62963 reproductive HealtH at a GLance May 2011 jordan country context jordan: MdG 5 Status Jordan is a lower middle income country with a per capita MdG 5a indicators GDP of $3,596.1 One of the most important factors in the Maternal Mortality Ratio (maternal deaths per 100,000 live 59 government’s efforts to improve the well-being of its citi- births) UN estimatea zens is the macroeconomic stability that has been achieved Births attended by skilled health personnel (percent) 99.1 since the 1990s. Jordan’s 2008 and 2009 budgets empha- MdG 5B indicators sized increases in the social safety net to help people most Contraceptive Prevalence Rate (percent) 59.3 impacted by high inflation.2 Only 2 percent of the popula- tion subsists on less than US $1.25 per day.1 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 24.3 Antenatal care with health personnel (percent) 98.8 Jordan’s large share of youth population (35 percent of the Unmet need for family planning (percent) 11.9 country population is younger than 15 years old)1 provides Source: Table compiled from multiple sources. a window of opportunity for high growth and poverty re- 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- sure to high volatility in commodity prices. 1990 and 2015, the Maternal Mortality ratio Jordan has been making progress over the past two decades on ma- Gender equality and women’s empowerment are impor- ternal health but it is not yet on track to achieve its 2015 targets.5 tant for improving reproductive health. Higher levels of women’s autonomy, education, wages, and labor market Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target participation are associated with improved reproductive 120 health outcomes.3 110 100 95 In Jordan, the literacy rate among females ages 15 and 80 79 above is 89 percent. More girls are enrolled in secondary 66 59 60 MDG schools compared to boys with a ratio of female to male Target 40 secondary enrollment of 104 percent.1 Nearly 25 percent 28 20 of adult women participate in the labor force.1 Gender in- equalities are reflected in the country’s human development 0 1990 1995 2000 2005 2008 2015 ranking; Jordan ranks 80 of 157 countries in the Gender- related Development Index.4 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. Economic progress and greater investment in human capital of women will not necessarily translate into bet- ter reproductive outcomes if women lack access to repro- World Bank Support for Health in jordan ductive health services. It is thus important to ensure that The Bank’s latest Country Assistance Strategy was for fiscal years 2003 to health systems provide a basic package of reproductive 2005. health services, including family planning.3 current project: None pipeline project: None previous Health projects: P078104 Enhancing Women’s health in Jordan THE WORLD BANK P078107 National Council for Family Affairs n Key challenges Use of modern contraception is increasing. Current use of contraception among married women was 59 percent in 2007, High fertility 35 percent in 1990 and 23 percent in 1976.6 More married Fertility has been declining over time but remains high women use modern contraceptive methods than traditional among the poorest. Total fertility rate (TFR) dropped signifi- methods (42 percent and 17 percent, respectively). Injectables cantly from 6.6 births per woman in 1983 to 4.4 births per wom- are the most commonly used method (23 percent), followed an in 1997 to 3.6 in 2007.6 Fertility remains very high among the by the pill (8 percent).6 Use of long-term methods such as poorest Jordanians at 4.8 in contrast to 2.5 among the wealthiest intrauterine device and implants are negligible. There are so- (Figure 2).6 Similarly, TFR is 3.5 among women with secondary cioeconomic differences in the use of modern contraception education or higher compared to 4.1 among women with no among women: modern contraceptive use is 49 percent among formal education. It is also lower among urban women at 3.8, women in the wealthiest quintile and 37 percent among those compared to rural women at 4.0 births per woman.6 in the poorest quintile (Figure 4).6 Similarly, just 24 percent of women with no education use modern contraception as com- Figure 2 n total fertility rate by wealth quintile pared to 41 percent of women with secondary education or 6 higher, and 36 percent for rural women versus 43 percent for 5 4.8 3.6 overall urban women. 4.4 4 3.6 3 2.8 2.5 Figure 4 n use of contraceptives among married women by wealth 2 quintile 1 70 0 59.3 Overall (All methods) 60 16.1 Poorest Second Middle Fourth Richest 15.3 17.6 20.1 50 16.9 40 49.2 Source: DHS Final Report, Jordan 2007. 