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Low- - the future of Europe?

THE EUROPEAN MAGAZINE FOR SEXUAL AND No.63 - 2006 The European Magazine for Sexual and Reproductive Health Contents Entre Nous is published by: Reproductive Health and Research Programme WHO Regional Office forE urope Scherfigsvej 8 DK-2100 Copenhagen Ø Denmark Tel: (+45) 3917 1602 Fax: (+45) 3917 1818 Editorial E-mail: [email protected] By Gunta Lazdane, Jacqueline Bryld 3 www.euro.who.int/entrenous Chief editor Is Europe trapped in/by low fertility? Dr Gunta Lazdane By Nikolai Botev 4 Editor rights considerations in addressing low fertility Jacqueline Bryld By Jane Gauthier 8 Editorial assistant Dominique Gundelach Current trends of fertility – and infertility-in Europe Layout By Karl Nygren, Gunta Lazdane 10 Sputnik Reklame Aps, Denmark. www.sputnikreklame.dk The determinants of low fertility in Europe Print By Hans-Peter Kohler 12 Central tryk Hobro a/s Europe’s looming population bust Entre Nous is funded by the United Nations By David E. Bloom, David Canning 14 Population Fund (UNFPA), New York, with the assistance of the World Health Organization Low fertility, low modern contraceptive prevalence and Regional Office for Europe, Copenhagen, the high number of – the case of Serbia Denmark. By Mirjana Ra˘sevic´, Katarina Sedlecki 16 It is published three times a year. Present Defending the – the Latvian experience distribution figures stand at: 3,000 English, By Linda Anderson 18 2,000 Spanish, 2,000 Portuguese, 1,000 Bul- garian, 1,500 Russian and 500 Hungarian. Sexual and reproductive health in low fertility countries By Radosveta Stamenkova, Todor Chernev 20 Entre Nous is produced in: Bulgarian by the Ministry of Health in Bul- Between policy-maker awareness and policy responses: garia as a part of a UNFPA-funded project; lowest-low fertility in Italy Hungarian by the Department of Obstetrics By Francesco C. Billari 24 and Gynaecology, University Medial School of Debrecen, PO Box 37, Debrecen, Hungary; Behind the surprising stability of romanian fertility Portuguese by the General Directorate for By Vasile Ghetau, Laurian Arghisan 18 Health, Alameda Afonso Henriques 45, P-1056 Lisbon, Portugal; Recent changes in family policies in Austria and Russian by the WHO Information Centre for – A response to very low fertility Health for the Central Asian Republics; By Alexia Prskawetz, Isabella Buber, Tomas Sobotka, Henriette Engelhardt 27 Spanish by the Instituto de la Mujer, Minis- Resources terio de Trabajo y Asuntos Sociales, Almagro By Jacqueline Bryld 30 36, ES-28010 Madrid, Spain. The Portuguese and Spanish issues are dis- tributed directly through UNFPA representa- tives and WHO regional offices toP ortuguese and Spanish speaking countries in Africa and South America. The Entre Nous Editorial Advisory Board Material from Entre Nous may be freely trans-  lated into any national language and reprinted Dr Assia Brandrup- Dr Evert Ketting Dr Peer Sieben in journals, magazines and newspapers or ­Lukanow Netherlands School of Public UNFPA Representative and placed on the Web provided due acknowl- Senior Adviser, Division for and Occupational Health Country Director, Romania edgement is made to Entre Nous, UNFPA and Health, Education and Social Utrecht, The Netherlands Ms Vicky Claeys the WHO Regional Office forE urope. Protection Dr Malika Ladjali Regional Director Articles appearing in Entre Nous do not German Agency for Technical Senior Programme Specialist International Planned Parent- necessarily reflect the views of UNFPA Co-operation (GTZ) UNESCO/Headquarters, Paris hood Federation, European or WHO. Please address enquiries to Mr Bjarne B. Christensen Ms Adriane Martin Hilber Network (IPPF-EN), Brussels the authors of the signed articles. Head of secretariat, Sex & Technical Officer, Department Dr Robert Thomson For information on WHO-supported activi- Samfund, the Danish Member of Reproductive Health and Adviser on Sexuality, Repro- ties and WHO documents, please contact the Association of IPPF Research, WHO Headquarters, ductive Health & Advocacy, Family and Community Health unit at the Dr Helle Karro Geneva UNFPA Country Technical address given above. Head, Department of Obstet- Ms Nell Rasmussen LLM Services Team for Europe, Please order WHO publications directly from rics and Gynaecology, Medical Director, PRO-Centre, Bratislava the WHO sales agent in each country or from Faculty, University of Tartu, Copenhagen Marketing and Dissemination, WHO, Estonia CH-1211, Geneva 27, Switzerland

ISSN: 1014-8485

Jacqueline Gunta Editorial Bryld Lazdane

More than half of the coun- (POA ICPD, 1994). The 57th World are trying to respond to what by some is Health Assembly in 2004 approved the discussed as the ‘fertility crises’ through tries that make up the WHO World Health Organization’s first Global support to couples with children and to European Region have fertil- Reproductive Health Strategy to acceler- create family friendly environments. We ate progress towards the attainment of have invited authors, specialist in this field ity levels, which are defined international development goals and from academic institutions, professional as low or lowest-low. This targets. Since then many countries have associations and UN agencies to discuss analyzed the reproductive health of their the role of the health care services in in- significant population fea- population and developed their national creasing the birth rates. The role of social ture of the European region strategies for the further improvement factors is emphasized in many articles, and of reproductive health. Parallel to this the national experts in the field present is in some countries causing process the question has been asked: examples of the policies in countries from concern, due to changes in “How important are these international different parts of the European region. agreements as well as the goal to achieve It is beyond any doubt that all efforts the structures of the la- universal access to reproductive health should be made to ensure that health and bour market and national services for the countries in the European sexuality education is combined with Region of WHO, where more than half of analysis of human values and respon- economy, or might do so in the Member States have low fertility rates sibilities for every single adolescent. the future. This issue of Entre and a negative population growth?” Information and knowledge increases the Let us make it clear – these agreements possibilities of making informed choices Nous illustrates that the pol- are still of high importance, some might and preventing mistakes in reproductive icy solutions to the ‘demo- argue now more than ever. Since the behaviour that may have long lasting con- ICPD in 1994 and the World Summit in sequences. Reproductive health services graphic crises’ are complex 2000 there have been several attempts to are to meet the needs of all women and and context specific. undermine the global commitments to men to fulfil their goals in family plan- ensure and access to ning. The global community is trying to The Museum of Contraception presents sexual and reproductive health services. achieve universal access to reproductive the history of humankind in trying to As can be read from several of the articles health by 2015, in less than 10 years. We plan a family and prevent unwanted preg- in this issue of Entre Nous, upholding are to ensure that reproductive health nancies. Since the discovery of hormonal the reproductive rights of women and services are accessible and of high quality contraception in the middle of the last men, also in a European context, can be a in all countries, including those with low century, the research in this field has re- challenge and several governments have fertility rates. sulted in providing a significant diversity led pro-natalist policies, which in some We hope that you will find this issue of of choices to couples in order to ensure cases have been in conflict with ensuring Entre Nous helpful for your future activi- “ability to have a satisfying and safe sex reproductive rights. ties in the area of sexual and reproductive life and capability to reproduce and the The fact that many policy makers in health and rights and beyond. freedom to decide if, when and how often Europe are following the development of to do so” (Programme of Action (POA) the fertility trends closely is signified by Gunta Lazdane adopted at the International Conference the fact that several countries have estab- [[email protected]]  on Population and Development (ICPD), lished high-level national committees to Chief Editor 1994). evaluate the possibilities of changing the During the last 20-30 years the interna- present demographic trends. For example Jaqueline Bryld tional community has changed the focus President highlighted the [[email protected]] of the development goals from reducing demographic crisis of the Russian Federa- Editor the global population growth to ensuring tion in his state-of-the-nation address this sexual and reproductive health and rights. year and has made it one of the countries Several international agreements have highest priorities: ”First a lower death rate; set the scene and recommended the way second, an efficient migration policy; and to achieve “a state of complete physical, third, a higher ”. mental and social well-being and not This edition of Entre Nous is planned merely the absence of disease or infirmity, to assist policy makers to learn more in all matters relating to the reproductive about the general trends of fertility rates system and to its functions and processes” in Europe and the ways some countries

No.63 - 2006 Is Europe Trapped in/by Low Fertility? The “Low Fertility Trap”

Birth rates throughout Moreover, in a number of these countries years, and the latest data suggests that TFR is even below 1.3, a level that Kohler, in 2002 its TFR was already 1.48 (3). In Europe (a) have declined to Billari and Ortega (2) refer to as “lowest Latin America, Cuba had a TFR below very low levels – currently low fertility”(c) - see Figure 1. 1.5 during the mid 1990s, although that There have been occasions when country is one of the few examples where the majority of countries populations have experienced very low that indicator has resurged above the 1.5 have total fertility rates fertility in the past (e.g. the well known threshold. example of France during World War I). (TFR) below 1.5 children Until the early 1970s, when former West Is it “Quantum”, or is it “Tempo”? per woman. Several recent Germany’s TFR dropped below 1.5, this This is the question that experts have had occurred only under exceptional been asking themselves when it comes studies have suggested that circumstances (e.g. wars) and was always to interpreting the decline in birth rates. this level might be a thresh- followed swiftly by a recovery. Italy and This is because the levels and trends of Spain were the first to break through the period fertility indicators, like the TFR, old that triggers self-rein- “lowest-low fertility” barrier in 1993, fol- could be driven by two mechanisms: forcing mechanisms, which lowed within two years by several Central changes in the number of children that and East European countries (Bulgaria, women have, and changes in the timing tend to further suppress the Czech Republic, Latvia and Slovenia). of births. The TFR measures the average fertility. Hence, once TFR What was East Germany bears the dubi- number of births a woman would have ous fame of being the first to have a TFR by the time she reaches the end of her falls below 1.5, bringing it of under 1 in peace time - TFR there was reproductive years, if she experiences back up will be more dif- below 1 during the period 1991 to 1996, the age-specific fertility rates observed dropping to as low as 0.77 in 1993 and in a given period. This measure “trans- ficult. Lutz (1) termed this 1994. poses” a momentary experience over the the “low fertility trap”(b). Very low fertility levels are no longer lifetime of a cohort. The postponement confined to Europe. Several Asian coun- of fertility introduces distortions in that Most countries of Southern, tries have also fallen in the “low fertility transposition. The completed fertility rate Central and Eastern Europe, trap” – Hong Kong was the first to do so (CFR), on the other hand, presents the in 1985, and currently along with Macao, actual average number of children that including the European the other Special Administrative Region women of a real cohort have by the end parts of the former Soviet of the People’s Republic of China, has of their childbearing years. The changes a TFR of below 1. , the Republic in completed fertility are often referred to Union, seem to have fallen of Korea and also have TFRs as “quantum” effects, while the changes in this “trap”. below 1.5. In North America, Canada in timing of childbearing -- as “tempo” has been close to the “trap” for several effects. The bottom line is that because of Figure 1 Mean age of women at birth of first child, around 2003

 Nikolai Botev

Figure 2 the postponement of births, TFRs under- Total fertillity rate (TFR) in Europe around 2003 (children per women) estimate somewhat the completed fertility that will be reached by the cohorts cur- rently in childbearing ages. The map in figure 2 presents the mean ages of mothers at first birth in Europe around 2003, and shows the extent of postponement in the timing of parent- hood. To put these data in perspective -- in 1975 the highest mean age at first birth registered in Europe was 25.7 (in Switzerland), and in the majority of countries that indicator was between 22 and 24 years. Most researchers interpret this as part of the general trend towards postponement of choices that are ir- reversible or hardly reversible, usually associated with the ideational and other changes linked to the so-called “sec- Table 1 ond demographic transition”. Again in Proportion of women aged 18-34 and 55 and over having declared ‘none’ as ideal number of children (%) line with the predictions of the second demographic transition theory about the Country Age group Age group Country Age group Age group importance of individual autonomy and 18-34 55+ 18-34 55+ self-expression, the differences between individuals within a population in the Austria 12.6 6.1 Latvia 1.9 1.8 timing of parenthood are also increasing (4). Belgium 9.4 5.5 Lithuania 2.2 2.2 Another of the salient trends underly- ing low fertility in Europe is the increas- Bulgaria 0 0.8 Luxem- 6.2 4.4 ing childlessness in many parts of Europe. bourg Motherhood is still nearly universal Cyprus 1.8 0 Malta 1.9 5.8 among the women in most Central and East European countries, where the Czech 5.2 1.0 Nether- 12.2 5.7 proportion of women who reach age 50 Republic lands childless is well below 10 percent and Denmark 2.0 1.6 Poland 4.1 1.6 relatively little change has been observed across cohorts. In the rest of Europe, Estonia 1.5 4.0 Portugal 3.7 2.3 however, that proportion is generally above 10 percent and has been increasing.  Finland 4.3 3.3 Romania 3.1 2.1 According to some estimates the child- lessness among women born after 1970 France 3.7 3.9 Slovakia 2.0 1.3 might approach 25 percent in countries like Austria, Germany (specifically its Germany 16.6 5.0 Slovenia 3.4 1.3 western parts), and England and Wales (5). Unexpectedly for many observers, Greece 3.4 0.6 Spain 3.9 3.9 there is increasing evidence that in some West European countries (specifically

Hungary 4.1 1.4 3.1 1.5 Austria, Germany, and the Netherlands), childlessness emerges as an ideal life style (4). Data from the 2002 EuroBarometer Ireland 4.8 3.4 Turkey 0.8 0 survey indicate that over one in ten young women (aged 18 to 34) in these countries Italy 3.8 2.4 United 3.5 3.6 Kingdom have declared “none” as the ideal number

Source: Fahey, T. and Z. Spéder (2004). Fertility and family issues in an enlarged Europe. Dublin., p. 30

No.63 - 2006 of children (see table 1). Figure 3 There is evidence that involuntary Reported incidence of syphilis per 100,000 population childlessness is also on the rise. Part of 300 it is driven by factors related to union Russian Federation formation (i.e. the inability to find a suit- EU (15) EU (new 10) able partner); another part, by biological CIS factors (infertility). The levels and trends 300 in infertility are difficult to ascertain because of definitional and measurement issues, however, there is evidence that as 300 postponement has pushed births towards the end of a woman’s reproductive years, where fecundability is reduced, steril- 300 ity is higher, and the risk of miscarriage is increasing, more and more women report problems becoming pregnant. In some countries of Eastern Europe and the 300

