62952 RepRoductive HealtH at a GLaNce may 2011 zimbabwe country context zimbabwe: mdG 5 status Zimbabwe’s real annual GDP growth rate declined by two- mdG 5a indicators fifths cumulatively in the last decade, the health and educa- Maternal Mortality Ratio (maternal deaths per 100,000 live 790 tion sectors lost many skilled workers who out-migrated, births) UN estimatea and the country experienced food insecurity and overall Births attended by skilled health personnel (percent) 59.8 poverty.1 Exacerbating this was the cholera outbreak of mdG 5b indicators 2008/09 and the national HIV/AIDS pandemic.1 Contraceptive Prevalence Rate (percent) 64.9 Zimbabwe’s large share of youth population (40 percent of Adolescent Fertility Rate (births per 1,000 women ages 15–19) 64 the country population is younger than 15 years old2) pro- Antenatal care with health personnel (percent) 93.4 vides a window of opportunity for high growth and poverty Unmet need for family planning (percent) 12.8 reduction—the demographic dividend in the medium to long term. But for this opportunity to result in accelerated growth, Source: Table compiled from multiple sources. a Official estimate of 725 maternal deaths per 100,000 live births. the government needs to invest in the human capital forma- tion of its youth. Gender equality and women’s empowerment are important mdG target 5a: Reduce by three-quarters, between for improving reproductive health. Higher levels of women’s 1990 and 2015, the maternal mortality Ratio autonomy, education, wages, and labor market participation Zimbabwe has not made progress over the past two decades on are associated with improved reproductive health outcomes.3 maternal health and is not yet on track to achieve its 2015 targets.6 In Zimbabwe, the literacy rate among females ages 15 and above is 89 percent. Fewer girls are enrolled in second- Figure 1 n maternal mortality ratio 1990–2008 and 2015 target ary schools compared to boys with a ratio of female to male 1000 secondary enrollment of 92 percent.2 Only 35 percent of girls 830 790 800 make it to upper secondary education. Three-fifths of adult 670 women participate in the labor force2 that mostly involves 600 450 MDG work in agriculture and are more likely to not receive cash pay- 400 390 Target ment for their work.4 Gender inequalities are reflected in the 200 country’s human development ranking; Zimbabwe ranks 130 98 of 157 countries in the Gender-related Development Index.5 0 1990 1995 2000 2005 2008 2015 Economic progress and greater investment in human Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. capital of women will not necessarily translate into better reproductive outcomes if women lack access to reproduc- tive health services. It is thus important to ensure that health systems provide a basic package of reproductive health ser- world bank Support for Health in zimbabwe vices, including family planning.3 The Reproductive Health The Bank’s new Interim Strategy Note under preparation (P122495) is Department in the Ministry of Health and Child Welfare scheduled to be approved by the Executive Board. and the Zimbabwe National Family Planning Council current projects: (ZNFPC) working with other development partners pro- P111031 Zimbabwe: Strengthening Health Care Service Delivery Capacity, vide reproductive health services including family planning. Monitoring and Evaluation, and Accountability in MIssion Hospitals pipeline project: P125229 Zimbabwe Health Results Based Financing previous Health project: THE WORLD BANK None n Key challenges use modern contraceptive methods than traditional methods (63 percent and 2 percent, respectively). The pill is the most com- High fertility monly used method (50 percent), followed by the injectables (8 Fertility has been declining over time but remains high among percent).1 Use of long-term methods such as intrauterine device the poorest. Total fertility rate (TFR) declined from 5.5 births per and implants are negligible. There are socioeconomic differenc- woman in 1988 to 4.0 births per woman in 1999 to 3.7 in 2009.1 es in the use of modern contraception among women: modern Fertility remains high among the poorest Zimbabweans at 5.6 in contraceptive use is 68 percent among women in the wealthi- contrast to 2.4 among the wealthiest (Figure 2). Similarly, TFR est quintile and 55 percent among those in the poorest quintile is 3.3 among women with secondary education or higher com- (Figure 4).1 Similarly, just 48 percent of women with no educa- pared to 4.8 among women with no formal education. It is also tion use modern contraception as compared to 67 percent of lower among urban women at 2.6, compared to rural women at women with secondary education or higher, and 61 percent for 4.4 births per woman.4 rural women versus 67 percent for urban women.1 Figure 2 n total fertility rate by wealth quintile Figure 4 n use of contraceptives among married women by wealth quintile 6 5 5.6 60 4.5 3.8 