62961 REPRoducTivE HealtH at a GLANcE June 2011 EGYPT country context Egypt: MdG 5 Status Egypt has experienced improvements in health outcomes MdG 5A indicators over the past two decades, including a halving of the in- Maternal Mortality Ratio (maternal deaths per 100,000 live 82 fant mortality and malnutrition among children under five, births) UN estimatea and an increase in life expectancy from 64 to 71 years. Real Births attended by skilled health personnel (percent) 78.9 GDP grew 5.3 percent in FY10, which was an increase from MdG 5B indicators FY09’s 4.7 percent, but below the 7 percent growth from Contraceptive Prevalence Rate (percent) 60.3 FY06–FY08. Nearly a fifth of the population live below na- tional poverty line.1 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 38.4 Antenatal care with health personnel (percent) 73.6 Egypt’s large share of youth population (33 percent of the Unmet need for family planning (percent) 9.2 country population is younger than 15 years old) provides a Source: Table compiled from multiple sources. window of opportunity for high growth and poverty reduc- tion—the demographic dividend.2 But for this opportunity to result in accelerated growth, the government needs to invest in the human capital formation of its youth. This is MdG Target 5A: Reduce by Three-quarters, between especially important in a context of decelerated growth rate 1990 and 2015, the Maternal Mortality Ratio arising from the global recession and the country’s expo- Egypt has made remarkable progress over the past two decades sure to high volatility in commodity prices. on maternal health and is on track to achieve its 2015 targets.4 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 250 220 participation are associated with improved reproductive 200 health outcomes.3 150 150 In Egypt, the literacy rate among females ages 15 and 110 MDG 100 90 82 Target above is 58 percent. Fewer girls are enrolled in primary 54 schools compared to boys with a ratio of female to male pri- 50 mary enrollment of 95 percent.2 Nearly 25 percent of adult 0 women participate in the labor force2 that mostly involves 1990 1995 2000 2005 2008 2015 work in agriculture. 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 Egypt ductive health services. It is thus important to ensure that health systems provide a basic package of reproductive The Bank’s new Country Assistance Strategy under preparation (P123386) health services, including family planning.3 is scheduled to be approved by the Bank’s Executive Board on January 26, 2012. current Project: P080228 EG-Health Insurance Systems Development ($75m) • Establishment of the single national health insurance Payor’s IT-enabled operations as part of the new national health insurance program Pipeline Project: None. Previous Health Project: None. THE WORLD BANK n Key challenges Use of modern contraception is increasing. Current use of contraception among married women was 60 percent in 2008,5 Fertility is declining up from 52 percent in 1998 and 38 percent in 1988. More mar- Fertility has been declining over time but remains high among ried women use modern contraceptive methods than traditional the poorest. Total fertility rate (TFR) decreased from 3.9 births methods (58 percent and 3 percent, respectively). IUDs are the per woman in 1990–92 to 3.2 births per woman in 2000–2003 to most commonly used method (36 percent), followed by the pill 3.0 in 2008.5 Fertility remains higher among the poorest Egyptians (12 percent). Use of long-term methods such as intrauterine de- at 3.4 in contrast to 2.7 among the wealthiest (Figure 2). Similarly, vice and implants are negligible. There are socioeconomic differ- TFR is 3.0 among women with secondary education or higher ences in the use of modern contraception among women: mod- compared to 3.4 among women with no formal education. It is ern contraceptive use is 62 percent among women in the wealthi- also lower among urban women at 2.7, compared to rural women est quintile and 52 percent among those in the poorest quintile at 3.2 births per woman.5 (Figure 4).5 Similarly, 58 percent of rural women and 64 percent of urban women use modern contraception, although there is not Figure 2 n Total fertility rate by wealth quintile much difference by education level at 56 percent of women with 4.0 no education and 59 percent of women with secondary education 3.5 3.4 or higher who use it. 3.1 3.0 2.9 3.0 overall 3.0 2.7 2.5 2.0 Figure 4 n use of contraceptives among married women by wealth 1.5 quintile 1.0 0.5 70 60.3 Overall (All methods) 0 2.1 3.1 60 2.4 Poorest Second Middle Fourth Richest 3.5 2.3 50 Source: DHS Final Report, Egypt 2008. 