Commonwealth of Independent States, (per 100,000) incidence Syphilis two other factors are often quoted as con- tributing to increasing infertility -- the 300 high incidence of repeat , and the spread of sexually transmitted infections (STIs). Figure 3 gives a picture of the dra- 300 matic increase in STIs after the collapse of Source: WHO/Europe, European HFA Database, June 2006 the former Soviet Union (d). NOTE: The designations used are as follows: EU (15) - the 15 Member States of the In addition to the postponement of European Union prior to 1 May 2004; EU (new 10) - the 10 new Member States of the parenthood and the increasing childless- European Union from 1 May 2004; CIS - the 12 countries of Commonwealth of ness, several other changes are occurring Independent States; along with the decline of fertility. One of the most salient among them is the weak- in interventions to influence birth rates birth rates. This reflected the fact that ening link between childbearing and mar- vary across Europe. France, a country these regimes were much more likely to riage. This has lead to the reversal of the that up to the Second World War had the perceive policy intervention in private relationship between fertility levels and lowest fertility in the world, has had a lives acceptable, and people were more nuptiality, as birth rates are now higher long-standing pro-natalist policy. A broad likely to tolerate that. As a result, some of in countries with higher proportions of consensus across the political spectrum these policies created serious problems extramarital births, higher divorce rates, exists there around that policy and in the reproductive health field. The case and higher mean age at first marriage (for around the need for strong family sup- with Ceausescu’s policies in the 1960s more details see (4)). The proportion of port programmes. The policy in France is probably the best-known example.  extramarital births has been increasing includes, among other things, relatively Nowadays, the concern about low fertility throughout Europe. In the northern parts generous family allowances, parental in some countries in Eastern Europe is of the continent more than half of the leave, tax breaks, and other incentives. fueled by nationalist and/or ethno-centric births are extramarital – this proportion According to many, the fact that France sentiments, and voices are often heard is highest in Iceland, where up to 65 per- currently has one of the highest fertility that favour measures to increase the cent of children are born out of wedlock. levels in Europe is due to that policy. In birth rates at the expense of reproductive It has to be noted, however, that the vast general, however, the evidence about the health and rights, and in detriment to majority of these take place within cohab- success of such kind of policies is limited women’s status. iting unions. and there is an on-going debate about In the rest of Europe, governments their efficacy and efficiency. have been guided by the understand- Pro-natalist Policies: The communist regimes in Central ing that it is the right of individuals to To Be or Not To Be and Eastern Europe also had a tradition determine freely the number of children This Hamletian question has been on of active pro-natalism. At different times, they have. In addition, objections are the minds of many policy-makers in they used restrictions on abortions, or raised that pro-natalist measures might Europe. Attitudes towards, and traditions fiscal and other incentives to increase the jeopardize what has been achieved in

the field of , as increased the specific conditions and circumstances Fertility Countries. Population and fertility could interfere with the educa- in a country; (5) they certainly need to Development Review 31 (4): 699-720 tional opportunities and career aspira- be non-coercive, to respect the rights of (2005). tions of women and might confine them individuals, and to be acceptable across a 2. Kohler, H.-P., F. C. Billari, and J. A. to the traditional family roles. The bitter broad political spectrum; (6) last but not Ortega. The emergence of lowest-low lessons of history, where pro-natalism is least, the policies need to be financially fertility in Europe during the 1990s. associated with fascism and eugenicism viable, i.e. they need to be within the Population and Development Review have also often been evoked. In light fiscal capacity of a country in the long 28 (4): 641–681 (2002). of the dramatic decline of birth rates, run – making commitments that are not 3. United Nations. Demographic Year- however, more and more governments sustainable financially runs the risk of book 2003. New York (2004). are reconsidering their position. As the jeopardizing economic growth and fur- 4. Billari, F. C. The transition to parent- United Nations system for monitoring ther aggravating the population situation hood in European societies. Paper government perceptions and policies on in a country. prepared for the European Population population have shown, between 1996 In a sense the Hamletian question no Conference 2005, Council of Europe and 2003, the proportion of governments longer stands in front of the governments (2005). in Europe that perceive their fertility – most of them are persuaded that they 5. Sobotka, T. Postponement of Child- levels as too low has increased by one need to act. bearing and Low Fertility in Europe. third, and those that perceive their rate of Amsterdam (2004). population growth as too low have almost ENDNOTES 6. United Nations. doubled. The proportion of governments (a) Unless stated otherwise, for the Policies 2005. New York (2006). that have declared that they are putting in purposes of this article we define 7. Bourgeois-Pichat, J.. Baisse de la place policies to raise fertility levels and Europe in the strict geographic sense, fécondité et descendance finale. Popu- rates of population growth has increased and not in the broader senses used lation 31 (6): 1045-97 (1976). respectively by twenty five, and by over by the United Nations, World Health 8. MacDonald, P. Low fertility in Sin- fifty percent (6). Organization and other international gapore: Causes, consequences and All this raises the issue of finding the organizations. policies. Paper prepared for the Forum most effective and efficient ways and (b) Jean Bourgeois-Pichat was probably on Population and Development in means to react to the dramatic demo- the first to assume that a completed East Asia, Beijing (2005). graphic changes in Europe. As pointed fertility of 1.5 children per woman out earlier, the debate on that issue is still presents a “limiting value”, which Eu- raging. Several broad points could be ropean countries might be approach- highlighted though: (1) policies narrowly ing (7). The notion that once TFR focused on increasing birth rates are not falls below 1.5, fertility will stay low likely to be successful; instead, demo- was first suggested by Peter MacDon- Nikolai Botev graphic change needs to be addressed ald (8). [[email protected]] though comprehensive population poli- (c) Fertility settings where TFR is higher Population and Development cies (i.e. those that address all underlying that 1.3 but lower than 1.5 Kohler, Adviser Country Technical Services Team for processes, not just fertility), which in turn Billari and Ortega (2) refer to as “very Europe & Central Asia need to be an integral part of modern low fertility”. The term “lowest low United Nations Population Fund  social polices; (2) two of the elements fertility” is disputable, at least because of these policies have to be programmes it precludes “naming” situations of focusing on social integration of young even lower fertility. people, particularly through youth (d) Although the graph shows data for employment, and on better reconcilia- syphilis infections, which are more tion of work and family obligations; (3) easily identifiable and better reported, consistency and continuity have to be it can also be seen as a marker for among the primary characteristics of chlamydial infection and gonorrhea, these policies – most observers agree that the two STIs most tightly liked to if French polices are to be considered infertility. successful, it is because they have been ap- plied consistently over many decades; (4) REFERENCES these policies also need to be contextual, 1. Lutz, W. and V. Skirbekk. Policies i.e. the mix of policy tools need to reflect Addressing the Tempo Effect in Low-

No.63 - 2006 Human Rights Considerations in Addressing Low Fertility

Concern about falling fertil- 2 children per woman) and Macedonia rights. During this time period, with no (1.77), all countries have rates below access to legal abortion and no access to ity rates, in particular where 1.4 (2). Some Eastern European coun- contraception, women resorted to illegal fertility rates are below re- tries have the lowest fertility levels ever and unsafe abortion as their primary recorded worldwide. method of fertility control. One of the placement levels, has often Faced with fertility rates below replace- tragic results of this violation of basic led governments to imple- ment levels, many governments are con- reproductive rights was that Romania sidering implementing, or have already had the highest maternal mortality rate in ment, or to consider imple- implemented, pronatalist policies aimed all of Europe, by a factor of ten, and one menting, pronatalist poli- at increasing their country’s birth rate. of the highest infant mortality rates (3).. Such policies should be carefully exam- The pronatalist policy of the government cies. This paper will briefly ined from two perspectives to understand did not increase the fertility rate. It only examine a situation where their actual effect. Firstly, such policies increased the suffering of the women and should not violate the human rights and of Romania. It is estimated that pronatalist policies were autonomy of the women and men that almost 20% of women of reproductive implemented and comment they will affect. Secondly, the policies age may have become infertile. On aver- should be closely examined to determine age, every woman may have undergone on the effectiveness and if they would actually be effective in at least five illegal and unsafe abortions human rights implications achieving the desired outcomes. Further- by the age of 40 (3). The high maternal more, pronatalist policies should be con- mortality rate meant that thousands of of such policies. It is beyond sidered in conjunction with a country’s orphans were left to suffer from illness the scope of this paper to immigration policies. For, if the desired and poverty. outcome is to increase the population of In 2003, the Romanian Ministry of Ed- dissect the xenophobic as- the country, an increase in the birth rate ucation implemented a sexual education sumptions that often under- is not the only means to achieve this end. curriculum. Although this is an impor- A rights based holistic approach to the tant step towards lowering the abortion lie pronatalist policies. promotion of population growth would rate in Romania, there are also significant include progressive immigration policies social factors that contribute to the high European countries have experienced that were developed using an anti-racism rate of abortion. The transition from dramatic demographic changes in the framework. a planned central economy under the past thirty years. Fertility rates have communist regime to a market economy declined constantly, in most cases well The case of Romania and Russia has resulted in an increase in poverty below the replacement rate of 2.1 children From 1966 through 1989, Romania had levels from 7% in 1989 to 44% in 2000 per woman (1). In addition to very low one of the most repressive population (4). Added to this are gender inequities fertility rates, mortality has continued to policies in the Warsaw pact countries. that result in women being concentrated decline, resulting in the acceleration of Basic rights to reproductive choice and in low paying jobs, or being unemployed. demographic ageing. These trends have autonomy were disregarded by a govern- This economic reality effectively limits a led to major concerns about the decrease ment intent on increasing fertility. In woman’s reproductive rights and makes  in labour supply and the impact on future 1966, abortion was outlawed and the it virtually impossible for her to afford economic growth, and the inability of importation of contraceptives was dis- contraceptives. economies to provide pensions and health continued. Sexual education was either The Russian Federation’s fertility rate care for ageing populations. entirely unavailable, or it took the form is among the lowest in the world, at a rate Fertility rates in the EU15 have been of a propaganda campaign that misstated of 1.62 lifetime births per woman in 2005 below the population replacement level the risks of contraception. The long term (5). Life expectancy at birth has shown for three decades and now are only at two effect of the lack of evidence based sexual significant declines and is far below thirds of that level. Portugal, Spain, Italy education during this period of time European average, at 71.9 for women and and Greece were among the countries is that even today, many individuals in 58.9 for men (5). Combined with the with the highest fertility rates in the mid- Romania are ill informed about matters decline in fertility, the Russian Federation 1970s. They now have the lowest fertil- relating to their sexual health and repro- has one of the fastest growing HIV/AIDS ity rate in Europe. Central and Eastern ductive choice.4 pandemics in the world, which has hit European countries have also experienced Despite the coercive measures taken young people the hardest. As a result of significant declines in their fertility rates. by the government, women in Romania these factors, the Russian Federation’s With the exception of Albania (more than struggled to exercise their reproductive population has aged rapidly over the past

Jane Gauthier

decade. Furthermore, unemployment and organization on a wide scale will be Resources poverty are widespread, causing further required. It will be necessary to recognize 1. Serbanescu, F. Morris, L. Reproduc- barriers for persons wishing to have children as a social good, not merely as tive Health in Transition Countries children. In May, 2006, Vladimir Putin a private optional pleasure. This would in the European Context, Table 1. offered a bonus of 250,000 rubes (about include recognition that family benefits, Prepared for the European Population US$9,200.) to women who have a second such as maternity and , and Forum 2004. child (6). As articulated below, this will high quality universal childcare, are not 2. Popescu, R. Fertility and Social Policies likely not be sufficient to reverse the merely benefits for the families who use in Europe’ (2004), online: Academia declining fertility rate. them, but are a benefit to all of society. Romana http://www.iccv.ro/ro- For governments that are consider- mana/conf/conf.sibiu.2004/papers/ Policies addressing low-fertility ing implementing pronatalist policies to 05.%20Raluca.pdf rates counter the effects of falling fertility rates, 3 Center for Reproductive Rights, Rather than implementing a coercive it is essential that such policies respect “Rethinking Population Policies: A approach to increasing fertility rates, gov- human rights, take a holistic approach, Reproductive Rights Framework” ernments should understand that there ensure measures are designed to promote (February 2003), online: Center for is a strong relationship between social the advancement of women and consider Reproductive Rights at p. 11. ment, inadequate housing, lack of access Conclusion 4. Kirkorian, A. I. Abortion in Roma- to affordable child care, poor health care, International consensus agreements, such nia: The Consequences of Pronatal- and difficulties in balancing career and as the Programme of Action adopted ist Policy during the Ceausescu Era parental responsibilities, lead individuals by 179 governments at the 1994 Inter- (2004), online: Human Biology at the to have fewer children than they actually national Conference on Population and University of Virginia http://www. desire. Therefore, government investment Development (ICPD), and the five and virginia.edu/humanbiology/new_ in social services would be a more effec- ten year reviews, the 1995 United Nations site_files/class_2004_papers_pdf/ tive way to increase fertility rates. Fourth World Conference on Women in Iasmine%205%20page.pdf When a society is organized in such a Beijing (Beijing Conference), and the five 5. United Nations Population Fund, way that parents can achieve a balance be- and ten year reviews, go beyond tradi- UNFPA Worldwide. Population, tween work and family, the indirect costs tional and are grounded Health & Socio-Economic Indicators/ associated with parenting fall. This may in a human rights and reproductive rights Policy Developments, http://www. partly explain why countries with high based approach to issues of population. unfpa.org/profile/russia.cfm. labour force participation rates for moth- These agreements embrace the necessity 6. Gross, G. Russia’s campaign to increase ers have relatively high rates of fertility of securing women’s rights and equality its birthrate’, online: http://www.slate. and countries with low labour force par- and involving women in the formulation com/id/2142366 ticipation for mothers have low fertility. of laws and policies relating to population Similarly, gender equity in the workplace and development. Jane Gauthier and in society generally is correlated to These are essential principles to be fol- [[email protected]] higher fertility rates. For example, Sweden lowed by governments in both the devel- Associate Executive Director experienced an increase in fertility rates opment and implementation of fertility Action Canada for Population and  Development in the late 1980s. No one factor was policies. Policies should clearly articulate responsible for this increase in fertility. references to principles of human rights, Rather, it appears that the combination of including free and informed choice, non- the availability of high-quality childcare, discrimination, equal access to repro- extensive equitable parental leave, and a ductive health care and women’s rights. general environment of equality between Policies should also include an explicit men and women, worked together to provision covering non-discrimination contribute to higher levels of fertility.8 for minority or indigenous populations. A market economy, no matter how successful the market is, will always pro- vide lower benefits to those with children than to those without children.9 In order to increase fertility rates in a non-coercive manner, changes in social and economic

