The Recent Fertility Transition in Rwanda Charles F. Westoff Rwanda is a small, poor country in Central Africa surrounded by the Democratic Republic of Congo, Uganda, Tanzania, and Burundi. With an estimated population of about 11 million, the country has the highest population density in the African continent (415 persons per square kilometer). In addition, at the beginning of the twenty-first century it had one of the world s highest population growth rates. However, during the first decade of this century, this country, commonly remembered for the genocidal massacres in 1994, has experienced a very rapid demographic transition. The government first became concerned about rapid population growth in 1982 when a National Office of Population was created to confront the problem and to promote family planning. In 1990, a formal policy with similar objectives was adopted, but progress came to a halt with the 1994 genocide in which an estimated 800,000 to one million persons were killed. Following this crisis, the promotion of birth control was unpopular for several years (BBC News 2007) because of the enormous loss of life during the mid-1990s. At the time it seemed difficult to believe that overpopulation would ever be a problem (Kinzer 2007). The genocide and the associated collapse of the health system reduced the total population from 7.1 million in 1990 to 5.6 million in 1995. This trend reversed quickly, however, and by 2000 the population had reached 8 million with a growth rate of 3 percent per year. As a result, concern about rapid population expansion returned and a new national population policy was issued in 2003. This policy was strongly endorsed by the country s female legislators, who have spent years pushing for a serious population control effort (Kinzer 2007). In the late 1990s, the reconstruction of a devastated health system resumed and by 2001 the Ministry of Health had implemented a national network of mutuelles, innovative community-based health insurance schemes supported by member premiums and government funding. Although family planning was not a primary focus, it grew in importance over time (Madsen 2011). Population and Development review 38 (Supplement): 169 178 (2012) 169 2013 The Population Council, Inc.
170 R e c e n t Fe rt i l i t y Tr a n s i t i o n in Rwa n d a This essay first examines the very rapid changes in reproductive behavior and preferences that have occurred over the past decade. Next, trends in socioeconomic characteristics and child mortality are discussed to elucidate these reproductive trends. The concluding section reviews government policies and program developments that appear to underlie these population changes. The demographic changes described below are based on national Demographic and Health Surveys (DHS) conducted in Rwanda in 1992, 2000, 2005, and 2010. Occasional reference will be made to an Interim survey in 2007 08, which first documented the striking developments that were subsequently confirmed in the 2010 DHS (Ayer and Hong 2009). Reproductive behavior Fertility Figure 1 plots the total fertility rate (TFR) in the three years before surveys conducted from 1992 to 2010. Between 1992 and 2000 the TFR declined from 6.2 to 5.8 before rebounding to 6.1 in 2005. The temporary decline in the late 1990s can plausibly be attributed to the disturbances caused by the civil war in the mid-1990s (Schindler and Brück 2011). The fertility effect of the crisis was moderated by the continued high fertility in refugee camps (Verwimp and Van Bavel 2005). Between 2005 and 2010, the total fertility rate dropped from 6.1 to 4.6, a 25 percent decline. A more current estimate of fertility trends uses data for the 12 months (instead of 36 months for the standard TFR) preceding the FIGURE 1 Trends in fertility and contraceptive use, 1992 2010 Births per woman 7 6 5 4 3 2 1 TFR Contraceptive use 0 1990 1995 2000 2005 2010 60 50 40 30 20 10 0 Contraceptive use (married women) SOURCE: DHS surveys.