42.7 41.1 41.1 30 36.6 20 Adolescent fertility adversely affects not only young wom- 10 en’s health, education and employment prospects but also 0 that of their children. Births to women aged 15–19 years old Poorest Second Middle Fourth Richest have the highest risk of infant and child mortality as well as a Modern Methods Traditional Methods higher risk of morbidity and mortality for the young mother.3, 7 Source: DHS Final Report, Jordan 2007. In Jordan, adolescent fertility rate is high at 24.3 reported births per 1,000 women aged 15–19 years. Unmet need for contraception is 12 percent6 indicating that some women may not be achieving their desired family size.8 Early childbearing is slightly more common among the poor. While 22 percent of the poorest 20–24 years old women Health concerns or fear of side effects are the predominant have had a child before reaching 18, 18 percent of their richer reasons women do not intend to use modern contraceptives in counterparts did (Figure 3). future, not including fertility related reasons (such as menopause and infecundity). Ten percent not intending to use contracep- Figure 3 n percent women who have had a child before age 18 tion cited health concerns and 7 percent cited fear of side effects years by age group and wealth quintile as the main reason while 8 percent expressed opposition to use, primarily by themselves, their husband, or due to their religion.6 25% Poorest Poorest Cost and access are lesser concerns, indicating further need to 20% Richest Richest strengthen demand for family planning services. 15% Poorest 10% Richest 5% poor pregnancy outcomes 0% The majority of pregnant women use antenatal care and have 20–24 years 25–34 years >34 years institutional deliveries. Nearly all (99 percent) pregnant women Source: DHS Final Report, Jordan 2007 (author’s calculation). receive antenatal care from skilled medical personnel (doctor, Human resources for maternal health are limited with 2.6 nurse, or midwife) with 94 percent having the recommended physicians per 1,000 population but nurses and midwives are four or more antenatal visits.6 Additionally, 99 percent deliver slightly more common, at 3.2 per 1,000 population.1 with the assistance of skilled medical personnel, including 100 percent of women in the wealthiest quintile and 98 percent of women in the poorest quintile (Figure 5). 39 percent of all preg- Hiv prevalence is low in jordan nant women are anaemic (defined as haemoglobin < 110g/L) in- HIV prevalence is low in Jordan, at a rate of 0.1 to 0.2 percent of creasing their risk of preterm delivery, low birth weight babies, the adult population.10 stillbirth and newborn death.9 Knowledge of HIV prevention methods is high. More than Figure 5 n Birth assisted by skilled health personnel (percentage) half of married women (53 percent) in Jordan know that con- by wealth quintile doms can help reduce risk of transmission, and 51 percent of Jordanians have knowledge of mother-to-child transmission 100.5 99.1% overall 100.0 through breastfeeding.6 100.0 99.8 99.5 99.3 99.0 98.8 98.5 98 98.0 97.5 97.0 Poorest Second Middle Fourth Richest Source: DHS Final Report, Jordan 2007. Among all women ages 15–49 years who had given birth, 32 percent had no postnatal care within 6 weeks of delivery.6 Forty-three percent of women say the concern no female provider is available is a problem they face in accessing health care (Table 1).6 Further, one third of women cite transport, dis- tance to the facility, not wanting to go alone, and getting money needed for treatment as problems they face in accessing health technical notes: care. Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for table 1 n problems in accessing health care contraception, improving pregnancy outcomes, and reducing STIs. reason % The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health At least one problem accessing 73.1 health care systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 live births and TFR is Concern no female provider available 43.0 greater than 3.These countries are also a sub-group of the Countdown Having to take transport 37.1 to 2015 countries. Details of the RHAP are available at www.worldbank. Distance to health facility 36.1 org/population. Not wanting to go alone 36.0 The Gender-related Development Index is a composite index Getting money needed for treatment 33.0 developed by the UNDP that measures human development in the Not knowing where to go 23.0 same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank Getting permission to go for treatment 10.6 was recalculated. Source: DHS final report, Swaziland 2006–07. n Key actions to improve rH outcomes Strengthen gender equality • Promote the use of ALL modern contraceptive methods, in- • Support women and girls’ economic and social empowerment. cluding long-term methods, through proper counseling which Increase school enrollment of girls. Strengthen employment may entail training/re-training health care personnel. prospects for girls and women. Educate and raise awareness on • Secure reproductive health commodities and strengthen sup- the impact of early marriage and child-bearing. ply chain management to further increase contraceptive use as • Educate and empower women and girls to make reproductive demand is generated. health choices. Build on advocacy and community participation, and involve men in supporting women’s health and wellbeing. reducing maternal mortality • Target the poor and women in rural areas in the provision of reducing high fertility basic and comprehensive emergency obstetric care (renovate • Address the issue of opposition to use of contraception and and equip health facilities). promote the