Three PhD-defences on 'Breaking the cycle'
15 January 2016
14 December 2015 was a memorable day for the Population, Reproductive Health and Economic Development (PopDev) project ‘Breaking the cycle: Reproductive health and poverty decline in Rwanda‘: not less than three PhD candidates defended their thesis. NWO-WOTRO congratulates Joseph Nkurunziza, Pierre Claver Rutayisire and Ignace Habimana-Kabano and of course project leader Pieter Hooimeijer.
Poverty and high population growth seem joined at the hip. According to the United Nations Population Fund, over the past seventy years, high fertility and poverty have been strongly correlated. The countries with the highest poverty levels are generally those with the most rapid population increases and the highest fertility levels. This correlation has been widely studied. Findings show that in general families with low incomes often see children as contributors to household’s income and as a form of security for their old age. Having many children, however, also means having to spend more money on food, housing and clothing, leaving less for investments that enhance the overall welfare of the family. This population-poverty trap has many poor people firmly in its grip.
The project aims at providing evidence whether or not reproductive health can be a useful instrument in breaking the cycle of overpopulation and poverty continuation in Rwanda. The central hypothesis is that reproductive health policies can bring down these levels in the short run and will create the surplus at the household level to invest in the health and education of the children. Diminishing excess fertility - due to unmet needs - and reducing infant and child mortality help to bring down actual fertility in the short run and lead to wealth creation at the level of the household and the nation. This might be a decisive step towards an upward cycle that might also bring desired family size down.
The upward cycle of employment and education
PhD student Joseph Nkurunziza analysed Rwandan policy on education, social security and rural development. The development of human capital is a policy priority for the Rwandan government. Nkurunziza found that policies aimed at poverty reduction and rural development contribute to the willingness of parents to invest in education.
More children from poor families, both boys and girls, are now going to school and there has been an increase in secondary education attendance. Orphans and foster children still have fewer educational opportunities though. Having younger siblings decreases the chances to finish school, especially for girls and for children from single-parent families.
Children who go to private schools were found to achieve more and to have an increased chance to be admitted to public secondary schools, instead of having to go to the poorer quality schools that are located in existing primary schools.
Access to basic health facilities and to employment in job creation projects are related to a modest increase in school spending. The presence of formal paid work at the district level has had a positive impact, confirming that labour market factors are important when deciding whether to allow children to follow education.
The amount of children desired
In his thesis PhD student Pierre Claver Rutayisire investigated the connection between war and genocide on the one hand and the actual and desired amount of children on the other. In the ten year period after the 1994 genocide actual fertility remained high at a level of six children per women. He found that many women became widowed or separated from their husband during and after the civil war, which would have led to lower fertility. Yet the ones in a union got more children than before. Many women got pregnant to replace the children they had lost in the hostilities. In particular those that had to flee to refugee camps lost infants. But also the women that did not suffer such direct loss preferred to have more children than usual. Many were born in dire circumstances as people got more children than they could feed and raise.
This situation improved after 2000 when the economy recovered and health care services were rebuilt. The infant mortality rate went down and people became more aware of the negative effects of having many children. The government also launched a sensitizing campaign to promote having no more than three children. This led to a sharp decline in the desired number. After 2005 access to and availability of contraceptives was greatly improved, causing a drop in the fertility rate from 6 to 4 children per women.
The role of inter-pregnancy intervals
Rwanda pays little attention to 'healthy' intervals between pregnancies awareness programs on family planning and maternal and child health. Ignace Habimana Kabano researched the connection between previous pregnancy outcome and fetal survival, neonatal mortality and maternal morbidity. He found that both short and long intervals between pregnancies (IPIs) lead to higher odds of consecutive miscarriages and neonatal mortality. Policy wise, avoiding short intervals can be achieved through the use of post-partum contraception, while long intervals appear to remain problematic to avoid.
Among those that delivered in a hospital, short intervals were not associated with higher levels of maternal morbidity. Long intervals are associated with higher risks of third trimester bleeding, premature rupture of membrane and lower limb edema, irrespective of the age of the mother. This finding contributes to the debate whether older age of the mother might be hiding behind the effect of very long interval length. The findings support the physiological regression hypothesis that states that longer intervals lead to adverse outcome regardless of the age.
After a pregnancy loss, a pregnancy interval longer than six months must be observed to prevent recurrence. Also women with intervals between pregnancies longer than 5 years have consistently shown increased risks of fetal loss, neonatal death and maternal morbidity.
In the context of poor countries like Rwanda, pregnancy management strategies should be encouraged through family planning for spacing pregnancies, and the promotion of health seeking behaviour. For instance, poor women from rural areas and with limited health insurance are less often admitted to a hospital. Health centres in remote areas of the country should be less reluctant in transferring pregnant women and should not wait until their situation becomes critical. Besides, hospitals should encourage post-abortion medication.