Bangladesh - Multiple Indicator Cluster Survey - 2012

Publication date: 2012

CHAPTER NAME l a Government of the People’s Republic of Bangladesh Bangladesh Bureau of Statistics (BBS) Statistics and Informatics Division (SID) Ministry of Planning United Nation Children’s Fund Multiple Indicator Cluster Survey 2012-2013 Progotir Pathey Final Report Bangladesh IMPORTANT NOTICE Sticky Note The Final Report for 2012-2013 for Bangladesh, published in March 2015, has undergone some changes in December 2015. The changes relate to the estimates on Low Birth Weight where the estimates using a wrongly generated table has been replaced with the correct table and text. Another change is a formatting change in the table on 'Persons collecting drinking water' (WS.4). The current version of the report on the website is final and integrates all the changes. b l PROGOTIR PATHEY 2012-2013 Bangladesh Multiple Indicator Cluster Survey 2012-2013 Progotir Pathey ii l PROGOTIR PATHEY 2012-2013 ©Bangladesh Bureau of Statistics (BBS) and United Nations Children’s Fund (UNICEF) March, 2015 All UNICEF materials are protected by copyright, including text, photographs, images and videotapes. Permission is required to reproduce any part of this publication. Permission will be freely granted to educational or non-profit organizations. Please contact: Bangladesh Bureau of Statistics (BBS) Statistics and Informatics Division, Ministry of Planning Government of the People’s Republic of Bangladesh Dhaka, Bangladesh www.bbs.gov.bd Social Policy, Planning, Monitoring and Evaluation Section (SPPME) United Nations Children’s Fund (UNICEF) BSL Office Complex 1, Minto Road, Dhaka-1000, Bangladesh Telephone: (880-2) 55668088 Email: dhaka@unicef.org www.unicef.org.bd The Multiple Indicator Cluster Survey (MICS) was carried out in 2012-2013 by Bangladesh Bureau of Statistics (BBS) in collaboration with UNICEF Bangladesh, as part of the global MICS programme. Technical and financial support was provided by the United Nations Children’s Fund (UNICEF). The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Suggested citation: Bangladesh Multiple Indicator Cluster Survey 2012-2013, ProgotirPathey: Final Report. Bangladesh Bureau of Statistics (BBS) and UNICEF Bangladesh, 2014, Dhaka, Bangladesh. ISBN: 978-984-8969-21-2 Cover photo: © UNICEF/BANA2013-01079/Shafiqul Alam Kiron Design and layout: Dhrupadi Summary Table of Survey l iii Summary Table of Survey Implementation and the Survey Population, Bangladesh MICS, 2012-2013 Survey implementation Sample frame Population and Housing Census, 2011 Questionnaires Household Women (age 15-49) Children under five Water quality testing Training of Trainers Interviewer training October 1-14, 2012 November 1-14, 2012 Fieldwork December 2012 – April 2013 Survey sample Households Sampled Occupied Interviewed Response rate (Per cent) 55,120 52,711 51,895 98.5 Children under five Eligible Mothers/caretakers interviewed Response rate (Per cent) 23,402 20,903 89.3 Women Eligible for interviews Interviewed Response rate (Per cent) 59,599 51,791 86.9 Water quality testing for households Arsenic Planned Tested Response rate (Per cent) E. coli Planned Tested Response rate (Per cent) 13,800 12,952 93.9 2,760 2,588 93.8 Survey population Average household size Percentage of population under: Age 5 Age 18 Percentage of women age 15-49 years with at least one live birth in the last 2 years 4.6 9.9 39.0 15.3 Percentage of population living in Urban areas Rural areas Division Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet 20.7 79.3 6.3 20.1 30.7 11.2 13.0 11.9 6.7 Housing characteristics Household or personal assets Percentage of households with Electricity Finished floor Finished roofing Finished walls 61.5 25.7 97.4 29.4 Percentage of households that own A television A refrigerator Electric fan Almirah / Wardrobe Agricultural land Farm animals/livestock 37.7 14.2 53.0 41.4 43.0 62.9 Mean number of persons per room used for sleeping 2.7 Percentage of households where at least a member has or owns a Watch Mobile phone Bicycle Computer Car or truck 33.0 85.9 28.7 3.4 0.7 iv l PROGOTIR PATHEY 2012-2013 Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Bangladesh MICS, 2012-2013 Child mortality Early childhood mortality* MICS Indicator Indicator Description Value 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 46 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 58 * Indicator values are per 1,000 live births and refer to 2008.3. The West Model was assumed to approximate the age pattern of mortality in Bangladesh. Nutrition Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 31.9 8.8 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 42.0 16.4 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 9.6 1.6 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 1.6 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 97.1 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 57.4 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 56.4 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 71.9 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 95.3 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 87.5 2.11 Median duration of breastfeeding The age in months when 50 per cent of children age 0-35 months did not receive breast milk during the previous day 32.1 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 66.5 1 See Appendix E for a detailed description of MICS indicators Summary Table of Findings l v Nutritional status MICS Indicator Indicator Description Value 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 42.4 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 12.1 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate 54.3 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 26.0 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 35.9 Child health Tetanus toxoid MICS Indicator Indicator Description Value 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 80.8 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 3.9 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre- packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 64.6 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 3.2 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 35.8 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 74.3 Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 88.2 vi l PROGOTIR PATHEY 2012-2013 Water and sanitation MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 97.9 4.2 Water treatment Percentage of household members in households us- ing unimproved drinking water who use an appropriate treatment method 25.6 4.3 MDG 7.9 Use of improved sanita- tion Percentage of household members using improved sanitation facilities which are not shared 55.9 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 38.7 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleans- ing agent are present 59.1 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 94.0 4.S1a Source water quality: arsenic content Percentage of households using source water contain- ing: a) over 50 ppb Arsenic concentration 12.5 4.S1b b) over 10 ppb Arsenic concentration 25.5 4.S2a Arsenic concentration of household drinking water Percentage of household members using drinking water with: a) over 50 ppb Arsenic concentration 12.4 4.S2b b) over 10 ppb Arsenic concentration 24.8 4.S3 E.coli concentration in source water Percentage of households with E.coli risk level in source water ≥ 1 cfu/100ml 41.7 4.S4 E.coli concentration in household drinking water Percentage of household members with E. coli risk level in household water ≥ 1 cfu/100ml 61.7 Reproductive health Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women age 15-49 years 2.3 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 83 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 24.4 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 61.8 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 13.9 Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 58.7 24.7 Summary Table of Findings l vii Maternal and newborn health : continued MICS Indicator Indicator Description Value 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 38.0 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 43.5 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 31.0 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 19.1 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the deliv- ery of their most recent live birth in the last 2 years 82.8 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 41.2 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 40.4 Child development MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 13.4 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 78.0 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 10.1 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 40.8 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 8.8 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 60.3 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 11.6 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social- emotional, and learning 63.9 viii l PROGOTIR PATHEY 2012-2013 Literacy and education MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young women Percentage of young women age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 82.0 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 43.5 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 33.1 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 73.2 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 46.1 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 96.4 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 79.5 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 94.7 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 1.07 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.30 Child protection Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 37.0 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 82.3 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of women age 15-49 years who were first married or in union before age 15 23.8 8.5 Marriage before age 18 Percentage of women age 20-49 years who were first married or in union before age 18 62.8 8.6 Young women age 15-19 years currently married or in union Percentage of young women age 15-19 years who are married or in union 34.3 8.7 Polygyny Percentage of women age 15-49 years who are in a polygynous union 4.2 Summary Table of Findings l ix Early marriage and polygyny : continued MICS Indicator Indicator Description Value 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older, (a) among women age 15-19 years (b) among women age 20-24 years 20.4 21.8 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 3.8 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 4.3 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 4.8 HIV/AIDS HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of women age 15-49 years who have heard of AIDS 55.8 9.1 MDG 6.3 Knowledge about HIV prevention among young women Percentage of young women age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 9.1 9.2 Knowledge of mother-to- child transmission of HIV Percentage of women age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV 21.7 9.3 Accepting attitudes towards people living with HIV Percentage of women age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 37.2 HIV testing 9.4 Women who know where to be tested for HIV Percentage of women age 15-49 years who state knowledge of a place to be tested for HIV 11.3 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 2.5 Orphans 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non- orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents 0.88 Access to mass media and ICT Access to mass media MICS Indicator Indicator Description Value 10.1 Exposure to mass media Percentage of women age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 1.6 Use of information/communication technology 10.2 Use of computers Percentage of young women age 15-24 years who used a computer during the last 12 months 6.1 10.3 Use of internet Percentage of young women age 15-24 years who used the internet during the last 12 months 3.0 x l PROGOTIR PATHEY 2012-2013 Table of Contents Summary Table of Survey Implementation and the Survey Population, Bangladesh MICS, 2012-2013 . iii Summary Table of Findings . iv Table of Contents .x List of Tables . xii List of Figures . xv List of Maps . xvi List of Abbreviations . xvii Message (Minister for Planning) . xix Message (State Minister for Planning) . xx Message (Secretary SID) . xxi Foreword . xxii Executive Summary . xxiii I. Introduction .1 Background. 1 Survey Objectives . 2 II. Sample and Survey Methodology .3 Sample Design . 3 Questionnaires . 4 Training and Fieldwork . 5 Data Processing . 5 III. Sample Coverage and the Characteristics of Households and Respondents .7 Sample Coverage . 7 Characteristics of Households . 8 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 11 Housing characteristics, asset ownership, and wealth quintiles . 13 IV. Child Mortality.17 V. Nutrition .21 Low Birth Weight . 21 Nutritional Status . 23 Breastfeeding and Infant and Young Child Feeding . 26 Salt Iodization . 35 VI. Child Health .37 Neonatal Tetanus Protection . 37 Care of Illness . 38 Diarrhoea. 40 Acute Respiratory Infections . 45 Solid Fuel Use . 49 Table of Contents l xi VII. Water and Sanitation .53 Use of Improved Water Sources . 