Rwanda Country Profile for Demographic and Health Surveys, the Years Refer to When the Surveys Were Conducted

WHO Director-General Roundtable with Women Leaders on Millennium Development Goal 5

Rwanda Country profile For Demographic and Health Surveys, the years refer to when the Surveys were conducted. Estimates from the Surveys refer to three or five years before the Surveys.

Rwanda and the world

1. Maternal mortality ratio: global, regional and 2. Lifetime risk of maternal death (1 in N), 2005 country data, 2005

A maternal death is defined as the death of a woman while pregnant or The lifetime risk of maternal death is the estimated risk of an individual within 42 days of termination of pregnancy from any cause related to woman dying from pregnancy or childbirth during her adult lifetime the pregnancy or its management but not from accidental or incidental based on maternal mortality and the fertility rate in the country. The causes. The maternal mortality ratio is the number of maternal lifetime risk of dying from pregnancy-related causes in Rwanda is 1 in deaths per 100 000 live births per year. The ratio in Rwanda is 1300 per 16 which is higher than the average of 1 in 22 in sub-Saharan Africa, as 100 000 live births, which is much higher than the average of 900 per well as the global figure of 1 in 92. 100 000 live births in sub-Saharan Africa and more than three times the global average of 400 per 100 000 live births.

2/25 1300 1400 1/16 1200 3/50 1/22 1000 900 1/25 800 600 1/50 400 1/92 Deaths per 400 0 100 000 live births 200 Lifetime risk of death (1 in N) Rwanda Sub-Saharan World 0 Africa Rwanda Sub-Saharan World Africa

Source: Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 Source: Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www.who.int/reproductive-health/publications/maternal_mortality_2005/index.html). (http://www.who.int/reproductive-health/publications/maternal_mortality_2005/index.html).

Demographic and health data

3. Total population (in thousands)1 9 464 (2006) Lifetime risk of maternal death (1 in N)2 16 (2005) Total maternal deaths2 4 700 (2005)

Sources: 1World Health Organization 2008, World Health Statistics 2008 Geneva, Switzerland (http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf). 2Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www.who.int/reproductive-health/publications/maternal_mortality_2005/index.html).

4. Causes of maternal deaths 1997–2002 5. Total fertility A maternal death is defined as the death of a woman while pregnant or The total fertility is the average number of children that would be born within 42 days of termination of pregnancy from any cause related to to a woman over her lifetime. The total fertility rate can be separated into the pregnancy or its management but not from accidental or incidental the births that were planned (wanted total fertility rate) and those that causes. The most frequent causes of maternal deaths in Africa (for were unintended (unwanted total fertility rate). According to a survey 1997–2002) were haemorrhage (uncontrolled bleeding), infection conducted in 2005, the total fertility rate was 6.1 per woman in Rwanda.. (including HIV), hypertensive disorders (high blood pressure) and other causes. There are no country-specific data for Rwanda.

Obstructed labour 4%

1.1 1.5 Anaemia 4% Abortion 4% 2.0

Hypertensive disorders 9% Haemorrhage 4.7 4.6 34% 4.2 Africa Total fertility rate (per woman) Total

Sepsis or Infections, including HIV 16% Other causes 30% Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy Safer; http://www.who.int/making_pregnancy_safer/en). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ Source: Khan KS et al. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006, 367:1066–1074. search/start.cfm).

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6. Proportions of births by urban versus rural 7. Perinatal mortality rate 2005 location Perinatal mortality refers to deaths of fetuses in the womb and newborn Among the women interviewed in a survey conducted in 2005, about babies early after delivery. It includes (1) death of fetus in the womb after 86% of births occurred in rural areas.1 22 weeks of gestation and during childbirth, and (2) death of a live-born The total number of births (in thousands): 405 (2005)2 child within the first seven days of life. These deaths are considered an indication of the availability and quality of both maternal and newborn health care. According to a survey conducted in 2005, the perinatal mortality rate in Rwanda was 44 per 1000 pregnancies.