40 30 54.8 58.8 59.3 62.3 51.9 20 Adolescent fertility adversely affects not only young women’s 10 health, education and employment prospects but also that of 0 their children. Births to women aged 15–19 years old have the Poorest Second Middle Fourth Richest highest risk of infant and child mortality as well as a higher risk of Modern Methods Traditional Methods morbidity and mortality for the young mother.3, 6 In Egypt, adoles- Source: DHS Final Report, Egypt 2008. cent fertility rate is 38 births per 1,000 women aged 15–19 years. Unmet need for contraception is 9 percent5 indicating that Early childbearing is more prevalent among the poor. While women may not be achieving their desired family size.7 37 percent of the poorest 20–24 years old women have had a child before reaching 18, only 10 percent of their richer counterparts Health concerns or fear of side effects are the predominant did (Figure 3). The rich-poor gap in prevalence of early child- reasons women do not intend to use modern contraceptives in bearing is similar across cohorts. future, not including fertility related reasons (such as menopause and infecundity). Seventeen percent not intending to use contra- Figure 3 n Percent women who have had a child before age 18 ception cited health concerns or fear of side effects as the main years by age group and wealth quintile reason while 6 percent expressed opposition to use, primarily by themselves, their husband, or due to their religion.5 Cost and 40% 35% Poorest access are lesser concerns, indicating further need to strengthen Poorest 30% Richest demand for family planning services. 25% Richest 20% Poorest 15% 10% Richest 5% improving Pregnancy outcomes 0% The majority of pregnant women use antenatal care and in- 20–24 years 25–34 years >34 years stitutional deliveries. Nearly one quarter of pregnant women Source: DHS Final Report, Egypt 2008 (author’s calculation). receive antenatal care from skilled medical personnel (doctor, nurse, or midwife) with 66 percent having the recommended Human resources for maternal health are limited with 3 physicians four or more antenatal visits.5 Additionally, 79 percent deliver per 1,000 population but nurses and midwives are slightly more com- with the assistance of skilled medical personnel. While 97 percent mon, at 4 per 1,000 population.2 of women in the wealthiest quintile delivered with skilled health personnel, 55 percent of women in the poorest quintile obtained such assistance (Figure 5). Further, 86 percent of urban women Hiv knowledge in Egypt could be increased as opposed to 59 percent of rural women delivered with skilled Knowledge of HIV prevention methods is still relatively low. health personnel. Further, 45 percent of all pregnant women are Eighteen percent of women ages 15–49 years and 37 percent of anaemic (defined as haemoglobin < 110g/L) increasing their men know that condoms can help reduce risk of transmission. risk of preterm delivery, low birth weight babies, stillbirth and Further, knowledge of mother-to-child transmission through newborn death[8]. Among all women ages 15–49 years who had breastfeeding is 35 percent for women and 34 percent for men given birth, 34 percent had no postnatal care within 6 weeks of ages 15–49 years.5 delivery while only 0.1 percent received postnatal check-up from a traditional birth attendant.5 Figure 5 n Birth assisted by skilled health personnel (percentage) by wealth quintile 120 100 96.9 90.7 78.9% overall 82.9 80 70.1 60 55.1 40 20 0 Poorest Second Middle Fourth Richest Source: DHS Final Report, Egypt 2008. Seventy-four percent of women who did not delivery in a health facility indicated it is not necessary or customary to de- liver in the health facility. (Table 1).5 A smaller proportion, 23 percent, were concerned about the associated costs. Technical Notes: Table 1 Reason for not delivering last birth in health facility n Improving Reproductive Health (RH) outcomes, as outlined in the (women age 15–49) RHAP, includes addressing high fertility, reducing unmet demand for Reason % contraception, improving pregnancy outcomes, and reducing STIs. Not necessary 62.9 The RHAP has identified 57 focus countries based on poor reproductive Costs too much 23.4 health outcomes, high maternal mortality, high fertility and weak health Not customary 11.3 systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 live births and TFR is Sudden delivery 6.1 greater than 3.These countries are also a sub-group of the Countdown Facility not open 2.5 to 2015 countries. Details of the RHAP are available at www.worldbank. Poor quality service 2.5 org/population. Too far/no transport 2.1 The Gender-related Development Index is a composite index developed Husband/family did not allow 1.5 by the UNDP that measures human development in the same dimensions Other 1.3 as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank was recalculated. No female provider 0.5 Source: DHS final report, Egypt 2008. n Key Actions to improve RH outcomes Strengthen gender equality Reducing maternal mortality • Support women and girls’ economic and social empowerment. • Encourage and promote community participation in the care Increase school enrollment of girls. Strengthen employment for pregnant women and their children. This will require a prospects for girls and women. Educate and raise awareness on greater focus on the use of mass media and community out- the impact of early marriage and child-bearing. reach, especially to educate women about the importance of • Educate and empower women and girls to make reproductive delivery with a skilled health personnel in health facilities and health choices. Build on advocacy and community participation, receiving postnatal check. and involve men in supporting women’s health and wellbeing. • Promote institutional delivery through both demand and sup- ply side incentives: pilot voucher schemes to women in hard- Reducing high fertility to-reach areas for transport and/or to cover cost of delivery services, and also give provider incentives to promote outreach • Address the issue of