C h a r l e s F. We s t o f f 171 surveys; this measure dropped 27 percent for all women and 33 percent for married women between 2005 and 2010. Family planning The recent decline in fertility is primarily the result of an expansion of the use of birth control; changes in proportions of women married and in the age at first birth, on the other hand, have been small. The use of contraception among currently married women rose sharply from 17 percent in 2005 to 52 percent in 2010 (see Figure 1). This new level is among the highest in sub-saharan Africa, placing Rwanda in a group of countries that includes Botswana, Lesotho, Malawi, Namibia, South Africa, and Swaziland. The primary method of contraception used in Rwanda is the injectable, which accounts for about half of all use. A multivariate analysis of the covariates of contraceptive use among married women shows strong associations with education and wealth and with having heard radio messages about the benefits of family planning. There seems to be little impact of religious affiliation, despite the opposition of the Catholic Church to controlling births (Wadhams 2010). The proportion of Catholics using modern contraceptive methods is actually higher than among Protestants (49 vs. 41 percent). Abortion is legal only on very restricted grounds. As a result, the abortion rate is low (25 abortions per 1,000 women of reproductive age) and has only a small impact on fertility (Basinga et al. 2012). Reproductive preferences and their implementation The number of children that Rwandan women consider ideal has declined from 4.9 to 3.3 over the past decade, with the most rapid change since 2005. Declines have occurred at all ages (Figure 2), but for young women under 30 the drop is much greater than among those over 30. The ideal number of children among cohorts of women also shows a sharp decline (not shown here). For example, the cohort born in 1981 85 desired an average of 5.1 children in 2000 (at ages 15 19), 4.1 in 2005 (at ages 20 24), and 3.2 in 2010 (at ages 25 29). These results are for all women. Confining the comparisons to currently married women does not change the picture. However, the pattern for nevermarried women shows an even more radical drop. Among never-married women ages 15 19, the average number of children desired declined from 5.1 in 2000 to 4.3 in 2005 and 2.7 by 2010. Large reductions are also evident for never-married women aged 20 34.
172 R e c e n t Fe rt i l i t y Tr a n s i t i o n in Rwa n d a FIGURE 2 Mean ideal number of children for all women by age in Rwanda in 2000, 2005, and 2010 6.0 5.5 Ideal number of children 5.0 4.5 4.0 3.5 3.0 2.5 2000 2005 2010 15 19 20 24 25 29 30 34 35 39 40 44 45 49 Age An alternative measure of preferences is the desire to stop childbearing. Figure 3 presents trends in proportions of women and men who want no more children (or who are sterilized) by their current number of living children. The shapes of the two sets of curves are similar and indicate a strong increase over time in the intention to terminate childbearing. These trends are fully consistent with the observed declines in desired family size. As expected, the downward trend in ideal family size is accompanied by a similar trend in the wanted total fertility rate (see Table 1). Between 2000 and 2010 the wanted TFR declined from 4.7 to 3.1 births per woman. Unwanted FIGURE 3 Trends in the percentage of married women and men in Rwanda who want no more children, by parity Want no more children (percent) 100 90 80 70 60 50 40 30 20 10 0 Women Men 4 4 3 3 2 2 2000 2005 2010 2000 2005 2010
C h a r l e s F. We s t o f f 173 Table 1 Trends in wanted and actual total fertility rates, Rwanda 2000 2010 Wanted total Year fertility rate a Total fertility rate 2000 4.7 5.8 2005 4.6 6.1 2007 08 3.7 5.5 2010 3.1 4.6 a The total wanted fertility rate is calculated in the same way as the standard total fertility rate, except that the numerator excludes unwanted births. fertility remains substantial, which suggests a potential for further declines in actual fertility when women control their fertility more fully. Preference implementation The decline in desired family size has led to a rise in the demand for contraception to avoid unplanned pregnancies. Figure 4 plots trends in the demand for contraception as measured by the proportion of women at risk of pregnancy who do not want to get pregnant. Between 2000 and 2010 this demand FIGURE 4 Trends in the demand for family planning, unmet need, and the percentage of demand satisfied, currently married women in Rwanda, 2000, 2005, and 2010 100 90 80 2000 2005 2010 70 Percent 60 50 40 30 20 10 0 Demand Unmet need Percent of demand satisfied NOTE: Demand is the sum of unmet need and contraceptive use. SOURCE: Demographic and Health Surveys, Rwanda: 2000, 2005, 2010.
