62933 reproduCtIve HealtH at a GLANCe April 2011 Côte d’IvoIre Country Context Côte d’Ivoire: MdG 5 Status Côte d’Ivoire is the second largest economy in West Africa, MdG 5A indicators accounting for almost 40 percent of GDP of the 8-member Maternal Mortality Ratio (maternal deaths per 100,000 live 470 West African Economic Monetary Union.1 It is the world’s births) UN estimatea largest exporter of cocoa and of cashew nuts.1 The country Births attended by skilled health personnel (percent) 56.8 suffered from political instability since 2002, and saw pov- MdG 5B indicators erty increase to 49 percent in 2008, up from 10 percent in Contraceptive Prevalence Rate (percent) 12.9 1985.1 Thirteen percent of the population still subsists on less than US $1.25 per day.2 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 130 Antenatal care with health personnel (percent) 84.8 Côte d’Ivoire’s large share of youth population (41 per- Unmet need for family planning (percent) 29.0 cent of the country population is younger than 15 years old2) provides a window of opportunity for high growth Source: Table compiled from multiple sources. a The 2006 DHS estimated maternal mortality ratio at 543. and poverty reduction—the demographic dividend. For this opportunity to result in accelerated growth, the gov- ernment needs to invest more in the human capital forma- tion of its youth. This is especially important in a context of MdG target 5A: reduce by three-quarters, between decelerated growth rate arising from the global recession 1990 and 2015, the Maternal Mortality ratio and the country’s exposure to high volatility in commodity Côte d’Ivoire has been making progress over the past two de- prices. cades on maternal health but it is not on track to achieve its 2015 Gender equality and women’s empowerment are impor- targets.5 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 800 participation are associated with improved reproductive 690 700 health outcomes.3 In Côte d’Ivoire, the literacy rate among 620 600 580 530 females ages 15 and above is 44 percent.2 Fewer girls are 500 470 enrolled in primary schools compared to boys with a 79 400 MDG Target percent ratio of female to male secondary enrollment.2 Half 300 200 170 of adult women participate in the labor force2 that mostly 100 involves work in agriculture. Gender inequalities are re- 0 flected in the country’s human development ranking; Côte 1990 1995 2000 2005 2008 2015 d’Ivoire ranks 146 of 157 countries in the Gender-related Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. Development Index.4 Greater human capital for women will not translate into greater reproductive choice if women lack access to repro- World Bank Support for Health in Côte d’Ivoire ductive health services. It is thus important to ensure that The Bank’s current Country Assistance Strategy is for fiscal years 2010 to 2013. health systems provide a basic package of reproductive Current project: health services, including family planning.3 P071631 CI-Emerg Multi-Sect HIV/AIDS Proj (FY08) ($13.2m) pipeline project: None previous Health project: None THE WORLD BANK n Key Challenges Figure 3 n use of contraceptives among married women by wealth quintile High fertility 25 5.5 Fertility has been falling over time but it is high among the 20 18.3 poorest. Total fertility rate (TFR) fell from 67.2 births per woman 15 6.3 12.9 Overall (All methods) in 1980 to 5.2 in 1998 and to 4.6 in 2008.6 Disparities exist be- 10 9.6 5.5 3.9 3.3 tween women in rural areas at 5.5 births per woman compared 5 5.2 5.7 3.0 to 3.6 for those in urban areas, and vary by education levels at 0 5.3 births per woman with no education, and 2.7 with secondary Poorest Second Middle Fourth Richest education or above. Similarly, TFR is among women in the lowest Modern Methods Traditional Methods quintile is nearly twice those in the highest quintile (Figure 2).6 Source: MIC3 Côte d’Ivoire, 2006. Unmet need for contraception is high at 29 percent8 indi- Figure 2 n total fertility rate by wealth quintile cating that women may not be achieving their desired family 10 9 size.9 The forthcoming Côte d’Ivoire DHS 2011 will provide data 8 7 6.1 on the reasons why women do not use contraception. 6 5.7 4.2 4.3 4.6 overall 5 4 3.2 3 2 poor pregnancy outcomes 1 0 While majority of pregnant women use antenatal care, institu- Poorest Second Middle Fourth Richest tional deliveries are less common. Over four-fifths of pregnant Source: DHS Final Report, Côte d’Ivoire 2005. women receive antenatal care from skilled medical personnel (doctor, nurse, or midwife).8 However, a smaller proportion, 57 Adolescent fertility rate is high (130 reported births per percent deliver with the assistance of skilled medical personnel. 