RepROducTive HealtH 62917 at a GLANce May 2011 BOTSWANA country context Botswana: MdG 5 Status Botswana gained independence in 1966 and has transitioned MdG 5A indicators from one of the world’s poorest nations to one of the fast Maternal Mortality Ratio (maternal deaths per 100,000 live 190 growing economies in the world, enjoying a growth rate aver- births) UN estimatea aging 13 percent, largely due to diamond mining. Botswana’s Births attended by skilled health personnel (percent) 94.6 steady economic growth has enabled improvements to infra- MdG 5B indicators structure, health, and education programs.1 Health facilities Contraceptive Prevalence Rate (percent) 52.8 are located within 8 to 15 kilometers of all Batswana and 98 percent of the population has access to safe drinking water.2 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 51.4 Antenatal care with health personnel (percent) 94.1 Botswana’s large share of youth population (34 percent of Unmet need for family planning (percent) — the country population is younger than 15 years old3) pro- vides a window of opportunity for high growth and poverty Source: Table compiled from multiple sources. a The Botswana Central Statistics Office estimate for year 2009 is 190. reduction—he demographic dividend. But for this opportu- nity to result in accelerated growth, the government needs to invest in the human capital formation of its youth. This is MdG Target 5A: Reduce by Three-quarters, between especially important in a context of decelerated growth rate arising from the global recession and the country’s expo- 1990 and 2015, the Maternal Mortality Ratio sure to high volatility in commodity prices. Botswana has made insufficient progress over the past two de- cades in reducing maternal mortality and is not yet on track to Gender equality and women’s empowerment are impor- achieve its 2015 targets.6 The HIV/AIDS epidemic contributed tant for improving reproductive health. Higher levels of to the increased AIDS deaths. women’s autonomy, education, wages, and labor market par- ticipation are associated with improved reproductive health Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target outcomes.4 350 310 In Botswana, the literacy rate among females ages 15 and 300 280 250 above is 84 percent. More girls are enrolled in secondary MDG 200 190 schools compared to boys with a ratio of female to male sec- Target 150 130 ondary enrollment of 106 percent.3 Three-quarters of adult 100 83 women participate in the labor force.3 Gender inequalities 50 21 are reflected in the country’s human development ranking; 0 Botswana ranks 109 of 157 countries in the Gender-related 1990 1995 2000 2005 2008 2015 Development Index.5 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. Economic progress and greater investment in human capital of women will not necessarily translate into bet- ter reproductive outcomes if women lack access to repro- ductive health services. It is thus important to ensure that World Bank Support for Health in Botswana health systems provide a basic package of reproductive The Bank’s current Country Assistance Strategy is for fiscal years 2009 to 2013. health services, including family planning.4 current project: P102299 BW-HIV/AIDS Project SIL (FY09) ($42.4m) pipeline project: None previous Health project: None THE WORLD BANK n Key challenges Figure 3 n use of contraceptives among married women by year 70 High fertility 60 60.8 2.6 50 Fertility has been declining over time but remains high among 40 8.0 0.3 41.1 the poorest. Total fertility rate (TFR) dropped significantly since 30 33.9 20 7.5 1981, from 7.1 births per woman to 2.9 in 2007—the sharpest 10 16.0 decline in TFR in sub-Saharan Africa during that time period.2 A 0 main contributor to this decline was the country’s strong national 1985 1988 1996 2007 family planning program.2 However, fertility remains relatively Modern Methods Traditional Methods high among Batswana women with no formal education at 5.8 Source: Botswana Family Health Survey IV Report 2007. compared to 3.3 among women with secondary education and 2.6 for those with a university education. The TFR is also lower Abortion became legal in Botswana in 1991. It must be con- among city and town dwellers at 2.4, compared to 4.6 among ru- ducted by a medical doctor in a health facility during the first ral women.2 16 weeks of pregnancy, and another doctor must also provide written consent. It can take place under one of three condi- Figure 2 n Total fertility rate, 1981-2007 (selected years) tions: in cases of rape or incest, if childbearing poses a risk to the woman’s physical or mental health, or if there is, or is a risk 8 7.1 7.1 7 