20 19.8 19.5 19.1

11.5 9.9 12.7 10

9.9 8.0 per 1000 pregnancies per 1000 pregnancies 6.4 0 Total Urban Rural

Still birth rate Early neonatal death rate Sources: 1Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy Safer; http://www.who.int/making_pregnancy_safer/en). Perinatal mortality Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ search/start.cfm). Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy 2World population prospects: the 2006 revision. CD-ROM edition – extended dataset in Excel and ASCII formats. New York, United Nations Department Safer; http://www.who.int/making_pregnancy_safer/en). of Economic and Social Affairs, Population Division, 2007 (United Nations publications, ST/ESA/SER.A/266). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ search/start.cfm).

8. Adolescent pregnancy rate by age for women 9. Adolescent pregnancy rate by urban versus rural 15–19 years old location A survey conducted in 2005 showed that 19-year-old women had the In Rwanda, surveys conducted in 1992, 2000 and 2005 reported a highest adolescent pregnancy rate of 3.3%. decline in adolescent pregnancy in both urban and rural areas. In 2005, 0.8% of women 15–19 years old were pregnant with their first child.

...... pregnant with their first child

pregnant with their first child .

% of women (15-19 years old) . % of women (15-19 years old) . . . . .

Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Preg- Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Preg- nancy Safer; http://www.who.int/making_pregnancy_safer/en). nancy Safer; http://www.who.int/making_pregnancy_safer/en). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ search/start.cfm). search/start.cfm).

10. Adolescent pregnancy by subregion Adolescent pregnancy rates vary between different parts of Rwanda. Adolescent pregnancy rates can vary for many reasons including cultural norms, socioeconomic deprivation, education, access to sexual health information and contraceptive services and supplies.

......

pregnant with their first child . % of women (15-19 years old) . .

Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy Safer; http://www.who.int/making_pregnancy_safer/en). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ search/start.cfm).

Rwanda 3

Intervention coverage for mothers and newborns

11. Unmet need for family planning, 2007 38% 13. Contraceptive use by urban versus rural location The unmet need for family planning is the proportion of all women who In Rwanda, a survey conducted in 2005 reported that 10% of currently are at risk of pregnancy and who want to space or limit their childbearing married women were using modern contraceptive methods: 21% in but are not using contraceptives. urban areas and 9% in rural areas. Source: World contraceptive use 2007. New York, United Nations Department of Economic and Social Affairs, Population Division, 2007 (http://www.un.org/esa/population/publications/contraceptive2007/contraceptive2007.htm, accessed 18 August 2008).

12. Family planning: modern contraceptive use by age group

Modern contraceptive methods include oral and injectable hormones, intrauterine devices, diaphragms, hormonal implants, female and male . sterilization, spermicides and condoms. In general, according to surveys . conducted in 1992, 2000 and 2005, contraceptive use increased across all . age groups particularly in the 30–34 and the 40–44 age groups...... % currently married women using modern contraceptives using modern

......

. . . . . modern contraceptives ......

% currently married women using . 15–19 20–24 25–29 30–34 35–39 40–44 45–49

Age (years)

Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy Safer; http://www.who.int/making_pregnancy_safer/en). Safer; http://www.who.int/making_pregnancy_safer/en). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ search/start.cfm). search/start.cfm).

14. Contraceptive use by subregion 15. Antenatal care The prevalence of contraceptive use varies in different subregions Antenatal care visits (ANC) include all visits made by pregnant of Rwanda. According to surveys conducted in 1992, 2000 and 2005, women for reasons relating to pregnancy. According to a survey modern contraceptive use was consistently higher in Kigali Ville (PVK). conducted in 2005, approximately 94% of women received ANC for The prevalence in the survey in 2005 ranged from 28% in Kigali Ville (PVK) their latest pregnancy that ended in a live birth. Of the pregnancies to 4% in Gikongoro. that ended in a live birth, approximately 81% were given ANC by a skilled provider at least once.

......

. . . % currently married women using modern contraceptives using modern % women who gave birth . . .

–

Unknown or missing

16. Utilization of skilled birth attendants

A skilled birth attendant is an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to . . proficiency in the skills needed to manage normal (uncomplicated) . pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications among women . and newborns. All women should have access to skilled care during . . .

skilled birth attendant . pregnancy and at delivery to ensure that complications are detected and % of births assisted by . managed. A survey in 2005 showed that 28% of childbirths were assisted by a skilled birth attendant: 56% in urban areas and 24% in rural areas.

