Finisterra, LXI(131), 2026, e43096

ISSN: 0430-5027

doi: 10.18055/Finis43096

Artigo de Investigação

RELATIONSHIP BETWEEN FERTILITY RATES AND UNMET NEED FOR

FAMILY PLANNING IN THE NILE BASIN COUNTRIES (1990-2023):

A POPULATION GEOGRAPHY STUDY

1

AHMED FOUAD ELMOUGHAZI

2

ISLAM M. HAMDI

ABSTRACT – High Total Fertility Rates (TFR) in the Nile Basin countries remain a significant demographic and

public health challenge. This study examines whether higher TFR is associated with higher unmet need for family planning

across 11 Nile basin countries over the period 1990-2023. We conducted an ecological, cross-national analysis using country-

level data aggregated over the study period, drawing on publicly available sources from the World Bank, the United Nations

Population Division, and the Global Religious Futures database. The study employed Pearson correlation analysis and Principal

Component Analysis (PCA) with Varimax rotation to assess the strength and underlying structure of these relationships. A

strong and statistically significant positive correlation was found between TFR and unmet need for family planning across the

region (r = 0.93, p < 0.0001), with a coefficient of determination of r² = 0.86, indicating that differences in unmet need may

contribute to 86% of the cross-national variation in TFR in 2023. This association was especially pronounced in countries such

as Kenya, Rwanda, Ethiopia, Eritrea, Egypt, and Uganda. PCA revealed a three-factor solution collectively explaining 78.74%

of the total variance across the analytical variables; the first factor, on which unmet need for family planning was among the

variables with notable loadings (λ = 0.59), accounted for 38.2% of this total variance. These findings underscore the critical

importance of addressing unmet need for family planning as a central strategy for managing population growth in the Nile

Basin. Targeted interventions, particularly in underserved rural areas, are essential to reduce TFR and advance reproductive

health equity across the region.

Keywords: Correlation analysis; family planning; spatial distribution; total fertility rate; unmet need.

RESUMO – RELAÇÃO ENTRE AS TAXAS DE FERTILIDADE E AS NECESSIDADES NÃO SATISFEITAS DE

PLANEAMENTO FAMILIARES NOS PAÍSES DA BACIA DO NILO (1990-2023): UM ESTUDO DA GEOGRAFIA DA

POPULAÇÃO. As elevadas taxas de fecundidade total (TFT) nos países da bacia do Nilo continuam a representar um desafio

demográfico e de saúde pública significativo. Este estudo examina se uma TFT mais elevada está associada a uma maior

necessidade não satisfeita de planeamento familiar em 11 países da bacia do Nilo, no período de 1990-2023. Realizámos uma

análise ecológica transnacional utilizando dados a nível nacional agregados ao longo do período do estudo, com base em fontes

publicamente disponíveis do Banco Mundial, da Divisão de População das Nações Unidas e da base de dados Global Religious

Futures. O estudo empregou a análise de correlação de Pearson e a Análise de Componentes Principais (ACP) com rotação

Varimax para avaliar a força e a estrutura subjacente destas relações. Foi encontrada uma correlação positiva forte e

estatisticamente significativa entre a TFT e a necessidade não satisfeita de planeamento familiar em toda a região (r = 0,93; p

< 0,0001), com um coeficiente de determinação de r² = 0,86, indicando que as diferenças na necessidade não satisfeita explicam

86% da variação transnacional da TFT em 2023. Esta associação foi especialmente pronunciada em países como o Quénia,

Ruanda, Etiópia, Eritreia, Egito e Uganda. A ACP revelou uma solução de três fatores que, coletivamente, explicam 78,74%

da variância total entre as variáveis analíticas; o primeiro fator, no qual a necessidade não satisfeita de planeamento familiar se

encontrava entre as variáveis com cargas fatoriais notáveis (λ = 0,59), explicou 38,2% desta variância total. Estas descobertas

realçam a importância crucial de abordar a necessidade não satisfeita de planeamento familiar como uma estratégia central para

a gestão do crescimento populacional na bacia do Nilo. As intervenções direcionadas, especialmente em zonas rurais

carenciadas, são essenciais para reduzir a TFT e promover a equidade em saúde reprodutiva em toda a região.

Palavras-chave: Análise de correlação; planeamento familiar; distribuição espacial; taxa de fecundidade total;

necessidade não satisfeita.

HIGHLIGHTS

•

Correlation between fertility and unmet need in the Nile basin countries.

Ongoing challenges in ensuring equitable access to reproductive health services.

Positive correlation was found between fertility and unmet needs.

Unmet needs accounted for 38.2% of the variance in fertility rates.

Recebido: 08/09/2025. Aceite: 14/12/2025. Publicado: 22/06/2026.

Ahmed Fouad Elmoughazi: elmoughazi@gmail.com

¹Department of Geographical Studies and Research, Afro-Asian Institute, Suez Canal University, 4.5km the Ring Road, Ismailia Egypt.

²Department of Geography & GIS, Faculty of arts, Beni-Suef University, Egypt.

Published under the terms and conditions of an Attribution-NonCommercial-NoDerivatives 4.0 International license.

Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

1.

INTRODUCTION

The unprecedented pace of population growth in the Nile basin countries – comprising Burundi, the

Democratic Republic of the Congo, Ethiopia, Eritrea, Kenya, Rwanda, South Sudan, Sudan, Uganda, Egypt,

and Tanzania –poses formidable obstacles to the attainment of sustainable development goals (Abbas &

Hamdi, 2022; El‐Fadel et al., 2003; Nahas et al., 2025). Demographic projections forecast a dramatic

escalation in the region's population, from 556 million in 2020 to an estimated 1 044 million by 2050

(Elmoughazi, 2025; Younis Elsary & Elmoughazi, 2026), with the Democratic Republic of the Congo

anticipated to reach 197 million inhabitants by 2050, thus becoming the most populous nation within the

basin. This demographic surge, particularly when it surpasses the rate of economic advancement, accentuates

the imperative for robust and effective family planning interventions (Bokhari, 2024; Heuveline, 2001;

McNamara, 1991).

Current demographic analyses indicate that several Nile Basin countries have exceeded the population

size that their available resources and economic capacity can optimally sustain, underscoring the urgency of

recalibrating population policies in line with resource availability and development targets (Kemei, 2024;

Mandavilli, 2024). Fertility indicators serve as essential metrics for the formulation of evidence-based

policies and strategic planning to address the evolving needs of the Nile Basin populace. The prevalence of

unmet needs for family planning remains a critical determinant of elevated Total Fertility Rates (TFR) in the

region. Empirical studies have documented substantial unmet needs for modern contraceptive methods

among postpartum women in Sub-Saharan Africa, frequently resulting in unintended pregnancies and

persistently high TFR (Vahdaninia, 2021). Addressing these gaps is indispensable for moderating population

growth and enhancing reproductive health outcomes.

Over recent decades, the implementation of family planning programs has been instrumental in

precipitating fertility decline across Africa. Longitudinal analyses indicate that the adoption of contraceptive

methods has significantly contributed to this trend (Garenne, 2018), although persistent barriers – particularly

in rural locales with limited access to services –continue to impede progress. Evidence from analogous

contexts, such as rural Pakistan, demonstrates that exposure to family planning initiatives can profoundly

influence reproductive choices and health care utilization, suggesting the potential efficacy of similar

interventions in the Nile Basin (Khan & Wang, 2021). Fertility patterns within the reproductive age cohort

of 15 to 34 years exhibit notable homogeneity (Beaujouan, 2023; Sobotka, 2004), with education emerging

as the predominant socioeconomic variable driving fertility reduction (Bongaarts, 2020). Women in this

demographic not only display higher TFR but also face heightened susceptibility to pregnancy-related health

risks compared to older women.

