The relationship between improvements in child survival, family planning, and fertility is viewed here as the outcome of a process of family building that evolves through distinct phases as the mortality transition progresses. The speed with which family building strategies evolve from "family building by fate" to "family building by design" and from "insurance" to "replacement" as child survival improves depends on the pattern (by age and causes of death) of mortality decline and the sociocultural context. While child survival improvements will not lead to compensatory declines in fertility when fate or replacement behavior govern family building, more than compensatory fertility declines can result when families shift to family building by design, which, in its initial phases, is manifested by so-called insurance behavior. A literature review supports these hypotheses and identifies family planning availability as a critical additional factor. These results provide strong support for an integrated approach to the delivery of health and family planning services.
PIP: A literature review supports the hypothesis that family building strategies follow a predictable course throughout the mortality transition, leading to a clear relationship between child survival and contraceptive practice. When mortality is high, natural fertility is the rule, only limited by lactation and postpartum abstinence. Family building is by fate. After a notable decrease in child mortality, families limit conception by the insurance strategy, followed by the replacement strategy. Finally, family building by design emerges. The speed with which family building strategies evolve depends on the pattern, by age and causes of death, of mortality decline in the socio-cultural context. These patterns can be seen historically, by reviewing empirical studies, or by surveying regions and nations today. Behavioral responses can be strengthened by providing public health programs to improve infant or child survival, and the appropriate family planning methods to suit family strategies in the given context.