No.63No.61 - -2005 2006

Current trends of fertility – and infertility-in Europe

’7.2. All persons have the Figure 1 is currently low through- Total Fertility Rates out Europe, much lower than the right of access to reproduc- Countries Last available data replacement level - 2.1 children per tive healthcare services Belarus (2004) 1,2 woman during her lifetime, which is Bosnia and Herzegovina 1,2 (2004) required for a stable population including those who are Italy (2003) 1,2 (see Figure 1). infertile, or whose fertility San Marino (2003) 1,2 It follows that European populations are Spain (2003) 1,2 presently declining. is jeopardized by sexually Poland (2003) 1,22 There are no strong effects from medi- transmitted infections’ ICPD, Ukraine (2004) 1,22 cal factors behind this. The explanation is Czech Republic (2004) 1,23 rather socio-economic in nature and con- POA, 1994 (1) Latvia (2004) 1,24 cerns most of all the status for women in Slovenia (2004) 1,25 education, economy, working conditions Lithuania (2004) 1,26 and family life. Less children are being Republic of Moldova 1,26 (2004) born at a higher age of their mothers Slovakia (2004) 1,26 (and fathers), the delay in childbear- Andorra (2004) 1,27 ing being very substantial, in several Hungary (2004) 1,28 countries three years or more, and in Bulgaria (2004) 1,3 subgroups even much longer. There have Greece (2003) 1,3 been different attempts to increase the Romania (2004) 1,3 fertility of the population in Europe by Croatia (2003) 1,33 encouraging women to have the first child Russian Federation (2004) 1,34 earlier in life and to have more than one Malta (2004) 1,37 child per couple. However, it is a very Armenia (2004) 1,38 Georgia (2003) 1,4 complex issue and there is not one solu- Germany (2004) 1,4 tion. Fertility healthcare is part of it. Austria (2004) 1,42 The prevalence of infertility, on the Switzerland (2004) 1,42 other hand, is essentially stable over time Portugal (2003) 1,44 at around 10-12%. Some variation occurs Estonia (2004) 1,47 following changing life-styles (smoking, Cyprus (2004) 1,49 stress, overweight and sexually transmit- Belgium (2002) 1,53 ted disease) resulting in the future, pos- Serbia and Montenegro 1,6 sibly, in a moderate increase of infertil- (2003) Luxembourg (2004) 1,7 ity problems, as these life-style factors United Kingdom (2003) 1,72 increase in Europe. Netherlands (2004) 1,73 The possibility of a thorough and cor- Monaco (2003) 1,8 rect medical investigation and diagnosis Albania (2004) 1,8 of a couple’s infertility problem is today 10 Denmark (2004) 1,8 in Europe excellent, in most areas. There Finland (2004) 1,8 are hormone tests, ultra-sound and x-ray Lowest-low Norway (2004) 1,8 more readily available, whereas 40 years fertility countries Sweden (2004) 1,8 ago there were hardly any of these. Low fertility France (2004) 1,89 Treatment options for infertility have countries Azerbaijan (2003) 1,9 increased dramatically since some 20 TFYR Macedonia (2003) 1,9 Below replace- years back, especially now that assisted ment countries Ireland (2004) 1,95 reproduction techniques, like in-vitro Iceland (2004) 2,0 fertilization (IVF), have become available. Replacement Kazakhstan (2004) 2,2 countries However, availability to IVF treatments Turkey (2004) 2,21 differs substantially between European Uzbekistan (2004) 2,46 Kyrgyzstan (2004) 2,5 countries and elsewhere. About three Turkmenistan (2003) 2,7 million children have been born after IVF Israel (2004) 2,9 treatment worldwide so far, and 60% of Source: WHO HFA Database Tajikistan (2003) 3,0 these were born in Europe, since 1978, Karl G. Gunta Nygren Lazdane

when the first IVF child was born (in the In the Nordic countries up to 4 % of all equal access to fertility services. In many UK). children born come from IVF treatments, ways such a development would be very Demand for services related to infertil- another 2-3 % from other forms of infer- positive also for many other countries ity management comes from the need for tility treatments summing up to 6-7% of in Europe. Politicians, professional and treatment in relation to confidence in the all children born. However, the situation patient groups need to open a dialogue treatment methods (efficacy, safety and differs in many countries due to number to reach conclusions of a positive at- quality of services), from ethical and cul- of reasons (Fig.2). titude and positive actions to help people tural considerations and from alternatives There are two main scenarios in avail- achieve their reproductive goals and to available, e.g. adoption. ability and cost of infertility treatment. In stop . Availability of services results from a many countries of Europe cost of treat- demand in a population met politically ment is partially covered by the society. It References with legal regulation and allocation of results in patients seeking treatment soon 1. http://www.iisd.ca/Cairo/program/ public funding. Some countries in Europe after infertility diagnosis, they are young- p07000.html have a generous attitude towards infertil- er and there is good efficiency of the ity treatments (e.g. the Nordic countries) treatment. If the cost of treatment is paid For additional reading while other countries are more restrictive to a large extent by the couple, patients 1. Vayena, E., Rowe, P. J. and Griffin, P. (e.g. Italy). are saving up money and waiting to seek David (Eds.). Current practices and Fertility healthcare is part of the treatment. Patients in this scenario are controversies in assisted reproduc- actions to increase the fertility of the older, the efficiency of treatment is lower tion. Report from a WHO meeting. population and consists of prophylactic and often they seek treatment where Department of Reproductive Health measures and available and effective available resulting in patient tourism. and Research, Family and Community infertility treatment. The cost of infertil- Infertility is a disability and infertile Health, World Health Organization, ity management is determined by the couples deserve the moral, legal and Geneva, (2002). proportion of the patients seeking infer- economic support of the society to attain 2. Andersen, A.N. et al. Assisted Re- tility treatment (domestic and abroad; the highest standard of reproductive productive Technology in Europe on equal terms or only the well-off), its health. Investments in infertility research – Results generated from European impact in the population and the quality and treatment are profitable both for the Registers by ESHRE. Human Repro- of the treatment (the total cost to the individual and for the society. duction, Vol 21, No. 7: 1680-1697 society, multiple and births, In Europe one in six couples is affected (2006) side effects and health of the children). by unwanted childlessness. In many 3. Adamson, G.D. et al. World Collabor- Reproductive medicine helps individu- countries due to the local regulations ative Report on in vitro fertilization, als to reach their individual goals for a or the cost of treatment not all patients 2000. Fertility and Sterility, Vol. 85, family. However, the increasing success have the same access to treatment and it Issue 6: 1586-1622 (2006). rates and the better availability in some is restricted to women and men who can countries is now reaching the level when afford it. The Nordic countries have a fa- the effects of these treatments reach a sig- vourable framework for modern, effective Karl G. Nygren nificant level also for population growth. infertility treatment and patients have an [[email protected]] Chairman of the European IVF Moni- toring Consortium of ESHRE Figure 2 11 Medically assisted reproduction in Europe European Society for Human Repro- (N of cycles/per million population, 2001) duction and Embryology Gunta Lazdane Lithuania 54 [[email protected]] Regional Adviser Latvia 83 Reproductive Health and Research Estonia 246 WHO Regional Office for Europe

Netherlands 963

Iceland 1410

Denmark 1923 0 500 1000 1500 2000

No.63 - 2006 The Determinants of Low Fertility in Europe

s a consequence of below-replace- will soon result in declining numbers lies, or fierce competition in rigid labor ment fertility that has prevailed of potential parents (4). A continuation markets—are likely reinforce delayed Ain many parts of Europe for of this trend could substantially exacer- childbearing. Postponed childbearing several decades starting since the 1960s bate the future aging of the population, thus originates in individual’s responses and 1970s, low birthrates have begun to reinforce a future decline in the popula- to new socioeconomic contexts that make generate negative population momentum, tion size and constrain the effectiveness of late childbearing a rational decision, and that is, a new force for population shrink- policy interventions aimed at increasing this response is exacerbated by social age over the coming decades due to the the number of births. feedbacks that cause large and persistent fact that past below-replacement fertility changes in the mean age at birth at the will soon result in declining numbers of Social factors contributing to low population level. This widespread transi- potential parents fertility tion towards a late pattern of childbear- The global population is at a turning Demographic analyses suggest that the ing in Europe, however, implies that the point as, for the first time, the majority of decline in the desire to have at least one extent to which specific socioeconomic the world’s population is living in coun- child has not been a primary driving force and institutional contexts in different tries or regions with below-replacement in the emergence of very low fertility in European countries accommodate late fertility levels. Several aspects of this trend the Southern, Central and Eastern Euro- childbearing has become an essential towards low fertility are striking. First, pean countries (2; 6). While childlessness determinant of cross-country variation in the spread of below-replacement fertility is likely to rise, it is projected to remain at fertility levels. A striking example in this to formerly high fertility countries has relatively modest levels even in very low context is the reversal of the aggregate occurred at a remarkably rapid pace and fertility countries (exceptions, however, relationship between female labor force implied a global convergence of fertility include Germany and Austria where participation and fertility. Conventional indicators that has been quicker than the already relatively high levels of child- economic theory predicts that increases in convergence of many other socioeco- lessness are likely to further increase). the wage rate of women lead to increases nomic characteristics. Second, earlier These findings on childlessness therefore in women’s labor force participation on notions that fertility levels may naturally suggest that the biological, social and the one side, and decreases of fertility on stabilize close to replacement level—that economic incentives for children are the other side due to increased opportu- is fertility levels with slightly more than sufficiently strong that most women (or nity costs of children in combination with two children per women—have been couples) desire to have at least one child a low income elasticity of the number of shattered. Sustained below-replacement (3). Nevertheless, while first births are children. However, several recent studies fertility has become commonplace, and not necessarily foregone even in very have documented that the cross-country Europe has been a leader in the trend low fertility countries, they are delayed correlation between the total fertility level towards low and very low fertility. While to an increasingly late age. In many low and women’s labor force participation there is considerable variation in the fertility countries, this postponement (FLFPR) reversed (5): while high levels of fertility levels across European coun- has been very intense and has lead to fertility in the 1970s were associated with tries—with TFRs ranging in 2002 from some of the highest mean ages at first low levels of female labor force participa- 1.13 in the Czech Republic to almost 2.0 birth worldwide. The reasons underlying tion, high fertility was associated with in Ireland—the median , this postponement of childbearing are high female labor force participation in i.e., the TFR level below which 50% of the often a rational response to the specific the late 1990s, and the lowest fertility populations in Europe live, is currently situation of young adults that is charac- levels in Europe since the mid-1990s are 12 near 1.3. The implications of such low terized by a high level of uncertainty due often found in countries with the lowest fertility are substantial. For instance, in to high unemployment, uncertain labor FLFPR. Moreover, the very low in South- the absence of migration, sustained TFR market prospects, and rapid socioeco- ern Europe has occurred in a rigid labor levels at or below 1.3 imply a reduction of nomic change. Young adults thus face an market characterized by a low compat- the annual number of births by 50% and incentive to delay decisions that imply ibility of childbearing with woman’s labor a halving of the population size in less long-term commitments, such as the market participation, which is due to the than 45 years. Moreover, as a consequence decision to have children, and prefer to difficulties in entering and re-entering the of below-replacement fertility that has invest in education, human capital and labor market and the limited flexibility of prevailed in many parts of Europe for labor market experience. working hours. several decades starting since the 1960s These rational responses, however, are Very low fertility in Europe is therefore and 1970s, low birthrates have begun to not a complete explanation of delayed caused by the combination of several generate negative population momentum, childbearing. In addition, social feedback factors: (a) Socioeconomic incentives to that is, a new force for population shrink- mechanisms—resulting from changes in delay childbearing that make postponed age over the coming decades due to the the norms about the timing of childbear- fertility a rational response to high fact that past below-replacement fertility ing, shifts in the attitudes towards fami- economic uncertainty in early adulthood, Hans-Peter Kohler

increased returns to education, shortages United States, it does not constitute the increase, a loss of demographic weight in the labor market and similar factors. primary explanation. Instead, it appears within the global population, a decline (b) Social feedback effects on the timing that an overriding factor is their greater in the population size during the coming of fertility that reinforce the adjust- ability to combine work and childbear- decades and a substantial aging of the ment of individual’s desired fertility to ing, thanks to a variety of institutional population are therefore safe predic- socioeconomic changes. (c) Institutional factors. In general, women (and couples) tions for the Europe of the twenty-first settings, characterized by labor market are deterred from having children when century. It is clear that current social and rigidities, insufficient child-care support the economic cost—in the form of lower economic institutions are not sustainable and a prevalence of relatively traditional lifetime wages—is too high. Compared to in light of these trends, and individual’s gender roles, favor an overall low quan- other high-income countries, this cost is life-courses already have been—and will tum of fertility and lead to reductions diminished by an American labor market continue to be— transformed in response in completed fertility that are causally that allows more flexible work hours to reductions in fertility and increases in related to the delay in childbearing. While and makes it easier to leave and then longevity. Adjusting to the demographic each of these factors already contributes re-enter the labor force. The importance reality of the 21st century will therefore to reduced fertility, it is the combination of this situation is reflected in the posi- constitute a major challenge for policy and interaction of these factors that leads tive relationship between measures of makers and companies on the one, and to very low fertility. women’s labor force activities and levels for individuals and families on the other of fertility across wealthy countries in side. Whether the adjustment to these U.S. versus European fertility: what recent years. As a result, despite a lack of trends can be successful, and whether explains the difference? public financial support for families with these trends lead to a reduced well being In contrast to the projected population children, it appears that the flexibility of individuals if appropriate policies are shrinkage due to low fertility and negative offered to individuals through the market implemented, is still an open question. population momentum in Europe, the in the U.S. facilitates integration of work U.S. population continues to be charac- and traditional family life. References terized by rapid growth. The majority of 1. M. Balter. The baby deficit. Science, this growth in recent years is attributed Policy responses 312(5782): 1894–1897, 2006. to natural increase—that is, an excess of The only viable long-term strategy to 2. H.-P. Kohler, F. C. Billari, and J. A. birth over deaths—while net immigration limit the extent of population aging and Ortega. The emergence of lowest-low accounted for about 40%. The U.S. popu- the decline of the population size will be fertility in Europe during the 1990s. lation is also projected to grow by almost an increase in the level of fertility. The Population and Development Review, 50% in the coming decades. Why is the policy options available to European low 28(4):641–681, 2002. U.S. different? One might argue that the and very low fertility countries, however, 3. H.-P. Kohler, J. R. Behrman, and A. U.S. fertility trends simply trails behind are limited (1). The existing empirical Skytthe. Partner + children = hap- Europe and Japan, and that the TFR in evidence provides mixed conclusions as piness? An assessment of the effect the U.S. will fall to historically low levels to the effects of various policies on fertil- of fertility and partnerships on in future years, as occurred for so many ity behavior. On balance, the evidence subjective well-being in Danish twins. wealthy countries in recent decades. How- supports a weak positive relation between Population and Development Review, ever, the situation of the U.S. compared to reproductive behavior and a variety of 31(3):407–445, 2005. most other high-income countries differs policies, but policy measures, which may 4. W. Lutz, B. C. O’Neil, and S. Sherbov. in at least two respects. First, population potentially affect reproductive behavior Europe’s population at a turning 13 composition favors a higher fertility level, will manifest their influence only in the point. Science, 299(5615):1991–1992, since some of the largest immigrant and long-term. Policy measures that aim to 2003. minority groups within the U.S. have make women’s participation in the formal 5. S. P. Morgan. Is low fertility a 21st fertility levels that lie above than the labor force compatible with childrear- century demographic crisis? national average. Second, fertility in the ing are in our opinion among the most Demography, 40(4): 589–603, 2003. U.S. is relatively high for the population promising alternatives. The effectiveness 6. T. Sobotka. Postponement of Child- as a whole. Notably, the TFR of non-His- of such measures, however, is likely to bearing in Europe. Dutch University panic White women, falling in a range be limited due to a negative population Press, Population Studies Series, from 1.77 to 1.87 during 1990–2001, momentum that results from decades Amsterdam, The Netherlands, 2004. exceeds the national average for most of below-replacement fertility in many other high-income countries. While the parts of Europe since the 1960s and Hans-Peter Kohler heterogeneity of the U.S. population is 1970s. Even if policies are effective in [[email protected]] therefore one factor that contributes to raising women’s or couple’s fertility, and Professor of Sociology the relatively high level of fertility in the even if levels of immigration into Europe University of Pennsylvania

