62914 RepRoductive HealtH at a glance april 2011 angola country context angola: Mdg 5 Status Eight years after the end of the decades-long war in April Mdg 5a indicators 2002, Angola has made substantial economic and po- Maternal Mortality Ratio (maternal deaths per 100,000 live 614 litical progress. However, the country continues to face births) UN estimatea developmental challenges including reducing the depen- Births attended by skilled health personnel (percent) 51.8 dency on oil and diversifying the economy, rebuilding Mdg 5B indicators its infrastructure, improving institutional capacity, gov- Contraceptive Prevalence Rate (percent) 6.2 ernance, public financial management systems, human development indicators and the living conditions of the Adolescent Fertility Rate (births per 1,000 women ages 15–19) 165 population. About 37 percent of the population still lives Antenatal care with health personnel (percent) 79.8 below the poverty line.1 Unmet need for family planning (percent) NA Angola’s large share of youth population (45 percent of Source: Table compiled from multiple sources. a The 2008–2009 DRC DHS estimated maternal mortality rate at 498. the country population is younger than 15 years old2) pro- vides a window of opportunity for high growth and poverty reduction—the demographic dividend. For this opportu- Mdg target 5a: Reduce by three-quarters, between nity to result in accelerated growth, the government needs 1990 and 2015, the Maternal Mortality Ratio to invest more in the human capital formation of its youth. This is especially important in a context of decelerated Angola has been making progress over the past two decades on growth rate arising from the global recession. maternal health but it is not on track to achieve its 2015 targets.6 Gender equality and women’s empowerment are im- Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target portant for improving reproductive health. Higher levels 1200 of women’s autonomy, education, wages, and labor mar- 1000 1000 1000 880 ket participation are associated with improved reproduc- 800 720 610 MDG tive health outcomes.3 In Angola, the literacy rate among 600 Target females ages 15 and above is 57 percent.2 Fewer girls are 400 260 enrolled in secondary schools compared to boys with a 200 83 percent ratio of female to male secondary enrollment.4 0 Three-quarters of adult women participate in the labor 1990 1995 2000 2005 2008 2015 force2 that mostly involves work in agriculture. Gender in- Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. equalities are reflected in the country’s human development ranking; Angola ranks 142 of 157 countries in the Gender- related Development Index.5 World Bank Support for Health in angola The Bank’s new Country Assistance Strategy under preparation (P115339) is Greater human capital for women will not translate into scheduled to be approved by the Bank’s Executive Board on December 21, 2010. greater reproductive choice if women lack access to repro- current project: ductive health services. It is thus important to ensure that P111840 AO-Municipal Health Serv Strength (FY10) ($70.8m) health systems provide a basic package of reproductive • Improved health service delivery including training of health personnel, scaling up of outreach and community health services, strengthening of health services, including family planning.3 obstetric care, and improvement of hospital waste management • Facilitate access to child delivery services and pre-natal care through cash transfer programs • Strengthen capacity for Project Management and Monitoring and Evaluation pipeline project: None previous Health project: THE WORLD BANK P083180 AO-HAMSET SIL (FY05) n Key challenges Figure 3 n use of contraceptives among married women by wealth quintile High fertility 20 Fertility remains high, especially among the poorest. Total fer- 15 3.3 tility rate (TFR) fell from 7.2 births per woman in 1990 to 5.8 in 10 13.5 2006(2, 7). TFR is very high at 8.0 births per woman among women 6.2 Overall (All methods) 1.7 5 in the lowest quintile in contrast to 2.8 among women in the high- 1 0.7 1.6 1.2 1.5 1 3.4 est wealth quintiles (Figure 2). Disparities exist between women in 0 rural areas at 7.7 births per woman compared to 4.4 for those in Poorest Second Middle Fourth Richest urban areas, and vary by education levels at 7.8 births per woman Modern Methods Traditional Methods with no education, and 2.5 with secondary education or above.7 Source: MICS2 Final Report, Angola 2001. Figure 2 n total fertility rate by wealth quintile women receive antenatal care from health personnel (doctor, nurse/midwife, or auxiliary nurse/midwife).7 However, a smaller 9 8 8.0 7.4 5.8 overall proportion, 47 percent deliver with the assistance of health per- 7 6.7 6 sonnel but this is up from 45 percent in 2001.7, 9 According to the 4.9 5 4 2001 MICS2, while 67 percent of women in the wealthiest quin- 3 2.8 tile delivered with skilled health personnel, only 23 percent of 2 1 women in the poorest quintile obtained such assistance (Figure 0 4).9 Additionally, 29 percent of women with no education deliv- Poorest Second Middle Fourth Richest ered with skilled health personnel as compared to 82 percent of Source: Malaria Indicator Survey Final Report, Angola 2006-07. women with secondary education or higher. Further, 57 percent of all pregnant women are anaemic (defined as haemoglobin < Adolescent fertility rate is high affecting not only young 110g/L) increasing their risk of preterm delivery, low birth weight women and their