THE WORLD BANK

UGANDARepRoDUctive HealtH

GLANceat a

April 2011

MDG target 5A: Reduce by three-quarters, between 1990 and 2015, the Maternal Mortality RatioUganda has been making progress over the past two decades on maternal health but it is not on track to achieve its 2015 targets.5

Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target

01990 1995 2000 2005 2008 2015

MDGTarget

100200300400500600700800

670 690640

510430

170

Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report.

country contextStrong economic growth enabled substantial poverty reduction and some progress towards MDGs in recent years in Uganda. GDP growth accelerated from an average of seven percent per year in the 1990s to over eight percent during the seven years to 2007/08.1 Still, half of the popula-tion still subsists on less than US $1.25 per day.2 While life expectancy rose from 48 years in 1990 to 53 in 2008, gains made on this front could have been higher but were limited by the HIV/AIDS epidemic.

Uganda’s large share of youth population (49 percent of the country population is younger than 15 years old2) pro-vides a window of opportunity for high growth and pov-erty reduction—the demographic dividend. For this op-portunity to result in accelerated growth, the government needs to invest more in the human capital formation of its youth. This is especially important in a context of deceler-ated growth rate arising from the global recession and the country’s high rapid population growth.

Gender equality and women’s empowerment are im-portant for improving reproductive health. Higher levels of women’s autonomy, education, wages, and labor mar-ket participation are associated with improved reproduc-tive health outcomes.3 In Uganda, the literacy rate among females ages 15 and above is 67 percent.2 Fewer girls are enrolled in secondary schools compared to boys with a 85 percent ratio of female to male secondary enrollment.2 81 percent of adult women participate in the labor force2 that mostly involves work in agriculture. Gender inequalities are reflected in the country’s human development ranking; Uganda ranks 132 of 157 countries in the Gender-related Development Index.4

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 health services, including family planning.3

World Bank support for Health in UgandaThe Bank’s current Country Assistance Strategy is for fiscal years 2011 to 2015.

current projects:P115563 – UG Health Syst. Strength. Project (FY10) ($130m)P104527 UG-GPOBA W3: Reprod. Health (FY08) ($4.3m)

pipeline project: None

previous health project: None

Uganda: MDG 5 status

MDG 5A indicators

Maternal Mortality Ratio (maternal deaths per 100,000 live births) UN estimatea

430

Births attended by skilled health personnel (percent) 430

MDG 5B indicators

Contraceptive Prevalence Rate (percent) 23.7

Adolescent Fertility Rate (births per 1,000 women ages 15–19) 152

Antenatal care with health personnel (percent) 93.5

Unmet need for family planning (percent) 40.6

Source: Multiple sourcesa The 2006 DHS estimated maternal mortality ratio at 435

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

n Key challenges

High FertilityFertility is high and almost stagnant for the past twenty years. Total fertility rate (TFR) fell slightly from 7 births per woman in 1990 to 6.7 in 2006.6

Figure 2 n total fertility rate by wealth quintile

8 7.97.0 6.8

4.3

0

321

54

6

987

6.7 overall

Poorest Second Middle Fourth Richest

Source: DHS Final Report, Uganda 2006

Poorest and less educated women, as well as those living in ru-ral areas have about twice the number of births than their richer, more educated and urban counterparts. TFR is very high (over 6) among women in the lower four wealth quintiles6 (Figure 2).

Adolescent fertility rate is high affecting not only young women and their children’s health but also their long-term education and employment prospects. Births to women aged 15–19 years old have the highest risk of infant and child mortality as well as a higher risk of morbidity and mortality for the young mother.3, 7

Early childbearing is high but much more frequent among the poor. While 60 percent of the poorest 20–24 years old women have had a child before reaching 18, 32 percent of their richer counterparts did (Figure 3). Furthermore, reduction in early childbearing mostly has taken place among the rich where younger cohorts of girls are less likely than older cohorts to have a child early in life.

Figure 3 n percent women who have had a child before age 18 years by age group and wealth quintile

Poorest PoorestPoorest

RichestRichest

Richest

>34 years20–24 years 25–34 years0%

10%20%30%40%50%

70%60%

Source: DHS Final Report, Uganda 2006 (author’s calculation)

Over a fifth of women use contraception. Current use of contraception among married women was 24 percent in 2005.6 Injectables are the most commonly used method among married women followed by the pill. Use of long-term methods such as intrauterine device and implants are negligible.

