Productivity, Family Planning & Reproductive Health: an inter-disciplinary study in Burkina Faso

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Epidemiology and Population Health

Abstract

Our study focuses on the impact of reproductive health on women's economic empowerment at both the household and individual levels in Burkina Faso, a country in Sub-Saharan Africa with high fertility, high unmet need for family planning and high female labour participation. The ultimate aim of this research project is to conduct multi-disciplinary research on the impact of pregnancy on income-generating and non-income-generating production in Burkina Faso; and to investigate how investments in reproductive health might contribute to reducing poverty and fostering economic development and equity.

The proposed project consists of three interlinked study components:

Study A: will be a secondary analysis of existing data (collected by Immpact) on the productivity costs of pregnancy and childbearing.

Study B: will collect primary quantitative data on reproductive health, family planning behaviour and productivity in a prospective cohort.

Study C: will be a qualitative, ethnographic analysis of women's reproduction, productivity and empowerment. Study C will be nested within the prospective cohort of Study B, allowing us to link to the quantitive data. We will also interview the husband/partners of these women, to enable us to explore men's perspectives and roles.

The three studies provide complementary information. Our mixed methods approach will allow us to triangulate data from different sources and explore the key issues from the perspectives of each key discipline represented in the team (demography, economics, anthropology and epidemiology). Analysis of the Immpact data (Study A) gives us access to a rich data source on the direct and productivity costs of delivery. However, Immpact did not collect information on a number of key variables (most importantly family planning); therefore we propose to collect primary prospective data (through Studies B and C) to supplement the findings of Study A.

The main project outputs anticipated are:
(i) increased knowledge and understanding of the relationship between reproduction and production in Burkina Faso
(ii) policy & practice-relevant results published in at least three open-access peer-reviewed publications
(iii) two archived datasets (1x quantitative, 1x qualitative) available to other researchers for future analysis
(iv) increased capacity in Burkina Faso.

Planned Impact

We expect our results to have direct relevance to economics, health and development professionals, and other societal stakeholders, working in the governmental and non-governmental sectors since our findings can be used to develop interventions to assist households in preparing for birth and the postpartum period, and to promote effective family planning methods after childbirth. Also, as a representative of a NGO specialising in family planning told us during the our planning workshop, the study results could help demonstrate the economic advantages of vigorous family planning provision to the pro-natalist government. We have decided to include the perspectives of husbands/partners in Study C in order to increase the relevance and transferability of our results, since men play an important role in decision-making related to fertility and women's work in Burkina Faso.

To ensure our results are applicable to policy and practice at the country-level we have adapted our original research proposal in response to feedback received from PopDev reviewers and from stakeholders at our planning workshop, held in Ouagadougou in May 2012. We have also planned ongoing communication activities to keep interested parties updated on progress. Our plans for stakeholder engagement are detailed in the full proposal attached. In brief, our target groups are:

In Burkina Faso:
1. Research participants and their communities
2. Regional and national policy-makers in key departments (Health, Promotion of Women, Work & Social Security).
3. Interested Members of Parliament, in particular female MPs
4. Local bureau of international organizations (such as UNFPA, WHO, World Bank)
5. NGOs working in reproductive health and/or family planning, e.g. ABBEF; MSI; White Ribbon Alliance.
6. Health workers who provide reproductive health services
7. Local researchers (e.g. from Association Koasanga, IRSS etc)
8. National and local media

Internationally:
9. Policy makers working in relevant multilateral organisations, including the WHO working group on maternal morbidity
10. Donor organisations, particularly those working on gender issues and reproductive health
11. Wider community of academics

Ongoing communication activities will be targeted to the stakeholder group throughout the study, but with more concentrated activities during the planning phase (December 2012-April 2013), the dissemination of Study A (May-June 2013), and the dissemination of Studies B and C (July-November 2014). For policy makers these will include face-to-face meetings, e-mails with study updates, bilingual (French/English) web pages hosted on our institutional websites, and the production of at least one policy brief (sent to key stakeholders and made available on the website). One of the participants at our stakeholder workshop presents a regular radio programme discussing women's issues; broadcast in a number of local languages, and we discussed disseminating our findings via such media. VF was interviewed after the workshop indicating strong journalistic interest.