53 Use of Improved Sanitation . 59 Handwashing . 66 Drinking Water Quality . 70 VIII. Reproductive Health .81 Fertility . 81 Contraception . 85 Unmet Need . 87 Antenatal Care. 90 Assistance at Delivery. 93 Place of Delivery . 96 Post-natal Health Checks . 98 IX. Early Child Development .107 Early Childhood Care and Education . 107 Quality of Care . 109 Developmental Status of Children . 114 X. Literacy and Education .117 Literacy among Young Women . 117 Results on education . 118 School Readiness . 118 Primary and Secondary School Participation . 119 XI. Child Protection .131 Birth Registration . 131 Child Discipline . 134 Early Marriage and Polygyny . 136 Children’s Living Arrangements . 141 XII. HIV/AIDS .143 Knowledge about HIV Transmission and Misconceptions about HIV . 143 Accepting Attitudes toward People Living with HIV . 147 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 149 HIV Indicators for Young Women . 151 Orphans . 152 XIII. Access to Mass Media and Use of Information/Communication Technology .153 Access to Mass Media . 153 Use of Information/Communication Technology . 154 Appendices: Appendix A. Sample Design . 157 Appendix B. List of Personnel Involved in the Survey . 163 Appendix C. Estimates of Sampling Errors . 165 Appendix D. Data Quality Tables . 177 Appendix E. MICS5 Indicators: Numerators and Denominators . 191 Appendix F. Questionnaires . 197 xii l PROGOTIR PATHEY 2012-2013 List of Tables Table HH.1: Results of household, women’s and under-5 interviews .7 Table HH.2: Household age distribution by sex .8 Table HH.3: Household composition .10 Table HH.4: Women’s background characteristics .11 Table HH.5: Under-5’s background characteristics .13 Table HH.6: Housing characteristics .14 Table HH.7: Household and personal assets .15 Table HH.8: Wealth quintiles .16 Table CM.1: Children ever born, children surviving and proportion dead .17 Table CM.2: Infant and under-5 mortality rates by time since first birth groups of women .18 Table CM.3: Infant and under-5 mortality rates by background characteristics .18 Table NU.1: Low birth weight infants .22 Table NU.2: Nutritional status of children .24 Table NU.3: Initial breastfeeding .28 Table NU.4: Breastfeeding .30 Table NU.5: Duration of breastfeeding .31 Table NU.6: Age-appropriate breastfeeding .32 Table NU.7: Introduction of solid, semi-solid, or soft foods .33 Table NU.8: Bottle feeding .34 Table NU.9: Iodized salt consumption .35 Table CH.1: Neonatal tetanus protection .37 Table CH.2: Reported disease episodes .39 Table CH.3: Feeding practices during diarrhoea .41 Table CH.4: Oral rehydration solutions and recommended homemade fluids.42 Table CH.5: Oral rehydration therapy with continued feeding and other treatments .44 Table CH.6: Care seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) .46 Table CH.7: Knowledge of the two danger signs of pneumonia .48 Table CH.8: Solid fuel use .50 Table CH.9: Solid fuel use by place of cooking .51 Table WS.1: Use of improved water sources .54 Table WS.2: Household water treatment .56 Table WS.3: Time to source of drinking water .57 Table WS.4: Person collecting water .58 Table WS.5: Types of sanitation facilities .60 Table WS.6: Use and sharing of sanitation facilities .62 Table WS.7: Drinking water and sanitation ladders .64 Table WS.8: Disposal of child’s faeces .66 Table WS.9: Water and soap at place for handwashing .67 Table WS.10: Availability of soap .69 Table WQ.1: Source water quality: Arsenic .71 Table WQ.2: Household water quality: Arsenic .73 Table WQ.3: Source water quality: E. coli .75 Table WQ.4: Household water quality: E. coli .77 Table WQ.5: Source water quality: arsenic and E. coli .79 Table WQ.6: Household water quality: arsenic and E. coli .80 List of Tables l xiii Table RH.1: Fertility rates .81 Table RH.2: Adolescent birth rate and total fertility rate .82 Table RH.3: Early childbearing .83 Table RH.4: Trends in early childbearing .84 Table RH.5: Use of contraception .86 Table RH.6: Unmet need for contraception .88 Table RH.7: Antenatal care coverage .90 Table RH.8: Number of antenatal care visits .91 Table RH.9: Content of antenatal care .93 Table RH.10: Assistance during delivery and caesarian section .94 Table RH.11: Place of delivery .97 Table RH.12: Post-partum stay in health facility .99 Table RH.13: Post-natal health checks for newborns .100 Table RH.14: Post-natal care visits for newborns within one week of birth .101 Table RH.15: Post-natal health checks for mothers .102 Table RH.16: Post-natal care visits for mothers within one week of birth .104 Table RH.17: Post-natal health checks for mothers and newborns .105 Table CD.1: Early childhood education .108 Table CD.2: Support for learning .110 Table CD.3: Learning materials .112 Table CD.4: Inadequate care .114 Table CD.5: Early child development index .115 Table ED.1: Literacy among young women .117 Table ED.2: School readiness .119 Table ED.3: Primary school entry .120 Table ED.4: Primary school attendance and out of school children .121 Table ED.5: Secondary school attendance and out of school children .123 Table ED.6: Children reaching last grade of primary school .125 Table ED.7: Primary school completion and transition to secondary school .126 Table ED.8: Education gender parity .127 Table ED.9: Out of school gender parity .128 Table CP.1: Birth registration .131 Table CP.2: Child discipline .134 Table CP.3: Attitudes toward physical punishment .136 Table CP.4: Early marriage and polygyny .137 Table CP.5: Trends in early marriage (women) .139 Table CP.6: Spousal age difference .140 Table CP.7: Children’s living arrangements and orphanhood .141 Table CP.8: Children with parents living abroad .142 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women) .143 Table HA.2: Knowledge of mother-to-child HIV transmission (women) .146 Table HA.3: Accepting attitudes toward people living with HIV (women) .147 Table HA.4: Knowledge of a place for HIV testing (women) .149 Table HA.5: HIV counselling and testing during antenatal care .150 Table HA.6: Key HIV and AIDS indicators (young women) .151 Table HA.7: School attendance of orphans and non-orphans .152 Table MT.1: Exposure to mass media (women) .153 Table MT.2: Use of computers and internet (women) .154 xiv l PROGOTIR PATHEY 2012-2013 Appendices: Table SD.1: Overall sample size .158 Table SD.2: The allocation of sample size among strata and its urban-rural distribution .158 Table SD.3: Division level distribution of Sample Clusters (Primary Sampling Units) and sample households .160 Table SE.1: Indicators selected for sampling error calculations .166 Table SE.2: Sampling errors: Total sample .167 Table SE.3: Sampling errors: Urban .168 Table SE.4: Sampling errors: Rural .169 Table SE.5: Sampling errors: Barisal division .170 Table SE.6: Sampling errors: Chittagong division .171 Table SE.7: Sampling errors: Dhaka division .172 Table SE.8: Sampling errors: Khulna division .173 Table SE.9: Sampling errors: Rajshahi division .174 Table SE.10: Sampling errors: Rangpur division .175 Table SE.11: Sampling errors: Sylhet division .176 DQ.1: Age distribution of household population .177 DQ.2: Age distribution of eligible and interviewed women .179 DQ.3: Age distribution of children in household and under-5 questionnaires .180 DQ.4: Birth date reporting: Household population .180 DQ.5: Birth date and age reporting: Women .181 DQ.6: Birth date and age reporting: Under-5s .181 DQ.7: Birth date reporting: Children, adolescents and young people .182 DQ.8: Birth date reporting: First and last births .182 DQ.9: Completeness of reporting .182 DQ.10: Completeness of information for anthropometric indicators: Underweight .183 DQ.11: Completeness of information for anthropometric indicators: Stunting .183 DQ.12: Completeness of information for anthropometric indicators: Wasting .183 DQ.13: Heaping in anthropometric measurements .184 DQ.14: Observation of birth certificates .185 DQ.15: Observation of women’s health cards .185 DQ.16: Observation of places for handwashing .186 DQ.17: Presence of mother in the household and the person interviewed for the under-5 questionnaire .186 DQ.18: Selection of children age 1-17 years for the child labour and child discipline modules .187 DQ.19: School attendance by single age .188 DQ.20: Sex ratio at birth among children ever born and living .189 List of Figures l xv List of Figures Figure HH.1: Age and sex distribution of household population .9 Figure CM.1: Under-5 mortality rates by background characteristics .19 Figure CM.2: Trend in under-5 mortality rates .20 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe) .25 Figure NU.2: Initiation of breastfeeding .29 Figure NU.3: Percentage of children (0-5 months) exclusively breastfed by background characteristics .31 Figure NU.4: Children age 0-23 months fed with a bottle with a nipple by background characteristics .34 Figure NU.5: Percentage of households consuming adequately iodized salt .36 Figure CH.1: Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus by background characteristics .38 Figure CH.2: Children under-5 with diarrhoea who received ORS or recommended homemade liquids .43 Figure CH.3: Children under-5 with diarrhoea receiving oral rehydration therapy (ORT) and continued feeding .45 Figure WS.1: Per cent distribution of household members by source of drinking water .55 Figure WS.2: Person usually collecting drinking water when the water source is not within household premises .59 Figure WS.3: Per cent distribution of household members by use and sharing of sanitation facilities .61 Figure WS.4: Use of improved drinking water sources and improved sanitation facilities, by wealth .65 Figure WQ.1: Proportion of households by E. coli with medium, high and very high risk level in source water by background characteristics .76 Figure WQ.2: Proportion of population by E. coli with medium, high and very high risk level in household drinking water by background characteristics .78 Figure RH.1: Age-specific fertility rates by area .82 Figure RH.2: Early childbearing among women age 15-19 years .84 Figure RH.3: Differentials in contraceptive use .87 Figure RH.4: Women age 15-49 years currently married or in union with an unmet need for contraception by age .89 Figure RH.5: Women age 15-49 years with a live birth in the last two years by number of antenatal care visits by any provider .92 Figure RH.6: Person assisting at delivery .95 Figure RH.7: Per cent distribution of women age 15-49 with a live birth in the last two years by place of delivery of their last birth .98 Figure RH.8: Post-natal health checks for mothers and newborns within 2 days of birth .106 Figure CD.1: Children under age 5 by numbers of learning materials present in the household .113 Figure ED.1: Education indicators by sex .129 Figure CP.1: Percentage of children under age five whose births are registered .133 Figure CP.2: Child disciplining methods, children age 1-14 years.135 Figure CP.3: Early marriage among women .139 xvi l PROGOTIR PATHEY 2012-2013 Figure HA.1: Women age 15-49 years with comprehensive knowledge of HIV transmission .145 Figure HA.2: Accepting attitudes of women towards people living with HIV/AIDS .148 Appendix: Figure DQ.1: Household population by single ages .179 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points .184 List of Maps Map HH.1: Number of enumeration areas covered in the survey by UNDAF and non-UNDAF districts .3 Map CM.1: Under-five mortality rate by division .20 Map NU.1: Children under five years of age who are stunted by district .26 Map CH.1: Children age 0-59 months with diarrhoeain the last two weeks by district .40 Map WS.1: Percentage of households with improved sanitation facility by district .63 Map WS.2: Water and soap at place for handwashing by district .68 Map WQ.1: Proportion of households by arsenic concentration >50ppb in source water for drinking by division .72 Map WQ.2: Proportion of population by arsenic concentration >50ppb in household drinking water by division .72 Map RH.1: Percentage of women age 20-24 who have had a live birth before 18 by district .85 Map RH.2: Percentage of births attended by skilled health personnel by district .96 Map CD.1: Children age 36-59 months attending early childhood education by district .108 Map CD.2: Early child development index by district .116 Map ED.1: Women age 15-24 years who are literate by district .118 Map ED.2: Children of secondary school age attending secondary school or higher (adjusted net attendance ratio) by district .124 Map CP.1: Children under age five whose births are registered by district .133 Map CP.2: Women age 15-19 years currently married by district .138 Map HA.1: Women age 15-49 who have heard of AIDS by district .144 List of Abbreviations l xvii List of Abbreviations AIDS Acquired Immune Deficiency Syndrome BBS Bangladesh Bureau of Statistics CSPro Census and Survey Processing System GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IUD Intrauterine Device LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme NAR Net Attendance Rate ORT Oral rehydration treatment ppb Parts Per Billion ppm Parts Per Million SPSS Statistical Package for Social Sciences UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization xviii l PROGOTIR PATHEY 2012-2013 © U N IC EF /B A N A 20 14 -0 07 68 /M aw a Message l xix It is my pleasure to compliment the Bangladesh Bureau of Statistics (BBS) on issuing the results of the Multiple Indicator Cluster Survey (MICS) conducted during 2012-2013. The