62920 RepRoDUctIve HealtH at a GLANce April 2011 BURUNDI country context Burundi: MDG 5 Status Burundi was devastated by many years of civil conflict and MDG 5A indicators four wars following its independence in 1962.1 During the Maternal Mortality Ratio (maternal deaths per 100,000 live 975 last conflict, GNI per capita (Atlas method) decreased by births) UN estimatea nearly 40 percent between 1993 and 2005. With a 3 percent Births attended by skilled health personnel (percent) 31.8 average growth rate from 2001 to 2008, and a stagnant GDP MDG 5B indicators per capita (US$110), Burundi is one of the poorest coun- Contraceptive Prevalence Rate (percent) 9.1 tries in the world.1 The number of people below the poverty line almost doubled from 35 percent in 1993 67 percent in Adolescent Fertility Rate (births per 1,000 women ages 15–19) 185 2006.1 Recent estimates based on wealth index comparison Antenatal care with health personnel (percent) 92.5 indicate that poverty might have worsened from 2005 to Unmet need for family planning (percent) NA 2009.1 Four-fifths of the population still subsists on less Source: Data compiled from multiple sources. than US $1.25 per day.2 a The 2005 MICS3 estimated maternal mortality ratio at 615. Burundi’s large share of youth population (39 percent of the country population is younger than 15 years old2) pro- vides a window of opportunity for high growth and poverty MDG target 5A: Reduce by three-quarters, between reduction—the demographic dividend. For this opportunity 1990 and 2015, the Maternal Mortality Ratio to result in accelerated growth, the government needs to in- Burundi has made insufficient progress over the past two de- vest more in the human capital formation of its youth. This cades on maternal health and is not on track to achieve its 2015 is especially important in a context of decelerated growth targets.5 rate arising from the global recession and the country’s high vulnerability to shocks and its rapid population growth. Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target Gender equality and women’s empowerment are important 1400 for improving reproductive health. Higher levels of women’s 1200 1175 1180 1160 1060 autonomy, education, wages, and labor market participation 1000 970 are associated with improved reproductive health outcomes.3 800 MDG In Burundi, the literacy rate among females ages 15 and 600 Target above is 59.9 percent.2 Fewer girls are enrolled in secondary 400 300 schools compared to boys with a 71 percent ratio of female 200 to male secondary enrollment.2 Ninety-two percent of adult 0 women participate in the labor force2 that mostly involves 1990 1995 2000 2005 2008 2015 work in agriculture. Gender inequalities are reflected in the Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. country’s human development ranking; Burundi ranks 147 of 157 countries in the Gender-related Development Index.4 World Bank Support for Health in Burundi Greater human capital for women will not translate into greater reproductive choice if women lack access to repro- The Bank’s current Country Assistance Strategy is for fiscal years 2009 to 2012. ductive health services. It is thus important to ensure that current projects: health systems provide a basic package of reproductive P109964 BI-Second HIV/AIDS MAP (FY08) ($10.05m) health services, including family planning.3 P101160 BI-Health Project (FY09) ($23m) pipeline project: None previous Health projects: P071371 BI-Multi Sec HIV/AIDS & Orph APL (FY02) THE WORLD BANK P078111 BI-Health & Pop SIL 2 Supl (FY03) n Key challenges (doctor, nurse. or midwife).8 However, a smaller proportion, 32 percent deliver with the assistance of skilled health personnel. High fertility While 54 percent of women in the wealthiest quintile delivered Fertility has decreased over time, although it remains high. with skilled health personnel, only 22 percent of women in the The total fertility rate (TFR) has decreased from an estimated 6.9 poorest quintile obtained such assistance (Figure 3). Additionally, births per woman in 19876 to 4.6 births per woman in 2008.2 The 28 percent of women with no education delivered with skilled forthcoming Burundi DHS 2010 will provide more recent infor- health personnel as compared to 84 percent of women with sec- mation on socio-economic disparities. ondary education or higher. Further, 47 percent of all pregnant women are anaemic (defined as haemoglobin < 110g/L) increas- Adolescent fertility rate is high affecting not only young ing their risk of preterm delivery, low birth weight babies, still- women and their children’s health but also their long-term birth and newborn death.9 education and employment prospects. Births to women aged 15–19 years old have the highest risk of infant and child mortality The forthcoming Burundi DHS 2010 will provide information as well as a higher risk of morbidity and mortality for the young on women’s perception on the barriers to accessing health care. mother.3, 7 In Burundi, there are 