62927 reproDuctive HealtH at a glance Democratic republic of congo april 2011 country context Drc: mDg 5 status The Democratic Republic of Congo (DRC) is a country mDg 5a indicators of enormous potential, with a large land mass and natural Maternal Mortality Ratio (maternal deaths per 100,000 live births) 670 resources, still recovering from a long decade of conflict. 2008 UN estimatea Despite DRC’s relatively high annual rate of growth (aver- Births attended by skilled health personnel (percent) 64.4 aging 6% in 2007 and 2008)1, 59 percent of the population mDg 5b indicators still subsists on less than US $1.25 per day.1 The DRC is Contraceptive Prevalence Rate (percent) 5.8 one of only 3 countries to have a lower HDI than in 1970. Further, it is one of only 9 countries where life expectancy Adolescent Fertility Rate (births per 1,000 women ages 15–19) 124 has fallen below 1970 levels, likely impacted by HIV and Antenatal care with health personnel (percent) 85.3 civil unrest.2 Unmet need for family planning (percent) 24.4 DRC’s large share of youth population (47 percent of the Source: Table compiled from multiple sources a The 2007 DRC DHS estimated maternal mortality rate at 549 country population is younger than 15 years old) provides a window of opportunity for high growth and poverty reduc- tion—the demographic dividend. For this opportunity to target 5a: reduce by three-quarters, between 1990 result in accelerated growth, the government needs to in- and 2015, the maternal mortality ratio vest more in the human capital formation of its youth. DRC has made insufficient progress over the past two decades on Gender equality and women’s empowerment are impor- maternal health and is not 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 1000 900 910 health outcomes.3 In DRC, the literacy rate among females 850 ages 15 and above is 56 percent. Fewer girls are enrolled 800 740 670 in secondary schools compared to boys with a 55 percent 600 MDG ratio of female to male secondary enrollment.1 Nearly Target 400 three-fifths of adult women participate in the labor force 230 that mostly involves work in agriculture. Gender inequali- 200 ties are reflected in the country’s human development rank- 0 ing; DRC ranks 148 of 157 countries in the Gender-related 1990 1995 2000 2005 2008 2015 Development Index.4 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. Greater human capital for women will not translate into greater reproductive choice if women lack access to repro- World bank support for Health in Dr congo ductive health services. It is thus important to ensure that The Bank’s current Country Assistance Strategy is for fiscal years 2008 to 2011. health systems provide a basic package of reproductive current project: health services, including family planning.3 P082516 ZR-Multisectoral HIV/AIDS (FY04) ($81.6m) • Strengthen response of the public sector and nongovernmental sector to the epidemic • Build support for community initiatives • Improve skills for coordination & communication, monitoring and evaluation and capacity building pipeline project: P122251 DRC additional financing malaria control Approval date 12/15/2010 THE WORLD BANK previous health project: P088751 ZR-Health Sec Rehab Supt (FY06) n Key challenges by the pill (1 percent). Use of long-term methods such as intra- uterine device and implants are negligible. High fertility Fertility is high across wealth quintiles. DRC has one of the figure 4 n use of contraceptives among married women by wealth quintile highest total fertility rates (TFR) in the world with 6.3 births per 50 woman (2007).6 40 20.6 Overall (All methods) 23.7 30 figure 2 n total fertility rate by wealth quintile 8 20 7.4 15.2 7 7.0 6.8 6.3 overall 13.0 6.4 10 11.5 12.5 14.9 6 7.0 0 2.8 2.6 3.6 5 4.2 4 Poorest Second Middle Fourth Richest 3 2 Modern Methods Traditional Methods 1 Source: DHS Final Report, DRC 2007 0 Poorest Second Middle Fourth Richest Unmet need for contraception is high at 24 percent with min- Source: DHS Final Report, DRC 2007 imal variation among women different socio-economic groups.6 TFR is below 5 births per woman for women in the wealthiest The high unmet need suggests that some women may not be quintile (Figure 2). Similarly, TFR is below 5 among women with achieving their desired family size.8 tertiary education or higher and those living in Kinshasa prov- Wanting more children (26 percent) and opposition to use ince (the capital).6 of modern contraceptive methods (21 percent) are the pre- Adolescent fertility rate is high (124 births per 1,000 wom- dominant reasons women do not intend to use them in future.6 en) affecting not only young women and their children’s health Another 11 percent had no knowledge of modern contraceptive but also their long-term education and employment prospects. methods or where to obtain them. Births to women aged 15–19 years old have the highest risk of in- fant and child mortality as well as a higher risk of morbidity and poor pregnancy outcomes mortality for the young mother.3, 7 While majority of pregnant women use antenatal care, institu- Early childbearing is more frequent among the poor. While tional deliveries are less common. About 85 percent of pregnant 42 percent of the poorest 20–24 years old women have had a child women receive antenatal care from skilled health personnel and before reaching 18, only 16 percent of their richer counterparts 64 percent deliver with the assistance of skilled health personnel.6 did (Figure 3). Furthermore, reduction in early childbearing While 92 percent of women in the wealthiest quintile delivered mostly has taken place among the rich where younger cohorts of with skilled health personnel, only 47 percent of women in the girls are less likely than older cohorts to have a child early in life. poorest quintile obtained such assistance (Figure 5). Further, two thirds of all pregnant women are anaemic (defined as haemoglo- figure 3 n percent women who have had a child before age 18 bin < 110g/L) increasing their risk of preterm delivery, low birth years by age group and wealth quintile weight babies, stillbirth and newborn death.9 Postnatal care is ef- 45% fectively used mostly by those women who delivered in a health 40% Poorest Poorest Poorest 35% Wealthier facility. 