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17. Utilization of skilled birth attendants by wealth 18. Utilization of skilled birth attendants by subregion quintile Whether a woman delivers with the assistance of a skilled attendant is The percentage of women giving birth with the assistance of a skilled highly influenced by how rich she is. A survey conducted in Rwanda in birth attendant varies by subregional location within Rwanda. According 2005 showed that 66% of women in the highest wealth quintile had a to a survey conducted in 2005, 66% of births were assisted by a skilled skilled attendant present at birth versus 27% of women in the lowest birth attendant in Kigali Ville (PVK) versus less than 42% in all other areas. wealth quintile, more than a two-fold difference.

. skilled birth attendant . % of births assisted by . . . skilled birth attendant % of births assisted by

19. Place of delivery 20. Caesarean section rates by urban versus rural location Delivery in a health facility can reduce maternal and neonatal death and morbidity. According to a survey conducted in 2005, 70% of Caesarean section is a surgical procedure in which incisions are made pregnant women in Rwanda delivered at home, with the associated through a woman’s abdomen and womb to deliver her baby. It is risks and only 28% in a health facility. These rates remained fairly performed whenever abnormal conditions complicate vaginal delivery, constant in surveys conducted in 1992, 2000 and 2005. threatening the life and health of the mother and/or the baby. According to a survey conducted in 2005, 3% of births were delivered by caesarean section in Rwanda: 2% in rural areas and 8% in urban areas. The very low caesarean section rates, especially in rural areas, could indicate an unmet need for access to adequate health system infrastructure, which needs to be met if maternal deaths are to be reduced. . . .

. . . skilled birth attendant % of births assisted by

. . . Caesarean section % of births delivered by

21. Caesarean section by subregion 22. Low birth weight

Caesarean section rates also vary between subregions in Rwanda. Babies weighing less than 2500 g at birth are considered to have low birth According to a survey conducted in 1995, caesarean section rates ranged weight. According to a survey conducted in 2005, of the babies who were from 1% in Kigali Rurale to 12% in Kigali Ville (PVK). weighed at birth, 2% were reported to weigh less than 2500 g (2.5 kg). Low-birth-weight babies often face severe short- and long-term health consequences and tend to have higher mortality and morbidity. Caesarean section % of births delivered by % of births

. . . % babies weighing less than 2500 g % babies weighing

Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Preg- Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Pregnancy nancy Safer; http://www.who.int/making_pregnancy_safer/en). Safer; http://www.who.int/making_pregnancy_safer/en). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ search/start.cfm). search/start.cfm).

Rwanda 5

23. Anaemia in pregnancy 24. Prevention of mother-to-child transmission of HIV Anaemia refers to abnormally low levels of haemoglobin (iron-containing The percentage of pregnant mothers living with HIV receiving oxygen proteins) in the blood. According to a survey conducted in 2004, antiretroviral drugs (ARVs) to prevent the transmission of HIV to their the percentage of pregnant women with low haemoglobin levels (less child (PMTCT) increased steadily by 30 percentage points between 2004 than 110 g/l) was approximately 35%. Severe anaemia is an important and 2006. contributing factor to maternal deaths due to haemorrhage during childbirth. 75

5% 17% 60 55

45 38

13% 65% 30 25 15 receiving ARVs for PMTCT ARVs receiving Severe anaemia Moderate anaemia % pregnant women living with HIV % pregnant women 0 Mild anaemia Not anaemia 2004 2005 2006

Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making Preg- Sources: Making Pregnancy Safer country profiles [online database]. Geneva, World Health Organization, in press (Department of Making nancy Safer; http://www.who.int/making_pregnancy_safer/en). Pregnancy Safer; http://www.who.int/making_pregnancy_safer/en). Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsurveys/ Demographic and Health Surveys [web site]. Calverton, MD, MEASURE DHS, Macro International Inc. (http://www.measuredhs.com/aboutsur- search/start.cfm). veys/search/start.cfm).

