FERTILITY CONTROL IN TURKEY NUSRET H.
FI~EK
AND FREDERIC C. SHORTER·
The promotion of population growth was a formal policy of the Turkish Government for many decades. This policy was changed recently. The sale and use of contraceptives has been legalized, and education of the public concerning family planning was started in 1965. A brief history of population policies in Turkey is available elsewhere.v- The purpose of this paper is to present the results of some recent studies relating to fertility control carried out by different researchers on Turkey.
The most recent figure is 54 years for both sexes. In order to form some idea of the longterm trends in the expectation of life at birth, it is necessary to assume values for child mortality for which no real data exist. Plausible assumptions lead to the conclusion that the expectation at birth was definitely below 40 years in the 1930's -just how much below can only be guessed. When we consider that the expectation today is at least 15 years higher, and rising, it is clear that families face greatly reduced risks of losing sons or MORTALITY AND FERTILITY TRENDS daughters prematurely by death, especialThe decline of the death rate helps to ly after they have survived the first years set the stage for a fertility decline, so of life. The motivation to limit family size is mortality trends will be discussed first. Estimates of mortality above age five probably connected most closely with the have been extracted from the quinquen- trend of early childhood mortality. Child nial census statistics collected between mortality in Turkey is heavy relative to 1935 and 1965 (Table 1). In the late 1930's what one would expect from an inspection the average expectation of life at age five of nineteenth and early twentieth century was about 50 years for both sexes com- European life tables having comparable bined. Today it is in the lower 60's. This adult mortality. Gains in child health is the only statistical index available which have lagged behind those for adults during describes the long-term trend. the recent compressed period of progress The prospects for survival of young in Turkey. We note that environmental children is shown by the proportion of hazards, protein deficiencies, and inadechildren who survive to age two. This quate health care particularly affect the index has risen rapidly in recent years, at health of children. These problems depend a time when adult mortality gains have upon education for their solutions and levelled off. The elevating effect of better take longer to remedy than the control of child mortality on the expectation of life communicable diseases, such as malaria, at birth has been substantial (Table 1). and the rendering of patient care services * Institute of Population Studies, Hacettepe to adults through hospitals and clinics. In University, Ankara. Turkey, the age-specific pattern of reductions in mortality appears to have depart1 Nusret H. Fisek, "Planned Parenthood: Responsibility of the State in Family Planning," ed from historic norms under the impact Sex and HU7IUJ,n Relations (Proceedings of 4th of accelerated progress using modern medConference on the Region for Europe, Near East, and Africa of the International Planned Parent- ical techniques. hood Federation, Excerpta Medica Foundation, Child care is now catching up. As the 1965). proportion surviving beyond early childS Nusret H. Fisek, "Problems in Starting a hood grows, increased demographic presProgram," Family Planning and Population Prosure will be felt by families, and the motigrams (edited by Bernard BereIson, Chicago: University of Chicago Press, 1965), pp. 297-304. va tion for family planning will be strength578
Fertility Control in Turkey 579
ened. In the cities, child mortality has already come down to a more nearly European historical relationship with adult mortality-->. The resulting demographic pressure is undoubtedly one of the factors IF. C. Shorter, "Information on Fertility, Mortality, and Population Growth in Turkey," Chapter 2, Turkish Demography (Proceedings of a conference sponsored by the Institute of Population Studies, Hacettepe University, forthcoming).
encouraging more family planning in the cities than in the villages. The national trend of fertility is more difficult to evaluate statistically, The primary evidence upon which to base conclusions consists of the census age distributions going back to 1935, These are used in conjunction with information 4 Aysel Alpay, "Abridged Life Tables for Selected Regions and Cities of Turkey by Sex," Chapter 5, Turkish Demography, op. cit,
Table I.-MORTALITY TRENDS IN TuRKEY, 1935-66 Proportion surviving
Expectation of life at age 5 Time period
(0
e
to age 2 ( 1 radix 2, = 1 )
in years)
5
Males
Females
Expectation of life at birth (
0
eO in years)
Both sexes
Both sexes
1935- 40 ••••••• , ••
51,5
49,6
na
na
1940_45 ••.•••• , ••
46.5
46.2
na
na
1945_ 50 ..••••.•••
52,4
53.4
na
na
1950_55 ..........
