62951 RepRoductive HealtH at a GLaNce may 2011 zambia country context zambia: mdG 5 Status Zambia gained independence from British rule in 1962. mdG 5a indicators Since then, it has been a peaceful country and has made ef- Maternal Mortality Ratio (maternal deaths per 100,000 live 470 forts towards improving its economic and social condition. births) UN estimatea In recent years, Zambia experienced significant economic Births attended by skilled health personnel (percent) 46.4 growth with its gross domestic product nearly doubling mdG 5b indicators between 2000 and 2008 from 3.6 to 6.3 percent.1 However, Contraceptive Prevalence Rate (percent) 40.8 over two-thirds of the population subsists on less than US $1.25 per day.1 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 139.4 Antenatal care with health personnel (percent) 93.7 Zambia’s large share of youth population (46 percent of Unmet need for family planning (percent) 26.5 the country population is younger than 15 years old1) pro- vides a window of opportunity for high growth and pov- Source: Table compiled from multiple sources. a The 2007 DHS estimate is 591. erty reduction—the demographic dividend. But for this opportunity to result in accelerated growth, the govern- ment needs to invest in the human capital formation of its youth. This is especially important in a context of deceler- ated growth rate arising from the global recession and the mdG target 5a: Reduce by three-quarters, between country’s exposure to high volatility in commodity prices. 1990 and 2015, the maternal mortality Ratio Gender equality and women’s empowerment are impor- Zambia has not made progress over the past two decades on ma- tant for improving reproductive health. Higher levels of ternal health and is not yet on track to achieve its 2015 targets.4 women’s autonomy, education, wages, and labor market participation are associated with improved reproductive Figure 1 n maternal mortality ratio 1990–2008 and 2015 target health outcomes.2 700 600 600 560 In Zambia, the literacy rate among females ages 15 and 500 490 470 390 above is 61 percent. Fewer girls are enrolled in secondary 400 MDG Target schools compared to boys with a ratio of female to male 300 200 secondary enrollment of 83 percent.1 Three-fifths of adult 99 100 women participate in the labor force1 that mostly involves 0 work in agriculture. Gender inequalities are reflected in the 1990 1995 2000 2005 2008 2015 country’s human development ranking; Zambia ranks 144 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. of 157 countries in the Gender-related Development Index.3 Economic progress and greater investment in human capital of women will not necessarily translate into bet- World bank Support for Health in zambia ter reproductive outcomes if women lack access to repro- The Bank’s current Country Assistance Strategy is for fiscal years 2008 to 2011. ductive health services. It is thus important to ensure that current projects: health systems provide a basic package of reproductive P111106 ZM-Capacity Building in PET for HIV/AIDS health services, including family planning.2 pipeline project: P120872 ZM:Malaria Booster-Additional Financing Approval date12/7/2010 previous Health project: P003248 ZM-Zanara HIV/AIDS APL (FY03) P096131 ZM-Malaria Health Booster SIL (FY06) THE WORLD BANK n Key challenges 2001–2002.5 More married women use modern contraceptive methods than traditional methods (33 percent and 8 percent). High fertility The pill is the most commonly used method (11 percent), fol- Fertility has been declining over time but remains high among lowed by injectables (9 percent). Use of long-term methods such the poorest. Total fertility rate (TFR) dropped significantly from as intrauterine device and implants are negligible. There are 6.5 births per woman in 1992 to 6.1 births per woman in 1996 but socioeconomic differences in the use of modern contraception has since stalled with a TFR of 6.2 in 2007.5 Fertility remains very among women: modern contraceptive use is 48 percent among high among the poorest Zambians at 8.4 in contrast to 3.4 among women in the wealthiest quintile and 31 percent among those in the wealthiest (Figure 2). Similarly, TFR is 2.4 among women the poorest quintile (Figure 4).5 Similarly, just 27 percent of wom- with secondary education or higher compared to 8.2 among en with no education use modern contraception as compared to women with no formal education. It is also lower among urban 50 percent of women with secondary education or higher, and women at 4.3, compared to rural women at 7.5. 