Appalachia’s Aging Population—More Residents Ages 65+, Fewer Ages 25 to 64—Signals Challenges Ahead

The Appalachian Region’s aging population may pose challenges “down the road” for local governments and community service providers, say the authors of a new Population Reference Bureau (PRB) report for the Appalachian Regional Commission. The Region’s share of residents ages 65 and older exceeds the national average, and Appalachia’s population in the prime working years (ages 25 to 64) declined between 2010 and 2016, while it grew nationally.

The Appalachian Region: A Data Overview From the 2012-2016 American Community Survey—coauthored by Kelvin Pollard, PRB senior demographer, and Linda A. Jacobsen, PRB vice president for U.S. Programs—examines trends and population characteristics at the regional, subregional, state, and county levels using recently released American Community Survey data and the Census Bureau’s latest population estimates.

The Region encompasses 205,000 square miles along the Appalachian Mountains from southern New York to northern Mississippi, including portions of 12 states and all of West Virginia.

An Aging Population Creates New Demands on the Region

The report shows that the share of residents ages 65 and older (17.6 percent) in the Appalachian Region exceeded the national average (15.2 percent) by two percentage points in 2016. Older persons made up at least 20 percent of the population in 157 of 420 Appalachian counties, almost three-fourths of which were rural counties outside metropolitan areas. In contrast, most of the 40 Appalachian counties with older population shares below the national average contain either metropolitan areas or colleges and universities.


The overall share of Appalachian residents ages 65 and older exceeds the U.S. average, but varies by county.

The authors point out that as the large baby boom generation ages, the share of residents ages 65 and older will continue to increase in both Appalachia and the nation. Yet while both the young adult (ages 18 to 24) and working-age populations have increased nationally since 2010, Appalachia has lost people in these age groups. For example, the Region had 13.2 million residents ages 25 to 64 in 2016, down 1 percent from six years earlier.

“The shifting age distribution of the Region’s population means that fewer workers are supporting a growing older population, which can have implications for the local tax base and the demand for community services for the elderly,” says Jacobsen. “In addition, adults in their prime working years are the economic engine of a community.”

Appalachia’s Education and Disability Levels Differ by Geographic Area

The report provides data on education and disability in the Region, key features of human capacity. It shows that while working-age adults in Appalachia are nearly as likely to have completed high school as Americans in general, they are significantly less likely to have completed at least four years of college.

Since 2007-2011, the share of Appalachia’s working-age population with a bachelor’s degree or more has risen nearly two percentage points to just under 25 percent in 2012-2016. Room for further improvement remains, however, as the Region’s current prevalence is seven percentage points lower than the U.S. average of 32 percent. The authors call this “a striking indicator of the lower educational level of the Appalachian workforce,” and also point to variation within the Region. For example, they note that while less than 18 percent of working-age adults in Appalachian counties lying outside of metropolitan areas had bachelor’s degrees, the share in counties that are part of large metropolitan areas of at least 1 million was 33 percent—above the national average.


The share of Appalachian residents with a bachelor’s degree or more increased more than 2 percentage points between 2007-2011 and 2012-2016.

Disability rates in the Appalachian Region are higher than the national average. In the 2012-2016 period, approximately one in seven adults ages 18 to 64 in Appalachia reported a disability, compared with about one in 10 nationally, the report shows. (The ACS only includes disability data for civilians living outside of nursing homes and other institutions; it defines persons with a disability as having difficulty in at least one of the following six areas: hearing, vision, cognition, walking or climbing, self-care, or attending to the functions of independent living.)

Some parts of the Region have particularly high disability rates. In Central Appalachia, for example, more than one-fifth of working-age adults had a disability. Central Appalachia had 56 of the 101 Appalachian counties where the disability rate among 18- to 64-year-olds was 20 percent or higher.

“Central Appalachia’s historic reliance on mining and related resource-based industries, as well as Appalachia’s relatively high rates of cancer, heart disease, and diabetes, may be associated with the subregion’s high disability prevalence,” Pollard suggests. He also notes that among the 61 Appalachian counties where at least half of persons ages 65 and older had a disability, two-thirds were in Central Appalachia.