opposition to use of contraception and to pregnant women. promote the benefits of small family sizes. Increase family plan- ning awareness and utilization through outreach campaigns • Extend the reach of the formal health care to rural areas and and messages in the media. Enlist community leaders and strengthen the referral system by: instituting emergency trans- women’s groups. port, training health personnel in appropriate referral proce- dures (referral protocols and recording of transfers) and estab- • Provide quality family planning services that include coun- lishing maternity waiting huts/homes at hospitals to accommo- seling and advice, focusing on young and poor populations. date women from remote communities who wish to stay close Highlight the effectiveness of modern contraceptive methods to the hospital prior to delivery. and properly educate women on the health risks and benefits of such methods. Reducing STis/Hiv/AidS • Promote the use of ALL modern contraceptive methods, in- cluding long-term methods, through proper counseling which • Integrate HIV/AIDS/STIs and family planning services in rou- may entail training/re-training health care personnel. tine antenatal and postnatal care. • Secure reproductive health commodities and strengthen sup- ply chain management to further increase contraceptive use as demand is generated. References: 1. World Bank, Egypt Country Brief. http://go.worldbank.org/ 8. Worldwide prevalence of anaemia 1993–2005: WHO global da- VCSFSEB5H0. tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, 2. World Bank. 2010. World Development Indicators. Washington DC. Ines Egli and Mary Cogswell. . in Rights, Resources, and Voice. 2001. 4. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank 5. Egypt Demographic and Health Survey 2008. El-Zanaty, Fatma and Way, Ann. USAID, UNICEF, El-Zanaty and Associates, Ministry of Health. March 2009. 6. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. correspondence details Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- This profile was prepared by the World Bank (HDNHE, and PRMGE). ics/adolescent_pregnancy/en/index.html. For more information contact, Samuel Mills, Tel: 202 473 9100, email: 7. 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. Available at website: www.worldbank.org/population. http://www.worldbank.org/hnppublications. EGYPT REPRoducTivE HEALTH AcTioN PLAN iNdicAToRS indicator Year Level indicator Year Level Total fertility rate (births per woman ages 15–49) 2008 3.0 Population, total (million) 2008 81527172 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 38.4 Population growth (annual %) 2008 1.8 Contraceptive prevalence (% of married women ages 15–49) 2008 60.3 Population ages 0–14 (% of total) 2008 32.5 Unmet need for contraceptives (%) 2008 9.2 Population ages 15–64 (% of total) 2008 63.0 Median age at first birth (years) from DHS 2008 22.5 Population ages 65 and above (% of total) 2008 4.5 Median age at marriage (years) 2008 20.6 Age dependency ratio (% of working-age population) 2008 58.7 Mean ideal number of children for all women 2008 2.9 Urban population (% of total) 2008 42.7 Antenatal care with health personnel (%) 2008 73.6 Mean size of households — — Births attended by skilled health personnel (%) 2008 78.9 GNI per capita, Atlas method (current US$) 2008 1800 Proportion of pregnant women with hemoglobin <110 g/L 2008 45.4 GDP per capita (current US$) 2008 1991 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 218 GDP growth (annual %) 2008 7.2 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 152 Population living below US$1.25 per day 2004 2.0 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 111 Labor force participation rate, female (% of female population ages 15–64) 2007 24.4 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 90 Literacy rate, adult female (% of females ages 15 and above) 2006 57.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 82 Total enrollment, primary (% net) 2007 95.4 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 54 Ratio of female to male primary enrollment (%) 2007 95.1 Infant mortality rate (per 1,000 live births) 2008 19.8 Ratio of female to male secondary enrollment (%) — — Newborns protected against tetanus (%) 2008 85 Gender Development Index (GDI) — — DPT3 immunization coverage (% by age 1) 2008 97.6 Health expenditure, total (% of GDP) 2007 6.26 Pregnant women living with HIV who received antiretroviral drugs (%) — — Health expenditure, public (% of GDP) 2007 2.38 Prevalence of HIV, total (% of population ages 15–49) — — Health expenditure per capita (current US$) 2007 101 Female adults with HIV (% of population ages 15+ with HIV) 2007 28.9 Physicians (per 1,000 population) 2005 3 Prevalence of HIV, female (% ages 15–24) — — Nurses and midwives (per 1,000 population) 2005 4 Poorest-Richest Poorest/Richest indicator Survey Year Poorest Second Middle Fourth Richest Total difference Ratio Total fertility rate DHS 2008 3.4 3.1 3.0 2.9 2.7 3.0 0.7 1.3 Current use of contraception (Modern method) DHS 2008 51.9 54.8 58.8 59.3 62.3 57.6 –10.4 0.8 Current use of contraception (Any method) DHS 2008 55.4 57.1 61.2 61.4 65.4 60.3 –10.0 0.8 Unmet need for family planning (Total) DHS 2008 12.8 10.4 19.3 7.8 6.1 9.2 6.7 2.1 Births attended by skilled health personnel DHS 2008 55.1 70.1 82.9 90.7 96.9 78.9 –41.8 0.6 (percent)