62948 RepRoductive HealtH at a Glance June 2011 Swaziland country context Swaziland: MdG 5 status The Kingdom of Swaziland is a lower-middle-income MdG 5a indicators country. Its Gini coefficient of 0.61 is one of the highest in Maternal Mortality Ratio (maternal deaths per 100,000 live 420 the world, indicating wide disparities in household income. births) UN estimatea Sixty-three percent of the population subsists on less than Births attended by skilled health personnel (percent) 82.0 US $1.25 per day.1 Swaziland has made some improvements MdG 5B indicators in the past three decades; however, one of its greatest chal- Contraceptive Prevalence Rate (percent) 49.3 lenges is an HIV prevalence of 26 percent among 15–49 year olds—the highest in the world. Adolescent Fertility Rate (births per 1,000 women ages 15–19) 82.3 Antenatal care with health personnel (percent) 84.8 Swaziland’s large share of youth population (40 percent Unmet need for family planning (percent) 24.0 of the country population is younger than 15 years old)1 provides a window of opportunity for high growth and Source: Table compiled from multiple sources. a Official estimate of 725 maternal deaths per 100,000 live births. poverty 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- Swaziland has not made progress over the past two decades on tant for improving reproductive health. Higher levels of maternal 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.2 500 440 420 In Swaziland, the literacy rate among females ages 15 and 400 340 above is 86 percent. Fewer girls are enrolled in secondary 300 260 220 schools compared to boys with a ratio of female to male sec- MDG 200 Target ondary enrollment of 90 percent.1 Fifty-five percent of adult women participate in the labor force1 that mostly involves 100 64 work in agriculture. Gender inequalities are reflected in the 0 country’s human development ranking; Swaziland ranks 123 1990 1995 2000 2005 2008 2015 of 157 countries in the Gender-related Development Index.3 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- world Bank Support for Health in Swaziland ter reproductive outcomes if women lack access to repro- ductive health services. It is thus important to ensure that The new Bank’s Country Assistance Strategy under preparation (P112618) is scheduled to be approved by the Bank’s Executive Board on September 15, 2011. health systems provide a basic package of reproductive health services, including family planning.2 current projects: TF09255 Project For Delivering Maternal And Child Health Care To Vulnerable Populations ($2.57m) P110156 – Swaziland Health, HIV/AIDS and TB Project ($41m). pipeline project: None THE WORLD BANK previous Health project: None n Key challenges male condom (12 percent). Use of long-term methods such as intrauterine device and implants are negligible. There are socio- High fertility economic differences in the use of modern contraception among Fertility has been declining over time but remains high among women: modern contraceptive use is 51 percent among women in the poorest. Total fertility rate (TFR) dropped significantly from the wealthiest quintile and 43 percent among those in the poorest 5.6 births per woman in 1991 to 4.5 births per woman in 1997 to quintile (Figure 4).7 Similarly, just 27 percent of women with no 3.9 in 2006–07.5 Fertility remains higher among the poorest at 5.5 education use modern contraception as compared to 72 percent in contrast to 2.6 among the wealthiest (Figure 2). Similarly, TFR is of women with secondary education or higher, and 45 percent for 2.4 among women with tertiary education compared to 4.9 among rural women versus 56 percent for urban women.5 women with no formal education. It is also lower among urban women at 3.0, compared to rural women at 4.2 births per woman.5 Figure 4 n use of contraceptives among married women by wealth quintile Figure 2 n total fertility rate by wealth quintile 60 49.3 Overall (All methods) 2.0 1.4 50 0.8 6 1.5 1.1 51.3 50.8 5.5 3.9 overall 40 45.4 46.1 4.9 43.4 5 3.9 30 4 3.3 20 3 2.6 10 2 0 1 Poorest Second Middle Fourth Richest 0 Poorest Second Middle Fourth Richest Modern Methods Traditional Methods Source: DHS Final Report, Swaziland 2006–07. Source: MICS Preliminary Report, Swaziland 2010. Adolescent fertility adversely affects not only young wom- Unmet need for contraception is high at 24 percent5 indi- en’s health, education and employment prospects but also that cating that women may not be achieving their desired family of their children. Births to women aged 15–19 years old have the size.8 highest risk of infant and child mortality as well as a higher risk Unsafe