3.7 overall 49.3 Overall (All methods) 2.0 1.4 4 50 0.8 3.3 1.5 1.1 51.3 50.8 40 43.4 45.4 46.1 3 2.4 2 30 1 20 0 10 Poorest Second Middle Fourth Richest 0 Poorest Second Middle Fourth Richest Source: MIMS Preliminary Report, Zimbabwe 2009. Modern Methods Traditional Methods Adolescent fertility adversely affects not only young wom- Source: MIMS Preliminary Report, Zimbabwe 2009. en’s health, education and employment prospects but also that of their children. Births to women aged 15–19 years old have the Unmet need for contraception is 13 percent4 indicating that highest risk of infant and child mortality as well as a higher risk of women may not be achieving their desired family size.8 morbidity and mortality for the young mother.3, 7 In Zimbabwe, Religious prohibition, fear of side effects and health con- adolescent fertility rate is high at 64 reported births per 1,000 cerns are the predominant reasons women do not intend to use women aged 15–19 years. Incorrect knowledge about pregnancy modern contraceptives in future, not including fertility related among young girls and economic pressures contribute to the high reasons (such as menopause and infecundity). Eleven percent not fertility rates amongst adolescent girls. intending to use contraception cited religious prohibition, 9 per- Early childbearing is more prevalent among the poor. While cent cited fear of side effects and 6 percent cited health concerns 50 percent of the poorest 20–24 years old women have had a child as the main reason.4 Cost (0.8 percent) and access (0.1 percent) before reaching 18, only 17 percent of their richer counterparts are lesser concerns, indicating further need to strengthen de- did (Figure 3). mand 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 While the majority of pregnant women use antenatal care, 60% 50% Poorest Poorest institutional deliveries are less common. Over nine-tenths of Poorest 40% pregnant women receive antenatal care from skilled medical 30% Richest personnel (doctor, nurse, or midwife).1 However, a smaller pro- 20% Richest Richest portion, 60 percent deliver with the assistance of skilled medical 10% 0% personnel. While 92 percent of women in the wealthiest quintile 20–24 years 25–34 years >34 years delivered with skilled health personnel, only 38 percent of wom- en in the poorest quintile obtained such assistance (Figure 5).1 Source: DHS Final Report, Zimbabwe 2005–06 (author’s calculation). 40 percent of women overall, and half of all rural women, deliver Use of modern contraception is increasing. Current use of at home,1 a figure which has increased from 23 percent in 1999.4 contraception among married women was 38 percent in 1988, 54 This took place in the context of Zimbabwe’s socio-economic percent in 19994 and 65 percent in 2009.1 More married women challenges and a weakened health delivery system.1 Further, 19 percent of all pregnant women are anaemic (defined as haemo- Hiv prevalence has decreased in zimbabwe in the past globin < 110g/L) increasing their risk of preterm delivery, low seven years birth weight babies, stillbirth and newborn death.9 HIV prevalence is high in Zimbabwe and women are one of the most vulnerable groups. In 2009, the percentage of adult Figure 5 n birth assisted by skilled health personnel (percentage) by wealth quintile population aged 15–49 years who had HIV was 14 percent, ranking Zimbabwe among the four highest prevalence rates in 100 82% overall 86.9 89.2 94.2 the world.1 However, the prevalence has declined from 25 per- 80 75.9 cent in 2003, the first decline of this type in Southern Africa.1 65.0 60 Of the total population ages 15 years and older with HIV, 57 percent are women.2 40 20 Knowledge of HIV prevention methods is high. More than three-quarters of Zimbabweans know that condoms can help re- 0 Poorest Second Middle Fourth Richest duce risk of transmission. Further, knowledge of mother-to-child transmission through breastfeeding has increased from around Source: MIMS Preliminary Report, Zimbabwe 2009. one third of people in 1999 to 80 percent in 2005–06.4 The num- Among all women ages 15–49 years who had given birth, 46 ber of Zimbabweans who know that the risk of transmission from percent had no postnatal care within 6 weeks of delivery.4 mother-to-child can be reduced by using medication is 57 per- cent for females and 46 percent for males.4 Overall, 76 percent of Nearly 3 out of 5 women report getting money needed for women aged 15–49 years knew two ways to prevent HIV trans- treatment as a serious problem in accessing health care for mission, 69 percent correctly identified 3 misconceptions about themselves when they are sick (Table 1).4 Further, nearly half of HIV transmission, and 55 percent knew both.1 women report the concern that no drugs would be available as a serious problem in accessing health care. table 1 n Reasons for not delivering in a health facility (women age 15–49) Reason % technical Notes: At least one problem