No.63 - 2006 Europe’s Looming Population Bust

hile global population contin- Figure 1 Total Fertility Rate ues to increase, with medium Wor high fertility combined with 3.5 UN projektion variant falling infant and child mortality to produce 3.0 swelling cohorts of young people, that of 2.5 Europe is changing in a very different way. High Sharp declines in fertility threaten to shrink 2.0 Medium the region’s population, and increasing life 1.5 expectancy is tilting the demographic bal- Low ance from young to old, with large potential 1.0 impacts on living standards. 0.5 This article discusses Europe’s demo-

Children per women Children 0.0 graphic prospects and their implications for 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 population growth and age structure (a). It then assesses the possible effects of popula- Source: United Nations, World Population Prospects 2004 tion change on Europe’s economies and working age. There are currently more than in order to maintain a comfortable standard societies, before concluding with a discus- two people aged 15-64 for every individual of living. Increased savings will mean that sion of the policies used by countries to halt outside that age bracket. As the proportion more funds are available for investment for fertility decline and mitigate the impacts of of elderly grows and that of young people businesses. With fewer children, moreover, aging populations. falls, this ratio will plummet to below 1.5 parents will be inclined to invest more in people of working age per dependent by the health and education of each child. In The future of Europe’s population 2050. This will be a lower ratio than at any countries where health and various levels of Since 1950 Europe has experienced rapid other time between 1950 and 2050. education are free, this will not matter; but demographic change. The region’s fertility where they are not, the increased incentive rate has fallen steadily and to a very low The consequences of change to invest in children could strengthen hu- level, the population growth rate is slowing The possible consequences of these demo- man capital. and will likely turn negative in the next graphic changes encompass the economic, Even if GDP per capita does not decrease few decades, and the ratio of working- the social, and the political. dramatically, however, the absolute size of age to non-working age people is about The combination of low birth rates and a economies may contract. The president of to plummet as the proportion of elderly large elderly generation may leave Europe the Russian Federation, Vladimir Putin, has mushrooms. with a shortage of workers to support el- described population decline as “the most Halfway through the last century, derly dependents. For the former, support- acute problem” facing the country. Shrink- Europe’s total fertility rate stood at almost ing the pension payments and health and ing economies and shrinking populations 2.9 children per woman (1). Today women social security costs of large elderly cohorts may cede political and economic power have an average of less than 1.6 children may prove a burdensome task. Tax rates to countries whose demographic and eco- (see Figure 1), well below the replace- may need to rise for economies to cope. nomic trends are moving in the opposite ment rate of 2.1. In the next 40 years, the Some have forecast dire consequences, with direction. United Nations projects a small increase in the Economist arguing that, “the political fertility under its medium variant scenario, and economic renaissance of Europe that Responses to change 14 although with a possible range between was predicted at the European convention Many European countries have taken steps 1.33 and 2.33 children per woman by 2045, [of July 2003] is likely to be stillborn” (4). to halt population decline and mitigate the much uncertainty clouds this forecast. A lower ratio of workers to dependents effects of aging. In a 2005 United Nations Europe’s age structure is also likely to will, other things equal, tend to reduce per survey, 32 European governments viewed change markedly. As fertility has fallen, capita gross domestic product, but econo- their countries’ fertility as too low. Twenty- life expectancy in most parts of the region mies and individuals will naturally adjust to seven of these had implemented policies to has increased. Since 1950, life expectancy mitigate these impacts. Adopting capital- increase it (5). at birth has risen from 66 to 73 years (2). rather than labor-intensive technologies Measures to encourage couples to have This would be still higher if it were not could mitigate a fall in GDP per capita in more children vary across countries. They held down by Russia, where male life the medium term. As people live longer and range from reducing support for contra- expectancy is just 59 years. As a result, remain healthy longer, some will choose to ception to making life more painless for the proportion of Europeans aged 65 and work beyond retirement age, thereby reduc- working parents. In developed regions as over is expected to increase from 16% to ing the fiscal pressure on younger workers. a whole, the proportion of governments 24% between 2000 and 2030 (3). (In some countries laws may need to be providing direct support for contraception This aging of the European popula- changed to accommodate such desires.) fell from 62% in 1976 to 38% in 2005 (5). tion will lead to a large shift in the ratio Rising life expectancy means that those Some countries, such as Italy and Poland, of people of working age to those not of who choose to retire will need to save more provide one-time payments to couples that David E. David Bloom Canning

have children (in Italy’s case this starts with countries such as the UK. blues. BBC Online, March. Available at: the second child), while in others parents http://news.bbc.co.uk/1/hi/world/eu- receive income tax benefits depending on Conclusion rope/4768644.stm the number of children they produce. As described above, European countries 7. Hoehn, C. Policy Responses to Population Once they have persuaded couples to grappling with demographic change po- Ageing and Population Decline in Ger- have children, governments then endeav­ tentially have three broad policy measures many’. In: United Nations Expert Group or to make parenthood easier. Countries at their disposal: pro-natalist policies, Meeting on Policy Responses to Population including France and the United Kingdom increased immigration, and encouraging Ageing and Population Decline. October give monthly allowances to couples with people to work longer and save more. None (2002). children. In France this allowance increases will be easy to sell to electorates, however, 8. Lesthaeghe, R. Europe’s Demographic for families with three children. Mothers and the effectiveness of each is unproven. Issues: Fertility, Household Formation and sometimes fathers receive paid ma- Both more rigorous research and clearer and Replacement Migration”. In: United ternity leave – Spanish mothers’ 16 weeks advocacy by governments may help con- Nations Expert Group Meeting on Policy of paid leave and Norwegian mothers’ 10 vince societies that such policies are needed Responses to Population Ageing and Popu- months are fully funded by the state. When and likely to work. The challenges posed lation Decline, October (2002). they return to work, parents benefit from by Europe’s looming population bust are 9. McDonald, P. Low fertility not politically state-funded child-care – France provides not insurmountable but there is no time to sustainable”. Population Today, August fee day care at crèches to younger children, dawdle: Pro-natalist policies cannot pro- (2001). and Italy gives free places at nurseries (6). duce new workers in less than a generation; 10. Milligan, K. Subsidizing the Stork: New The efficacy of these policies is unclear. immigration can surely not increase quickly, Evidence on Tax Incentives and Fertility. France, whose family-promoting (or pro- and as the share of the elderly population National Bureau of Economic Research, natalist) policies are among the most com- increases, its political power may make Working Paper 8845, March (2002). prehensive in the world, has a high fertility other changes hard to bring about. Given 11. Chamie, J. Low fertility: Can Governments rate for Europe, at 1.9 children per woman the scale of the challenges, policy-makers make a difference?, UNPD, New York, 2 (1). A number of studies have found that would be well advised to act sooner rather April (2004). policies that promote childbearing reduce than later. 12. Hoem, J., Prskawetz A. and Neyer, G. the costs of childrearing, enable parents to Third births in Austria: The effect of work, and involve fathers in parenting help Endnotes public policies, educational attainment, increase fertility (7-12). a) By ‘Europe’ we refer to those countries and labour force attachment, Stockholm On the other hand, the benefits of pro- defined by the World Health Organization Research Reports in Demography, 134. natalist policies in Singapore, which include as making up the European region – see Stockholm University Demography Unit tax credits, one-time payments to parents, http://www.euro.who.int/AboutWHO/ (1999). and priority housing for families with three About/MH for the full list of countries. 13. Legislate to procreate: solution to birth or more children, were short-lived, with crisis. The Scotsman. 13 October (2004). fertility rising briefly after implementation References 14. European Commission. European At- in the early 1980s before falling off to 1.42 1. World Population Prospects: The 2004 titudes to Parental Leave. Eurobarometer, children per woman by 2001 (13). This may Revision. United Nations. Department of (2004). in part be due to limited uptake or imple- Economic and Social Affairs, Population mentation of some policies. The European Division, New York (2005). Acknowledgement Union’s public opinion Eurobarometer 2. Yaukey, D, and Anderton, D.L. Demog- The authors thank the John D. and Cath- 15 found that 84 per cent of men surveyed had raphy: The Study of Human Population. erine T. MacArthur Foundation for its not taken or did not intend to take parental Prospect Heights, IL: Waveland (2001). support of this work. leave because, for example, either such leave 3. Centers for Disease Control and Preven- did not exist, they could not afford it, they tion). Public Health and Aging: Trends perceived such leave as being mainly for in Aging – United States and Worldwide. David E. Bloom women, or their wife or partner did not Morbidity and Mortality Weekly Report. [[email protected]] work (14). 52(06): 101-106 (2003). Clarence James Gamble Professor of Governments may also choose to tackle 4. Economist. Europe’s population implo- Economics and Demography Department of Population and the fiscal burden of an aging population sion. Economist, London, 17 July (2003). International Health by encouraging people to work for longer. Europe’s Looming Population Bust Harvard School of Public Health Raising the retirement age, ensuring that Introduction individuals receive (and know that they will 5. World Population Policies 2005. United David Canning receive) all pension benefits to which they Nations, Department of Economic and [[email protected]] are entitled, and encouraging workers to Social Affairs, Population Division, New Professor of Economics and Interna- save more for their retirement are among York (2006). tional Health the measures already being considered in 6. BBC News (2006): The EU’s baby Harvard School of Public Health No.63 - 2006 LOW FERTILITY, LOW MODERN CONTRACEPTIVE PREV ALENCE AND THE HIGH NUMBER OF ABORTIONS – The case of Serbia

Transition in fertility in condoms (1). The consequence of the number of abortions in Serbia. The main conservative model is the are insufficient knowledge of contracep- Serbia (excluding Kosovo huge number of induced abortions. tion and abortion, a belief that modern and Metohija) began during The data on abortions are deemed contraceptive methods are harmful to complete as from 1969 to 1989 (figure 1). health, and a number of psychological the closing decades of the The number of abortions kept growing barriers, also those arising from rela- nineteenth century. Total continuously until 1985, from 167,383 tionships with partners (3). Addition- in 1969 to 222,573 in 1985, meaning that ally, there are few organized efforts to fertility rate of about 2,1 it went up by a third. In 1986, 1987 and promote sex education and information was measured as early as in 1988, the absolute number of abortions on contraception, as well as limitations was decreasing, so that in 1989, with level in the family planning programme. It the mid-1950s. As soon as of 201,660 it was the same as that in the should be stressed out that liberalization in 1971 the rate was about preceding year. The estimated number of of the occurred at a time of induced abortions today is about 200,000 decrease birth rate and very modest pres- 20% lower than the popu- abortions per a year or 90.5 abortions per ence of modern contraceptive methods. lation replacement level. 1,000 women in the age 15-44 (2). Namely, socio-medical indications were accepted as grounds for abortion The rate was more or less Figure 1 from 1952. In 1969 the law was further Number of abortions in Serbia, 1969 liberalized. Abortion was permitted at stabilized over the next two 1989 a woman’s request up to the tenth week decades. There is an obvious Number (thousands) Rate of and, beyond ten weeks, decline in the number of 250 160.0 with the approval of a medical commis- sion. Age limit was 18 years, but from births across low fertility re- 140.0 230 1995 abortion is available on request for gions of Serbia in the 1990s. 120.0 women aged 16 or more years. 100.0 The high prevalence of induced abor- 210 Between 1991 and 1999, tions is the main reproductive health 80.0 total fertility rate in Serbia problem in Serbia, having in mind the 190 60.0 cost of this procedure for fertility and declined from 1,73 to 1,41. 40.0 quality of women’s lives. The incidence In 2000 and 2001 total fer- 170 of early complications following induced 20.0 abortion in Serbia can be assessed as tility rate slightly increased, 150 0.0 high. The result of representative survey and in the period 2001-2004 implied that the rate of early complica- 1969 1975 1980 1983 1984 1985 1986 1987 1988 1989 tions is 21.3% (4). However, severe early remained stable at the level Number of abortions complications of abortion were found to be rare, but the risk of their occurrence of about 1.50. Per 100 live births is higher compared to the developed 16 Parallel, the transition from traditional Per 1000 women 15-49 countries. birth control to modern contraceptive use The reasons for the high incidence of Source: Official health and vital statistics data did not take place in Serbia. The method complications of induced abortion are of coitus interruptus was not replaced by In 1989, last year with complete statisti- considered to be the huge number of hormonal oral contraception or intra- cal data, the structure of the women who these procedures conducted in abortion uterine device. Although official statistical have had an abortion, shows that major- services per day, inadequate pre-operative contraceptive base has not been estab- ity of them were aged between 20 and 39 measures, as well as the predominant use lished, according to the results of several years (90%), married (92.1%), with one of conventional abortion techniques. investigations in this domain about 10% or two living children (75.8%). Mention Results of the survey on the psycho- of women in reproductive age have any worthy is also the fact that 22% woman logical consequences of abortion (3) experience with modern and effective subjected to abortion had already had have confirmed that women assess this contraception. Precisely, the results of four or more abortions in the history. procedure as a complex and difficult the last study show that 11.2% of women Research findings discovered a complex experience. About 45% of women show in reproductive age use combined oral array of factors linked to conservative unexplained emotional reactions towards contraception, intrauterine device or birth control model with resulting huge abortion even two months after the Katarina Mirjana LOW FERTILITY, LOW MODERN CONTRACEPTIVE PREV ALENCE AND THE HIGH Sedlecki Ras˘evic´ NUMBER OF ABORTIONS – The case of Serbia

