62916 REpRoductIvE HealtH at a GLANcE April 2011 BENIN country context Benin: MdG 5 status Benin’s per capita income of US$7501 and the country’s MdG 5A indicators sustained growth rates averaging 4.7 percent annually dur- Maternal Mortality Ratio (maternal deaths per 100,000 live 410 ing the last decade, resulting in modest increases in its per births) UN estimatea capita income (US$750) as well as improvements in human Births attended by skilled health personnel (percent) 77.7 development.2 Nevertheless, poverty remains widespread, MdG 5B indicators with 47 percent of the population still subsisting on less Contraceptive Prevalence Rate (percent) 17.2 than US $1.25 per day,3 and the economy remains undiver- sified and vulnerable to external shocks. Adolescent Fertility Rate (births per 1,000 women ages 15–19) 112 Antenatal care with health personnel (percent) 88.0 Benin’s large share of youth population (43 percent of the Unmet need for family planning (percent) 29.9 country population is younger than 15 years old3) provides a window of opportunity for high growth and poverty re- Source: Table compiled from multiple sources a 2006 DHS estimated MMR at 397 per 100,000 live births. duction—the demographic dividend. For this opportunity to result in accelerated growth, the government needs to in- vest more in the human capital formation of its youth. This is especially important in a context of decelerated growth MdG target 5A: Reduce by three-quarters, between rate arising from the global recession. 1990 and 2015, the Maternal Mortality Ratio Gender equality and women’s empowerment are impor- Benin has been making progress over the past two decades on ma- tant for improving reproductive health. Higher levels of ternal health but it is not yet on track to achieve its 2015 targets.6 women’s autonomy, education, wages, and labor market participation are associated with improved reproductive Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target health outcomes.4 In Benin, the literacy rate among females 900 790 ages 15 and above is 28 percent.3 Fewer girls are enrolled in 800 690 700 secondary schools compared to boys with a 57 percent ra- 560 600 tio of female to male secondary enrollment.3 Two-thirds of 500 460 410 MDG adult women participate in the labor force3 that mostly in- 400 Target volves work in agriculture. Gender inequalities are reflected 300 200 200 in the country’s human development ranking; Benin ranks 100 145 of 157 countries in the Gender-related Development 0 Index.5 1990 1995 2000 2005 2008 2015 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- ductive health services. It is thus important to ensure that health systems provide a basic package of reproductive World Bank support for Health in Benin health services, including family planning.4 The Bank’s current Country Assistance Strategy is for fiscal years 2009 to 2012. current projects: P096482 BJ-Malaria Cntrl Booster Prgm SIL (FY06) ($31m) P113202 BJ-Health System Performance proj (FY10) ($33.8m) pipeline project: P121534 BJ: Strengthening EpidemiologicalSurveill PCN date 11/30/2010 previous health projects: P073118 BJ-HIV/AIDS Multi-Sec APL (FY02) THE WORLD BANK P096193 BJ-IDF Female Genital Mutilation (FY06) n Key challenges methods).7 Injectables are the most commonly used modern method. Use of long-term methods such as intrauterine device High Fertility and implants are negligible. There are socioeconomic differences Fertility has been declining over time but remains high, espe- in the use of modern contraception among women: it is high cially among the poorest. The total fertility rate (TFR) has fallen among women with secondary education or higher (19 percent), from 6.3 births per woman in 1996 to 5.7 in 2006.7 urban women (9 percent) and women in the in the wealthiest quintile (13 percent)(Figure 4).7 Figure 2 n total fertility rate by wealth quintile Figure 4 n use of contraceptives among married women by wealth 8 7 7.0 6.6 6.2 5.7 overall quintile 6 5.3 5 40 4.2 4 30 20.4 3 2 17.1 Overall (All methods) 1 20 0 12.3 10 7.8 8.6 13.2 Poorest Second Middle Fourth Richest 5.3 2.4 3.7 5.0 6.7 0 Source: DHS Final Report, Benin 2006 Poorest Second Middle Fourth Richest Modern Methods Traditional Methods Wide disparities exist with the fertility of women in the lowest wealth quintile being almost twice