abortion is common, accounting for 50 percent of all of morbidity and mortality for the young mother.2, 6 In Swaziland, obstetric complications and 37 percent of health facility based adolescent fertility rate is high at 82.3 reported births per 1,000 maternal deaths.9 women aged 15–19 years. Opposition to use, health concerns or fear of side effects are Early childbearing is more prevalent among the poor. While the predominant reasons women do not intend to use mod- 47 percent of the poorest 20–24 years old women have had a child ern contraceptives in future, not including fertility related rea- before reaching 18, only 35 percent of their richer counterparts sons (such as menopause and infecundity). Eleven percent not did (Figure 3). intending to use contraception cited health concerns and 8 per- cent cited fear of side effects as the main reason while 12 percent Figure 3 n percent women who have had a child before age 18 expressed opposition to use, primarily by themselves, their hus- years by age group and wealth quintile band, or due to their religion.5 Cost and access are lesser con- 70% cerns, indicating further need to strengthen demand for family 60% Poorest Poorest 50% Poorest planning services. 40% Richest 30% Richest Richest 20% poor pregnancy outcomes 10% 0% The majority of pregnant women use antenatal care and have 20–24 years 25–34 years >34 years institutional deliveries. Eighty-five percent of pregnant women Source: DHS Final Report, Swaziland 2006–07 (author’s calculation). receive antenatal care from skilled medical personnel (doctor, nurse, or midwife) with 79 percent having the recommended Use of modern contraception is moderately high. Current use four or more antenatal visits.5 Eighty-two percent of women de- of contraception among married women is 49 percent.7 More mar- liver with the assistance of skilled medical personnel.7 While 94 ried women use modern contraceptive methods than traditional percent of women in the wealthiest quintile delivered with skilled methods (48 percent and 1 percent, respectively). Injectables are health personnel, only 65 percent of women in the poorest quin- the most commonly used method (17 percent), followed by the tile obtained such assistance (Figure 5). Further, 24 percent of all Figure 5 n Birth assisted by skilled health personnel (percentage) Hiv prevalence high by wealth quintile HIV prevalence is high in Swaziland and women are one of 100 86.9 89.2 the most vulnerable groups. The percentage of adult population 82% overall 94.2 80 75.9 aged 15–49 years who have HIV is high at 26 percent.1 However, 65.0 the prevalence among females is much higher than among males 60 (31 percent and 20 percent, respectively).5 40 20 Knowledge of HIV prevention methods is high. More than 90 percent of people know that condoms can help reduce risk of 0 transmission. Four out of 5 people have knowledge of mother- Poorest Second Middle Fourth Richest to-child transmission through breastfeeding and slightly more Source: MICS Preliminary Report, Swaziland 2010. people know that the risk of transmission from mother-to-child of HIV can be reduced by using medication.5 pregnant women are anaemic (defined as haemoglobin < 110g/L) increasing their risk of preterm delivery, low birth weight babies, stillbirth and newborn death.10 Among all women ages 15–49 years who had given birth, 76 percent had no postnatal care within 6 weeks of delivery and only 0.4 percent received a postnatal check-up from a traditional birth attendant.5 technical notes: Sixty-nine percent of women report that the concern no Improving Reproductive Health (RH) outcomes, as outlined in the drugs were available was a serious problem in accessing health RHAP, includes addressing high fertility, reducing unmet demand for care (Table 1).5 Forty percent of women report that the concern contraception, improving pregnancy outcomes, and reducing STIs. no provider was available was a serious problem in accessing The RHAP has identified 57 focus countries based on poor health care. reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high table 1 n problems in accessing health care priority countries as those where the MMR is higher than 220/100,000 Reason % live births and TFR is greater than 3.These countries are also a sub- At least one problem accessing health care 77.5 group of the Countdown to 2015 countries. Details of the RHAP are Concern no drugs available 68.5 available at www.worldbank.org/population. Concern no provider available 40.0 The Gender-related Development Index is a composite index Getting money for treatment 25.2 developed by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its