185 reported births per 1,000 women aged 15–19 years. Figure 3 n Birth assisted by skilled health personnel (percentage) by wealth quintile Less than a tenth of women use contraception. Current use of 60 53.7 contraception among married women was 9 percent in 2005 and 50 more married women use modern contraceptive methods than 40 31.8% overall traditional methods (7 percent and 2 percent).8 Injectables are the 29.2 30 27.6 27.8 most commonly used method among married women at 5 per- 22.7 20 cent. Use of long-term methods such as intrauterine device and 10 implants are negligible. There are socioeconomic differences in the use of modern contraception among women: it is 12 percent 0 Poorest Second Middle Fourth Richest among women in the highest wealth quintile and 6 percent among those in the poorest quintile (Figure 2). Similarly, just 5 percent of Source: MICS3 Final Report, Burundi 2005. women with no education use modern contraception as compared Human resources for maternal health are limited with only to 26 percent of women with secondary education or higher, and 7 0.03 physicians per 1,000 population but nurses and midwives are percent for rural women versus 16 percent for urban women. slightly more common, at 0.19 per 1,000 population.2 The forthcoming Burundi DHS 2010 will provide data on un- The high maternal mortality ratio at 970 maternal deaths per met need for contraception as well as reasons why women do not 100,000 live births indicates that access to and quality of emer- use contraception. gency obstetric and neonatal care (EmONC) remains a challenge.5 Figure 2 n Use of contraceptives among married women by wealth quintile StIs/HIv/AIDS prevalence is low but a growing public 16 health concern 14 12 2.3 The adult population that has HIV is estimated at 1.3 percent.2 9.1 Overall (All methods) 10 8 1.0 11.6 The forthcoming Burundi DHS 2010 might provide informa- 1.5 1.7 6 1.4 6.9 6.2 7.8 tion on HIV/AIDS-related knowledge, attitudes, and sexual 4 5.5 2 behaviour 0 Poorest Second Middle Fourth Richest Modern Methods Traditional Methods References: Source: MICS3 Final Report, Burundi 2005. 1. World Bank, Burundi Country Brief. . 2. World Bank. 2010. World Development Indicators. Washington DC. poor pregnancy outcomes 3. World Bank, Engendering Development: Through Gender Equality While majority of pregnant women use antenatal care, insti- in Rights, Resources, and Voice. 2001. tutional deliveries are less common. Over nine-tenths of preg- 4. Gender-related development index. Available at http://hdr.undp. nant women receive antenatal care from skilled health personnel org/en/media/HDR_20072008_GDI.pdf. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. technical Notes: 6. Enquête Démographique et de Santé au Burundi, Ministère de Improving Reproductive Health (RH) outcomes, as outlined in the l’Intérieur, Département de la Population, Gitega, Burundi and RHAP, includes addressing high fertility, reducing unmet demand for Institue for Resource Development/Westinghouse, Columbia, contraception, improving pregnancy outcomes, and reducing STIs. Maryland, USA, 1987. 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. The RHAP has identified 57 focus countries based on poor reproductive Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high priority countries as ics/adolescent_pregnancy/en/index.html. those where the MMR is higher than 220/100,000 live births and TFR is 8. MICS3: Enquête Nationale d’Évaluation des Conditions de vie de greater than 3.These countries are also a sub-group of the Countdown l’Enfant et de la Femme au Burundi – 2005, Rapport définitif, Institut to 2015 countries. Details of the RHAP are available at www.worldbank. de Statistiques et d’Études Économiques du Burundi (ISTEEBU), org/population. Vice-Ministère chargé de la Planification, UNICEF, UNFPA and World Bank. The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions 9. Worldwide prevalence of anaemia 1993–2005 : WHO global da- as the HDI while adjusting for gender inequality. Its coverage is limited tabase on anaemia / Edited by Bruno de Benoist, Erin McLean, to 157 countries and areas for which the HDI rank was recalculated. Ines Egli and Mary Cogswell. . n Key Actions to Improve RH outcomes Strengthen gender equality Reducing maternal mortality • Support women and girls’ economic and social empowerment. • During antenatal care, educate pregnant women about the im- Increase school enrollment of girls. Strengthen employment portance of delivery with a skilled health personnel and getting prospects for girls and women. Educate and raise awareness on postnatal check. Encourage and promote community partici- the impact of early marriage and child-bearing. pation in the care for pregnant women and their children. • Educate and empower women and girls to make reproduc- • Promote institutional delivery through provider incentives and tive health choices. Build on advocacy and community par- possibly, implement risk-pooling schemes. Provide vouchers