79534 Reproductive Health at a GLANCE December 2011 Yemen Country Context Yemen: MDG 5 Status Yemen is a country with many traditions, existing for thou- MDG 5A indicators sands of years.1 Water and arable land are in short supply, Maternal Mortality Ratio (maternal deaths per 100,000 live 210 and its economy is dominated by the oil sector (90 percent births) UN estimatea of merchandise exports and 27 percent of GDP).1 Its grad- Births attended by skilled health personnel (percent) 35.7 ual depletion of oil reserves and the decline of oil prices MDG 5B indicators led to a steep decline in oil revenues, causing severe fiscal Contraceptive Prevalence Rate (percent) 27.7 difficulties.1 Nearly 18 percent of the population subsists on less than US $1.25 per day.2 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 73,7 Antenatal care with health personnel (percent) 47.0 Yemen’s large share of youth population (44 percent of the Unmet need for family planning (percent) 23.6 country population is younger than 15 years old)2 provides Source: Table compiled from multiple sources. a window of opportunity for high growth and poverty re- a The 1997 DHS estimate is 351. duction—the demographic dividend. But for this opportu- nity to result in accelerated growth, the government needs to invest in the human capital formation of its youth. This is especially important in a context of decelerated growth rate Mdg Target 5A: Reduce by Three-quarters, between arising from the global recession and the country’s expo- 1990 and 2015, the Maternal Mortality Ratio sure to high volatility in commodity prices. Yemen has been making progress over the past two decades on maternal health but it is not yet on track to achieve its 2015 targets.5 Gender equality and women’s empowerment are impor- tant for improving reproductive health. Higher levels of Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target women’s autonomy, education, wages, and labor market participation are associated with improved reproductive 600 540 health outcomes.3 500 460 400 340 In Yemen, the literacy rate among females ages 15 and MDG 300 Target above is 43 percent. Fewer girls are enrolled in secondary 250 210 200 schools compared to boys with a ratio of female to male 130 secondary enrollment of 49 percent.2 One fifth of adult 100 women participate in the labor force2 that mostly involves 0 work in agriculture. Gender inequalities are reflected in the 1990 1995 2000 2005 2008 2015 country’s human development ranking; Yemen ranks 136 of Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. 157 countries in the Gender-related Development Index.4 Economic progress and greater investment in human capital of women will not necessarily translate into bet- n  Key Challenges ter reproductive outcomes if women lack access to repro- High Fertility ductive health services. It is thus important to ensure that health systems provide a basic package of reproductive Fertility has been declining over time but remains high among health services, including family planning.3 the poorest. Total fertility rate (TFR) decreased from 7.7 births per woman in 1991–92 to 6.4 births per woman in 19976 and in THE WORLD BANK 2006 reached a TFR of 5.2.7 Fertility remains very high among Adolescent fertility adversely affects not only young women’s the poorest Yemenis at 6.6 in contrast to 3.4 among the wealthiest health, education and employment prospects but also that of (Figure 2). Similarly, TFR is 4.7 among women with some educa- their children. Births to women aged 15–19 years old have the tion compared to 5.8 among women with no formal education. highest risk of infant and child mortality as well as a higher risk of It is also lower among urban women at 4.0, compared to rural morbidity and mortality for the young mother.3, 8 In Yemen, adoles- women at 5.8 births per woman.7 cent fertility rate is 74 reported births per 1,000 women aged 15–19 years. Figure 2 n Total fertility rate by wealth quintile Use of modern contraception is increasing.Current use of 7 6 6.6 5.2 5.2 overall contraception among married women was 21 percent in 1997,6 6.2 4.9 5 and 28 percent in 2006.7 More married women use modern 4 3.4 contraceptive methods than traditional methods (19 percent 3 2 and 8 percent, respectively). The Pill is the most commonly 1 used method (9 percent), followed by LAM (6 percent). Use of 0 intrauterine devices was third most commonly used at 4 per- Poorest Second Middle Fourth Richest cent. There are socioeconomic differences in the use of modern Source: MICS3 Final Report, Yemen 2006. contraception among women: modern contraceptive use is 34 percent among women in the wealthiest quintile and 5 percent among those in the poorest quintile (Figure 3).7 Similarly, just 15 percent of women with no education use modern contra- ception as compared to 30 percent of women with secondary World Bank support for Health in Yemen education or higher, and 13 percent for rural women versus 34 percent for urban women.7 The Bank’s current Country Assistance Strategy is for fiscal years 2010 to 2013. Figure 3 n Use of contraceptives among married women by wealth Current Projects: quintile P104946 GPOBA W3 – Yemen Health-Safe Motherhood ($4.88m) 50 • Assist with Project Preparation and Start-up 40 9.5 • Conduct community outreach and capacity building activities to 30 27.7 Overall (All methods) 7.0 support project implementation • Conduct education and public awareness campaigns to promote 8.4 20 34.2 quality maternal care in targeted districts 7.4 