AN INTRODUCTORY

COURSE TO
DEMOGRAPHY
For postgraduate students in
Community Medicine and
Family Medicine
 By
Dr. Omran S. Habib
Professor of Epidemiology and Health Care
,Department of Community Medicine
College of Medicine, University of Basrah
OBJECTIVES OF THE
COURSE
1. To understand the concept of demography
2. To list, define and use various demographic
indicators
3. To understand the dynamics of population
changes
4. To recognize the significance of
demography in health
5. To grasp some idea about demographic
characteristics of Iraqi population
DEFINITION OF DEMOGRAPHY
The study of population, especially with
:reference to
Size and density, fertility, mortality, .1
.growth, age structure
Migration and its relation to economic .2
.conditions
Change of population as a result of births, .3
. marriages and deaths
The level of education and other social and .4
economic aspects. And
Statistics on crime, illegitimacy and suicide .5
RELEVANCE OF DEMOGRAPHIC DATA
Very relevant for effective health care
:planning which requires data on
a. Demographic characteristics of the target
.population
b. Population health status in terms of
. morbidity and mortality indicators
.c. Available and potential health resources
d. Population- health services interaction in
.terms of utilization and impact
:SOURCES OF DEMOGRAPHIC DATA

a. Population censuses.
censuses Periodic enumeration
of the population usually every ten years.
The census gives full picture of the
characteristic features of population. It
provides the basic data for the most
relevant population statistics thus helping in
planning socioeconomic development
.programmes
b. Vital statistics registries (births, deaths,
marriage and divorce)
A major source of data on the demographic .
and some health characteristics of
population. When they are complete, they
form the most readily available data for the
calculation of different rates. They also
form an important determinant of
.population growth
c. Special surveys. In such instances,
complete enumeration is carried out but at
a limited scale (sample survey) to serve a
specific purpose. A number of household
surveys were carried out in Basrah over the
last 10 years and provided very useful
demographic and health data on the
.*surveyed population
d. Population projection or estimation
.during the years following censuses
Presentation of
demographic data:
Measurements of
population fertility
:Measurements of fertility .1

A. Fertility rates: To measure the level of

population fertility we commonly use the
:following rates of fertility
a. Crude birth rate which summarizes the
average annual number of live births per
1000 population
b. General fertility rate
It represents the average annual number of
live births per 1000 women in the
reproductive age (15-49)

.c. Marital specific fertility rate

It represents the average annual number of
live births per 1000 married women in the
.reproductive age (15-49 years)
.
.d. Age-specific birth rate
It refers to the average births per females of
specific age. For example, for women aged
15-19 years, it refers to the average annual
number of live births to females aged 15-19
.years per 1000 women aged 15-19 years
e. Total fertility rate.
rate It refers to the average
number of live births per woman
completing her reproductive age. It may be
calculated in relation to all women but, it is
preferable to be calculated in relation to
.married women
It is calculated by one of the following two
:formulae
On the basis of cross-sectional study on -
women in their reproductive age
Total fertility rate (TFR) = Summation of age
specific fertility rates
F (15-19) + F (20-24) +….+ F (45-49) 5 =
This gives the total fertility rate per woman
and can be calculated per 100 or per 1000
.women
Total fertility rate (TFR) = Summation of age
specific fertility rates
)F 15-19 + F 20-24 +….+ F 45-49 ( 5 =
This gives the total fertility rate per woman
and can be calculated per 100 or per 1000
.women
:Alternatively, TFR equals -

Number of all live births for  a given number of  

    women completing their reproductive age
------------------------------------------------------------------ 
Total number of women under study
This gives the total fertility rate per women
and can be calculated per 100 or per 1000
.women
A summary of crude birth rates and total
fertility rates in a number of Arab
.Countries is given in Table 1
Countries TFR CBR
** 2000-05 *1970-75 **2000-05*1970-75
Iraq 6.9 4.28 41.6 36.5
Kuwait 7.2 2.97 51.1 21.0
Jordan 6.5 2.71 50.0 22.8
Syria 7.6 3.5 47.8 36.9
Bahrain 6.7 2.63 45.0 19.6
Qatar 7.2 2.87 50.0 NA
S. Arabia 7.1 4.04 48.9 40.9
Yemen 6.5 6.67 47.0 NA
Lebanon 4.6 1.92 33.0 23.2
UAE 5.2 2.94 NA NA
Egypt 5.0 2.88 35.5 24.5
Oman 7.3 6.5 50.0 40.8
Tunisia 7.0 2.5 NA 20.6
Sudan NA 5.6 NA 39.6
B. Age composition as a proxy measure
of population fertility: Tabulation of the
age composition of the population. When
the distribution of any population is
presented in the form of a table describing
age groups in a convenient layout, it might
be possible to deduce some idea about the
fertility of the population as in Table 2
below
Table 2:2 Age composition of two populations
Age groups (yrs) Population A Population B
Less than a year 1.2 3.7
12.8 5.1 4-1
26.4 12.2 5-14
42.1 43.3 15-44
11.3 21.3 45-64
   above & 65
Total 100.0 100.0
:C. Measurement of fertility changes