Age-specific fertility rates (ASFRs) decline markedly with advancing age beyond the peak

reproductive years (20-29), a pattern observed irrespective of urban or rural residence (Murray et al., 2018).

Socioeconomic inequities and environmental stressors –including rapid urbanization, land degradation, and

industrial pressures in arid environments – further complicate the demographic landscape of the Nile Basin

(Hamdi et al., 2026). Analyses of the growth-poverty-inequality nexus reveal pronounced disparities in

access to family planning services, as evidenced by spatial data spanning two decades (Lin et al., 2022).

Rectifying these inequities is essential to ensure universal and equitable access to reproductive health care.

While notable progress has been achieved in expanding family planning coverage (Sharan et al., 2011),

substantial challenges persist, necessitating sustained efforts to fulfil the reproductive health needs of the

population.

The influence of contraceptive utilization and access to safe abortion services on TFR is profound.

Increased availability and uptake of these services have been shown to contribute significantly to fertility

decline in Sub-Saharan Africa (Singh et al., 2017). The reliability of contraceptive supply chains and the

quality-of-service delivery environments are pivotal in shaping contraceptive use patterns (Wang, 2012). In

the context of the Nile Basin, strengthening these dimensions is critical to addressing the persistent unmet

need for family planning. A substantial body of literature elucidates the broader ramifications of family

planning and fertility dynamics in Sub-Saharan Africa. Family planning is recognized as a cornerstone for

achieving international development targets, including the Millennium Development Goals, by directly

impacting maternal and child health, poverty alleviation, and gender equity (Cleland et al., 2006).

Addressing the unmet need for family planning is vital for reducing TFR and advancing women’s

health and empowerment (Casterline & Sinding, 2004). Effective family planning programs, underpinned by

governmental commitment and international collaboration, have demonstrated the capacity to yield

significant demographic and socioeconomic dividends, including economic growth, enhanced educational

attainment, and improved health indicators (Bongaarts, 2011; Cohen, 2000). The Sustainable Development

Goals (SDGs) explicitly advocate for universal access to sexual and reproductive health care, encompassing

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

comprehensive family planning services (Islam, 2024). This commitment is intended to empower women to

make informed decisions regarding contraceptive use, tailored to their individual circumstances. Despite

ongoing initiatives, global projections indicate that the unmet demand for family planning will remain above

10% until at least 2030 (Nsashiyi et al., 2024), although some regions may experience reductions (Kebede et

al., 2023).

Modern contraceptive modalities encompass female sterilization, oral contraceptive pills, intrauterine

devices (IUDs), injectable contraceptives, implants, condoms, and diaphragms (Anderson & Johnston, 2023;

Thakur et al., 2023), while traditional methods include periodic abstinence, withdrawal, and prolonged

breastfeeding. The unmet need for family planning constitutes a significant determinant of TFR (Adeokun,

1983; Agbana et al., 2023). To effectively promote contraceptive uptake, policy frameworks must address

both demand- and supply-side barriers. Comprehensive strategies should incorporate educational

interventions within schools and communities to enhance awareness of pregnancy risks, underscore the health

and familial benefits of contraception, and dispel pervasive misconceptions regarding its adverse effects

(Ahinkorah et al., 2023; Soucy et al., 2023).

The principal objectives of this study are threefold: (i) to investigate TFR and their spatiotemporal

patterns across the Nile Basin countries from 1990 to 2023, with particular attention to regional disparities;

(ii) to assess the unmet needs for family planning methods, analyzing their distribution, variability, and

influence on TFR among the constituent countries; and (iii) to elucidate the correlation between TFR and

unmet needs for family planning, quantifying the strength and significance of this relationship through

rigorous statistical analysis. A nuanced understanding of the multifaceted determinants of fertility in the Nile

Basin – including unmet family planning needs, economic disparities, and access to reproductive health

services – will enable policymakers to devise targeted interventions to manage population growth and

optimize health outcomes in the region.

2.

MATERIALS AND METHODS

2.1

Study area

The study area comprises the 11 Nile Basin countries interconnected by the Nile River, which stretches

6695km across approximately 35º latitude, from 4° South to 31° North (fig. 1).

Fig. 1 – Resident population size of the Nile Basin countries, 2023.

Fig. 1 – Dimensão da população residente dos países da Bacia do Nilo, 2023.

Source: United Nations Population Division Data Portal, 2024

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

This vast latitudinal range results in significant climatic, cultural, and demographic diversity,

transitioning from the tropical headwaters in the south to the arid Mediterranean region in the north (Lin et

al., 2022).

As illustrated in (fig.1), the region exhibits stark contrasts in population size, with each circle's area

scaled directly to the absolute population of the corresponding country. Three nations, Egypt, Ethiopia, and

the Democratic Republic of Congo, form the demographic heavyweights of the basin, each exceeding 100

million inhabitants.

A secondary tier comprises Tanzania and Kenya, with populations in the range of 50 to 100 million,

followed by Sudan, which occupy intermediate population scales. Uganda represents a moderately populated

state within the basin, while Rwanda, Burundi, and South Sudan have comparatively smaller populations.

Eritrea remains the least populous riparian state, with fewer than 5 million residents. This pronounced

demographic asymmetry, as visually conveyed through the proportional symbols in (fig.1), underscores the

highly uneven pressures on shared water resources, infrastructure, and governance frameworks across the

basin's riparian states.

2.2

Data collection

This study adopts a quantitative approach in which fertility is operationalized specifically as TFR,

rather than other fertility-related indicators such as the crude birth rate, age-specific fertility rate (ASFR), or

fecundity rate (Hauer et al., 2013). TFR is defined as the average number of children a woman would have

over her reproductive lifespan if she experienced the prevailing age-specific fertility pattern observed in the

population.

In this study, TFR is computed by aggregating ASFRs across the reproductive age range (15-49 years)

using standard demographic procedures, and all subsequent analyses and interpretations of refer to TFR

unless otherwise stated (Hauer & Schmertmann, 2020; Rallu & Toulemon, 1994).

Data were compiled from multiple authoritative sources. Demographic indicators – including TFR,

family planning metrics, and population projections – were obtained from the United Nations Population

Division Data Portal (United Nations Population Division, 2024).

Sociocultural and religious variables were sourced from the Pew Research Center’s Global Religious

Futures Project (Pew Research Center, 2024).

Socioeconomic and health-related development indicators were drawn from the World Bank’s World

Development Indicators database (World Bank, 2024), while governance and fragility metrics were obtained

from the Fragile States Index (The Fund for Peace, 2024). Integrating these sources provides a cross-

sectional, multi-source framework for examining fertility determinants across the Nile Basin countries.

2.3

Data Analysis

Data processing and statistical analyses were conducted using the Statistical Package for the Social

Sciences (SPSS), a widely adopted tool for quantitative research in demographic and public health studies.

Both descriptive and inferential statistical techniques were employed to rigorously examine the determinants

of women’s fertility in the Nile Basin countries, following current methodological standards in the field

(Alemu et al., 2024).