Other Key Findings

  • The Region’s overall population growth was just over 1 percent between 2010 and 2016, less than one-fourth the national average of 4.5 percent. Two out of three Appalachian counties lost population during this period.
  • Although the share of the total population made up of minorities increased by almost two percentage points between 2010 and 2016, the Appalachian Region continues to be significantly less racially and ethnically diverse than the United States as a whole. In 2016, minorities comprised 18.2 percent of the Appalachian population—less than half the national average of 38.7 percent. Although African Americans make up the largest minority group in Appalachia, Hispanics have fueled much (if not most) of the minority increase.
  • Homeownership rates in Appalachia fell nearly two percentage points between 2007-2011 and 2012-2016, but the decline was smaller than the national average. This drop likely reflects the continued effects of the 2007-2009 recession and the slow economic recovery that has followed, the authors suggest.
  • At 6 percent, the unemployment rate in Appalachia matched the national average in 2012-2016—a full percentage point lower than it was in 2007-2011. Yet great variation existed within the Region: The jobless rate was less than 5 percent in 68 counties, but it reached 10 percent or higher in 37 others.

Appalachia’s unemployment rate matched the national average in 2012-2016, but great variation existed within the Region.

  • About 32 percent of Appalachian workers ages 16 and older commuted to jobs outside their county of residence during 2012-2016, four percentage points above the share nationwide.
  • In 2012-2016, median household income in Appalachia was more than $9,000 lower than the national median. In 75 counties, the median household income was less than $35,000. After adjusting for inflation, median household income declined less in Appalachia than in the nation as a whole between 2007-2011 and 2012-2016, and it increased in 192 counties scattered throughout the Region.
  • The share of Appalachian residents who are low-income (between 100 percent and 199 percent of the poverty level) is two percentage points above the national average. For every age group under age 65, the share of Appalachian residents living below the poverty level exceeded the national average, with the highest rates in Central Appalachian and rural counties. In Central Appalachia one in four residents lived below the poverty line, including one in three children.
  • Residents of all ages are less likely to be without health insurance in Appalachia than in the nation, but exceptions exist in several subregions and in rural counties. One in six young adults lacked health insurance in 2012-2016, but this share was 25 percent or more in 137 counties, concentrated in the Appalachian central, south central, and southern subregions. Lack of health insurance in young adulthood could contribute to the development of chronic conditions that might limit the ability to work and lead to disability later, Jacobsen notes.

The full report includes detailed tables and county-level maps, covering state- and county-level data on population, age, race and ethnicity, housing occupancy and tenure, housing type, education, labor force and commuting, employment and unemployment, income and poverty, health insurance coverage, disability status, migration patterns, and veteran status.


Family Caregiving for Older People

In the United States, the vast majority of care that allows older people to live in their own homes is provided by family members who do not receive pay for their services. As the older share of the population increases and people live longer with chronic disabling conditions, particularly dementia, meeting the care needs of older Americans will become more challenging for families.

This report highlights recent National Institute on Aging-supported research on the impact of caregiving on family members, the dynamics of caregiving within extended families, and the future need and availability of family care. As policies deemphasize nursing home care in favor of community-based long-term support services, a better understanding of the family’s central role in caregiving is needed. This perspective can help policymakers, health care providers, and planners identify and implement strategies that better meet the care needs of older Americans and improve the lives of the family members who care for them.

Caregiver Availability and Constraints

A variety of trends have contributed to a widening gap between older Americans’ need for care and the availability of family members to provide that care, raising the potential for growing unmet needs, a heavier burden on individual caregivers, and increased demand for paid care. The combined effects of delayed childbearing and longer life expectancy mean more adults in later-middle age may be “sandwiched” between the competing demands of their children and those of their aging parents and parents-in-law. Women—who have traditionally served as parent care providers—are more likely to be employed than in previous generations, limiting their availability, and increasing their time constraints.