There are important socioeconomic differences in the use of modern contraception: while 38 percent of women in the highest wealth quintile use modern contraceptive methods, only 7 percent among those in the poorest quintile do (Figure 4). Similarly, just 9 percent of women with no education use modern contraception compared to 35 percent of women with secondary education or higher, and 15 percent for rural women versus 37 percent for urban women.

Figure 4 n Use of contraceptives among married women by wealth quintile

0

20

10

30

50

40

23.7 Overall (All methods)

Poorest Second Middle Fourth Richest

Modern Methods Traditional Methods

7.2 12.1 13.120.3

37.9

2.73.6 6.3

9.6

7.3

Source: DHS Final Report, Uganda 2006

Unmet need for contraception is high at 41 percent indi-cating that women may not be achieving their desired family size.8 Unsafe abortion remains common. It is estimated that an-nually 297,000 induced abortions are performed annually result-ing in 85,000 complications that require treatment.9

Fear of side effects (32 percent) and opposition to use (18 percent) are the predominant reasons women do not intend to use modern contraceptives in future.6 Cost and access are lesser concerns, indicating further need to strengthen demand for fam-ily planning services.

poor pregnancy outcomesWhile majority of pregnant women use antenatal care, in-stitutional deliveries are less common. Over nine-tenths of pregnant women receive antenatal care from skilled medical personnel (doctor, nurse/midwife, and medical assistant/clini-cal officer) with 47 percent having the recommended four or more antenatal visits.6 However, a smaller proportion, 43 per-cent deliver with the assistance of skilled medical personnel predominantly in the public sector. While 77 percent of women in the wealthiest quintile delivered with skilled health person-nel, only 29 percent of women in the poorest quintile obtained such assistance (Figure 5). Additionally, 26 percent of women with no education delivered with skilled health personnel as compared to 75 percent of women with secondary education or higher. Further, 41 percent of all pregnant women are anaemic (defined as haemoglobin < 110g/L) increasing their risk of pre-term delivery, low birth weight babies, stillbirth and newborn death.10

Figure 5 n Birth assisted by skilled health personnel (percentage) by wealth quintile

Poorest Second Middle Fourth Richest

42.6% overall

0102030405060708090

28.8 31.9 35.2

50.1

77.0

Source: DHS Final Report, Uganda 2006

Of those women who did not give birth in a health facility, 87 percent never received postnatal care, and only 11 percent got a postnatal check-up within two days.6

Nearly two-thirds of women who indicated problems in ac-cessing health care cited concerns regarding inability to afford the services while about half long distance, transport difficul-ties, or unavailability of drugs (Table 1).6

table 1 n Barriers in accessing health care (women age 15–49)

Reason %

At least one problem accessing health care 85.9

Getting money for treatment 65.2

Distance to health facility 54.5

Having to take transport 48.9

Concern no drugs available 46.2

Concern no provider available 27.2

Not wanting to go alone 26.9

Concern no female provider available 16.7

Getting permission to go for treatment 8.1

Source: DHS Final Report, Uganda 2006

Human resources for maternal health are limited with only 0.12 physicians per 1,000 population but nurses and midwives are slightly more common, at 1.3 per 1,000 population.2

Most maternity services are in poor condition and health fa-cilities lack the basic necessities like water, power, equipment and supplies which makes the use of health services less attractive to patients.

Stis/Hiv/AiDS prevalence is decliningThe adult population that has HIV has fallen from 15 percent in 1991 to 5.4 percent but it is still high among women among women at 7.3 percent (11, 12).

There is a large knowledge-behavior gap regarding condom use for HIV prevention. While most young women are aware that using a condom in every intercourse prevents HIV, only 9

percent of them report having used condom at last intercourse (Figure 6). This gap widens among older aged women.

Figure 6 n Knowledge behavior gap in Hiv prevention among young women

15–19 years 20–24 years

Knowledge Condom use at last sex

0%

20%

40%

60%

80%

10%

30%

50%

70%

Source: DHS Final Report, Uganda 2006 (author’s calculation)

National policies and strategies that have influenced reproductive healthNational Adolescent Health policy – the goal of the policy is to mainstream adolescent health concerns in the national development process to improve the quality of life and standard of living of young people.

technical notes:Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs.

