The presentation of the context of this research is important to clarify the problem and deepen the understanding of the issue of maternal mortality. The context in which the study is undertaken and location of the target population support the importance and need for such research. In this section, the context of Burkina Faso in relation to maternal mortality is highlighted.
1.2.1 Presentation of Burkina Faso
Brief presentation at national scale
Burkina Faso is a West African country bordered by Ghana, Cote d’Ivoire, Mali, Niger, Togo and Benin (Figure 1.1). According to the last census, the country had 14 017 626 inhabitants in 2006 on a surface of 274 200 km2 (Ouedraogo and Ripama, 2009).
Figure 1.1: Administrative division of Burkina Faso per region
Source: http://www.planete-burkina.com/geographie_burkina.php
The population of the country is characterised by a preponderance of females, youngsters and people living in rural areas with agriculture as the principal activity. Indeed, half of the entire population of the country is below 15.5 years old and around 52 % are female (Ouedraogo and Ripama, 2009).
Figure 1.2: Age pyramids of Burkina Faso from 1975 to 2006
Source: census 1975, 1985, 1996 and 2006
The figure 1.2 clearly shows that the age and sex structure of the population in Burkina Faso has not changed that much since 1975. The predominance of women at reproductive age is also a sign of potential high risk of maternal mortality and high fertility level. In fact, the age pyramids of the population since 1975 indicate a low change in the fertility rate and remaining efforts in term of fertility transition in the country. The rapid demographic growth associated with the youth of the population mainly female, reflects a high demand for reproductive health care. The rural area still hosts about 80
% of the entire population of the country despite the progressive increase of rural exodus. In fact, the urbanization rate is 22.7 % according to the last census 2006 (Ouattara, 2009).
The population size and particularly the population growth constitute a serious concern in the country.
Indeed, the population size changed from 5 638 203 to 7 984 705 and 10 312 609 inhabitants in 1975, 1985 and 1996 respectively (figure 1.3). The annual population growth rate passed from 2.7 % in 1985 to 2.4 % in 1996 and 3.1 % in 2006 (figure 1.3). The current annual population growth rate is among the highest in the world and at this speed, the population of the country is going to double in 22 years.
The problem lies in the important gap between the increase of population size and available economical resources. In consequence, this demographic pressure is the main source of important unmet needs in education, health and other development aspects. Indeed, the population growth annihilates most of the efforts made by authorities to maintain a sustainable development in the country. In this context, the fight against maternal mortality is also affected by a very limited budget and a lot of challenges.
Figure 1.3: Population growth from 1975 to 2006
Source: census 1975, 1985, 1996 and 2006
The annual population growth in Burkina Faso is among the highest in the world while the country is among the poorest in the world. The UNDP ranked Burkina Faso among the 10th lowest developed country in the world along with Liberia, Tchad, Mozambique, Burundi and the Democratic Republic of Congo during the period 2005-2011 (table 1.1).
Table 1.1: Human development Index (HDI)
Rank HDI Country 2005 2006 2007 2008 2009 2010 2011
.. HDI very high 0.876 0.879 0.882 0.885 0.885 0.888 0.889 .. HDI medium 0.587 0.595 0.605 0.612 0.618 0.625 0.63
.. HDI weak 0.422 0.43 0.437 0.443 0.448 0.453 0.456
181 Burkina Faso 0.302 0.307 0.313 0.321 0.326 0.329 0.331
182 Liberia 0.3 0.298 0.319 0.328 0.32 0.325 0.329
183 Tchad 0.312 0.311 0.313 0.316 0.323 0.326 0.328
184 Mozambique 0.285 0.29 0.299 0.304 0.312 0.317 0.322
185 Burundi 0.267 0.281 0.289 0.301 0.308 0.313 0.316
186 Niger 0.265 0.269 0.273 0.282 0.285 0.293 0.295
187 Congo, RD Congo 0.26 0.266 0.271 0.27 0.277 0.282 0.286
Source: UNDP (2011)
The values of the Human Development Index (HDI) in the country have always been below the average of the world (UNDP, 2011). In addition to the macro indicators presented in table 1.1, table 1.2 also highlights another dimension of the level of poverty in the population.