57.6
59,2
na
na
1955_60, ••• " ••••
60,7
,77
62,7
61
ca. 1966 ••.•.•••• Source:
50
.79
1960-65 •.•.••••.•
The estimates of
63
.82
54
up to 1965 are based on the method of 5 cumulative census survival (cf. ~ Nations ~ IV), 0
e
wi th averaging of estimates over two periods where neces-
sary because of census irregularities. estimates of 1
2
The earliest two
are based on national survey data concer-
ning children ever born and children surviving by age of mother collected in 1963 and in 1966-67 respectively. This type of data gives a retrospective estimate 3 to 8 years before the survey date. °e
o
'
The earliest estimate of
1955_65, is deduced from the other columns using
"East" model life tables to translate 1 2 into values for 5
Land 1 • 0
5
All the estimates for around 1966 are an
expansion based on current death reports collected by the Turkish Demographic Survey for four out of five geographic regions of the country (cf. 3, 4)
580 DEMOGRAPHY
about child mortality to make estimates of birth rates by a reverse-projection procedure. The weak link is assumptions about child mortality for the earlier years. Nevertheless, something can be said, because it is plausible to assume that child mortality was poorer in the 1930's than today by some minimum amount. However, even if no improvement between 1935 and 1960 is assumed, the resulting estimate of the birth rate for the early years is higher than an estima te for around 1967. Our own minimumassumption about improvements in child mortality, namely, that child mortality in 1935 was no worse than the European pattern would suggest, leads to estimates of the national birth rate in the 1930's of around 50 per thousand. In 1967, the birth rate is estimated at around 41 per thousand using data from the Turkish Demographic Survey (Table 2). This long-term decline in the birth rate has been due both to a real decline in the fertility of women and to a temporary shortage of women in the childbearing ages relative to other age groups in the last part of the time period. Taking into consideration that the shortage of mothers will soon pass, we may expect an upward pressure on the birth rate from this source in the future. Hence, in order for the birth rate to continue falling at a similar pace as in the past an acceleration of fertility control will be necessary. The rate of population growth in Turkey responded to these trends in mortality and fertility by rising sharply during the 1940's and 1950's. Some relief was experienced after the 1955-60 period due to the effects on the birth rate of the change in age distribution mentioned above and due to international migration. In the 1960's there has been an outflow of Turkish workers going to western Europe for contract jobs. Another factor was that inward migration from neighboring countries was important in the 1950's but not in the 1960's. In the mid-1960's, the growth rate of the Turkish population was approximately 25 per thousand.
GEOGRAPHIC DIFFERENCES IN FERTILITY
Information on fertility and its variation among different parts of the country is derived from two major sources in Turkey. Foremost is the population censuses. The census statistics, when combined with periodic survey data concerning child mortality, provide basic fertility estimates on a regional basis. The second major source is a nationwide monthly survey of vital events started in 1965 by the Ministry of Health in the School of Public Health called the Turkish Demographic Survey. Its national sample of 235,000 persons is used to make basic demographic estimates for thirteen rural and urban subdivisions of the population. The five main regions used by the TDS are not a generally accepted pattern of regionalization in Turkey. They were created by assembling the sixteen regions of the Ministry of Health into five. These regions are not well designed to maximize inter-region variation in such variables as fertility, mortality, socioeconomic level, industrialization, and education. This creates some difficulty when studying factors affecting demographic events. Nevertheless, sample surveys are essential, and those wishing to use the facts uncovered by the TDS must accept the regional divisions. To this rule, we are no exoeption." Birth rates have already been published for four regions by the TDS. For the fifth region, Eastern Anatolia, a provisional estimate can be made from the age and sex distribution of the 196&census using a plausible mortality assumption, admitting that the estimate has an earlier time reference period than the TDS figures. Combining statistics from both sources, we estimate that the national birth rate around 1967 was approximately 41 per thousand (Table 2). One important fact revealed by these figures is that there are large regional differences in birth rates; this is seen even Ii J. C. Rumford, Y. Heperkan, and N. Fincancioglu "The Principles and Preliminary Results of' the Turkish Demography Survey," Public Health Reports, 38(7) (1968), p, 573 fl.
