UNIT 5 FERTILITY AND FERTILITY

RELATED ASPECTS
Structure
5.0 Objectives
5.1 Introduction
5.2 Definition of Terms
5.3 Influencing Factors
, 5.3.1 Factors Influencing Fertility
5.3.2 Factors Influencing Family Size and High Birth Rate
5.4 'Measurements of Fertility
5.4.1 Birth Rate
5.4.2 General Fertility Rate
5.4.3 Age SpecificFedlity Rate
5.4.4 Total Fertility Rate
5.4.5 Gross Reproduction Rate
5.4.6 Net Reproduction Rate
5.4.7 Child Women Ratio
5.5 Fertility Trends
5.6 Fertility Control Measures
5.7 Role of Community Health Nurse
5.8 Let Us Sum Up
5.9 Key Words
5.10 Answers to Check Your Progress

5.0 OBJECTIVES
After 'the completion of this unit, you should be able to:
o define fertility, fecundity, ~nultiparityand family size;
define factors influencing fertility,multipariw, family size and high birth rate; .
explain the measurements and indicators of fertility;
e describe fertility trends and the fertility control measures; and
e discuss nurse's role and functions.

5.1 INTRODUCTION
In Unit 4, you have learnt about infertility. In this unit, you will learn about fertility
and fertility related aspects, which include classification of fertility and fertility
related concepts, its determinants, measurements and indicators. You will also learn
about fertility trends, fertility control measures and the nurse's role.
As you know India's population, according to the 2000 census, is more than 1 I
I
tiillion. It is the second most populous country in the world, next only to China and s

I
72 seventh in land area. India supports 16 per cent of the world's population with only l 1
I

1
1 I
---- -
2.4 per cent of the world's land area. India's population has grown from 238.4 Fertility and Fertility
million in 1901 to more than 1 billion in 2000. India's population is currently Related Aspects
increasing at ihe r a i of
~ 16 million each year. The increase in population is due to
steady decline 111 the death rate and almost negligible decline in the birth rate.
In other words, fertility behaviour of the people is one of the important factors
responsible For increasing population, growth, and, therefore, fertility is the first area
of concern. Fertility related aspects, which are included for discussion in this unit
are multiparity, fa~nilysize, birth rate. These aspects are the outcome of fertility,
which affects population growth and quality of life. Let us begin with definitions.

DEFINITION OF TE
i) Fertility: It refers to actual bearing of children by a women in the age group
of 15 to 45 years - a reproductive period of 30 years. Natality and fertility
are synonymous ternls. Soine demographers prefer to use the'tenn
'Natality'.
ii) Fecundity: It refers to physiological ability of a women of reproductive age
to produce children. Tt implies that a women, who is found to be fertile, will
actually bear children, when exposed to the chance of bearing children.
iii). Multiparity: It refers to be&ng of more than one child.
iv) Family Size: Demographically and from the family planning point of view, it
refer to the total number of children a woman has born at a given point in
time. The complete faxnily size refers to the total number of children born to a
woman in the reproductive period, i.e., 15 to 45 years. Multiparity on the
other hand refers to the number of times a woinan has become pregnant, The
average completed family size in India is 4 to 5.

