At the end of a dusty road in the southern African hinterland sits a small concrete building with an orange door. It is a structure so modest and remote that it is hard to believe it could hold lessons for addressing one of the world’s biggest challenges.
The unit is the medical hub for Gasita, a village of 2,000 people in the south of Botswana. Inside one of the rooms, pharmaceutical supplies are neatly stashed on shelves while a photograph of the country’s president, Mokgweetsi Masisi, is propped up on a counter next to a window that is ajar, letting in a warm breeze.
Outposts like these — offering family planning services, contraception, education — have helped bring about one of the world’s most remarkable demographic shifts. In a continent where fertility rates are the highest in the world and populations are soaring, Botswana has a different story to tell.
Fifty years ago, Botswanan women would have seven children on average. Now they have fewer than three. It’s one of the fastest falling fertility rates anywhere in the world — a dramatic decline that merits scrutiny.
The world’s population is on track to hit 8 billion in 2023, and almost 10 billion by 2050. Sub-Saharan Africa is set to grow faster than anywhere: there were 1 billion Africans in 2010, but that number will grow to 2.5 billion by 2050.
Some have warned that this growth risks “driving civilization over the edge,” a controversial view given that it is rich countries, not poor, that lead the way on consuming the world’s resources.
But enabling women to control their fertility — a move that almost inevitably leads to them having fewer babies — is not just about a tussle over resources, or the environment: It brings enormous ramifications for women’s health, education, and employment — with knock-on effects for society and the economy.
So what did Botswana get right?
In a ground floor office at the University of Botswana, in the country’s capital of Gaborone, Dr. Chelsea Morroni considers the issue. “Everyone is always asking, ‘how did this happen?’ ”
An expert in international sexual and reproductive health at the Liverpool School of Tropical Medicine, Morroni has lived in Botswana with her family for five years. As founder and director of the Botswana Sexual and Reproductive Health Initiative, she spends her days delving into issues around fertility and contraception.
But Morroni says understanding Botswana’s dramatic fertility decline involves teasing apart a complex web of factors.
“There’s been a huge amount of change in Botswana,” she says, pointing out that since Botswana became an independent country in 1966, the landscape developed quickly, with high levels of economic growth and development of both health care infrastructure and education infrastructure, enabling young women to become educated and have employment opportunities.
“All of those things on the macro level are really important to fertility declines anywhere in the world,” says Morroni, whose work is part of the Botswana UPenn Partnership: a collaboration between the Botswana health ministry, the University of Botswana, and the University of Pennsylvania.
But the country made more direct strides, too. “Botswana also was very proactive in the early years in establishing a family planning program, so in setting up a program that was far-reaching in terms of its geographical reach, providing access to most people in the country to a range of contraceptive methods,” says Morroni.
Maternal and child health and family planning services were integrated from the outset more than 40 years ago. A suite of contraceptives are now available through facilities ranging from the most rural health posts to urban hospitals. An NGO, the Botswana Family Welfare Association (Bofwa), works with the government to reach out to even the most rural of locations around the country to improve access to sexual and reproductive health services, particularly among young people.
There are other considerations, too. The infant mortality rate decreased from 97.1 deaths per 1,000 live births in 1971 to 17 in 2011, while an increasing proportion of the population living in urban settings could also play a role: Fertility rates are generally higher in rural areas.
And there is another issue. “Botswana … has been very hard hit by HIV, one of the hardest hit countries in the world,” says Morroni. And as she points out, research suggests there is an association between HIV infection and reduced fertility, although how much of a contribution that has made to the steep fertility decline is very difficult to say. “Luckily with the advent of universal access to antiretroviral therapy we are seeing a narrowing of the gap between fertility in HIV infected and uninfected people which is really, really a step in the right direction,” she says.
All of which mean that women like Chyna are becoming statistically rarer. “I have seven children and all the time I was bearing these seven children, there was never a break in between eight years,” says the 30-year-old, sitting inside the Gasita room, the fabric around her hair bright with the colors of the Botswana flag.