intervention (figure 2). The psychologi- providing an integral program for young kinds of modern contraceptive methods, cal trauma varies in degree. In retrospect, persons and not just isolated rendering of widening the categories of health care abortion is felt as a hard experience but services for their various problems. Im- workers who are involved in offering a without cognitive signs (14%), painful plementation of these principles assumes contraceptive advice, increasing public experience which often comes to mind uniting the existing prevention and cura- information and advertising of contra- (14.6%), or an experience which is so tive measures of health services, namely ceptives, stressing out the importance of disturbing that one prefers not to think of establishing reproductive health coun- post abortion counseling, involvement it (15.9%). seling services for young people within of males in taking over responsibility primary health centers, above all as an for birth control. Also, very important Figure 2 activity of the school-age unit. According is to establish a legal basis for voluntary Women’s experience of abortion to this model, youth friendly reproductive sterilization, as accessibility to this birth health care services have been opened in a control method clearly correlates with the 100% quarter of municipalities in Serbia. reduction of repeat abortions. Reproductive health education in Results are not likely to be achieved Serbia has never been a component of quickly. Duration of prevalence of in- 80% a school curriculum. By updating the duced abortions indicates that underlying school law in 2003, the legal assumptions causes of frequency are numerous and enabled carrying out actions of activating stable over time. Considering this, and 60% elementary schools in maintaining and the slowness of any spontaneous change, promoting youth reproductive health. it may be expected that the problem of In that sense, a handbook for teachers abortions will be present in the years to 40% of various subjects as well as for expert come. However, duration of abortion associates of elementary schools was first prevalence will depend, to a large extent, made, due to a lack of adequate educa- on the ability and willingness to cope tional material, for work with pupils of with this issue. 20% the final three grades. Focus was given on concrete work with pupils. The following References themes were elaborated: puberty, emo- 1. Multiple Indicator Cluster Survey II. 0% tional life of young persons, reproduction UNICEF, Belgrade (2000). Experience so disturbing one physiology, adolescent pregnancy, com- 2. Raševic´ M. Family Planning as a Life prefers not to think of it munication skills, risky behavior, contra- Style. Institute of Social Sciences, Painful experience which ception, sexually transmitted infections Belgrade (2000). often comes to mind including HIV and significance of family 3. Raševic´ M. Towards an Difficult experience but and children. Publishing of the handbook Understanding of the Abortion in without cognitive signs is underway. Serbia. Institute of Social Sciences, Difficult experience but with cognitive signs Enabling young people to make right, Belgrade (1993). Common experience responsible and healthy choices regarding sexual life is very important. Especially because advancement of reproductive Mirjana Raševic´ 17 Source: Raševic´ M. Towards an Understanding of the Abortion health, apart from direct health effects, [[email protected]] in Serbia. Institute of Social Sciences, Belgrade (1993). achieves a range of other benefits. It in- Principal Research Fellow Two actions in reproductive health sphere creases the level of health and sexual cul- Director of Institute of Social Sci- ences (Belgrade) promotion have been carried out in ture of a couple, prevention and healthy University of Belgrade Serbia from the end of 1990s. First action life becomes a style of living and a way of has been related to network developing thinking and personal responsibility for of reproductive health counseling centers one’s own health is promoted. But, it is Katarina Sedlecki for young people and the aim of the only one step in diminishing the abortion [[email protected]] second action was activating schools for problem. Specialist of gynecology and ob- maintaining and promoting reproductive Namely, the conservative birth control stetrics Director of the Family Planning health for young people. model in Serbia is complex, serious and Centre Development of the youth friendly asks for many solutions. It supposes the Mother and Child Health Care Insti- reproductive health counseling service promotion of knowledge, the network of tute of Serbia model was based on the principle of family planning services, the access to all Belgrade, Serbia

No.63 - 2006 Defending the family: The Latvian experience

The demographic and factors that influence the increase of the first child additionally to the grant 100 family situation in Latvia demographic load of Latvia, which means LVL (142 EUR) are paid, for the birth In many countries in Europe there are that the society in general and the local of the second child respectively 150 LVL problems of low birth rates and age- governments shall have to divert more (213 EUR) are paid additionally but for ing populations. This often results in a resources for social needs. the third and coming children – 200 LVL demographic crisis. This is also the case (285 EUR). This is an increase compared in Latvia, where we are speaking of a de- Means of solving the critical demo- to 2005 when the amount of the child- mographic crisis and a crisis of the family graphic situation birth grant was 98 LVL (139 EUR). as a value. Since 1989 our population has Since 2003 the Latvian government has decreased by 13%, from 2.6 million in officially recognized the task to overcome Support for incomplete families 1989 to fewer than 2.3 million in 2005. the demographic crisis and to develop In 2003 there were 11400 minors who did In 2005 Latvia had a fertility rate of 1.29, a family friendly environment as a top not receive maintenance (child support) which has decreased from 2,0 in 1990 and political priority. The Declaration of the in a sufficient amount from their parents. increased from 1.21 in 2001. Cabinet of Ministers clearly defines the Maintenance means the expenses of sup- The divorce rate is one of the highest in family as a priority (2). Consequently, porting a child, which each parent has Europe with more than 51% of marriages the government has put on the political the responsibility to provide to his or her ending in divorce. There is high number agenda measures necessary for satisfying child irrespective of his or her financial of abortions: in 2003 of every 1000 preg- the needs of families and children. In or- condition. In 2004, in order to improve nancies there were 691 induced abortions, der to develop a family friendly environ- the situation, the Maintenance Guaran- and in 2004 of every 1000 pregnancies ment, to provide effective protection of tee Fund was established. The principal there were 674 induced abortions (1). the rights of the child and to improve the objective of the Maintenance Guarantee One of the reasons for the high abortion situation of the child, family and youth Fund is to guarantee the rights of the rate is the fact that there are insufficient it was concluded that it is necessary to child to social security, guaranteeing the preventive measures for abortion, among establish a special institution to address minimal amount of child support for them poor knowledge of contraceptives matters related to family, children and children, who are being maintained only and other information regarding sexual youth. Therefore in May 2004 the Min- by one of the parents because the other and reproductive health. istry for Children and Family Affairs, the parent does not fulfill a court adjudica- leading state administration institution tion regarding the recovery of child sup- Main reasons behind the critical responsible for drafting and implementa- port. The fund provides maintenance for demographic situation tion of children rights protection, state children in a minimal amount set by the The main reasons for the decrease in youth policy and state family policy, was Cabinet of Ministers but not more than is the demographic curve on a whole are established. set according to the court decision. This insufficient state support for families with is only awarded if the bailiff has admitted children providing opportunities for the Increasing the allowance for child- that collection of maintenance from the parents as need arises to be together with care and child birth grant child’s parent is impossible or the parent their child at the same time not harm- The main achievements since 2004 are does not pay full amount of the mainte- ing their career, and the presently ruling substantial increases of allowance for nance set by the court decision. system of values in the society, which childcare as well as a huge increase in the 18 brings forward as priority the increase of amount of the grant. In 2005 Out-of-family care the standard of welfare instead of starting the allowance for child care was increased Children, who are left without parental a family and bringing up children. – the amount for a person who cares for a care, depending on the age and state As a consequence of the declining child until the age of one year if the per- of health receive social care services at fertility rate, the number of children and son is employed and is on parental leave three different types of childcare and youth has decreased and the proportion now is 70 percent of the person’s average educational institutions. In order to of persons in the old age has risen (the insurance premium salary but no less provide a family-oriented environment aging of the population has sped up also than 56 LVL (80 EUR) per month and not for children left without parental care by the extension of the lifespan during more than 392 LVL (565 EUR) per month and to diminish the number of children the last decade). The number of children for an unemployed person the amount of placed in childcare institutions, a complex and juveniles up to the age of 14 since the allowance is 50 LVL (71 EUR) (3). set of activities is being implemented the year 2000 has decreased to 99,500. From the year 2006 the amount of the in the field of out-of-family care system At the same time the number of people childbirth grant is 296 LVL (421 EUR) coordination and methodical support for older than 65 has increased by 32,200. – 100% of the value of the layette in the foster families, guardians, adopters and Therefore the low birth rate is one of the meaning of money. For the birth of the specialists working for the local govern- Linda Andersone

ments. As a result in May 2006 the num- Child initiated an inquiry in educational - to create a network of state co-fi- ber of foster families was 204 comparing institutions to find out how children are nanced family support centers in the with the years 2003 and 2004 when the informed about hotlines. It was con- municipalities. respective number was 15 and 47. In 2003 cluded that children are not sufficiently Due to the aging of the Latvian popula- there were 15 children adopted domesti- informed about hotlines: the respond- tion it is possible that until the year 2050 cally and 62 children adopted through ing children could not name hotline the population of Latvia, especially the inter-country adoptions. In the year 2005 telephone numbers. Considering the number of the able-bodied will swiftly there were already 88 domestically ad- actual operation of the hotlines as well as decrease, which could also influence opted children and 111 children adopted the number of complaints about possible Latvia’s fiscal situation negatively. Accord- through inter-country adoption. The violations of the rights of the child in Lat- ing to the data provided by international number of children in out-of-family care via, from the February 2006 Inspectorate’s credit rating agency Standart & Poors institutions continues to decrease. Com- free of charge hotline for children and the able-bodied population from 2005 to paring to the last year when there were teenagers has begun its work in order to 2050 could decrease from 69 percent to registered 3093 children in out-of-family provide support in hard and difficult life 59 percent. The agency also forecasts a de- care institutions, on 1st January, 2006 this situations, psychological and practical crease in the total number of population number was 2881. help in problem solving. in Latvia from 2.3 million in 2005 to 1.9 By providing an opportunity of whole- The hotline is a mechanism by which, million in 2050, which will be followed some development for orphans and chil- it is possible to find and readjust the by continued and increasing pressure on dren left without parental care in families failures in the state administration thus the State budget. In order to improve the the state will promote the possibility for providing better support among others demographic situation it is necessary to the children to participate actively in the for families and children, improving the continue to increase the State support development of the civic society and after environment of the family. for families, creating adequate conditions reaching the respective age to participate such as providing financial support and successfully in the labor market and be Action plan for the realization services for families to create an enabling able to live independently (social inclu- of the conception “State Family environment for families to grow. sion). Policy” In order to create favorable conditions for References Rights of the child the family in the year 2004, the Cabinet 1. Children in Latvia, Statistical data By analyzing complaints received at the of Ministers accepted the action plan for collection, (2005). For more infor- Ministry for children and Family Affairs the realization of the conception “State mation please see http://www.csb. about violations in the field of the protec- Family Policy” for the period 2004-2013 lv/satr/cat2006.cfm?nodala=03 tion of the rights of the child, it has been (4). The most significant activities of the 2. R¯ïc¯ïbas pl¯ans koncepcijai „Valsts ˛ concluded that the number of cases of Action Plan are: gimenes politika” Ministru Kabinets emotional and physical abuse in families - to develop a state system for the pro- 2004.gad¯a 30.novembr¯ï http://www. and educational institutions is increasing. motion of employment by creating a bm.gov.lv/lat/gimenes_valsts_poli- It was realized also that parents, employ- network of information of the profes- tika/ ees at out-of-family care institutions, sions demanded; these measures will 3. http://www.bm.gov.lv/lat/infor- pedagogues of preschool educational provide the unemployed with effec- macija/informacija_vecakiem/ institutions and primary schools lack tive re-qualification opportunities; ?doc=613&underline=pabalsti ˛ 19 understanding about matters related to - to develop a concept for a complex 3. 4. Valsts gimenes politika children’s rights. Taking into consider- solving of the family lodging prob- http://www.bm.gov.lv/lat/gi- ation the above mentioned conditions on lem; menes_valsts_politika/ministri- the 1st of December 2005 a special state - to reconsider the amount of state jas_aktivitates_gimenes_atbalstam/ institution Inspectorate for the Protection family allowance; ?doc=532&underline=%ECimene of the Children’s Rights was established - to enlarge the proportion of the skills for with the aim of providing recognition family life that have to be acquired in the Linda Andersone of the rights of the child in Latvia and to educational program of social studies for [[email protected]] implement a single system of protection pupils studying in grades 5 to 12; Deputy Director of Department of of the rights of the child. - to increase the number of regional Children and Family Policy Ministry for Children and Family centers that offer a complex aid in Affairs Hotline for children and youth situations of crisis (inter alia provide In the first half of 2005 the State Inspec- short-term stay for mothers with tors for the Protection of the rights of the children in situations of crisis);

No.61No.63 - - 2005 2006 Sexual and reproductive health in low fertility countries - the Bulgarian example of policies that have been initiated against low-fertility

rom a demographic point of view half of the year. Seasonal workers, with peer education and life skills education Bulgaria is not a very promising considerably lower levels of education, from NGOs and UNFPA. The perspec- Fcountry. Bulgaria’s population is are mostly using illegal channels, which tives regarding the inclusion of health among the fastest shrinking in Europe increases their vulnerability to trafficking and sexuality education as a separate and has been reduced by 908,000 from and are difficult to include in the statis- discipline are not very promising. 1990 till 2004, according to data from the tics. This type of immigration leads to a National Strategy for Bulgaria’s Demo- change in the typical family model, which Addressing low-fertility graphic Development 2006-2020 (1). By includes grandparents, children and The health reform, and its main instru- the end of 2004, 7,761,049 were perma- parents. The youngest generation usually ment - the Health Insurance System, nently residing in Bulgaria and of these remains in country with a member close that started in 1998-1999, is advancing every fourth Bulgarian was over 60 years to the narrow family circle. slowly and is facing serious problems. The of age. The population went down by 337 Without speaking about migrants, introduction of the figure of the General 000 in the period between the two latest what stops those that are still remain- Practitioner, the private health units, censuses, which were conducted in 1992 ing in the country from reproduction? as well as the corruption mechanisms and 2001. The demographic trends sug- On the one hand, economic issues – low in hospital and the traditionally mod- gest low birth rates and some of Europe’s economic status, instability, insecurity, est state health budget has led to several highest death rates. Considering that this lack of relevant investments in social crisis: hospitals going bankrupt, lack of is happening in combination with the programs and one of the lowest standards systematic prophylactic programs directly constant migration, mainly consisting of of living in Europe. Additionally, the fam- affecting the reproductive status (no people in the reproductive age, makes the ily model is changing and is following the screening and prophylaxis for breast and outlook for the future rather negative. Western European tendency, where the cervical cancer), over one million people In the light of these demographic majority of the young people and a large outside of the Health Insurance System. trends, which are not surprising consider- share of all people of reproductive age live At the moment the health insurance does ing the demographic development in the as cohabitants, without formalizing their not cover the cost of contraception or the rest of Europe, the questions are: “What relations (in Bulgaria the law doesn’t give treatment of endometriosis, and till the is done?” and “What should be done?” opportunity for treating such partner- end of 2005 it was not covering expenses The debate about the demographic crisis, ships as “legal” couples and the father has related to treatment of infertility. Since the ageing of the nation, migration, the to formally and officially “recognize” the 2006, a small step in this direction was newcomers to the country mainly from child). made, which, hopefully, is a good sign developing countries, the disparities in Another big issue linked to fertility is for the future development. The Health demographic trends for different ethnici- infertility. In Bulgaria there are over 240 Insurance Fund now covers one IVF (in ties started with little voices few years ago 000 infertile couples (the total number vitro fertilization) cycle per annum for and are becoming deeper and broader. for all the cases with primary and second- women under 40. This is insufficient, Unfortunately and not surprisingly, in ary infertility). The percentage of cases especially considering that the coverage is some political aspects they are following of male and female infertility is relatively partial – only for the materials and con- the already tried Balkan model, as shown equal. The main reason for secondary sumables, in the light of cycles per annum below. infertility is a history of reproductive tract funded in most of EU countries, but it is infection among adolescents – mainly a good beginning and a sign of changing 20 What leads to the low-fertility due to lack of or inappropriate health attitudes. levels? and sexuality education, which provides Other approaches towards improv- What stops people in reproductive age inadequate preparation for adolescents’ ing low-fertility statistics in the medical from reproduction? Migration, on the sexual life. It is important to underline sphere are: to reduce infant mortality one hand – young people of reproductive that despite all the efforts of the NGO (including perinatal mortality), improve age, the majority with a high educational community, UN agencies in the country, and optimize prophylactic programs and status, prefer to realize their reproductive and even after gaining the strong support treatment of diseases of social relevance rights abroad, where they feel economi- of the Ministry of Health in recent years, such as cardiovascular diseases, obesity, cally more secure. According to differ- the Ministry of Education still shows re- respiratory tract diseases, put efforts ent sources, over one and a half million sistance and delays the inclusion of health and emphasis on treatment of sexually Bulgarians live abroad and the majority and sexuality education in the school transmitted infections (STI) and ensure have settled down. Another part of the curriculum. Actually, young people can nationwide options for voluntary coun- migration wave consists of people living choose sexuality education as a discipline seling and testing (VCT) for HIV/AIDS half of the year (mainly in neighboring in some high schools in selected munici- and other STIs, including hepatitis B and countries), and then return for the other palities and receive interactive trainings, C. The program funded by the Global Radosveta Todor Stamenkova Chernev

