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A perfect storm of poverty and over-population

Burundi is one of the poorest countries in the world – it is also one of the most densely populated. It has the third highest fertility rate in the world, standing at 5.7 children per woman.* All this compounds the challenge of poverty – food in Burundi is often scarce and 58% of children are severely malnourished.**

Currently, there is estimated to be an unmet need for family planning of 29%. That compares to just 6% in the UK.***

The problem has deep cultural roots and is indicative of family dynamics, where the topic is not discussed among men and women. Our survey at the beginning of the project revealed that only 13% of couples discussed birth spacing and family planning together.

* The World Bank  

**US Department for Health and Security

*** The UN, World contraception use, 2018

Women in Burundi have six children on average. 58% of children are malnourished
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There have been some initiatives from the government of Burundi to increase access to family planning services – this includes the provision of services at health clinics across the country since 1980. However, their progress is often inhibited by opposition from religious leaders.

In Burundi, 94% of people identify with a religious faith – the most prominent being Christianity, followed by Islam.* The position of the religious leader, especially in rural areas, is extremely influential – including in matters relating to family planning.

Scripture is often used as the basis for objections to the use of contraception. For example, God’s instruction to Adam and Eve in Genesis 1, v28 to ‘be fruitful, and multiply, and replenish the earth’.

* Institute of statistics and economic studies of Burundi

Be fruitful and multiply, and replenish the whole earth

- Genesis 1, v28 .

The religious landscape on family planning is not a straightforward one of course. Within Christianity, as one might expect, there is a spectrum of attitudes, with more fundamental opposition to family planning within the Catholic Church. But even among what could be described as more 'progressive' parts, there is evidence of the deep-seated cultural norms that discourage the use of modern family planning approaches.

Equipping faith leaders as agents of change

Here lies the challenge, but also the opportunity – to engage and inform religious leaders on the topic of family planning, with particular reference to scripture, so that they can help to challenge cultural norms within their congregations and help families to access family planning services. This formed the focus of the ITL project.

Faith leaders received training, faith-based communication resources and were linked with health workers. They were supported to conduct awareness sessions in their congregations, communities and through small group approaches such as couple’s counselling to improve dialogue between women and men on family planning.

A total of 254 religious leaders from both Christian and Muslim faiths were engaged through existing leadership structures and faith networks including the Anglican Province of Burundi (PEAB), Network of Faith Based Organisations for Integral Well-being of the Family (RCBIF), World Outreach Initiatives (WOI) and Burundi Network of Religious Leaders Living or Affected by HIV (BUNERELA+).

They were trained as the main agents of change, working alongside community health workers, women and youth leaders in the communities and supported to develop and implement action plans, integrating these themes within their daily work. They were also linked with local health committees (who oversee health clinics), to provide feedback and ensure that community concerns around family planning are addressed.

Pastor Jonas Sindamuka of Kabonga Parish in Makamba

Pastor Jonas Sindamuka of Kabonga Parish in Makamba Province was one of participants who was able to use the teachings from the project to good effect. He helped to organise a workshop at his church on sexual and reproductive health and family planning. As he and his wife were no longer of childbearing age, he started by engaging his married children. Interestingly, two of his children who had previously not been using any family planning methods, went to consult with local health services around contraception following their conversation with their father.

With members of his church, Jonas discussed biblical passages which are commonly interpreted as a commission to have many children. He specifically referred to God’s instruction to Noah and his sons in Genesis 9, v1 to ‘be fruitful and increase in number and fill the earth’. Pastor Jonas was able to argue that this command was relevant to a time when the earth needed to be re-populated and that God has given man discernment to correctly interpret these passages.

Jonas’ example appears to be symptomatic of a broader change among some religious leaders, where they are becoming proponents, rather than barriers to sexual and reproductive health. According to data from the final evaluation of the project, religious leaders are listed by community members as the second most influential group who promoted family planning.

Men and women brought together

As mentioned, one of the main barriers to family planning is a lack of informed discussion around the topic between men and women.

To address this issue, the project promoted discussions between couples, specifically on the issues of birth spacing, birth control and preferred number of children between the couple.

The percentage of men and women discussing sexual and reproductive health and family planning rose to 97.24% (from 13%) by the end of the project.

Karenzo Margerite

Karenzo Marguerite, who is married with six children, participated in the project. She says that before the project, there was a lot of miscommunication around family planning between her and her husband. Her husband was encouraging the use of family planning methods, partly because of the number of the children they already had. However, Karenzo resisted because she considered it to be a sin –  citing that the Bible speaks of multiplication and not the limitation of births. When their pastor started to teach on family planning, giving reference to scripture, Karenzo began to reconsider her stance and dialogue began between her and her husband on the topic. Shortly afterwards, Karenzo and her husband started to use contraception, which so far has been successful. Today, Marguerite is sharing her experience with other women.