37 percent for rural women versus 42 percent for urban women. Figure 2 n total fertility rate by wealth quintile Figure 4 n use of contraceptives among married women by wealth quintile 3.4 9 60 8 8.4 7.6 7.2 50 5.9 7 6.2 overall 40.8 Overall (All methods) 48.3 6 40 5.7 5.2 9.9 38.6 5 30 10.1 4 3.4 30.6 8.8 3 20 24.1 22.5 2 10 1 0 0 Poorest Second Middle Fourth Richest Poorest Second Middle Fourth Richest Modern Methods Traditional Methods Source: DHS Final Report, Zambia 2007. Source: DHS Final Report, Zambia 2007. Adolescent fertility adversely affects not only young wom- en’s health, education and employment prospects but also that Unmet need for contraception is high at 27 percent5 indicat- of their children. Births to women aged 15–19 years old have the ing that women may not be achieving their desired family size.7 highest risk of infant and child mortality as well as a higher risk Infecundity and fear of side effects are the predominant rea- of morbidity and mortality for the young mother.2, 6 In Zambia, sons women do not intend to use modern contraceptives in adolescent fertility rate is high at 139 reported births per 1,000 future. Twenty-three percent not intending to use contraception women aged 15–19 years. cited infecundity and 18 percent cited fear of side effects as the Early childbearing is more prevalent among the poor. While main reason while 11 percent expressed opposition to use, pri- 63 percent of the poorest 20–24 years old women have had a child marily by themselves, their husband, or due to their religion, and before reaching 18, only 23 percent of their richer counterparts 11 percent cited wanting as many children as possible.5 Cost and did (Figure 3). The rich-poor gap in prevalence of early child- access are lesser concerns, indicating further need to strengthen bearing has increased across cohorts. demand for family planning services. Figure 3 n percent women who have had a child before age 18 years by age group and wealth quintile poor pregnancy outcomes 70% While the majority of pregnant women use antenatal care, Poorest 60% Poorest Poorest institutional deliveries are less common. Over nine-tenths of 50% 40% pregnant women receive antenatal care from skilled medical per- Richest 30% Richest sonnel (doctor, nurse, or midwife) with 60 percent having the Richest 20% recommended four or more antenatal visits.5 However, a smaller 10% 0% proportion, 46 percent deliver with the assistance of skilled medi- 20–24 years 25–34 years >34 years cal personnel. While 91 percent of women in the wealthiest quin- Source: DHS Final Report, Zambia 2007 (author’s calculation). tile delivered with skilled health personnel, only 27 percent of women in the poorest quintile obtained such assistance (Figure Use of modern contraception is increasing. Current use of 5). Further, 47 percent of all pregnant women are anaemic (de- contraception among married women was 41 percent in 2007, fined as haemoglobin < 110g/L) increasing their risk of preterm a steady increase from 26 percent in 1996 and 34 percent in delivery, low birth weight babies, stillbirth and newborn death.8 Figure 5 n birth assisted by skilled health personnel (percentage) the prevalence among females is nearly 30 percent higher than by wealth quintile among males (16 percent and 12 percent, respectively). 100 91.3 Knowledge of HIV prevention methods is high. Nearly three- 80 71.4 quarters of Zambians know that condoms can help reduce risk of 60 46.4% overall transmission. Further, knowledge of mother-to-child transmis- 40 36.4 sion through breastfeeding is relatively high at 85 percent for 26.9 27.7 women and 75 percent for men.5 The number of Zambians who 20 know that the risk of transmission from mother-to-child can be 0 reduced by using medication is relatively high, at 68 percent of Poorest Second Middle Fourth Richest women at 75 percent of men. Source: DHS Final Report, Zambia 2007. Among all women ages 15–49 years who had given birth, 52 percent had no postnatal care within 6 weeks of delivery while 4 percent received postnatal check-up from a traditional birth attendant.5 Fifty-four percent of women reported the concern that no drugs would be available as a problem in seeking medical care technical Notes: (Table 1).5 Further, two in five women cited having to take trans- Improving Reproductive Health (RH) outcomes, as outlined in the port and distance to the health facility as a problem, and one RHAP, includes addressing high fertility, reducing unmet demand for third cited the difficulty in getting money needed for treatment contraception, improving pregnancy outcomes, and reducing STIs. as a problem. The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health table 1 n barriers in accessing health care (women age 15–49) systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 live births and TFR is Reason % greater than 3.These countries are also a sub-group of the Countdown At least one problem accessing health care 73.5 to 2015 countries. Details of the RHAP are available at www.worldbank. Concern no drugs available 53.5 org/population. Having to take transport 42.4 The Gender-related Development Index is a composite index Distance to health facility 40.8 developed by the UNDP that measures human