benefits of small family sizes. Increase family plan- • Improve and continuously upgrade the skills of staff for the ning awareness and utilization through outreach campaigns and Emergency Obstetric Care at all levels of service starting form messages in the media. Enlist community leaders and women’s community to the facility levels. groups. • Provide quality family planning services that include counseling reducing Stis/Hiv/aidS and advice, focusing on young and poor populations. Highlight • Integrate HIV/AIDS/STIs and family planning services in rou- the effectiveness of modern contraceptive methods and properly tine antenatal and postnatal care. educate women on the health risks and benefits of such methods. references: 1. World Bank. 2010. World Development Indicators. Washington DC. 9. Worldwide prevalence of anaemia 1993–2005: WHO global da- 2. United Nations in Jordan: About Jordan. http://jo.one.un.org/index. tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, php?page_type=pages&page_id=329. Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- 3. World Bank, Engendering Development: Through Gender Equality tions/2008/9789241596657_eng.pdf. in Rights, Resources, and Voice. 2001. 10. UNAIDS 2004. Epidemiological Fact Sheets on HIV/AIDS and 4. Gender-related development index. http://hdr.undp.org/en/media/ Sexually Transmitted Infections. http://data.unaids.org/publications/ HDR_20072008_GDI.pdf. Fact-Sheets01/jordan_en.pdf. 5. Trends in Maternal Mortality: 1990-2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. 6. Demographic and Health Surveys. Jordan Population and Family Health Survey 2007. Department of Statistics Amman, Jordan and Macro International Inc. Calverton, Maryland, USA. August 2008. http://www.measuredhs.com/pubs/pdf/FR209/FR209.pdf. correspondence details 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. This profile was prepared by the World Bank (HDNHE, and PRMGE). Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- For more information contact, Samuel Mills, Tel: 202 473 9100, email: ics/adolescent_pregnancy/en/index.html. 8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- smills@worldbank.org. This report is available on the following ception. Human Development Network, World Bank. http://www. website: www.worldbank.org/population. worldbank.org/hnppublications. jordan reproductive HeaLtH action pLan indicatorS indicator Year Level indicator Year Level Total fertility rate (births per woman ages 15–49) 2008 3.5 Population, total (million) 2008 5.8 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 24.3 Population growth (annual %) 2008 3.2 Contraceptive prevalence (% of married women ages 15–49) 2007 57.1 Population ages 0–14 (% of total) 2008 35.1 Unmet need for contraceptives (%) 2007 11.9 Population ages 15–64 (% of total) 2008 61.3 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 3.6 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 63.2 Mean ideal number of children for all women — — Urban population (% of total) 2008 78.4 Antenatal care with health personnel (%) 2007 98.8 Mean size of households — — Births attended by skilled health personnel (%) 2007 99.1 GNI per capita, Atlas method (current US$) 2008 3470 Proportion of pregnant women with hemoglobin <110 g/L 2008 38.7 GDP per capita (current US$) 2008 3596 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 110 GDP growth (annual %) 2008 7.9 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 95 Population living below US$1.25 per day 2005 2 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 79 Labor force participation rate, female (% of female population ages 15–64) 2007 24.7 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 66 Literacy rate, adult female (% of females ages 15 and above) 2007 88.9 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 59 Total enrollment, primary (% net) 2008 93.7 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 28 Ratio of female to male primary enrollment (%) 2008 100.7 Infant mortality rate (per 1,000 live births) 2008 17 Ratio of female to male secondary enrollment (%) 2008 103.9 Newborns protected against tetanus (%) 2008 87 Gender Development Index (GDI) 2007 87 DPT3 immunization coverage (% by age 1) 2008 97 Health expenditure, total (% of GDP) 2007 8.9 Pregnant women living with HIV who received antiretroviral drugs (%) — — Health expenditure, public (% of GDP) 2007 5.4 Prevalence of HIV, total (% of population ages 15–49) — — Health expenditure per capita (current US$) 2007 248 Female adults with HIV (% of population ages 15+ with HIV) — — Physicians (per 1,000 population) 2007 2.6 Prevalence of HIV, female (% ages 15–24) — — Nurses and midwives (per 1,000 population) 2006 3.2 poorest-richest poorest/richest indicator Survey Year poorest Second Middle Fourth richest total difference ratio Total fertility rate DHS 2007 4.8 4.4 3.6 2.8 2.5 3.6 2.3 1.9 Current use of contraception (Modern method) — — — — — — — — — — Current use of contraception (Any method) — — — — — — — — — — Unmet need for family planning (Total) DHS 2007 14.9 13.1 12.3 8.4 10.7 11.9 4.2 1.4 Births attended by skilled health personnel — — — — — — — — — — (percent)