2.3.1. Total Fertility Rate

The TFR is defined as the average number of children a woman would have if she experienced the

current age-specific TFR throughout her reproductive years (typically ages 15-49) (Murray et al., 2018). It is

mathematically derived by aggregating these age-specific rates:

49

∑

TFR = _푎=15ꢀ ASFR_푎× 푖

(1)

Where:

ASFR_푎= Age-Specific TFR for age group ꢁ

푖 = Width of the age interval (usually 5 years)

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

2.3.2. Age-Specific Fertility Rate

The Age-Specific Fertility Rate (ASFR) for a given age cohort constitutes the foundational metric for

fertility analysis and is calculated as follows (Yasmeen & Mahmood, 2014):

Number of live births to women aged 푎

ASFR_푎=

(2)

Number of women aged 푎

2.3.3. Pearson Correlation coefficient

The Pearson correlation coefficient is utilized to quantify the strength and direction of the linear

relationship between two continuous variables, such as unmet need for family planning and TFR (Asmamaw

& Negash, 2022).

This statistical metric evaluates how changes in one variable correspond to changes in another,

providing a standardized value that indicates whether the association is positive, negative, or neutral. By

calculating this coefficient, the analysis determines the degree to which these demographic indicators move

in tandem across the study's observations.

2.3.4. Principal Component Analysis

Principal Component Analysis (PCA) is a multivariate statistical technique widely used to reduce the

dimensionality of datasets by transforming a set of correlated observed variables into a smaller number of

uncorrelated components, known as principal components.

In demographic and fertility research, PCA is frequently applied to summarize the main dimensions

of variation in the observed variables, thereby facilitating the interpretation of complex data structures (Aylie

et al., 2020; Kellow, 2006; Krishnan, 2010). PCA seeks linear combinations of the observed variables that

maximize the variance explained.

The first principal component is defined as:

푃퐶₁= ꢁ₁₁푋₁+ ꢁ₁₂푋₂+ ⋯ + ꢁ_1푝푋_푝

(3)

Where:

푃퐶₁= first principal component

ꢁ_1j= coefficient (loading) for variable 푋_jin the first component

푋_j= observed variable 푗

ꢂ = total number of observed variables

The coefficients ꢁ_1jare chosen so that the variance of 푃퐶₁is maximized, subject to the constraint that

the sum of the squared coefficients equals one:

푝

_ꢃ=1ꢀ ꢁ₁²_ꢃ= 1

(4)

∑

These equations form the analytical foundation for the quantitative assessment of TFR, its

determinants, and the relationship with unmet needs for family planning in the Nile Basin countries (Alie et

al., 2022; Asmamaw & Negash., 2022).

To elucidate the underlying structure of components influencing TFR in the Nile Basin countries, PCA

was conducted using the demographic, socioeconomic, and health-related variables listed. The suitability of

the data for this analysis was confirmed by a Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy of

0.81, indicating that the correlation matrix was appropriate for components extraction.

The rotation process converged after five iterations, yielding a final solution of three principal

components that collectively summarized the variance in the dataset. Variables exhibiting significant cross-

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

loadings were excluded from the final rotated component matrix to ensure distinct components definitions.

Figure 2 depicts a visualization of the working method and methodology of the study.

Fig. 2 – Overall flowchart of research method.

Fig. 2 – Fluxograma geral do método de investigação.

Source: Authors

3.

RESULTS

3.1

Statistical analysis of fertility determinants

PCA was conducted to identify the main dimensions associated with TFR in the Nile Basin countries,

as presented in table I. The analysis incorporated demographic, socioeconomic, and health-related variables,

with particular attention to unmet need for family planning.

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.81, indicating that the

correlation structure of the data was suitable for component extraction (Kaiser, 1974).

Components with eigenvalues greater than 1.0 were retained in accordance with the Kaiser criterion

(Kaiser, 1960), and Varimax rotation with Kaiser normalization was applied to improve the interpretability

of the solution (Kaiser, 1958).

Six variables were excluded from the rotated component matrix due to substantial cross-loadings,

defined as secondary loadings exceeding 0.32 or a difference between primary and secondary loadings of

less than 0.10. The PCA yielded three named components with eigenvalues exceeding 1.0, collectively

explaining 78.74% of the total variance.

The first component, Socioeconomic Development and Reproductive Health, explained 38.21% of the

variance and loaded strongly on female labour force participation; Christian religious affiliation; cause of

death by communicable diseases and maternal and nutritional conditions; Gross Domestic Product (GDP)

per capita; female employment in agriculture; women’s autonomy in reproductive decision-making;

maternal mortality ratio; unmet need for family planning; and the proportion of female contributing family

workers. The second component, Women’s Empowerment and Healthcare Access, accounted for 22.28% of

the variance and was defined by adult female literacy rate; prenatal care coverage; the Women’s

Empowerment Index; births attended by skilled health staff; contraceptive prevalence; and female age at first

marriage. The third component, Adolescent Fertility and Rurality, explained the remaining 18.25% of

variance and loaded on the proportion of teenage mothers; rural population share; adolescent fertility rate;

and female industrial employment.

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

Component scores were used to characterise the relative position of each country along the three

identified dimensions, with positive scores indicating alignment with the dominant pattern of the component

and negative scores indicating divergence from it.

For Socioeconomic Development and Reproductive Health, positive scores were observed across most

Nile Basin countries, with the exception of Egypt and Sudan, where labour force participation and economic

indicators were less consistent with the regional pattern. For Women’s Empowerment and Healthcare Access,

positive scores were recorded in Kenya, Uganda, Rwanda, Tanzania, Egypt, and the Democratic Republic of

Congo, reflecting comparatively higher levels of female education, healthcare utilisation, and contraceptive

uptake in those countries. For Adolescent Fertility and Rurality, positive scores were found in Rwanda,

Kenya, Ethiopia, Burundi, South Sudan, and Egypt, indicating that rural residence and adolescent

reproductive characteristics contributed more strongly to fertility variation in these settings.

Table I – Rotated principal component structure of variables associated with total fertility rate in the Nile Basin countries,

2023.

Quadro I – Estrutura rotacionada dos componentes principais das variáveis associadas à taxa de fecundidade total nos

países da Bacia do Nilo, 2023.

Component

1

2

3

#

Item

Socioeconomic

Development and

Reproductive Health

Women’s

Empowerment and

Healthcare Access

Adolescent

Fertility and

Rurality

Labor force, female (% of total labor force)

Christianity

0.97

0.89

1

2

Cause of death, by communicable diseases and maternal,

prenatal and nutrition conditions (% of total)

0.86

0.81

0.78

3

4

5

GDP per capita (current US$)

Employment in agriculture, female (% of female

employment)

Women making their own informed decisions regarding

sexual relations, contraceptive use and reproductive

health care (% of women age 15-49)

0.66

6

Maternal mortality ratio (per 100 000 live births)

0.64

0.59

7

8

Unmet need for family planning: Any modern method (%

of married women ages 15-49)

Contributing family workers, female (% of female

employment)

0.57

9

Literacy rate, adult female (% of females ages 15 and

above)

0.95

10

Pregnant women receiving prenatal care (%)

Women’s Empowerment Index (WEI)

0.90

0.78

0.76

11

12

13

Births attended by skilled health staff (% of total)

Contraceptive prevalence, any method (% of married

women ages 15-49)

0.76

0.70

14

15

16

17

18

Age at first marriage, female

Teenage mothers (% of women ages 15-19 who have had

children or are currently pregnant)

0.86

0.73

0.56

Rural population (% of total population)

Adolescent fertility rate (births per 1000 women ages 15-

19)

Employment in industry, female (% of female

employment)

0.39

19

Source: Authors

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

3.2

Geographic and demographic patterns

Figure 3 illustrates the spatial distribution of TFR and unmet needs for family planning across the Nile

Basin countries in 2023. The spatial distribution of TFR in 2023, as depicted in the thematic map (fig. 3a),

categorizes the Nile Basin countries into three classes based on the average number of children born per

woman.