30% Wealthier 25% 20% 15% Wealthier figure 5 n birth assisted by skilled health personnel (percentage) 10% by wealth quintile 5% 0% 100 91.7 20–24 years 25–34 years >34 years 80 76.8 Source: DHS Final Report, DRC 2007 (author’s calculation) 64.4% overall 64.1 60 50.6 47.1 Less than a tenth of married women use modern contracep- 40 tion. More married women use traditional methods than modern 20 contraceptive methods (figure 4).6 Despite the low use of modern contraceptives (6 percent in 2007), it is even lower at only 3 per- 0 cent among women in the poorest quintiles (Figure 4).6 Condom Poorest Second Middle Fourth Richest is the most commonly used modern method (3 percent), followed Source: DHS Final Report, DRC 2007 Three-quarters of women who indicated problems in access- figure 6 n Knowledge behavior gap in Hiv prevention among young ing health care cited concerns regarding inability to afford the women services while two-fifths indicated difficulty in getting to the 70% health facility (Table 1).6 60% 50% table 1 n reasons for not delivery in a health facility 40% (women age 15–49) 30% reason % 20% At least one problem accessing 85.1 10% health care 0% Getting money for treatment 75.6 15–19 years 20–24 years Having to take transport 44.0 Knowledge Condom use at last sex Distance to health facility 40.4 Source: DHS Final Report, DRC 2007 Not wanting to go alone 25.9 Getting permission to go for treatment 22.1 Concerned no female provider available 14.8 Source: DHS Final Report, DRC 2007 technical notes: Human resources for maternal health are limited with only 0.11 physicians per 1,000 population but nurses and midwives are Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for more common, at 0.53 per 1,000 population.1 contraception, improving pregnancy outcomes, and reducing STIs. The high maternal mortality ratio at 670 maternal deaths The RHAP has identified 57 focus countries based on poor per 100,000 live births indicates that access to and quality of reproductive health outcomes, high maternal mortality, high fertility emergency obstetric and neonatal care (EmONC) remains a and weak health systems. Specifically, the RHAP identifies high challenge.5 priority countries as those where the MMR is higher than 220/100,000 live births and TFR is greater than 3.These countries are also a sub- group of the Countdown to 2015 countries. Details of the RHAP are available at www.worldbank.org/population. Stis/Hiv/aiDS prevalence is low but a growing public health concern The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the HIV prevalence is relatively low (1.3 percent) in DRC but same dimensions as the HDI while adjusting for gender inequality. Its women are one of the most vulnerable groups. coverage is limited to 157 countries and areas for which the HDI rank was recalculated There is a large knowledge-behavior gap regarding condom use for HIV prevention. The HIV prevalence among the 15–19 years old population is 1.2 percent, while condom use among this age group is only 4.7 percent.6 While most young women are aware that using a condom in every intercourse prevents HIV, only 7.5 percent of them report having used condom at last in- tercourse (Figure 6). This gap widens among older aged women Development partners support for reproductive health in likely due to the fact that the chances of using condoms as a form Democratic republic of congo of contraception diminishes with marriage. unfpa: Reproductive health and rights unicef: child protection; under-5 mortality uSaiD: Health systems strengthening; skilled birth attendance Jica: Healthcare workforce ngos: There are international NGOs involved in RH n Key actions to improve rH outcomes Strengthen gender equality reducing maternal mortality • Support women and girls’ economic and social empowerment. • Promote institutional delivery through provider incentives and Increase school enrollment of girls. Strengthen employment generating demand for the service. During antenatal care, edu- prospects for girls and women. Educate and raise awareness on cate pregnant about the importance of delivery with a skilled the impact of early marriage and child-bearing. health personnel and getting postnatal check. Encourage and promote community participation in the care for pregnant • Educate and empower women and girls to make reproduc- women and their children. tive health choices. Build on advocacy and community par- ticipation, and involve men in supporting women’s health and • Target the poor and women in hard-to-reach rural areas in the wellbeing. provision of basic and comprehensive emergency obstetric care (renovate and equip health facilities). Implement risk-pooling schemes and make