PRB

(May 2006) The “fertility transition”—the shift from large to small families that demographers have observed throughout much of the world—has been remarkably rapid in Morocco, according to a recently released demographic and health survey on that country.

The 2003-2004 Demographic and Health Survey found that Moroccan women were having 2.5 children on average—three fewer births than the average recorded in 1980. The change has been particularly dramatic among women living in rural areas, whose fertility declined from 6.6 births in 1980 to 3.0 births on average in 2004 (see Table 1).

Table 1
Fertility Decline in Morocco, 1962 to 2003-04

Source: Moroccan Ministry of Health, ORC Macro, and League of Arab Nations, Demographic and Health Survey: Morocco 2003-2004 Final Report (2005).

But while these and other health indicators for women and children have improved substantially in Morocco, the country still faces many challenges regarding women and reproductive health, including limited contraceptive options, disparities between rich and poor in access to contraception, and a need to translate revised family laws into practical legal progress for women.

Factors in Morocco ‘s Fertility Decline

Morocco’s fertility decline is primarily attributable to increases there in women’s average age at marriage and in married women’s contraceptive use. The proportion of all young Moroccan women ages 15-19 who were married dropped from 21 percent in 1980 to 11 percent in 2004. During the same period, the proportion of women ages 20-24 who were married dropped from 64 percent to 36 percent, and contraceptive use among married women of reproductive age increased from 19 percent to 63 percent.

Socioeconomic improvements have played a role in spurring both the rising age at marriage and Moroccans’ desire for smaller families, as an increasing number of girls have been entering school and remaining in school longer. For example, between 1992 and 2004, the proportion of girls ages 15-24 years with no education in Morocco decreased from 50 percent to 34 percent, and the proportion of those with secondary and higher educational attainment increased from 29 percent to 42 percent.

And although unemployment among young Moroccan women remains much higher than young men, more and more girls in the 15-24 age group are entering the labor force—especially in export processing industries and export agriculture as well as clothing manufacturing, microfinance, and tourism.

A Political Commitment to Family Planning

The Moroccan government’s commitment to women’s and reproductive health issues has also played a key role in these trends. During the last three decades, family planning has spearheaded progress in basic health care for Morocco. The country’s family planning program started in 1966, when both a national population commission and local population commissions were established. Among the most significant early achievements of the program was the repeal in 1967 of the French Law, which prohibited the advertising, sale, and distribution of contraceptives.

During the 1990s, issues related to human rights and women’s rights increasingly gained political attention in Morocco. Inspired by the 1994 United Nations’ International Conference on Population and Development (ICPD) and the 1995 Fourth World Conference on Women, nongovernmental organizations (NGOs) working for the advancement of women began flourishing throughout the country. The national population commission was also reactivated in 1996 through the Ministry for Economic Forecasting and Planning, whose mandate (along with the 16 regional commissions) was to ensure the integration of population concerns into development planning.

By the end of the 1990s, Morocco had made such impressive gains in family planning and maternal and child health that the U.S. Agency for International Development (USAID), the country’s largest grant donor in family planning and reproductive health, decided to phase out its direct assistance to the country’s health, population, and nutrition sector. In 2003, the Moroccan Ministry of Health started to purchase contraceptives without any financial contribution from donors and partners in development.

Thanks to its strong household service delivery, the Moroccan government has been crucial in meeting the rising demand for contraception—particularly in making modern contraceptives available to low-income and rural women who would otherwise not have access to private-sector services. In 2004, more than 50 percent of married women in rural areas were using a modern family planning method—an increase from 8 percent in 1980. Such an increase in modern contraceptive use is significant, especially because one-half of women in Morocco ages 15-49 years have no formal education and 65 percent in rural areas.

These efforts have helped narrow the gap between the poor and rich segments of Moroccan society in access to family planning services and (to some extent) in access to broader reproductive health services. For instance, the average difference in family size between the country’s poorest and richest quintiles was narrowed by three children between 1992 and 2004 (see Table 2).¹ Over the same period, modern contraceptive use among married women in the poorest quintile rose from 18 percent to 51 percent—not far behind that of women in the richest quintile.

Table 2
Fertility and Reproductive Health Indicators for Morocco by Selected Wealth Quintile, 1992 and 2003-04

*Unmet need includes pregnant women whose pregnancy was mistimed or unwanted, amenorrheic women who are not using family planning and whose last birth was mistimed or unwanted, and fecund women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say they want to wait two or more years for their next birth or they want no more children.

Sources: M. Azelmat, M. Ayad, and E.A. Housni, Demographic and Health Survey: Morocco 1992 Final Report (1993); and Moroccan Ministry of Health, ORC Macro, and League of Arab Nations, Demographic and Health Survey: Morocco 2003-2004 Final Report (2005).

Progress on Other Reproductive Health Indicators

Morocco has also improved dramatically in providing care at birth and professional antenatal care. Between 1992 and 2004, for instance, the percentage of antenatal care given by a professional increased from 32 percent to 68 percent of all births. The gap between lowest and highest quintiles in terms of such care also narrowed, although only 40 percent of newborns in the lowest quintile received professional antenatal care in 2004.