development in the Getting money needed for treatment 33.6 same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank Not wanting to go alone 25.6 was recalculated. Concern no provider available 25.4 Concern no female provider available 17.1 Getting permission to go for treatment 4.2 Source: DHS final report, Zambia 2007. National policies and strategies that have influenced Human resources for maternal health are limited with only reproductive health 0.06 physicians per 1,000 population but nurses and midwives are slightly more common, at 0.71 per 1,000 population.1 Abortion is made legal (through the Penal Code (Amendment) in any of these three circumstances: rape or incest; to save a woman’s life; The high maternal mortality ratio at 470 maternal deaths per if there is a fetal impairment. Two doctors must consent, and the 100,000 live births indicates that access to and quality of emer- procedure must be done in the first 16 weeks of pregnancy. gency obstetric and neonatal care (EmONC) remains a challenge.4 Marriage Act when enacted, legal age for marriage 18 years Maternal death – Is it not yet notifiable event under Public Health Act. This has to be amended Hiv prevalence is falling in zambia Reproductive health commodity security was finalized HIV prevalence has slightly declined in Zambia but wom- Comprehensive abortion care strategy is completed and circulated en are one of the most vulnerable groups. The percentage of Midwifery Act allows midwives and nurses to conduct post abortion adult population aged 15–49 years who have HIV has declined acre and give oxytocin and remove RPOCs, and retained placenta. from 16 percent in 2001–2002 to 14 percent in 2007.5 However, n Key actions to improve RH outcomes Strengthen gender equality Reducing maternal mortality • Support women and girls’ economic and social empowerment. • Strengthen the referral system by instituting emergency trans- Increase school enrollment of girls. Strengthen employment port, training health personnel in appropriate referral proce- prospects for girls and women. Educate and raise awareness on dures (referral protocols and recording of transfers) and estab- the impact of early marriage and child-bearing. lishing maternity waiting huts/homes at hospitals to accommo- • Educate and empower women and girls to make reproduc- date women from remote communities who wish to stay close tive health choices. Build on advocacy and community par- to the hospital prior to delivery. ticipation, and involve men in supporting women’s health and • Address the inadequate human resources for health by training wellbeing. more midwives and deploying them to the poorest or hard-to- reach districts. Reducing high fertility • Promote institutional delivery through provider incentives and • Address the issue of opposition to use of contraception and implement risk-pooling schemes. Provide vouchers to women promote the benefits of small family sizes. Increase family plan- in hard-to-reach areas for transport and/or to cover cost of de- ning awareness and utilization through outreach campaigns livery services and messages in the media. Enlist community leaders and • Generate demand for the service and address the perception that women’s groups. it not necessary to deliver at a health facility. This will require a • Provide quality family planning services that include coun- combination of Behavior Change Communication (BCC) pro- seling and advice, focusing on young and poor populations. grams via mass media and community outreach as well as deploy- Highlight the effectiveness of modern contraceptive methods ing midwives to assist women with home deliveries. During ante- and properly educate women on the health risks and benefits natal care, educate pregnant women about the importance of de- of such methods. livery with a skilled health personnel and getting postnatal check. • Promote the use of ALL modern contraceptive methods, in- cluding long-term methods, through proper counseling which Reducing Stis/Hiv/aidS may entail training/re-training health care personnel. • Integrate HIV/AIDS/STIs and family planning services in rou- • Secure reproductive health commodities and strengthen sup- tine antenatal and postnatal care. ply chain management to further increase contraceptive use as • Focus HIV/AIDS providing information, education and com- demand is generated. munication efforts on adolescents, youth, married women, and other high risk groups including IDUs, sex workers and their clients, and migrant workers. References: 1. World Bank. 2010. World Development Indicators. Washington 7. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- DC. ception. Human Development Network, World Bank. Available at 2. World Bank, Engendering Development: Through Gender Equality http://www.worldbank.org/hnppublications. in Rights, Resources, and Voice. 2001. 