that of women in the high- Source: DHS Final Report, Benin 2006 est wealth quintile (7.0 and 4.2 births per woman, respectively)7 Unmet need for contraception is high at 30 percent7 indicating (Figure 2). Similarly, while TFR is 3.4 among women with sec- that women may not be achieving their desired family size.9 ondary education or higher, TFR reaches 6.4 among women with no formal education.7 Health concerns (22 percent) and opposition to use (20 per- cent) are the predominant reasons women do not intend to use Adolescent fertility rate is high (112 reported births per modern contraceptives in future.7 1,000 women) affecting not only young women and their chil- dren’s health but also their long-term education and employ- ment prospects. Births to women aged 15–19 years old have the poor pregnancy outcomes highest risk of infant and child mortality as well as a higher risk Majority of pregnant women use skilled health personnel for an- of morbidity and mortality for the young mother4, 8. tenatal care and delivery. Nearly nine-tenths of pregnant women Early childbearing is more frequent among the poor. While receive antenatal care from health personnel (doctor, nurse, mid- 54 percent of the poorest 20–24 years old women have had a child wife, or auxiliary wives) with 61 percent having the recommend- before reaching 18, only 11 percent of their richer counterparts ed four or more antenatal visits.7 Further, 77 percent of pregnant did (Figure 3). Furthermore, reduction in early childbearing women deliver with the assistance of health personnel, with the mostly has taken place among the rich where younger cohorts of majority being assisted by a nurse or midwife (69 percent) mostly girls are less likely than older cohorts to have a child early in life. in public facilities.7 While 96 percent of women in the wealthi- est quintile delivered with skilled health personnel, 51 percent of Figure 3 n percent women who have had a child before age 18 women in the poorest quintile obtained such assistance (Figure 5). years by age group and wealth quintile 60% Figure 5 n Birth assisted by health personnel (percentage) by Poorest 50% Poorest Poorest wealth quintile 40% 120 30% Richest 95.5 20% Richest 100 77.7% overall 87.2 10% Richest 80 74.8 66.7 0% 60 50.6 20–24 years 25–34 years >34 years 40 Source: DHS Final Report, Benin 2006 (author’s calculation). 20 Less than a fifth of women use contraception. Current use of 0 contraception among married women was 17 percent in 200611 Poorest Second Middle Fourth Richest percent traditional methods and 6 percent modern contraceptive Source: DHS Final Report, Benin 2006 Nevertheless, 73 percent of all pregnant women are anaemic Figure 6 n Knowledge behavior gap in HIv prevention among young (defined as haemoglobin < 110g/L) increasing their risk of pre- women term delivery, low birth weight babies, stillbirth and newborn 80% death.10 60% Nearly three-quarters of women who indicated problems in 40% accessing health care cited concerns regarding inability to af- ford the services (Table 1).7 20% 0% table 1 n Barriers in accessing health care (women aged 15–49) 15–19 years 20–24 years Reason % Knowledge Condom use at last sex At least one of the problems for accessing health care 84.6 Source: DHS Final Report, Benin 2006 (author’s calculation). Getting money for treatment 73.9 Too costly 56.7 Distance to health facility 38.1 Having to take transport 36.6 Too long of a wait 30.4 technical notes: Personnel absent or late 29.2 Care received not good 24.2 Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for Poor reception 23.6 contraception, improving pregnancy outcomes, and reducing STIs. Not wanting to go alone 21.6 The RHAP has identified 57 focus countries based on poor Knowing where to go 18.3 reproductive health outcomes, high maternal mortality, high fertility Concern no female provider available 16.0 and weak health systems. Specifically, the RHAP identifies high Getting permission to go for treatment 14.9 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- Source: DHS final report, Benin 2006 group of the Countdown to 2015 countries. Details of the RHAP are available at www.worldbank.org/population. Human resources for maternal health are limited with only The Gender-related Development Index is a composite index 0.14 physicians per 1,000 population