Book Reviews 103 
encouraging refugee settlements to take their place in the national economy. In 
addition a wide range of skills and services are provided through refugee cooperatives, 
which have developed a local economy for the settlements. 
Recently many of the earlier settlements have assumed the status of ordinary 
Tanzanian villages, either through voluntary repatriation or, in cases where 
this was not a possibility, the mass naturalisation of refugees. 
Gasarasi emphasises that other African countries hosting refugees would 
greatly benefit from this tripartite experience and believes this deserves wide 
dissemination. I would endorse his view, with the reservation that the 
development of this co-operative approach requires a particular set of 
favourable circumstances to facilitate this process. In addition it seems evident 
tha the different terms of reference of the operational partners inevitably 
creates a degree of mistrust between them. However, we should bear in mind 
that in all likelihood these three agencies will need to develop a modus 
operandi in coping with refugee problems in any case. Other countries apart 
from Tanzania have experimented in a similar way, with one implementing 
donor agency working hand in glove with both Government and UN agencies 
such as UNHCR. Although beset with difficulties, a tripartite approach may be 
the only way to work towards the provision of effective co-ordination and 
planning for refugees in the long term. 
Reviewed by N Hall, School of Social Work, Harare. 
References 
KIBREAB G 1983 Reflections on the African Refugee Problem: 
A Critical Analysis of Some Basic Assumptions. 
Research Report No 47, The Scandinavian 
Institute of African Studies, Uppsala. 
Sweden. 
REFUGEES 1983 Refugees Magazine, Office of the United 
Nations High Commissioner for Refugees. 
Public Information Section, No 5, Dec 1983. 
13-18. 
Zimbabwe National Family Planning Council. Zimbabwe Reproductive 
Health Survey 1984. Harare, June 1985. 
The Zimbabwe Reproductive Health Survey (ZRHS) Report is written with 
clarity and principled simplicity. These are important attributes for a 
pathbreaking report in the field of fertility in Zimbabwe. The ZRHS was 
conducted between July and October 1984, and the sample is comprised of 
2 574 women aged 15-49 of whom two thirds are rural residents. 
The report consists of eight chapters. The first chapter provides the 
historical, socio-economic and demographic backdrop on which the study
104 Book Reviews 
rests. The organisational structure of the Zimbabwe National Family Planning 
Council (ZNFPC), the national executing agency for family planning programmes, 
is presented. As Zimbabwe does not have an explicit population policy, the 
official support of family planning activities is for other than demographic 
reasons. Like other countries which fall in this category, family planning is 
supported for reasons of health and as a human right, and any antinatalistic 
effect is a by-product and not an objective. Yet the necessity of such a byproduct 
is not underplayed in the report. Chapter two deals with the survey 
methodology while chapters three to five present the survey results on the 
socio-economic and demographic variables of age, place of residence, 
education, work status, nuptiality, desired family size and material and child 
health. The traditional concepts of knowledge, attitude and practice of family 
planning are the focus in chapters six and seven. In the last chapter, availability 
of contraceptive methods, a proxy for cost of fertility regulation, is discussed. 
The socio-economic and demographic characteristics of Zimbabwe are not 
typical of most developing countries. Zimbabwe has experienced a significant 
mortality decline without a concommitant proportionate fertility decline and 
hence has suffered a consequent high growth rate. The sample shows a young 
age structure with an urban bias. The literacy rate of approximately 75 percent 
is fairly high particularly for women. However, while this may be a true 
reflection of the country's literacy rate, it is important to note that the liberal 
definition of literacy "the ability to read a letter or newspaper" was used. A 
modest female labour force participation rate of approximately 33 percent is 
reported. 
The pattern of nuptiality, the socially sanctioned context within which 
fertility takes place, has important implications for the fertility level of any 
country. Universal and early marriage are characteristic of Zimbabwe. The 
authors rightly observe the "critical importance" of contraception to effect a 
significant fertility change given the reported mean age at first marriage of 17,8 
years. While this mean age at marriage is quite plausible for a developing 
African country, the deviation from the census estimate of 22 years is a matter 
of concern. Can a 4,3 year difference be simply explained away by random 
error? 
High fertility is a characteristic of the Zimbabwean population, although it is 
suggested that a decline is underway. If fertility continues at its present level, 
an average woman would have 6,5 births before the end of her reproductive 
career. The census total fertility rate estimate is 5,6. The total fertility rate 
estimates are consistent with those of the mean age at first marriage assuming 
an inverse relationship between these two variables. Fertility is reported to be 
higher among women who are rural, poorly educated with poorly educated 
spouses, and not employed outside the home.