survey report, titled 'Progotir Pathey' (Road to Progress) provides detailed information and analysis on the situation of children and women of Bangladesh in relation to indicators on health, nutrition, water and sanitation, education, protection, HIV and access to Information and Communication Technology (ICT). I am particularly pleased to know that BBS, for the first time, has collected information on drinking water quality in the survey which, I believe, will be very useful to all relevant stakeholders to take appropriate corrective measures to improve the quality of drinking water in Bangladesh. The report also includes evidence on a wide range of other issues concerning the wellbeing of children and women. Therefore, I hope that policy-makers, planners, researchers, development partners and NGOs from all sectors will use the findings to inform the formulation of appropriate strategies for their programmes. The findings of the survey will also contribute to the UN Secretary-General's report to UN general assembly on the achievements of Millennium Development Goals (MDGs) by Bangladesh. My sincere thanks goes to UNICEF Bangladesh for their continuous support at all stages of conducting the survey and publishing the report. I would like to congratulate the Secretary, Statistics and Informatics Division, the Director General of BBS, the Project Director and the team of officials of the 'Monitoring the Situation of Children and Women Project' of BBS on the completion of this important report. Dhaka March, 2015 AHM Mustafa Kamal, FCA, MP Minister Ministry of Planning Government of the Pepole's Republic of Bangladesh © U N IC EF /B A N A 20 14 -0 07 68 /M aw a Message xx l PROGOTIR PATHEY 2012-2013 I would like to congratulate the Bangladesh Bureau of Statistics for carrying out the Multiple Indicator Cluster Survey (MICS) 2012-2013, with the support of UNICEF. MICS is well-known to researchers and planners globally for its high standard and rigorous methodology. Since 1995, UNICEF has supported about 240 MICS surveys in more than 100 countries. The report presents the situation of children in Bangladesh based on 79 indicators and its findings will provide useful information for the UN Secretary-General's Final MDG progress report to be presented to the General Assembly in September 2015. The present report and the earlier surveys on MICS are the result of continued cooperation between BBS and UNICEF since 1994. I thank UNICEF for extending its support to conducting MICS and helping to generate important evidence to assess progress towards MDGs, in particular those related to women's and children's wellbeing. My sincere thanks to the Secretary, Statistics and Informatics Division, Ministry of Planning for giving her valuable strategic support and guidance for publishing MICS 2012-2013. I would like to extend my sincere thanks to the Director General of BBS , Project Director of the Monitoring the Situation of Children and Women Project together with the team of BBS officials for issuing this report. Dhaka M. A. Mannan, MP March, 2015 Minister of State Ministry of Finance & Ministry of Planning Government of the Pepole's Republic of Bangladesh Message Message Message l xxi The Bangladesh Bureau of Statistics has been conducting the Multiple Indicator Cluster Survey (MICS) since 1993 in order to provide information on the situation of children and women. The fieldwork for this round of the MICS survey was conducted during December 2012-April 2013. It involved the collection of information on 79 indicators related to children and women, many of which are MDG indicators. Data on MDG indicators are expected to be used for reporting achievements of Bangladesh in the UN Secretary General’s final MGD Progress report. An important new addition to this round of MICS in Bangladesh is the collection of information on the quality of drinking water used by households for Arsenic and microbial (E.coll) contamination levels. It is the first time that such data has been collected for such a large scale survey in Bangladesh. I would like to thank Director General, Bangladesh Bureau of Statistics for carrying out the survey work successfully and publishing the report. The formidable task of collecting data from 55,200 households from all over the country was successfully accomplished by the BBS officials associated with Monitoring the Situation of Children and Women (MSCW) Project. I take this opportunity to thank the Project Director, Deputy Project Director and the entire team for collecting and analyzing data for the report. The key findings of MICS 2012-2013 covering important indicators have already been released in June, 2014. In conclusion, I believe the results of Bangladesh MICS 2012-2013 will be useful to policy-makers, researchers, planners and programme implementation managers in understanding and formulating strategies to improve the lives of children and women in Bangladesh. Dhaka Kaniz Fatema ndc March, 2015 Secretary-in-charge Statistics and Informatics Division Ministry of Planning Message xxii l PROGOTIR PATHEY 2012-2013 Foreword Foreword We are very pleased that the Bangladesh Bureau of Statistics (BBS) through a longstanding partnership with the UNICEF has successfully completed the Bangladesh Multiple Indicator Cluster Survey (MICS) for which data collection was undertaken during 2012-2013. The Bureau has been conducting the MICS since 1993, with the objective of generating information on the situation of children and women for effective use by planners, policy-makers, researchers and programme implementers at the national, regional and global levels. The Bangladesh MICS 2012-2013 focused on indicators related to child mortality, nutrition and breastfeeding, child health, access to safe drinking water and improved sanitation, reproductive health, maternal and newborn health, child development, literacy and education, child protection, HIV/AIDS, and access to mass media and ICT. It provides estimates at national level with disaggregated data by division, location, sex, age, education and wealth quintile. For the first time, the survey included the assessment of the quality of drinking water for arsenic and microbial (E.coli) contamination levels. The findings of the MICS 2012-2013, inform a wide range of Millennium Development Goal (MDG) indicators and could not have been made available at a better time as countries across the globe will report on the achievement of MDGs by 2015. We would like to express our sincere thanks to the Secretary of the Statistics and Informatics Division, Ministry of Planning for providing guidance and valuable support for completing this technical report within the stipulated time. Members of the Steering Committee, Technical Committee and Working Group deserve special thanks for their contribution to the survey. Furthermore, we express our sincere appreciation to Dr. Dipankar Roy, Project Director, Mr. Mohammad Shaheen, Deputy Project Director, Md. Abdur Rashid Howlader, Programmer, Mr. Abdul Latif, Statistical Officer and Mr. S.M. Anwar Hossain, Statistical Assistant of the Monitoring the Situation of Children and Women Project for their hard work and dedication for completing the survey and preparing this report. Mr. Isa Achoba, Chief of Social Policy, Planning, Monitoring and Evaluation, Mr. Shantanu Gupta, Monitoring and Evaluation Specialist, Mr. Mashiur Rahman Khan, Knowledge Management Officer, all of UNICEF Bangladesh provided valuable support at all stages of the survey. Prof. Syed Shahadat Hossain, Ph.D. and Prof. Muhammad Shuaib, Director of Institute of Statistical Research and Training (ISRT), University of Dhaka, provided their expert opinion and supported development of the sampling design and training of survey officials. Our sincere thanks also goes to MICS global team at UNICEF New York and Regional Office for South Asia (ROSA), including Mr. Attila Hancioglu, Mr. Turgay Unalan, Ms. Ivana Bjelic and Ms. Rhiannon James, for their continuous technical guidance throughout the survey implementation and finalization of this report. Thanks are also due to Richard Johnston from JMP, WHO for his valuable support in collection and analysis of results on water quality. We hope that the report will prove useful to policy-makers, planners, researchers, development partners and NGOs in formulating their programmes and strategies for attaining national targets and assessing achievements for preparation of MDGs progress reports. Edouard Beigbeder Md. Baitul Amin Bhuiyan Representative Director General (A.C.) UNICEF Bangladesh Bangladesh Bureau of Statistics Executive Summary l xxiii Executive Summary The Bangladesh Multiple Indicator Cluster Survey (MICS 2012-2013) was conducted from December 2012 to April 2013 by the Bangladesh Bureau Statistics, Ministry of Planning. Technical and financial support for the survey was provided by the United Nations Children’s Fund (UNICEF) in Bangladesh. MICS 2012-2013 provides valuable information and the latest evidence on the situation of children and women in Bangladesh, updating information from the previous 2006 Bangladesh MICS survey as well as earlier data collected in the MICS rounds since 1996. The survey presents data from an equity perspective by indicating disparities by sex, area, division, education, living standards, and other characteristics. Bangladesh MICS 2012-2013 is based on a sample of 51,895 households interviewed and provides a comprehensive picture of children and women in the seven divisions of the country. Child Mortality In the MICS, child mortality rates are calculated based on an indirect estimation technique known as the Brass method using the data collection method of ‘time since first birth’ (TSFB). According to the survey results, the infant mortality rate in Bangladesh is 46 per 1,000 live births, and the under-five mortality rate 58 per 1,000 live births when a reference of TSFB 5-9 years is considered. Substantial disparities exist along the dimensions of education and living standards and between the different divisions for this estimate: children in the poorest households are four times as likely to die before reaching one and five years of age compared to children living in the richest households. In Sylhet division, both under-five and infant mortality rates are well above the national average. Nutritional Status and Breastfeeding Of the 35.9 per cent children below two years of age weighed at birth, 37.7 per cent were born with low weight. Proportion of children weighed at birth is more among households in the urban areas, as also in households with better educated head and having more wealthy households. During the data collection for the survey, weights and heights/lengths of all children under 5 years of age in the sample households were measured using recommended anthropometric equipment (see www.childinfo.org). Analysis of data show that about one in three children (31.9 per cent) were underweight (weight-for-age malnourished), two in five (42 per cent) were stunted (height- for-age malnourished), and one in every ten children (9.6 per cent) were wasted (weight-for-height malnourished). Some 8.8 per cent of children were severely underweight and one in every 6 children (16.4 per cent) were stunted. Also about 1.6 per cent children in that age group were overweight. Disparities exist between urban and rural children and between children living in households of different education and wealth background. Almost all newborn in Bangladesh, 97.1 per cent, were breastfed at some point after birth. However, only 57.4 per cent started breastfeeding at the correct time (i.e. within one hour of birth). The percentage of infants under 6 months of age who were exclusively breastfed is 56.4 and who received breast milk as the predominant source of nourishment during the day prior to the survey is 71.9. Overall, just two thirds, or 66.5 per cent, of children younger than two years were appropriately breastfed on the day prior to the survey. There is little difference in the pattern of breastfeeding across the country. xxiv l PROGOTIR PATHEY 2012-2013 As far as complimentary feeding is concerned, 42.4 per cent infants aged 6-8 months received solid, semi-solid or soft foods during the day prior to the survey. Among children below the age of two years feeding with a bottle continued for 12.1 per cent cases. Adequately iodized salt, defined as containing 15 or more parts per million (15+ ppm), is used in just over half of all households (54.3 per cent), with considerably higher consumption in urban areas and among richer households that than those in rural areas and from the poorer households. The overall consumption of iodized salt remains far below global standards: The World Health Organization (WHO) and UNICEF recommend Universal Salt Iodization as a safe, cost-effective and sustainable strategy to ensure sufficient intake of iodine. Child Health and Care of Illness Four of five mothers who gave birth within two years prior to the survey were adequately protected against neonatal tetanus (80.8 per cent). However, mothers in Sylhet division had significantly low protection from neonatal tetanus (66.7 per cent). Of the children with diarrhoea, 64.6 per cent received oral rehydration therapy (ORT) and continued feeding during the episode. About 3 per cent of children under-5 showed symptoms of pneumonia in the two weeks preceding the survey, of whom 35.8 per cent were taken to an appropriate health provider. Although