but nurses and midwives developed by the UNDP that measures human development in the are slightly more common, at 0.60 per 1,000 population.11 same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank The high maternal mortality ratio at 410 maternal deaths was recalculated per 100,000 live births indicates that access to and quality of emergency obstetric and neonatal care (EmONC) remains a challenge.6 StIs/HIv/AIdS prevalence is relatively low but a growing public health concern development partners support for reproductive health in The percentage of adult population aged 15–49 years who have Benin HIV is 1.2 percent. uSAId: Integrated ‘family health’ and HIV WHo: Safer pregnancy; maternal and youth health; sexual, There is a large knowledge-behavior gap regarding condom reproductive, and women’s health focus use for HIV prevention. While most young women are aware that using a condom in every intercourse prevents HIV, only 13 uNIcEF: Maternal and child mortality reduction; girls’ education percent of them report having used condom at last intercourse uNFpA: Reproductive health and rights (Figure 6). This gap widens among older aged women. n Key Actions to Improve RH outcomes Strengthen gender equality modern contraceptive methods and properly educate women • Support women and girls’ economic and social empowerment. on the health risks and benefits of such methods. Increase school enrollment of girls. Strengthen employment prospects for girls and women. Educate and raise awareness on Reducing maternal morbidity and mortality the impact of early marriage and child-bearing. • Improve obstetric care in facilities and community and • Educate and empower women and girls to make reproduc- strengthen delivery of the package of emergency obstetric and tive health choices. Build on advocacy and community par- neonatal care (EmONC) services as an integrated approach. ticipation, and involve men in supporting women’s health and • Improve and expand EmONC training for health personnel wellbeing. and strengthen the referral system • Improve institutional delivery through provider incentives and Reducing high fertility possibly, implement risk-pooling schemes. Provide vouchers • Address the issue of opposition to use of contraception and to women in hard-to-reach areas for transport and/or to cover promote the benefits of small family sizes. Increase family plan- cost of delivery services. ning awareness and utilization through outreach campaigns and messages in the media. Enlist community leaders and • Strengthen the referral system by instituting emergency trans- women’s groups. port and training health personnel in appropriate referral pro- cedures (referral protocols and recording of transfers). • Address the issue of opposition to use of contraception and promote the benefits of small family sizes. Increase family plan- ning awareness and utilization through outreach campaigns Reducing StIs/HIv/AIdS and messages in the media. Enlist community leaders and • Integrate HIV/AIDS/STIs and family planning services in rou- women’s groups. tine antenatal and postnatal care. • Increase access to modern contraceptives for rural women and • Lower the incidence of new HIV infections by strengthening emphasize community-based distribution. Behavior Change Communication (BCC) programs via mass media and community outreach to raise HIV/AIDS awareness • Provide quality family planning services that include coun- and knowledge. seling and advice, focusing on women with no formal educa- tion, rural and poor populations. Highlight the effectiveness of References: 1. World Bank. http://web.worldbank.org/WBSITE/EXTERNAL/COU 10. Worldwide prevalence of anaemia 1993–2005: WHO global da- NTRIES/AFRICAEXT/BENINEXTN/0,,menuPK:322649~pagePK:1 tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, 41132~piPK:141107~theSitePK:322639,00.html. Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- 2. World Bank, Benin Country Brief. http://go.worldbank.org/OEOIT tions/2008/9789241596657_eng.pdf. K6RX0. 11. World Bank. 2010. Analytical report on health and poverty in Benin, 3. World Bank. 2010. World Development Indicators. Washington DC. #AAA51-BJ. Washington DC 4. World Bank, Engendering Development: Through Gender Equality in Rights, Resources, and Voice. 2001. 5. http://hdr.undp.org/en/media/HDR_20072008_GDI.pdf 6. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank 7. DHS Final Report, Benin 2006, Institut National de la Statistique et correspondence details de l’Analyse Économique (INSAE), and Macro International Inc. This profile was prepared by the World Bank (HDNHE, PRMGE, 8. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO. http://www.who.int/making_pregnancy_safer/topics/ and AFTHE) and Management Science for Health (MSH). For more adolescent_pregnancy/en/index.html. information contact, Samuel Mills, Tel: 202 473 9100, email: smills@ 9. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- worldbank.org. This report is available on the following website: ception. Human Development Network, World Bank. http://www. www.worldbank.org/population. worldbank.org/hnppublications. BENIN REpRoductIvE HEALtH ActIoN pLAN INdIcAtoRS Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15–49) 2006 5.7 Population, total (million) 2008 8.7 Adolescent fertility rate (births per 1,000 women ages 15–19) 2006 112 Population growth (annual %) 2008 3.2 Contraceptive prevalence (% of married women ages 15–49) 2006 17 Population ages 0–14 (% of total) 2008 43.2 Unmet need for contraceptives (%) 2006 29.9 Population ages 15–64 (% of total) 2008 53.6 Median age at first birth (years) from DHS - - Population ages 65 and above (% of total) 2008 3.2 Median age at marriage (years) 2006 18.8 Age dependency ratio (% of working-age population) 2008 86.7 Mean ideal number of children for all women 2006 4.9 Urban population (% of total) 2008 41.2 Antenatal care with health personnel (%) 2006 88 Mean size of households 2006 5 Births attended by skilled health personnel (%) 2006 77.7 GNI per capita, Atlas method (current US$) 2008 700 Proportion of pregnant women with hemoglobin <110 g/L 2008 72.7 GDP per capita (current US$) 2008 771 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 790 GDP growth (annual %) 2008 5.1 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 690 Population living below US$1.25 per day 2003 47.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 560 Labor force participation rate, female (% of female population ages 15–64) 2008 68.1 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 460 Literacy rate, adult female (% of females ages 15 and above) 2008 28.1 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 410 Total enrollment, primary (% net) 2008 92.8 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 200 Ratio of female to male primary enrollment (%) 2008 86.6 Infant mortality rate (per 1,000 live births) 2008 76 Ratio of female to male secondary enrollment (%) 2005 56.7 Newborns protected against tetanus (%) 2008 92 Gender Development Index (GDI) 2008 145 DPT3 immunization coverage (% by age 1) 2006 64.5 Health expenditure, total (% of GDP) 2007 4.8 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 16.6 Health expenditure, public (% of GDP) 2007 2.4 Prevalence of HIV, total (% of population ages 15–49) 2007 1.2 Health expenditure per capita (current US$) 2007 31.9 Female adults with HIV (% of population ages 15+ with HIV) 2007 62.7 Physicians (per 1,000 population) 2008 0.059 Prevalence of HIV, female (% ages 15–24) 2007 0.9 Nurses and midwives (per 1,000 population) 2008 0.771 poorest-Richest poorest/Richest Indicator Survey Year poorest Second Middle Fourth Richest total difference Ratio Total fertility rate DHS 2006 7.0 6.6 6.2 5.3 4.2 5.7 2.8 1.7 Current use of contraception (Modern method) DHS 2006 2.4 3.7 5.0 6.7 13.2 6.1 –10.8 0.2 Current use of contraception (Any method) DHS 2006 7.7 11.5 13.6 19 33.6 17.0 –25.9 0.2 Unmet need for family planning (Total) DHS 2006 30.3 30.1 31.2 31.3 26.5 29.9 3.8 1.1 Births attended by skilled health personnel DHS 2006 57.6 71.7 80.6 91.4 97.5 77.7 –39.9 0.6 (percent) National policies and strategies that have influenced reproductive health National policy and Norms document for HIv testing: UNAIDS/WHO supported regulations for improved HIV testing coverage and quality, and reduced stigma 1996 Essential Services package: Defined essential services of the MoH for children’s health, women’s health, adolescent health, and men’s health 1999 policy and Standards in Family Health: Strategy for development of the health sector specific to reproductive health 2006 National strategy for reducing maternal and neonatal mortality