View Infographic

Using the nationally representative Panel Survey of Income Dynamics (PSID), Wiemers and Bianchi (2015) showed a 20 percent increase between 1988 and 2007 in the share of women ages 45 to 64 who had both children and living parents or parents-in-law. One in 10 women in this age group provided significant parental care and either financial assistance or housing (within their homes for one year or more) to both an adult child (age 25 or older) and a parent during the period. Supporting multiple generations “may affect well-being in retirement if women decrease labor supply to care for parents or if money transfers to children are made at the expense of retirement savings,” the researchers argue.

Adults in their 50s, 60s, and 70s are more likely than those in previous generations to have divorced, increasing their likelihood of reaching old age without a spouse to assume the role of caregiver. Divorce also has implications for whether older adults will receive care from their children. In particular, divorce and remarriage may weaken adult children’s sense of obligation to provide elder care, particularly for fathers with whom they did not reside and for stepparents (Silverstein and Giarrusso 2010).

Taking a variety of trends into account including divorce, low fertility, and rising life expectancy, Ryan and colleagues (2012) created a model of the baby boom population to examine the future availability of family support. The model, based on census data and findings from the nationally representative Health and Retirement Study (HRS), allowed researchers to estimate how many baby boomers would have the types of family members who are the most common care providers—a living spouse or an adult child within 10 miles. The projections show that the share of 75-year-olds without the most common care providers will increase substantially between 2010 and 2030. Given the size of the baby boom population, the number of 75-year-olds without a spouse could more than double from roughly 875,000 in 2010 to 1.8 million in 2030, and those without an adult child nearby could increase by a multiple of six during that time—from about 100,000 to more than 600,000. The researchers suggest that baby boomers may need to rely on paid care providers or nontraditional caregivers such as siblings or stepchildren. Unmarried women with few economic resources are likely to be particularly disadvantaged by not having a spouse to provide care. To address this widening care gap, researchers argue for expanding long-term care insurance, designing aging-friendly neighborhoods, and planning for an increased demand for paid care services.

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Another way to meet older adults’ care needs is to better involve grown children who live at a distance from their parents, proposes Piette and colleagues (2010). Their analysis of HRS data showed that one in three chronically ill older adults had no children nearby but did have adult children living elsewhere. And three in four grown children were in frequent contact with their aging parents despite distance, through phone calls or visits (especially those who lived within a one-hour drive). More than half of the older adults said they could rely on their children if they had a serious problem and that their relationships were amicable. Involving out-of-town adult children in parents’ medical care and medication management is one way to better meet the needs of this group of chronically ill older people, the authors suggest.

Satariano, Scharlach, and Lindeman (2014) identify a wide range of new technologies that can support older adults and their caregivers, such as electronic medication reminders and ingestible devices to improve medication compliance, and wearable sensors that immediately report abrupt movements related to fall or injury. They recommend that research on the safety and effectiveness of these devices include input from caregivers and give special attention to economic barriers to their use.

Understanding the Impact of Caregiving on Family Members

Providing uncompensated care for a spouse or parent living with physical limitations can be both rewarding and stressful, and new research has helped identify how— and under what circumstances—providing care to an older relative is beneficial or harmful to the care provider’s well-being.

Roth, Fredman, and Haley (2015) examined five studies that followed groups of people over time and found that those who became caregivers tended to live longer and had lower mortality rates than similar noncaregivers. The researchers noted that “most caregivers also report benefits from caregiving, and many report little or no caregiving-related strain.” In one of those studies, Brown and colleagues (2009) tracked more than 3,300 married people ages 50 and older for eight years using HRS data. They found that those who spent 14 or more hours weekly caring for a spouse had a lower risk of death than otherwise comparable non-caregivers.