174 R e c e n t Fe rt i l i t y Tr a n s i t i o n in Rwa n d a rose from 49 to 76 percent of exposed women. Among these women who do not want to get pregnant, some are not using contraception, resulting in a so-called unmet need for contraception (the second set of bars). Unmet need was high in 2000 and 2005 (36 and 38 percent) but dropped to 24 percent in 2010, as a result of a sharp rise in contraceptive use. The last set of columns in Figure 4 shows the percent of the demand for contraception that is satisfied (i.e., the percent of women at risk of pregnancy who are using contraception). It rose from 26 to 69 percent between 2000 and 2010. This indicates an increase in the implementation of preferences as actual use of contraception catches up with demand. Socioeconomic change The trends in reproductive behavior and preferences described above are in part a response to social and economic changes underway in Rwanda. One of the most important of these changes has occurred in education. Between 2005 and 2010 the proportion of women with no formal schooling dropped from 23 to 15 percent, while school attendance above the primary level increased from 10 to 16 percent. A similar picture appears for men, with the percentage with no schooling declining from 17 to 10 percent and the percentage with more than primary school increasing from 11 to 20 percent. Improvements in education levels are even larger among younger men and women. Social change is also driven by increased exposure to mass media, particularly the radio. Between 2000 and 2010 proportions reporting at least weekly exposure to radio rose from 39 to 68 percent among women and from 63 to 87 percent among men. Exposure to television is still low but rising, reaching 9 percent for women and 24 percent for men in 2010 (when only 10 percent of households had electricity). The spread of the mobile phone now owned by 40 percent of households has also become an important source of social interaction and change. Education and mass media exposure have been shown in many countries to influence contraceptive behavior and the number of children desired (Westoff and Koffman 2011). In Rwanda in 2010, the odds of using a contraceptive method increased strongly with increasing education, while the main influence of radio seems to lie in having heard messages about the advantages of family planning. Rapid economic growth in recent years has undoubtedly also contributed to reproductive change. During the civil war of the mid-1990s gross domestic product declined, but after 1996 Rwanda experienced a steady economic recovery. Since 2002, the economy has grown at around 4 percent annually, reaching 8 percent by 2010. Nonetheless, about half of the population still lives in extreme poverty (Kinzer 2007).
C h a r l e s F. We s t o f f 175 A final factor with a likely impact on reproductive behavior is the recent decline in child mortality. The mortality of children under age five dropped from 196 per 1,000 live births in 2000 to 152 in 2005 (back to pre-war levels) and then to 76 in 2010. These are substantial declines, especially the 50 percent drop between 2005 and 2010. The 2010 DHS report attributes this decline to the implementation of integrated management of childhood illness in health facilities and communities and also the introduction of new vaccines (National Institute of Statistics 2012). As the chances of child survival rise, parents feel less need to have many children to ensure the survival of a few. The family planning program The new national population policy developed in 2003 embedded a reinvigorated family planning program within general social and economic development goals. The effort to reduce the birth rate was seen as essential to improving the quality of life for the Rwandan population. Initially there were sensitivities about promoting birth control after nearly a million deaths in the 1994 genocide, but the new policy was a broad-based effort to respond to a rapidly expanding population. Political opposition diminished greatly with the strong leadership of President Kagame and with the increased recognition of the positive effects of family planning in various sectors including health, environment, education, and women s status. A 2008 review of the policy emphasized the environmental connections: As population pressure is one of the key drivers of environmental degradation and poverty, the implementation of the population policy, especially aspects that address high fertility rates, gender and reproductive health, migration and human settlements, constitute important triggers for sustainable natural resources management is important (sic) (Rwanda State of Environment and Outlook 2009, p. 13). These efforts followed the publication of Rwanda Vision 2020, an influential report published in 2000 that set development goals for Rwanda. The report s section on population refers to the high annual population growth rate, then close to 3 percent. It notes that family planning is crucial for reducing birth rates as well as the prevalence of HIV/AIDS. Targets included a TFR of 5.5 for 2010 and 4.5 for 2020. The 2010 target has already been surpassed with a rate of 4.6 in 2008 10. In the more recently proposed new set of targets, the TFR was set at 3.4 for 2020 (Cabinet Paper for Revised Vision 2020, p. 6). The National Reproductive Health Priority policy of 2003 is described by the Ministry of Health as a key part of Rwanda s commitment to the United Nations Millennium Development Goals (Ministry of Health 2006). The document asserts that unplanned fertility fuels a rate of population growth that is outpacing economic production... constituting a real hindrance to the achievement of the Vision 2020 to reduce poverty. Family planning is regarded as a key intervention; fertility concerns will be mainstreamed into