232
152
395
296
6,230
4,157
8,387
5,380
North ••••••.•••
South •••••••.••
Central ••..•..•
East ••••.••••••
Source:
55
47
37
37
31
41 24
. ...
48
2,017
31
....
....
. ...
....
20
657
....
.... ....
....
na
na
na
rate
Birth
na
1,901
1,809
1,266
2,242
na
Popu-. lation
na
66
58
44
60
na
births
Number
Urban
na
35
32
35
27
na
Birth of rate
na
5,829
2,348
4,964
4,088
na
Population
na
309
94
188
147
na
of births
Number
Rural
na
53
40
38
36
na
rate
Birth
Turkish Demographic Survey for four regions. For the East we have estimated the birth rate by reverse projections from the 1965 census, assuming current mortality similar to th~t of Central Anatolia.
Definitions: Rural places are villages with a population of less than 2,000. Urban places are all communities of 2,000 and above, except three large cities which are separately classified as metropolitan (Ankara, Istanbul, and Izmir). The population figures are estimates from the TDS sample for the first four regions and from the census for East. un: Not available,
255
8,347
West •••••••.•••
Notes:
1,33U
Population
Number of births
Birth rate
Number
of births
32,501
Po pu-, lation
Metropolitan
Total
'I'o t a L, •••••
Region
Metropolitan - rural distribution
(population and number of births in thousands)
Table 2.-REGIONAL DIFFERENCES IN POPULATION, NUMBER OF BIRTHS, AND BIRTH RATE, BY REGION AND METROPOLITAN-RURAL DISTRIBUTION, TURKEY, 1967
~
(J>
M(tlrofoli~«n hirtb. rate fer thousand
o
Figure i.-Regional birth rates in Turkey.
'Reolofldl svereoe. birth. raJe 'Per Ihousand - 0 . . 0 /
o
S.y;a
Jra1
Fertility Control in Turkey 583
though the definition of boundries does in Western Anatolia. The differences not maximize variances. Reading from among regions antedate the initiation of West to East in Table 2, Western Anatolia the government program in 1965. At a has a birth rate of 31 per thousand and very general level, one explanation is that Eastern Anatolia, 55. A similar pattern low fertility norms, and knowledge of of differences is found using a nine-region birth control methods, are attributes of a classification in conjunction with data Western-type culture which is in the procfrom the 1963 KAP survey and the 1960 ess of diffusion. Its entry into Turkey has census. 6 been through the historic European conThe figures do not imply that family tact centers of Istanbul and Izmir. planning services have been more effective More specific interpretation of the fac6 Paul Demeny and F. C. Shorter, Estimating tors responsible for the fertility differences Turkish Mortality, Fertility, and Age Structure: will require extensive analysis; only a few Application of Some New Techniques (Faculty of Economics Pub. No. 218, University of Istanbul), suggestions will be made here. First, we may note that regional birth 1968. Table 3.-REGIONAL BIRTH RATES AND RELATED INDICES, TuRKEY Regions
~::;;~:~~~~(a)
Variable
West
North
South
Central
East
(r)
..
.
31
37
37
47
55
females ......................
20.1
19.0
19.3
18.9
18.7
-.83
Percent single at age 50 .....
2.2
1.3
1.1
1.2
1.0
-.71
1.
Birth rate per 1000 ..........
2.
Mean age at first marriage,
3. 4.
Index of socio-economic development ••..• , . . . . . . . . .. . .
135
93
97
66
-.87
5.
Percent urban ......•......•..
48.0
20.5
35.1
35.3
25.3
-.46
6.
Percent literate:
74.6 50.4
60.6 24.0
64.5 30.7
66.5 32.9
45.1 14.3
-.82 -.76
Males ...••.•.• '" ••••..••• Females ••..•••••••••••••••
(a)
102
Least squares r-egre s saon on the birth rate.
