What did Morocco do?

Improvements in reproductive, maternal, newborn, and child health indicators

This section will explore indicators describing access to reproductive, maternal, newborn, and child health services at the population level. Indicators are ordered according to a woman’s potential reproductive journey, beginning with contraception, followed by antenatal care, institutional delivery, cesarean section, and postnatal care.

Contraception access

Morocco has experienced a substantial increase in the proportion of women using modern methods of contraception as shown in Figure 9. Between the 1987 and 2003–2004 Demographic and Health Surveys (DHS) in Morocco, the modern contraceptive prevalence rate nearly doubled from 28.9% to 54.8%.¹ During this period, women’s rights increasingly gained political attention in Morocco. A key convention affirming the reproductive rights of women was ratified in 1987, followed by the rise of efforts focusing on women’s advancement. Morocco’s national population commission was also reactivated in 1996 to integrate reproductive health into development planning.^2,3

Since 2003, the country’s modern contraceptive prevalence rate has increased slightly, and by the 2018 Enquête Nationale sur la Population et la Santé Familiale (ENPSF), it was 59.1%.⁴ The most common form of modern contraceptive used in Morocco has historically been and continues to be the pill. As of the 2018 ENPSF, 82% of women who used modern contraceptives reported that they used the pill.⁴

Demand for family planning satisfied by modern methods similarly improved substantially during the 1990s and early 2000s, remaining high in recent years. From Morocco’s 1992 to 2004 DHS surveys, demand satisfied by modern methods increased sharply from 54.6% to 77.8%.¹ This continued to increase slightly in later years, reaching 88.7% by Morocco’s 2018 ENPSF.⁴

Increases in family planning coverage levels has contributed to fertility declines in Morocco. Fertility levels declined most sharply between Morocco’s 1987 and 2003–2004 DHS, from 4.6 to 2.5 births per woman.¹ According to Morocco’s 2018 ENPSF, the total fertility rate was slightly lower at 2.4 births per woman.⁴ The Haut-Commissariat au Plan estimates that fertility rate had declined further in 2023 to 2.1 births per woman.⁵ Age-specific fertility rates, shown in Figure 10, highlight that fertility levels declined across age groups and especially for women in their twenties. The adolescent fertility rate also experienced a 58% decrease, from 46 to 19 births per 1,000 woman-years between Morocco’s 1987 DHS and 2018 ENPSF.^1,4

Fertility declines, especially among younger women, are linked not only to increased contraceptive use but also increased female education, improved women’s autonomy, and evolving views about the ideal number of children. The Context section of this narrative describes several policy shifts that have empowered women in Morocco, including the 2004 revision of the Moudawana family code and the gender equality laws that followed. Notably, the 2004 family code revision raised the legal age of marriage from 15 to 18 for both boys and girls, and granted women greater rights in marriage, divorce, and child custody.

Antenatal care coverage

Morocco has drastically increased coverage of antenatal care (ANC), as shown in Figure 11. Between Morocco’s 1992 DHS and 2018 ENPSF, the percentage of women receiving ANC at least four times (ANC4+) increased from 9.4% to 60.9%.^1,4 During this same period, the percentage of women receiving ANC at least once increased from 37.4% to 95.8%.^1,4 Importantly, these ANC visits have largely begun earlier in pregnancies as well. The percentage of women who received ANC in their first four months of pregnancy increased from 23.9% to 65.5% between Morocco’s 1992 DHS and 2018 ENPSF.^1,4 Most ANC is provided at private doctor’s offices or public health center (RESSP) facilities, respectively accounting for 52.6% and 36.5% of women’s final ANC visits in 2018.

Antenatal care quality

Several markers of ANC quality have also improved substantially in recent decades. Between Morocco’s 2003–2004 DHS and 2018 ENPSF, the percentage of women who received ANC and had a blood sample taken increased from 52% to 84%, and the percentage of women who received iron supplementation increased from 38% to 74%.^1,4 Additionally, the percentage of pregnant women who have received an ultrasound at an ANC visit has risen dramatically, reaching 92% as of Morocco’s 2018 ENPSF.⁴

Improving the quality of maternal health services was a key pillar of the landmark 2008–2012 Maternal Mortality Reduction Acceleration Plan (Plan national pour l’accélération de la réduction de la mortalité maternelle et néonatale), referred to in this narrative as the 2008 Acceleration Plan. Several legal decrees and subsequent policies have supported quality improvements for ANC services, including the following recommendations: a minimum of four ANC visits, provision at least two ultrasounds and several tests such as syphilis screening and hemoglobin levels, improved medicine and equipment availability, improved patient privacy at health facilities, and referrals to specialist doctors for high-risk pregnancies. More information about these mortality reduction plans, as well as quality improvement initiatives, can be found in the How did Morocco implement? section.