8. Worldwide prevalence of anaemia 1993–2005: WHO global da- 3. Gender-related development index. http://hdr.undp.org/en/media/ tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, HDR_20072008_GDI.pdf. Ines Egli and Mary Cogswell. . WHO, UNICEF, UNFPA, and the World Bank. 5. Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC),University of Zambia, and Macro correspondence details International Inc. 2009. Zambia Demographic and Health Survey This profile was prepared by the World Bank (HDNHE, PRMGE, and 2007.Calverton, Maryland, USA: CSO and Macro International Inc. AFTHE). For more information contact, Samuel Mills, Tel: 202 473 9100, 6. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO. http://www.who.int/making_pregnancy_safer/ email: smills@worldbank.org. This report is available on the following topics/adolescent_pregnancy/en/index.html. website: www.worldbank.org/population. zambia RepRoductive HeaLtH actioN pLaN iNdicatoRS indicator Year Level indicator Year Level Total fertility rate (births per woman ages 15–49) 2007 6.2 Population, total (million) 2008 12.6 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 139.4 Population growth (annual %) 2008 2.5 Contraceptive prevalence (% of married women ages 15–49) 2007 40.8 Population ages 0–14 (% of total) 2008 46.2 Unmet need for contraceptives (%) 2007 26.5 Population ages 15–64 (% of total) 2008 50.7 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 3 Median age at marriage (years) 2007 18.4 Age dependency ratio (% of working-age population) 2008 97.1 Mean ideal number of children for all women — — Urban population (% of total) 2008 35.4 Antenatal care with health personnel (%) 2007 93.7 Mean size of households 2007 5 Births attended by skilled health personnel (%) 2007 46.4 GNI per capita, Atlas method (current US$) 2008 950 Proportion of pregnant women with hemoglobin <110 g/L 2008 46.9 GDP per capita (current US$) 2008 1134 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 390 GDP growth (annual %) 2008 6 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 490 Population living below US$1.25 per day 2004 64.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 600 Labor force participation rate, female (% of female population ages 15–64) 2008 60.4 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 560 Literacy rate, adult female (% of females ages 15 and above) 2008 61 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 470 Total enrollment, primary (% net) 2008 96.7 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 99 Ratio of female to male primary enrollment (%) 2008 97.9 Infant mortality rate (per 1,000 live births) 2008 92 Ratio of female to male secondary enrollment (%) 2008 83.3 Newborns protected against tetanus (%) 2008 90 Gender Development Index (GDI) 2008 144 DPT3 immunization coverage (% by age 1) 2008 80 Health expenditure, total (% of GDP) 2007 6.2 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 14.5 Health expenditure, public (% of GDP) 2007 3.6 Prevalence of HIV, total (% of population ages 15–49) 2007 15.2 Health expenditure per capita (current US$) 2007 57.1 Female adults with HIV (% of population ages 15+ with HIV) 2007 57.1 Physicians (per 1,000 population) 2006 0.055 Prevalence of HIV, female (% ages 15–24) 2007 11.3 Nurses and midwives (per 1,000 population) 2006 0.706 poorest-Richest poorest/Richest indicator Survey Year poorest Second middle Fourth Richest total difference Ratio Total fertility rate DHS 2007 8.4 7.6 7.2 5.2 3.4 6.2 5.0 2.5 Current use of contraception (Modern method) DHS 2007 30.6 24.1 22.5 38.6 48.3 32.7 –17.7 0.6 Current use of contraception (Any method) DHS 2007 40.5 34.2 31.3 44.3 54.2 40.8 –13.7 0.7 Unmet need for family planning (Total) DHS 2007 26.4 31.4 29.7 25.4 19.0 26.5 7.4 1.4 Births attended by skilled health personnel DHS 2007 26.9 27.7 36.4 71.4 91.3 46.4 –64.4 0.3 (percent) development partners support for reproductive health in zambia WHo: Safe motherhood, adolescent reproductive health and cidRz: PMTCT, focused ANC in PMTCT EmONC, safe motherhood action groups, PMTCT Sida: Procurement of equipment uNFpa: Sexual reproductive health and rights, family planning cida: procurement of equipment training and procurement and support for reproductive health commodities, safe motherhood action groups, vesicle vaginal Gtz: Gender mainstreaming, (no active right now in RH) fistuales Jica: Procurement of equipment uNiceF: EmONC, safe motherhood action groups, procurement of uSaid: Deliver project – family planning commodity security equipment, PMTCT WoRLd baNK Results based financing for MDG5- EmONC, procurement of uSaid: Health systems strengthening, skilled birth attendance, equipment, focused ANC, PMTCT, health systems strengthening, skilled birth capacity building in focused ANC, safe motherhood action groups attendance, human resource for health, community mobilization. dFid: procurement of equipment, human resource for health, community mobilization for demand creation