ticipation, and involve men in supporting women’s health and to women in hard-to-reach areas for transport and/or to cover wellbeing. cost of delivery services. Reducing high fertility • Target the poor and women in hard-to-reach rural areas in the • Increase family planning awareness and utilization through provision of basic and comprehensive emergency obstetric care outreach campaigns and messages in the media. Enlist commu- (renovate and equip health facilities). nity leaders and women’s groups and emphasize community- • Address the inadequate human resources for health by training based distribution. more midwives and deploying them to the poorest or hard-to- • Provide quality family planning services that include coun- reach districts. seling and advice, focusing on young and poor populations. • Strengthen the referral system by instituting emergency trans- Highlight the effectiveness of modern contraceptive methods port, training health personnel in appropriate referral proce- and properly educate women on the health risks and benefits dures (referral protocols and recording of transfers) and estab- of such methods. lishing maternity waiting huts/homes at hospitals to accommo- • Promote the use of ALL modern contraceptive methods, in- date women from remote communities who wish to stay close cluding long-term methods, through proper counseling which to the hospital prior to delivery. may entail training/re-training health care personnel. Reducing StIs/HIv/AIDS • Secure reproductive health commodities and strengthen sup- • Integrate HIV/AIDS/STIs and family planning services in rou- ply chain management to further increase contraceptive use as tine antenatal and postnatal care. demand is generated. • Lower the incidence of HIV infections by strengthening Behavior Change Communication (BCC) programs via mass media and community outreach to raise HIV/AIDS awareness and knowledge. BURUNDI RepRoDUctIve HeALtH ActIoN pLAN INDIcAtoRS Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15–49) 2008 4.6 Population, total (million) 2008 8.1 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 185 Population growth (annual %) 2008 3 Contraceptive prevalence (% of married women ages 15–49) 2005 9.1 Population ages 0–14 (% of total) 2008 39 Unmet need for contraceptives (%) — — Population ages 15–64 (% of total) 2008 58.2 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 2.8 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 71.7 Mean ideal number of children for all women — — Urban population (% of total) 2008 10.4 Antenatal care with health personnel (%) 2005 92.5 Mean size of households — — Births attended by skilled health personnel (%) 2005 31.8 GNI per capita, Atlas method (current US$) 2008 140 Proportion of pregnant women with hemoglobin <110 g/L 2008 47.1 GDP per capita (current US$) 2008 144 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 1180 GDP growth (annual %) 2008 4.5 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 1180 Population living below US$1.25 per day 2001 81.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 1160 Labor force participation rate, female (% of female population ages 15–64) 2008 91.5 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 1060 Literacy rate, adult female (% of females ages 15 and above) 2008 59.9 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 970 Total enrollment, primary (% net) 2008 99.4 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 290 Ratio of female to male primary enrollment (%) 2008 95 Infant mortality rate (per 1,000 live births) 2008 102 Ratio of female to male secondary enrollment (%) 2008 70.6 Newborns protected against tetanus (%) 2008 78 Gender Development Index (GDI) 2008 147 DPT3 immunization coverage (% by age 1) 2008 92 Health expenditure, total (% of GDP) 2007 13.9 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 3.3 Health expenditure, public (% of GDP) 2007 5.2 Prevalence of HIV, total (% of population ages 15–49) 2007 2.0 Health expenditure per capita (current US$) 2007 17.3 Female adults with HIV (% of population ages 15+ with HIV) 2007 58.9 Physicians (per 1,000 population) 2004 0.03 Prevalence of HIV, female (% ages 15–24) 2007 1.3 Nurses and midwives (per 1,000 population) 2004 0.19 poorest-Richest poorest/Richest Indicator Survey Year poorest Second Middle Fourth Richest total Difference Ratio Total fertility rate — — — — — — — — — — Current use of contraception (Modern method) MICS3 2005 5.5 6.9 6.2 7.8 11.6 7.5 –6.1 0.5 Current use of contraception (Any method) MICS3 2005 6.9 8.4 7.9 8.8 13.9 9.1 –7.0 0.5 Unmet need for family planning (Total) — — — — — — — — — — Births attended by skilled health personnel MICS3 2005 22.7 27.6 27.8 29.2 53.7 31.8 –31.0 0.4 (percent) correspondence Details This profile was prepared by the World Bank (HDNHE, PRMGE, and AFTHE). For more information contact, Samuel Mills, Tel: 202 473 9100, email: smills@worldbank.org. This report is available on the following website: www.worldbank.org/population.