accessing health care 79.4 Improving Reproductive Health (RH) outcomes, as outlined in the Concern no drugs available 57.8 RHAP, includes addressing high fertility, reducing unmet demand for Concern no provider available 47.5 contraception, improving pregnancy outcomes, and reducing STIs. Getting money for treatment 42.1 The RHAP has identified 57 focus countries based on poor Distance to health facility 41.3 reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high Having to take transport 22.8 priority countries as those where the MMR is higher than 220/100,000 Not wanting to go alone 22.6 live births and TFR is greater than 3.These countries are also a sub- Concern no female provider available 9.8 group of the Countdown to 2015 countries. Details of the RHAP are Getting permission to go for treatment 6.6 available at www.worldbank.org/population. Source: DHS final report, Zimbabwe 2005–06. The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to Human resources for maternal health are limited with only 157 countries and areas for which the HDI rank was recalculated. 0.16 physicians per 1,000 population but nurses and midwives are slightly more common, at 0.72 per 1,000 population.2 A chal- lenge the Government is addressing is the need to upgrade skills of Primary Care Nurses to enable them to provide maternal health National policies and strategies that have influenced services at the primary level of care instead of referring to higher reproductive health levels of care. National Health Strategy 2009–2013 The high maternal mortality ratio at 790 maternal deaths Investment Case for Health 2010–2012 per 100,000 live births indicates that access to and quality of emergency obstetric and neonatal care (EmONC) remains a National New Born Child Survival Strategy challenge.6 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 especially in secondary edu- port, training health personnel in appropriate referral proce- cation. Strengthen employment prospects for girls and women. dures (referral protocols and recording of transfers) and estab- Educate and raise awareness on the impact of early marriage lishing maternity waiting huts/homes at hospitals to accommo- and childbearing and promote delayed sexual debut. date women from remote communities who wish to stay close • Support women and girls’ economic and social empowerment. to the hospital prior to delivery. Increase school enrollment of girls. Strengthen employment • Address the inadequate human resources for health by training prospects for girls and women. Educate and raise awareness on more midwives and deploying them to the poorest or hard-to- the impact of early marriage and child-bearing. reach districts. • Educate and empower women and girls to make reproductive • Promote institutional delivery through provider incentives and health choices. Build on advocacy and community participation, implement risk-pooling schemes. Provide vouchers to women and involve men in supporting women’s health and wellbeing. in hard-to-reach areas for transport and/or to cover cost of de- livery services. Reducing high fertility • Generate demand for the service and address the perception that • Address the issue of opposition to use of contraception and it not necessary to deliver at a health facility. This will require a promote the benefits of small family sizes. Increase family plan- combination of Behavior Change Communication (BCC) pro- ning awareness and utilization through outreach campaigns grams via mass media and community outreach as well as deploy- and messages in the media. Enlist community leaders and ing midwives to assist women with home deliveries. During ante- women’s groups. Strengthen and revitalize the role of ZNFPC natal care, educate pregnant women about the importance of de- Community Based Distributors (CBD) who provided family livery with a skilled health personnel and getting postnatal check. planning services within communities. • 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. • Focus HIV/AIDS providing information, education and com- • Promote the use of ALL modern contraceptive methods, in- munication efforts on adolescents, youth, married women, and cluding long-term methods, through proper counseling which other high risk groups including IDUs, sex workers and their may entail training/re-training health care personnel. clients, and migrant workers. • Secure reproductive health commodities and strengthen sup- ply chain management to further increase contraceptive use as demand is generated. References: 1. Central Statistical Office (CSO) [Zimbabwe] and UNICEF. 2009. 8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- Multiple Indicators Monitoring Survey (MIMS) 2009, Preliminary ception. Human Development Network, World Bank. http://www. Report. November 2009. worldbank.org/hnppublications. 