Some of the factors associated with delivery outcome include the place where a mother delivers a baby and the assistance during delivery. Here, too, Morocco has improved. While almost 75 percent of all births in Morocco in 1992 took place at home, by 2004 that figure had declined to 39 percent. But the gap in home deliveries between the poorest and richest quintiles widened from 1992 to 2004.

Assistance at delivery is another important variable that influences the delivery outcome and reduces the health risks for mothers and children. In 1992, only 31 percent of Morocco ‘s births were delivered by trained medical providers—but by 2004, that proportion increased to 63 percent. And the disparity in trained deliveries between the poorest and richest women has also been reduced, although only 30 percent of women in Morocco ‘s lowest quintile had trained deliveries in 2004.

Remaining Challenges

Morocco still faces many challenges to further improve the reproductive health (including family planning) of all Moroccan couples and individuals:

• Contraceptive options lack diversity. Family planning in Morocco remains defined by one dominant method: the pill. In 2004, almost three-quarters of married women using a modern method were using the pill. The country’s family planning program should ensure access to a broad, balanced mix of methods, including the so-called male method.
• Private provision of family planning could be increased. Although the proportion of private providers for family planning increased from 34 percent in 1992 to 42 percent in 2004, there is still room for improvement—especially considering Morocco ‘s relatively high levels of economic development and urbanization.
• Equity in access to contraception is still lacking. While the gap in contraceptive use between poor and rich and between rural and urban women has narrowed considerably in Morocco, there is still wide disparity between these groups regarding access to professional antenatal care and home delivery.
• Services for single mothers are inadequate. Single mothers are more likely to give birth outside the health system—resulting in more high-risk deliveries—because unwed mothers are stigmatized in Morocco and lack social service institutions. While NGOs are helping young adults and unwed mothers deal with issues related to sexuality, contraception, STIs, and HIV/AIDS, they cannot replace the funding and trained staff of government institutions such as the Ministry of Health or the Ministry of Youth and Sports.
• Moroccan women need improved legal standing. The empowerment of Moroccan women is progressing slowly, although more quickly than other countries in the region. The 2003 reforms to the country’s family code (Mudawana) came after years of advocacy for women’s increased rights regarding marriage and divorce. Yet despite improved legislation, procedural obstacles in legal proceedings in cases involving women’s rights are often insurmountable.

Mohammed Ayad is regional coordinator for ORC Macro/Demographic and Health Surveys. Farzaneh Roudi-Fahimi is a senior policy analyst at the Population Reference Bureau.

References

1. Mustapha Azelmat and Ahmed Abdelmoneim, Enquête Nationale sur la Santé de la Mère et de l’Enfant (ENSME) 1997 (Cairo: Ministry of Health and PAPCHILD, League of Arab Nations, 1999).
2. Mustapha Azelmat, Mohamed Ayad, and El Arbi Housni, Demographic and Health Survey: Morocco 1992 Final Report (Calverton, MD: Ministry of Public Health and Macro International Inc, 1993), accessed online at www.measuredhs.com/pubs/pdftoc.cfm?ID=87, on April 13, 2006.
3. Mustapha Azelmat, Mohamed Ayad, and El Arbi Housni, Demographic and Health Survey: Morocco 1995 Final Report (Calverton, MD: Ministry of Public Health and Macro International Inc., 1996), accessed online at www.measuredhs.com/pubs/pdftoc.cfm?ID=109, on April 13, 2006.
4. Mustapha Azelmat, Mohamed Ayad, and Houcine Belhachmi, Demographic and Health Survey: Morocco 1987 Final Report (Columbia, MD: Ministry of Public Health and Institute for Resource Development/Westinghouse, 1989), accessed online at www.measuredhs.com/pubs/pdftoc.cfm?ID=75, on April 13, 2006.
5. Julia Beamish and Lina Tazi Abderrazik, Adolescent Reproductive Health in Morocco: Status, Policies, Programs, and Issues (Washington, DC: Policy Project, 2003), accessed online at www.policyproject.com/pubs/countryreports/ARH_Morocco.pdf, on April 13, 2006.
6. Davidson R. Gwatkin et al., Socio-Economic Differences in Health, Nutrition, and Population in Morocco (Washington DC: HNP/Poverty Thematic Group, The World Bank, 2006), accessed online at www1.worldbank.org/prem/poverty/health/data/morocco/morocco.pdf, on April 13, 2006.
7. DevTech Systems, Gender Assessment for USAID/Morocco (Washington, DC: USAID, 2003), accessed online at www.usaid.gov/our_work/cross-cutting_programs/wid/pubs/ga_morocco_fullreport.pdf, on April 13, 2006.
8. Moroccan Ministry of Health, ORC Macro, and League of Arab Nations, Demographic and Health Survey: Morocco 2003-2004 Final Report (Calverton, MD: Moroccan Ministry of Health and ORC Macro, 2005), accessed online at www.measuredhs.com/pubs/pdftoc.cfm?ID=524, on April 13, 2006.
9. United Nations Population Fund (UNFPA), Recommendation by the Executive Director: Assistance to the Government of Morocco (New York: UNFPA, 2001), accessed online at www.unfpa.org/exbrd/2001/secondsession/dpfpamar6_eng.doc, on April 13, 2006.