The most recent survey information in Azerbaijan is the Reproductive Health Survey, Azerbaijan, 2001 (RHS)2. In the absence of more recent data, most of the information in this section is from this survey. However, there are no obvious reasons to believe there have been major changes in the situation in the last five years. A Demographic and Health Survey (DHS) is currently in the field. Results of this survey will add more current information, as well as document and changes and trends that have emerged.
3.1Desired family size and fertility in Azerbaijan
Desired family size in Azerbaijan is currently estimated at about 2 children per family. This is in line with a world-wide trend to smaller families, with virtually all countries in the world experiencing decline in desired family size, while none are experiencing increases. In Azerbaijan, 77% of women that have two children want no more children; 88% of women with three children want no more, and even 21% of women with one child want no more.
Couples in Azerbaijan have been successful in achieving their desired family size, with the Total Fertility Rate (TFR) declining to 2.1 in 2001 from, 2.8 in 1994-963. The TFR in Azerbaijan is slightly higher than other nations in the Caucasus (Armenia, 1.7, Georgia, 1.7), higher than countries in Eastern Europe (1.3 to 1.9), and somewhat less than countries in Central Asia (2.1 to 3.4)
Population momentum, the result of a relatively large population in its reproductive years, will cause the population of Azerbaijan to continue to grow after it achieves replacement fertility, or a TFR of 2.1. The population of Azerbaijan is expected to stabilize in 2025 at about 9.5 million. Some officials have speculated that the low fertility rate is a result of bad economic conditions, and that higher fertility will occur when the economy improves. However, world-wide, regional, and European experience indicates that such a rebound in fertility is unlikely.
The use of modern contraception for married women in Azerbaijan is only 12% -- the lowest in the region. The most widely-used method is the IUD, which is used by 6% of married women, followed by condoms (3.2%), tubal ligation, which appears to almost always be used by women experiencing other reproductive problems (1.2%), pills (1%), and “other modern” methods, presumably spermicides (0.4%). The dominance of the IUD is typical of the region, as there is some remaining historical distrust of hormonal methods. However, in a country which still has significant anemia, particularly in rural regions, the favoring of IUDs in the method mix over hormonal contraception is concerning. Figure 1 compares modern method use in Azerbaijan to other regional and European countries. As can be seen, Azerbaijan has the lowest modern method use in the countries presented.
Traditional method use (43.5%) dwarfs modern method use (11.9%) in Azerbaijan. The very high use of withdrawal, at 41%, is especially striking. (Azerbaijan may have the highest reported use of withdrawal in the world.) The RHS noted that withdrawal was higher in rural areas, among women with three or more children, and among women with low SES. Use of withdrawal at such a high level is important because it requires the participation of both partners to avoid pregnancy. In fact, when OB/GYNs in the Central and Southern regions were queried about why so many couples used withdrawal, the response was “Some choose to use it, and other use it because they cannot afford modern contraception.”
High failure rates for withdrawal and other traditional methods contribute significantly to Azerbaijan’s high abortion rate. The abortion rate in Azerbaijan, 116 per 1000 Women of Reproductive Age (WRA), is second only to that of Georgia at 125 per 1000 WRA. According to the RHS, failure of traditional methods accounts for 58% of abortions, resulting in over 150,000 abortions per year4. The high volume of abortions and ensuing complications (20.6% of abortions result in complications5) strain the health care system while contributing to maternal morbidity.
Traditional method users are likely to play a key role in a transition from dependence on traditional methods backed up by abortion to improved contraceptive use with less need for back up abortion as a strategy for fertility regulation. Turkey’s experience may be instructive in understanding the dynamics between traditional method use, abortion and adoption of modern contraception in neighboring – and culturally linked -- Azerbaijan. In Turkey the process of persuading women to give up ineffective traditional family planning methods such as withdrawal – and the back-up method of abortion when those methods invariably failed – in favor of more effective modern contraceptive methods took place over a long period of time. Abortion rates dropped sharply over the decade 1988-1998 while the total contraceptive rate remained stable. Women slowly shifted away from the use of traditional methods and abortion to acceptable modern methods (See Senlet, 2001). Senlet and colleagues conclude, "Marked reductions in the number of abortions have been achieved in Turkey through improved contraceptive use rather than increased use" (italics added). In Azerbaijan, where withdrawal is the most commonly method practiced and here half of all abortions in the country are preceded by the failure of a traditional method , a shift in the method mix toward more effective methods and more effective use of methods has considerable potential to reduce abortion levels, even in the absence of increased use.