(a)

(b)

Fig. 3 – (a) Spatial distribution of TFR and (b) unmet needs for family planning tools in the Nile Basin countries, 2023.

Fig. 3 – (a) Distribuição espacial da TFR e (b) necessidades não satisfeitas de ferramentas de planeamento familiar nos

países da Bacia do Nilo, 2023.

Source: United Nations Population Division Data Portal, 2024

Egypt, Eritrea, Kenya and Rwanda, shaded in light blue, exhibit the lowest TFR (2.9-4.0), reflecting

advanced progress in family planning and demographic transition. Countries such as Sudan, South Sudan,

Ethiopia, Uganda, and Tanzania fall into the medium category (4.1-5.0), shaded in medium blue. The highest

TFR (5.1-6.2), represented in dark blue, is observed in the Democratic Republic of Congo and Burundi. This

north-south gradient aligns with established demographic transition theory, wherein countries with more

advanced socioeconomic development tend to have lower TFR.

The second thematic map (fig. 3b) illustrates the unmet need for family planning, also classified into

three categories. Egypt, Kenya and Rwanda, shaded in light purple, report the lowest levels of unmet need

(10.3-15.0), indicative of better access to reproductive health services and effective family planning

programs. Countries including Sudan, Eritrea, Ethiopia, Burundi, and Tanzania occupy the medium range

(15.1-20.0), represented in medium purple. Meanwhile, the highest levels of unmet need (20.1-30.4), shown

in dark magenta, are found in the Democratic Republic of Congo, South Sudan, and Uganda.

These findings highlight significant disparities in access to contraceptive and family planning services

across the region. A visual inspection of the two maps suggests a broadly consistent spatial pattern, whereby

countries with higher TFR tend to report greater unmet need for family planning; this descriptive observation

is supported by the strong and statistically significant positive correlation documented in the quantitative

analysis (r = 0.93, p < 0.0001; see Section 3). Notably, the Democratic Republic of the Congo exhibits both

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

the highest TFR and the greatest unmet need, while South Sudan and Uganda report the highest unmet need

alongside medium TFR levels.

3.3

Spatial association between total fertility and unmet need

The bivariate spatial analysis (fig. 4) reveals a pronounced north-south dichotomy in the relationship

between TFR and unmet need for family planning across the Nile Basin countries in 2023.

A distinct "high-burden" cluster is evident in the central and southern equatorial regions,

encompassing the Democratic Republic of Congo, South Sudan, Uganda, and Tanzania. In these nations,

depicted in magenta, high TFR spatially coincides with elevated levels of unmet need, suggesting that the

inability to access contraceptive services remains a primary driver of rapid population growth in this sub-

region. Conversely, the northern and eastern territories specifically Egypt, Sudan, Eritrea, Ethiopia, and

Kenya demonstrate a contrasting pattern characterized by relatively lower unmet need and moderate-to-low

TFR, shown in cyan. This distribution reflects the varying degrees of success in national family planning

programs, with Egypt exhibiting the most advanced demographic transition. Burundi emerges as notable

exception, depicted in turquoise. This nation display relatively lower unmet need but persistent higher

fertility, indicating that factors other than service access, such as desired family size or cultural norms, may

be sustaining fertility levels in these specific contexts.

Fig. 4 – Spatial relationship between TFR and unmet need for family planning in the Nile Basin countries, 2023.

Fig. 4 – Relação espacial entre as TFT e a necessidade não atendida de planeamento familiar nos países da Bacia do Nilo,

2023.

Source: Authors

3.4

Comparative Analysis of TFR and unmet family planning needs in the Nile Basin (1990-2023)

Table II delineates the mean and standard deviation (SD) of unmet needs for family planning methods

and women’s TFR across the Nile Basin countries from 1990 to 2023. The data reveal pronounced

heterogeneity in both TFR and unmet needs for family planning throughout the region.

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

TFR remain markedly elevated in countries such as the Democratic Republic of the Congo

(6.54ꢀ±ꢀ0.18) and Burundi (6.37ꢀ±ꢀ0.76), signifying persistently high birth rates over the study period.

Similarly, South Sudan (6.22ꢀ±ꢀ1.39) and Uganda (6.11ꢀ±ꢀ0.87) exhibit substantial fertility levels, indicating

that reproductive health interventions have yet to yield significant reductions in these contexts. In contrast,

Egypt (3.41ꢀ±ꢀ0.42) demonstrates the lowest TFR among the Nile Basin countries, reflecting the effectiveness

of comprehensive family planning policies and sustained fertility decline.

The extent of unmet needs for family planning methods also varies considerably. The Democratic

Republic of the Congo reports the highest unmet need (33.29ꢀ±ꢀ1.24), followed by Uganda (26.69ꢀ±ꢀ2.89) and

Tanzania (23.20ꢀ±ꢀ1.93). These elevated levels of unmet need are closely associated with higher TFR,

underscoring persistent barriers to accessing reproductive health services.

Conversely, Egypt’s unmet need (12.08ꢀ±ꢀ2.60) is the lowest in the region, suggesting more robust

access to family planning and contributing to its lower TFR.

At the aggregate level, the Nile Basin exhibits a mean TFR of 5.42ꢀ±ꢀ0.75 and an unmet need of

22.11ꢀ±ꢀ2.50, both of which substantially exceed global averages (World TFR: 2.64ꢀ±ꢀ0.24; World unmet

need: 14.68ꢀ±ꢀ1.31). These disparities highlight the significant reproductive health challenges confronting the

Nile Basin countries relative to global trends.

The variability in unmet needs, as indicated by the SD, is particularly pronounced in Kenya

(21.52ꢀ±ꢀ6.05) and Rwanda (20.66ꢀ±ꢀ5.57), reflecting inconsistent access to modern family planning methods.

In contrast, South Sudan (23.14ꢀ±ꢀ0.40) and the Democratic Republic of the Congo (33.29ꢀ±ꢀ1.24) display

minimal variability, indicative of persistently high and uniform levels of unmet need.

Table II – TFR and unmet family planning needs across Nile Basin countries (1990-2023).

Quadro II – TFT e necessidades de planeamento familiar não satisfeitas nos países da bacia do Nilo (1990-2023).

Countries

Burundi

TFR (Mean ± SD)

6.37 ± 0.76

6.54 ± 0.18

5.69 ± 1.12

4.92 ± 0.79

4.57 ± 0.83

5.14 ± 1.05

6.22 ± 1.39

5.18 ± 0.50

6.11 ± 0.87

3.41 ± 0.42

5.42 ± 0.45

5.42 ± 0.75

2.64 ± 0.24

Unmet Needs (Mean ± SD)

21.99 ± 1.17

33.29 ± 1.24

21.76 ± 4.84

19.12 ± 2.28

21.52 ± 6.05

20.66 ± 5.57

23.14 ± 0.40

19.68 ± 1.00

26.69 ± 2.89

12.08 ± 2.60

23.20 ± 1.93

22.11 ± 2.50

14.68 ± 1.31

Democratic Republic of Congo

Ethiopia

Eritrea

Kenya

Rwanda

South Sudan

Sudan

Uganda

Egypt

Tanzania

Nile Basin

World

Source: United Nations Population Division Data Portal, 2024

3.5

Correlation between TFR and unmet needs for family planning in the Nile Basin (1990-2023)

Table III presents the results of a correlation analysis examining the relationship between TFR and

unmet needs for family planning methods in the Nile Basin countries from 1990 to 2023.