Book Reviews 105 
'Demand' for contraception is affected by the proportion of women who do 
not want any more children, would like to delay further pregnancy or who wish 
a desired number of children vis-a-vis potential fertility. Apparently 25 
percent of the women reported no desire for more children while ten percent of 
those who still want more children would like to delay the next pregnancy. The 
reported number of children is six with a minimal bias in favour of rural areas. 
Another subjective cost of fertility regulation is the attitudinal component 
which is reported to be very positive. Women reported their partners attitudes 
on family formation as similar to theirs. Indeed these results, not questioning 
their validity, suggest a substantial demand for contraception for spacing 
purposes rather than to stop altogether. Such contraception is of little 
relevance to fertility decline considering the deep rootedness of spacing in our 
culture. We may be just observing a simple replacement of traditional methods 
by modern methods and hope this will trigger the desire to limit family size. 
High infant mortality has been hypothesised as underlying high fertility, a 
consequence of the 'hoarding' or 'insurance' mechanism. In such a context the 
rationale behind large families is explained by the perceived higher probability 
of a modest number of children surviving from a larger 'risk pool'. Zimbabwe is 
reported to be experiencing fairly high (although moderate by African 
standards) infant mortality. The infant mortality rate is approximately 79 
deaths per thousand births. However, breastfeeding, an important determinant 
of infant mortality, is still high, a reported average of 19 months. Closely 
related to infant and maternal health is prenatal care for mothers which is 
reported to be almost universal, but with an urban bias. 
It has been empirically proved that women under age 18 and over age 35, 
women with more than four births and those with interbirth intervals of less 
than two years, have a higher morbidity and mortality risk. Apparently 80 
percent of the Zimbabwean women fall into at least one of these risk 
categories. The indispensability of family planning services simply for the 
protection of such mothers is obvious and well articulated by the ZNFPC. 
Knowledge of, and attitudes to, contraceptive methods are important determinants 
of the deliberate adoption of contraception. Perhaps of paramount 
importance is the attitude towards the whole notion of fertility regulation and 
also particularly that towards use of modern contraceptives. These attitudes 
are acquired and nurtured within a socio-cultural context in which the 
individual woman is 'constrained' to behave in a manner perceived as normal 
by the significant others and other societal members. 
The ZRHS shows that 'ever-married' women display a very high level of 
knowledge of family planning methods. Approximately 90 percent of the 
women are reported to know at least one method while 70 percent reported to
106 Book Reviews 
know a family planning outlet. One is, however, bound to be wary of the 
suggestive nature of the question on knowledge: 
"As you know, there are various ways a couple can delay the next 
pregnancy or avoid having children if they do not want them. Do you know 
or have you heard about any of these family planning methods?" 
The first part of this question is not necessary if a more objective response to 
the question is expected. 
Favourable attitudes towards family planning are characteristic of the 
sample. Approximately 63 percent of the women reported partner's approval 
of family planning, 80 percent of them would like additional information about 
family planning. It is interesting to note that approximately 56 and 16 percent 
of the respondents are reached by radio and television programmes, respectively, 
while family planning brochures reach about 32 percent of the women. It is 
abundantly clear that these sources of information do not provide adequate 
information to enable women to make a final decisioin on the adoption of 
contraception. Perhaps one of the weak components of the programme is 
communication. And perhaps the 'knowledge' reported here is not a valid 
measure of that attribute expected to have a great bearing on the adoption of 
contraception. The following questions were used to elicit information on 
knowledge: 
Have you ever heard a family planning announcement on the radio? 
Have you ever heard a family planning announcement on television? 
Have you ever seen a family planning brochure or pamphlet? 
Note that ever heard or seen can mean once or a hundred times; the 
regularity is definitely not clear. Questions asking for ownership of radio and 
or television, and regularity of listening to family planning programmes, would 
be of great relevance to the measurement of dissemination of knowledge. 
A pertinent, yet separate, issue is the effectiveness of these means of 
communication, especially since those initiating the communication and those 
receiving it may be very different. Perhaps more intensive face-to-face 
discussion would make a big difference. This definitely facilitates immediate 
correction on misinterpreted messages, and immediate filling-up of gaps in 
such messages. 
Discussion of yet another determinant of deliberate fertility regulation, 
availability of contraception, is in order. This is, however, a reversal of the 
sequencing of chapters in the report ZNFPC's community-based distributors 
(CBDs) and government hospitals and climes are the principal service providers 
for women currently using contraceptives. These sources are also reported to 
be easily accessible - approximately 75 percent of all users either receive their 
contraceptive at home from a CBD or are within 30 minutes travel time of the 
source they prefer.
Book Reviews 107 
It is reported that users are generally satisfied with the services they get. 