Fund against AIDS, Tuberculosis and Ma- located to healthcare, optimizing the and statements are more emotional and laria (GFATM) in Bulgaria, implemented system of collecting revenues and through populist than structured and competent. by the Ministry of Health and many other searching for donors and investors within This brings serious potential problems: NGO and Government partners covers an the EU funds coming to country. The Na- on the one hand, to use the demographic amount of 16 million USD for the period tional Healthcare Strategy provides for an slogan and to try to harm the reproduc- 2004-2008. The network of service deliv- increase in public funds for healthcare to tive rights of people (pretending that ery points, providing VCT, is established 5.5% of the GDP as of next year and for abortion regulations are too liberal, which under this program. Besides mainstream a gradual increase to 8% of the GDP by could guide us to the dark side of unsafe young people, special attention is put 2012. It is the hope that it will not just be abortion and tensions and debates). The on vulnerable and underserved groups another document without implementa- chance for this is not so big, but the other – Roma ethnic minority, intravenous tion. Because for the time being the direct problem to be highlighted is more fright- drug users (IDUs), commercial sexual economic incentives for the potential par- ening: the attempt of some politicians workers (CSW) and people living with ents are very limited: fully paid maternity to give to the demographic situation an HIV/AIDS (PLWHA). Prevention and leave is 5 months (however, positively, it ethnic face (emphasizing that the Roma educational programs, trainings and rais- should be noted that it can be used both community has better population data ing awareness are among the main strate- by the mother and the father or other than other ethnic groups, or not willing gies aiming to improve the reproductive relatives). Currently there is a bill in to understand the migration waves that status of the nation as a whole together parliament to prolong maternity leave to sooner or later will hit us from the other with the main goal of HIV/AIDS preven- 12 months. Unemployed mothers for the parts of the world). This scenario has to tion. The integration of AIDS and SRHR same period receive the minimum salary be avoided, mainly by installing favorable is an important step in the right direc- (75 Euro). After the end of the maternity economic and health conditions for work tion. Improving the reproductive health leave the monthly allowance for one child and reproduction for the young gen- situation in Bulgaria is among the main in socially deprived families is only about eration. It is for our common European priorities of the Ministry of Health, UN- 10 Euro. In comparison even with the future. FPA and various NGOs, among which the three years maternity leave before 1989, it most prominent efforts and expertise is in cannot be considered as widely promoted Resources the Bulgarian Family Planning and Sexual by the government policy on retaining 1. National Council for Ethnic and Health Association (BFPA). Besides pre- young people in country and stimulat- Demographic Issues and partners. vention and health promotion, maternal ing them to raise children in Bulgaria. A Demographic Development of the and child health, including early diagnosis good step is the proposal to give a lump Republic of Bulgaria, Sofia (2005). and screenings during pregnancy, are a sum for every newborn child to help the priority. In the National Health Strategy family in the first months. The amount Other relevant documents 2007 – 2012 some of the main goals are is to be negotiated – the increase in this 1. Ministry of Health. National targeted towards coping with the low- investment should be considerable and it Health Strategy 2007-2012, Sofia. fertility situation, without being directly should affect the labor market as well to Can be downloaded from: www. pro-natalist. Strategic goal1: “Improving include interesting places of employment mh.government.bg. the health of the nation”, is having among which are compatible to the European 2. Ministry of Health, UNFPA and part- its objectives raising public awareness standards salaries in order to make young ners. Research on the Frequency and of healthy lifestyle and the threats to people feel economically secure and to Causes of Sterility in Bulgaria, Sofia 21 health and optimization of public health motivate them to stay in the country. (2005). protection work; introduction of a system of national monitoring of the health The future response Todor Chernev of schoolchildren and improvement of Government, politicians and society have [[email protected]] the conditions at children’s medical and started to listen to scientists and demog- Member of the Board of Directors social care institutions. raphers in the last two years and the University Maternity Hospital ”Maichin Dom” of Sofia demographic crisis is an issue, which is Hon.President of BFPA Economic measures now discussed in the public sphere. Actu- What about economic measures? The ally almost every political formation and Radosveta Stamenkova National Health strategy in its goal 8 is social movement has a policy or attitude [[email protected]] focused on: “Guaranteeing the financial to the demographic crisis. The President, Executive Director stability and sustainability of the national ministers, heads of parties and various Bulgarian Family Planning and healthcare system.” This will be achieved stakeholders urge that something should Sexual Health Association (BFPA) by increasing the share of the GDP al- be done, but there is no realistic strategy,

No.61No.63 -- 20052006 Between Policy-Maker Awareness and Policy Responses: Lowest-low Fertility in Italy

pervasive stereotypical view de- government views and policies tells an in- what follows, we focus on cash benefits scribes the typical Italian family teresting story: still in 1996, i.e. when Italy and services. as large. On the contrary, Italians was already top of the world league in A Cash benefits linked to children: have been the “champions” of low fertility low fertility and indicators were publicly since the early 1990s. The total fertility available, the fertility level was perceived new attempts rate (TFR) fell below 1.3 children per by the government as “satisfactory”, with The recent increase in TFR (a difference woman—the threshold of so-called “low- policies aiming at no intervention. In of 0.16 between 2005 estimates and 1995) est-low” fertility—in the year 1993 and 2003 the Italian government started per- is probably also connected to some mea- reached a minimum level of 1.18 in 1995. ceiving fertility as “too low”, but still no surement issues connected to TFR, which Total fertility has thereafter increased, intervention was regarded as necessary; is a problematic indicator when (such as attaining a level of 1.34 in 2005 (estima- the government then published a “White in Italy) the mean age at childbearing is tion by the Italian National Statistical Paper on Welfare State” emphasising low not constant. However, we here focus on Institute). To what extent and since when fertility as a key societal problem (1). The policy changes during this period and has lowest-low fertility been perceived as “White Paper” includes statements such explore their potential effect on fertility. a policy issue? Have policy changes, and as “an increase in the rate of births keeps In Italy, a traditional family allowance in particular cash benefits and childcare on being a necessary presupposition, if for workers was introduced first in the services, had a role in the recent increase we are to restore in Italy a context of gen- 1930s. After extensions in the following in Italian fertility? In what follows we try erational renovation consistent with the decades, it became income-tested in 1983. to discuss these issues and, if possible, to preservation of social cohesion and eco- Self-employed and non-employed were answer the questions. nomic development. In fact, as previously excluded from the allowance. Indeed, pointed out, even though the decision contributions to the family allowance A family-unfriendly and child-un- whether to have children or not keeps funds have since then been regularly friendly society on being made by the individual couple, shifted to the payment of old-age pen- Competing explanations have been put it is unquestionable that everything sions. Paid maternal leave for working forward in the scientific literature on why becomes much more difficult if there are mothers was extended to 5 months. Did Italian fertility attained lowest-low levels. no suitable family-supporting policies” these policies change after the emergence There is however a general agreement (1). Finally, in the 2005 UN survey, the of lowest-low fertility level and with the that both national-level institutional and Government declared that policies should new policy-maker awareness? policy environments cannot be charac- aim at raising fertility levels. The answer is positive. A new policy terised as family-friendly nor as child- In May 2006, power shifted from the was introduced, mostly with anti-poverty friendly. On the contrary, the Italian Centre-Right to the Centre-Left coalition, aims, in January 1999, together with other society is largely seen as family-unfriendly but also the new government stated that minor tax changes; this policy is still in and child-unfriendly. fertility is too low and that higher levels place as of July 2006. The policy has two According to Eurostat data from 2003, would be desirable. Interestingly, this is components. First, a sizable cash benefit the average level of public spending for one of the few issues for which there is a for households with at least three co-resi- welfare in favour of families and children clear agreement between the two main dent children under 18 and low (house- is 2.2% of the GDP within the EU15. In coalitions of Italian politics. Much less hold) income levels: 118 Euros per month Italy, this level is 1%, with OECD recon- agreement within Italian politics (and in 2005, i.e. approximately 7% of the 22 structions showing a fairly constant level society) can be found concerning issues yearly income at the level of the testing since 1980, oscillating from 0.8% to 1.3% of reproductive health and rights, i.e. threshold. The share of households re- at most. Neither is this picture changed especially on the basic right to choose ceiving this transfer has been particularly by tax relief policies: OECD recently freely and responsibly the timing and the sizeable for larger households, especially estimated “net social expenditure”, i.e. number of children. The Centre-Right in the less wealthy part of the country, social expenditure taking into account the government during the period 2001-2006, i.e. Southern Italy, where in the year 2000 effects of the tax system and of private backed by the , passed 64.2% of households with three or more voluntary social expenditures. For net laws forbidding the use of abortive pills children received the benefit. Second, a social expenditure, Italy is ranked as 19th on the one hand, and the use of various benefit to households in which one of out of 23 countries, with 1% of the GDP artificial insemination techniques (such the partners (typically the woman) is not against 2.1% for the OECD average. as artificial insemination by donor) on employed, with relatively mild restric- Why this? A possible reason is that the other hand. These issues have hardly tions on income levels, for 5 months (284 Italian policy-makers have not perceived been connected to the debate on low Euros per month in 2005). The benefit fertility levels as being too low until very fertility, which indicates a general scarcity is designed to target mothers who were recently. The periodic UN survey on of reflection on reproductive rights. In not eligible for standard maternal leave Francesco C. Billari

benefits. A first analysis of the effect of with respect to this, even in a country average, more than 1% of the GDP needs such policy shows a mild but statistically where traditionally mothers and (usually to be dedicated to this. This is unlikely significant impact on the progression to female) relatives helped in providing to be the case, also because of “political third birth, and a drop in the abortion childcare. As mothers and other relatives economics” reason: the median voter in ratio of mothers with two children that progressively enter the labour market the 2006 elections was approximately 47 are potentially eligible (2). and are increasingly less able or willing to years old, which makes problematic for In September 2003, another cash ben- provide support, compatibility is strictly any future Italian government both the efit was introduced subsequently to the linked to meeting childcare needs (2). redistribution of social expenditure from presentation of the “White Paper”, with Childcare centres (known as nidi, other categories to families and children, limited validity for 2003 (retrospectively) public and/or private, usually open from and a new attention on reproductive and 2004. The benefit amounted to a 8 am to 6 pm) are the main publicly rights—for instance, a 2005 referendum one-shot transfer of 1000 Euros imme- regulated and solicited instrument in Italy that aimed at the abolition of restrictions diately after the birth of each child. First for children aged 0-2. The number of nidi on artificial insemination was invalid births and births born from mothers with has been increasing (at the national level) because of too low voters attendance. non-EU citizenship were excluded (the from 2,180 in the year 1992 to 4,885 for total share of children from parents with the latest available data (usually referring References foreign citizenship was 8.7% in 2004, the to the year 2004 or 2005). Consequently, 1. Ministero del Lavoro e delle Politiche vast majority from mothers with non-EU the proportion of children aged 0-2 in Sociali (Ministry of Labor and Social citizenship). This measure was not reno- nidi has increased from 5.8% in 1992 to Affairs). White Paper on Welfare State. vated, but then subsequently reiterated 9.9% for 2004/05, with the population Proposals for a Dynamic and Soli- at the end of 2005, with retrospective aged 0-2 practically constant across the dary Society. Rome, February 2003. validity also for 2005 and first births, but period. Italian, English, French, German, still excluding newborns from non-EU To what extent is the increase in fertil- Spanish versions accessible (as of July mothers. This benefit could be added on ity over about the last 10 years connected 2nd, 2006), at: http://www.welfare. top of the benefits previously described. to the increased childcare availability? gov.it/EaChannel/MenuTematiche/ The retrospective and one-shot nature The scientific literature has yet to provide PoliticheFamiliari/LibroBiancoWel- of the benefit, not planned as a constant an answer. Regions are responsible for fare.htm. measure, together with its size make it policies concerning nidi, with municipali- 2. Billari, F.C., Zuanna, G. D. and unlikely as a measure to influence fertility. ties or other institutions managing the Loghi, M. Assessing the impact of The exclusion of newborns in Italy from centres. Huge regional variation emerged family-friendly monetary transfers in non-EU mothers also includes a discrimi- as a consequence. The recent fertility a lowest-low fertility setting (Italy). nation towards children that is hardly increase has been most prominent in re- Paper presented at the XXV Interna- justifiable. gions of Northern and Central Italy, were tional Population Conference of the both female labour force participation International Union for the Scientific An increasing share of children and nidi are more widespread. Study of Population, Tours, France, aged 0-2 in childcare centres: does An additional but related issue is July 18-23, 2005. it matter? whether the increase in childcare provi- 3. Del Boca, D., Locatelli, M. and Vuri, The scientific literature has shown sion is sufficient to meet the needs of D. Child-Care Choices by Working that—at least in the Western world—fer- parents. There is a clear signal that unmet Mothers: The Case of Italy. Review of 23 tility levels are higher in countries where needs for childcare do indeed exist: at Economics of the Household, 3 (4): female labour force participation is the national level, in the year 2000, only 453-477, December 2005: higher, i.e., that the cross-country correla- 68.1% of the eligible applicants to nidi tion between fertility and female labour could actually be accepted. For more Francesco C. Billari force participation has become positive. recent years, data for specific regions indi- [[email protected]] In Italy, according to recent Eurostat data cate the persistence of an unmet need. Director related to 2005, the total female employ- Carlo F. Dondena Research Center on Social Dynamics ment rate is 57.6%, against an average for Concluding remarks: public budget Università Bocconi. the EU15 of 65.2%. The ability to com- and political economy bine paid work, childbearing and chil- Italy faces its fertility problems in a drearing is the main explanation for the period of serious budgetary restrictions, emerging compatibility of relatively high with public debt approaching 108% of fertility and female labour force participa- the GDP. If social expenditure towards tion. Childcare services are fundamental families and children is to reach EU15