Publications

10 25 50
 
Description Despite their high fertility, 82% of women in Burkina Faso work outside of the home. The majority of these women work within the informal economy where labour conditions are precarious and incomes low and unpredictable. Moreover, Burkinabe women face a double burden of income-generating activities and labour-intensive domestic and agricultural work, even during pregnancy. This PopDev project examined women's work in Burkina Faso and how their reproductive health, pregnancy and childbirth impacted on their productivity, a topic that is relevant to the global sustainable development agenda and to the "Women and Health" Lancet Commission from 2015. The project involved interdisciplinary collaboration between public health researchers and social scientists from Burkina Faso, the UK and Norway, and generated new research opportunities and policy debate. Our findings show that women in Burkina Faso are still far from achieving gender parity in reproductive and work-related issues. For example:
- Women are active in the workforce (six of ten pregnant/delivered women in our study), but spend more time of domestic activities than income-generating work.
- Women's income is low, but it is very important to their sense of independence and well-being.
- Women are largely excluded from the national social security system, because they rarely have formal employment. Of the working women in our study, nine out of 10 women worked in the informal sector (e.g. petty trading and other services).
- Despite their legal right to 14 weeks' maternity leave, only half of women in the formal sector get maternity leave.
- Women struggle to prepare for the costs of delivery and the loss or reduction of income during pregnancy and in the first months after childbirth.
- Semi-formal social protection mechanisms like group savings and help from neighbours and family members are important to help women cope with loss of income during pregnancy and after childbirth.
- Women return to work quickly after delivery. Women reduce their workload in the weeks before and after childbirth, but resume domestic work around a week after delivery and income-generating activities within two month. Rural women and those who work in the informal sector often return to work sooner to avoid impoverishment.
- Family planning could help women achieve their work-related ambitions, but is often opposed by men. Although only 1% of women in our study wanted a new pregnancy within the next two years, only 45% of sexually active women used contraception after delivery.
On the basis of these findings, we recommend that:
- Burkina Faso's government should work to improve knowledge and implementation of existing social protection mechanisms for formal sector workers, and develop mechanisms to protect informal sector workers against loss of income and work opportunities during pregnancy and childbirth
- 'Postpartum preparedness', including logistics and financial planning during pregnancy for postnatal care, family planning and work, should be considered for inclusion in public health programmes as a way to help women prepare better for the period after delivery.
- Research and policy should address men's involvement in reproductive health decision-making, especially with regard to family planning.
Exploitation Route We are actively disseminating our findings to non-academic audiences, with support from our colleagues in the POPPOV network, who advise us on public dissemination of scientific research.
In June 2015, we organised a workshop with Burkinabe stakeholders on the policy implications of our findings, and disseminated a research brief which included multi-sectorial recommendations on family planning and reproductive rights. We have/will reinforce these messages through local presentations and publications in French.
Our findings may also be taken forward through inter-disciplinary research, for instance on men's involvement in family planning, how to improve 'preparedness' for loss of work and income during pregnancy and after childbirth, the social significance of women's work, and the development and implementation of social protection mechanisms in contexts with large informal sectors.
As a direct outcome of this study, one of the study participants (Marine Daniele) has been awarded an ESRC doctoral studentship to conduct a randomised control trial to test whether increasing men's contact with providers and access to information can increase uptake of family planning, postnatal care and exclusive breastfeeding. Another study participant (Seydou Drabo) has received a University of Oslo doctoral fellowship for an anthropological study on the circulation of contraceptives within Burkina Faso.
We will continue to take our findings forward in the consultations which are organised by the UK Research Council and the Department for International Development and other funders on the research agenda that will accompany the new SDGs.
Sectors Communities and Social Services/Policy,Healthcare,Other

URL http://maternalhealthgroup.lshtm.ac.uk/resources-3/
 
Description In June 2015, key findings on each of these thematic areas were presented at a dissemination workshop with stakeholders from a range of backgrounds (NGOs working on reproductive health and rights, Ministries of Family Affairs and Social Security, Health, Women's affairs etc) in Burkina Faso. The findings were summarised in a research brief (available in French and English), which were both printed and published on the websites of AfricSanté and London School of Hygiene and Tropical Medicine. Great interest was expressed at the workshop for the novelty and complexity of our topic, bringing together reproductive health issues as well as issues related to women's work, and several ground-breaking recommendations were made at the workshop to stimulate potential social and health policy changes. The workshop's main recommendations included: 1. Communicating that the importance of family planning (women and couples having the desired number of children when wanted) requires the involvement of multiple sectors such as ministries in charge of the condition of women, social action, and work, and does not entirely fall under the responsibility of the Ministry of Health; 2. Informing women working in the formal economy, as well as their employer, of their existing rights to maternity leave; 3. Encouraging the government to ensure access to existing mechanisms of social protection and introduce new ones, particularly aimed at those with temporary contracts or active in the informal sector; 4. Encouraging families to subscribe to a health protection system and Burkina Faso to promote universal access to health care; 5. Raising awareness among young boys and girls on gender equality during their education; 6. Encouraging male participation in maternal and reproductive health, household activities, and ensuring that health services involve husbands/future fathers as appropriate 7. Explaining to women that it takes time to get back to a normal health state during the postpartum; and stressing the importance of a good nutrition and a delay in engaging in physical activities. Unfortunately there were major disturbances and changes among stakeholders and policy makers due to the revolution of autumn 2015 and the terrorist attacks in January 2016, and we have not found ourselves in a position where we could easily follow-up on these recommendations. One incredibly important policy change is that Burkina Faso has now made maternity care completely free of charge. While this is difficult to prove, the evidence that has accumulated through our group's collaborative research over the past several years, with this ESRC grant and other research funded by ESRC and other funders, contributed to the motivation and development of this landmark policy. With respect to recommendation 6, Dr Marina Daniele, an ESRC-funded 1+3 PhD student associated to this work, completed her doctoral thesis in 2017. Her successful mixed method intervention study, with a randomised control trial of male involvement in maternity care, led to policy recommendations which have been disseminated in Burkina Faso and at the World Health Organisation in 2017 with the support of STEP-UP (a DFID-funded Research Programme Consortium on reproductive health). At the global level, our research fits extremely well with the Sustainable Development Goals agenda and, we think, can help inform joined-up responses to the complex interactions between the goals of health and wellbeing (goal 3), gender equality (goal 5), decent work and economic growth (goal 8). Our focus on social protection in relation to reproductive health is particularly relevant in this respect. Finally, our research has also enabled us to inform the agenda of the department of Reproductive Health and Research at the World Health Organisation by contributing to discussions on the importance of measuring health-related functioning for maternal health.
Sector Communities and Social Services/Policy,Healthcare
Impact Types Societal,Economic,Policy & public services

