Recently we commented on an article in the Bulletin of WHO concerning fertility and equity.Â Now a manuscript by Conley, McCord and Sachs look specifically at the relationship between malaria and excess fertility (see attached map on total fertility rates in 2003 from WHO).Â They note that, â€œMuch of Africa has not yet gone through a â€˜demographic transitionâ€™ to reduced mortality and fertility rates.â€ They found that, â€œchild mortality (proxied by infant mortality) is by far the most important factor among those explaining aggregate total fertility rates, followed by farm productivity. Female literacy (or schooling) and aggregate income do not seem to matter as much, comparatively.â€
Maternal malaria is also implicated when they note that, â€œThere is some evidence that malaria may reduce lactation period, which might increase fertility through decreased child spacing. Likewise, malaria in pregnancy is also associated with low birthweight and increased neonatal and infant mortalityâ€”which is in line with our models.â€
They conclude that, â€œThis is where the theory of the demographic transition started: save the children and families will choose to have fewer children.â€Â They do explain that the transition time between reduced infant and child mortality and reduced fertility may take a generation or two.Â The lesson here is that increased fertility may in fact be an inequity caused by child deaths, especially from malaria, and that family planning alone will not address this imbalance.
Malaria is holding back the demographic transition and economic development in Africa.Â An investment in treating and preventing malaria in women and children will have long term benefits.Â International donor programs like GFATM, World Bank Booster and PMI can help start the process of reducing mother and child mortality, but the effect on fertility and economic development will require a long term commitment by governments in endemic countries. There is no room for complaints about the cost of ACTs and LLINs!