The American University in Cairo UNFPA/ASRO Social Research Center Policies to Address Fertility Plateau October 2011

Table of content Nature of The Project Aim of The Project Sequence of Project Activities Main Findings of The Background Report 1.International Experience 2.Egyptian Context Evidence Based Policy Recommendations

Nature of The Project The project is conducted by the Social Research Center of the American University in Cairo in partnership with UNFPA/ASRO The first phase involves Egypt while the second phase proposes partnership with Jordan and Syria

Aim of The Project To study the reasons behind the deceleration of fertility decline in Egypt, and recommending a number of policies and programs to face this plateau. To conduct a scientific meeting to discuss the results and recommendations of the studies to the decision makers, researchers, civil society, and interested partners.

Sequence of project activities Background report was conduced in Oct to review the international and Egyptian experience The report suggested a number of research topics to tackle fertility challenges in Egypt Technical meetings were conducted to discuss the suggested research topics with the experts and decision makers, along with the participation of representatives from Syria and Jordon.

Sequence of project activities (cont.) The suggested research topics were assigned to research experts. A meeting was held to discuss the preliminary findings. This meeting was attended by the researchers, officials from the ministry of health and population, and different stakeholders. A final report with policy recommendations is yet to be finalized.

Main Findings of The Report 1) International Experience Showed that Government commitment is essential to a society’s fertility transition as the importance of a sufficient and organized public family planning service. (Costa Rica and South Korea) Encouraging social and economic development to form a basis for reducing the demand of children in developing countries (empowerment of women, standard of living) (Kerala in India and Sri Lanka)

1) International Experience (Cont.) Strengthening the family planning program focusing on reduction of the number of unplanned pregnancies as well as the unmet need for contraception. (Costa Rica and South Korea)

2) Egyptian Context The Challenge Fertility preference in Egypt is still (2.9) children per family for all geographic regions, educational levels, and employment status of women. The suggested research topics Can work, education, and female empowerment help to reach replacement level? A Qualitative Study to assess the current attitudes and perceptions toward the two child norm in Egypt and the influence of religion. Family formation and fertility desires and behavior among youth and their future implications. Profile of women who desire two children and how to scale up their experience The Policy Dimension Influencing the desired number of children per family.

2) Egyptian Context (Cont.) The Challenge The actual level of fertility is around the same level as the desired (3.0) and above the targeted. The suggested research topics Why urban areas did not complete their transition to replacement levels and how to influence this transition? Actions to speed-up fertility decline in rural areas and their potentials to avoid future stalling in fertility Family formation and fertility desires and behavior among youth and their future implications. The Policy Dimension Supporting a lower level of actual number of children

2) Egyptian Context (Cont.) The Challenge Different patterns: Rural Upper Egypt fertility is still declining while other urban and rural areas are showing fertility plateau. Trends in the TFR for Different Regions

2) Egyptian Context (Cont.) The suggested research topics Why urban areas did not complete their transition to replacement levels and how to influence this transition? Actions to speed-up fertility decline in rural areas and their potentials to avoid future stalling in fertility The Policy Dimension Adopt & design a disaggregated approach to reduce fertility in different geographical areas

2) Egyptian Context (Cont.) The Challenge There appears to be a service potential missed in the form of unmet need for women especially in rural areas (10.9 %), and discontinuation of use (25.9 %) due to side effects of contraceptives (9.4 % of discontinuers). The suggested research topics Actions to speed-up fertility decline in rural areas and their potentials to avoid future stalling in fertility Are urban areas reflecting a missed service potential? The Policy Dimension Address missed service potentials

2) Egyptian Context (Cont.) The Challenges Changes in the organizational structure Uncertainty of international funding (contraceptives, surveys) Reproductive health model is perceived as a competitor to the family planning program Signals of backlash The Suggested research topic Analysis of structure and current fertility policies and recommendations for the future (pillars, institutional framework, new initiatives, proposed reforms) The Policy Dimension Improve the organizational and administrative component of the program