The analysis demonstrates a consistently strong and statistically significant association between these

two variables across the region. R values range from 0.55 to 0.99, with all corresponding p-values indicating

high statistical significance (p < 0.001). The findings reveal that in nearly all Nile Basin countries, higher

levels of unmet need for family planning are closely linked to elevated TFR. For instance, Eritrea (r = 0.99,

p = 0.000) and Kenya (r = 0.99, p = 0.000) exhibit near-perfect correlations, suggesting that inadequate access

to modern contraceptive methods is a primary factor sustaining high TFR in these contexts. Similarly, Sudan

(r = 0.99, p = 0.000) and Uganda (r = 0.91, p =

0.000) also display very strong associations, further

emphasizing the critical role that unmet contraceptive needs play in maintaining high birth rates.

South Sudan stands out as having the lowest, yet still significant, correlation (r = 0.55, p = 0.001). This

result suggests that while unmet need for family planning remains an important determinant of fertility, other

influences such as cultural norms, socio-political dynamics, or health system limitations may also be shaping

fertility patterns in this country. When considering the aggregate data, both the Nile Basin as a whole (r =

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

0.99, p = 0.000) and the global context (r = 0.97, p = 0.000) confirm the broader trend that unmet needs for

family planning are a major driver of elevated TFR. These high correlation coefficients at both regional and

global levels underscore the importance of expanding access to family planning services as a strategy for

fertility reduction.

Table III – Correlation of TFR with unmet needs for family planning methods in the Nile Basin Countries (1990-2023).

Quadro III – Correlação da TFT com as necessidades não satisfeitas de métodos de planeamento familiar nos países da

bacia do Nilo (1990-2023).

Countries

Burundi

D. R. Congo

Ethiopia

Eritrea

r

p-value

0.000

0.001

0.000

0.85

0.76

0.99

0.98

0.55

0.99

0.91

0.95

0.97

0.99

0.97

Kenya

Rwanda

South Sudan

Sudan

Uganda

Egypt

Tanzania

Nile Basin

World

Source: United Nations Population Division Data Portal, 2024

Figure 5 illustrates the association between unmet need for family planning and TFR in 2023 across

the Nile Basin countries. The scatterplot indicates a pronounced positive relationship between these two

variables, consistent with the Pearson correlation coefficient of 0.93 (p < 0.0001) and a 95% confidence

interval ranging from 0.73 to 0.98, confirming that the association is statistically significant and robust.

Fig. 5 – Scatterplot of unmet needs family planning with TFR.

Fig. 5 – Diagrama de dispersão das necessidades não satisfeitas de planeamento familiar com TFT.

Source: United Nations Population Division Data Portal, 2024

The strength of this relationship is further supported by the coefficient of determination (r²= 0.86),

which indicates that 86% of the variation in TFR across countries can be explained by differences in unmet

need for family planning in 2023. This implies a strong linear association, although it is not a near-perfect

fit; therefore, the statement that unmet need is strongly associated with almost all fertility variation should

be moderated accordingly.

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

Countries such as the Democratic Republic of the Congo and South Sudan, which report some of the

highest levels of unmet need, also exhibit persistently high TFR. Conversely, nations like Egypt, where

access to family planning services is more widespread, demonstrate lower TFR and reduced unmet need.

The spatial patterns observed in the scatterplot reinforce the critical role of reproductive health services in

shaping demographic trends.

4. DISCUSSION

4.1. Regional evidence on TFR-unmet need link

Despite decades of research on fertility and family planning in sub-Saharan Africa, significant

knowledge gaps persist regarding the persistence and drivers of high TFR in the Nile Basin countries. While

the association between unmet need for family planning and elevated fertility is well recognized, few studies

have systematically quantified the strength and consistency of this relationship across the entire Nile Basin

over an extended period (Ainsworth et al., 1996). Much of the existing literature focuses on national or

subnational trends, often neglecting the comparative, cross-country perspective essential for understanding

regional disparities and informing coordinated policy responses (Bongaarts, 2020; Wildeman et al., 2023).

Recent studies have also highlighted the need to disentangle the effects of unmet need from other

determinants such as education, socioeconomic status, and health system access, yet comprehensive,

multivariate analyses remain scarce (Alie et al., 2022).

This study addresses these gaps by providing a robust, region-wide analysis of the correlation between

TFR and unmet need for family planning across 11 Nile Basin countries from 1990 to 2023. The results

reveal a strong and statistically significant positive correlation (r = 0.93, p < 0.0001) between TFR and unmet

need for family planning. The first principal component of the PCA, which was heavily loaded by unmet

need and related reproductive health indicators, accounted for 38.21% of the total variance in the multivariate

dataset, underscoring the centrality of this dimension within the overall structure of fertility determinants.

This finding is consistent with recent evidence from sub-Saharan Africa, where unmet need for contraception

remains high –often between 20% and 30% – and is closely linked to elevated fertility, particularly in

countries with limited access to reproductive health services (Alayande et al., 2023; Alemu et al., 2024).

The observed regional decline in TFR, especially in Kenya, Rwanda, Ethiopia, Eritrea, Egypt, and

Uganda, aligns with previous studies documenting the impact of expanded education and increased

contraceptive use among women (Ainsworth et al., 1996; Bongaarts, 2020). For example, recent analyses in

Ethiopia and Egypt have shown that improvements in female education and targeted family planning

programs are associated with both reduced unmet need and lower TFR (Abdelsalam et al., 2021; Getachew

& Kibret, 2025). However, the persistence of high fertility and unmet need in countries such as DRC,

Burundi, South Sudan, Sudan, Uganda, and Tanzania underscores ongoing barriers to contraceptive access

and use, echoing findings from recent multi-country studies in the region (Baranon et al., 2024; Turner &

Götmark, 2023).

The magnitude of the correlation found in this study is notably higher than that reported in some earlier

research, which often identified weaker associations between unmet need and fertility decline, particularly

when controlling for confounding factors such as education and socioeconomic status. For instance,

Casterline & El‐Zeini (2014) noted that fertility decline in sub-Saharan Africa is only weakly associated with

trends in unmet need, suggesting that other factors such as desired family size and cultural norms play

substantial roles. However, more recent studies using updated datasets and advanced statistical methods have

reported stronger links, particularly in contexts where family planning programs have been effectively

implemented (Alie et al., 2022; Kraft et al., 2022).

4.2. Country heterogeneity and multidimensional determinants

Country-specific patterns further illustrate the complexity of these relationships. In Ethiopia, for

example, a reduction in unmet need has not always translated into a proportional decline in fertility, likely

due to uneven implementation of family planning programs and persistent regional disparities (Teferi &

Schröders, 2023). In contrast, Egypt, Eritrea, and Rwanda have demonstrated more consistent progress, with

well-integrated family planning policies leading to both lower unmet needs and reduced fertility. These

findings are supported by recent national surveys and program evaluations, which highlight the importance

of comprehensive, context-specific interventions (Aly & Aly, 2023; Zalak & Goujon, 2017).

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Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

The PCA conducted in this study revealed that unmet need, along with socioeconomic status, health

system access, and cultural norms, constitutes a principal dimension of the fertility landscape, with the three

extracted components collectively accounting for nearly 79% of the total variance in the multivariate dataset.