The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high 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.

The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank was recalculated.

n Key Actions to improve RH outcomes

Strengthen gender equality• Support women and girls’ economic and social empowerment.

Increase school enrollment of girls. Strengthen employment prospects for girls and women. Educate and raise awareness on the impact of early marriage and child-bearing.

Reducing high fertility• 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 and messages in the media. Enlist community leaders and women’s groups and emphasize community-based distribution

• Improve access to quality family planning services that in-clude counseling and advice, focusing on rural women and the youth. Highlight the effectiveness of modern contraceptive methods and properly educate women on the health risks and benefits of such methods.

• Promote the use of ALL modern contraceptive methods, in-cluding longterm methods, through proper counseling which may entail training/re-training health care personnel.

• Strengthen post-abortion care (treatment of abortion compli-cations with manual vacuum aspiration, post-abortion family planning counseling, and appropriate referral where necessary) and link it with family planning services.

Reducing maternal mortality• Ensure health facilities have basic necessities like water, power,

equipment and supplies for the smooth running of maternity services.

• Promote institutional delivery through provider incentives and possibly, implement risk-pooling schemes. Provide vouchers to women in hard-to-reach areas for transport and/or to cover cost of delivery services.

• Target the poor and women in hard-to-reach rural areas in the provision of basic and comprehensive emergency obstetric care (renovate and equip health facilities).

• Address the inadequate human resources for health by training more midwives and deploying them to the poorest or hard-to-reach districts.

• Strengthen the referral system by instituting emergency trans-port, training health personnel in appropriate referral proce-dures (referral protocols and recording of transfers) and estab-lishing maternity waiting huts/homes at hospitals to accommo-date women from remote communities who wish to stay close to the hospital prior to delivery.

• During antenatal care, educate pregnant women about the im-portance of delivery with a skilled health personnel and getting postnatal check. Encourage and promote community partici-pation in the care for pregnant women and their children.

Reducing Stis/Hiv/AiDS• Integrate HIV/AIDS/STIs and family planning services in rou-

tine antenatal and postnatal care.

• Lower the incidence of HIV infections by strengthening Behavior Change Communication (BCC) programs via mass media and community outreach to raise HIV/AIDS awareness and knowledge.

correspondence DetailsThis profile was prepared by the World Bank (HDNHE, PRMGE, and AFTHE) and Management Science for Health (MSH). For more information contact, Samuel Mills, Tel: 202 473 9100, email: smills@worldbank.org. This report is available on the following website: www.worldbank.org/population.

References: 1. World Bank, Country Brief, available at http://go.worldbank.org/

AZAMVFH710. 2. World Bank. 2010. World Development Indicators. Washington DC. 3. World Bank, Engendering Development: Through Gender Equality

in Rights, Resources, and Voice. 2001. 4. Gender-related development index. http://hdr.undp.org/en/media/

HDR_20072008_GDI.pdf. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by

WHO, UNICEF, UNFPA, and the World Bank 6. Uganda Bureau of Statistics (UBOS) and Macro International Inc.

2007. Uganda Demographic and Health Survey 2006. 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva:

WHO. http://www.who.int/making_pregnancy_safer/topics/adoles-cent_pregnancy/en/index.html.

8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra-ception. Human Development Network, World Bank. http://www.worldbank.org/hnppublications.

9. Singh S, Prada E, Mirembe F, Kiggundu C. The incidence of induced abortion in Uganda. Int Fam Plan Perspect. 2005 Dec;31(4):183–91.

10. Worldwide prevalence of anaemia 1993–2005: WHO global da-tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica-tions/2008/9789241596657_eng.pdf.

11. STD/AIDS Control Programme, Ministry of Health, Kampala, Uganda. Trends in HIV prevalence and sexual behaviour (1990–2000) in Uganda. Kirungi WL, Musinguzi JB, Opio A, Madraa E; International Conference on AIDS. 2002 Jul 7–12; 14.