But other evidence indicates that prolonged caregiving for a spouse can negatively affect physical and mental health. Two recent studies based on eight years of HRS data tracked older married people who did not have high blood pressure or cardiovascular disease (CVD) at the beginning of the study (Capistrant, Moon, and Glymour 2012; and Capistrant et al. 2012). Caregiving for 14 hours or more weekly for two or more years doubled the risk of CVD onset and significantly increased the risk of developing high blood pressure compared to other similar adults who were not caregivers. Becoming a caregiver for a spouse (14 hours per week or more) also significantly increased an older adult’s risk of depression, according to another study of married HRS participants (Capistrant, Berkman, and Glymour 2014). But long-term caregiving (for two or more years) did not elevate the risks further, suggesting that grief related to experiencing a spouse’s functional decline rather than the long-term “wear and tear” of caregiving may be at the root of depression.

New findings from the nationally representative 2011 National Study of Caregiving offer a window into how caregivers experience their roles and which caregivers might be at risk of debilitating stress. This study collected information on the entire network of caregivers of each adult age 65 or older with activity limitations identified as part of the 2011 National Health and Aging Trends Study (NHATS), making it more comprehensive than previous large studies. Nine out of 10 informal caregivers are family members, mainly spouses or adult children (Spillman et al. 2014).

In interviews, nearly two out of three caregivers rated their caregiving experience as largely positive, pointing to benefits such as feeling closer to the care recipient and assured that the recipient was receiving high-quality care (Spillman et al. 2014). But one in 10 caregivers found caregiving a negative experience overall. Additionally, one in four caregivers surveyed said caregiving took an emotional toll and about one in seven cited either financial difficulties or physical problems related to their caregiving responsibilities. About one in six caregivers told researchers that they had more than they can handle, were exhausted at the end of the day, or had little personal time.

Those who experienced caregiving as negative and stressful tended to care for recipients with greater limitations or with dementia symptoms, provided more hours of care, or had health problems of their own. Specifically, caregivers with symptoms of depression and anxiety as well as those with their own physical limitations were much more likely to experience caregiving as negative and stressful.

Researchers are gaining a better understanding of how the stress and time demands of intensive caregiving may weaken the immune system and increase the risk of accelerated aging by examining telomeres—structures found on the ends of chromosomes that protect against DNA damage. Over the past decade, a growing body of research has identified links between shorter telomeres and increased risks for depression and for a number of chronic diseases, including CVD, some cancers, and diabetes. Researchers have documented that caregivers experiencing the greatest stress have shorter telomeres than other caregivers, adding to evidence that chronic stress affects caregivers’ bodies at the genetic and molecular level (Litzelman et al. 2014). Another study that examined differences in telomeres suggests that the chronic stress spouses and adult children experience while caring for Alzheimer’s disease patients may shorten the caregivers’ lives by as much as four to eight years (Damjanovic et al. 2007).

Caregiving Patterns Within Families

For an older married person living with a disability, the spouse is usually at the forefront of care activities. And traditionally, parents have tended to rely on daughters (and daughters-in-law) for more care than sons. Recent studies examining the dynamics of elder care within families show how gender and proximity continue to influence who makes up an older person’s network of caregivers.

Wives tended to be the sole care providers for their husbands no matter how much personal care the men needed, according to analysis of the HRS-related Asset and Health Dynamics Among the Oldest Old (AHEAD) study, which examined more than 7,000 adults ages 70 and older not living in nursing homes in the early 1990s (Feld et al. 2010). But the more functional limitations a wife had, the less likely her husband was her only caregiver and the more likely others helped provide her care, particularly daughters.

This difference in who provides care for married men and women may reflect the fact that many wives are younger than their husbands and are often less disabled. Hands-on caregiving is frequently central to a woman’s identity and may cause her to resist seeking or accepting help, suggest Feld and colleagues (2010). Another study, based on HRS data, showed that adult children tend to be involved in their mothers’ care no matter what their fathers’ health level, but are much more likely to provide care for their fathers after their mothers’ death (Noël-Miller 2010).