In Burkina Faso, the poverty line is increasing and the headcount index is decreasing but still high. The headcount index is the proportion of the population living below the poverty line. Table 1.2 shows that the percentage of people living in poor conditions, changed from 46.4 % in 2003 to 42.6 % in 2007 through 42.1 % in 2006. In other words, more than 2 people out of 5 were living under the poverty line during the period 2003-2007. In fact, the GDP per capita was 1060 and 1 078 dollars in 2006 and 2009 respectively (World Bank, 2011).
Table 1.2: Poverty indicators
Indicators 1994 1998 2003 2004 2005 2006 2007 2009
Absolute poverty line (in FCFA) 41 099 72 690 82 672 82 347 87 609 89 712 91 598 108 454
Headcount index (%) 44.5 45.3 46.4 46.6* 43.0* 42.1* 42.6* 43.9
Source: Tableau de bord social,2008, INSD, Enqutes prioritaires 1994 et 1998, Enqute burkinab´e sur les conditions de vie des m´enages 2003, Ministry of finance and economy
* Estimates from macro economy simulation and poverty analysis
The high level of poverty in the country and particularly female poverty also has its roots in the rapid population growth for a limited territory in a context where the main activity is based on land work.
One of the consequences of the rapid population growth is the increase in the population density to 51.4 inhabitants per km2 in 2006. The continuous increase of people influences the availability of arable land where agriculture is still traditional using manual techniques. The surface of the country is fixed but the population size is always growing, therefore problems arise concerning land accessibility and property.
In many traditions, women in rural areas are not allowed to possess their own land. That is why women are generally the first to suffer from the lack of land. This could be among the reasons of the enormous poverty among them. The lack of money also limits access to health services.
The rapid growth of the population is mainly due to the high level of fertility and the continuous decrease of mortality while the level of migration is still negligible. The level of fertility is dropping in Burkina Faso but very slowly and the level is still among the highest in the world. The crude birth rate was 45.8
% in 2006 and the total fertility rate (TFR) was 6.1, 6.7, 7.2, 6.8 and 6.2 children per woman in 1961, 1976, 1985, 1996 and 2006 respectively (table 1.4). Therefore, in 2006 a young Burkinab`e female was likely to face the risk of maternal death 6.2 times during her life time.
Figure 1.4: Fertility trend in Burkina Faso
Source: Census Burkina Faso 2006 Dakuyo L. M. (2009)
The high exposure to maternal deaths is combined with other risks of death due to the precariousness of the health system. The country recorded an improvement in life expectancy, rising from 54 years in 1996 to 56.7 years in 2006, thus two years expectancy gained in 10 years (Banza and Bonkoungou, 2009).
However, the health services in the country are still poor and need a lot of improvement compared to other countries in the world. Despite the important increase in the number of health professionals in the country, all the indicators in the table 1.3 show that the WHO’s norms in terms of number of inhabitants per health professional are far from being met. Indeed, there were 23 726 inhabitants per midwife in 2006 while the WHO fixed the acceptable limit at 5000 (table 1.3).
Table 1.3: Number of people per health professional
Health personnel WHO norms 2001 2002 2003 2004 2006 2007 Physicians 10000 36311 24744 37981 36439 56003 32496
midwives 5000 29158 21050 28163 25243 30580 23726
State nurses 5000 7588 7141 7142 6413 8854 6129
Auxiliary nurses 3000 8553 8126 7891 7333 8227 7448
Source: Statistics yearbook, Burkina Faso
This situation indicates the need for midwives and improved service delivery for pregnant women. Un-fortunately, the same situation or even worse exists regarding the availability of physicians, state nurses and auxiliary nurses.
In addition to the availability of health professionals, the problem of the accessibility of existing health services should also be mentioned because having facilities and making use of them are two different things. The lack of health services can be expressed in terms of distance to the closest health facility.