Source:
1.
Table 2.
3.
Census. 3.
5.. 6.
Proportion living in places 10,000 and over, from 1965 census. Proportion literate of ages 6+, from Turkish Demographic Survey.
2.
Hajnal index based on 1965 census.
state Planning Office (cr , ref. 13).
Table 4.-RURAL AND BIRTH URBAN RATES AND MEAN AGE AT FIRST MARRIAGE, FOR FOUR OUT OF FIVE TDS REGIONS, TuRKEY
Demographic area
Birth rate per
1.000
Mean age at first
marriage, females
Percent single at age
50 females
4.7
Metropoli tan •...•.....•
25
22.1
Othern urban ..•••.••.••
32
19.9
1.6
Rural •••..•••.••••••••.
43
18.8
1.0
Source;
Table 2 for birth rates, and 1965 Census for data used in calculation of the mean age at first
marriage.
~
584 DEMOGRAPHY
rates are a reasonably good index both for the general population and for married women alone because there is little variation in the age of marriage among regions. In Table 3 the correlation between birth rates and the age of marriage is high in a statistical sense, but has little quantitative importance. Postponing marriages a year or two cannot explain a range of birth rates as high as we observe in Turkey. In connection with urban-rural differences, the age of marriage acquires some importance, but even then the differences are not as important practically as differences in fertility within marriage (Table 4). Several indices of social background are shown in Table 3. They are a general index of socioeconomic development, the percent urban, the percent literate among males, and the percent literate among females. Each shows an association with birth rates, and helps to describe the kinds of situations which accompany different levels of the birth rate. A consistent exception in Table 3 is the Black Sea region to the north. It has a Table 5.-BIRTH AND LITERACY RATES, BY REGION, TURKEY, 1967 Li t e r-acy r-a-te percent (a)
Birth
Region
rate per 1, 000
Male
Female
51 67 76
West
~ral .•..•••••...•..• Urban ••.•••••••••••••
Istanbul •.....•....•• Izmir ••••.•••..••••••
36 27 24 25
71
34 47 63 56
38 35
49 63
18 35
40 32
50 64
29 41
significantly lower birth rate than would be predicted by any of the four regression equations (Tables 4-7). The exception is not due to an erroneous estimate of the birth rate, since an analysis of the 1960 data (mentioned earlier) placed the Black Sea region's birth rate in a similar relation to other parts of the country according to two different fertility indices. One possible explanation is that Black Sea males migrate in large numbers for about one-half of each year to Istanbul, Ankara, and elsewhere for employment, mainly in construction, some of them remaining even longer." This practice may contribute additionally to fertility control. A particularly reliable association is the relationship of birth rates to literacy rates. This is confirmed by the TDS data in Table 5 where the correlation coefficients for male and female literacy are - .87 and - .90 respectively. It is confirmed again using the 1960 census data with a nineregion classification for the rural areas as in Table 6. The correlation coefficient for male literacy is - .94. When literacy rates are low enough to indicate virtually natural fertility regimes, as in all three rural eastern regions (Table 6), exceptionally low literacy rates as in the South East exert no further upward influence on the birth rate. Removing that instance (SE) 7 Erol Tumertekin, Internal Migration in Turkey (Geographical Institute Publication 54, University of Istanbul, 1968).
Table 6.-BIRTH AND MALE LITERACY RATES (DATA FROM 1960 CENSUS AND 1963 SURVEY), TuRKEY, 1960
North
RUral ................ Urban ••••••••••••••••
Birth Subdivisions of the popuLa t i on
rate per 1,000
Male I i teracy
percent
South
Rural ...•••.•••...••• Urban •.••••••••••••••
Central ~
................
Urban •••••.•••••.••••
Ankar-a ••.•••. " .•••.•
53 35 31
17 35 56
52 61 74
23.7
82.0
35.1
71.1
52,3 39.7 39.8 53.6 56.3
47.2
Rural regions: 1. No r-t hvcent r-al •.•...•••••••• 2,
Aegean •••••••• _ ..••••••••••
3.