28.4 10 9.8 18.6 • Establish satellite clinics to provide maternal care services to 4.9 9.0 eligible 0 • Beneficiaries within the targeted districts Poorest Second Middle Fourth Richest • Subsidy provision for maternal health care services delivery to Modern Methods Traditional Methods eligible Beneficiaries Source: MICS3 Final Report, Yemen 2006. P113102 RY-Schistosomiasis Control Project ($25.00m) • Preventive chemotherapy for Schistosomiasis Control by supporting Unmet need for contraception is high at 24 percent7 indicat- two anthelminthic drug delivery strategies (i) campaign-based ing that women may not be achieving their desired family size.9 preventive chemotherapy using fixed and temporary sites; and (ii) routine preventive chemotherapy. These interventions will be preceded by national and cascade training sessions that will Poor Pregnancy Outcomes first target trainers at the national level, and then the providers (drug distributors) such as health workers, school staff and other While the majority of pregnant women use antenatal care, in- community-based workers/volunteers. stitutional deliveries are less common. Nearly half of pregnant • Independent monitoring, audit and project administration by women receive antenatal care from skilled medical personnel supporting activities related to the independent monitoring of (doctor, nurse, or midwife)7 with 11 percent having the recom- project targets and audit of project campaigns mended four or more antenatal visits.6 However, a smaller pro- P116110 RY Healthy Motherhood JSDF ($3.00m) portion, 36 percent deliver with the assistance of skilled medical P115673 RY-Employment for Marginalized Youth ($1.24m) P118211 RY-Family-Community Programs ($0.96m) personnel. While 74 percent of women in the wealthiest quin- P094755 RY-Health & Population ($35.00m) tile delivered with skilled health personnel, only 17 percent of women in the poorest quintile obtained such assistance (Figure Pipeline Project:None 4). Similarly, 61 percent of women with secondary education or Previous health project: P043254 RY-Health Reform Support Proj higher compared to less than half (27 percent) of women with no (HRSP) formal education deliver with the assistance of skilled medical References: personnel. It is also higher among urban women at 62 percent, 1. World Bank, Country Brief: Yemen. Available at: . Accessed August 7, 2011. of all pregnant women are anaemic (defined as haemoglobin < 2. World Bank. 2011. World Development Indicators. Washington DC. 110g/L) increasing their risk of preterm delivery, low birth weight 3. World Bank, Engendering Development: Through Gender Equality babies, stillbirth and newborn death.10 in Rights, Resources, and Voice. 2001. 4. Gender-related development index. Available at http://hdr.undp. Figure 4 n Birth assisted by skilled health personnel (percentage) org/en/media/HDR_20072008_GDI.pdf. Accessed March 1, 2011. by wealth quintile 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by 80 WHO, UNICEF, UNFPA, and the World Bank 70 73.6 6. Yemen Demographic and Health Survey 1997 (DHS). Available at: 60 . Accessed August 8, 2011. 40 32.0 7. UNICEF Multiple Indicator Cluster Surveys. YEMEN Monitoring 30 20 17.1 19.8 the situation of children and women. Available at . 0 Accessed August 7, 2011. Poorest Second Middle Fourth Richest 8. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: Source: MICS3 Final Report, Yemen 2006. WHO. Available at http://www.who.int/making_pregnancy_safer/ topics/adolescent_pregnancy/en/index.html. Accessed March 1, 2011 Human resources for maternal health are limited with only 9. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for con- 0.3 physicians per 1,000 population but nurses and midwives are traception. Human Development Network, World Bank. Available slightly more common, at 0.66 per 1,000 population.2 at http://www.worldbank.org/hnppublications. Accessed March 1, 2011 The moderate maternal mortality ratio at 210 maternal deaths 10. Worldwide prevalence of anaemia 1993–2005 : WHO global data- per 100,000 live births indicates that access to and quality of emer- base on anaemia / Edited by Bruno de Benoist, Erin McLean, Ines gency obstetric and neonatal care (EmONC) remains a challenge.5 Egli and Mary Cogswell. Available at: http://whqlibdoc.who.int/pub- lications/2008/9789241596657_eng.pdf. Accessed October 19, 2011. HIV knowledge is low Knowledge of HIV prevention methods is low. In Yemen, 61 per- cent of ever-married women ages 15–49 interviewed have heard of AIDS. However, knowledge of the role condoms can play in pre- venting the transmission of HIV is low at 21 percent. Many inter- viewed women erroneously believe that AIDS can be transmitted by mosquito bites (24 percent) and by sharing food (28 percent). Knowledge of mother-to-child transmission through breast- feeding is 41 percent among ever-married women ages 15–49 Technical Notes: years. Only 12 percent of ever-married women know a place to be Improving Reproductive Health (RH) outcomes, as outlined in the tested for HIV and only 1.9 percent of the women have actually RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs. been tested. Two percent of ever-married women who gave birth in the 2 years preceding the survey were provided information The RHAP has identified 57 focus countries based on poor about HIV prevention during an antenatal care visit. reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 live births and TFR is greater than 3.These countries are also a sub- group of the