With a gross national income of US$380 per capita in 2005, Mali is one of the poorest and least developed countries in the world. 1 Seventy percent of the population is rural. In 2001, as many as 80% of women had no education, 43% were in polygamous unions and just 4% had access to newspapers, television or radio. Additionally, only about one-half of women had consulted a health professional at least once during their last pregnancy. 2 The country's total fertility rate (TFR) of 6.8 births per woman has remained fairly stable over the past decade and is one of the highest in Africa. 2 With an infant mortality rate of 120 deaths per 1,000 live births in 2005 and a maternal mortality ratio of 1,200 deaths per 100,000 births in 2000, the country faces significant maternal and child health challenges. 3 Family planning was introduced in Mali in the late 1960s. In 1967, the Association Malienne pour la Promotion et la Protection de la Famille began a small family planning pilot project in the capital city, Bamako. However, the government of Mali did not establish an official family planning policy until 1972, when a decree authorizing voluntary birth regulation was issued. 4 Between 1972 and 1990, family planning services were limited to Bamako and other major urban areas. In 1990, however, the government embarked on a family planning promotion campaign. 5 Nationwide campaigns to promote family planning have continued since then. Despite these efforts, contraceptive use in Mali is still very low. For example, the pill, which is the most widely adopted method, is used by only 3% of women in union. Yet, by 2001, 76% of women knew of a modern method of contraception and nearly 29% were considered to have an unmet need for family planning. 2 In addition to reporting Mali's high TFR, the 2001 Demographic and Health Survey (DHS) indicates that only 22% of women in Mali reported an ideal family size of four or fewer children. 2 In light of the widespread desire for large families and other common pronatalist attitudes, understanding why individuals who practice family planning choose to do so is an important area of research. Additionally, understanding the extent to which a pronatalist environment inhibits adoption of contraceptives is critical in efforts to promote family planning in Mali and other low-prevalence countries.There is increased interest in exploring the importance of the environment in health behavior changes. Research on this topic generally seeks to look at the relative influences on health behavior of characteristics of the individuals in a community and the environment in which these individuals reside.A number of theories have been presented to explain

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The debate around the relative influence of ideation versus development on fertility reduction has been ongoing at least since Cleland & Wilson's "iconoclastic view" of fertility transition was published in 1987. While there is fairly wide recognition that the diffusion of new behaviors through a community can play an important role in fertility transitions, there is relatively little research on the effect of changes in the normative environment-a predictable consequence of the ideational process-on a woman's fertility decisions. For the current study, we focus on collective or group norms, which have been defined as "regularities in attitudes and behavior that characterize a social group and differentiate it from other groups." We infer these regularities in behavior and attitudes by aggregating across individual reports to calculate the objective prevalence of these phenomena within groups. Using multilevel analysis of consecutive 1995, 2000 and 2005 Egypt Demographic and Health Surveys (EDHS), we test the effect of changes in the norms related to the desire for a large family and the use of family planning at parity 0 or 1 on self-reported contraceptive use among married women in Egypt. The analysis included 2432 married women 15-49 years for the 1995-2000 period and 5285 women for the 2000-2005 period. Norms are defined at the cluster level, which serves as our community-level unit of analysis. After controlling for individual and other community factors, including changes in literacy, we found that women residing in communities where the desire for large families increased from 1995-2000 were more than 70% less likely to use a contraceptive method. While the trend was similar, no such effect of desired family size was observed from 2000-2005. Instead, residence in a community where use of family planning after the first child increased from 2000-2005 resulted in a more than threefold increase in contraceptive use in 2005. Results indicate that changes in norms measured at the collective level affect individual contraceptive use. Specific attitudinal and behavioral changes that influenced individual action, however, changed over time, consistent with shifts in the emphasis of the national family planning program.

Africa, for example, found that women who had been coerced at first intercourse were more likely than those whose first sex had not been coerced to report subsequent risky