This multidimensional perspective is supported by recent research emphasizing the interplay between

individual, household, and community-level factors in shaping reproductive behavior (Alie et al., 2022;

Wildeman et al., 2023). For example, studies have shown that women with higher levels of education, greater

autonomy, and better access to health services are less likely to have unmet needs and more likely to achieve

their desired family size (Bongaarts, 2011; Gausman et al., 2023).

Importantly, the persistence of high fertility and unmet need in countries like the Democratic Republic

of Congo and South Sudan highlights the urgent need for tailored policy interventions that address local

demographic, economic, and infrastructural conditions (Baranon et al., 2024; Turner & Götmark, 2023).

Recent systematic reviews and meta-analyses have called for the expansion of family planning services,

targeted outreach to underserved populations, and the integration of reproductive health education into

broader development programs (Chaurasia, 2023; Nsashiyi et al., 2024). Addressing these challenges is

essential for achieving the Sustainable Development Goals related to health, gender equality, and poverty

reduction (Islam, 2024).

4.3. Study limitations

This study is subject to several important limitations that should be considered when interpreting its

findings. The analysis is based on cross-sectional averages spanning a long period (1990-2023); using

averages may yield different results than when the median is applied, which means that year-to-year changes,

policy impacts, and temporal trends within individual countries may be obscured (Hamdi et al., 2025). Such

an approach increases the risk of ecological fallacy and aggregation bias, as it does not capture within-country

variations or short-term fluctuations. Furthermore, the study does not sufficiently control for confounding

variables such as education, urbanization, economic status, health system quality, and cultural factors, all of

which are known to influence both TFR and unmet need for family planning. While the PCA incorporates

multiple variables, the interpretation and control of these confounders remain limited, and a regression-based

approach would be required to formally quantify the independent contribution of any single variable to

variation in TFR.

Another significant limitation relates to data quality and consistency. The study draws data from

multiple reputable sources, including the United Nations, World Bank, and Pew Research Center, but

differences in definitions, data collection methods, and reporting standards across countries and years may

affect the comparability and reliability of the results. Issues such as underreporting, missing data, or

inconsistencies in national surveys are not fully addressed, which could impact the robustness of the

conclusions, in addition to factors related to the climate and geographic character of each region and the

extent of its influence on the population (Hamdi et al., 2024).

5. CONCLUSION

This study establishes a strong and statistically significant positive association between TFR and

unmet need for family planning across the Nile Basin countries from 1990 to 2023 (r = 0.93, p < 0.0001).

The PCA identifies unmet need as a central dimension of the fertility landscape in the region, with the first

principal component – heavily characterized by unmet need and related reproductive health indicators –

accounting for 38.21% of the total variance in the multivariate dataset. While notable progress has been made

in countries such as Kenya, Rwanda, and Egypt – where declines in both indicators reflect successful policy

implementations – nations like the Democratic Republic of Congo, Uganda, and Sudan continue to

experience persistently high levels of both fertility and unmet need. These disparities highlight the critical

role of equitable access to reproductive health services in shaping demographic outcomes.

However, the findings also indicate that reducing unmet need alone is insufficient for lowering TFRs,

as the relationship is mediated by broader socioeconomic and structural factors. The multidimensional

analysis reveals that female labour force participation, maternal health indicators, and cultural contexts are

integral components of the fertility landscape. Consequently, effective interventions must go beyond the

provision of contraceptives to encompass comprehensive development strategies, including improvements

in women’s education, economic empowerment, and health infrastructure. Future research should prioritize

13

Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

longitudinal and spatially disaggregated approaches to better capture local nuances and inform targeted,

context-specific policies that can sustain fertility transitions across the region.

ORCID

Ahmed Fouad Elmoughazi

https://orcid.org/0000-0001-6322-6160

Islam M. Hamdi https://orcid.org/0000-0003-1151-2119

AUTHORS’ CONTRIBUTIONS

Ahmed Fouad Elmoughazi: Conceptualization, Data curation, Formal Analysis, Investigation, Resources,

Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Islam M.

Hamdi: Conceptualization, Data curation, Formal Analysis, Investigation, Resources, Software, Supervision,

Validation, Visualization, Writing – original draft, Writing – review & editing.

REFERENCES

Abbas, W., & Hamdi, I. (2022). Satellite-based discrimination of urban dynamics-induced local bias from day/night

temperature trends across the Nile Delta, Egypt: a basis for climate change impacts assessment. Sustainability,

14(21), 14510. https://doi.org/10.3390/su142114510

Abdelsalam, S. A., El‐Sayed, S. E. D., Khafagy, M. A., & Alemam, D. S. (2021). Unmet need for family planning among

married women of reproductive age in an Egyptian village. Egyptian Journal of Community Medicine, 39(4), 12-20.

https://www.researchgate.net/publication/360963151

Adeokun, L. A. (1983). Marital sexuality and birth-spacing among the Yoruba. In C. Oppong (Ed.), Female and male in West

Africa (pp. 127-138). Routledge. https://pubmed.ncbi.nlm.nih.gov/12264950/

Agbana, R. D., Michael, T. O., & Ojo, T. F. (2023). Family planning method discontinuation among Nigerian women:

evidence from the Nigeria demographic and health survey 2018. Journal of Taibah University Medical Sciences,

18(1), 117-124. https://doi.org/10.1016/j.jtumed.2022.08.003

Ahinkorah, B. O., Kang, M., Perry, L., & Brooks, F. (2023). Knowledge and awareness of policies and programmes to reduce

adolescent pregnancy in Ghana: a qualitative study among key stakeholders. Reproductive health, 20, 143.

https://doi.org/10.1186/s12978-023-01672-2

Ainsworth, M., Beegle, K., & Nyamete, A. (1996). The impact of women’s schooling on fertility and contraceptive use: a

study of fourteen sub-Saharan African countries. The World Bank Economic Review, 10(1), 85-122.

https://doi.org/10.1093/wber/10.1.85

Alayande, A., Bello, Y., Bajowa, L., Evborein, E., Nuhu, I. A., & Umeh, G. (2023). Trends in unmet need for family

planning 1990-2018: its correlation with socio-demographic indices and modern contraceptive prevalence rates in

Nigeria. Journal of Community Health and Preventive Medicine, 3(1), 32-41.

https://doi.org/10.21776/ub.jochapm.2023.003.01.4

Alemu, M. D., Workie, S. B., Kussa, S., Gidey, T. T., & Berheto, T. M. (2024). Trend and determinants of unmet need for

family planning among married women in Ethiopia, evidence from Ethiopian demographic and health survey 2000-

2016; multilevel analysis. PLOS One, 19(1), e0296382. https://doi.org/10.1371/journal.pone.0296382

Alie, M. S., Abebe, G. F., & Negesse, Y. (2022). Magnitude and determinants of unmet need for family planning among

reproductive age women in East Africa: multilevel analysis of recent demographic and health survey data.