appropriate medical care was sought for only one third of the children with ARI symptoms, antibiotic treatment was given to 74.3 per cent of them. The very high usage of antibiotics without prescription is prevalent across Bangladesh across all dimensions of education and wealth levels. Additionally, only 10.8 per cent of mothers or caretakers recognized the two danger signs of pneumonia, viz., fast breathing and difficulty in breathing, while 46.9 per cent knew at least one of them. Cooking and heating with solid fuels lead to high levels of indoor smoke, thus causing damage to children’s health. MICS show that solid fuels is widely used as a main source of energy for domestic cooking in Bangladesh (88.2 per cent), particularly in rural areas (96 per cent versus 58.3 per cent in urban areas), although the main place of cooking is mostly in a separate building (57.8 per cent) or outdoors (21.2 per cent). Water and Sanitation Drinking water is used from the improved drinking water sources almost universally (97.9 per cent of the population). Among those who do not use improved drinking water sources, one fourth (25.6 per cent) use an appropriate water treatment method. About 74.2 per cent of users of improved drinking water sources have a water source directly on their premises, 20.4 per cent take less than 30 minutes to get to improved drinking water sources. In the majority of households where water sources is not available on the premises, water is usually collected by adult woman (88.8 per cent) in the household. The time taken to reach improved drinking water sources varies significantly between divisions, and between households of different education and wealth levels. Safe drinking water is a human right and a basic requirement for good health. Microbiological contamination of drinking water can lead to diarrhoeal diseases including shigellosis and cholera. Arsenic content in drinking water was measured in Bangladesh for both household drinking and source water. About 24.8 per cent of the population had drinking water in the household with arsenic above the WHO provisional guideline value of 10 parts per billion (ppb), and 12.4 per cent of the population exceeded the Bangladesh standard of 50 ppb. Arsenic contamination was slightly greater at the source, with 25.5 per cent exceeding 10 ppb and 12.5 per cent above 50 ppb. Executive Summary l xxv The bacteria species Escherichia coli (E. coli) is the most commonly recommended faecal indicator, and many countries including Bangladesh have set a standard that no E. coli should be found in a 100 mL sample of drinking water. Overall, 41.7 per cent of the population had source water with detectable E. coli, while this value was 61.7 per cent for household samples, reflecting contamination occurring at the household level. Over half of Bangladesh population use improved sanitation facilities that are not shared (55.9 per cent). Open defecation is not widespread with only 3.9 per cent of the population practicing it. However, in Rangpur division and also in the poorest quintiles of households, open defection is more prevalent (15.5 and 13.5 per cent respectively). Child faeces are disposed of in a safe manner in 38.7 per cent of children under the age of 2; unsafe child faeces disposal practices are again most common in Rangpur division and among the poorest households. Soap or other cleansing agents for handwashing are available in 94 per cent of Bangladesh households. In households where a place for handwashing was observed, 59.1 per cent had both water and soap present at the designated place, 35 per cent had only water, and 4.3 per cent had neither water nor soap. The proportion of households with both water and soap present is lower in rural areas and also in the poorer and less educated households, mainly due to the lack of availability of soap. Reproductive Health The Total Fertility Rate (TFR) in Bangladesh is 2.3, meaning that a Bangladeshi woman, by the end of her reproductive years, will have given birth to an average of 2.3 children. There were 83 number of births to women 15 to 19 years of age per 1,000 women in that age group (adolescent birth rate). Early childbearing is relatively common, with about one in four women (24.4 per cent) age 20- 24 having had live birth before the age of 18. About 61.8 per cent of women aged 15-49 and currently married use some form of contraception. Of these, 59.3 per cent use modern methods of contraception. The unmet need for contraception is relatively low among women age 15-49 (13.9 per cent). About 58.7 per cent of women aged 15–49 who gave birth in the two years preceding the survey received antenatal care from skilled health personnel at least once, and 24.7 per cent had the recommended four antenatal care visits by any provider. Some 38 per cent had their blood pressure measured and gave urine and blood samples during antenatal checkup. Considerable differences exist in availing antenatal care between urban and rural areas, and between women of different education levels and from households of different wealth levels. Only 31 per cent of all deliveries took place in health facilities and only 43.5 per cent of women were attended by skilled health personnel during their most recent live birth. Of all the births, 19.1 per cent of women had delivery by caesarean section. Substantial disparities exist by all dimensions of background characteristics. A woman who completed secondary or higher education, for example, is five times as likely to have delivery in a health facility as a woman with no education. About 82.8 per cent of women age 15-49 years with a live birth in the last two years stayed in the health facility for 12 hours or more after the latest delivery. While 41.2 per cent of the newborns in the last two years received a post natal health check within 2 days after delivery, 40.4 of the mothers received a health check within 2 days after delivery. Provision of post-natal care service differs substantially between different divisions and between urban and rural areas. Education and wealth also play an important role in the level of service received by the mothers and the newborns. xxvi l PROGOTIR PATHEY 2012-2013 Early Childhood Development Only 13.4 per cent of children aged 3-4 years receive early childhood education. However, a much higher proportion of children (78 per cent) have adults engage with them in four or more activities that promote learning and school readiness during the three days prior to the survey. Survey shows that, 40.8 per cent of children’s biological mother and 10.1 per cent of children’s biological father engaged in four or more activities during the three days prior to the survey. Exposure to books in early years in Bangladesh is poor; less than one in ten children under 5 have three or more children’s books at home (8.8 per cent). Children of mothers with the higher education are relatively more exposed to books with 24.6 per cent having three or more children’s books at home. The percentage of children with two or more types of playthings stands at 60.3 per cent. One in ten children under-5 were left under inadequate care sometime during the week preceding the survey (11.6 per cent), which was mainly in terms of either left alone or in the care of another child under the age of 10. The child development index score in Bangladesh is 63.9. The score is calculated based on the percentage of children aged 3-4 years who are developmentally on track in at least three of the following four domains: literacy/numeracy, physical, social/emotional and learning. Urban children, children who are attending early childhood education, and children of better educated mothers and wealthier households have slightly higher development index score. Literacy and Education Overall literacy among Bangladesh women age 15–24 years is high, at 82 per cent. Less than half of children in the first grade of primary school, attended pre-school during the previous school year (43.5 per cent). The net intake rate in primary education, i.e. the percentage of children of school-entry age who enter the first grade of primary school, is low at 33.1 per cent, and there are significant differences between divisions, with Sylhet having the lowest at 23.1 per cent. The primary school adjusted net attendance ratio is 73.2 per cent. 96.4 per cent of children entering the first grade of primary school eventually reach last grade, and the primary completion rate is 79.5 per cent. The primary completion rate is positively associated with mother’s education and household wealth status, but it is lower in urban areas than in rural areas. Girls have much higher completion rate than boys. Transition rate to secondary school in Bangladesh is 94.7 per cent. 46.1 per cent of children of secondary school age currently attend secondary school or higher, 33.7 per cent are still attending primary school, and 14.6 per cent are out of school. Compared with urban areas, rural areas have lower percentage attending secondary school or higher, and higher percentage legging behind in primary education. However, the out of school ratio is almost the same in urban and rural areas. Mother’s education and household social economic status have a strong association with the out of school ratio. Girls are in advantage in both primary school and secondary school attendance; the gender parity index for primary school age is 1.07 and for secondary school is 1.30. Gender disparity is significant in children of secondary school age, and is strongly associated with mother’s education and household wealth. Child Protection The percentage of mothers or caretakers of children under the age of 5 whose birth has not been registered but know how to register a birth is relatively high in Bangladesh (60.5 per cent), and registration of birth is still not widely practiced, with only 37 per cent of births registered. Executive Summary l xxvii The difference between knowledge and practice persists across all background dimensions of households. Majority of children aged 1-14 years in Bangladesh experienced some form of psychological aggression or physical punishment in the month prior to the survey (82.3 per cent). This again does not match with only about 33.3 per cent of respondents believing that children need to be physically punished. Almost one in four women age 15-49 were (first) married before the age of 15 (23.8 per cent). Among women aged 20-49 years, the proportion who married before the age of 18 is 62.8 per cent. Of young women between 15 and 19, 34.3 per cent are already married. Early marriage is widely practiced in Bangladesh and is prevalent across all household background, although trends based on other data sources show that it is in decline in recent years. Polygyny is rare among Bangladesh women, particularly towards recent years. Only 1 per cent of youngest women (aged 15-19) are in polygynous union as compared to 7 per cent of the oldest (aged 45-49). The age difference between spouses is large and marriage to a much older husband or partner is common in Bangladesh. Some 20.4 per cent of women age 15-19, and 21.8 per cent of women age 20-24, are married to spouses who are 10 or more years older. Surprisingly, marriage to older spouse is more common in women with better education and living in richer households. About 3.8 per cent of children aged 0-17 years live with neither of the biological parents. For 4.3 per cent of children reported to have one or both of his/her biological parents passed away. About 5 per cent of children have at least one biological parent living abroad. HIV/AIDS and Orphanhood More than half of women aged 15-49 in Bangladesh have heard of AIDS (55.8 per cent), but very few (6.6 per cent) have a comprehensive knowledge of HIV, meaning they can correctly identify two ways of preventing HIV infection; know that a healthy looking person can have HIV, and reject the two most common misconceptions about HIV transmission. Only one in five correctly identified all three means of mother-to-child transmission of HIV (21.7 per cent). On the whole, 37.2 per cent expressed accepting attitude towards people living with HIV on all four questions. On all HIV/AIDS related indicators, there are significant differences between urban and rural areas, between divisions, and between different education levels and socio-economic status. Among young women of 15-24 years, 9.1 per cent correctly identified ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission. Additionally, 11.3 per cent of women age 15-49 know a place where they can be tested for HIV and 2.5 per cent of those who received antenatal care during their last pregnancy reported that they received counselling on HIV during antenatal care. Some 0.3 per cent of children age 10-14 years in Bangladesh are orphans, of whom 76.7 per cent attend school. The ratio of school attendance of orphans to school attendance of non-orphans is 0.88. Access to Mass Media and ICT Of all women age 15-49 in Bangladesh, only 1.6 per cent read a newspaper or magazine, listened to the radio, and watched television, at least once a week. In young women between 15 and 24, 6.1 per cent used a computer and 3.0 per cent used internet during the 12 months prior to the survey. Access to mass media and ICT is more prevalent among younger women, and women who live in urban areas, with better education and living in richer households. xxviii l PROGOTIR PATHEY 2012-2013 © U N IC EF /B A N A 20 10 -0 01 43 /H aq ue Introduction l 1 I. Introduction Background This report is based on the Bangladesh Multiple Indicator Cluster Survey (MICS), conducted in 2012- 2013 by the Bangladesh Bureau of Statistics, Statistics and Informatics Division, Ministry of Planning. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” Bangladesh has been responding to its commitment to children by implementing various development programmes through different social sector ministries such as the ministry of Health and Family Welfare, Ministry of Primary and Mass education, Ministry of Education, Ministry of Social Welfare, etc. A good number of laws/acts for protecting the rights of children have been enacted such as, the Children Act 2013, Birth and Death Registration Act 2013, Disabled People’s Rights and Protection Act 2013, National Human Rights Act 2009. These were complemented by a number of national policies: Early Childhood Care and Development Policy 2013, National Children Policy 2011, National Health Policy 2011, National Education Policy 2010, Child Labor Elimination Policy 2010, National Population Policy 2012, etc. The government has also formulated the national development strategy and the Five Year Development Plans. The Bangladesh MICS results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post-2015 era. © U N IC EF /B A N A 20 10 -0 01 43 /H aq ue 2 l PROGOTIR PATHEY 2012-2013 Bangladesh MICS is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women’s and Children’s Health. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2012-2013 Bangladesh MICS has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Bangladesh; • To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; • To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable; • To contribute to the generation of baseline data for the post-2015 agenda; • To validate data from other sources and the results of focused interventions. Sample and Survey Methodology l 3 II. Sample and Survey Methodology Sample Design The sample for the Bangladesh Multiple Indicator Cluster Survey (MICS) was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, seven divisions and sixty four districts. The districts were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size (pps). After a household listing was carried out within the selected enumeration areas, a systematic sample of 20 households was drawn in each sample enumeration area. Four (04) of the selected enumeration areas were not visited because they were inaccessible due to rough weather and hilly remote road communication during the fieldwork period. These enumeration areas were one each from Bagerhat, Gaibandha, Rangamati and Sirajganj districts. The sample was stratified by districts, and is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A, Sample design. Readers may note that we have included maps showing the districts for some of the indicators with different colours being used to represent different ranges of values. The reader should treat interpretation of these maps with some caution, because the associated sampling errors at the district level would be larger than those at the division level. Map HH.1 shows the number of enumeration areas under the districts visited during the survey with division boundaries. It is to be noted that a new Rangpur division has been created in 2010 comprising eight districts from formerly Rajshahi division. Map HH.1: Number of enumeration areas covered in the survey by UNDAF and non-UNDAF districts, Bangladesh, 2012-2013 Naoganon Dinajpur KurigramRangpur Joypurhat Gaibandha Nawabganj Rajshahi Bogra Jamalpur Sherpur Mymensingh Gazipur Tangail Netrokona Kishoreganj Maulvibazar SylhetSunamganj Sirajganj Narsingdi Brahmanbaria Habiganj ComillaMunshiganj Manikganj DhakaNarayanganj Natore Pabna Kushtia Chandpur Lakshmipur Noakhali Faridpur Gopalganj Shariatpur Bagerhat Pirojpur Patuakhali Barguna Jhalokati Bhola Meherpur Rajbari Jhenaidah Magura Chuadanga Jessore Narail Satkhira Khulna Khagrachhari Feni Ramgamati Chittagong Bandarban Cox's Bazar Barisal Madaripur Thakurgaon Nilphamari Panchagarh Lalmonirhat 4 l PROGOTIR PATHEY 2012-2013 Questionnaires Four sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; 3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 living in the household; and 4) a water quality testing questionnaire to measure arsenic and E.coli content in the household drinking water in a sub-sample of households. The questionnaires included the following modules: The Household Questionnaire included the following modules: • List of Household Members • Education • Household Characteristics  Child Discipline  Water and Sanitation  Handwashing  Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules:  Women’s Background  Access to Mass Media and use of Information/Communication Technology  Marriage  Child Mortality  Desire for Last Birth  Maternal and Newborn Health  Post-Natal Health Checks  Contraception  Unmet Need  Illness Symptoms  HIV/AIDS The Questionnaire for Children Under Five was administered to mothers or caretakers of children under 5 years of age2 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules:  Age  Birth Registration  Early Childhood Development  Breastfeeding  Care of Illness  Anthropometry 2 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. Sample and Survey Methodology l 5 The Questionnaire on Water Quality Testing was administered to a sub-sample of sampled households for measuring arsenic and E. coli- content in the household drinking water and included only one module. A sub-sample of 5 households were selected per cluster, out of the selected 20 household for the survey, to test arsenic content of the household drinking water and one of these 5 households was identified to test E.coli content in the drinking water. Source water for this household was tested for arsenic and E.coli content.  Water Quality The questionnaires are based on the MICS5 model questionnaire3 tested during the global MICS5 pilot study in Sirajganj and Bogra during May-June 2012. From the MICS5 pilot English version, the questionnaires were translated into Bengali and tested during the global MICS5 pilot. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Bangladesh MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for handwashing and measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 14 days in November, 2012. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent 2 (two) days in practice interviewing in Dhaka and Narayanganj. The data were collected by 32 teams; each was comprised of four (04) female interviewers, one editor, one measurer and a supervisor. Fieldwork began in December, 2012 and concluded in April, 2013. Data Processing Data were entered using the CSPro software. The data were entered on 30 microcomputers and carried out by 30 data entry operators and 1 data entry supervisors. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS5 programme and adapted to the Bangladesh questionnaire were used throughout. Data processing began simultaneously with data collection in December, 2012 and was completed in May, 2013. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 18, and the model syntax and tabulation plans developed by UNICEF were used for this purpose. 3 The model MICS5 questionnaires can be found at http://www.childinfo.org/mics5_questionnaire.html 6 l PROGOTIR PATHEY 2012-2013 © U N IC EF /B A N A 20 09 -0 04 60 /N oo ra ni Sample Coverage and the Characteristics of Households and Respondents l 7 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 55,120 households selected for the sample, 52,711 were found to be occupied. Of these, 51,895 were successfully interviewed for a household response rate of 98.5 per cent. In the interviewed households, 59,599 women (age 15-49 years) were identified. Of these, 51,791 were successfully interviewed, yielding a response rate of 86.9 per cent within interviewed households. There were 23,402 children under age five listed in the household questionnaires. Questionnaires were completed for 20,903 of these children, which corresponds to a response rate of 89.3 per cent within interviewed households. Overall response rates for households, women’s questionnaire, and overall response rate for under-5 questionnaire are calculated for the individual interviews of women, and under-5s, respectively (Table HH.1). Overall response rates 85.6 and 87.9 per cent are calculated for the individual interviews of women and under-5s, respectively (Table HH.1). Table HH.1: Results of household, women’s and under-5 interviews Number of households, women and children under 5 by results of the household, women’s and under-5’s interviews, and household, women’s and under-5’s response rates, Bangladesh, 2012-2013 Total Area Division Urban Rural Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Households Sampled 55,120 9,080 46,040 5,400 9,580 14,000 8,580 6,580 7,180 3,800 Occupied 52,711 8,628 44,083 5,296 9,209 13,056 8,187 6,343 6,975 3,645 Interviewed 51,895 8,421 43,474 5,138 9,041 12,913 8,138 6,247 6,820 3,598 Household response rate 98.5 97.6 98.6 97.0 98.2 98.9 99.4 98.5 97.8 98.7 Women Eligible 59,599 10,279 49,320 5,766 10,603 14,671 9,332 6,922 7,642 4,663 Interviewed 51,791 8,951 42,840 4,966 9,084 12,767 8,273 6,070 6,724 3,907 Women’s response rate 86.9 87.1 86.9 86.1 85.7 87.0 88.7 87.7 88.0 83.8 Women’s overall response rate 85.6 85.0 85.7 83.6 84.1 86.1 88.1 86.4 86.0 82.7 Children under 5 Eligible 23,402 3,673 19,729 2,232 4,917 5,820 3,013 2,254 2,892 2,274 Mothers/caretakers interviewed 20,903 3,331 17,572 1,929 4,343 5,235 2,729 1,996 2,639 2,032 Under-5’s response rate 89.3 90.7 89.1 86.4 88.3 89.9 90.6 88.6 91.3 89.4 Under-5’s overall response rate 87.9 88.5 87.8 83.8 86.7 89.0 90.0 87.2 89.2 88.2 The household response rates were similar across divisions and areas of residence. The response rates of women and children under 5 were also in the same situation, with the exception of Sylhet where the women’s response rate was 83.8 per cent. Low response of Sylhet for women could be due to the regions’ known conservative social norms in practice, although this is not confirmed by any indicator. The results for Sylhet should be interpreted with some caution, as the response rate is low. © U N IC EF /B A N A 20 09 -0 04 60 /N oo ra ni 8 l PROGOTIR PATHEY 2012-2013 Characteristics of Households The weighted age and sex distribution of survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 51,895 households successfully interviewed in the survey, 237,396 household members were listed. Of these, 119,684 were males, and 117,712 were females. Table HH.2: Household age distribution by sex Per cent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Bangladesh, 2012-2013 Total Males Females Number Per cent Number Per cent Number Per cent Total 237,396 100.0 119,684 100.0 117,712 100.0 Age 0-4 23,430 9.9 12,014 10.0 11,416 9.7 5-9 27,574 11.6 13,897 11.6 13,676 11.6 10-14 27,839 11.7 14,085 11.8 13,754 11.7 15-19 23,262 9.8 12,065 10.1 11,198 9.5 20-24 20,036 8.4 9,314 7.8 10,722 9.1 25-29 20,210 8.5 9,422 7.9 10,788 9.2 30-34 16,262 6.9 7,949 6.6 8,313 7.1 35-39 15,218 6.4 7,481 6.3 7,737 6.6 40-44 13,307 5.6 6,912 5.8 6,395 5.4 45-49 10,796 4.5 5,788 4.8 5,008 4.3 50-54 11,345 4.8 5,103 4.3 6,243 5.3 55-59 7,973 3.4 4,126 3.4 3,848 3.3 60-64 7,126 3.0 3,981 3.3 3,144 2.7 65-69 4,509 1.9 2,581 2.2 1,928 1.6 70-74 3,863 1.6 2,338 2.0 1,525 1.3 75-79 1,810 0.8 1,095 0.9 715 0.6 80-84 1,413 0.6 805 0.7 609 0.5 85+ 1,377 0.6 705 0.6 672 0.6 Missing/DK 45 0.0 24 0.0 21 0.0 Dependency age groups 0-14 78,842 33.2 39,996 33.4 38,846 33.0 15-64 145,537 61.3 72,142 60.3 73,395 62.4 65+ 12,973 5.5 7,523 6.3 5,450 4.6 Missing/DK 45 0.0 24 0.0 21 0.0 Children and adult populations Children age 0-17 years 92,546 39.0 47,526 39.7 45,020 38.2 Adults age 18+ years 144,805 61.0 72,133 60.3 72,672 61.7 Missing/DK 45 0.0 24 0.0 21 0.0 Table HH.2 shows the age-sex structure of the household population. The proportions of child, working and old-age groups (0–14, 15–64 and 65 years and over) in the household population of the sample were 33.2, 61.3 and 5.5 per cent, respectively. In MICS 2006, these figures were 35.5, 59.8 and 4.7 per cent, higher in younger age and lower in older age. More significantly, the proportion of children aged 0-4 is 9.9 per cent in this survey as compared to 11.6 per cent in MICS 2006, indicating a drop of birth rate in recent years. Birth rate decrease is a trend that MICS 2006 had already identified after comparison with the census 2001. Sample Coverage and the Characteristics of Households and Respondents l 9 The surveyed population indicates a sex ratio of 102, unchanged from that of MICS 2006. The dependency ratio was 63.2 per cent, much reduced from 67.2 per cent of MICS 2006. Similarly, the proportion of children aged 0-17 has also reduced from 42.3 per cent in MICS 2006 to 39.0 per cent in this survey. The total number of the children aged 0-17 is 92,546. Figure HH.1: Age and sex distribution of household population, Bangladesh, 2012-2013 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49 and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers4. Table HH.3 provides basic background information on the households, including the sex of the household head, division, area, number of household members and education of head of the household head are shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. 