Mal"ffiara......
4.
MeJit.H'I'anelln, •••••••• , •.••
~.
East
-Rural and ur-ban ••••••
(,,)
Metropolitan (national) ••......••.
Other urban (national) .....•.•..•.
Bose:
55
32
12
Population over 6 years of age.
SOU1'C(.':
Birth rates from Table 2. rates from the TDS.
Li t e r a cy
' •••.....•••
Not"til_east, •.•.. , •••••••••
G.
s0uth_eu;;t., ••.•.•..•••••••
7. IL 9.
Black Sea .•..•.•••••••••••• East cen t r-n'l ••...••...•.•• South cen t ru.l •. " ..
Sour-c e :
56.4 51.1 56.6 49.7
For the lJl rtf! r-at.e s , see r-s f e t-enc e (4). rates above ag e
(j
54.4 59.5 43.2 39.6 20.6 41.7 37,1 42.1
Lk teracy
are from the 19GO ce n su s ,
Fertility Control in Turkey 585
from the regression analysis gives a value for r of -.97, and a standard error of estimate of the birth rate of only 2.84 per thousand of population. Although these are impressive associations, we note that literacy is less controlling in rural than in urban areas. The values for r in the rural areas as compared with urban areas are +.69 and -.77 respectively for males, and -.83 and -.93 respectively for females, using the TDS data in Table 5. The data in Table 6 show the same tendency; the r drops from -.94 to - .83 when urban observations are excluded. Presumably social factors other than those indexed by literacy are more
carried out in Ankara by Goldberg" and in the Etimesgut Rural Health Region by Ozbay and Shorter. to In these surveys, approval rates were up and the level of information was strikingly high either before program action had begun or at 8 Bernard Berelson, "Turkey: National Survey on Population," Studies in Family Planning, No. 5( 1964). 9 David Goldberg and Greer Litton, "Family Planning: Observations and an Interpretive Scheme," Chapter 12, Turkish Demography, op,
cit. 10 Ferhunde Ozbay and F. C. Shorter, "Fertility and Family Planning in the Etimesgut Rural Health Region," Chapter 13 in Turkish Demography, op. cit.
Table 7.-REGRESSION ON THE BIRTH RATE,(a) TuRKEY, 1960 y Observations
All regions ••••..•
~
a+bX
n
11
a
b
75.87
- .59
r
Sy.x
Sy
3.89
10.73
.22
_.94
Sb
All except South_ east .....................
10
82.03
-.70
2.84
10.80
.06
-.97
Only rural ••...•.•
9
73.48
- .53
3.68
6.62
.12
- .83
(a)
y~
b1rth rate per 1,000,
X~
percent of male 11teracy.
important influences on the birth rate in the rural areas. CONTRACEPTIVE PRACTICE
On the basis of a national KAP study in 1963, and several smaller studies since then, there is reason to be optimistic about the receptivity of the Turkish population to family planning. In 1963, when it was still prohibited to produce or market contraceptives in Turkey, the data seemed to show that the small-family norm was wellestablished, that a majority of husbands and wives approved of contraception, and that about two-thirds expressed an interest in learning more. But knowledge of contraceptive methods was very limited at that time; 43 percent of husbands and wives said they did not know of any way to avoid conception. 8 Since then, KAP studies have been
Table 8.-IUeD ACCEPTANCE RATES, TuRKEY, 1965-68 Acceptance rate
Region Turkey •••..••..••••••
2.2
West •••......•••..•••
2.2
North
1.4
..
South ••••.••.••••..••
1.6
Central ••.•.•......••
3.7
East •.....•....•..•••
1.5
Definitions: Accepatance rates are the number of IUCD's inserted from June, 1965, to September 20, 1968, divided by the married female population aged 15-44 in 1968. Source:
Insertions from (II), and female population projectedfrom the 1965 census by regions.