Distance to health facility 24.5 coverage is limited to 157 countries and areas for which the HDI rank Having to take transport 18.3 was recalculated. Not wanting to go alone 10.8 Concern no female provider available 7.5 Getting permission to go for treatment 1.8 Source: DHS final report, Swaziland 2006–07 national policies and Strategies that have influenced Reproductive Health Human resources for maternal health are limited with only national Health policy: Strategic plan of the Ministry of Health 0.16 physicians per 1,000 population but nurses and midwives are largely centered around achieving MDG targets by 2015. more common, at 6.3 per 1,000 population.1 Multisectoral strategies/action frameworks to address the The high maternal mortality ratio at 420 maternal deaths per following target populations, settings, and cross-cutting issues: 100,000 live births indicates that access to and quality of emer- Women and girls; adolescents; orphans and vulnerable children; HIV/AIDS; stigma and discrimination; gender empowerment and/or gency obstetric and neonatal care (EmONC) remains a chal- gender equality lenge.4 Nearly all community clinics and health centers do not Source: UNAID provide EmONC.9 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 and encourage female adoles- port, training health personnel in appropriate referral proce- cents to stay in school through scholarship programs. Strengthen dures (referral protocols and recording of transfers) and estab- employment prospects for girls and women. Educate and raise lishing maternity waiting huts/homes at hospitals to accommo- awareness on the impact of early marriage and child-bearing. date women from remote communities who wish to stay close • Educate and empower women and girls to make reproductive to the hospital prior to delivery. health choices. Build on advocacy and community participation, • Address the inadequate human resources for health by training and involve men in supporting women’s health and 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 and livery services. messages in the media. Enlist community leaders and women’s • Target the poor and women in hard-to-reach rural areas in the groups. provision of basic and comprehensive emergency obstetric care • Provide quality family planning services that include coun- (renovate and equip health facilities). seling and advice, focusing on young and poor populations. • Augment post-abortion care (treatment of abortion complica- Highlight the effectiveness of modern contraceptive methods tions with MVA, post-abortion family planning counseling, and properly educate women on the health risks and benefits and appropriate referral where necessary) to reduce abortion- of such methods. related morbidity and mortality and provide post-abortion • Promote the use of ALL modern contraceptive methods, in- care clients family planning services. cluding long-term methods, through proper counseling which may entail training/re-training health care personnel. Reducing Stis/Hiv/aidS • Secure reproductive health commodities and strengthen sup- • Integrate HIV/AIDS/STIs and family planning services in rou- ply chain management to further increase contraceptive use as tine antenatal and postnatal care. demand is generated. • Focus HIV/AIDS providing information, education and com- • Strengthen post-abortion care (treatment of abortion compli- munication efforts on adolescents, youth, married women, and cations with manual vacuum aspiration, post-abortion family other high risk groups including IDUs, sex workers and their planning counseling, and appropriate referral where necessary) clients, and migrant workers. and link it with family planning services. References: 1. World Bank. 2010. World Development Indicators. Washington DC. 9. Mills S, Lyimo O, Mabuza PSP, Ankrah V, Dlamini D, Thwala-Tembe 2. World Bank, Engendering Development: Through Gender Equality in M, Nhlabatsi B, Bango M. November 2010. Improving the Quality of Rights, Resources, and Voice. 2001. Maternal and Neonatal Health Services in Swaziland: A Situational 3. Gender-related development index. http://hdr.undp.org/en/media/ Analysis. Swaziland Ministry of Health, World Bank, UNICEF, WHO HDR_20072008_GDI.pdf. and UNFPA. www.worldbank.org/population. 4. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, 10. Worldwide prevalence of anaemia 1993–2005: WHO global database on UNICEF, UNFPA, and the World Bank. anaemia/Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary 5. Central Statistical Office (CSO) [Swaziland], and Macro International Inc. Cogswell. http://whqlibdoc.who.int/publications/2008/9789241596657_ 2008. Swaziland Demographic and Health Survey 2006–07. Mbabane, eng.pdf. Swaziland: Central Statistical Office and Macro International Inc. 6. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO. http://www.who.int/making_pregnancy_safer/topics/adolescent_ correspondence details pregnancy/en/index.html. This profile was prepared by the World Bank (HDNHE, PRMGE, 7. Multiple Indicator Cluster Survey 2010 Preliminary Report, Swaziland, and AFTHE) and Management Science for Health (MSH). For more March 2011. information contact, Samuel Mills, Tel: 202 473 9100, email: smills@ 8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contracep- worldbank.org. This report is available on the following website: www. tion. Human Development Network, World Bank. http://www.world- worldbank.org/population. bank.org/hnppublications. Swaziland RepRoductive HealtH action plan indicatoRS indicator Year level indicator Year level Total fertility rate (births per woman ages 15–49) 2006/07 3.9 Population, total (million) 2008 1.2 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 82.3 Population growth (annual %) 2008 1.4 Contraceptive prevalence (% of married women ages 15–49) 2010 49.3 Population ages 0–14 (% of total) 2008 40 Unmet need for contraceptives (%) 2006/07 24.0 Population ages 15–64 (% of total) 2008 56.7 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 3.3 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 76.2 Mean ideal number of children for all women — — Urban population (% of total) 2008 24.9 Antenatal care with health personnel (%) 2007 84.8 Mean size of households 2006/07 5 Births attended by skilled health personnel (%) 2010 82.0 GNI per capita, Atlas method (current US$) 2008 2600 Proportion of pregnant women with hemoglobin <110 g/L 2008 24.3 GDP per capita (current US$) 2008 2429 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 260 GDP growth (annual %) 2008 2.4 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 220 Population living below US$1.25 per day 2001 62.9 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 340 Labor force participation rate, female (% of female population ages 15–64) 2008 55.2 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 440 Literacy rate, adult female (% of females ages 15 and above) 2008 85.6 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 420 Total enrollment, primary (% net) 2007 82.9 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 64 Ratio of female to male primary enrollment (%) 2007 92.8 Infant mortality rate (per 1,000 live births) 2008 59 Ratio of female to male secondary enrollment (%) 2007 90.1 Newborns protected against tetanus (%) 2008 86 Gender Development Index (GDI) 2008 123 DPT3 immunization coverage (% by age 1) 2008 95 Health expenditure, total (% of GDP) 2007 6.0 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 34.1 Health expenditure, public (% of GDP) 2007 3.8 Prevalence of HIV, total (% of population ages 15–49) 2007 26.1 Health expenditure per capita (current US$) 2007 151.1 Female adults with HIV (% of population ages 15+ with HIV) 2007 58.8 Physicians (per 1,000 population) 2004 0.16 Prevalence of HIV, female (% ages 15–24) 2007 22.6 Nurses and midwives (per 1,000 population) 2004 6.3 poorest-Richest poorest/Richest indicator Survey Year poorest Second Middle Fourth Richest total difference Ratio Total fertility rate DHS 2006/07 5.5 4.9 3.9 3.3 2.6 3.9 2.9 2.1 Current use of contraception (Modern method) MICS 2010 43.4 45.4 46.1 51.3 50.8 47.9 –7.4 0.9 Current use of contraception (Any method) MICS 2010 44.9 46.5 46.9 53.3 52.2 49.3 –7.3 0.9 Unmet need for family planning (Total) DHS 2006/07 32.7 25.6 24.2 24.2 17.0 24.0 15.7 1.9 Births attended by skilled health personnel MICS 2010 65.0 75.9 86.9 89.2 94.2 82.0 –29.2 0.7 (percent) development partners Support for Reproductive Health in Swaziland wHo: Integration of family planning, maternal health, and HIV uniceF: Providing technical and financial support to increase the uptake of prevention and care. PMTCT and pediatric AIDS care services and for preventive and curative health and nutrition for mothers, newborns, and children. unFpa: Improving the national capacity for reproductive health commodity security by procuring reproductive health commodities. MSH: Preventing unintended pregnancies; averting maternal deaths; promoting healthy families; scaling up MNCH interventions. Supports mobile clinic services for vulnerable and underserved groups in textile industries and in rural areas. intraHealth international: HIV/AIDS; health workforce expansion. ippF: HIV/AIDS testing, prevention, management and PMTCT; post-abortion care; family planning; STI treatment.