of, fetal impairment. Sixteen percent of maternal deaths in 2007 6 5 5.0 were caused by septic abortion. Unsafe abortions were a major 4.2 4 3.4 3.3 3.2 2.9 cause of maternal mortality when abortion was illegal before 3 2 1991.2 1 0 Health problems and opposition to use are major reasons 1981 1984 1988 1991 1998 2001 2006 2007 women not currently using contraceptives do not intend to Source: Fertility Decline in Botswana report, 2010. use them in future. Twenty-three percent not intending to use contraception cited health concerns as the main reason while 5 Adolescent fertility adversely affects not only young wom- percent expressed opposition to use, 5 percent expressed that the en’s health, education and employment prospects but also that husband/partner disapproved, and 4 percent cited religion.1 Cost of their children. Births to women aged 15–19 years old have the and access are much lesser concerns, indicating further need to highest risk of infant and child mortality as well as a higher risk strengthen demand for family planning services. of morbidity and mortality for the young mother.4, 7 In Botswana, adolescent fertility rate is moderate at 51 births per 1,000 women aged 15–19 years. poor pregnancy Outcomes Use of modern contraception is increasing. Because of Majority of pregnant women use antenatal care and have Botswana’s strong family planning program, use of modern con- institutional deliveries. Over nine-tenths of pregnant women traceptives among all women 15–49 increased during the last three receive antenatal care from skilled medical personnel (doctor, decades from 16 percent in 1984 to 29 percent in 1988, 40 percent nurse, or midwife) with 73 percent having the recommended in 1996, and 51 percent in 2007.2 Use of traditional methods of four or more antenatal visits.1 95 percent of women deliver with contraception decreased from 7.5 percent in 1984 to 2.6 percent the assistance of skilled medical personnel. While 98 percent of in 2007.2 Male condoms are the most commonly used method of women with secondary education delivered with skilled health contraception (42 percent), followed by injectables (7 percent) personnel, 80 percent of women with no formal education and oral contraceptives (6 percent). Use of long-term methods obtained such assistance (Figure 4).1 One fifth of all pregnant such as intrauterine device and implants are negligible. The use of women are anaemic (defined as haemoglobin < 110g/L) in- male condoms increased from 1 percent in 1984 to 11 percent in creasing their risk of preterm delivery, low birth weight babies, 1996 and 42 percent in 2007. This increase has been attributed to stillbirth and newborn death.8 an effective multimedia dual protection HIV campaign.2 Figure 4 n Birth assisted by skilled health personnel (percentage) Due to free anti-retrovirals being made available since 2002, by education level of mother 91 percent of women living with HIV are now receiving the 100 antiretroviral drugs necessary to help prevent transmission to 97.8 80 94.6% Overall 87.7 their child. HIV/AIDS services have been integrated into family 80.2 planning and maternal and child health services since the 1990’s. 60 Additionally, routine HIV testing has been available in all public 40 hospitals since late in 2003. 20 0 No formal education Primary education Secondary education Source: Botswana Family Health Survey IV Report 2007. Technical Notes: Human resources for maternal health are limited with 0.4 Improving Reproductive Health (RH) outcomes, as outlined in the physicians per 1,000 population but nurses and midwives are RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs. more common, at 2.65 per 1,000 population.3 The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health Hiv prevalence is high in Botswana systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 live births and TFR is HIV prevalence is high at 17.6 percent9 and women are one of greater than 3.These countries are also a sub-group of the Countdown the most vulnerable groups. Nearly one-quarter of the popula- to 2015 countries. Details of the RHAP are available at www.worldbank. tion ages 15 and above is HIV positive. Of the HIV positive popu- org/population. lation, 61 percent are women of childbearing age. The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions Reductions in prevalence are most prominent in youth ages as the HDI while adjusting for gender inequality. Its coverage is limited 15–19 and 20–24.10 Prevalence has decreased in youth ages 15–19, to 157 countries and areas for which the HDI rank was recalculated. from 6.5 percent in 2004 to 3.7 percent in 2008. Prevalence has also decreased significantly in the 20–24 age range, from 19 percent in 2004 to 12.3 percent in 2008.11 National policies and strategies that have influenced reproductive health 1973 The Maternal and Child Health/Family Planning (MCH/FP) Unit 1994 The Family Planning General Policy Guidelines and Service (under Primary Health care) is established. Family planning is integrated Standards are reviewed. into maternal and child health from the outset. 