If a couple has both sons and daughters, the daughters are much more likely to become their mother’s primary caregivers, underscoring the “primacy of the mother-daughter tie,” report Leopold, Raab, and Engelhart (2014). Their analysis of HRS data tracked 2,400 previously independent adults and their grown children over a decade. Geography was the main factor determining which adult child provided care when a parent began needing assistance; caregivers’ work and family constraints had somewhat less influence. Other factors influencing caregiver selection included parent expectations, frequency of contact before the caregiving need arose, and whether the parent had provided financial assistance to the adult child or made the child a beneficiary of a will.

Among siblings, daughters and grown children living in close proximity to parents were more likely to be continuous care providers, according to another HRS-based study that tracked changes in primary caregivers over a two-year period (Szinovacz and Davey 2013). Parents were more likely to experience a switch in caregivers if they lived alone, had more sons than daughters, or had a higher number of children (and thus more alternative caregivers). The researchers found that the choice of a primary caregiver had more to do with expected gender norms and availability than adult children’s competing obligations such as work or family. The researchers point out that society has traditionally expected daughters to care for their parents and argue that it might be “psychologically more costly for women to decrease their care commitments,” despite the burden or conflicts they may experience.

Economics of Caregiving

The dollar value of the informal care that family and friends provide for older Americans totals an estimated $522 billion a year—more than total Medicaid spending ($449 billion in 2014), according to Chari and colleagues (2015). The researchers used new data from the 2011 and 2012 American Time Use Survey—which uses a relatively broad definition of elder care—to calculate the monetary value of the time uncompensated caregivers gave up in order to provide care. Replacing that care with unskilled paid care at minimum wage would cost $221 billion, while replacing it with skilled nursing care would cost $642 billion annually. Because most caregivers are employed, “the bulk of the economic burden of elderly care is shouldered by working adults,” the researchers argue.

Caregiving responsibilities appear to influence labor force participation, according to a study based on HRS data (Van Houtven, Coe, and Skira 2013). Providing personal care assistance to a parent slightly reduced men’s likelihood of working and may lead employed women to work fewer hours. The researchers suggest that women may seek lowerpaying jobs with more flexibility to accommodate caregiving. Among older workers who left a full-time position, taking on new caregiving responsibilities appeared to act as a barrier to working part time, according to Carr and Kail’s analysis of HRS data (2012). The more caregiving responsibilities the individuals had, the less likely they were to work parttime. “Providing support to new caregivers as they leave fulltime work may help them remain engaged in the workforce longer,” the authors suggest.

To estimate the impact of parent care on adult daughters’ current and future labor force participation and earnings, Skira (2015) created a model that accounts for declining parental health, the impact of a leave on daughters’ work history and experience, and the availability of job offers afterward. Incorporating data from HRS, she found that after taking an employment leave or cutting hours to provide parental care, the chances are low that adult daughters will return to work or increase their work hours. “Women who leave work forgo experience and the associated wage returns and also face a lower expected wage if they return to work,” she writes. The model suggests that the overall median cost to a woman in her mid-50s who leaves work is about $165,000 over two years, about equal to the cost of two years of nursing home care. This estimate is many times higher than estimates that only take into account the cost of lost wages.

Policy Implications

Family caregivers provide the majority of support that allows older adults with disabilities to live independently and avoid costly nursing home care. The estimated dollar value of uncompensated family care overshadows many large federal programs.

As the disproportionately large baby boom generation ages, the gap between elder care needs and available caregivers will widen dramatically. In 2010, there were seven potential caregivers ages 45 to 64 (the age group of the average family caregiver) for every person age 80 and older (the age group most likely to have a disability) (Redfoot, Feinberg, and Houser 2013). That ratio is projected to drop to 4 to 1 by 2030 and bottom out at 3 to 1 in 2050 when the entire baby boom generation passes the age 80 milestone. The shrinking pool of potential caregivers reflects the combined impact of lower fertility and longer life expectancy; the former reduces the number of adult children and grandchildren that an older person can turn to for care and the latter increases the length of time individuals may need care. This demographic shift is occurring alongside other trends that also limit the availability of potential caregivers, including an increased share of employed women and caregiving expectations weakened by divorce.