However, those who rely on sources other than CBDs recommended that the 
number of clinics and staff be increased and that men be educated about family 
planning. CBD users recommended that these services can be improved by 
increasing the number of distributors, having them visit more often and having 
them 'be more polite and helpful'. A recommendation is, to a large extent, a 
subtle criticism which is difficult to tap in a large scale survey research. CBDs 
impoliteness and unhelpfulness is a negation of well-intended efforts - the 
often observed gap between planning and implementation. Also note the need 
mentioned here to educate the husbands who are elsewhere reported as 
generally supportive of family planning. 
Contraceptive use, which is the dependent variable, is the highest ever 
reported in any country in Sub-Saharan Africa. Approximately 66 percent 
of the women report 'ever-use' of fertility control while 38 percent are current 
users of contraceptives; 27 percent rely on modern methods. The differential 
level of use is in favour of women aged 20-34, literate women and working 
women. The main reason for nonuse is lack of information about family 
planning. It is further reported that one out of seven currently in union women 
is in immediate need of family planning for limiting or spacing reasons since 
they are exposed to the risk of getting pregnant. A contraceptive prevalence of 
38 percent on the one hand appears to be low, and yet further scrutiny suggests 
that this level is rather high. While I personally subscribe to the notion that 
fertility decline is country specific I do recognise that general trends are often 
discernible and deviations from these trends can be explained. It is important 
to evaluate the implications of a prevalence rate within a general theoretical 
model. Bongaarts (1984) formulated a model for the estimation of contraceptive 
prevalence required to achieve a particular target fertility level. In its 
application in Pakistan, he concluded that with a contraceptive use-effectiveness 
of 90 percent, a contraceptive prevalence of 28 percent would result in a 
total fertility rate of 5. A contraceptive prevalence of approximately 36 
percent would translate into a total fertility rate of 4,5. Indeed a number of 
variants to these levels are included in his model. If one assumes this variant to 
be true of the Zimbabwean case, then it will be obvious that our contraception 
is basically for spacing and not for stopping which will make our fertility 
transition more protracted. 
Not withstanding wilful misreporting by the respondents perhaps a relevant 
technical question is the one pertaining to the measurement of'prevalence' of 
contraception. Contraception prevalence, in this report, is gleaned from 
responses to the following questions: 
"Are you or your spouse currently using some family planning method or 
doing something to avoid a pregnancy? Have you or your spouse used any 
method in the past month?"
108 Book Reviews 
These questions refer to two measures of use, 'ever-use' and 'current-use'. 
Current use or contraceptive pervalence must only consider responses to the 
first question. Responses from the second question can be used if data on 
contraception are diffentiated by method of use in which case women who, for 
instance, had an injection a month prior to the date of the survey, are 
legitimately current contraceptors assuming a three-month protection. However, 
if differentiation by method is not made, as is the case of the ZRHS, a 
combination of responses to both questions inflates the contraceptive prevalence 
figures. If the contraceptive prevalence is indeed a true representation of 
reality, the implication is that Zimbabwe needs a much higher level of 
contraceptive prevalence to achieve an equivalent proportionate reduction in 
fertility. 
In summary, then, it can be said that the ZRHS report provides invaluable 
information for planning and implementing programmes to effect fertility. 
However, it is disturbing to note that estimates of very important indices 
deviate from those of the national census. While the reconciliation of these 
differences is definitely beyond the scope of such a report, one cannot 
underplay the exigency of such an exercise if the estimates are to be 
meaningfully utilised for any future planning with an acceptable degree of 
confidence. Perhaps cautionary footnotes would have been helpful. There is 
also an inconsistency between the reported high (positive) determinants of 
contraception and the reported level of contraception. Perhaps the determinants 
in this report are of little significance to the adoption of fertility control in 
Zimbabwe, but this is doubtful. However, these few shortfalls must not 
overshadow the acceptability of the ZRHS report as an important document on 
Zimbabwean fertility. In this report lies a strong foundation for future research 
and planning. 
Reviewed by Marvelous Mhloyi, University of Zimbabwe, Harare 
Reference 
BONGAARTS J 1984 "A Simple Method for Estimating the Contraceptive 
Prevalence Required to Reach a Fertility 
Target" in Studies in Family Planning 
15(4), 184-190. 
David Sanders with Richard Carver, The Struggle for Health: Medicine and 
the Politics of Underdevelopment. Macmillan Publishers, London, 1986, 
£2,95. 
This book has been written for the general public but is particulary useful to 
health professionals, the business community and politicians. It is written in 
clear and easy to understand language, makes use of extensive examples from 
developing and developed countries and is well illustrated. It is an excellent