a. All the fertility measurements discussed

above can be used to measure changes in
population fertility over time or to compare
.different populations at the same time
b. Other measurements of fertility change are
also used: These are many. We present only
few of them
births averted
The number of births that did not occur
during specified reference period due to
programme effect (equal to the difference
between potential /expected and
observed/actual fertility during the period
.of time
.
:Parity-specific birth rate
The number of births of specific parity during
a reference period per 1000 women of
.reproductive age
:It is calculated as follow
PSBRi= (Bi/EF 15-49) X 1000
:Where
PSBRi= the rate per 1000 women of
reproductive age with certain parity(i)
Bi= the number of birth of parity i in a given year
or reference period and
EF15-49= the number of person-years lived during
the reference period by women 15-49
year of age
c- Proportion of births above (or below)
:a specified parity
The proportion of births occurring during a
given reference period that are above (or
below) a specified parity (e.g the proportion
.of births that are parity 5 or higher)
d- Proportion of births by women above
:or below a specified age
This refers to the proportion of births during
a given year or other reference period that
are born to women above or below specified
:age It is calculated as
PBLT20=BLT20/B
Where: PBLT20= the proportion of births
during a given year or reference period to
.women less than 20 years of age
BLT20= the number of births during the
specified reference period to
.women less than 20 years of age
B= the total number of births during
reference period in the same
.population
Other fertility related measurements .4
:Median length of birth intervals
Open interval which measures number of-
months between a specified reference data
(e.g. the date of survey) and the last birth
.among women with one or more births
Closed interval which measures the median -
number of months separating successive
.birth among women with two or more birth
:The proportion of unwanted children -
The number of unwanted children that would
be born per women (or per 1000 women) if
she/they were to pass through the
reproductive years bearing children
?WHY DO WE STUDY DEMOGRAPHY
Population studies are important in many
:aspects. They form a basis for
a. Supplying health services and health
manpower. Without studying our population:
who are they? and how will they be in the
future? We can not plan effectively for current
.and future development
b. Understanding the growth trend of the
population, which is important to understand
and/or to anticipate so that its effects on future
economic development can be expected. It is
possible to list important issues related to
:population dynamics and population growth
Health
Poverty
Employment
Maternal mortality
Infant mortality
Nutrition
Educational opportunities
Peace and security
Socioeconomic development
To give a simplified example on the interaction
of different factors in shaping the relations of
health and development, we shall exhibit a
general model and then give one possible
effect of each element in the model on the
.other elements
5 4
Health Nutrition
8 6 3 2