586 DEMOGRAPHY
least before it had become extensive. In addition, the mobile teams giving family planning services have reported a generally favorable reception almost everywhere they have gone. The staff of the Hacettepe Institute of Population Studies conducted another nationwide KAP study in the summer of 1968 which will soon provide extensive additional information about recent trends. Contraceptive practice lags behind attitudes and knowledge. This lag has to be understood in terms of the impact of official policy before 1965 and the slow start of the national family-planning program after that date. Before 1965 knowledge of such modem contraceptive devices as oral contraceptives, the rUCD, and foam tablets was limited among the public and even among a majority of physicians. The only contraceptive market was the condom. The reason the condom could be freely sold was that it qualified as a prophylactic device against veneral disease. The first rUCD was inserted by Erenus in 1964.u Oral contraceptives were marketed in 1966; vaginal creams and foam tablets in 1967. In order to get an idea of the extent to which contraceptives are used in Turkey, one can use the results of special surveys, statistics on rUCD insertions from the Ministry of Health, and sales figures from pharmaceutical firms. The Ministry of Health reports that 114,763 rUCD's have been inserted between 1965 and the present (September 1968),12 That comes to an insertion rate of only 2.2 percent, considering that there are 5.2 million married women aged 15-44. The actual use rate is lower because of expulsions and removals. The other modern contraceptives used on a significant scale in Turkey are the II Necdet Erenus, "Population Increase and Control in Turkey," Intra-uterine Contraception. (Procedings of Second International Conference, edited by S. J. Segal, New York: Population Council, 1964), p. 220 fI.
11
tion.
Nuray Fincancioglu, Personal communica-
oral pill, the condom, and, to a small extent, foam tablets. According to estimates of wholesale sales by manufacturers of oral contraceptives, about 100,000 cycles are sold monthly. The extent of use of the condom and foam tablets has to be guessed from the 1963 KAP study on the assumption that these particular methods have not increased much. The 1963 study gave a figure of 7.0 percent of couples using one of those methods. Combining figures for these four popular methods in Turkey suggests that at most 11 percent of the couples in the childbearing ages use modem contraception. When allowance is made for IUCD discontinuation rates and ineffective application of the oral pill or the other contraceptives, the percent protected by a safe method must be significantly smaller than 11 percent. If we compare the present situation with the results of the 1963 KAP study, there is already a clear increase in the use of effective eontraeeptives.P Meanwhile, glimpses of the new pattern of contraceptive practice are provided by a KAP study of the Etimesgut region conducted in 1967 (mentioned above), and by a national study of the characteristics of rUCD acceptors by Yurt6ren and Fincaneioglu." In the Etimcsgut study, a cross section of women aged 15-44 in the sample gives the picture shown in Figure 2. It describes a typical age pattern for the status of women in terms of four conditions: unmarried; married and pregnant; married and protected by some method or by the husband's absence; or married and not protected. Note the sizable proportion protecting themselves in some fashion from age 25-29 onward. The villages of Etimesgut are located within 10 to 30 miles of Ankara. Hacettepe University's School of Medicine is responsible for the health services which Berelson, op, cit. Serim Yurtoren and Nuray Fincancioglu, "Demographic and Socio-Economic Characteristics of Turkish IUCD Acceptors," Chapter 10, Turkish Demography, op. cit. 11
14
Fertility Control in Turkey 587
have reached even the most remote vil- children also are visited once every 2-3 lages. The present birth rate, more than months. The midwives are therefore in a year after the 1967 study, is estimated continuous and close relation with all from health unit records to be in the mid- families, being acknowledged and respect30's per thousand, whereas the rate is 53 ed persons. It cannot be said that rural for other villages of the Central Anatolian midwives give a high priority to family plateau. Considering that the birth rate planning work in this district. Despite is 32 per thousand in Ankara, a metropol- this fact the evident improvement in itan center, the Etimesgut region, which health and the falling birth rate provide still has many of the characteristics of a evidence of the tremendous effectiveness rural area, has covered a great deal of of health organizations in rural areas. The Etimesgut study of 1967 showed ground in fertility control. In our opinion, the reasons for success lie in the extensive that the target population for family rural health services of the area. planning ought to include all currently The Etimesgut Health Center which pregnant women. In Figure 3, note that is a model for the National Health Serv- almost none of the pregnant women had ices, serves a population of 60,000. There ever tried an effective contraceptive methare seven health units and these health od before. Yet they are the women of curunits are backed by one rural hospital. rent demonstrated fertility. We believe There are 12 physicians, one surgeon, one that if implemented, a post-partum proobstetrician, 8 Maternal-Child Health gram will bring about further rapid denurses, 8 male public health nurses and 25 creases in the birth rate. The study of IUCD acceptors by Yurrural midwives in the district. The population covered by one rural midwife is in toren and Fincanioglu has been exceptionthe vicinity of 2,000-2,500. The rural mid- ally useful in evaluating family planning wife visits regularly all pregnancy cases activities in Turkey. The study covered from the fourth month of pregnancy on, 68,000 IUCD acceptors. Acceptors had a and all children under the age of six. median age of 29 and an average of 3.2 Households with no pregnancy cases or living children. Their fertility was gener100 90
80 70
(:t ~ l..