children’s health but also their long-term babies, stillbirth and newborn death.10 education and employment prospects. Births to women aged 15–19 years old have the highest risk of infant and child mortality There is no available information on women’s perception on as well as a higher risk of morbidity and mortality for the young the barriers to accessing health care. mother.3, 8 In Angola, there are 165 reported births per 1,000 women aged 15–19 years. Figure 4 n Birth assisted by health personnel (percentage) by wealth quintile Less than a tenth of women use contraception. Current use of 80 contraception among married women was 6 percent in 2001 and 70 67.4 more married women use modern contraceptive methods than 60 44.7% overall 53.5 traditional methods (4 percent and 2 percent).9 50 40 36.2 37.0 The use of modern contraception methods shows important 60 22.8 20 socioeconomic differences: it is 14 percent among women in the 10 highest wealth quintile and 1 percent among those in the poorest 0 quintile (Figure 3). Similarly, among women with no education Poorest Second Middle Fourth Richest use modern contraception is negligible as compared to 25 per- Source: MICS2 Final Report, Angola 2001. cent of women with tertiary education, and 1 percent for rural women versus 6 percent for urban women. There is no available Human resources for maternal health are limited with only data on unmet need for contraception as well as reasons why 0.08 physicians per 1,000 population but nurses and midwives are women do not use contraception. slightly more common, at 1.35 per 1,000 population.2 The high maternal mortality ratio at 610 maternal deaths poor pregnancy outcomes per 100,000 live births indicates that access to and quality of While majority of pregnant women use antenatal care, insti- emergency obstetric and neonatal care (EmONC) remains a tutional deliveries are less common. Four-fifths of pregnant challenge.6 Stis/Hiv/aidS is a growing public health concern The HIV/AIDS prevalence is estimated at 2.1 percent which is correspondence details comparatively lower than that of neighboring countries. However, This profile was prepared by the World Bank (HDNHE, PRMGE, the opening of borders and increased population movements and AFTHE) and Management Science for Health (MSH). For more could potentially lead to rapid spread of the epidemic, especially information contact, Samuel Mills, Tel: 202 473 9100, email: smills@ in border provinces. worldbank.org. This report is available on the following website: www.worldbank.org/population. n Key actions to improve RH outcomes Strengthen gender equality to women in hard-to-reach areas for transport and/or to cover • Support women and girls’ economic and social empowerment. cost of delivery services. Increase school enrollment of girls. Strengthen employment • Target the poor and women in hard-to-reach rural areas in the prospects for girls and women. Educate and raise awareness on provision of basic and comprehensive emergency obstetric care the impact of early marriage and child-bearing. (renovate and equip health facilities). • Educate and empower women and girls to make reproduc- • Address the inadequate human resources for health by training tive health choices. Build on advocacy and community par- more midwives and deploying them to the poorest or hard-to- ticipation, and involve men in supporting women’s health and reach districts. wellbeing. • Strengthen the referral system by instituting emergency trans- port, training health personnel in appropriate referral proce- Reducing high fertility dures (referral protocols and recording of transfers) and estab- • Increase family planning awareness and utilization through lishing maternity waiting huts/homes at hospitals to accommo- outreach campaigns and messages in the media with particu- date women from remote communities who wish to stay close lar focus on vulnerable populations such as youth, the poor, to the hospital prior to delivery. and women in hard-to-reach areas. Enlist community lead- • During antenatal care, educate pregnant women about the im- ers and women’s groups and emphasize community-based portance of delivery with a skilled health personnel and getting distribution. postnatal check. Encourage and promote community partici- • Provide quality family planning services that include coun- pation in the care for pregnant women and their children. seling and advice, focusing on young and poor populations. Highlight the effectiveness of modern contraceptive methods Reducing Stis/Hiv/aidS and properly educate women on the health risks and benefits of such methods. • Integrate HIV/AIDS/STIs and family planning services in rou- tine antenatal and postnatal care. • Promote the use of ALL modern contraceptive methods, in- cluding longterm methods, through proper counseling which • Lower the incidence of HIV infections by strengthening may entail training/re-training health care personnel. Behavior Change Communication (BCC) programs via mass media and community outreach to raise HIV/AIDS awareness and knowledge. Reducing maternal mortality • Strengthen screening and surveillance systems, particularly in • Promote institutional delivery through provider incentives and border areas, to track the epidemic and ensure appropriate dis- possibly, implement risk-pooling schemes. Provide vouchers tribution of services References: 1. World Bank, Country Brief, available at Improving Reproductive Health (RH) outcomes, as outlined in the 2. World Bank. 2010. World Development Indicators. Washington DC. RHAP, includes addressing high fertility, reducing unmet demand 3. World Bank, Engendering Development: Through Gender Equality in for contraception, improving pregnancy outcomes, and reducing Rights, Resources, and Voice. 