2. World Bank. 2010. World Development Indicators. Washington DC. 9. Worldwide prevalence of anaemia 1993–2005: WHO global da- 3. World Bank, Engendering Development: Through Gender Equality tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, in Rights, Resources, and Voice. 2001. Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- 4. Central Statistical Office (CSO) [Zimbabwe] and Macro Internation- tions/2008/9789241596657_eng.pdf. al Inc. 2007. Zimbabwe Demographic and Health Survey 2005–06. Calverton, Maryland: CSO and Macro International Inc. 5. Gender-related development index. Available at http://hdr.undp. org/en/media/HDR_20072008_GDI.pdf. Accessed March 1, 2011. correspondence details 6. Trends in Maternal Mortality: 1990–2008: Estimates developed by This profile was prepared by the World Bank (HDNHE, PRMGE, and WHO, UNICEF, UNFPA, and the World Bank. AFTHE). For more information contact, Samuel Mills, Tel: 202 473 9100, 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. email: smills@worldbank.org. This report is available on the following Geneva: WHO. http://www.who.int/making_pregnancy_safer/ website: www.worldbank.org/population. topics/adolescent_pregnancy/en/index.html. zimbabwe RepRoductive HeaLtH actioN pLaN iNdicatoRS indicator Year Level indicator Year Level Total fertility rate (births per woman ages 15–49) 2009 3.7 Population, total (million) 2008 12.5 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 63.5 Population growth (annual %) 2008 0.1 Contraceptive prevalence (% of married women ages 15–49) 2009 64.9 Population ages 0–14 (% of total) 2008 40.2 Unmet need for contraceptives (%) 2005/06 12.8 Population ages 15–64 (% of total) 2008 55.7 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 4 Median age at marriage (years) 2005/06 19.4 Age dependency ratio (% of working-age population) 2008 79.4 Mean ideal number of children for all women — — Urban population (% of total) 2008 37.3 Antenatal care with health personnel (%) 2009 93.4 Mean size of households 2005/06 4 Births attended by skilled health personnel (%) 2009 59.8 GNI per capita, Atlas method (current US$) 2005 360 Proportion of pregnant women with hemoglobin <110 g/L 2008 18.8 GDP per capita (current US$) 2005 274 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 390 GDP growth (annual %) 2005 –5.3 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 450 Population living below US$1.25 per day — — Maternal mortality ratio (maternal deaths/100,000 live births) 2000 670 Labor force participation rate, female (% of female population ages 15–64) 2008 60.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 830 Literacy rate, adult female (% of females ages 15 and above) 2008 88.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 790 Total enrollment, primary (% net) 2006 90.5 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 98 Ratio of female to male primary enrollment (%) 2006 99.0 Infant mortality rate (per 1,000 live births) 2008 62 Ratio of female to male secondary enrollment (%) 2006 92.4 Newborns protected against tetanus (%) 2008 76 Gender Development Index (GDI) 2008 130 DPT3 immunization coverage (% by age 1) 2009 66.6 Health expenditure, total (% of GDP) 2007 8.9 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 8.6 Health expenditure, public (% of GDP) 2007 4.1 Prevalence of HIV, total (% of population ages 15–49) 2009 13.7 Health expenditure per capita (current US$) 2007 78.6 Female adults with HIV (% of population ages 15+ with HIV) 2007 56.7 Physicians (per 1,000 population) 2004 0.16 Prevalence of HIV, female (% ages 15–24) 2007 7.7 Nurses and midwives (per 1,000 population) 2004 0.72 poorest-Richest poorest/Richest indicator Survey Year poorest Second middle Fourth Richest total difference Ratio Total fertility rate MIMS 2009 5.6 4.5 3.8 3.3 2.4 3.7 3.2 2.3 Current use of contraception (Modern method) MIMS 2009 55.3 62.0 61.2 67.7 67.6 63.0 –12.3 0.8 Current use of contraception (Any method) MIMS 2009 58.1 64.2 62.8 68.9 69.5 64.9 –11.4 0.8 Unmet need for family planning (Total) DHS 2005/06 20.2 14.8 12.5 9.4 7.6 12.8 12.6 2.7 Births attended by skilled health personnel MIMS 2009 38.2 45.1 55.5 80.5 92.0 59.8 –53.8 0.4 (percent) development partners support for reproductive health in zimbabwe wHo: Reproductive health and HIV/AIDS Sida: Women’s rights; girls’ education european commission: Health systems strengthening, HIV/AIDS, human cida: Human resources for health resources for health JSi: Supply chain management family planning products uNFpa: Reproductive health and rights mcHip: Maternal and child health uNiceF: Child protection; under-5 mortality, health systems LatH : Maternal and newborn services strengthening, PMTCT, pediatric HIV, supply chain management marie Stopes international: FP training; contraception distribution uSaid: Health systems strengthening; skilled birth attendance, quality of care, pediatric HIV population Services zimbabwe: FP training, contraception services dFid: Maternal and new born services, child protection, health systems strengthening,