The Theoretical Mean Action Radius (TMAR) is a good indicator to measure the mean distance to the closest health centre. The initiative of Bamako fixed the maximum acceptable distance at 5 Km. Table 1.4 shows that the TMAR decreased from 9.18 to 9.07, 7.83 and 7.69 in 2001, 2002, 2006 and 2007 but is still far from the target of 5 km. The long distance to health centres (more than 5 Km) constitutes an obstacle to the access and willingness to use health facilities.
The number of assisted deliveries is an indicator of maternal mortality level related to the access and use of health centres. From 2001 to 2007, the percentage of assisted deliveries increased but still remains low (table 1.4). During the period from 2001 to 2006, more than half of deliveries were not assisted by a health professional but in 2007 the percentage of assisted deliveries was 54.6 %. The improvement of assistance at delivery is not enough because the lower level observed within 7 years was slightly 2 out of 5 deliveries without any assistance from a qualified person (table 1.4).
The poor use of health services can also be explained by the budget allocated to health and the amount
Table 1.4: Indicators of access to health services
Indicators 2001 2002 2003 2004 2005 2006 2007
TMAR 9.18 9.07 8.68 8.34 8.19 7.83 7.69
Assistance at delivery (%) 36.09 39.9 43.69 43.45 54.24 42.9 54.63 Health budget (% in national) 6.3 7.1 7.2 7.4 11.77* 7.8 8.34
Source: Statistics yearbook, Burkina Faso
*: concerns the percentage in the national budget excluded the loan directed to health
allocated to deliveries and other obstetrical services. Indeed, WHO recommends that 10 % of the budget of countries should be allocated to health. But, Burkina Faso is still far from considering this recommendation. However, we noted that this indicator is continuously increasing from 6.3 % in 2001 to 8.3 % in 2007 through a level of 7.8 % in 2006 (table 1.4).
The high level of fertility, inadequate use of health centres and high level of poverty is also reflected in the educate the population. Indeed, the level of education in Burkina Faso is low and the quality of education also needs improvement. Table 1.5 shows that the highest level of literacy in the country was 28.3 % in 2007. The level of literacy in the country has constantly increased since 1975 but is still very low. Indeed, a lower number of females are able to read and write in any language compared to males. The difference is about 10 %. Table 1.6 presents information about formal schooling levels in the country measured with the primary gross enrolment rate (GER), the ratio of students per teacher and students per classroom. The low level of female education reduces their access to information related to sexual and reproductive health as well as their power in decision making.
Table 1.5: Indicators of education: literacy rate (%)
Indicators 1975* 1985* 1991 1994 1996* 1998 2003 2005 2006* 2007 Literacy (Male) 11.4 19.4 21.3 27.1 26.6 24.8 29.4 31.5 29.7 36.7 Literacy (Female) 3.6 6.7 10.1 11.4 12.8 12.9 15.2 16.6 16.3 21.0 Literacy (Total) 7.5 12.5 15.5 18.9 19.5 18.4 21.8 23.6 22.5 28.3
Source: Statistics yearbook, Burkina Faso.
* Concern individuals from 10 years and above
GER is the number of children in primary school over the number of children aged between 7 and 12 years. Like the literacy rate, this indicator shows the huge delay of females in terms of access to education compared to males but a progressive improvement in the education level of the country remains low (table 1.6). Indeed, almost one third of children of primary school ages were outside the education system in 2007 (table 1.6). Concerning the quality of education, data from the Ministry of Education (table 1.6) indicates that the number of students per teacher and the number of students per classroom were in the range of 51-54 and 49-54 for the period 2001 to 2007 respectively. The levels of these indicators differ according to the place of residence because most of the students are concentrated in urban areas, especially in the capital cities Ouagadougou and Bobo-Dioulasso where the number of students per classroom in public schools is sometimes above the 100.