1,000 women aged 15–19 years6) affecting not only young While 95 percent of women in the wealthiest quintile delivered women and their children’s health but also their long-term with skilled health personnel, only 29 percent of women in the education and employment prospects. Births to women aged poorest quintile obtained such assistance (Figure 4). Additionally, 15–19 years old have the highest risk of infant and child mortality 47 percent of women with no education delivered with skilled as well as a higher risk of morbidity and mortality for the young health personnel as compared to 87 percent of women with sec- mother.3, 7 42 percent of women aged 15–49 have begun child- ondary education or higher. Further, 55 percent of all pregnant bearing by the age of 18.6 women are anaemic (defined as haemoglobin < 110g/L) increas- Over a tenth of women use of contraception. Current use of ing their risk of preterm delivery, low birth weight babies, still- contraception among married women was 13 percent in 2006 birth and newborn death.10 and more married women use modern contraceptive methods The forthcoming Côte d’Ivoire DHS 2011 will provide infor- than traditional methods (8 percent and 5 percent).8 The pill is mation on women’s perception on the barriers to accessing health the most commonly used method among married women at 6. care. Use of long-term methods such as intrauterine device and im- plants are negligible. There are socioeconomic differences in Figure 4 n Birth assisted by health personnel (percentage) by the use of modern contraception among women: it is 18 per- wealth quintile cent among women in the highest wealth quintile and 3 percent 100 among those in the poorest quintile (Figure 3). Similarly, just 5 94.5 78.9 percent of women with no education use modern contraception 80 56.8% overall as compared to 20 percent of women with secondary education 60 58.7 or higher, and 5 percent for rural women versus 13 percent for 40.3 40 urban women.8 28.5 20 0 Poorest Second Middle Fourth Richest Source: MIC3 Final Report, Côte d’Ivoire 2006. Human resources for maternal health are limited with only StIs/HIv/AIdS is public health concern 0.14 physicians per 1,000 population but nurses and midwives are HIV infection is declining but women are one of the most vul- slightly more common, at 0.48 per 1,000 population.2 nerable groups. The adult population that has HIV is 4.7 percent The high maternal mortality ratio at 470 maternal deaths in 2005 but the prevalence among females is significantly higher per 100,000 live births indicates that access to and quality of than among males (6.4 percent and 2.9 percent, respectively).6 emergency obstetric and neonatal care (EmONC) remains a Knowledge of mother to child prevention methods is lim- challenge.5 ited. Less than half of women know that HIV can be transmitted through breast milk and that the likelihood of passing HIV from mother to child can be reduced by drugs.6 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 possibly, implement risk-pooling schemes. Provide vouchers prospects for girls and women. Educate and raise awareness on to women in hard-to-reach areas for transport and/or to cover the impact of early marriage and child-bearing. cost of delivery services. • Educate and empower women and girls to make reproductive • Target the poor and women in hard-to-reach rural areas in the health choices. Build on advocacy and community participation, provision of basic and comprehensive emergency obstetric care and involve men in supporting women’s health and wellbeing. (renovate and equip health facilities). • Address the inadequate human resources for health by training reducing high fertility more midwives and deploying them to the poorest or hard-to- • Address the issue of opposition to use of contraception and reach districts. promote the benefits of small family sizes. Increase fam- • Strengthen the referral system by instituting emergency trans- ily planning awareness and utilization through outreach cam- port, training health personnel in appropriate referral proce- paigns and messages in the media. Enlist community leaders dures (referral protocols and recording of transfers) and estab- and women’s groups. lishing maternity waiting huts/homes at hospitals to accommo- • Provide quality family planning services that include coun- date women from remote communities who wish to stay close seling and advice, focusing on young and poor populations. to the hospital prior to delivery. Highlight the effectiveness of modern contraceptive methods • During antenatal care, educate pregnant women about the im- and properly educate women on the health risks and benefits portance of delivery with a skilled health personnel and getting of such methods. postnatal check. • Promote the use of ALL modern contraceptive methods, in- cluding longterm methods, through proper counseling which reducing StIs/HIv/AIdS may entail training/re-training health care personnel. • Integrate HIV/AIDS/STIs and family planning services in rou- • Secure reproductive health commodities and strengthen sup- tine antenatal and postnatal care. ply chain management to further increase contraceptive use as • Lower the incidence of HIV infections by strengthening demand is generated. Behavior Change Communication (BCC) programs via mass media and community outreach to raise HIV/AIDS awareness and knowledge. references: 1. The World Bank, Côte d’Ivoire: Country Brief. . contraception, improving pregnancy outcomes, and reducing STIs. 2. World Bank. 2010. World Development Indicators. Washington DC. 3. World Bank, Engendering Development: Through Gender Equality The RHAP has identified 57 focus countries based on poor reproductive in Rights, Resources, and Voice. 