~
'0 1- ..+ ..
itt
50
40
?R.OTfCT£D ~
30
-I
2-D
20-4
2~-29
30-3,+
.35-39
AGE GI10UPS
Figure 2.-Contraceptive status of women in Etimesgut,
588 DEMOGRAPHY
ally higher than that of other women of their same age. The literacy rate among acceptors was not much different from that of the remaining community. Members of the community at the highest socioeconomic levels, however, seemed reluctant to use tbe IUCD. The geographic distribution of IUCD acceptors shows much higher acceptance rates in urban than rural places. For example, metropolitan acceptance rates were 6! times as high as village rates, with cities and towns at intermediate rates."
Furthermore, the highest response is in Central Anatolia where Ankara is located (Table 7). This may be explained by the more successful work of the family planning organization in certain cities such as Ankara. CONCLUSION
A general fertility decline appears to have started in Turkey. Although its on16 N. Olcen, "The Geographical Distribution of Public Instruments," Planning in Turkey (edited by S. Ilkin and E. Inane, Ankara: Middle East Technical University, 1967), pp. 274-278.
8 8
)b
Not sure
e
(0
G
e
0)
o
Prime
SUb - fecund:
~argd:
Includes women who are not rre!],nan!. are no! cummll.9 using a meJhod of.conlraceptioll, and have nol: had a live birlh for at least .3 Jjcars since marria~/z or /-beir lasl birlh. If lhe woman or husband had an ofcra/iotl whick sJ:erilized one 01' -them, tile woman is "nelue/cd here.
Figure 3.-Target population for family planning program, Etimesget (in percents).
Fertility Control in Turkey
gin cannot be dated precisely, it appears to have been in progress for some time, and probably began before the 1960's. The decline is accompanied by major fertility differences among regions, as well as between rural and urban places. These fertility differences are of long-standing. They correlate well with socioeconomic and literacy indices. The change in government population policy in 1965 in favor of family planning, and the general background of educational and economic development in Turkey may be supportive of an acceleration of the fertility decline in the future. We have also noted the increased sale of contraceptives and the initiation of a government IUeD program. However, Turkey's birth rate remains above 40 per thousand today, and the country has yet to enter a phase of rapid fertility decline. The goals for family planning set in the Second Five-year Plan (1967-72) are to bring family planning to an additional 5 percent of the target population each year (i.e. to an average of about 275,000 couples per year), and to have a total of 2
589
million couples practicing effective contraception by 1972.16 With a current IUeD insertion rate of only about 55,000 per year, and the increase of other contraceptive practice uncertain, a serious gap presently exists between goals and their realization. The government has emphasized the health aspects of the family planning program when called upon to justify its positive policy. Economic justifications have figured less, and consequently the family planning program has not always been successful in the competition for public funds and administrative attention. In addition, significant groups among the educated classes of Turkey continue to be unconvinced. Nevertheless, public awareness of the relationship between fertility control and the realization of social and economic objectives over a wide front is steadily increasing, and a stronger consensus may be expected in the future. 16 Prime Ministry, State Planning Office, Second Five-Year Development Plan (1967-1972) (Ankara: 1967), p. 227.
