. Some women felt pressure to conceive, especially after an abortion or fetal loss, to avoid marital strife [93]. When a wife does not want her husband to take another wife, she may increase her desired family size to match his [40]. Higher fertility can strengthen the wife’s relationship with her in-laws [94]. Women may also try to gain status within their marriage by having more children to persuade their new husband to accept children from a previous marriage [95].

Several studies (n = 15) found that spousal influence increases desired number of children, with both sexes willing to defer childbearing decisions to the more pronatalist partner. With men likely to be more pronatalist and with a wife’s fertility intentions more likely to be influenced by her husband’s fertility desires than vice versa, spousal influence often plays out in gendered ways [96]. Additionally, several studies (n = 17) found that spousal joint-decision making or discussion about family size decreased desired fertility for both spouses. In some cases, though, spousal discussion increased desired fertility when wives’ preferences were influenced by their spouse’s preference for more children [74, 97, 98]. Women who are older, have more than two children already, and desire to cease childbearing, have reported higher confidence in spousal communication on these issues, demonstrating that it is important to consider the potential implications of spousal discussion on fertility desires in the context of a highly patriarchal society [93].

Smaller ideal family sizes have been found among divorced/separated and widowed women compared to currently married ones [66], and remarriage often lends itself to higher fertility desires to accommodate the preferences of a new spouse [32]. Remarriage during and immediately after war—a survival strategy for women—can mean raising their desired fertility to have children with their new husband [95]. Specific circumstances of a marriage can also affect fertility desires. A higher age at marriage is associated with a lower desired number of children, and a larger age difference between spouses is associated with a lower desire to limit fertility compared to a smaller age difference [99].

Mortality and health

Forty-four studies found that high rates of infant and child mortality increase desired fertility. Both men and women endorse having many children where mortality rates are high [100]. Those with direct experience of child death are more likely to engage in replacement and insurance strategies—having many children to ensure some survive to adulthood—in case future children also die [100, 101]. As SSA shifts from a high mortality to lower mortality regime, insurance strategies are no longer necessary in most contexts, but there can be cultural lag where structural conditions have changed but individual fertility desires and behaviors do not immediately adapt [102]. In the case of war or other traumatic violence, where mortality rates of children rise, included studies suggest that people may respond in one of two primary ways. They may wish to decrease childbearing or have no more children because of the effects of trauma on their physical and/or psychological well-being as well as a fear of bringing children into a world with greater uncertainty of future peace [47, 103,104,105]. Others may wish to have additional children to make up for ones that were killed, or for security in case of future war or violence which may subsequently increase mortality [95, 106]. The death of other family members also influences fertility desires. The death of a sibling is negatively associated with a preference for a large family [106], while the recent death of a parent led both men and women to desire more children [107]. When children’s parents die, other individuals may foster orphaned children. Fostering a child is associated with increased odds of reducing one’s ideal family size, indicating that foster children can contribute to achieving ideal family size in ways similar to biological children [108].

While we excluded studies that examined the fertility desires of HIV + individuals for reasons already described, we did include studies (n = 20) that examined how the context of the HIV/AIDS epidemic shapes fertility desires for HIV − individuals. There is a great deal of fear and stigma associated with HIV/AIDS, even for those who are not positive themselves. The sex of the participant influenced the effect of HIV/AIDS on desired fertility with women being more likely to fear HIV infection and, thus reduce desired fertility [101, 109]. Knowing someone with AIDS, high community mortality levels, and household child death were significant predictors of lower desired fertility for women but not for men [101].

Women’s perceptions of their own health also affect their fertility desires. Increased awareness of the detrimental health impacts of high parity and short birth spacing—awareness promoted by formal schooling and family planning programs—leads to reduced desired fertility [98, 110,111,112,113,114]. Women who participated in focus groups cited being tired of giving birth, too old, or of poor health as reasons for wanting to stop childbearing [115]. They also noted the toll that consecutive childbearing, breastfeeding and managing a large family takes on their bodies [93]. Difficult pregnancies and births may alter women’s initial fertility aspirations. When a woman thought that a pregnancy would threaten her health, her odds of wanting to stop childbearing increased [98]. Furthermore, women cited that the social value of their bodies declined with age and repeated deliveries; longer birth spacing and/or fewer births permitted them to remain attractive and physically fit [61].

Influence of others

This theme encompasses the influence of other individuals or groups beside spouses on people’s fertility desires as well as the influence of social and cultural norms on fertility desires. Some studies found that larger families of origin were associated with a higher likelihood of desiring more children compared to respondents with smaller families of origin [44, 116]; this was particularly strong for men [116]. In one qualitative study on women who desired to be childfree, participants cited their large families of origin and amount of time spent mothering siblings and other children as a reason behind their decision [117].

Several studies (n = 22) found that desired fertility is influenced by family networks, and this effect varies according to which member of the family is the primary source of influence. For example, mothers-in-law or individuals’ own mothers may be particularly salient influences for increasing desired fertility [118]. Young people often felt the weight of their parents’ expectations that they would and should have children [119].

Many studies (n = 48) found that having many children can bring social status and prestige to families and communities. Large family size can symbolize and bring wealth, influence, and respect for men and women, and having many children can expand their social networks and may elevate them above their peers [48]. Often, rather than relying on their personal evaluation of resources, individuals rely on community perceptions and norms to determine their own fertility desires [120]. Observation of neighbors and other large families can influence individuals’ own ideal family sizes [120]. Some studies found that observing small families prompted participants to desire smaller families themselves and facilitated communication about family planning within their networks [15, 52, 67, 121, 122].

Three quantitative studies found no relationship between community influence and desired fertility; in these studies, community influence was operationalized as adolescent’s and women’s social interaction with their peers and/or community [96, 97, 123]. However, some individuals said their desired number of children was influenced by their local clinic(s), which might expand our conception of who is included in the ‘community’ and who might have influence on community members [120].

Another cultural and social norm that can influence fertility desires is gender/sex preference. In many communities, male offspring are more highly valued than female, and this preference has an effect on fertility desires, with extended childbearing in order to have male children a common practice [41]. Most studies (n = 32) found that persons who hold a sex preference have higher fertility desires. Five studies found that sex preference had little to no influence on desired fertility in settings where the desire for additional children was so comprehensive that children were highly valued and desired irrespective of sex [111, 124,125,

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