INFLUENCING FACTORS
The various factors influencing fertility, family size and birth rate are given below.
5.3.1 Factors Influencing Fertility
A women, who is married at the age of 15 years, and lives with her husband till the
age of 45 years, is exposed to the chance of producing children for 30 years, and
may given birth to 15 childrei~,General observation sllow that this inaxilnum
number is rarely achieved. The average number of children born to an Indian
mother in six or seven.
In today's society, several factors are found to affect'lhe number of children born . .
to women in their reproductive period and exposed to the risk of pregnancy.
Factors which highlighted by the demographers are:
i) Age at Marriage: It is a very important factor. The earlier the female
rn~u-riesthe more children she produces. It has been estimated that 20 to 30
per cent of births can be reduced by postponing marriage from 16 years to 20-
21 years..
ii) Duration of Married Life: Studies have shown thil the majority of the
births occur during the first 15 years of married life, ie., 10-25 per cent: of
the total births within1 to 5 years and 50 to 55 per cent of the total births
within 5 to 15 years of maded life. After 25 years of married 1ife:i.e.
cohabitation very few children we born. Fertility is reduced by postponing
birth during this period of married life.
iii) Spacing of Children: Studies have indicated that fertility is reduced by
postpan+ ' i %++. by one year in each age group of females,
i
Role of Nurse in Specific iv) Socio-economic Conditions: These include education, economic status,
Societal Health Prohlents
caste, religion, traditional customs, and habits.
Education: Fertility is inversely related to education, i.e., wit11 increasing
education there is decline in the number of children born.
9 Econonzic Status: Studies have also shown inverse relation between
economic status and fertility, i.e., the total number of children born
decline with increase per capita expenditure.
9 Caste and Religion: Fertility rate varies with religious beliefs. Thc
Muslim have a higher fertility rate (5.03) than the Hindus (4.46). r r l ~ e
Hindu have a higher than Christians (3.50) in the rural areas of Indin as
reported by the Registrar. General, Government of India.
Traditional Custoins and Habits: Traditionally, children arc considered
gift, and their birth should not be obstructed. According to custom, it is
very essential to have a son to perform the last rites and inherit one's
property, These customs and habits affect the number of children born.
V) Nutrition: It is observed that people who are well fed have lowel. fertility
n ~ ~ l is
than those who are poorly fed. It may be because the n ~ ~ t r i t i o status
directly associated with poor socio-economic conditions.
vi) Family Planning: The use of family planning devices is an iinport:~ntfilclor
in reducing festility rates in many developed and developing countnics.
Other factors which affect fertility are status of women, value of children it1
society, breast-feeding practices, industrialization, urbanization and better health
condition. Improving the status of women through their education, employment and
involvement in community development activities is a key factor in reducing fertility.
This has been the main factor in the lower birth rate in Kerala.
5.3.2 Factors Influencing Family Size and High Birth Rate
India, like many other developing countries, is faced with problems of a l u g e fn'arnily
size, grand multipasity and high birth rate. These problems are interrelrited, and are
affected by fertility behaviour of the people. All those factors which influence
these fertility also influence these fertility-related problems. Some of the specific
factors related to the family size and multiparity are: duration of married life,
education of the couple, the number of live births and living children, preference for
the male children, use of contraceptives and the desired fanlily size.
As far as the high birth rate is concerned, all these factors hlus univessulity of
marriage, early puberty and early marriage, late menopause, low standards of living,
traditional customs and habits, and absence of family planning illfluelice it.
Family planning can decrease the family size without reducing fertility.
 Fertility and Fertility
2) Enumerate fttctors which influence fertility and fertility related factors Related Aspects

..............................................................................................................................
3j State [he influence of the following on fertility:
a) Age at rnaisiage

.....................................................................................................................
bj Duration of Married lile

.....................................................................................................................
c) Spacing of children

d) Education and economic conditions

.....................................................................................................................

5.4 MEASUIREMENTS OF FERTILITY

Measurement of fertility which also refer to its indicators are discussed as under
5.4.11 Birth Rate
The birth rate is defincd ns "the number of live births per 1000 of estimated mid-
year population in 21 given year"

Pd; of live births during the year

B r[k Kllte .= -- ---------- >( 100
Esti~xlatctimid-yex pop111ation
Thc birth rate, tlzough n very simplie lneasilre and inclicutor of fertility. is n cmde
and unsittisfactory measure, because the total popitlation is not exposed to the risk
of child bearing. However, it is ilseluul indicator, when other paraineters or rates
are not nvailal;lle, to cornpurr, the fertility of clii'ferent communities.
5.13,2 Genaeraii Fertility Rate (GYGRo)
This refers to "the e~lanl'ocrof livc births per 1006)womw in the rcproductivc age
group ( 15 to 45 nr 4.9 yciirt;) in ;I. given year''.

No of live births during lhe year

GIER. = --- x 1000
Mid-year female population
The G4FFR.
is a better measures of fertility than the crude birth rate, because the
Role of Nurse in Specific denominator is the female population at risk and not the whole population. The
Societal Health Problems major drawback with this is not all female population in the reproductive age is
exposed to the risk of bearing children. This problem can be overcome by
calculating the General marital Fertility Rate (G,M.FR.). This refers to "The
number of live births per 1000 of married women in the reproductive age group in a
given year".
No of live births during the year
G.M.F.R. = X 100
Mid-year married women population
(15 - 45 or 49 years in the same year)

5.4.3 Age Specific Fertility Rate

This is defined as "the number of live births per 1000 women in any specifigd'age
group in a given year."