Fertility preference around 3 for all geographic regions. Actual fertility around desired & above target Different patterns, In different geographical areas There is a service potential missed Unstable organizational structure of FP Uncertainty of international funding RH model is perceived as a competitor to FP Signals of backlash Profile of women who desire two children and how to scale up their experience. Can work, education, and female empowerment help to reach replacement level? A Qualitative Study to assess the attitudes & perceptions toward the two child norm & the influence of religion. Family formation and fertility desires and behavior among youth Why urban areas did not complete their transition? Actions to speed-up fertility decline in rural areas. Analysis of structure and current policies and future recommendations Influencing the desired number of children per family. Supporting a lower level of actual number of children Adopt & design a disaggregated approach to reduce fertility in different geographical areas Address missed service potentials Improve the organizational and admin. component of the program

A. Fertility desires are still high (Collective direction): because there are key challenges around gender empowerment, youth ideational values, narrow religious interpretations. Findings

i. Women employment per se is not an influencing factor Women employment does not necessarily lead to lower desires/fertility. Low skill jobs are associated with higher fertility levels. Interestingly, women having jobs with low security are associated with higher risks of having 4 or more children. Distribution of respondents by number of live birth and index of job quality Findings (cont.)

ii. Youth do not portray different ideational norms Among the unmarried (15-29), the Mean Ideal Number of children (MINC) is 2.7 among male young people and 2.6 among females. Among those married, the MINC is 2.8 among males and 2.9 among females iii. Religious based interpretations are negatively affecting desires/practices. While FP practice is socially acceptable, it is not acceptable according to some religious points of views 20% of women think that religion is against the use of family planning methods

iv. Profile of achievers (40+) reflects High access and utilization of health centers: place of birth not at home (100% vs. 74.3%) Husbands’ support: don’t desire more children (84.7% vs. 75.8%) Higher level of education (67.7% vs. 40.3%) Higher rate of participation in the labor market (47.8% vs. 24.6%) Higher standard of living (48.3% vs. 25.5%)

B. Markedly different challenges for different regions and within regions (Spatial direction) i. Among regions Failure of the practices in rural Egypt to fully capture changes in demand. The Urban governorates showed the lowest rates of unmet needs for FP (5.9%) followed by urban lower Egypt (6.4%). While rural upper Egypt displayed the highest rates of unmet needs (15.4%).

TFR between slum and non-slum in Greater Cairo ii. Within regions (Urban areas) Different Urban regions are not homogeneous in their characteristics. Urban South Upper Egypt and Urban North Upper Egypt and Frontier Governorates seem to have the highest fertility levels compared to other urban regions in Egypt. TFR of slum areas also differ from that of non-slum areas. While the TFR of urban greater Cairo was 2.3 children per woman in 2003, it reached 3.1 children per woman in the slum areas of greater Cairo

iii. High levels of missed potential practices in rural areas The qualitative research shows that services are inaccessible to some communities, especially those living in remote areas, and the shortage of female service providers hinders the utilization of FP services. There has been a sharp decrease in the percentage of women that have been exposed to any FP message, from 92% in 2005 to 64%in If unmet need for limiting was satisfied in Rural Lower Egypt and Rural Upper Egypt this would lead to increase in contraceptive use to 69% and 57.9%, respectively, in addition TFR will decline to 2.3 in both.

C. Problematic features of organizational and administrative structure. (Structural direction) Frequent restructuring: changing responsibilities between different ministries. Shifting emphasis from services only to development only, as well as superficial implementation of RH.

Policy Recommendations 1.Renewed political commitment and revisiting the existing structure. 2.A paradigm shift from narrow focus on FP to RH (needed shift from a growth paradigm (FP) to individual informed choice paradigm (RH). 3.A human development approach and discourse is very much needed, hand in hand with an RH frame.

Policy Recommendations 4.Adopt a disaggregated approach to reduce fertility in different geographical areas 5.Focus on service potential missed and quality of services. 6.Female empowerment requires an integrated approach beyond education and low quality jobs 7.Renewed focus on ideational changes particularly for youth, continue engagement with religious leaders.