2001. health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high priority countries as 4. Gender-related development index. http://hdr.undp.org/en/media/ those where the MMR is higher than 220/100,000 live births and TFR is HDR_20072008_GDI.pdf. greater than 3.These countries are also a sub-group of the Countdown 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by to 2015 countries. Details of the RHAP are available at www.worldbank. WHO, UNICEF, UNFPA, and the World Bank org/population. 6. Institut National de la Statistique (INS) et Ministère de la Lutte contre le Sida [Côte d’Ivoire] et ORC Macro. 2006. Enquête sur les The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the Indicateurs du Sida, Côte d’Ivoire 2005. Calverton, Maryland, U.S.A.: same dimensions as the HDI while adjusting for gender inequality. Its INS et ORC Macro. coverage is limited to 157 countries and areas for which the HDI rank 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. was recalculated. Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- ics/adolescent_pregnancy/en/index.html. 8. République de Côte d’Ivoire, MICS3 2006, Enquête par grappes à indicateurs multiples, Ministère d’Etat, Ministère du Plan et du Développement, Institut national de la Statistique, and UNICEF, March 2007 9. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- ception. Human Development Network, World Bank. Available at Correspondence details http://www.worldbank.org/hnppublications. This profile was prepared by the World Bank (HDNHE, PRMGE, and 10. Worldwide prevalence of anaemia 1993–2005: WHO global da- AFTHE). For more information contact Samuel Mills, Tel: 202 473 9100, tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, email: smills@worldbank.org. This report is available on the following Ines Egli and Mary Cogswell. . Côte d’IvoIre reproduCtIve HeALtH ACtIoN pLAN INdICAtorS Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15–49) 2005 4.6 Population, total (million) 2008 20.6 Adolescent fertility rate (births per 1,000 women ages 15–19) 2005 130 Population growth (annual %) 2008 2.3 Contraceptive prevalence (% of married women ages 15–49) 2006 12.9 Population ages 0–14 (% of total) 2008 40.9 Unmet need for contraceptives (%) 2006 28.9 Population ages 15–64 (% of total) 2008 55.3 Median age at first birth (years) from DHS — Population ages 65 and above (% of total) 2008 3.8 Median age at marriage (years) — Age dependency ratio (% of working-age population) 2008 80.7 Mean ideal number of children for all women 1998–99 5.4 Urban population (% of total) 2008 48.8 Antenatal care with health personnel (%) 2006 84.8 Mean size of households Births attended by skilled health personnel (%) 2006 56.8 GNI per capita, Atlas method (current US$) 2008 980 Proportion of pregnant women with hemoglobin <110 g/L 2008 55.1 GDP per capita (current US$) 2008 1137 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 690 GDP growth (annual %) 2008 2.2 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 620 Population living below US$1.25 per day 2003 13.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 580 Labor force participation rate, female (% of female population ages 15–64) 2008 51.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 530 Literacy rate, adult female (% of females ages 15 and above) 2008 44.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 470 Total enrollment, primary (% net) — Maternal mortality ratio (maternal deaths/100,000 live births) 2015 170 Ratio of female to male primary enrollment (%) 2008 79.4 target Infant mortality rate (per 1,000 live births) 2008 81 Ratio of female to male secondary enrollment (%) — Newborns protected against tetanus (%) 2008 92 Gender Development Index (GDI) 2008 146 DPT3 immunization coverage (% by age 1) 2006 74.1 Health expenditure, total (% of GDP) 2007 4.2 Pregnant women living with HIV who received antiretroviral drugs 2005 4.5 Health expenditure, public (% of GDP) 2007 1.0 (%) Prevalence of HIV, total (% of population ages 15–49) 2007 3.9 Health expenditure per capita (current US$) 2007 40.7 Female adults with HIV (% of population ages 15+ with HIV) 2007 59.5 Physicians (per 1,000 population) 2008 0.144 Prevalence of HIV, female (% ages 15–24) 2007 2.4 Nurses and midwives (per 1,000 population) 2004 0.483 poorest-richest poorest/richest Indicator Survey Year poorest Second Middle Fourth richest total difference ratio Total fertility rate DHS 2005 6.1 5.7 4.2 4.3 3.2 4.6 2.9 1.9 Current use of contraception (Modern method) MICS3 2006 3 5.2 5.7 9.6 18.3 8 –15.3 0.2 Current use of contraception (Any method) MICS3 2006 8.5 9.1 9 15.9 23.8 12.9 –15.3 0.4 Unmet need for family planning (Total) MICS3 2006 28.9 31.3 31.4 28.2 24.6 28.9 4.3 1.2 Births attended by skilled health personnel MICS3 2006 28.5 40.3 58.7 78.9 94.5 56.8 –66.0 0.3 (percent)