No of live births during the year

A.S.F.R. = X 100
Mid-year population of women in the specified
Age group in the same year .
This is a more precise measure which determines the fertility pattern and indicates
achievements of the family planning. However, the data for calculating this rate is no1
so easily available. Still better and a more precise measure is age specific marital
fertility rate. In this the denominator is married women in the specified age group.
5.4.4 Total Fertility Rate (T.F.R.)
The T.F.R. gives an estimate of,the average total number of children that may be
born to a woman, if she passes through her entire reproductive period, experiencing
the age specific fertility rates currently prevalent in the comnunity. It is derived by
adding the yearly age specific fertility rates during the age 15-45 years. Since the
age specific rates are usually given for 5 ,years age intervals, the rates of an interval
have to be multiplied by 5.
It may be noted that while G.F.R. reflects births per 1000 women per year, T.F.R.
reflects births per women through her life time. The T.F.R. gives the approximate
magnitude of the completed family size.
Total Marital Fertility Rate (T.M.F.R.): Average number of children that would
be born to a married worn&, if she experiences the current fertility pattern through
her reproductive span, This rate is better than the T.F.R., because it is restricted to
a married woman who is exposed to the ~jskof bearing children. The method of
calculation is the same as for the T.F.R. except the age specific rates of married
women in each age group.
5.4.5 Gross Reproduction Rate (G.R.R.)
~ h refers
k to the average number of girls that would be born to a woman if she
experiences the current fertility pattern throughout her reproductive span (15-44 or
49 years) assuming no mortality.
5.4.6 Net Reproduction Rate (N.R.R.)
The Net Reproduction Rate is defined as the number of daughters a new born girl
will bear during her life time, assuming fixed age specific fertility and mortality
rates. The N.R.R. in India no 1.48. The target is to attain the N.N.R. of 1. An
N.R.R. of 1 means that one woman will replaced by one woman. If it is below 1
then the reproductive performance of the population is said to be below
replacement level N.R.R. is a demographic indicator. The demographers are of the
view that the goal of N.R.R. = l.can be achieved only if at least 60% of the eligible
couples are effectively practicing family planning.
5.4.7 Child Woman Ratio Fertility and Fertility
Related Aspects
I
This ratio is useful where registration of birth is either not done or inadequate. I1 is
derived from data retrieved from Census. It is defined as "the number of children of
4 years of age per 1000 women in child bearing age."

Fertility statistics show that there has.been a decline in the crude birth rate. In
some states, like Punjab and Kerala, the bii-th rate is much lower, e.g; 25 per
thousand in Kerala. ThZre has also been decline in the age specific fertility rates.
Table 5. l a A reduction in the total fertility rate is important as it reduces the risk of
pregnancy related morbidity and mortality. The T.F.R., which was 597 in 1951-61
has declined to 3.2 in 1999 with a range of 1.8 i n Kerala to 5.1 in Uttar Pradesh.
, Table 5.l(a)

... < P , '

Source: Crude birth rate (2002) and Total fertility rate (1999) ibr major states.

The all India fertility indicators of 1999 are given below in Table 5.l(b).

Source :Park J.E, Parkk l k x ~ ! ~ o o( ~k S o c i nnrzd

l IJreverztive Medicine.
 Role of Nurse in Specific
Societal Health Problems

I
Birth and Death Rate: The birth and death rates are important components of
Population growth . The death rate in India has considerably declined from 27.4 in
1951 to 8.1 per thousand in 2002, the birth rate has declined from 39.9 in 1951 to
an estimated 25.0 per thousand in 2002.
The level of;fertility rate in India is beginnlng to decline. The crude birth
rate whlch was about 39.9 per thousand during 1941-1950 has declined to
about 25 per thousand in 2002.
India like other developing countries is faced with dilemma of a high Birth rate and
a declining death rate. The causes of high birth rate:
1) Early marriage
2) Early Puberty
3) Low level of literacy
4) Traditional customs and habits
5) Absence of planning habits.
The decline in death rate has been attributed to:
1) Absence of natural checks, e.g., Famines and large scale epidemics
2) Mass control of diseases, e.g.,Small box, plaque, cholera, malaria etc.
3) Advanced Medical science
4) Better health facilities
5) Impact of National Health Programmes
6) Improvement in food supply.
Growth Rate Fertility and Fertility
Related Aspects
The population growth rate in India grew at slower rate prior to 1921, this was due
to natural calamities. After 1921, the occurrence of famines, epidemics were
effectively controlled through better health care services.
India is now second most populous country in the world, adding 16 million every
year.
India's population crossed 1 Billion on May 1l'h,2000. Most recent date indicates a
decline in India's Population growth rate to an estimated 1.79 in 2001. The total
population of India was 1027.0million in 2001.
Currently National Health goal is to attain birth rate of 21 and death rate
9 per thousand by 2007, with an annual growth rate of 1.2 per cent which
was considered essential for stabilization of Population in India over next 50
years or so.
5.5.1 Adolescent Fertility
Babies born to young women aged 15-19 years is an emerging concetn throughout
the developing and developed countries in 1995, 17 million (or 13% ) of babies were
boin to adolescents, Nine in every 10 of these babies (13 million) are born in
developing countries. These are high risk births from the perspective of the health
of both mother and child, and also high cost births when associated negative
effects on the quality of life and role of women in society are considered.
Adolescent fertility is estimated at 66 births per thousand women aged 15-19
years in 1995. It is falling, and is expected to reach 52 births per thousa~id
adolescent woinen by 2025, with projected births declining by 6% of the number
of occurring in 1995 over the course of the next 30 yews mainly due to rising age
at marriage increasing educational and economical opportunities for young
womeil and increased use of contraception.