Institutional delivery

Morocco’s institutional delivery rate increased rapidly in recent decades, predominantly driven by the public sector as shown in Figure 12. Key causes of maternal and neonatal mortality, such as postpartum hemorrhage and prematurity, can be better addressed through delivery at health facilities -- making institutional delivery an important driver of mortality decline. Between Morocco’s 1992 DHS and 2018 ENPSF, the country’s institutional delivery rate tripled from 28.3% to 86.1%.^1,4 An important pillar of Morocco’s 2008 Acceleration Plan was the removal of user fees for delivery care for all women, including for delivery via C-section. The following 2012 Consolidation Plan broadened the removal of user fees for complications and several other maternal, newborn, and child health (MNCH) services. These policies contributed to increases in institutional delivery rates by mitigating financial barriers to health care. More details are explored further in the How Did Morocco Implement? section.

Although the role of the private sector has increased over time, the vast majority (81.6%) of institutional deliveries occur in public facilities, as of Morocco’s 2018 ENPSF.⁴ The most common type of facility for deliveries in Morocco is public hospitals (56.5%), followed by private clinics (14.6%) and public health centers (RESSP) (13.7%).⁴ Upgrades to public maternity care facilities and improvements to medicine/equipment availability were key components of the 2008 Acceleration Plan; these quality improvements also encouraged women to deliver in health care facilities.

Cesarean section

In recent decades, the C-section rate in Morocco has substantially increased as shown in Figure 13. Between Morocco’s 1992 DHS and 2018 ENPSF, the C-section rate in Morocco grew tenfold from 2.0% to 21.2%.^1,4 The increase occurred most rapidly between the country’s 2003–2004 DHS and 2011 ENPSF when the rate nearly tripled.^1,6 The expansion of C-sections with indication was encouraged in the early 2000s, when the Ministry of Health (Ministère de la Santé) set a target of 5% for the proportion of C-sections as a share of all deliveries. The decision in 2008 to remove user fees from delivery via C-section also accelerated this increase.

The institutional C-section rate in Morocco is markedly different in public and private facilities—12.0% and 62.2%, respectively, as of the 2018 ENPSF.⁴ While the institutional C-section rate in private facilities is particularly high, only 15.7% of all deliveries in Morocco occurred in private facilities according to the 2018 ENPSF.⁴ While C-sections are a lifesaving intervention for women and newborns in the case of obstetric complications, the WHO has proposed that C-section rates exceeding 10% of births are not necessarily associated with a further reduction in a country’s MMR.⁷ High C-section rates in private facilities indicate that a substantial portion are likely not medically necessary, suggesting possible over-use of the procedure. When considering the coverage and potential overuse of C-section as an intervention, it is crucial to stratify and evaluate use across demographic dimensions—further explored in the Benchmarking Progress in Morocco section.

Postnatal care

Between Morocco’s 2011 and 2018 ENPSF surveys, coverage of postnatal care (PNC) for women remained constant at 21.9%.^4,6 According to Morocco’s 2018 ENPSF, 13.9% of women received PNC from doctors while 9.7% received PNC from nurses/midwives.⁴ Although these coverage levels indicate that a substantial percentage of women who delivered in a health facility did not receive PNC, Morocco’s 2018 ENPSF found that 70.9% of these women did not receive a PNC checkup because they did not have any complications.⁴ Variations in how PNC visits are defined, recalled and reported by respondents can impact these figures: for example, women may not consider certain types of interactions with healthcare workers as PNC, thus contributing to under-reporting. In the ENPSF, a relatively low portion of these women reported obstacles to accessing postnatal care, with 7.5% citing financial challenges, 2.9% highlighting distance to care, and 1.6% recounting that PNC was unavailable.⁴ However, barriers like transportation costs, geographical distance, and cultural factors may still limit women's access to PNC services in underserved regions.

Additionally, Sante en Chiffres reports from the MoH include information about PNC visits in public health facilities. Sante en Chiffres 2022 data reports 608,291 maternal PNC visits and 585,886 neonatal PNC visits in 2022, with 684,738 expected births that year -- suggesting that the coverage of PNC visits may be higher than reported in the ENPSF.⁸

Connecting reproductive, maternal, newborn, and child health indicators to mortality reductions

Fertility decline as a moderate driver of NMR/MMR decline

Our analysis, using Jain’s decomposition method, isolates the impact of fertility declines on maternal and neonatal mortality. Fertility decline alone in Morocco was found to explain 12% of MMR reduction and 27% of NMR reduction.⁹ These mortality reductions associated with fertility decline correspond to 64 fewer maternal deaths in 2017 and 1,694 fewer neonatal deaths in 2019 alone than would have been expected if fertility levels had stayed constant since 2000. This decomposition approach attributes other improvements to “safe motherhood” initiatives, a term used to collectively refer to improving intervention coverage and services such as antenatal care, in-facility delivery, skilled birth attendance, and emergency care services.

Together, fertility decline and safe motherhood initiatives were attributed to 984 maternal lives saved in 2017 and 12,272 neonatal lives saved in 2019 alone compared to what would have been expected if fertility rate and care coverage levels had remained constant since 2000. This result, illustrated in Figure 14, highlights the impact of fertility decline as a key driver of MMR and NMR decline, in tandem with other health care indicators commonly associated with MMR and NMR decreases.