1997 National Population Policy is developed, with a goal to decrease 1979 The MCH/FP Unit, along with the nutrition and health education the total fertility rate from 4.0 (in 1996) to 3.4 by 2011. (This goal was units, becomes the Family Health Division. achieved by 2009.) 1984 MCH/FP services begin to be offered daily at most health facilities. 1996 Family Planning Procedures Manual is developed. 2000 Adolescent 1987 Family Planning Policy Guidelines and Service Standards are Sexual & Reproductive Health: A Trainers Manual is developed for developed. service providers. 1988 Botswana Population Sector Assistance Project begins (runs 2002 Department of Public Health is reorganized. MCH/FP Unit becomes through 1996). the Sexual and Reproductive Health Division. 1998 Family life education is introduced into the school curriculum. 2003 Adolescent Sexual and Reproductive Health Implementation Strategy is developed. 1989 Family planning logistics manual (contraceptive commodities and drugs) is developed. 2001 Marriage Act 2001 is enacted, raising the legal age for marriage from 14 to 18 with parental consent and to 21 if there is no parental consent. 1989 National AIDS Control Program is established. 2006 Maternal death is classified as a notifiable event (recommendation 1991 Abortion is made legal through the Penal Code (Amendment) Act submitted for Public Health Act). of 1991 in any of these three circumstances: rape or incest; to save a woman’s life; or fetal impairment. Two doctors must consent, and the 2008 Family planning manual and family planning trainers manual procedure must be done in the first 16 weeks of pregnancy. (Adolescent Sexual & Reproductive Health) are revised. 2008 A strategy for reproductive health commodity security is finalized. n Key Actions to improve RH Outcomes Strengthen gender equality • Strengthen post-abortion care (treatment of abortion compli- • Support women and girls’ economic and social empowerment. cations with manual vacuum aspiration, post-abortion family Increase school enrollment of girls. Strengthen employment planning counseling, and appropriate referral where necessary) prospects for girls and women. Educate and raise awareness on and link it with family planning services. the impact of early marriage and child-bearing. • Educate and empower women and girls to make reproductive Reducing maternal mortality health choices. Build on advocacy and community participation, • Address the inadequate human resources for health by training and involve men in supporting women’s health and wellbeing. more midwives and deploying them to the poorest or hard-to- reach districts. Reducing high fertility • Strengthen the Sexual and Reproductive Health Division’s • Address the issue of opposition to use of contraception and pro- Monitoring and Evaluation (M&E) Unit. Ensure adequate mote the benefits of small family sizes. Increase family planning staffing and training of the M&E Unit to produce timely re- awareness and utilization through outreach campaigns and mes- ports and ensure accuracy and completeness of data on sexual sages in the media. Enlist community leaders and women’s groups. and reproductive health. • Provide quality family planning services that include coun- seling and advice, focusing on young and poor populations. Reducing STis/Hiv/AidS Highlight the effectiveness of modern contraceptive methods • Integrate HIV/AIDS/STIs and family planning services in rou- and properly educate women on the health risks and benefits of tine antenatal and postnatal care. such methods. Make information, education and communica- • Focus HIV/AIDS providing information, education and com- tions materials more available at MCH/FP clinics. munication efforts on adolescents, youth, married women, and • Promote the use of ALL modern contraceptive methods, in- other high risk groups including IDUs, sex workers and their cluding long-term methods, through proper counseling which clients, and migrant workers. may entail training/re-training health care personnel. • Strengthen the integration of sexual and reproductive health • Secure reproductive health commodities and strengthen sup- (including family planning) and HIV/AIDS services. These are ply chain management to further increase contraceptive use coordinated by different departments within the Ministry of as demand is generated. Strengthen the contraceptive logistics Health, and there is a need to strengthen their integration and management information system. collaboration. References: 1. Central Statistics Office and UNICEF. 