5.6 FERTILITY CONTROL MEASURES

Fertility control measures are directly related to their determinants. The following
are some of the measures which are considered by demographers, political leaders,
planners and executives. Many of these aspects require long term programmes
with adequale support of money, manpower and material.
Prevention of early marriage and postponing of mcvriage from 16 to 20-21 .
years of age can prevent 20-30 per cent of births. The earliest attempt to
prevent child marriage was done by enacting Sarda Act in 1929. In 1978, the
Child Maniage restraint Act was enacted which raised the legal age for
marriage from 15 to 18 years for girls and from 18 to 21 years for boys.
Studies indicate that in many states, the mean age at marriage'fol*girls has
already moved with 18 years in 1981 <andmany others are very close to this.
The exceptions are the rural areas of Madhya Pradesh, Rajasthan and Uitar
Pradesh where a substantial proportion of marriage continues to take place
when the girl is around 15 yeas of age.
Identification of eligible couples in the first few years of their married life (1 to
15 years) and motivating them for use of sdable contraceptive devices and
spacing of children. No woman should conceive before the age of 20 years.
Woman should also be advised to have a gap of at least three y e a s between
births. Birth spacing by reducing risks of severe complications and long term
morbidity has a positive influence in improving the health status of women and
children, According to SRS estimates, 38.5% the births in 1991 occurred at
an interval of less than two years including 42% of the birth occurred within .
- an interval of less than 1 year.
Role of Nurse in Specific iii) Improving the socio-economic status of people at large, which includes general
Societal Health Problems education, economic status and status of Scheduled Castes and Scheduled
Tribes. The Government of India has Iaunched several welfare and
development programmes, both for the rural and urban areas, including
Scheduled Castes, Scheduled Tribes and the residents of backward and hilly
areas, etc. Various anti-poverty programmes have also been introduced.
These prograinmes are helping people to improve their socio-economic
conditions. Besides the governmental programmes, charitable and voluntary
organizations also participate in improving socio-economic conditions directly
and indirectly. These programmes are described in Unit 3 of this block, and
you should review them.

iv) Health education on improving nutritional status,,breastfeeding, fainily

welfare, and girl child abuse.

v) Involvement of religious leaders, village leaders from different caste

organizations launching fertility-relatedprogramme. It should be done at the
governmental level to be effective and practical.

vi) lrnproving the status of women includes their education, employment,

involvement in community organization, politics, etc.

vii) Availability of the family planning services to all within easy access and
accordingly to the choice of the people.

5.7 ROLE OF THE GO TY NEALTPP NURSE

As you know, the nurse provides direct care to individuals, families and the
corninunity at large. She is in close contact with them, and, therefore, she can
contribute a lot to fertility control measures at various levels, which are presented in
this unit. The role of CHN as care-provider, teacher; guide and helper, counselor.
advocate, planner, organizer, etc., is listed below.
I

i) Provides family planning care directly and indirectly.

e She directly identifies eligible couples, registers them, motivates them,
guides and helps them in selecting appropriate methods, provides supplies
regularly, follow up, solves their problems, and helps them'to adopt the
two child small family norms.

Indirectly, she provides the same care through the multipurpose health
workers and health volunteers by effective supervision and guidance.
e She also helps in prevention of infertility, 'and gives appropriate cite and
, help to the infertile couples, as discussed in Unit 4 of this Block.
e Tries to achieve the target set, i.e., 60 per cent eligible couples to practice
family planning measures.

ii) Helps to improve general health status of people at large by identification of

high risk families and their health needs, and by planning and providing need
based care, directly and indirectly.

iii) Helps families to improve their socio-economic status by creating awareness

of social welfare schemes, and utilizing these services.

iv) Encourage women to improve theis status by awakening them, by motivating

them to get education theinselves to become self-dependent, socially and
economically.
 v) Provides Health education on various aspects of healthful living, breast feeding Fertility and Fertility
of children. etc. Related Aspects

vi) Commu~iiryorganization, involving religious leaders and leaders from various

socio-cullural groups, women leaders and teachers to plan, organize and
implement vniious health and welfare activities, and to develop positive attitude
towards fertility control.