Table 1.6: Indicators of education
Indicators 2001 2002 2003 2004 2005 2006 2007
Primary gross enrolment rate (male) 54.1 56.3 60.5 64.9 68.4 73.8 77.9 Primary gross enrolment rate (female) 38.9 41.1 46.1 50.5 54.3 60.1 65.7 Primary gross enrolment rate (Total) 46.5 48.7 53.3 57.7 61.4 67.0 71.8
Ratio students per teacher 52 52 51 53 52 52 54
Ratio students per classroom 52 49 49 51 52 54 54
Source: Statistics yearbook, Burkina Faso
Ethnic group is a key indicator of culture in Africa and an important aspect of reproductive health issues in terms of sexual behaviours and attitudes during pregnancy and delivery. The ethnic diversities constitute a cultural wealth but also a challenge in terms of addressing issues and policy implementation.
The country is home to between 63 and 64 ethnics groups (Jean-Francois and Marc, 2008).
These ethnics are generally grouped according to criteria of language similarities, socio-politics organi-sation, origin or location (Jean-Francois and Marc, 2008). In fact, the different ethnics in Burkina Faso are usually clustered into 9, 10 or 12 classic groups. Figure 1.5 presents the traditional ethnic groups as follows: Mossi, Peulh, Bobo, Gourounsi, Dagara, Lobi, Bisa, Samo, Marka, Snoufo and Gourmantch.
The multiplicity of ethnic groups in the country reflects the variety of cultures and therefore diverse perceptions of marriage, family size and reproductive health behaviour.
Figure 1.5: Traditional main ethnic groups in Burkina Faso
Source:http://www.planete-burkina.com/geographie_burkina.php
Brief presentation of the regions
To facilitate administration, the country has been divided into administrative areas since the colonial period. The division of the territory changed during time since the independence of the country making difficult today, the analyse of the trends of any demographic indicator at sub-national level. The process of decentralization has been initiated since 12 February 1995 with the aim of enabling every citizen to benefit from the development and also to reduce the disparities between zones of the country, (Ouedraogo and Ripama, 2009).
One of the aspects of decentralization mechanism is the new and current administrative division of the country into 13 regions, 45 provinces, 49 urban communes, 303 rural communes and about 9 000 villages (figure 1.1). These administrative divisions have been in place since the decision was taken in August 1998 by the law n040/98/AN (Ouedraogo and Ripama, 2009). The act 055-2004/AN of 21 December 2004 brought more details into the functioning of each administrative division (Ouedraogo and Ripama, 2009). Despite some remaining problems of functionality, different administrations have been in place since the election of communal majors on April 23th2006 (Ouedraogo and Ripama, 2009).
Financial autonomy and leading power have been given to governors of regions. Therefore, there is a growing huge demand for statistics at regional level of management, particularly on the level, trends and risk factors of maternal mortality. To better assess, understand and interpret results of this study at the regional level, it is imperative to present the different regions of the country.
Figure 1.6: Burkina Faso’s administrative regions according to the census 2006
The sizes of the populations in the regions of Burkina Faso differ. According to the last census in 2006, the most populated regions are the regions of Centre, Hauts-Bassins and Boucle du Mouhoun with 1 727 390, 1 469 604 and 1 442 749 inhabitants respectively (figure 1.6). The regions of Plateau Central, Centre-Sud, Sud-Ouest and Cascades are the less populated regions with 696 372, 641 443, 620 767 and 531 808 respectively (figure 1.6).
There are two main seasons in Burkina Faso, the rainy season from May to September and the dry season from October to April. The period from November to April is characterised by dry winds sometimes accompanied by dust which may spread diseases such as meningitis. Some regions such as Sahel with an average rainfall of less than 500 per annum for the period 1971-2000 present a problem of water (figure 1.7). In this part of the country, the majority of the population live from raising animals. The general picture shows a country with a watered south and a dry and arid north (figure 1.7).
According to census 2006, the regions of Sahel, Est and Sud-Ouest host the highest number of people living under poor conditions. In fact, figure 1.8 shows that these regions have 78.9 %, 67.7 % and 64 % of people living under poverty respectively. The region of Centre has a very low percentage of poverty (2.7 %). Poverty is a general issue in the country. Apart from the regions of Centre and Hauts-Bassins (25.1 %), people in all the other regions (30 %) live in poverty. These two regions host the capital
Figure 1.7: Average annual rainfall from 1971-2000 (mm)
cities of the country. The region of Centre includes the administrative capital city Ouagadougou and the region of Hauts-Bassins includes Bobo-Dioulasso.