2001. STIs. 4. World Bank, GenderStats (data is for 2004), available at . reproductive health outcomes, high maternal mortality, high 5. Gender-related development index. Available at http://hdr.undp.org/ fertility and weak health systems. Specifically, the RHAP identifies en/media/HDR_20072008_GDI.pdf. high priority countries as those where the MMR is higher than 6. Trends in Maternal Mortality: 1990-2008: Estimates developed by 220/100,000 live births and TFR is greater than 3.These countries WHO, UNICEF, UNFPA, and the World Bank are also a sub-group of the Countdown to 2015 countries. Details 7. Consultoria de Serviços e Pesquisas-COSEP Lda., Consultoria de of the RHAP are available at www.worldbank.org/population. Gestão e Administração em Saúde-Consaúde Lda. [Angola], and The Gender-related Development Index is a composite index Macro International Inc. 2007. Angola Malaria Indicator Survey developed by the UNDP that measures human development in the 2006–07. Calverton, Maryland: COSEP Lda., Consaúde Lda., and same dimensions as the HDI while adjusting for gender inequality. Macro International Inc. Its coverage is limited to 157 countries and areas for which the 8. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: HDI rank was recalculated. WHO. Available at http://www.who.int/making_pregnancy_safer/ topics/adolescent_pregnancy/en/index.html. 9 MICS2 Angola 2001, Available at: . 10 Worldwide prevalence of anaemia 1993-2005 : WHO global da- national policies and Strategies that have influenced tabase on anaemia / Edited by Bruno de Benoist, Erin McLean, Reproductive Health Ines Egli and Mary Cogswell. . and Family Planning to signal the importance of reproductive health to the health agenda in Madagascar. 2003 The Government took the lead in organizing a series of stakeholder meetings and a national conference to develop a new family planning strategy. Subsequently, the Family Planning program gained recognition at the same level as the fight against HIV/AIDS and Roll Back Malaria. 2006 For the first time, Malagasy government allocated funds to purchase contraceptives. Previously, family planning efforts have depended solely on donor financing. 2008 Safe delivery kits for both normal and cesarean deliveries were introduced by the Ministry of Health at the health center/ hospital level. Deliveries thus became free-of-charge for the patient. angola RepRoductive HealtH action plan indicatoRS indicator Year level indicator Year level Total fertility rate (births per woman ages 15–49) 2007 5.8 Population, total (million) 2008 18.0 Adolescent fertility rate (births per 1,000 women ages 15–19) 2007 165 Population growth (annual %) 2008 2.6 Contraceptive prevalence (% of married women ages 15–49) 2001 6.2 Population ages 0–14 (% of total) 2008 45.3 Unmet need for contraceptives (%) — — Population ages 15–64 (% of total) 2008 52.3 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 2.5 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 91.4 Mean ideal number of children for all women — — Urban population (% of total) 2008 56.7 Antenatal care with health personnel (%) 2007 79.8 Mean size of households 2006/07 6 Births attended by skilled health personnel (%) 2007 51.8 GNI per capita, Atlas method (current US$) 2008 3340 Proportion of pregnant women with hemoglobin <110 g/L 2008 57.1 GDP per capita (current US$) 2008 4714 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 1040 GDP growth (annual %) 2008 13.2 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 1024 Population living below US$1.25 per day — — Maternal mortality ratio (maternal deaths/100,000 live births) 2000 880 Labor force participation rate, female (% of female population ages 15–64) 2008 76.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 720 Literacy rate, adult female (% of females ages 15 and above) 2008 57 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 614 Total enrollment, primary (% net) — — Maternal mortality ratio (maternal deaths/100,000 live births) 2015 260 Ratio of female to male primary enrollment (%) 2008 81.1 target Infant mortality rate (per 1,000 live births) 2008 130 Ratio of female to male secondary enrollment (%) — — Newborns protected against tetanus (%) 2008 79 Gender Development Index (GDI) 2008 142 DPT3 immunization coverage (% by age 1) 2008 81 Health expenditure, total (% of GDP) 2007 2.5 Pregnant women living with HIV who received antiretroviral drugs 2005 1.1 Health expenditure, public (% of GDP) 2007 2.0 (%) Prevalence of HIV, total (% of population ages 15–49) 2007 2.1 Health expenditure per capita (current US$) 2007 85.7 Female adults with HIV (% of population ages 15+ with HIV) 2007 61.1 Physicians (per 1,000 population) 2004 0.08 Prevalence of HIV, female (% ages 15–24) 2007 0.3 Nurses and midwives (per 1,000 population) 2004 1.35 poorest-Richest poorest/Richest indicator Survey Year poorest Second Middle Fourth Richest total difference Ratio Total fertility rate MICS 2006/07 8 7.4 6.7 4.9 2.8 5.8 5.2 2.9 Current use of contraception (Modern method) MICS2 2001 1.2 1.5 1 3.4 13.5 4.5 –12.3 0.1 Current use of contraception (Any method) MICS2 2001 2.2 2.2 2.6 5.1 16.8 6.2 –14.6 0.1 Unmet need for family planning (Total) — — — — — — — — — — Births attended by skilled health personnel MICS2 2001 22.8 36.2 37 53.5 67.4 44.7 –44.6 0.3 (percent)