A single mother, Chyna found respite from multiple pregnancies through the work of Bofwa.
“I eventually got to find out about the implant from Bofwa — I asked for help because the pregnancies were getting out of hand and, knowing myself, if it wasn’t for the implant I would still be pregnant now,” says Chyna, speaking through an interpreter.
“I am very, very grateful. My only problem is that I have got so many kids that I can barely take care of [them]. They need clothing, they need to be fed.”
While the health post is government run, Bofwa makes a visit about once a quarter to Gasita and nine other settlements around Kanye, led by nurse and midwife Phenyo Ntoko. These outposts are replicated across rural Botswana, where women are increasingly keen to embrace contraception, including the implant, which sits in the upper arm and lasts for years.
Their priorities are as individual as the women themselves. For some it is about preventing pregnancies at an early age, for others the main goal is to space children. Many women gathered at the health posts said they only want two, with many years between them to help them raise their first child well.
Despite the complex range of factors behind the dramatic fertility decline, and the fact that different countries have different political histories and cultural and social influences that make comparisons difficult, Morroni believes other nations could take a leaf out of Botswana’s book.
“From my perspective it is really about having the political will for the development and implementation of a high quality family planning program with reach,” she says.
A World Bank report on Botswana’s fertility revolution says myriad other factors contribute to a more measured approach to family planning: the education of girls, encouraging women to enter in the workforce, and reaching individuals in their homes by means of visits by family welfare educators.
Una Ngwenya, the chief executive of Bofwa, agrees that the family welfare educators were a key factor behind the fertility decline. But, she adds that national averages don’t tell the whole story.
“Where I work, mothers still have six kids,” she says. “People tell you in Botswana you have an average of women having two kids — I ask you, where? I cannot see that.
“We are one of the most unequal countries in the world — what happens here in the big villages and in the cities does not necessarily happen in Lorolwane,” she adds, referring to a remote village beyond Gasita, as yet without electricity.
A member association of the International Planned Parenthood Federation, Bofwa receives core funding from the organization, as well as some government funding and contraceptive commodities and antiretroviral drugs from Botswana’s Ministry of Health and Wellness. Other partners include the Positive Action for Children Fund from private firm ViiV Healthcare.
“We have five centers,” Ngwenya says, ticking off sites around the country. “It gives me satisfaction to see a group of girls speaking very confidently about how they want to make their choices.” Ngwenya rejects the idea that contraception is being pushed on women, pointing out that communities are impatient for Bofwa to work with them. “It used to be difficult to go into a community and talk about contraception. Now they even [say], ‘hey you are taking too long, come to our community, we need you people here, now,’ ” she says.
But Bofwa has had to close at least two centers because of Donald Trump’s reinstatement of the controversial Global Gag Rule, which prevents U.S. federal funds going to any group that performs or even provides information about abortions.
Among the Bofwa services suspended are projects specifically engaging with populations, including sex workers and men who have sex with men, as well as another working with vulnerable children.
“Ah, that was such a blow,” says Ngwenya with a sigh. “The impact of the Gag Rule was so much on the clients, but also on Bofwa’s reputation. It really impacted our work in a very negative manner.”
Bofwa does not provide abortions, but it does counsel women who might be seeking one — which is legal under certain conditions in Botswana — and those who have had an abortion.
“For me, it is rewarding to see Bofwa help one girl to terminate a pregnancy that came from incest,” says Ngwenya, adding that improving understanding of when abortion is currently legal is important. “We want the community to know their rights,” she says, noting that the team sees cases of young teenagers becoming pregnant. “Our research tells us there is a lot of need here. What has happened to these kids? Could it be rape, could it be defilement?”
Nonetheless, Ngwenya is sanguine. “Bofwa is a very resilient organization; we have been here for 30 years and we will go on for a good while to come.”