The past few decades witnessed a considerable decline in total fertility rates over the world. In 2019, the global fertility rate stood at 2.5 births per woman, indicating a decline from 2.8 births per woman from the year 2000 [1]. In sub-Saharan Africa, this decline has been much slower [2]. For instance, whereas the total fertility rate (TFR) in SSA only declined from 6.57 births per woman in 1950 to 4.62 births per woman in 2019, TFR of Asia and Latin America declined sharply from 5.83 and 5.83 births per woman in 1950 to 2.15 and 2.04 births per woman in 2019 respectively [3, 4]. This is critical, given the alarming impacts of uncontrolled rapid population growth on the wellbeing of nations [5]. Although the high population may have some virtue, for instance; increasing workforce, its negative consequences appear to preponderate the positive ones [6]. For instance, with rapid population growth, there is pressure on social amenities as well as unemployment, which has negative implications for the growth and development of low- and middle-income countries such as Ghana. In South Africa for example, it is reported that rapid population growth and large increases in school-age population has undermined efforts to improve quality of education and in Mozambique, it is estimated that only 30% of the population has access to health services due to rapid population growth [7].
To offset the negative implications of high rapid population growth, low- and middle-income countries worldwide are putting in measures in an attempt to check uncontrolled rapid population growth. This involves the institution of policies and interventions. In 2015, the United Nations adopted the 2030 Agenda for Sustainable Development emphasizing universal access to a full range of reliable and safe family planning methods to help people to decide responsibly and freely the number and spacing of their children [1]. The international community has therefore sought to expand contraceptive utilization, counseling, information dissemination and other family planning services as one of the tools to check uncontrolled rapid population growth [2, 8, 9]. The increased patronage of such services and programs have resulted in improvements in health-related outcomes such as reductions in maternal and infant mortality, unintended and high-risk pregnancies, and improvements in economic and schooling outcomes, especially for girls and women.
Although the fertility rates of most high-income countries are declining, the programs and interventions seem not to be working in many SSA countries as the rate of fertility is either stable, reducing at a slower pace, or is on the rise [8, 10,11,12]. For example, In Ghana it is reported that the TFR has been fluctuating over 2 decades [13, 14]. Despite the introduction of many government policies, programs and interventions such as the 2004 National Population Policy, Ghana Population and AIDS project (1996–2000), 2002 Free Compulsory Universal Basic Education (FCUBE) Contraceptive Social Marketing project (1987–1990), Ghana Family Planning and Health Programme (1990–1996) and Free Senior High School programs, TFR has not seen major declines and it remains unclear the trend over the past few years.
Research has revealed some association between fertility and other variables such as educational background [15], unmet need for family planning [15] and contraceptive use [16] and the 2019 World Fertility Policy document has also illustrated that variations in the trends in fertility across countries are associated with the trend in growing national wealth, educational expenditures, and income inequalities [1]. Perhaps, these variables could also play critical roles in Ghana’s TFR trend.
According to the Ghana Demographic and Health Survey (GDHS) [14], there have been fluctuations in the fertility rate in the country, and the World Bank has also reported that Ghana’s TFR is declining at a much slower pace [14]. The rate of decline since 1980 has been reducing sharply. For example, between 1980 and 1990 the rate of decline was 0.937, between 1990 and 2000 the rate of decline was 0.776, between 2000 and 2010 the rate of decline was 0.553 and finally, between 2010 and 2019 the rate of decline was 0.457 [17]. This implies that even though TFR in Ghana has been declining over the years, the rate of decrease has also been decreasing sharply. These are at the backdrop of several interventions Ghana has implemented over the past 3 decades to curb the rapid population growth such as the FCUBE in 2002, Free SHS in 2017, introduction of Community Health nursing to scale up provision of family planning services in 1960, introduction of subsidies on the importation of contraceptives in 2002 and the adoption of the 2004 National Population Policy.
To better understand the TFR situation in Ghana and what needs to be done to ensure stable and sustainable decline, there is the need to first examine the TFR trend over a longer period while taking into consideration some inequality dimensions. Hence, this study was conducted to examine the trends in total fertility rate by different inequality dimensions between 1993 and 2014. Findings from such a nationally representative study will help formulate and strengthen programs, strategies, and interventions to check uncontrolled rapid population growth in Ghana.