12. Ministry of Health (MOH) [Uganda] and ORC Macro. 2006. Uganda HIV/AIDS Sero-behavioural Survey2004–2005.

UGANDA RepRoDUctive HeALtH ActioN pLAN iNDicAtoRS

indicator Year Level indicator Year Level

Total fertility rate (births per woman ages 15–49) 2006 6.7 Population, total (million) 2008 31.7

Adolescent fertility rate (births per 1,000 women ages 15–19) 2006 152 Population growth (annual %) 2008 3.3

Contraceptive prevalence (% of married women ages 15–49) 2006 23.7 Population ages 0–14 (% of total) 2008 49

Unmet need for contraceptives (%) 2006 40.6 Population ages 15–64 (% of total) 2008 48.4

Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 2.6

Median age at marriage (years) 2006 17.8 Age dependency ratio (% of working-age population) 2008 106.5

Mean ideal number of children for all women — — Urban population (% of total) 2008 13.0

Antenatal care with health personnel (%) 2006 93.5 Mean size of households 2006 5

Births attended by skilled health personnel (%) 2006 42.6 GNI per capita, Atlas method (current US$) 2008 420

Proportion of pregnant women with hemoglobin <110 g/L 2008 41.2 GDP per capita (current US$) 2008 453

Maternal mortality ratio (maternal deaths/100,000 live births) 1990 670 GDP growth (annual %) 2008 9.5

Maternal mortality ratio (maternal deaths/100,000 live births) 1995 690 Population living below US$1.25 per day 2005 51.5

Maternal mortality ratio (maternal deaths/100,000 live births) 2000 640 Labor force participation rate, female (% of female population ages 15–64) 2008 80.5

Maternal mortality ratio (maternal deaths/100,000 live births) 2005 510 Literacy rate, adult female (% of females ages 15 and above) 2008 66.8

Maternal mortality ratio (maternal deaths/100,000 live births) 2008 430 Total enrollment, primary (% net) 2008 97.2

Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 170 Ratio of female to male primary enrollment (%) 2008 101.1

Infant mortality rate (per 1,000 live births) 2008 85 Ratio of female to male secondary enrollment (%) 2008 85.3

Newborns protected against tetanus (%) 2008 85 Gender Development Index (GDI) 2008 132

DPT3 immunization coverage (% by age 1) 2006 58.9 Health expenditure, total (% of GDP) 2007 6.3

Pregnant women living with HIV who received antiretroviral drugs (%) 2005 11 Health expenditure, public (% of GDP) 2007 1.7

Prevalence of HIV, total (% of population ages 15–49) 2007 5.4 Health expenditure per capita (current US$) 2007 27.8

Female adults with HIV (% of population ages 15+ with HIV) 2007 59.3 Physicians (per 1,000 population) 2005 0.117

Prevalence of HIV, female (% ages 15–24) 2007 3.9 Nurses and midwives (per 1,000 population) 2005 1.306

indicator Survey Year poorest Second Middle Fourth Richest totalpoorest-Richest

Differencepoorest/Richest

Ratio

Total fertility rate DHS 2006 8.0 7.9 7.0 6.8 4.3 6.7 3.7 1.9

Current use of contraception (Modern method) DHS 2006 7.2 12.1 13.1 20.3 37.9 17.9 –30.7 0.2

Current use of contraception (Any method) DHS 2006 9.9 15.7 19.4 27.6 47.5 23.7 –37.6 0.2

Unmet need for family planning (Total) DHS 2006 46.5 45.9 43.6 39.7 26.2 40.6 20.3 1.8

Births attended by skilled health personnel (percent)

DHS 2006 28.8 31.9 35.2 50.1 77.0 42.6 –48.2 0.4

USAiD: Training community outreach workers – focus on expanding FP services.

DFiD: Social protection; gender equality

SiDA: Expanding health care to vulnerable rural areas

GiZ: HIV/AIDS mainstreaming

SNv: Girls’ education

WHo: Health systems strengthening; gender equity

UNiceF: Violence prevention; HIV/AIDS

UNFpA: Integrated approach to sexual and reproductive health and rights

MSH: Preventing unintended pregnancies; averting maternal deaths; promoting healthy families; village health teams

Marie Stopes: Family planning; HIV/STIs; maternal health; post-abortion care

FHi: Contraceptive methods education; HIV prevention

intraHealth international: Health workforce shortage; HIV/AIDS

engender Health: Obstetric Fistula care; family planning; HIV/AIDS

ippF: Family planning; RH rights advocacy; behavior change communication

pathfinder international: Community-based RH services; orphans and vulnerable children; adolescents; health systems capacity building

Development partners support for reproductive health in Uganda