To meet the growing care needs of older people, researchers underscore the importance of anticipating a growing demand for paid care services and designing neighborhoods that allow older people with disabilities to age in place more easily. Policies that enable employed caregivers to manage their competing roles are key to keeping families from seeking nursing home care for the older adults with functional limitations. Researchers also point to innovative approaches, such as designing ways to involve adult children living at a distance in managing their elderly parents’ health care.

New surveys document high levels of unmet care needs, particularly among older people with low incomes. New data on caregivers identify those who face particularly high caregiving burdens, such as those caring for older people with dementia or more mild cognitive impairment. These new data can guide policymakers and planners as they target home-based support services and caregiver assistance programs. Indeed, policies that improve long-term care services and supports, and reduce unmet needs, could benefit both older adults and their caregivers, now and in the future.


Please refer to PDF for references.


Occupational Earnings Gap

In the United States, full-time working women earn less than men, on average—even in female-dominated occupations (those in which women comprise 70 percent or more of workers), such as nurse practitioners, office clerks, and flight attendants. There are no occupations in which women’s median annual earnings are significantly higher than men’s. Using the latest and most detailed data available, the graphic below shows more than 50 occupations with the biggest gaps in pay parity, where full-time working women earn 75 cents or less, on average, for every dollar made by men in the same job.






A Decade of International Day of Zero Tolerance to Female Genital Mutilation/Cutting

(February 2013) Feb. 6, 2013, marks a decade since the first International Day of Zero Tolerance to Female Genital Mutilation was commemorated. An estimated 100 million to 140 million girls and women worldwide have undergone female genital mutilation/cutting (FGM/C), and more than 3 million girls are at risk for cutting each year on the African continent alone.

Zero Tolerance Day originated on Feb. 6, 2003, when the first lady of Nigeria, Mrs. Stella Obasanjo, officially declared “Zero Tolerance to FGM” in Africa during a conference organized by the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children. Since then, this day has been observed around the world. As we commemorate Feb. 6, we should acknowledge the bravery of those who first spoke out against it and recent hard-won successes. But we must also recognize the still-overwhelming challenges and those leaders who are continuing to work on the front lines to make change.

The last decade has seen progress toward abandonment. Studies have looked at the physical, emotional, and mental effects of FGM/C. Research has deepened our understanding of the diverse reasons for the continuation of the practice, providing insights about the origins and social dynamics that lead to its continuation. Reflecting the work of dedicated advocates, most practicing countries have passed laws banning FGM/C, and prevalence is beginning to decline in some countries.

Sierra Leone has no laws prohibiting FGM/C. However, prevalence rates have decreased from 94 percent in 2006 to 88 percent in 2010 according to the Demographic and Health Survey. A separate study found that while matters related to FGM/C remain largely decided by the women of the family, men may play a more important role than previously known. The study also uncovered evidence that the practice is becoming medicalized, with health professionals performing FGM/C. These findings suggest that targeting men and health personnel could be key in efforts to abandon the practice.

In the past year, Article 15 of the new constitution of Somalia has specifically prohibited FGM/C. In a country where an estimated 98 percent of women have undergone the practice, there is no doubt that translating the law into action will still be challenging. However, the high level of approval for the constitution as well as the positive example of efforts in neighboring Somaliland, provide hope that the region is moving in the right direction.

Yet challenges remain, even within countries where advances have been realized. In Malaysia, the health ministry is moving to reclassify FGM/C as a medical practice among Muslims. In 2009, a fatwa, or religious decree, from the country’s National Council of Islamic Religious Affairs made it obligatory for Muslim women to undergo the practice. Recent statistics show that more than 90 percent of Malay Muslim women and girls have been cut.