Contraception and Reproductive Medicine, 7, 2. https://doi.org/10.1186/s40834-022-00168-x

Aly, R., & Aly, M. (2023). The situation of Egyptian women in childbearing and family planning and some related factors: a

perspective of correspondence analysis. Universal Journal of Public Health, 11(1), 14-26.

https://doi.org/10.13189/ujph.2023.110103

Anderson, D. J., & Johnston, D. S. (2023). A brief history and future prospects of contraception. Science, 380(6641), 154-

158. https://doi.org/10.1126/science.adf9341

Asmamaw, D. B., & Negash, W. D. (2022). Magnitude of unmet need for family planning and its predictors among

reproductive age women in high fertility regions of Ethiopia: evidence from Ethiopian demographic and health

survey. BMC Women’s Health, 22, 408. https://doi.org/10.1186/s12905-022-01982-w

Aylie, N. S., Dadi, L. S., Alemayehu, E., & Mekonn, M. A. (2020). Determinants of fertility desire among women living with

HIV in the childbearing age attending antiretroviral therapy clinic at Jimma University medical center, Southwest

14

Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

Ethiopia: a facility‐based case‐control study. International Journal of Reproductive Medicine, (1), 6504567.

https://doi.org/10.1155/2020/6504567

Baranon, M. D., Nahini, A. T., Ayena, C., Soglo, A. M., & Kollie, T. C. (2024). Spatio-temporal trends and patterns of

synthetic fertility index across African countries: a comprehensive analysis from 1950 to 2023. East African Journal

of Interdisciplinary Studies, 7(1), 89-105. https://doi.org/10.37284/eajis.7.1.1948

Beaujouan, E. (2023). Delayed fertility as a driver of fertility decline? In R. Schoen (Ed.), The Demography of Transforming

Families (pp. 41-63). Springer. https://doi.org/10.1007/978-3-031-29666-6_4

Bokhari, A. (2024). Editorial; Population bomb explored in Pakistan with serious implications (population growth and

demographic dividend). Sial Journal of Medical Sciences, 2(4), 1-6. https://doi.org/10.60127/7f6nda73

Bongaarts, J. (2011). Can family planning programs reduce high desired family size in sub-Saharan Africa? International

perspectives on sexual and reproductive health, 37(4), 209-216. https://doi.org/10.1363/3720911

Bongaarts, J. (2020). Trends in fertility and fertility preferences in sub-Saharan Africa: the roles of education and family

planning programs. Genus, 76, 32. https://doi.org/10.1186/s41118-020-00098-z

Casterline, J. B., & El‐Zeini, L. O. (2014). Unmet need and fertility decline: a comparative perspective on prospects in

sub‐ Saharan Africa. Studies in family planning, 45(2), 227-245. https://doi.org/10.1111/j.1728-4465.2014.00386.x

Casterline, J. B., & Sinding, S. W. (2004). Unmet need for family planning in developing countries and implications for

population policy. Population and development review, 26(4), 691-723. https://doi.org/10.1111/j.1728-

4457.2000.00691.x

Chaurasia, A. (2023). Family planning progress in 113 countries using a new composite Progress Index. The Journal of

Population and Sustainability, 7(1), 71-122. https://doi.org/10.3197/JPS.63799953906866

Cleland, J., Bernstein, S., Ezeh, A., Faundes, A., Glasier, A., & Innis, J. (2006). Family planning: the unfinished agenda. The

Lancet, 368(9549), 1810-1827 https://doi.org/10.1016/S0140-6736(06)69480-4

Cohen, B. (2000). Family planning programs, socioeconomic characteristics, and contraceptive use in Malawi. World

Development, 28(5), 843-860. https://doi.org/10.1016/S0305-750X(99)00159-X

El‐Fadel, M., El‐Sayegh, Y., El‐Fadl, K., & Khorbotly, D. (2003). The Nile River Basin: a case study in surface water

conflict resolution. Journal of Natural Resources and Life Sciences Education, 32(1), 107-117.

https://doi.org/10.2134/jnrlse.2003.0107

Elmoughazi, A. F. (2025). The relationship between population growth and economic growth in Egypt: a geographical

perspective. Visnyk of V. N. Karazin Kharkiv National University. Series Geology. Geography. Ecology, (63), 197-

210. https://doi.org/10.26565/2410-7360-2025-63-15

Garenne, M. (2018). Family planning and fertility decline in Africa: From 1950 to 2010. In Z. O. Amarin (Ed.), Family

Planning (pp. 119-159). IntechOpen. http://dx.doi.org/10.5772/intechopen.71029

Gausman, J., Saggurti, N., Adanu, R., Bandoh, D. A., Berrueta, M., Chakraborty, S... & Jolivet, R. R. (2023). Validation of a

measure to assess decision-making autonomy in family planning services in three low-and middle-income countries:

the family planning autonomous decision-making scale (FP-ADM). PLOS One, 18(11), e0293586.

https://doi.org/10.1371/journal.pone.0293586

Getachew, B., & Kibret, A. (2025). Unmet need for family planning and associated factors among reproductive age women

working in Bole Lemi industrial park, Addis Ababa, Ethiopia 2024: an institution based cross-sectional study. BMC

Public Health, 25, 2082. https://doi.org/10.1186/s12889-025-23327-6

Hamdi, I. M., AbdAlmapoed, E. K., & AbdElaal, S. R. (2025). Assessment of urban heat island effects in industrial areas of

Egypt using robust statistical methods. Remote Sensing Applications: Society and Environment, 40, 101777.

https://doi.org/10.1016/j.rsase.2025.101777

Hamdi, I. M., Albalawi, E., AbdAlmapoed, E. K., & AbdElaal, S. R. (2026). Mitigating surface industrial heat island effects

in arid environments: a machine learning approach to sustainable planning. Energy & Buildings, 361, 117449.

https://doi.org/10.1016/j.enbuild.2026.117449

Hamdi, I. M., Fawzy, M., Zelenakova, M., & Abbas, W. (2024). Heat Island dynamics and heat stress implications on the

population of El-Mansourah conurbation, Egypt: temporal and proposed solutions using MODIS imagery and ENVI-

met simulation. Geomatics, Natural Hazards and Risk, 15(1), 2291328.

https://doi.org/10.1080/19475705.2023.2291328

Hauer, M. E., & Schmertmann, C. P. (2020). Population pyramids yield accurate estimates of total fertility rates.

Demography, 57(1), 221-241. https://doi.org/10.1007/s13524-019-00842-x

Hauer, M., Baker, J., & Brown, W. (2013). Indirect estimates of total fertility rate using child woman/ratio: a comparison

with the Bogue-Palmore method. PLOS One, 8(6), e67226. https://doi.org/10.1371/journal.pone.0067226

Heuveline, P. (2001). Demographic pressure, economic development, and social engineering: an assessment of fertility

declines in the second half of the twentieth century. Population research and policy review, 20, 365-396.

https://doi.org/10.1023/A:1013339124837

15

Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

Islam, M. R. (2024). Conclusions and Future Directions Toward Family Planning, Empowering Marginalized Communities

and Sustainable Development. In M. R. Islam (Ed.), Family Planning and Sustainable Development in Bangladesh:

Empowering Marginalized Communities in Asian Contexts (pp. 195-208). Emerald Insight.

https://doi.org/10.1108/978-1-83549-164-520241012

Kaiser, H. F. (1974). An index of factorial simplicity. Psychometrika, 39(1), 31-36. https://doi.org/10.1007/BF02291575

Kaiser, H. F. (1960). The application of electronic computers to factor analysis. Educational and Psychological

Measurement, 20(1), 141-151. https://doi.org/10.1177/001316446002000116

Kaiser, H. F. (1958). The varimax criterion for analytic rotation in factor analysis. Psychometrika, 23(3), 187-200.

https://doi.org/10.1007/BF02289233

Kebede, S. D., Mamo, D. N., Adem, J. B., Semagn, B. E., & Walle, A. D. (2023). Machine learning modeling for identifying

predictors of unmet need for family planning among married/in-union women in Ethiopia: Evidence from

performance monitoring and accountability (PMA) survey 2019 dataset. PLOS Digital Health, 2(10), e0000345.