2007 Botswana Family Health Ines Egli and Mary Cogswell. . 2. Mills, Samuel, Leburu, Veronica, El-Halabi, Shenaaz, Mokganya, 9. Central Statistics Office (CSO). 2008. Botswana AIDS Impact Lesego, and Chowdhury, Sadia. May 2010. Fertility Decline in Survey III (BAIS III). Preliminary Results, Stats Brief, No. 2009/8, Botswana 1980–2006: A Case Study. The World Bank. www.world- May 2009. Gaborone, Botswana. bank.org/population. 10. Ministry of State President. National AIDS Coordinating Agency. 3. World Bank. 2010. World Development Indicators. Washington DC. Government of Botswana Country Report, General Assembly 4. World Bank, Engendering Development: Through Gender Equality Special Session on HIV/AIDS. 2007. in Rights, Resources, and Voice. 2001. 11. Botswana AIDS Impact Survey III (BAIS III), 2008. 2009. Central 5. Gender-related development index. Available at http://hdr.undp. Statistics Office. Gaborone, Botswana. org/en/media/HDR_20072008_GDI.pdf. 6. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. correspondence details 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. This profile was prepared by the World Bank (HDNHE, PRMGE, and Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- AFTHE). For more information contact, Samuel Mills, Tel: 202 473 9100, ics/adolescent_pregnancy/en/index.html. email: smills@worldbank.org. This report is available on the following 8. Worldwide prevalence of anaemia 1993–2005: WHO global da- website: www.worldbank.org/population. tabase on anaemia / Edited by Bruno de Benoist, Erin McLean, BOTSWANA RepROducTive HeALTH AcTiON pLAN iNdicATORS indicator Year Level indicator Year Level Total fertility rate (births per woman ages 15–49) 2007 2.9 Population, total (million) 2008 1921122 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 51.4 Population growth (annual %) 2008 1.5 Contraceptive prevalence (% of married women ages 15–49) 2007 52.8 Population ages 0–14 (% of total) 2008 33.7 Unmet need for contraceptives (%) — — Population ages 15–64 (% of total) 2008 62.6 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 3.7 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 59.8 Mean ideal number of children for all women — — Urban population (% of total) 2008 59.6 Antenatal care with health personnel (%) 2007 94.1 Mean size of households 2006 4.2 Births attended by skilled health personnel (%) 2007 94.6 GNI per capita, Atlas method (current US$) 2008 6,640 Proportion of pregnant women with hemoglobin <110 g/L 2008 21.3 GDP per capita (current US$) 2008 6,982 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 83 GDP growth (annual %) 2008 2.9 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 130 Population living below US$1.25 per day — — Maternal mortality ratio (maternal deaths/100,000 live births) 2000 310 Labor force participation rate, female (% of female population ages 15–64) 2008 75.1 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 280 Literacy rate, adult female (% of females ages 15 and above) 2008 83.5 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 190 Total enrollment, primary (% net) 2006 89.5 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 21 Ratio of female to male primary enrollment (%) 2006 97.9 Infant mortality rate (per 1,000 live births) 2008 26 Ratio of female to male secondary enrollment (%) 2006 105.7 Newborns protected against tetanus (%) 2008 85 Gender Development Index (GDI) 2008 109 DPT3 immunization coverage (% by age 1) 2008 96 Health expenditure, total (% of GDP) 2007 5.71 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 53.9 Health expenditure, public (% of GDP) 2007 4.26 Prevalence of HIV, total (% of population ages 15–49) 2007 23.9 Health expenditure per capita (current US$) 2007 372 Female adults with HIV (% of population ages 15+ with HIV) 2007 60.7 Physicians (per 1,000 population) 2004 0.4 Prevalence of HIV, female (% ages 15–24) 2007 15.3 Nurses and midwives (per 1,000 population) 2004 2.65 poorest-Richest poorest/Richest indicator Survey Year poorest Second Middle Fourth Richest Total difference Ratio Total fertility rate BFHS 2007 — — — — — 2.9 — — Current use of contraception (Modern method) BDS 2006 — — — — — 28.9 — — Current use of contraception (Any method) BFHS 2007 — — — — — 52.8 — — Unmet need for family planning (Total) — — — — — — — — — — Births attended by skilled health personnel BFHS 2007 — — — — — 94.6 — — (percent)