While FGM/C has been outlawed in Cote d’Ivoire since 1998, it still occurs in many areas. Preliminary results from the 2012 Demographic and Health Survey show that FGM/C prevalence among women ages 15 to 49 in Cote d’Ivoire remains at 38 percent, compared to 36.4 percent in a survey six years ago. At the same time, and encouragingly, the 2012 survey shows only a 16 percent prevalence rate among women with secondary education or higher.

Donna Clifton is a communications specialist, International Programs, and Charlotte Feldman-Jacobs is program director, Gender, at the Population Reference Bureau.


Advancing Family Planning in French-Speaking West Africa: A Call to Action

  • This report also in French

(October 2012) Although family planning use is increasing in the majority of developing countries, West Africa is lagging behind. Fertility rates among the French-speaking countries of the region remain high with an average of 5.5 births per woman, and 28 percent of women of reproductive age have an unmet need for family planning—one of the highest rates of any region globally.

The recently released report—Family Planning: Francophone West Africa on the Move—is a call to action, compiled by members of the Ouagadougou Partnership and other experts in family planning from West Africa. The report presents targeted areas of investments in family planning to spur progress in the region, and provides recommendations for strengthening services, mobilizing political commitment and resources, and coordinating actions. The report is also designed to serve as an advocacy tool for high-level policymakers, government officials, parliamentarians, civil society, community leaders, and other potential partners.

Building Off the Ouagadougou Conference

In February 2011, representatives from eight francophone West African countries attended the “Population, Development, and Family Planning in West Africa: An Urgency for Action” conference in Ouagadougou, Burkina Faso, to discuss how to accelerate progress. Participating countries included Benin, Burkina Faso, Guinea, Mali, Mauritania, Niger, Senegal, and Togo, with Cote d’Ivoire joining the initiative later. Country delegations arrived at an important consensus, all agreeing to take concrete actions to increase the uptake of family planning in their respective countries. In addition, at the conclusion of the conference, participants issued a call to action through the Ouagadougou Declaration (see Box).

A similar commitment formed among the donors at the conference, who joined together to improve coordination and provide support for family planning at the country and regional levels. Spearheaded by the United States Agency for International Development (USAID) and the French government, the partnership includes the French Agency for Development, the French Ministry of Foreign and European Affairs, the Bill & Melinda Gates Foundation, the William and Flora Hewlett Foundation, the West African Health Organization, the World Bank, the David and Lucile Packard Foundation, the African Development Bank, the United Nations Population Fund (UNFPA), World Health Organization (WHO), Germany/KFW and GIZ, and the European Commission, among others.

Ouagadougou Declaration

  1. Integrate population issues, as well as reproductive health (RH) and family planning (FP), into national development plans and strategies for growth and poverty reduction.
  2. Accelerate the implementation of national strategies for RH and FP to address the unmet needs expressed by the populations, through best practices identified at the Ouagadougou conference.
  3. Continuously disseminate culturally appropriate messages about population issues and FP to promote major changes in attitudes and reproductive behavior, with emphasis on the quality of life.
  4. Increase by 30% the number of health professionals capable and authorized to offer the range of FP/RH services.
  5. Ensure a steady increase in contributions of national budgets to support the cost of contraceptives.
  6. Regularly monitor and evaluate the actions and measures implemented to ensure the achievement of the goal to reduce, by 2015, the maternal mortality ratio and the level of unmet family planning needs by at least 25% for the entire French-speaking region of West Africa.
  7. Raise the institutional placement of family planning programs with the goal of obtaining a high-level commitment.

The Economics of Reproductive Health in Accra, Ghana

(September 2012) Reproductive health services, in particular family planning and maternal health services, can help women avoid unplanned births, unsafe abortions, and pregnancy-related disabilities. Through modern contraception, couples have a safe and reliable way to have the number of children they want. With smaller families, women spend less time dealing with pregnancy and child care and have more time for work outside the home. Large families can be a drain on household resources, with school fees being the largest cash expenditure in many households.


With smaller families, women can stay healthier, become more economically productive, and have more opportunities for education, training, and employment. At the country level, women’s increased working outside the home also leads to an expanding labor force, which produces substantial economic benefits.