Figure 1.8: Incidence of poverty (%) per region in 2006 census
The regions of Sahel (7.1) and Est (7.8) are the regions where the level of fertility is the highest in the country (Figure 1.9). These regions are also among the poorest in the country, therefore poverty and
high fertility seem to be closely associated. The region of Centre differs from all the others with a total fertility rate of 4.4 while for all the others it is above 6 expect for the region of Hauts-Bassins (5.8).
Figure 1.9: Total fertility rate (TFR) per region in Burkina Faso 2006 census
Concerning the literacy in the country, the regions of Sahel and Est with respectively 10.4 % and 15.1 % are again the least educated. But, the region of Centre-Nord has a literacy rate of 19.3 %. The regions of Sud-Ouest (23.5 %), Centre-Est (23.8 %) and Plateau Central (23.2 %) also have low literacy rate.
The regions with highest literacy rate were again the regions of Centre (61.8 %) and Hauts-Bassins (34.9 %).
Centre is a particular region with the highest level of development indicators due to the political capital of the country (Ouagadougou) being situated there. With 518 Km2, Ouagadougou occupies 0.2 % of the country territory. The city is the economic hub of the country. The principal economic activities are industries, trades, banking, arts, transport and other diverse activities (Laure Leila, 2009). Ouagadougou is growing rapidly, from 441 514 inhabitants in 1985, the population rose to 709 736 in 1996 and 1 475 839 in 2006. In 2006, the population size of Ouagadougou was predicted to double by 2015. With such a population size, Ouagadougou represents 46.4 % of the entire urban population of the country. The town registered a numeric importance of females constituting 49.6 % of the citizens. Compared to the national density of 51.8 inhabitants per km2, Ouagadougou has a density of 2848 inhabitants per km2 which put it under demographic pressure (Laure Leila, 2009).
Figure 1.10: Literacy rates (%) per region of the population older than 6 years old
1.2.2 Policies related to maternal mortality
International policies
Policies related to reproductive health focussed for a long time on infant mortality reduction with little emphasis put on maternal health. It has been taken many years before maternal mortality was recognised as a critical issue and energetic actions were taken to reverse the trend. However, the issue of maternal mortality is not so new in the domain of population and health studies. The problem has been known to exist years 1960 but actions undertaken since that time to solve it were rather weak, inappropriate or just slow in curbing the progression of the problem, particularly in the developing world.
In fact, several questions remain about the efficiency of previous and ongoing maternal mortality related policies, programmes and projects.
Already in 1963, maternal health received international recognition when it was mentioned in the uni-versal declaration of human rights. The role of midwives in safe maternity is highlighted and precisely defined as well as motherhood protection. The issue of maternal health in Burkina Faso met new impor-tant support during the years 1970 with the Alma Ata Declaration in 1978. The strategy developed at Alma Ata is based on the Primary Health Care (PHC) Approach. This strategy focuses on prevention, equality and participation of the local community. The international resolution of 1978 regarding infant
and maternal mortality was the starting point of the strategy to reduce maternal mortality reduction in Burkina Faso (Marie Th´er`ese Arcens-Som´e and Brouwere, 2005).
Today, the question of maternal mortality is taken more seriously on an international level. This new importance can be seen in the succession of international conferences on the subject and international recommendations and initiatives to improve the situation and reinforce strategies to solve the problem.
The international conference held in Nairobi (Kenya) in 1987 was the start point of the safe motherhood initiative (Starrs, 2006). The target of this initiative was to reduce maternal mortality by 50% by 2000.
The recommendations of this initiative have been adjusted over time and new ideas added as a result of difficulties encountered in the implementation and the lack of expected results. Since 1987, many other conferences have been organised to evaluate and to discuss new perspectives. The international
The recommendations of this initiative have been adjusted over time and new ideas added as a result of difficulties encountered in the implementation and the lack of expected results. Since 1987, many other conferences have been organised to evaluate and to discuss new perspectives. The international