https://doi.org/10.1371/journal.pdig.0000345

Kellow, J. T. (2006). Using principal components analysis in program evaluation: Some practical considerations. Journal of

MultiDisciplinary Evaluation, 3(5), 89-107. https://doi.org/10.56645/jmde.v3i5.52

Kemei, Z. K. (2024). Modelling the effects of social factors on population dynamics using age-structured model as a

management strategy. [Doctoral thesis, University of Eldoret]. University of Eldoret Digital Repository.

http://41.89.164.27:8080/xmlui/handle/123456789/2276

Khan, Q., & Wang, S. (2021). The effect of family planning exposure on fertility choices and reproductive health care in

rural Pakistan. Journal of Asian Economics, 73, 101283. https://doi.org/10.1016/j.asieco.2021.101283

Kraft, J. M., Serbanescu, F., Schmitz, M. M., Mwanshemele, Y., Ruiz C, A. G., Maro, G., & Chaote, P. (2022). Factors

associated with contraceptive use in sub-Saharan Africa. Journal of Women’s Health, 31(3), 447-457.

https://doi.org/10.1089/jwh.2020.8984

Krishnan, V. (2010). Constructing an area-based socioeconomic index: A principal components analysis approach. Early

Child Development Mapping Project. https://www.ualberta.ca/en/community-university-partnership/media-

library/research/ecmap-reports/seicupwebsite10april13-1.pdf

Lin, Y., Zhang, T., Liu, X., Yu, J., Li, J., & Gao, K. (2022). Dynamic monitoring and modeling of the growth-poverty-

inequality trilemma in the Nile River Basin with consistent night-time data (2000–2020). International Journal of

Applied Earth Observation and Geoinformation, 112, 102903. https://doi.org/10.1016/j.jag.2022.102903

Mandavilli, S. R. (2024, November). Sound population management ad infinitum: how relatively low fertility rates can lead

to an "Evergreen demographic boon" Published in Google books. SSRN Blog.

http://dx.doi.org/10.2139/ssrn.5023928

McNamara, R.ꢀS. (1991). The population problem: time bomb or myth. Butterworth-Heinemann

Murray, C. J., Callender, C. S., Kulikoff, X. R., Srinivasan, V., Abate, D., Abate, K. H... & Lim, S. S. (2018). Population and

fertility by age and sex for 195 countries and territories, 1950-2017: a systematic analysis for the Global Burden of

Disease Study 2017. The Lancet, 392(10159), 1995-2051.

Nahas, F., Hamdi, I., Hereher, M., Zelenakova, M., & El Kenawy, A. M. (2025). Warming trends in the Nile Delta: a high-

resolution spatial statistical approach. Remote Sensing Applications: Society and Environment, 37, 101408.

https://doi.org/10.1016/j.rsase.2024.101408

Nsashiyi, R. S., Rahman, M. M., Ndam, L. M., & Hashizume, M. (2024). Contraceptive use, unmet need, and demand

satisfied for family planning across Cameroon: a subnational study including indirect effects of COVID-19 and

armed conflict on projections. BMC Global and Public Health, 2, 40. https://doi.org/10.1186/s44263-024-00071-4

Pew Research Center. (2022, December). Key findings from the global religious futures project. Pew Research Center.

https://www.pewresearch.org/religion/2022/12/21/key-findings-from-the-global-religious-futures-project

Pew Research Center. (2024). Global religious futures project. http://www.globalreligiousfutures.org/countries

Rallu, J-. L., & Toulemon, L. (1994). Period fertility measures: the construction of different indices and their application to

France, 1946-89. Population an English Selection, 6, 59-93. https://www.jstor.org/stable/2949144

Sharan, M., Ahmed, S., May, J., & Soucat, A. (2011). Family planning trends in sub-Saharan Africa: progress, prospects, and

lessons learned. In P. Pole, & M. Angwafo (Eds.), Yes Africa can: success stories from a dynamic continent (pp. 445-

463). The World Bank. https://documents1.worldbank.org/

Singh, S., Bankole, A., & Darroch, J. E. (2017). The impact of contraceptive use and abortion on fertility in sub-Saharan

Africa: estimates for 2003-2014. Population and development review, 43(S1), 141-165.

https://doi.org/10.1111/padr.12027

Sobotka, T. (2004). Postponement of childbearing and low fertility in Europe. Population studies series. Amsterdam: Dutch

University Press. https://research.rug.nl/files/9808319/c3.pdf

16

Elmoughazi, A. F., Hamdi, I. M. Finisterra, LXI(131), 2026, e43096

Soucy, N. L., Terrell, R. M., Chedid, R. A., & Phillips, K. P. (2023). Best practices in prenatal health promotion: perceptions,

experiences, and recommendations of Ottawa, Canada, prenatal key informants. Women’s Health, 19,

17455057231158223. https://doi.org/10.1177/17455057231158

Teferi, H. M., & Schröders, J. (2023). Contributing factors for urban-rural inequalities in unmet need for family planning

among reproductive-aged women in Ethiopia: a Blinder-Oaxaca decomposition analysis. BMC Women’s Health, 23,

158. https://doi.org/10.1186/s12905-023-02304-4

Thakur, S., Mohi, M. K., Pathak, N., & Sandhu, K. (2023). A longitudinal cross-sectional study on awareness of

contraception. Indian Journal of Obstetrics and Gynecology Research, 10(1), 54-58.

https://doi.org/10.18231/j.ijogr.2023.011

The Fund for Peace. (2024). Fragile states index: Global data. https://fragilestatesindex.org/global-data/

Turner, N., & Götmark, F. (2023). Human fertility and religions in sub-Saharan Africa: A comprehensive review of

publications and data, 2010-2020. African Journal of Reproductive Health, 27(1), 119-171.

https://doi.org/10.4314/ajrh.v27i1

United Nations Population Division. (2024). World population prospects 2024: Data portal. United Nations

https://population.un.org/DataPortal/

Vahdaninia, M. (2021). The unmet needs for modern family planning methods among postpartum women in sub-Saharan

Africa: a systematic review of the literature. BMC Reproductive Health, 18, 35. https://doi.org/10.1186/s12978-021-

01089-9

Wang, W., Wang, S., Pullum, T., Ametepi, P. (2012). How family planning supply and the service environment affect

contraceptive use: findings from four East African countries. ICF International.

https://dhsprogram.com/pubs/pdf/AS26/AS26.pdf

Wildeman, J., Schrijner, S., & Smits, J. (2023). Fertility rates and social media usage in sub‐Saharan Africa. Population,

Space and Place, 29(4), e35. https://doi.org/10.1002/psp.2635

World Bank. (2024). World development indicators. World Bank. https://data.worldbank.org/indicator/?tab=all

Yasmeen, F., & Mahmood, Z. (2014). An FDA approach to forecast age-specific fertility rates of Pakistan region-wise.

Computer Science and Applications, 1(6), 341-348. https://www.researchgate.net/profile/Farah-

Yasmeen/publication/269990133

Younis Elsary, A., & Elmoughazi, A. (2026). Geographic and Demographic Discrepancies in Stroke Deaths Among Elderly

in Nile Basin countries. Fayoum University Medical Journal, 16(3), 15-28.

https://doi.org/10.21608/fumj.2026.378953.1507

Zalak, Z. A., & Goujon, A. (2017). Exploring the fertility trend in Egypt. Demographic Research, 37 (32), 995-1030.

https://doi.org/10.4054/DemRes.2017.37.32

17