In Burundi, it is often understood to be the husband as the barrier to family planning, but a key learning from the project is that this is not always the case.

Another sign of improved relations between men and women was an increase in both parties attending family planning appointments and antenatal care sessions, whereas before this would typically just be women.

men and women going to antenatal and family planning sessions increased from 45% to 86%
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Uptake of family planning methods

The official unmet need for family planning – that is, the proportion of women who do not want additional children but are not using contraceptive methods – is 29% in Burundi. Amongst the respondents to the baseline survey at the beginning of the project, the unmet need was 81%. This is a clearly a significant difference but shows that in parts of Burundi, especially where, as in this case, family planning had been a taboo, the challenge of access to family planning is extreme.

By the end of the project, this figure had fallen to 18%. 

This significant improvement can be attributed, at least in part, to raising awareness of how to access the free family planning services which are provided in Burundi.  After the project, 71% reported that it is very easy to access these at the nearest health facility, compared to just 45% at the beginning.

By equipping men and women who have been involved in the project through workshops and other sessions, they have replicated this learning with other community members.

Suzanne Ntawumenyumusi

Mrs. Suzanne Ntawumenyumusi testifies that every time she meets a woman from her neighbourhood that she knows, she advises them to go to the health services to seek advice on birth control. She mentions that it’s especially those women who are clearly living in difficult circumstances who she tries to speak to – she gives the example of a pregnant woman who is also struggling to carry a new-born on her back.

Suzanne comes across resistance from many of the women that she speaks to, but she says she is always able to convince them of the importance of family planning measures – citing the shortage of land and the degradation of the soil.

Since 2016, she says she has been able to convince ten women on the importance of family planning, all of whom have subsequently started using contraception.

One of these women is Habonimana Triphonie. When Suzanne met Triphonie, she had five children. Triphonie explains that all her family were in bad health, requiring regular visits to the health clinic. Her husband was exhausted from working to support the family alone. Before meeting Suzanne, she had refused to be convinced by others on the importance of family planning, recalling a song she would sing at church, that Abraham’s descendants would be as many as there are ‘stars in the sky’. But, in speaking with Suzanne, she became convinced that it was not required of her to apply this message to her family. She had previously quarrelled with her husband, who didn’t want any more children, but she started to think about the future of her family and the fact they didn’t have any land to cultivate. She went to the health services and elected to have a contraceptive implant. She says that their income has now increased as she can now work and her children are well-nourished as a result.

Suzanne does also mention that there have been frustrations raised by several women with cases where contraception methods have failed, and in other cases where there have been side effects  this has been observed across all of the communities where the project worked. In these cases, Suzanne advises the women to go to the health services to ask about changing the contraceptive method.

Lessons learnt from the project

Overall, the evidence suggests that the project approach works. The influence of religious leaders in Burundi’s communities is significant. And, given the resources and confidence to speak about family planning, they can clearly use their influence and networks to promote it.

As one might expect, there is a spectrum of attitudes towards family planning, spanning across the various denominations within the country. The project engaged with Anglican faith leaders as well as those from Pentecostal and Catholic churches. Engaging with some Catholic church leaders on family planning was, as one might anticipate, a sensitive topic – they cannot openly promote modern contraceptive methods without permission from the Vatican. However, there was some progress made. 

In talks with Catholic church leaders, they agreed that family size is an issue and birth control is a solution.

It was also agreed that as part of the project, information relating to sexual and reproductive health and the importance of seeking advice from health professionals was broadcast on catholic radio in Burundi.

One of the recommendations from the project is that further research is undertaken on how to engage with the Catholic church on the topic of family planning. This may involve Christian Aid helping to advocate at an international level to them.

The other key consideration from the project was, even if men and women are convinced to make use of family planning services, what is the standard of those services which are provided – especially given that Burundi’s overall health service level doesn’t meet the minimum standard set by the WHO.

In our survey, the percentage of men and women who considered the quality of family planning services to be very good decreased from 72% at the beginning of the project, to 47% at the end of the project. This may in part be explained by a greater number of project beneficiaries accessing the service and having higher expectations. But it may also be the effect of the discontinuation of a financial incentive scheme which rewarded family planning service providers based on the number of people they helped, not the quality of service delivery.

The project established accountability committees – spaces where community members could voice their experiences of family planning services – and feedback was then shared with the local authorities. One of the main issues which came out of the committees was insufficient management of side effects or complications related to contraceptive methods.

Continuing the work

In November 2018, Christian Aid participated at the International Conference on Family Planning, In Rwanda.

Here, Dr Dieudonne Bikorimana from Christian Aid Burundi, presented the findings from the project to the global family planning sector.

Off the back of the conference, there are a number of funding possibilities for the scaling up of the work of the project.

 

NB: All statistics relating to survey question to beneficiaries are sourced from the official project baseline and endline evaluations.