7 1
18 17
Income
19 15
10 11 20 14 16
Fertility 13 9
Education
12
A general model of health and development
STAGES IN DEMOGRAPHIC
DEVELOPMENT: DEMOGRAPHIC
TRANSITION
The explosive increase in the number of
people in the world in the recent past has
resulted from the complex series of
development accompanying the
industrial revolution and the world- wide
.spread of advanced technology
It is possible to characterize trends in
population by describing several stages in
the transition from the agrarian, pre-
industrial culture to technologically
advanced societies. These stages are
summarized in Figure –2-. The overall
change is referred to as “ The demographic
.”transition
Stage 1:Agrarian
1 civilization. Stable
population or slowly growing population.
High birth rate is balanced by high death
rate from diseases, famine and wars.
Children represent an asset. It is considered
as a stage of high population growth
.potential
Stage 2:2 Advance in sanitation and improved
availability of food, shelter and water lead
to a fall in death rate and an increase in
life expectancy. Typically, this occurs
without any immediate change in birth
.rate. Birth rate may increase first
During this stage a marked excess of births
over deaths takes place leading to rapid
expansion in population. It is called stage of
transitional population growth. After a
time, birth rate tends to fall as a reflection
of industrialization and consequent
urbanization. Children represent financial
liability rather than an asset and some sort
of contraception and abortion may be
.practiced
Stage 3:
3 The end stage of this transition is a
situation in which birth and death rates are
again in balance but at a much lower level
.than in stage 1
Limitations of the demographic transition
1. It fails to account for variations in the
transition in many developing countries.
2. It fails to explain the initial rise in fertility
prior to the decline as well as the baby
boom following World War Two.
3. It lacks depth in that it does not illuminate
the determinants of the transition,
especially the forces of mortality and of age,
sex and urban-rural differential in risk of
morbidity and mortality.
POPULATION POLICIES:
DETERMINANTS OF  FERTILITY
Population policies are purposeful measures
aiming at affecting demographic process,
notably: fertility, mortality and migration
.or population movement
:Governments can affect population through
Influencing the distribution of its people by .1
redistribution or at least stabilizing them
by local or regional development policies
like agricultural projects, industrial
projects or even building new cities or
. towns
Improvement of supportive services to .2
rural areas such as electrification and
. making good roads
Improving health status by improving .3
health care services qualitatively and
quantitatively and by increasing their
income or by general development (health,
income, education, housing, nutrition
.…etc.)
Fertility control policies, family planning .4
and birth control. These are not
necessarily directed towards reduction of
fertility but may be directed to the
opposite. Some countries provide a
variety of incentives to encourage
.conception and child rearing
 Examples of population policies
In Iraq, the government encourages people .1
to have more children provided that care
: is available for them. Incentives include
.a. Financial incentives
.b. Motherhood leaves
c. Rewarding highly fertile women
(temporarily measure during the Iraq-
. Iran war)
.d. Encouragement of early marriage
2. In Romania in 1957, abortion was allowed
to be conducted freely. This led to
reduction of crude birth rate to as low as
15 per 1000 in 1966. At this point the
government stopped abortion practice and
the crude birth rate went up again to
reach 25 per 1000 which lasted for few
years then it declined slightly due to the
use of different alternative methods of
contraception.
3. Global approach to fertility regulation: On
world-wide scale and particularly in the
developing countries, two views developed
since population conference in Bucharest
in 1974.
The first view is conservative and looks to      
the possible ways of reducing or controlling
population growth rate through general
development and improvement in health
but family planning programmes should be
used to speed up development. The holders
of this view insist on the free access to
.family planning methods (contraceptives)
The second view is more radical and it      
looks to the problem as not merely rapid
population growth but rather as an unjust
economic system. The 77 group (Unctad) is
the leading group in this respect. Family
planning is not the answer to the problem of
poverty and ill health. It is only one aspect
.of approaching the problem
Other important events on population and
;health are three conferences
Nairobi Conference 1987 .1
Cairo conference 1994 .2
Factors affecting fertility:
Determinants of fertility
The level of fertility is a net of interaction of
many factors. The exact contribution of
each factor is difficult to quantify. Studies
of the causes of fertility levels and their
changes often seek to measure directly the
.impact of socioeconomic factors on fertility
Substantial insights can be gained if, in
addition to socioeconomic factors
influencing fertility, the specific
mechanisms through which these factors
.operate are identified
Indirect determinants Direct determinants

Socioeconomic variables, intermediate fertility Fertility

Cultural variables and variables
Environmental variables
Brief description of intermediate variables
1. Age at marriage: It is logical to think that
earlier age at marriage is associated with
more chance to have children. Evidence
from a recent study in Basrah supports this
(Table 3)
 Age at first marriage
Table 4.3: Age at first marriage by sex for ever married persons
Females Males Age at
No % No. % marriage
7.5 53 0.9 6 15<
36.6 259 8.8 56 15-19
33.4 236 34.6 221 20-24
25-29
15.3 108 33.6 215 30-34
4.2 30 15.2 97 35-39
2.4 17 3.9 25 and 40
0.6 4 3.0 19 above
707 100.0 639 Total
100.0

6.67 + 23.6 5.7 + 21.1 6.64 + 26.1 Mean + SD

20 25 Median
Table 3: No. of LB per woman by age at
marriage
No. of women No. of LB Age at marriage
per woman