This PopPov network research brief highlights findings from a recent study conducted by the Harvard School of Public Health and the University of Ghana, Legon. The study examined the associations between reproductive health, fertility, and economic outcomes for women living in the urban area of Accra, Ghana, and investigated this “health-wealth relationship” by analyzing the effects of fertility and family size on:

  • Women’s reproductive health status.
  • Female labor force participation.
  • Employment status of mothers.
  • Women’s wages and earnings.

The PopPov Network makes research grants, supports dissertation fellows, sponsors meetings and workshops, and now provides an online space for the poppov research community. The goal of the network is to highlight the needs of the researchers, highlight state of the art methodologies, encourage and teach the next generation of researchers, and share ideas and communicate findings among the research community.


For related research on other issues pertaining to women’s health in Accra, see the editorial in the June 2012 Ghana Medical Journal, and browse the rest of the issue.


Mahesh Karra was a policy analyst in International Programs at PRB. Marlene Lee is program director, Academic Research and Relations, at PRB.


Mother-Daughter Communication About Sexual and Reproductive Health in Rural Areas of Alexandria, Egypt

(September 2012) In many parts of the world, adolescents are poorly informed about their health, bodies, sexuality, and physical well-being. Adolescent girls in particular are often kept from learning about sexuality and reproductive health (SRH) issues because of cultural and religious sensitivities. This is particularly true in Egypt, where adolescents are often reluctant to ask for SRH information from adults in their families, communities, or in professional settings.


International studies show that parents are among the preferred sources of SRH education for adolescents around the world, and improving the quality of communication between parents and adolescents can protect adolescents from risky behavior. This working paper presents key findings from a study conducted in Egypt in the spring of 2011 on the frequency and quality of communication about SRH issues between mothers and adolescent daughters. The findings suggest that communication between mothers and daughters and knowledge about these sensitive topics is poor; however, both mothers and daughters are eager for more information on SRH matters. This study is part of a series of studies on the same topic sponsored by the Population Council and conducted in several countries using similar research methodologies.


Yasmine Y. Muhammad participated in a joint PRB-Assiut University training on policy communication held in Assiut in 2009. She is an assistant lecturer of Maternal and Child Health at the Family Health Department in the High Institute of Public Health at Alexandria University, Egypt. This paper is based on key findings of her research conducted in collaboration with Heba M. Mamdouh, her colleague at the High Institute. Their research was supported by the Population Council office in Cairo. Ms. Yasmine Muhammad can be reached at yasmine.yousri@gmail.com.


Costs of Induced Abortion and Cost-Effectiveness of Universal Access to Modern Contraceptives in Uganda

(September 2012) With a population of nearly 30 million and an annual population growth rate of 3.2 percent, Uganda is the third fastest-growing country in the world. Recent Demographic and Health Surveys indicate that only 31 percent of Ugandan women of reproductive age who want to use contraceptives report that they are indeed using a modern effective method. Over 37 percent of women want to postpone or limit childbearing but are not currently using modern contraception—these women have an unmet need for family planning. To respond to the high level of unmet need, the Ugandan government has begun to include family planning in its health program and has acknowledged that a high level of unmet need for family planning may negatively affect women’s health and overall well-being.


This PopPov network research brief highlights findings from two recent studies led by Joseph Babigumira and researchers at the University of Washington and in Uganda. Both studies use health economics methods to:


  • Investigate the economic consequences of not responding to unmet need for contraception.
  • Inform policymakers about the benefits of increasing family planning coverage.


The PopPov Network makes research grants, supports dissertation fellows, sponsors meetings and workshops, and now provides an online space for the poppov research community. The goal of the network is to highlight the needs of the researchers, highlight state of the art methodologies, encourage and teach the next generation of researchers, and share ideas and communicate findings among the research community.


Mahesh Karra was a policy analyst in International Programs at PRB. James N. Gribble is vice president of International Programs at PRB.


'The Faces of Unmet Need'. A PRB Infographic

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