No.63No.61 - - 2006 2005 BEHIND THE SURPRISING STABILITY OF ROMANIAN FERTILITY

The drastic fertility decrease Surprisingly enough, though it started from the Romanian fertility is situated, ana- relatively different levels at the end of the lyzed at an aggregate level. When analyzed in Romania after 1989 is 1980s, the fertility trends were similar in dif- at a deeper level, regionally, by urban/ not an unusual trend in the ferent political, economical and social con- rural areas, age groups and socio-eco- texts in the 1990s, resulting in a homogene- nomical characteristics of the woman, we European context, it is part of ous level, with total fertility rates almost can identify important particularities, dif- the general decreasing move- identical and stable after the year 2000 of ferent dynamics and structural changes. 1.2 to 1.3 births/woman (1). The fertil- Moreover, the effects of the economic ment recorded in the Central ity decrease in the 1990s in the countries measures taken by the government in and Eastern European coun- undergoing economic and social transition 2003 to stimulate birth rates, offer today was not determined and maintained by im- some interesting and relevant observa- tries undergoing economical mediate economic factors. The causes were tions and conclusions. and social transition after the different, mainly non-economic, emerging The birth rate and the total fertility from the deep changes those post-com- rate have been remarkably stable starting fall of communism. munist societies went through and which in the mid 1990s, at 10 per 1000 people influenced the attitude of the young couple and 1.3 children per woman. Behind regarding marriage, family and the place of this stability, structural and other types children in the hierarchy of priorities and of changes can be noted, that we could decisions (2). define as signs of the modernization of Romania’s case cannot be analyzed the Romanian fertility. The early Eastern apart from this general picture. There is, European model of fertility is still well although, one important particularity: defined, both by the curve of fertility Before 1990, Romania had a forced and rates by age and by the mean age of the brutal pronatalist policy (with severe women giving birth. Even if the mean restrictions upon access to contracep- age of women at the birth of the first tion and abortion) and the total fertility child increased with two years (from rate was slightly higher than in the other 23 to 25 years), it is still situated at a European communist countries (2.2 net lower value compared with the one – 2.3 children/woman). It was obvious from the developed European countries. that the level of fertility in Romania was Co-habitation and living in consensual artificially maintained at this level and unions is not very frequent, but there are we expected the decrease in the 1990s evident signs of expansion of this lifestyle to be higher, once the restrictive regula- among youth, and it is expected that the tions on abortion and contraception were phenomenon will be wider in the future. abolished at the end of 1989. Moreover, Despite the family planning programmes the economic crisis and the dramatic launched immediately after 1989 by the reduction of the living standards should government with support from non-gov- have amplified the fertility decline to a ernmental organizations (NGOs) and in- 24 higher level compared with the other ternational organizations, at a time when countries where the deterioration of the the education of the population regard- living standards was only moderate and ing contraception was still bearing the temporary (Czech Republic, Slovakia, consequences of the old forced pronatalist Poland and Hungary). There is, indeed, policy, modern contraceptive use is still a higher decrease of fertility in Romania. reduced and the number of abortions is The particularity of this trend is not extremely high, with all the consequences the magnitude of the decrease, but the and risks for the mother’s and children’s concentration of the decrease in only 3-4 health. The number of abortions is, years instead of a spread over a larger especially for the last years, underreport- period of time, like in the other countries. ed, an increasing number of abortions The already mentioned feature of the Ro- being performed in private clinics whose manian fertility before 1990, can explain statistical reports are incomplete. The Re- this particularity. productive Health Survey from 2004 (3) This is the regional context in which indicated a total abortion rate of 84/100 Vasile Laurian Ghetau Arghisan

Table 1 Live births and fertility in urban and rural areas, 2002-2005 Year Urban Rural Live births Change Crude birth Total Live births Change Crude birth Total - thousands from rate fertility rate - thousands from rate fertility rate previous - per 1000 - per woman previous - per 1000 - per woman year year - thousands - thousands 2002 98.2 -4.2 8.5 .99 112.3 -5.6 11.0 1.60 2003 100.9 +2.7 8.7 1.03 111.5 -0.8 11.0 1.61 2004 111.3 +10.4 9.4 1.11 104.9 -6.6 10.7 1.57 2005 117.8 +6.5 9.9 1.17 103.2 -1.7 10.6 1.55 Source: National Institute of Statistics, 2001b, 2002, 2003; 2004; 2005; 2006a, Bucharest women aged 15-44 for the period of the gross average income, considerably higher 2005. In the first year there is a significant three years before the survey. The com- than the average net income of employed increase of the second order births and parison between the official abortion data women. Since most employed women live in 2005 that increase is more important and the ones provided by the subjects of in urban areas, it is not surprising that than the one for the first order births. If the survey indicate an underreporting of the positive effects of this measure are vis- we consider the information from the 25 – 30%. The same survey indicates a ible in the increased number of children media, the dynamics for the second order modern contraception prevalence of 45% born in urban areas. The changes in the births in 2004 and 2005 has a very clear for women and 34% for men, while the birth rate trend in urban area in the last significance: a number of women who prevalence of the traditional methods is three years are extremely significant and had their first child and took advantage of still high of 17% and 24% respectively. As relevant to the influence of the economic the mentioned economical measures, de- a consequence, the unmet need for mod- factors on the birth rate. cided to have their second child and have ern contraception is also high, 28% of all If we analyze the dynamic of the another 24 months of well-paid maternity women and 40% of the married women. births during 2003-2005 by mother’s leave. It is admitted that this attitude is Romania had and still has a low urbani- occupational status (see Table 2), there well established and will be confirmed by zation level (55% of its population) and is an evident predominance of the the future trends. there have always been big economical, birth distribution among the employed The moderate increase of the birth social, cultural and demographic differ- women, who took advantage and will rate among employed urban women has ences between the two social environ- continue to benefit of the economical another positive side, being registered ments. It is important to note that, measures taken by the government. The mainly among the women with the especially after the year 2000, there is positive effects are definitely higher in the highest education level – post-high and a reduction of the difference between years 2004 and 2005, with the dissemina- university, which should have a positive the birth rate and fertility rate in urban tion of the information and increased effect on quality of children. The share and rural areas, as result of an opposite awareness regarding the financial benefits of births from women with post-high trend of the birth rate in the last years – a emerging from the legislation adopted and university level education is still decrease in rural area and a slight increase in 2003 and improved in 2004. In 2005, reduced – only 16% in 2005. This proves in the urban area (see Table 1). there was a moderate reduction of the not only the well-known lower fertility Only the urban area registered a positive number of births from employed women of women with higher level of education, 25 trend in the birth rate, determined by the and the development in 2006 is yet to be but also the general education level of the economic measures taken by the govern- determined. Romanian population. The percentage of ment to assist employed women with The birth rate decrease in Romania births from women having a high level children. We believe that the examination in the 1990s was the result of giving up of education was even lower before the of the characteristics of this reaction to having a second child or more, as well as moderate birth rate increase after 2002 economic incentives is interesting and of postponing the first birth or refusing to (9% in 2000). useful (see table 2). The government poli- have children. As seen in the above table, The Romanian fertility is in a process cies initiated in 2003, and improved in in 2003 and 2004, the birth rate increased of rapid structural changes through the 2004, state the possibility for the mother predominantly based for the first order reduction in the proportion of fertility at to benefit from a 24-months maternal births, showing that the financial incen- younger ages and the increase in the pro- leave for raising her baby. The monthly tives were the most effective on employed portion of fertility after the age of 30. It subsidy received for that period of time women who had no children. There is is a modernization of the fertility, getting is very high compared with the income however a very interesting change that closer to the structure from the developed level in Romania. It represents 85% of the occurred in 2004 and was consolidated in countries. The increase of the fertility of

No.63 - 2006 Table 2 Annual change in number of births by employment status of mother, In these circumstances, will we witness an live births order, education level and age of mother, 2003-2005 increase of the children abandonment, of 2003 / 2002 2004 / 2003 2005 / 2004 adoptions or placements in maternal care centers (public or belonging to NGOs)? By mother’s employment status It is difficult to give a straight answer and - employer +1 +4 -64 only the developments in the following - employee +2850 +7560 +7311 years will show if the respective policies - housekeeper +898 +872 -2066 will have such adverse effects. It will be an extremely useful experience for the - unemployed -1221 -96 -205 government in development of future - self-employed -153 +277 -341 policies to increase the birth rate. - other +350 +1816 +1797 Finally, without minimizing the im- By live births order portance of the measures taken, we need - order 1 +2011 +6963 +2646 to keep in mind that they are addressing only the employed women who contrib- - order 2 +751 +2546 +3554 uted to the social insurance system. They - order 3 -24 +381 +410 targeted thus only a narrow segment of - order 4 and more -13 +543 -178 the total female fertile population, who By mother’s level of education can have only a moderate contribution in recovering the Romanian fertility. - primary +308 +146 +193 However, we believe that the experience - secondary -742 +1979 -7 provided by these measures will be use- - vocational -25 +1033 +463 ful, when the financial resources of the - high school -84 +2187 +263 country will allow it, to formulate and implement national policies to increase - post college and +3035 +3431 +3317 university the birth rate. - other +233 +1657 +2203 References Fertility rates by age – in % 1. Council of Europe. Recent demo- 15-19 +4.4 +8.4 +1.9 graphic developments in Europe 20-24 -2.3 +2.2 -3.4 2004. Council of Europe Publishing, 25-29 +3.6 +5.1 +5.5 Strasbourg (2005). 2. United Nations and the Economic 30-34 +11.0 +17.5 +17.4 Commission for Europe. Economic 35-39 +12.6 +17.5 +9.5 Survey of Europe 2000, No.1. United 40-49 +4.5 +13.0 +11.5 Nations, New York and Geneva Mean age of mother (years) at (2000). 3. Ministry of Health, World Bank, - birth of first child 25.7 26.0 26.3 26 UNFPA, USAID, UNICEF. Reproduc- - at childbearing 27.1 27.3 27.6 tive Health Survey – Romania 2004, Source: National Institute of Statistics, 2001b, 2002, 2003; 2004; 2005; 2006a, Bucharest Bucharest, (2005). employed urban women confirms this observations to draw. We have mentioned structural change, the most important that the adopted measures determined Vasile Ghetau increases being recorded after age 30. a number of women to give birth to two [[email protected]] A few final remarks on the measures children. There is a risk that after four Director taken by the Romanian government in years of maternal leave, with a higher Population Research Center of the Romanian Academy 2003 and their effects. We are witnessing subsidy compared with the salary that the positive effects of financial incen- the women had before the leave and will Laurian Arghisan tives on the women and on couples. The have after the leave, a number of families [[email protected]] effects are modest, but the decrease of will have a lower average income/family Programme Officer Reproductive birth rate was thus stopped, even if its member. The living standards of these Health, Population and Develop- present level remains a low one - 10 per families will be reduced and the difficul- ment thousand. There are two more important ties of raising their children will increase. UNFPA Romania Recent changes in family policies in Austria and Germany - A response to very low fertility

ong-term trends in Austrian and Figure 1.a Period (1951-2005) and cohort (1900-1966) fertility indicators, Austria West German fertility (Figure 1a and Figure 1b) have evolved in 3,0 L Period TFR parallel with the trends in western and 2,5 northern European countries. After a Birth cohort 1966 Cohort TFR marked rise in fertility during the period 2,0 Birth cohort 1935 of economic and social recovery after 1,5 World War II that culminated in the early 1960s, a substantial drop in fertility 1,0

Total fertility Total Birth cohort 1900 took place between the mid-1960s and 0,5 the mid-1980s (early 1970s in the case of Germany). The period total fertility rate 0,0 Year (TFR) continued to decline after 1980, 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 although less rapidly than before, and Source: Sobotka (2005) for both countries the TFR has hovered around the level of 1.4-1.5 in the last two Figure1.b Period (1951-2005) and cohort (1900-1962) fertility indicators, Germany (East and West Germany combined) decades. Completed fertility has gradually declined among women born after 1935 3,50 for Austria (1933 for Germany), drop- 3,00 ping to a value of 1.7 and 1.5, respectively, Period TFR 2,50 among women born after 1965 for Aus- Birth cohort 1900 Birth cohort 1962 tria and Germany. 2,00 Low fertility levels combined with 1,50 increasing survival and rather modest 1,00 migration flows contribute to population fertility Total ageing—in particular also to ageing of the 0,50 labour force—both in Austria and in Ger- 0,00 many. As a consequence, family policies Year 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 aimed to increase fertility, have recently Source: Federal Statistical Office, Federal Institute for Population Research (2006) been implemented in both countries. Since differences in fertility levels between Both countries provide quite generous to remain in the workforce even dur- countries can be attributed to difference tax deductions and tax credits to families. ing childbearing years. The institutional in demographic and socio-economic fac- The support of working parents is at a arrangement in West Germany differed tors (Neyer 2003), family policies should medium level. There are relatively long from the East German one particu- be aiming to influence both of these parental and childcare leaves, but more larly in the way in which women were factors. A key demographic factor leading limited childcare facilities (in particular integrated into the labour market. While to low birth rates, and hence should be at ages below 3 years). Social policies in full-time employment was universal in subject to targeted family policies, is the Germany and Austria encourage mothers former East Germany, in West Germany postponement of childbearing. Among to exit from the labour force and support caring for one’s child was considered a 27 the socio-economic factors the increase men as the family breadwinners. For fur- highly legitimate reason for withdraw- in female labour force participation since ther details see Table 1 and Neyer (2). ing from the labour market. Moreover, a the 1970s has put the focus on employ- It needs to be mentioned that fam- ‘housewife bonus’ in the tax and transfer ment-related fertility policies. ily policies in the former German system assured that this family model was Within the typology of family policies Democratic Republic were quite different economically feasible. On the other hand, developed by Gauthier (1) Austria and from those in West Germany and were full labour participation was supposed to Germany correspond mainly to the ‘con- explicitly pro-natalist since 1972. In the be both ‘right and duty’ by East German servative’ regime, which is characterised East, continuous full employment of both constitution and women did not have a by a system of state support for fami- men and women was seen as the main real choice not to participate in employ- lies that tends to vary according to the foundation of gender equity. Exten- ment. In addition, combining full-time parents’ employment status, and that also sive and inexpensive public childcare, employment with childcare and house- tends to be driven by a more traditional including after-school clubs and crèches hold ‘obligations’ was difficult for many view of the gender division of labour. The for very young children, as well as other women due to underdeveloped service level of cash support is medium to high. social support measures allowed women sector.