Age at marriage(yrs):
3.5+ 5.1 249 <15
2.8+ 3.8 853 15-19
2.6+ 3.3 1009 20-24
2.1+ 2.4 414 25-29
Proportion of married women: This .2
variable is intended to measure the
proportion of women of reproductive age
who engage in regular sexual life. The
higher the proportion of women living in
stable formal marriages or consensual
.unions is, the greater the fertility is
Contraception:
Contraception Any deliberate parity .3
dependent practice including abstention
and sterilization, undertaken to reduce the
chance of conception is considered
contraception. When such measures as well
as abortion are not practiced, the natural
.fertility is expected to exist
4. Induced abortion:
abortion This variable includes
any practice that deliberately interrupts the
normal course of gestation. Induced
abortion is one of the strongest fertility
control measures and it is the method which
is subjected to great controversy and strong
objection from religious. legal as well as
medical viewpoints.
5. Lactational infecundability:
infecundability Following a
pregnancy a woman remains unable to
conceive until the normal pattern of
ovulation and menstruation is restored.
6. Frequency of intercourse:
intercourse This variable
measures normal variation in the rate of
sexual intercourse, including those due to
temporary separation or illness. Excluded is
the effect of voluntary abstinence (total or
periodic to avoid pregnancy).
7. Sterility:
Sterility Women are sterile before menarche,
at the beginning of menstruation and during
the menopause. A couple may become sterile
before menopause for reasons other than
contraceptive sterilization.
8. Spontaneous intrauterine mortality.
mortality A
proportion of conceptions does not result in
a live birth because some pregnancies end in
spontaneous abortion or stillbirth.
9. Duration of fertile period:
period A woman is able
to conceive for only a short period of
approximately two days in the middle of the
menstrual cycle when ovulation takes place.
The duration off the period is a function of
the viability of the sperm and ovum.
OBSTACLES TO POPULATION CONTROL
MEASURES
.Political and racial concerns .1
.Cultural and religious opposition .2
.Equation of numbers with power .3
.High childhood loss .4
5. Rural-agrarian orientation.
6. Low status of women in some societies.
7. Problems with current contraceptives, their
effectiveness and side effects.
8. Legal, ethical and religious opposition to
abortion, which is very effective     fertility
control measure.
SOCIOECONOMIC AND HEALTH
CONSEQUENCES OF RAPID
POPULATION GROWTH
1. Slowing of economic development.
2. Undermining major development projects.
3. Depletion of resources like food and energy.
4. Increasing demand for schooling and jobs.
5. Increasing dependency burden.
6. Increased pressure on urban residence with the
more slums of poor living     standards.
7. Social and political unrest.
8. Health consequences like increased mortality,
hereditary diseases, and other     problems such
as mental and intellectual maldevelopment.
POPULATION ESTIMATION
Population estimation is resorted to when other
sources for demographic data are not available
or it is not feasible to use any of these sources
at the time data are required. Three methods
can be used to estimate population. All depend
on a baseline provided by previous census
.data
1. The natural increase method: The
population of any given year can be obtained
by adding the difference between the annual
live births and the annual total deaths to the
total population in the previous year. Here it
is assumed that migration is of no significant
effect on population size. This method needs
reliable system of reporting and recording of
vital events (births and deaths).
For example:
example If the population of Basrah at the
end of the year 1999 was 1 200 000 and the
annual crude birth rate was 40 per 1000 and
the annual crude death rate was 7.5 per 1000,
it is possible to estimate the population of
Basrah at the end of the year 2001 as follows:
The total LB in Basrah during the year 2000
40
x ---------- =48 000 000 1200 =
1000
 The total annual number of deaths in the year 2000
7.5
x ------- = 9000 000 1200 =
  1000
The natural increase rate = Crude birth rate – crude
death rate = 40-7.5 = 32.5
The total population at the end of the year 2000
= 1200 000 +(48000- 9000) = 1239 000
 Or the population of 2000
32.5
1239000 = )------ X 000 1200( + 000 1200 =
1000
The same process is repeated for the year 2001

Population at the end of 2001

32.5
1279267 = )------- x 000 1239( +000 1239 =
1000
Geometric method: The most accurate .2
method since population growth is geometric.
.The following formula is used
 m-o
Pm = Po (1+r)
Pm = population to be estimated
Po = population of the previous census
year (baseline population).
r = annual increase rate (written as
proportion)
To use the same example in method one above:
2001-1999

Population of the year 2001 = population 1999(1+ 0.0325)

2

= 1200 000 (1.0325) = 1279267.5

which
is the same in method one above.
    2. Graphic method: In this method
the populations of successive
censuses are plotted and the future
population are extrapolated by
extending the graph in the best
fitting.
Pop.
Size 30 - *
25 - *
20 - *
15 - *
10 - *
5 - *
1947 1957 1967 1977 1987 1997
years
POPULATION DYNAMICS, POPULATION
GROWTH AND DETERMINANTS OF
POPULATION GROWTH.
 Broadly speaking, three factors
determine population growth:
1. Fertility expressed as crude birth rate
(CBR).       
2. Mortality expressed as crude death rate
(CDR).
  In stable population with non-significant
population movement (immigration and
emigration), the annual natural increase
rate = CBR – CDR.
3. Population movement (migration). This is
an important factor in determining both the
population growth and the shape of the
population structure (pyramid). In some
countries, migration is very crucial as in the
Arabian Gulf countries. In some western
countries, migration is also important where
fertility rate balances mortality rate and
almost no natural population growth takes
place.
Other factors which affect population change
and redistribution are:
- Physical conditions.
- Climatic conditions.
- Geology.
- Presence of diseases.
- Availability of water and quality of soil.
- Availability of services such as roads,,
electricity, markets ….etc.
Although CBR and CDR are important
indicators of population changes, they
are:
1. Not very sensitive indicators of future
changes.
2. They are not independent indicators.
CDR is very much affected by population
age structure. Crude birth rate is not
good measure of fertility unless it is
expressed as age specific birth rates.
To illustrate with an example on the age
specific and total fertility rates, we
quote the following results:
Table 4: Selected fertility indicators of ever married women: Basrah 2004-
.2005