emergency transport arrangements or pro- reducing high fertility vide transport vouchers to women in hard-to-reach areas. • Address the issue of opposition to use of contraception and promote the benefits of small family sizes. Increase family plan- • Address the inadequate human resources for health by training ning awareness and utilization through outreach campaigns more midwives and deploying them to the poorest or hard-to- and messages in the media. Enlist community leaders and reach districts. women’s groups. • Promote the use of ALL modern contraceptive methods, in- reducing Stis/Hiv/aiDS cluding longterm methods, through proper counseling which • Strengthen Behavior Change Communication (BCC) pro- may entail training/re-training health care personnel. grams via mass media and community outreach to raise HIV/ AIDS awareness and knowledge. • Promote a range of options for adolescents and youth includ- ing formal education, vocational training, skills development, • Integrate HIV/AIDS/STIs and family planning in routine ante- micro-credit schemes, and income generating activities. natal and postnatal care services. • Focus on adolescents, youth and married women in providing information, education and communication on HIV/AIDS. references: 1. World Bank. 2010. World Development Indicators. Washington DC. 8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- 2. UNDP, Human Development Report. The real wealth of nations: ception. Human Development Network, World Bank. http://www. pathways to human development. http://hdr.undp.org/en/reports/ worldbank.org/hnppublications. global/hdr2010/chapters/en/. 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. Gender-related development index. http://hdr.undp.org/en/media/ tions/2008/9789241596657_eng.pdf. HDR_20072008_GDI.pdf. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank 6. Democratic Republic of Congo Standard DHS 2007, Enquête correspondence Details Démographique et de Santé (EDS-RDC), Ministère du Plan, Ministère de la Santé and ORC Macro, Calverton, MD, USA, August This profile was prepared by the World Bank (HDNHE, PRMGE, and 2008. AFTHE). For more information contact, Samuel Mills, Tel: 202 473 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. 9100, email: smills@worldbank.org. This report is available on the Geneva: WHO. http://www.who.int/making_pregnancy_safer/topics/ following website: www.worldbank.org/population. adolescent_pregnancy/en/index.html. Democratic republic of congo reproDuctive HealtH action plan inDicatorS indicator Year level indicator Year level Total fertility rate (births per woman ages 15–49) 2007 6.3 Population, total (million) 2008 64.3 Adolescent fertility rate (births per 1,000 women ages 15–19) 2007 124 Population growth (annual %) 2008 2.7 Contraceptive prevalence (% of married women ages 15–49) 2007 20.6 Population ages 0–14 (% of total) 2008 47 Unmet need for contraceptives (%) 2007 24.4 Population ages 15–64 (% of total) 2008 50.4 Median age at first birth (years) from DHS - - Population ages 65 and above (% of total) 2008 2.6 Median age at marriage (years) 2007 18.7 Age dependency ratio (% of working-age population) 2008 98.4 Mean ideal number of children for all women 2007 6.3 Urban population (% of total) 2008 34.0 Antenatal care with health personnel (%) 2007 85.3 Mean size of households 2007 5 Births attended by skilled health personnel (%) 2007 64.4 GNI per capita, Atlas method (current US$) 2008 150 Proportion of pregnant women with hemoglobin <110 g/L 2008 67.3 GDP per capita (current US$) 2008 182 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 900 GDP growth (annual %) 2008 6.2 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 910 Population living below US$1.25 per day 2006 59.2 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 850 Labor force participation rate, female (% of female population ages 15–64) 2008 57.4 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 740 Literacy rate, adult female (% of females ages 15 and above) 2008 56.1 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 670 Total enrollment, primary (% net) - - Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 225 Ratio of female to male primary enrollment (%) 2008 83.4 Infant mortality rate (per 1,000 live births) 2008 126 Ratio of female to male secondary enrollment (%) 2008 55.2 Newborns protected against tetanus (%) 2008 75 Gender Development Index (GDI) 2008 148 DPT3 immunization coverage (% by age 1) 2008 43.8 Health expenditure, total (% of GDP) 2007 5.8 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 1.7 Health expenditure, public (% of GDP) 2007 1.2 Prevalence of HIV, total (% of population ages 15–49) - - Health expenditure per capita (current US$) 2007 9.2 Female adults with HIV (% of population ages 15+ with HIV) - - Physicians (per 1,000 population) 2004 0.11 Prevalence of HIV, female (% ages 15–24) - - Nurses and midwives (per 1,000 population) 2004 0.53 poorest-richest poorest/richest indicator Survey Year poorest Second middle fourth richest total Difference ratio Total fertility rate DHS 2007 7.4 7.0 6.4 6.8 4.2 6.3 3.2 1.8 Current use of contraception (Modern method) DHS 2007 2.8 2.6 3.6 7.0 14.9 5.8 –12.1 0.2 Current use of contraception (Any method) DHS 2007 14.3 15.1 16.6 22.2 38.6 20.6 –24.3 0.4 Unmet need for family planning (Total) DHS 2007 24.6 23.4 24.8 25.2 23.6 24.4 1.0 1.0 Births attended by skilled health personnel DHS 2007 47.1 50.6 64.1 76.8 91.7 64.4 –44.6 0.5 (percent)