Countdown to 2015 countries. Details of the RHAP are Correspondence Details available at www.worldbank.org/population. The Gender-related Development Index is a composite index This profile was prepared by the World Bank (HDNHE, PRMGE, and developed by the UNDP that measures human development in the MNSHH). For more information contact, Samuel Mills, Tel: 202 473 same dimensions as the HDI while adjusting for gender inequality. Its 9100, email: smills@worldbank.org. This report is available on the coverage is limited to 157 countries and areas for which the HDI rank following website: www.worldbank.org/population. was recalculated. n  Key Actions to Improve RH Outcomes Strengthen gender equality • Secure reproductive health commodities and strengthen sup- • Support women and girls’ economic and social empowerment. ply chain management to further increase contraceptive use as Increase school enrollment of girls. Strengthen employment demand is generated. prospects for girls and women. Educate and raise awareness on the impact of early marriage and child-bearing. Reducing maternal mortality • Educate and empower women and girls to make reproduc- • Generate demand for the service and address the perception tive health choices. Build on advocacy and community par- that it not necessary to deliver at a health facility. This will ticipation, and involve men in supporting women’s health and require a combination of Behavior Change Communication wellbeing. (BCC) programs via mass media and community outreach as well as deploying midwives to assist women with home deliver- ies. During antenatal care, educate pregnant women about the Reducing high fertility importance of delivery with a skilled health personnel and get- • Provide quality family planning services that include coun- ting postnatal check. Encourage and promote community par- seling and advice, focusing on young and poor populations. ticipation in the care for pregnant women and their children. Highlight the effectiveness of modern contraceptive methods and properly educate women on the health risks and benefits • Address the inadequate human resources for health by training of such methods. more midwives and deploying them to the poorest or hard-to- reach districts. • Promote the use of ALL modern contraceptive methods, in- cluding long-term methods, through proper counseling which may entail training/re-training health care personnel. Reducing STIs/HIV/AIDS • Integrate HIV/AIDS/STIs and family planning services in rou- tine antenatal and postnatal care. yemen Reproductive Health Action Plan Indicators Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15–49) 2006 5.2 Population, total (million) 2010 24.05 Adolescent fertility rate (births per 1,000 women ages 15–19) 2009 73.7 Population growth (annual %) 2010 3.1 Contraceptive prevalence (% of married women ages 15–49) 2006 27.7 Population ages 0–14 (% of total) 2010 44.2 Unmet need for contraceptives (%) 2006 23.6 Population ages 15–64 (% of total) 2010 53.2 Median age at first birth (years) from DHS — Population ages 65 and above (% of total) 2010 2.6 Median age at marriage (years) — Age dependency ratio (% of working-age population) 2010 87.9 Mean ideal number of children for all women — Urban population (% of total) 2010 31.8 Antenatal care with health personnel (%) 2006 47 Mean size of households — Births attended by skilled health personnel (%) 2006 35.7 GNI per capita, Atlas method (current US$) 2009 1070 Proportion of pregnant women with hemoglobin <110 g/L 2008 58.1 GDP per capita (current US$) 2009 1130.2 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 540 GDP growth (annual %) 2009 3.8 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 460 Population living below US$1.25 per day 2005 17.5 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 340 Labor force participation rate, female (% of female population ages 15–64) 2009 20.5 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 250 Literacy rate, adult female (% of females ages 15 and above) 2009 44.7 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 210 Total enrollment, primary (% net) 2008 72.7 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 130 Ratio of female to male primary enrollment (%) 2008 80.4 Infant mortality rate (per 1,000 live births) 2010 57.3 Ratio of female to male secondary enrollment (%) 2005 49.4 Newborns protected against tetanus (%) 2008 63 Gender Development Index (GDI) 2008 136 DPT3 immunization coverage (% by age 1) 2009 66 Health expenditure, total (% of GDP) 2009 5.6 Pregnant women living with HIV who received antiretroviral drugs (%) — Health expenditure, public (% of GDP) 2009 1.6 Prevalence of HIV, total (% of population ages 15–49) — Health expenditure per capita (current US$) 2009 64.0 Female adults with HIV (% of population ages 15+ with HIV) — Physicians (per 1,000 population) 2009 0.3 Prevalence of HIV, female (% ages 15–24) — Nurses and midwives (per 1,000 population) 2004 0.66 Poorest-Richest Poorest/Richest Indicator Survey Year Poorest Second Middle Fourth Richest Total Difference Ratio Total fertility rate MICS3 2006 6.6 6.2 5.2 4.9 3.4 5.2 3.20 1.94 Current use of contraception (Modern method) MICS3 2006 4.9 9.0 18.6 28.4 34.2 19.2 –29.30 0.14 Current use of contraception (Any method) MICS3 2006 14.7 16.4 27.1 35.4 43.7 27.7 –29.00 0.34 Unmet need for family planning (Total) MICS3 2006 31.7 29.5 23.3 20.2 13.8 23.6 17.90 2.30 Births attended by skilled health personnel (percent) MICS3 2006 17.1 19.8 32.0 50.1 73.6 35.7 –56.50 0.23