Equity Policies

26. Reproductive health Yes 25. Equity – gap in coverage of four major Maternal health Yes interventions by wealth quintile Source: WHO database on national health policies, 2008. This graph illustrates the gap in coverage of four key interventions (family planning, maternal and newborn care, immunization and treatment of childhood illness) by wealth. The coverage gap reflects the difference between the goal of universal coverage of everyone in these four intervention areas and actual coverage. Where the gap is larger, Resources it means that there is less adequate coverage. The opposite indicates better coverage. The graph indicates that, in the Demographic and Health Surveys (DHS) conducted in 2000 and 2005, the coverage gap is 27. Financial flow highest for the poorest and is lowest for the richer members of society (per capita expenditure on health, in US dollars) 2007 126 (wealthiest quintile). Overall, the gap in the survey conducted in 2005

(47%) was slightly lower (that is, improved coverage) than in the 2000 Source: Countdown to 2015. Tracking progress in maternal, newborn & child survival: the 2008 report. New York, United Nations Children’s Fund, 2008 survey (52%). Achieving equity requires improving coverage levels in (http://www.countdown2015mnch.org/index.php?option=com_content&view=article&id=68&itemid=61).. the poorest quintiles. 28. Human resources

The work of at least 23 health workers (doctors, nurses or midwives) per 100 10 000 population is estimated to be necessary to support the delivery of 80 the basic interventions required to achieve the Millennium Development Goals related to health. Globally, 57 countries have been identified with % 60 critical shortages below this minimum. These countries have a severe 40 crisis in human resources for health. Of these 57 countries, 36 are in sub- Saharan Africa. Rwanda, with about 5 health workers (as defined above) 20 per 10 000 population, is one of the countries facing this crisis daily, with mothers and children lacking access to proper maternal and child care, 0 HIV/TB and malaria care, and sexual and reproductive health information Poorest 2nd 3rd 4th Wealthiest and services, including skilled birth attendants. 2000 2005 DHS DHS The shortage is exacerbated by staff losses due to migration (in search of a better life) of skilled staff to high-income countries, leaving behind already impoverished health services and systems. Coverage gap (%) 52 47 Ratio Increasing the human resources around the world and establishing a poorest/wealthiest 1.4 1.5 balance between the services needed and the personnel available, and Difference their distribution, are key elements of a well-functioning health system poorest-wealthiest (%) 15 16 and critical requirements for achieving Millennium Development Goals.

Source: WHO Global Atlas of the Health Workforce [online database]. Geneva, World Health Organization, 2008 (www.who.int/globalatlas/autologin/ hrh_login.asp). Source: UNICEF (2008). Tracking progress in Maternal, Newborn and Child Survival: The 2008 Report. Geneva, Switzerland.

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29. Ratification of treaties and support of international consensus

Convention on the Elimination of All Forms of Discrimination against Women Yes

Convention on the Rights of the Child Yes

International Covenant on Economic, Social and Cultural Rights Yes

International Conference on Population and Development Yes

Fourth World Conference on Women Yes

Sources: Ratifications and reservations [web site]. Geneva, Office of the United Nations High Commissioner for Human Rights, 2008 (http://www2.ohchr.org/english/bodies/ratification/index.htm).

Report of the Fourth World Conference on Women, Beijing, 4–15 September 1995. New York, United Nations, 1996 (http://www.un.org/womenwatch/confer/beijing/reports).

Report of the International Conference on Population and Development, Cairo, 5–13 September 1994. New York, United Nations, 1994 (http://www.un.org/popin/icpd/conference/offeng/poa.html).

30. Other determinants of health: water, sanitation, communication and road networks

Fixed-line and mobile phone subscribers (per 100 population) 3 (2006)

Internet users (per 100 population) 1 (2006)

Roads paved (% of total roads) Unknown

Improved water source (% of population with access) 65 (2006)

Improved sanitation facilities (% of urban population with access) 34 (2006)

Source: World Bank indicators [online database]. Washington, DC, World Bank, 2008 (http://ddp-ext.worldbank.org/ext/ddpreports/ViewSharedReport?&CF=&REPORT_ID=9147&REQUEST_ TYPE=VIEWADVANCED&HF=N/CPP&WSP=N).

For further information contact:

Child and Adolescent Health and Development Gender, Women and Health Immunization, Vaccines and Biologicals Tel: +41 22 791 3281 Tel: +41 22 791 2394 Tel: +41 22 791 4612 E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] Web site: www.who.int/child_adolescent_health/en Web site: www.who.int/gender Web site: www.who.int/immunization/en

Making Pregnancy Safer Reproductive Health and Research Tel: +41 22 791 3966 Tel: +41 22 791 3372 E-mail: [email protected] E-mail: [email protected] Web site: www.who.int/making_pregnancy_safer/en Web site: www.who.int/reproductive-health

Rwanda