Contraceptive Prevalence
Contraceptive Prevalence is strongly related to the level of fertility, explaining about
90% of variance in TPR (total fertility rate). It is estimated that current
*
contraceptive use; the percentage ctmently using contraception sunong couples
with the woman of reproduction age is now reaching 60% globally compared with
about 57% in 1990. In developing countries Prevalence reached 53% in 1990 and
Role of Nurse in Specific
Societal Health Problems 5.8 LET US SUM UP
This unit deals with fertility and fertility related aspects. You have leatnl that
fertility is the first point of concern, because fertility behaviour of the people is one
of two factors for increasing population, the other being a steep fail in the death
rate, which is desirable. While fertility refers to actual bearing of children by a
woman in her reproductive period, multiparity 'refers to bearing of more than one
child, m d the family size refers to total number of children born to a woman at any
given point in time. The average family size in India is 4.5. The family size that is
advocated in the "two child" norm. Several factors, which influence fertility and
fertility related concepts, are age at marriagelearly age, duration of marriage,
spacing, socio-economic conditions, cultural traditions and habits, family planning
services, woman's status, and value of children. The fertility control measures are
directly based on these factors, the various programmes have been launched for
tackling this problem. As a result, there is a declining trend in fertility, as shown by
its various indicators like the death rate, age specific fertility, T.F.R. , G.G.R.,
N.R.R., G-ER., child-woman ratios.

Determinant : It refers to influencing factors

Eligible Couples : Couples, who are in the reproductive period, and are
capable of prqducing children. They can be categorized as
o Category 1 - the first five years of married life,
*)

@ Category 11- 5 to 15 years of married life, and

0 Category 111- 15 to 30 years of married life.

Fecundity : A woman in the reproductive period, who has the

physiological ability to produce children when exposed to
its risk.

ANSWERS TO CHECK YOUR PROGRESS

Cheek Your Progress 1

1) a) Fertility refers to actual bearing of children by a woman in her

reproductive period.

Fecundity refers to the ability of bearing children by a woman in her

productive period. Only a woman who is fecund will be fertile or
actually bear children.

b) Multiparity refers to bearing of more than one child by a woman.

The family size refers to the total n~~mber
of children borne by a
woman at any point in time.

2) Age i t marri&e, duration of marriage, spacing, socio-economic conditions,

nutritional status, cultural traditions and habits, woman's status, and family
planning services. *

3) a) Age at marriage: The earlier a woman marries, the more the number of
children she will bear, because the early reproductive period is more
fertile, and also such a woman has a longer duration of married life.
 b) Duration of married life: The majority of children are bol-n d~rringthe Fertility and Fertility
first few years of manied life, i.e., 1 to 5 years (is. 25% of the total), 5 Related Aspects
. to 15 years (50 - 55% of the total) probably because of more active sex
life.

c) Spacing of children: Spacing reduces fertility by postponing births by one

year in each age group.

d) Education and econotnic condition have an inverse (i.e. negative) relation.

Check Your Progress 2
1) a) No of live births during the year
C.B.R. = x 1000
Estimated mid-year population

b) No of live births during the year

G.F.R. = x 1000
Mid-yeas female population ( 15-45
Or 49 years in same year)

2) The G.F.R. is better than the crude bii-th rate, because its denominator is
restricted to woman in the reproductive age group (15 - 45 or 49 years)
The A.S.F.R. is more precise and sensitive, it determines age specific trends
and, accordingly suggests specific interventions.

3) The G.R.R. refers to the average number of girls that would be born to a
woi~lanexperiencing current fertility pattern throughout her seproductive
span, whereas the N.R.R. refers to the number of daughters a new born girl
will bear duiing her life-time, assuming fixed age specific fertility and
mortality.

4) There is decline in fertility trends, because of several fertility control measLtses

organized by the Government.

I) Prevention of early marriage <andpostponing the age of marriage

2) Identification of newly maruied couples

3) ' Improving socio-economic status of people
4) Health education on nutritian, breast feedingkirl child abuse
4#
5) Involving re1igio.u~leaders
6) Improving stahis of women

7) Availability of family planning services to all