Age (yrs) No. of women No. of ever born babies cumulative ASFR

0.5 71 142 15-19

1.3 558 429 20-24
2.2 1142 519 25-29
3.3 1749 530 30-34
4.5 1940 431 35-39
5.8 2163 373 40-44
-Current cross
sectional TFR 1993 7623 3.8
The cumulative age specific fertility rate
represents the total average live births
per women up to that specific age, i.e.,
the cumulative fertility up to that age
Note: when the number of births are
recorded for one year only for each age
group, the TFR then equals to the
summation of age specific fertility rates
TFR = summation of ASFRs multiplied by
the age interval used
Relationship of fertility, mortality and
population growth
Gross reproductive rate (GRR): It is a special
rate of total fertility rate. It measures the
outcome substitution of females by females
or males by males
GRR = TFR X proportion of female births
= TFR X .0485 0r 100/205
GRR = TFR x proportion of male births
= TFR X 0.515 0r 105/205
Net reproductive rate (NRR): A summary
measure of fertility and mortality. It
refers to the probability that a woman
replaces her self or a man replaces
himself.
 L27
NRR= TFR x prob. Of female birth x -----------
L0
L0 = Number of daughters born to a woman
L27= Number of daughters remain alive till the
age of 27 years.
Note:
If NRR =1 there is no population growth
If NRR = 2 the population will double in
27 years.
If NRR =3 the population will treble in 27
years.
Examples:
What is the rate of population growth in
each of the following situations?
1. A population in which a woman gives
birth to three children, 2 of them are girls.
One girl dies when she is 5 years old and
the second celebrates her 29th birthday.
2. A population in which a woman gives
birth to five children, three of them are
girls. One of the girls dies at the age of
9 years and the other two girls reach
menopause.
Answers
L 27 1
1. NRR= TFR x 0.485 x------- = 3 x 0.485 x ----- =
LO 2

=Approximately
1

The natural growth rate is zero because each women just

replaces herself.
 2
2. NRR = 5 x 0.485 x------ = approximately 2

3
This population doubles in 27 years
In most of developing countries, the TFR
is about 6 per woman and nearly two
thirds survive beyond the age of 27
years. Therefore:
2
NRR = 6 x 0.485 x ------ = 2
3
And for most of these countries,
population will double in one
generation (27 years).
On the other hand, in many industrialized
countries, as in Britain for example,
there is almost no natural growth rate
because the net reproductive rate in
these countries is nearly 1.

NRR = 2 x 0.485 x 0.95 = approx. 1

Relationship of fertility, mortality
and age structure
1. If fertility and mortality remain constant
over time, the age structure of that
population becomes fixed in a particular
form.
2. Fertility is the main determinant of age
structure of any population because a
change in fertility affects mainly the new
comers, while change in mortality usually
affects all age groups and introduces little
change in the overall population structure.
Exception to that is when death strikes one
narrow specific age group. In this instance
the age structure of the population is
changed.
3. Reduction in fertility is usually associated with reduction
in mortality.

Low fertility less people better health less deaths

4. Population growth trends are subject
to momentum. They start slowly but
once in motion, they take long time to
be brought under control It (may take
a generation). In other words, fertility
regulations take a quite long time to
be effective in reducing a high
population growth rate.
Some figures for the world
1. Population size in 1970 and 2000 (in millions):
Region 1970 2000 2050
World 3600 6057 8919
More developed 1008 1191 1220
Less developed 2688 4865 7699
2. Age structure 2000:
Region 0-14 15-64 65&above
World 29.7 63.4 6.9
More developed 18.2 67.4 14.4
Less developed 32.5 62.4 5.1
Basrah 39.9 57.8 2.3
3. Median age:
Region Median age
World 26.6 years
More developed 37.5 years
Less developed 24.4 years
Basrah 22.6 years