 
Description World Health Organization working group on maternal morbidity (2012-2017)
Geographic Reach Multiple continents/international 
Policy Influence Type Membership of a guideline committee
 
Description Poverty/international development (NB: PI is Dr Ben D'Exelle, University of East Anglia)
Amount £365,956 (GBP)
Funding ID ES/N014618/1 
Organisation Economic and Social Research Council 
Department ESRC-DFID Joint Fund
Sector Public
Country United Kingdom
Start 05/2016 
End 04/2019
 
Description WHO RHR Maternal Morbidity (systematic review on health functioning related to ill health in pregnancy)
Amount £75,000 (GBP)
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 07/2014 
End 05/2015
 
Title Productivity, family planning and reproductive health in Burkina Faso: PopDev qualitative data 
Description qualitative data collected for the popdev project 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact
URL http://datacompass.lshtm.ac.uk/108/
 
Title Productivity, family planning and reproductive health in Burkina Faso: the PopDev study quantitative data 
Description quantitative data collected during the study 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact
URL http://datacompass.lshtm.ac.uk/64/
 
Description Consultation workshop with policy makers and stakeholders 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The workshop allowed us to bring together stakeholders from a broad range of sectors in Burkina Faso: social protection, health, women's affairs, labour and economy. Stakeholders expressed keen interest in the multidisciplinary and multi-sectoral approach employed by the research team and discussed a number of policy recommendations relating to the findings.
Presentations were made by Maurice Yaogo, Patrick Ilboudo, Marina Daniele, Andre Soubeira, and Veronique Filippi. Jenny Cresswell and Rasmane Ganaba were also present at the meeting.

After the workshop, we summarised the results and the recommendations in a research brief (in French, with a translation available in English), which was circulated to all participants, as well as a broader group of stakeholders, and is now available both in print and electronically.
Year(s) Of Engagement Activity 2015
URL http://maternalhealthgroup.lshtm.ac.uk/resources-3/
 
Description Interview with Veronique Filippi disseminated by the PopPov website 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Publicise PopPov activities

Veronique Filippi has received requests for information from overseas, but the role of the interview in generating this interest is difficult to establish
Year(s) Of Engagement Activity 2013
URL http://poppov.org/Home/V%C3%A9roniqueFilippiInterview.aspx
 
Description Poster on "postpartum 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact The poster was presented at a large international conference with demographers and others involved in population studies and policy makers. it was also circulated through social media (twitter).
Year(s) Of Engagement Activity 2017
URL https://iussp.confex.com/iussp/ipc2017/meetingapp.cgi/Paper/2630
 
Description Selected Presentation (2015 PopPov Conference): Women's work and productivity during pregnancy and postpartum in Burkina Faso 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Talks and discussion afterwards. Networking with researchers working on similar studies on women's work & time use in Burundi, and family planning in Burundi and Kenya, as well as Burkinabe researchers.

Networking. Meeting with one of the conference participants in Zambia in July 2015.
Year(s) Of Engagement Activity 2015
URL http://poppov.org/~/media/PopPov/Documents/2015%20PopPov%20Conference%20abstracts.ashx
 
Description consultation meeting with stakeholders in Burkina Faso about Marina Daniele's doctoral thesis results 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Marina Daniele, ESRC-funded PhD student who did her thesis on a male involvement intervention associated with this project, and Veronique Filippi travelled to burkina faso to present results to health professionals in health centres where the intervention took place, and at the district and national level, and to other stakeholders including policy makers in Ministry of Health.
A research brief was prepared as well as a powerpoint presentation.
Year(s) Of Engagement Activity 2017