176 R e c e n t Fe rt i l i t y Tr a n s i t i o n in Rwa n d a health information and adult literacy courses in 2020 ; and the Government will ensure the availability of reproductive health services at the district level. The policy set the objective of 15 percent use of modern contraceptive methods by 2010, an objective that was greatly surpassed by the 2010 DHS estimate of 45 percent. Another objective, only partly realized by 2010, is the provision of a full range of methods, including sterilization. The National Family Planning Policy also calls for coordination among different government agencies and for the mobilization of Rwanda s parliamentarians to assume leadership roles in the advocacy of family planning. The latter task is made easier by the strong female presence in the parliament (56 percent female is the highest proportion in the world). The policy planned to launch a national targeted media campaign to increase public information about family planning (p. 16) and to ensure that private health providers include family planning within their services. Media activities maintain the visibility of the government s commitment to family planning: The Rwandan leaders have the duty of mobilizing the population about family planning activities at all levels of government and civil society. Furthermore, the Ministry of Health intends to integrate family planning into youth centers and clubs, to increase the involvement of men, and to train teachers to provide family planning education in nurseries, schools, and universities. According to the 2010 DHS, 91 percent of current contraceptive users obtain their supplies at government facilities. This statistic confirms the key role of the government s family planning program in providing women with access to contraceptive services. In addition, the program s media campaigns have undoubtedly contributed to the observed decline in desired family size. The widespread promotion of family planning has sensitized men and women to the advantages of having fewer children. A study based on the Rwanda 2005 DHS (Ndaruhuye, Broekhuis, and Hooimeijer 2009) demonstrated this effect: As our findings show, the dissemination of information about family planning through personal contact at health centers contributes to a high level of desire for family limitation. The costs of all of these activities, including the provision of contraceptive supplies, are being met partly through an increase in health insurance and partly through support from several international donors. How did all of this happen? This is a question posed by Julie Solo, who interviewed around 40 key informants and visited several health centers in an effort to identify factors that contributed to the program s success (Solo 2008). First is the fact that top governmental officials recognized the importance of limiting population growth to reduce poverty and to develop the country. President Kagame declared family planning to be a national priority, and, in the words of the Minister of
C h a r l e s F. We s t o f f 177 Health, Family planning is priority number one not just talking about it, but implementing it. Government officials promote the small-family ideal, which is communicated on the radio and through other means of community outreach. One of the key events that led policymakers to this commitment was a 2005 presentation of the RAPID model to parliamentarians. This model, developed by the Futures Group, communicated the advantages of smaller families for the country s economic, health, and educational goals. Another critical factor was the emphasis on coordinating family planning efforts among numerous governmental agencies and private organizations. Family planning has been integrated into all health services including HIV/AIDS programs and immunization programs. The Ministry of Health is committed to this coordination, and a consensus has developed around these concerns among the different agencies in recent years (Thaxton 2009) Finally, family planning services, including contraceptives, are free in Rwanda. This is in part due to the support of international donors. For example, USAID has funded contraceptive supplies and UNFPA provides support for training family planning workers. Conclusion Rwanda has made rapid strides toward the goal of providing universal access to reproductive health and family planning. The driving force has been the strong political determination of the country s leaders since the early 2000s to reduce the rate of population growth to promote economic development and reduce poverty. On the occasion of the 2011 London summit on family planning, the prime ministers of Rwanda and Ethiopia noted that family planning makes a major contribution to improving the health of mothers and children, while also empowering women to participate more in economic productivity and also helps to slow the high levels of population growth (Habumuremyi and Zenowi 2012). Strong governmental leadership coupled with concerns about the economic consequences of rapid population growth has also led to substantial expansions of family planning activities in a few other sub- Saharan African countries, in particular in Ethiopia and Malawi. In Nigeria a new National Population Commission has been established following the president s expression of concern about population growth. Many more African countries could benefit from Rwanda s experience.
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