National context

Population 

The Kingdom of Eswatini, a landlocked nation bordered by South Africa to the South, West and North and by Mozambique to the East, has a total area of 17,364 km². The Eswatini population is 1,202,285 with a sex distribution of 616, 386 females and 585, 899 males. About 75% (905,667) of the population resides in the rural areas with 296,618 (25%) residing in the urban areas. 

Fertility

The Total Fertility Rate (TFR) declined from 4.0 children per woman in 2007 to 3.2 in 2022 and the overall contribution by adolescent girls and young women aged 15 - 24 years is 38%.  rural adolescents contribute the highest at 38% compared with  urban adolescents at 36%. 

Adolescent fertility is highest among adolescents with a poor background at 122/1000  compared with only 29 for adolescents from richer households as shown in the graph below.

HIV and AIDS

Eswatini has a generalised HIV epidemic with a prevalence currently estimated at 24.8% which corresponds to approximately 185,000 adults living with HIV. Eswatini HIV prevalence declined from 31% in 2011, to about 24.8%  in 2023.  Prevalence of HIV is almost two times higher among females aged 15 years and older at 30.4% compared to males aged 15 years and older at 18.7%. 

Eswatini achieved the 95-95-95 global HIV targets well ahead of the 2030 targeted deadline as the country is currently at 95:97:96. Through the ART programme, the country has improved the life expectancy of people living with HIV. These achievements have contributed to a steady decline in HIV incidence among adults (aged 15 years and older) from 16.73 per 1000 population in 2010 to 4.19 per 1000 in 2023 (HIV estimates and Projections). 

Eswatini’s AIDS related deaths are significantly decreasing over the past decade and a half due to expanded Test and Treat Programs. The deaths have reduced from around 6200 in 2010 to about 3100 in 2023. Since 2010, HIV infections have fallen by about 75%, and AIDS-related deaths have decreased by about 50%. Even though HIV prevention and treatment programmes are accessible to all people, females still have higher HIV prevalence and incidence compared to males especially at the younger age bands. STIs are mostly common among the sexually active population aged 15-39 years and highest among females than males. The most common STIs include vaginal discharge, urethral discharge and genital ulcers.

Maternal mortality

The Maternal Mortality Ratio (MMR) stands at 452 per 100,000 live births (Population and Housing Census in 2017) which is a slight improvement from 593 per 100, 000 live births (Demographic Housing Survey in 2012). The rural setting has the highest maternal mortality ratio compared to the urban setting at 478 per 100,000 live births compared to 382 per 100,000 births (Population and Housing Census in 2017). Most deaths occurred among the 30-39 year olds.  The coverage of ANC visits of at least one is 96% (4 more visits ANC was 76%),  92.7% of women utilised facility-based delivery, and 87.5% of postpartum women received PNC services. The skilled birth attendance coverage is 93.4%. MTCT rate has been reduced from 25% in 2000 to 1.3% in 2022. Eswatini has successfully rolled out the PMTCT programme to reach an almost elimination stage of MTCT estimated at 1.3%  at a coverage of 95% in 2022. 

Most of the institutional maternal deaths are as a result of the third delay which is health systems related. For example, the quality of services delivered to these women is low due to poor management of the third and fourth stages of labour and monitoring of complications resulting in delay in referring to the next level of care.  Lack of medicines and supplies critical for maternal survival has been a persistent challenge resulting from fiscal challenges which was further exacerbated by the COVID-19 pandemic. For instance, magnesium sulphate and uterotonic medicines were in constant shortages which justify pregnancy-induced hypertension (36%) and postpartum haemorrhage (19.4%) abortion (8.3%) and sepsis (5.6%) as the leading causes of maternal deaths in 2022. Adolescent girls and young women contributed 17% to total maternal death in 2022. Furthermore, most maternity units’ infrastructure are dilapidated coupled with obsolete equipment which compromises quality of care especially during maternal and neonatal complications that require resuscitation.

Adolescent birth rate

Adolescent birth rate remains high, though having declined from 111 births per 1,000 adolescents aged 15-19 years in 2007 to 87 births per 1,000 in 2014. Teenage pregnancy is largely attributable to early and unprotected sexual activity, which rapidly increases from about 3% by age 15 years to about 50% by the time adolescent girl reaches the age of 17 years. Contraceptive use among unmarried adolescents is low (15.5%) and condom use even lower at 9%. Although 75% of health facilities provide adolescent health services only 26% of these provided youth-friendly and integrated family planning services.

Gender-based violence

Violence against women and girls continues to prevail in Eswatini despite a conducive legislative and policy environment that protects all citizens against violence. Among adolescents and young women, lifetime sexual violence is the most prevalent form of violence experienced by 8.1% of girls age 13-24 years, followed by lifetime physical violence at 5% of girls of the same age. However, it is worth noting that all types of violence experienced by girls aged 13-24 years declined drastically between 2007 and 2022 potentially as a result of a more focused approach of the GBV interventions implemented in the country.   

Physical violence is common among intimate partners, with 1 in 2 women reporting to have been abused by their current or former partner. Ever married women or in union as well as women who are formerly married or were once in a union, experience the highest levels of physical violence at 66.5% and 71.8% respectively, MICS (2021-2022).  Unmarried women have lower levels of physical violence at 36.3%. 

Urban women experience higher levels (59.1 percent) of IPV than their rural counterparts (50.7 percent). In terms of regional variation, Manzini women have the highest levels of IPV at 57.5 percent compared with 48.7 percent among women who live in Shiselweni.  Women with lower educational attainment experience higher levels of IPV than other women i.e. at 57 percent among women with only primary school education compared with 41.5 percent for women with higher educational attainment. Married women (66.5 percent) suffer more violence by their partners than unmarried women (36.3 percent). In the same vein, proportionately more women from the poorest wealth quintile (54.1 percent) experience violence than women in the fourth wealth quintile (48 percent).

In terms of attitudes to wife beating, the proportion of women who justify wife beating declined from 39.1% in 2010 to 12.1% in 2021. Among men, the proportion declined from 33.4% to 8.1% over the same period. More rural women (15.0%) accept wife beating than urban women (8.6%), acceptance levels are higher among rural men (8.1%) than among urban men (7.1%). These findings clearly demonstrate that attitudes towards wife beating are changing for the better. 

The country has a National Gender Policy (2023) and a National Strategy on Ending Violence (2023-2027) that enhance a coordinated response to GBV and harmful practices. In addition, the country has pieces of legislation that protect the rights of women and girls including children. These are the Sexual Offences and Domestic Violence Act (2018) and The Child Protection and Welfare Act.

(2012). Furthermore there are community, policy and technical high level coordination structures that facilitate implementation of these strategies and legal frameworks.  Child marriage declined significantly from 10.9% in 2010 to 1.9% in 2021-2022.