No.63 - 2006 Table 1: Family policies in Germany and Austria

Maternity provisions, 1999-2001 duration in weeks wage compensation in % paternity leave Austria 16 100 none Germany 14 100 none

Parental leave, duration benefit max. age of child part-time father 1999-2002 (year) Austria 2 years flat rate (30 3; 3 months unpaid yes 6 months ‘use or months+ 6 months until child is 7 loose for father) Germany 3 years flat rate 2 years 3; 1 year paid until yes yes means-tested, child is 8

Children in publicly funded childcare in Europe, 1993/1994 and 1998/2000 guaranteed children (under 3) in publicly childcare children (3-6)in publicly guaranteed children (6-10) in publicly funded childcare (under 3) funded childcare childcare (3-6) funded after-school care 1993/94 1998/2000 1993/94 1998/2000 1993/94 Austria 3% 4% no 75% 79% no 6% Germany 2% 10% no 85% 78% yes 5% (Germany West) 34% (Germany East)

Child benefits 2000-2002 basic principle by number of children by age Austria universal yes yes Germany universal yes no Source: Neyer (2003) Austria (4.9 percentage points) within 36 months leave for childcare which allows moth- In Austria, frequent changes in parental following the first child, which can be ers to stay at home with their young leave regulations during the last years attributed to the new leave regulations children. Preliminary analyses indicate created incentives for parents to space introduced in 1990. Part of this increase that the positive labour market incentives their second and subsequent children in a was due to more rapid child spacing, (by increasing the exemption limit) are way that they can receive continuous pay- but some positive effect (3.9 percentage outweighed by the negative ones caused ments of parental allowance while staying points) remained even ten years after the by the extension of parental leave. at home with their children. Moreover first childbirth. Focusing on third births, Combining work and family is difficult recent changes in family policies pro- Hoem et al. (4) suggest that many women for Austrian women due to the insuf- moted greater compatibility of work and spaced their third births shortly after the ficiency of public and private childcare childbearing. second one in order to qualify for an un- as well as inconvenient school hours In 1990 and 2002 policy changes interrupted period of parental leave. For and opening times of many day-care were enacted that extended parental second births Prskawetz and Zagaglia (5) institutions. In 1998/2000, only 4% of 28 leave periods and thereby increased the did not find a similar spacing effect. children under age three and 79% aged 3 incentive for mothers to have additional As of January 2002 parental leave is no to mandatory school age were benefiting children more quickly. As of July 1990 longer linked to previous work experi- from any publicly funded formal child- paid parental leave was extended from the ence and parents can take parental leave care arrangement (Table 1). When also first until the second birthday of a child for up to 30 months2. More flexibility has including private childcare facilities, this and even until the third birthday in the allowed to combine parental leave with number increases to 10%. case of part-time parental leave (see (2) part-time work more easily, letting each As of July 2004 there is a legal right for for more detailed descriptions of parental person who receives a parental allowance mothers employed full-time to reduce leave changes). This period was reduced earn a gross income of up to EUR 14,600 their working hours after the birth—if again in July 1996 to a maximum of 18 per year. This earning level is usually the company has more than 20 employees months following childbirth if only one exceeded by mothers employed full-time and the mother has been employed at parent takes the leave, making a ‘targeted’ with the consequence that they lose their least three years before pregnancy. Un- spacing behaviour more difficult. right to these social benefits. Instead of fortunately, only few mothers fulfil these The study by Lalive and Zweimüller facilitating women’s employment op- conditions. Generally, part-time jobs are (3) reports an increase in the probability portunities by providing services, the rare in Austria. In 1999, the employment of having another child by 15 percent government gave preference to extended rate of mothers with children under age Alexia Prskawetz, Isabella Buber, Tomas Sobotka, Henriette Engelhardt

6 in two-parent families was 66% and for the father takes leave for this period). References single mothers 76% (5). Parents who space their children closely 1. Gauthier, A. Family Policies in Industri- will obtain a further bonus on top of the alized Countries: Is there Convergence? Germany family allowances. Population 57: 447-474 (2002). A clear distinction between the Austrian To sum up, family policies in Austria 2. Neyer, G. Family Policies and Low Fertil- and German family policies lies in the and Germany are mainly directed towards ity in Western Europe. MPIDR Working taxation system. While most European financial incentives helping young moth- Paper 2003-021 (2003). countries introduced individual taxation ers to retreat from the labour market 3. Lalive, R. and J. Zweimüller. Does paren- by the beginning of the 1990s, in Ger- and much less to structural incentives tal leave affect fertility and return to work? many—even today— employed spouses that would support the compatibility of Evidence from a ‘true natural experiment’. have joint taxation and the family benefits childrearing and employment. Discussion Paper IZA DP No. 1613, gained through the family taxation sys- In both countries, however, there is a Institute for the Study of Labour (2006). tem are greater for one wage earner than clear tendency to increase the availability Accessed at www.iza.org. in families with two wage earners. The of childcare, partly also strengthened by 4. Hoem, J. M., A. Prskawetz, and G. R. system of income splitting provides sub- the EU’s goal of increasing female em- Neyer. Autonomy or conservative adjust- stantial tax relieves for traditional family ployment rates to 60% by 2010. The fact ment? The effect of public policies and forms and imposes “severe penalties on a that childcare services are currently being educational attainment on third births in working wife”. decentralised, marketised or moved to Austria, 1975-96. Population Studies, Vol. In order to encourage women to re- private initiatives could, however, increase 55(3), 249-261 (2001). enter the labour market, the right to part- social and economic inequality in their 5. Prskawetz, A. and Zagaglia, B. Second time work has been made a legal one in accessibility and affordability as pointed Births in Austria. Vienna Yearbook of 2001. Another important aspect in easing out in Neyer (2). Existing studies on ef- Population Research, 143-170 (2005). the combination of work and family is the fects of family policies on fertility suggest 6. Hank, K., Kreyenfeld, M. and Spieß, provision of day-care. Since 1996 children that policy effects are usually stronger C. Kinderbetreuung und Fertilität in older than three have been legally entitled with respect to fertility timing, often in- Deutschland. Zeitschrift für Soziologie to a place in a public centre, but this ducing short-term swings in period fertil- 33: 228-244 (2004). entitlement in fact only guarantees a place ity and in the number of births, but there 7. Sobotka, T. Fertility in Austria: An Over- in a relatively costly part-time centre is much less clear-cut evidence for lasting view. Vienna Yearbook of Population offering inflexible opening hours and no changes in fertility quantum. For family Research 2005, 243-259 (2005). lunch so that parents have to organise policies to have an influence on fertility it private day-care in the afternoon. is indispensable to also integrate measures There is empirical evidence regarding in labour market policies, care policies Alexia Prskawetz the impact of policy measures on fertility and gender policies (2). [[email protected]] in Germany. Monetary child benefits of Deputy Director and Research all kinds have a significant impact on Endnotes Group Leader Vienna Institute of Demography fertility. The number of places in day-care 1. Gauthier’s (2002) definition of family Austrian Academy of Sciences facilities was found to have a significant policy encompasses cash and in-kind effect for having a first child in the East benefits such as direct cash transfers Isabella Buber (6), whereas it has not been possible to to families, tax reliefs for families [[email protected]] 29 demonstrate that the local availability of with children, maternity and parental Vienna Institute of Demography institutional childcare services exerts a leave, childcare facilities and subsi- Austrian Academy of Sciences positive effect on birth rates in the West. dies, as well as certain provisions in In June 2006 a new law was passed by family law. Tomáš Sobotka the German government that will (start- 2. If both parents participate in the [[email protected]] ing in 2007) replace the current family parental leave, they are entitled to six Research Scientist allowance of 300 Euro per month by an additional months of paid leave since Vienna Institute of Demography Austrian Academy of Sciences income-dependent family allowance as 1996; i.e. three years in total since already practiced in Nordic countries. 2002. However, as parental leave con- Henriette Engelhardt This newly established family allow- tinues to be taken almost exclusively [henriette.engelhardt-woelfler@ ance payment is targeted to replace 67% by women (in 2004 men constituted sowi.uni-bamberg.de] of previous individual earnings up to a only two percent of parental leave Professor for Population Sciences maximum of 1,800 Euro per month and users; cf. Gisser and Fliegenschnee Department of Demography will be granted for 12 months (with an 2004), only few couples take advan- University of Bamberg, Germany extension for two additional months if tage of this possible prolongation.

No.63 - 2006 Resources

Relevant reports Federal Institute for Population Research and Robert Bosch Foundation (Eds.): ’The Demographic Future of Europe – Facts, Figures, Policies - Results of the Population Policy Acceptance Study (PPAS)’, Stuttgart, 2005. This report summarizes the results of an international comparative research project studying the attitudes of the population to de- mographic change and population-relevant policies. The report analyses what the population in fourteen European countries thinks about family, children, partnership, equity and ageing. The report can be downloaded at: http://www.bib-demographie.de/ppa/PPAS_brochure_en.pdf Kohler, H.-P. et al: ’Low fertility in Europe: Causes, Implications and Policy Options’ In F.R. Harris (Ed.): The Baby Bust: Who will do the Work? Who will Pay the Taxes?, Lanham, MD: Rowman & Littlefield Publishers, 48-109, 2006. This recently published paper presents an up-to-date picture of the European fertility patterns and provides an analysis about the causes and implications of, and potential policy responses to, low and lowest-low fertility in Europe. The paper can is available at: http://www.ssc.upenn.edu/~hpkohler/papers/Low-fertility-in-Europe-final.pdf Neyer G.: ‘Family Policies and Fertility in Europe: Fertility Policies at the intersection of gender policies, employment policies and care policies’, MPIDR Working Paper WP 2006-010, Max Planck Institute for Demo- graphic Research, Rostock, 2006. This working paper explores the relationship between family policies, fertility, employment and care. It suggests that similar family policies are likely to exert different effects in different contexts. It argues that a proper assessment of effects of family policies needs to take the combined spectrum of gender relations, welfare-state structures, and labor-market development into account. The paper can be downloaded from: http://www.demogr.mpg.de/papers/working/wp-2006-010.pdf

Recent WHO publications

Accelerating progress towards the attainment of international reproductive health goals – A framework for implementing the WHO Global Reproductive Health Strategy, WHO, Geneva, 2006.

This document provides a framework for implementing the Reproductive Health Strategy developed in 2004. It focuses on the five action areas to improve sexual and reproductive health defined in the strategy. For each of the key action areas, detailed actions are suggested for implementation at policy and programme levels. These are followed by the role WHO (with its partners) can play in supporting countries in that action area. A range of health-care and health status indicators relating to the five core elements of reproductive health are also provided to facilitate monitoring and evaluation of progress.

Global strategy for the prevention and control of sexually transmitted infections: 2006– 2015, WHO, Geneva. 30 This document was developed to complement the reproductive health strategy developed in 2004. The strategy offers four fundamental benefits of investing in STI control, namely: (i) reduction in STI-related morbidity and mortality; (ii) prevention of HIV through a cost-effective intervention; (iii) prevention of long-term sequelae of STIs, such as cancers, especially in women; and (iv) reduction in adverse outcomes of pregnancy (in women infected with STIs). The strategy highlights opportunities for scaling up an effective response to STI prevention and control and proposes feasible evidence-based interventions for implementa- tion at country level.

Sexual and reproductive health of women living with HIV/AIDS – Guidelines on care, treatment and support for women living with HIV/AIDS and their children in ressource- constrained settings, Published by WHO and co-produced by UNFPA, Geneva, 2006.

This publication addresses the specific sexual and reproductive health needs of women living with HIV/AIDS and contains recommendations for counselling, antiretroviral therapy, care and other interventions. Jacqueline Bryld

Comprehensive Cervical Cancer Control - A guide to essential practice, WHO, Geneva, 2006. This guide is intended to help those responsible for providing services aimed at reducing the burden posed by cer- vical cancer for women, communities and health systems. It focuses on the knowledge and skills needed by health care providers, at different levels of care, in order to offer quality services for prevention, screening, treatment and palliation of cervical cancer. The Guide presents guidelines and up-to-date, evidence-based recommendations covering the full continuum of care.

Reproductive Health Indicators - Guidelines for their generation, interpretation and analysis for global monitoring, WHO, Geneva, 2006. This document is intended for national public health administrators and health programme managers. It briefly reviews theoretical and practical considerations of indicators, followed by a discussion of the definition, data sources, collection methods, periodicity of collection, disaggregation, use, limitations and common pitfalls for each of the shortlisted indicators. It is hoped that the document will contribute towards a consistent global moni- toring and evaluation of reproductive health.

Important upcoming events

23rd Annual Meeting of the European Society of and Embryology 1– 4 July, 2007, Lyon, France. For more information regarding registration and programme please visit http://www.eshre.com/emc.asp?pageId=206

9th European Society of Contraception Seminar: ‘From Abortion to Contraception’, 21-22 September 2007, Bucharest, Romania. For more information please visit http://www.contraception-esc.com/future_esc_events.htm

10th ESC Congress: ‘Non-contraceptive impact of contraception and family planning’, 30 April – 3 May, 2008, Prague, Czech Republic. For more information please visit http://www.contraception-esc.com/future_esc_events.htm

”Youth Sex Education in a Multicultural Europe”, BZgA-WHO meeting in November 31 14-16 November 2006, Cologne, Germany. The German Federal Centre for Health Education, BZgA Cologne, a WHO Collaborating Centre for Reproductive and Sexual Health, is organizing an international conference on ”Youth Sex Education in a Multicultural Europe”. The conference will create a forum for technical experts from both governmental and non-governmental organisations to assess the present state of the art of sex education for youth in Europe. In particular, issues and dimensions of a multicultural approach to sex education and the question of quality management in youth sex education will be explored. The aim is to share experiences and best practices, identify challenges and promote partnerships and collaboration at the regional level. Participation at the conference is on invitation only.

Family Community Health meeting in Malaga 25-28 September 2006, Malaga, Spain. The Family and Community Health Section at the WHO Regional Office for Europe is hold- ing a meeting for focal points. The meeting will review and discuss the challenges, achievements and developments with national counterparts and other partners in Child and Adolescent Health, Making Pregnancy Safer, Reproductive Health and Research and gender Mainstreaming. Information on proceedings of the meeting and recommendations will be available in English and Russian on the web page of the WHO Regional office for Europe http://www.euro.who.int/.

No.63 - 2006 The European Magazine for Sexual and Reproductive Health

WHO Regional Office for Europe

Reproductive Health and Research Programme

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