4 See Appendix A: Sample Design, for more details on sample weights. age 8 6 4 2 0 2 4 6 8 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-29 10-14 5-9 0-4 Per cent Note: 45 household members with missing age and/or sex are excluded Males Females 10 l PROGOTIR PATHEY 2012-2013 Table HH.3: Household composition Per cent distribution of households by selected characteristics, Bangladesh, 2012-2013 Weighted per cent Number of households Weighted Unweighted Total 100.0 51,895 51,895 Sex of household head Male 90.3 46,868 47,242 Female 9.7 5,027 4,653 Division Barisal 6.1 3,155 5,138 Chittagong 17.9 9,278 9,041 Dhaka 31.9 16,556 12,913 Khulna 11.9 6,167 8,138 Rajshahi 14.4 7,449 6,247 Rangpur 12.4 6,454 6,820 Sylhet 5.5 2,836 3,598 Area Urban 21.5 11,144 8,421 Rural 78.5 40,751 43,474 Number of household members 1 1.9 987 971 2 8.7 4,490 4,238 3 18.1 9,407 9,073 4 26.3 13,659 13,470 5 20.3 10,551 10,823 6 11.8 6,122 6,502 7 6.0 3,123 3,276 8 3.1 1,603 1,617 9 1.6 840 845 10+ 2.1 1,112 1,080 Education of household head None 42.1 21,823 22,613 Primary incomplete 13.1 6,776 7,346 Primary complete 11.7 6,053 5,914 Secondary incomplete 17.2 8,938 8,790 Secondary complete or higher 15.9 8,271 7,193 Missing/DK (0.1) 34 39 Mean household size 4.6 51,895 51,895 () Figure based one 25-49 unweighted case. The weighted and unweighted total numbers of households are equal, since sample weights were normalized. The table also shows the weighted mean household size estimated by the survey. According to Table HH.3, the majority households in Bangladesh were headed by a male (90.3 per cent); nearly half of the households heads sampled had no education (42.1 per cent). The composition of households, where comparable, was similar to that of MICS 20065. The weighted number of households in some of the categories, such as, the divisions is very different from the unweighted number due to weights used in the calculation of proportions. Overall, 78.5 per cent of the population were living in rural areas. The division Dhaka had the largest share of the households, 31.9 per cent, and both Barisal and Sylhet had very small shares of the households, 6.1 and 5.5 per cent, respectively. Only 1.9 per cent of the household population was living in single households and about 73.4 per cent were living in households containing 2–5 persons. The average household size was 4.6 members, slightly reduced from 4.8 members in MICS 2006. 5 Corresponding table in MICS 2006 did not include the background variable education of household head. Sample Coverage and the Characteristics of Households and Respondents l 11 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female and of children under age 5. In both the tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4: Women’s background characteristics Per cent and frequency distribution of women age 15-49 years by selected background characteristics, Bangladesh, 2012-2013 Weighted per cent Number of women Weighted Unweighted Total 100.0 51,791 51,791 Division Barisal 6.0 3,083 4,966 Chittagong 18.9 9,794 9,084 Dhaka 31.7 16,411 12,767 Khulna 11.7 6,046 8,273 Rajshahi 13.7 7,088 6,070 Rangpur 11.9 6,156 6,724 Sylhet 6.2 3,212 3,907 Area Urban 22.9 11,856 8,951 Rural 77.1 39,935 42,840 Age 15-19 17.5 9,071 9,008 20-24 17.1 8,831 8,478 25-29 18.1 9,354 9,428 30-34 14.4 7,432 7,490 35-39 13.4 6,950 7,063 40-44 11.0 5,697 5,751 45-49 8.6 4,456 4,573 Marital status Currently married 81.6 42,263 42,389 Widowed 2.2 1,119 1,165 Divorced 1.0 509 545 Separated 0.5 258 224 Never married/in union 14.8 7,641 7,468 Motherhood and recent births Never gave birth 22.9 11,845 11,500 Ever gave birth 77.1 39,946 40,291 Gave birth in last two years 15.3 7,950 7,866 No birth in last two years 61.8 31,997 32,425 Education None 26.2 13,544 14,467 Primary incomplete 13.0 6,735 7,048 Primary complete 13.3 6,882 6,810 Secondary incomplete 31.7 16,420 16,220 Secondary complete or higher 15.9 8,210 7,246 Wealth index quintile Poorest 18.3 9,467 11,784 Second 19.1 9,872 10,790 Middle 19.8 10,264 10,417 Fourth 20.7 10,699 10,136 Richest 22.2 11,490 8,664 12 l PROGOTIR PATHEY 2012-2013 Table HH.4 provides background characteristics of female respondents aged 15-49 years. The table includes information on the distribution of women according to region, urban/rural area of residence, age, marital status, motherhood status, births in last two years, education6 and wealth index quintiles7,8. According to Table HH.4, the division Dhaka had the largest share of women (31.7 per cent). Barisal and Sylhet accounted for only 6 and 6.2 per cent respectively. Overall, 77.1 per cent of women live in rural areas. In the sample, 81.6 per cent of women were currently married and the percentages of divorced or separated women were very low (1.0 and 0.5 per cent respectively). Most women had given birth (77.1 per cent), but the majority did so more than two years ago (84.7 per cent). About 26.2 per cent of women had received no education, although a much higher 47.6 per cent had at least some education at secondary level. The distribution of women in the wealth index quintiles was fairly even, although the richest had slightly more share (22.2 per cent) than the poorest (18.3 per cent). The weighted number of households in some of the categories such as the divisions is very different from the unweighted number due to weights used in the calculation of proportions. The statistics in this survey are similar to that of MICS 2006 where comparable data are available, with the exception that women are better educated now than in 2006. The background characteristics of children under 5 years are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area of residence, age, mother’s or caretaker’s education and wealth. The table shows that, at the time of the survey, the proportion of boys was slightly higher than that of girls by 2.4 per cent. In total, 79.6 per cent of surveyed under-5 children live in rural areas and the division Dhaka has the highest share of the children, 30.9 per cent. The proportion of under-5 children with mother without education is 22.5 per cent, decreased from 35.6 per cent in MICS 2006. Nearly one quarter of, or 24.4 per cent, under-5 children were living in the poorest households, much more than the 18.5 per cent living in the richest households, although the percentage living in the poorest households had decreased from 25.3 per cent in MICS 2006. 6 Unless otherwise stated, “education” refers to the highest educational level attended by the respondent throughout this report when it is used as a background variable. 7 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In Bangladesh MICS 2012-2013, the following assets were used in these calculations: water sources, toilet facility, housing, fuel types for cooking, electricity, bank account, durable goods (such as radio, TV, refrigerator, fixed telephone, watch, mobile phone, bicycle, motorcycle, boat with motor, car), animals (such as buffalo, cattle, horse, donkey, goat, sheep, chicken, pig). The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D. and Pritchett, L., 2001. “Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India”. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro and Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. Calverton, Maryland: Macro International Inc. 8 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest household population”, which is used interchangeably with “women in the wealthiest survey population” and similar. Sample Coverage and the Characteristics of Households and Respondents l 13 Table HH.5: Under-5’s background characteristics Per cent and frequency distribution of children under five years of age by selected characteristics, Bangladesh, 2012- 2013 Weighted per cent Number of children Weighted Unweighted Total 100.0 20,903 20,903 Sex Male 51.2 10,694 10,732 Female 48.8 10,209 10,171 Division Barisal 6.1 1,270 1,929 Chittagong 22.9 4,792 4,343 Dhaka 30.9 6,456 5,235 Khulna 9.6 2,014 2,729 Rajshahi 11.5 2,405 1,996 Rangpur 11.3 2,372 2,639 Sylhet 7.6 1,595 2,032 Area Urban 20.4 4,268 3,331 Rural 79.6 16,635 17,572 Age 0-5 months 9.5 1,981 1,959 6-11 months 9.6 2,002 1,942 12-23 months 19.6 4,093 4,026 24-35 months 20.0 4,189 4,175 36-47 months 20.7 4,332 4,391 48-59 months 20.6 4,306 4,410 Respondent to the under-5 questionnaire Mother 98.6 20,498 20,503 Other primary caretaker 1.9 405 400 Mother’s education* None 22.5 4,700 5,255 Primary incomplete 14.1 2,944 3,034 Primary complete 15.6 3,256 3,219 Secondary incomplete 34.9 7,291 7,062 Secondary complete or higher 13.0 2,711 2,333 Wealth index quintile Poorest 24.4 5,105 6,264 Second 20.5 4,285 4,511 Middle 18.6 3,886 3,777 Fourth 17.9 3,750 3,415 Richest 18.5 3,877 2,936 * In this table and throughout the report, mother’s education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. The table HH.6 indicates that 61.5 per cent households have electricity nationally where urban gets the most share (88 per cent). Dhaka, Chittagong and Khulna divisions have over 60 per cent households connected with electricity while 62.4 per cent of households in Rangpur division do not have electricity. 14 l PROGOTIR PATHEY 2012-2013 The table HH.6 also gives information about structure of houses to assess the living conditions of the household members. As has been seen from the table the floor of 73.5 per cent households are considered to be natural, mostly located in rural areas (84.0 per cent) and only 25.7 per cent have finished floor. The natural floor is seen highest in Barisal divisions and lowest in Dhaka division. Most of the household roofs are considered to be finished (97.4 per cent) with no significant differences observed in urban and rural areas, and in divisions. The exterior walls are mostly rudimentary type (44.9 per cent) of which 49.3 per cent are in rural areas. The finished exterior wall seen only in 29.4 per cent households, are mostly located in urban areas (59.2 per cent). In terms of overcrowding, 3 or more persons sleeping in one room, little more than 1 in every five households was crowded. Difference between urban and rural areas are not significant but exists in the divisions where 38.7 per cent households in Chittagong is seen as the highest and 14.3 per cent Rangpur as the lowest. Table HH.6: Housing characteristics Per cent distribution of households by selected housing characteristics, according to area of residence and regions, Bangladesh, 2012-2013 Total Area Division Urban Rural Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Electricity Yes 61.5 88.0 54.2 52.2 65.5 71.2 64.1 58.1 37.6 59.1 No 38.5 12.0 45.8 47.8 34.5 28.8 35.9 41.9 62.4 40.9 Missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0w 0.0 0.0 Flooring Natural floor 73.5 35.3 84.0 89.1 72.1 61.9 74.3 81.1 87.2 76.0 Rudimentary floor 0.4 0.3 0.5 0.1 0.7 0.9 0.0 0.0 0.2 0.0 Finished floor 25.7 63.5 15.4 10.6 26.5 36.8 25.5 18.8 12.5 23.9 Other 0.3 0.8 0.2 0.1 0.7 0.4 0.1 0.1 0.0 0.0 Missing/DK 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 Roof Natural roofing 2.3 0.7 2.7 2.1 6.4 0.8 3.4 0.3 1.6 2.5 Rudimentary roofing 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.0 0.1 0.1 Finished roofing 97.4 99.0 96.9 97.8 93.2 99.1 94.8 99.7 98.3 97.4 Other 0.3 0.2 0.3 0.0 0.4 0.0 1.7 0.0 0.0 0.0 Missing/DK 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Exterior walls Natural walls 22.0 8.6 25.7 8.9 10.8 13.0 33.4 36.8 37.9 26.1 Rudimentary walls 44.9 28.7 49.3 74.9 46.0 56.6 16.9 32.5 42.8 37.4 Finished walls 29.4 59.2 21.3 16.0 23.8 30.3 49.6 29.7 19.2 36.4 Other 3.7 3.5 3.7 0.1 19.4 0.1 0.1 1.1 0.0 0.1 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rooms used for sleeping 1 37.4 37.9 37.2 23.0 19.7 43.8 42.6 43.3 45.2 29.0 2 39.7 38.5 40.0 40.8 41.1 37.8 40.7 40.3 40.2 40.0 3 or more 22.6 23.3 22.5 36.1 38.7 18.2 16.5 16.1 14.3 30.8 Missing/DK 0.3 0.3 0.3 0.2 0.5 0.2 0.2 0.4 0.3 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 51,895 11,144 40,751 3,155 9,278 16,556 6,167 7,449 6,454 2,836 Mean number of persons per room used for sleeping 2.7 2.6 2.7 2.3 2.5 2.8 2.7 2.6 2.8 2.9 Sample Coverage and the Characteristics of Households and Respondents l 15 In Table HH.7 households are distributed according to ownership of assets by households and by individual household members. This also includes ownership of dwelling. Among household items, most of the households owned cot/bet (96.5 per cent) and table (77.6 per cent) while two in every five household owned an almirah/wardrobe (41.4 per cent). Not much difference was observed in the area and in divisions. Results on ownership of some of the items like Television, Mobile phones, Refrigerator, Electric fan, etc., compare well with that of the Bangladesh Demographic and Health Survey undertaken in 2011. Among the personal things owned by at least one member of household, mobile phone was owned by the largest proportion of households, about 86 per cent, with urban households having higher mobile ownership (93 per cent) than their rural counterparts (84 per cent). About two in five households (43 per cent) possessed agricultural land with proportions higher in rural (46.5 per cent) than in urban areas (30.3 per cent). Ownership of agricultural land is much lower in Chittagong and Sylhet divisions as compared to other divisions. Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and per cent distribution by ownership of dwelling, according to area of residence and regions, Bangladesh, 2012-2013 Total Area Division Urban Rural Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Percentage of households that own a Radio 3.9 4.5 3.7 4.8 2.9 3.8 4.0 6.3 3.0 2.5 Television 37.7 65.6 30.0 22.2 39.2 45.7 37.9 36.4 25.4 33.4 Non-mobile phone 1.3 4.9 0.3 0.4 0.9 2.1 0.8 0.9 1.0 1.8 Refrigerator 14.2 36.0 8.2 7.7 18.0 21.0 9.7 8.8 4.5 14.5 Electric fan 53.0 82.8 44.8 33.6 58.1 63.8 54.0 51.7 31.2 45.6 Cot/Bed 96.5 96.8 96.4 97.3 90.6 98.1 97.3 98.1 98.7 95.2 Table 77.6 78.7 77.3 72.6 75.6 74.8 75.0 81.6 89.5 73.5 Almirah/Wardrobe 41.4 58.8 36.6 35.8 55.6 47.1 26.2 28.6 36.2 45.9 Sofa set 11.1 26.7 6.8 5.4 17.0 11.7 6.6 8.9 6.4 19.8 Water dispenser 5.5 16.1 2.6 1.7 7.6 6.7 5.5 2.7 1.4 11.5 Water pump 3.6 7.1 2.6 1.3 2.0 4.2 6.3 3.1 2.2 6.3 Percentage of households that own Agricultural land 43.0 30.3 46.5 45.4 36.2 44.5 46.2 47.2 42.3 37.7 Farm animals/Livestock 62.9 28.2 72.4 69.2 60.8 51.8 74.7 71.8 70.8 60.2 Percentage of households where at least one member owns or has a Watch 33.0 44.2 30.0 30.4 40.4 38.0 30.2 31.7 16.6 29.6 Mobile telephone 85.9 93.0 84.0 85.8 90.3 88.9 87.5 82.8 73.9 86.9 Bicycle 28.7 20.2 31.0 12.3 14.2 20.8 52.9 39.7 49.2 11.8 Motorcycle or scooter 5.8 8.6 5.0 3.3 3.9 4.9 8.3 7.7 7.9 4.5 Animal-drawn cart 0.3 0.1 0.3 0.0 0.0 0.1 0.8 0.6 0.2 0.3 Car or truck 0.7 1.7 0.4 0.2 0.7 1.2 0.4 0.4 0.3 0.8 Boat with motor 0.5 0.2 0.6 2.2 0.5 0.5 0.2 0.3 0.1 0.4 Rickshaw/Van 5.1 4.3 5.4 3.4 3.4 3.8 7.3 8.4 7.3 2.3 Nasiman/Kariman/ Votbati 0.7 0.4 0.8 0.6 0.5 0.4 1.6 1.4 0.4 0.4 Easy bike/Auto bike (battery driven) 0.4 0.6 0.4 0.3 0.5 0.5 0.4 0.3 0.2 0.8 Computer 3.4 11.3 1.2 1.2 2.2 5.7 2.6 2.7 1.9 2.9 Bank account 28.6 44.7 24.1 24.9 36.8 32.0 30.8 22.0 12.8 33.6 Ownership of dwelling Owned by a household member 81.7 54.4 89.1 88.8 84.9 72.6 83.8 85.6 89.3 83.8 Not owned 18.3 45.5 10.9 11.2 15.1 27.4 16.2 14.4 10.7 16.1 Rented 11.4 39.8 3.6 4.4 9.9 23.0 5.8 4.7 1.7 7.5 Other 6.9 5.7 7.3 6.8 5.2 4.4 10.4 9.7 9.0 8.6 Missing/DK 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 16 l PROGOTIR PATHEY 2012-2013 Table HH.8 shows how the household populations in areas and regions are distributed according to household wealth quintiles. It shows a high concentration of households in the richest quintile in urban areas (52.4 per cent) as compared to the rural areas (11.5 per cent). The rural areas, as expected, has a higher proportion of households in the poorest quintile than in the urban areas. Among divisions, Dhaka has higher concentration of households in the richest quintile while Rangpur and Sylhet show higher proportions in the poorest quintile. Table HH.8: Wealth quintiles Per cent distribution of the household population by wealth index quintiles, according to area of residence and regions, Bangladesh, 2012-2013 Wealth index quintile Total Number of household membersPoorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 237,396 Area Urban 8.4 7.9 11.2 20.0 52.4 100.0 49,249 Rural 23.0 23.2 22.3 20.0 11.5 100.0 188,147 Division Barisal 30.5 25.8 21.0 15.2 7.6 100.0 15,028 Chittagong 18.5 15.9 19.7 24.1 21.7 100.0 47,725 Dhaka 14.2 17.2 19.7 21.6 27.3 100.0 72,991 Khulna 19.4 19.9 21.1 20.9 18.7 100.0 26,508 Rajshahi 22.2 22.5 22.3 18.3 14.7 100.0 30,923 Rangpur 26.8 29.6 19.7 13.5 10.3 100.0 28,234 Sylhet 25.3 18.1 15.8 18.1 22.7 100.0 15,987 Child Mortality l 17 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) is the reduction of infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. The infant mortality rate is the probability of dying before the first birthday, while the under-five mortality rate is the probability of dying before the fifth birthday. In Bangladesh MICS, an indirect method, known as the Brass method9, was used. Robust estimates of the aforementioned indicators are produced by this indirect method, and are comparable with those obtained by applying direct methods. The data used by the indirect methods are: the mean number of children ever born for five-year time-since-first-birth groups of women age 15 to 49 years, and the proportion of these children who are dead, also for five-year time-since-first-birth groups of women (Table CM.1). The technique converts the proportions dead among children of women in each time-since-first-birth (TSFB) group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Bangladesh, the West model life table was selected as most appropriate. Table CM.1: Children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by time since first birth, Bangladesh, 2012-2013 Children ever born Children surviving Proportion dead Number of women age 15-49 years Mean Total Mean Total Total 2.5416 90,345 2.3444 83,333 0.0776 35,546 Time since first birth 0-4 1.2240 9,192 1.1659 8,756 0.0475 7,510 5-9 2.0275 16,474 1.9148 15,558 0.0556 8,125 10-14 2.8014 22,593 2.6033 20,995 0.0707 8,065 15-19 3.3388 22,039 3.0495 20,129 0.0866 6,601 20-24 3.8221 20,047 3.4120 17,895 0.1073 5,245 Table CM.2 provides estimates of infant and under-five mortality rates derived from proportion dead among children of women in various time-since-first-birth groups from 0-4 to 20-24. This table provides estimates of infant and under-5 mortality rates for various points in time prior to the survey. These estimates are later used in Figure CM.2 to compare the trend indicated by these rates with those from other data sources. 9 United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division. United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN. International Union for the Scientific Study of Population, 2013. Tools for Demographic Estimation. Paris, UNFPA 18 l PROGOTIR PATHEY 2012-2013 Table CM.2: Infant and under-5 mortality rates by time since first birth groups of women Indirect estimates of infant and under-5 mortality rates by time since first birth of women, and reference dates for estimates, West model, Bangladesh, 2012-2013 Reference date Infant mortality rate Under-5 mortality rate Time since first birth 0-4 2011.0 47 61 5-9 2008.3 46 58 10-14 2005.7 53 69 15-19 2003.1 60 80 20-24 2000.3 68 93 To obtain the most recent single estimates of the two indicators by background characteristics, estimates from time since first birth (TSFB) group 5-9 years are presented in Table CM.3. Estimates for TSFB group 5-9 have been used since estimates for TSFB 0-4 group are subject to selection bias as most of the women reporting on children in this TSFB group have given birth at very early ages and are predominantly first birth which have elevated mortality risks. The estimates on child mortality rates presented in the Key Findings report, using the reference period of ‘last 10 years’, have been revised to include estimates from TSFB group 5-9 years. Table CM.3: Infant and under-5 mortality rates by background characteristics Indirect estimates of infant and under-five mortality rates by selected background characteristics, time since first birth version, West Model, Bangladesh, 2012-2013 Infant Mortality Rate [1] Under-five Mortality Rate [2] Total 46 58 Sex Male 51 65 Female 40 52 Division Barisal 38 47 Chittagong 36 45 Dhaka 48 62 Khulna 33 41 Rajshahi 58 78 Rangpur 49 63 Sylhet 59 80 Area Urban 39 49 Rural 47 61 Mother’s education None 60 80 Primary incomplete 52 69 Primary complete 54 71 Secondary incomplete 37 46 Secondary complete or higher 29 35 Wealth index quintiles Poorest 59 79 Second 46 58 Middle 47 61 Fourth 41 52 Richest 29 35 [1] MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate [2] MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate Indicator values are per 1000 live births and refer to 2008.3. The West Model was assumed to approximate the age pattern of mortality in Bangladesh. Child Mortality l 19 The infant mortality rate is estimated at 46 per thousand live births, while the probability of dying under age 5 (U5MR) is around 58 per thousand live births. There is some difference between the probabilities of dying among males and female, with males having higher probabilities than females. Infant and under-5 mortality rates are lowest in Khulna division (33 and 41), while the figures for Sylhet are nearly 2 times higher (59 and 80) than that of Khulna division. Differentials in under-5 mortality rates by selected background characteristics are shown in Figure CM.1. Figure CM.1: Under-5 mortality rates by background characteristics, Bangladesh, 2012-2013 Bangladesh Division Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Mother's education None Primary incomplete Primary complete Secondary incomplete Secondary complete or higher Wealth index quintiles Poorest Second Middle Fourth Richest Area Urban Rural Mother’s educational and household wealth statuses are strongly associated with the mortality rates. The higher the mother’s education, or the richer the household, the lower the mortality rates. For example, under-five mortality rate is 35 in children of mothers who completed secondary education or higher, but 80, or more than two times of that, among children of mothers who have no education. Similar differentials in mortality are observed between the richest and the poorest households. 20 l PROGOTIR PATHEY 2012-2013 Map CM.1: Under-5 mortality rate by division, Bangladesh, 2012-2013 Rangpur Rajshahi Sylhet Dhaka Khulna Chittagong Barisal Figure CM.2 compares the findings of Bangladesh MICS with those from other data sources. Bangladesh MICS findings are obtained from Table CM.2. The MICS estimates indicate a decline in mortality during the last 8 years. The recent U5MR estimate (58 per thousand live births) from MICS using TSFB group 5-9 years is about 9 per cent higher than the estimate from Bangladesh Demographic and Health Survey (BDHS 2011) conducted about a year before MICS, though the two surveys use different methods of collecting the information and estimating the indicator. Further qualification of these apparent declines and differences as well as its determinants should be taken up in a more detailed and separate analysis. Figure CM.2: Trend in under-5 mortality rates, Bangladesh, 2012-2013 BDHS 2011 BDHS 2007 MICS 2012-2013 0 20 40 60 80 100 120 140 1992 1996 2000 2004 2008 2012 Year Dearths per 1,000 live births Nutrition l 21 V. Nutrition Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth10. 10 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16 22 l PROGOTIR PATHEY 2012-2013 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Bangladesh, 2014 Per cent distribution of births by mother’s assessment of size at birth Total Percentage of live births: Number of last live-born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams [1] Weighed at birth [2] Total 3.4 17.3 59.2 13.6 6.5 100.0 26.0 35.9 7,950 Mother’s age at birth Less than 20 years 2.6 19.8 58.0 13.2 6.3 100.0 26.7 38.3 1,555 20-34 years 3.4 16.4 59.9 14.0 6.3 100.0 25.5 36.3 5,809 35-49 years 5.7 19.6 55.7 10.8 8.1 100.0 28.7 25.4 586 Birth order 1 2.5 17.9 59.4 14.0 6.3 100.0 25.6 44.8 2,912 2-3 3.5 17.0 59.5 13.8 6.1 100.0 26.0 33.9 3,857 4-5 5.2 15.6 60.1 11.3 7.9 100.0 26.3 22.6 914 6+ 5.2 20.5 51.6 14.0 8.7 100.0 28.2 12.4 266 Division Barisal 1.2 19.6 63.1 9.8 6.3 100.0 26.3 17.5 475 Chittagong 3.6 20.7 63.0 7.3 5.4 100.0 29.2 25.8 1,851 Dhaka 3.3 16.3 57.4 14.0 8.9 100.0 25.0 40.6 2,503 Khulna 5.3 13.5 54.7 21.4 5.2 100.0 24.2 44.3 760 Rajshahi 2.7 11.8 64.7 16.3 4.6 100.0 22.6 34.5 850 Rangpur 1.6 18.8 50.4 22.5 6.7 100.0 24.2 59.3 886 Sylhet 5.6 19.4 63.6 7.8 3.6 100.0 29.3 19.5 625 Area Urban 4.2 16.8 58.9 14.8 5.3 100.0 26.2 52.2 1,681 Rural 3.2 17.4 59.3 13.3 6.8 100.0 25.9 31.5 6,268 Mothers’ Education None 4.6 22.5 55.2 9.9 7.8 100.0 29.5 19.2 1,460 Primary incomplete 5.6 20.3 54.3 12.0 7.7 100.0 29.1 21.9 1,056 Primary complete 3.6 18.9 55.5 14.2 7.9 100.0 26.5 25.4 1,231 Secondary incomplete 2.9 15.0 62.5 14.0 5.6 100.0 24.6 40.5 3,043 Secondary complete or higher .8 12.5 64.3 18.1 4.2 100.0 21.6 68.8 1,160 Wealth index quintile Poorest 4.9 22.4 53.3 11.2 8.1 100.0 29.6 20.4 1,828 Second 4.0 18.5 57.9 12.9 6.6 100.0 27.0 26.3 1,607 Middle 3.4 15.8 59.0 14.2 7.6 100.0 25.1 29.3 1,524 Fourth 3.3 14.9 61.6 14.9 5.4 100.0 24.7 40.8 1,415 Richest 1.0 13.7 65.7 15.4 4.2 100.0 22.7 65.6 1,575 [1] MICS indicator 2.20 - Low-birthweight infants [2] MICS indicator 2.21 - Infants weighed at birth DK: Don’t know Overall, 35.9 per cent of births were weighed at birth in Bangladesh and 26.0 per cent of infants are estimated to weigh less than 2500 grams at birth (Table NU.1). It is worth noting that children being weighed at birth is positively related to mother’s education and household wealth standard; children with mothers with secondary or higher education or from the richest households were three times more likely to have had their weight measured at birth than that for mothers with no education or belonging to the poorest households. These also vary significantly between urban and rural areas, and between different divisions. Nutrition l 23 Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Under nutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards11. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height - can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely wasted . Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height can be used to assess wasting and overweight status. Children whose weight- for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted . Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended12 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. Children whose full birth date (month and year) were not obtained, and children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.10, DQ.11, and DQ.12 in Appendix D. The tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, 4.7 per cent of 11 http://www.who.int/childgrowth/standards/technical_report 12 See MICS Supply Procurement Instructions here: http://www.childinfo.org/mics5_planning.html 24 l PROGOTIR PATHEY 2012-2013 children have been excluded from calculations of the weight-for-age indicator, 7.2 per cent from the height-for-age indicator, and 6.2 per cent for the weight-for-height indicator. As these percentages are a little higher than expected, result should be interpreted with caution. Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Bangladesh, 2012-2013 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z-Score (SD) Stunted Mean Z-Score (SD) Wasted Overweight Mean Z-Score (SD) Per cent below Per cent below Per cent below Above - 2 SD [1] - 3 SD [2] - 2 SD [3] - 3 SD [4] - 2 SD [5] - 3 SD [6] + 2 SD [7] Total 31.9 8.8 -1.5 19,921 42.0 16.4 -1.7 19,422 9.6 1.6 1.6 -0.7 19,640 Sex Male 32.1 8.8 -1.5 10,171 42.4 16.9 -1.7 9,920 10.4 2.1 1.6 -0.7 10,047 Female 31.8 8.7 -1.5 9,750 41.6 16.0 -1.7 9,502 8.8 1.1 1.6 -0.7 9,593 Division Barisal 35.2 9.7 -1.6 1,216 41.4 15.8 -1.7 1,199 11.7 1.5 0.8 -0.8 1,220 Chittagong 32.2 9.2 -1.5 4,499 43.1 18.7 -1.8 4,447 9.2 1.8 1.2 -0.7 4,550 Dhaka 30.8 8.9 -1.5 6,180 42.1 16.6 -1.7 6,007 9.2 1.3 2.2 -0.6 6,034 Khulna 28.5 6.2 -1.4 1,964 34.4 11.3 -1.5 1,925 10.0 1.7 1.1 -0.7 1,926 Rajshahi 29.9 7.2 -1.5 2,321 39.4 13.2 -1.7 2,278 9.1 1.5 1.2 -0.7 2,287 Rangpur 32.6 8.1 -1.5 2,275 43.7 16.2 -1.8 2,213 8.7 1.4 1.1 -0.7 2,227 Sylhet 39.7 13.1 -1.8 1,466 50.6 22.2 -2.0 1,353 13.3 2.8 2.9 -0.8 1,397 Area Urban 27.0 7.2 -1.3 4,049 36.3 14.3 -1.5 3,943 9.1 1.4 2.7 -0.6 4,013 Rural 33.2 9.1 -1.6 15,872 43.4 17.0 -1.8 15,479 9.8 1.7 1.3 -0.7 15,627 Age 0-5 months 21.8 6.9 -1.1 1,914 25.6 9.4 -1.0 1,839 10.0 2.1 4.1 -0.4 1,825 6-11 months 21.9 7.1 -1.2 1,945 24.6 8.1 -1.2 1,906 10.1 2.1 1.5 -0.6 1,930 12-23 months 30.8 9.3 -1.5 3,970 42.2 16.2 -1.7 3,885 12.7 2.4 1.2 -0.8 3,925 24-35 months 36.2 10.6 -1.6 3,989 49.5 21.3 -2.0 3,830 9.2 1.8 1.2 -0.7 3,852 36-47 months 35.8 9.5 -1.6 4,063 50.2 22.1 -2.0 3,979 7.6 0.9 1.6 -0.6 4,044 48-59 months 34.6 7.3 -1.7 4,041 42.3 13.5 -1.8 3,982 8.8 1.0 1.3 -0.8 4,063 Mother’s education None 40.5 12.7 -1.8 4,429 51.4 23.7 -2.1 4,296 11.2 1.9 1.1 -0.8 4,389 Primary incomplete 39.3 11.2 -1.7 2,807 51.1 20.2 -2.0 2,735 10.5 1.7 1.4 -0.8 2,758 Primary complete 35.7 9.7 -1.6 3,103 48.2 19.5 -1.9 3,031 10.0 1.9 1.5 -0.7 3,086 Secondary incomplete 27.2 6.7 -1.4 6,996 36.6 12.3 -1.6 6,852 9.3 1.7 1.6 -0.7 6,891 Secondary complete or higher 17.5 3.8 -1.0 2,586 23.3 7.4 -1.1 2,508 6.4 0.7 2.9 -0.4 2,516 Wealth index quintile Poorest 41.1 12.6 -1.8 4,832 52.8 23.2 -2.1 4,715 11.6 2.3 0.9 -0.8 4,803 Second 37.4 10.9 -1.7 4,081 47.0 18.3 -1.9 3,975 11.2 1.9 1.2 -0.8 4,015 Middle 33.3 9.0 -1.6 3,731 42.2 16.5 -1.8 3,632 9.5 1.8 1.2 -0.7 3,673 Fourth 27.2 6.2 -1.4 3,580 36.9 13.2 -1.6 3,502 8.5 0.9 1.5 -0.7 3,536 Richest 17.3 3.7 -1.0 3,696 27.0 8.7 -1.2 3,598 6.6 0.9 3.4 -0.4 3,612 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence Nutrition l 25 Almost one in every three children under five years of age in Bangladesh are moderately or severely underweight (31.9 per cent), and almost one in every ten are classified as severely underweight (8.8 per cent) (Table NU.2). About four in every 10 children (42 per cent) are moderately or severely stunted or too short for their age, and one in every ten children (9.6 per cent) are moderately or severely wasted or too thin for their height. Severely stunted and wasted children are respectively 16.4 and 1.6 per cent. Those children whose mothers have secondary or higher education or who are from the richest wealth quintile are the least likely to be underweight and stunted compared to children of mothers with no education or children from the poorest quintile class, respectively. Disparities exist between urban and rural children and between children living in households of different education and wealth background. Children in Sylhet division are more likely to be underweight and stunted than other children. The percentage of wasted children is also highest in this division. Children with mothers having secondary or higher education are the least likely to be underweight or stunted compared to those with no education or primary incomplete. The age pattern shows that a higher percentage of children aged 24-47 months are stunted or underweight in comparison to children who are younger or older (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. Children aged 12-23 however have higher percentage of wasting in comparison to younger and older children. Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Bangladesh, 2012-2013 Map NU.1 shows the distribution of children who are stunted by district. At least one in every two child is stunted in about 8 districts spread over different divisions with Netrokona in Dhaka division having the highest percentage of stunted children and Meherpur in Khulna division with the least proportion. 26 l PROGOTIR PATHEY 2012-2013 Map NU.1: Children under five years of age who are stunted by district, Bangladesh, 2012-2013 Naoganon Dinajpur KurigramRangpur Joypurhat Gaibandha Nawabganj Rajshahi Bogra Jamalpur Sherpur Mymensingh Gazipur Tangail Netrokona Kishoreganj Maulvibazar SylhetSunamganj Sirajganj Narsingdi Brahmanbaria Habiganj ComillaMunshiganj Manikganj Dhaka Narayanganj Natore Pabna Kushtia Chandpur Lakshmipur Noakhali Faridpur Gopalganj Shariatpur Bagerhat Pirojpur Patuakhali Barguna Jhalokati Bhola Meherpur Rajbari Jhenaidah Magura Chuadanga Jessore Narail Satkhira Khulna Khagrachhari Feni Ramgamati Chittagong Bandarban Cox's Bazar Barisal Madaripur Thakurgaon Nilphamari Panchagarh Lalmonirhat Per cent Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life13. UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond14. Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods15. A summary of key guiding principles16,17, for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. 13 Bhuta Z. et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 14 WHO (2003). Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February 2003. 15 WHO (2003). Global Strategy for Infant and Young Child Feeding. 16 PAHO (2003). Guiding principles for complementary feeding of the breastfed child. 17 WHO (2005). Guiding principles for feeding non-breastfed children 6-24 months of age Nutrition l 27 The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Diet diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For diet diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber)18. These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; (ii) food items form at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na na= not available 19 18 WHO (2008). Indicators for assessing infant and young child feeding practices. Part 1: Definitions. 19 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. 28 l PROGOTIR PATHEY 2012-2013 Table NU.3: Initial breastfeeding Percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Bangladesh, 2012-2013 Percentage ever breastfed [1] Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live-born children in the last two years Within one hour of birth [2] Within one day of birth Total 97.1 57.4 88.0 22.7 7,950 Division Barisal 96.4 55.8 86.4 15.4 475 Chittagong 95.0 53.1 88.3 16.1 1,851 Dhaka 97.8 59.6 87.3 31.0 2,503 Khulna 97.6 47.3 82.7 26.3 760 Rajshahi 97.8 56.5 85.5 31.6 850 Rangpur 98.7 59.1 93.2 13.0 886 Sylhet 97.8 73.5 93.6 11.5 625 Area Urban 96.7 52.7 84.4 24.4 1,681 Rural 97.3 58.6 89.0 22.3 6,268 Months since last birth 0-11 months 96.6 57.7 87.7 21.9 3,871 12-23 months 97.7 57.1 88.3 23.5 4,079 Assistance at delivery Skilled attendant 97.8 47.9 83.6 25.4 3,459 Traditional birth attendant 98.4 66.2 92.9 24.2 1,934 Other 98.7 66.0 93.6 18.5 2,426 No one/Missing 30.4 18.2 28.2 6.6 130 Place of delivery Public sector health facility 97.1 49.2 84.0 19.0 1,040 Private sector health facility 98.2 37.6 78.2 33.8 1,421 Home 98.5 65.4 92.9 20.8 5,346 Other/Missing 33.8 14.7 30.2 9.7 143 Mother’s education None 98.4 67.2 92.4 18.8 1,460 Primary incomplete 96.2 55.1 87.1 24.5 1,056 Primary complete 97.5 61.0 89.5 22.3 1,231 Secondary incomplete 96.6 55.3 86.8 23.2 3,043 Secondary complete or higher 97.5 48.8 84.9 25.2 1,160 Wealth index quintile Poorest 97.5 62.5 90.6 19.4 1,828 Second 97.3 61.7 89.9 19.5 1,607 Middle 97.3 58.2 88.6 23.3 1,524 Fourth 96.5 55.3 86.1 25.6 1,415 Richest 96.9 48.1 84.1 26.5 1,575 [1] MICS indicator 2.5 - Children ever breastfed [2] MICS indicator 2.6 - Early initiation of breastfeeding Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.20 20 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). Nutrition l 29 Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 57.4 per cent babies are breastfed for the first time within one hour of birth, while 88 per cent of newborns in Bangladesh start breastfeeding within one day of birth. Some 22.7 per cent of children received a prelacteal feed. Children born in the public sector health facilities are much more likely to be breastfed within one hour of birth (49.2 per cent) than children born in the private sector facilities (37.6 per cent). Large differences in breastfeeding within one hour or one day of birth are observed between the divisions. Khulna with 47.3 per cent of children breastfed within one hour is much lower than Sylhet at 73.5 per cent. Interestingly, breastfeeding within one hour or one day is found lower for deliveries with assistance from skilled birth attendants, though the attendants are trained to promote early breastfeeding practices. Prelacteal feeding seems to be associated with the wealth status of the household as higher proportion of children from the richest households receive a prelacteal feed. Figure NU.2: Initiation of breastfeeding, Bangladesh, 2012-2013 The set of Infant and Young Child Feeding indicators reported in tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed; referring to infants age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. 30 l PROGOTIR PATHEY 2012-2013 Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Bangladesh, 2012-2013 Children 0-5 months Children 12-15 months Children 20-23 months Per cent exclusively breastfed [1] Per cent predominantly breastfed [2] Number of children Per cent breastfed (Continued breastfeeding at 1 year) [3] Number of children Per cent breastfed (Continued breastfeeding at 2 years) [4] Number of children Total 56.4 71.9 1,981 95.3 1,575 87.5 1,149 Sex Male 55.9 70.4 974 95.8 780 87.4 626 Female 56.8 73.4 1,007 94.9 795 87.7 523 Division Barisal 65.0 74.5 127 94.3 98 90.5 58 Chittagong 69.4 82.8 440 93.2 405 77.7 299 Dhaka 46.2 64.8 639 97.3 457 91.0 350 Khulna 50.5 73.8 167 96.3 143 92.4 120 Rajshahi 50.1 61.0 193 92.7 179 91.9 123 Rangpur 67.7 75.7 235 98.2 174 92.8 114 Sylhet 52.2 73.9 179 94.3 119 85.5 84 Area Urban 52.7 71.4 380 93.8 326 86.8 262 Rural 57.3 72.1 1,601 95.7 1,249 87.7 887 Mother’s education None 59.3 74.4 356 96.9 297 87.8 240 Primary incomplete 59.5 75.9 273 99.2 170 84.0 171 Primary complete 49.0 66.0 300 96.3 261 93.3 153 Secondary incomplete 57.7 71.9 767 94.1 623 88.0 418 Secondary complete or higher 53.9 71.4 285 92.7 222 84.4 167 Wealth index quintile Poorest 58.5 73.8 449 97.5 365 89.9 302 Second 62.3 75.4 436 95.9 300 89.5 232 Middle 53.8 71.6 373 97.5 304 85.0 189 Fourth 53.3 69.0 330 93.3 315 89.6 188 Richest 52.4 68.8 393 92.0 292 83.1 238 [1] MICS indicator 2.7 - Exclusive breastfeeding under 6 months [2] MICS indicator 2.8 - Predominant breastfeeding under 6 months [3] MICS indicator 2.9 - Continued breastfeeding at 1 year [4] MICS indicator 2.10 - Continued breastfeeding at 2 years Approximately 56.4 per cent of children aged less than six months in Bangladesh were exclusively breastfed, a level lower than recommended. With 71.9 per cent predominantly breastfed, it is evident that water-based liquids are displacing feeding of breastmilk to a great degree. By age 12-15 months, 95.3 per cent of children are breastfed and by age 20-23 months, 87.5 per cent are breastfed. Differences in exclusive breastfeeding between girls and boys are minimal, and so are between different education of mother and wealth background. However, rates vary between divisions; some 46.2 per cent of children aged 0-5 months in Dhaka division were exclusively breastfed, as compared to 69.4 per cent in Chittagong. Figure NU.3 shows the level of exclusive breastfeeding of children 0-5 months by different background characteristics. Unlike other indicators higher proportion of children are exclusively breastfed by mothers of lower levels of education and belonging to lower wealth categories as compared to higher education and richer classes, respectively, though the patterns are not so pronounced. Nutrition l 31 Figure NU.3: Percentage of children (0-5 months) exclusively breastfed by background characteristics, Bangladesh MICS, 2012-2013 56.4 52.7 57.3 59.3 59.5 49.0 Mother’s Education Wealth index quintile National Area 57.7 53.9 58.5 62.3 53.8 53.3 52.4 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 32.1 months for any breastfeeding, 3.1 months for exclusive breastfeeding, and 4.9 months for predominant breast feeding. The differences in median duration of any breastfeeding and exclusive breastfeeding are not large across gender, but noticeable between areas and divisions; children in rural areas are likely to be breastfed for a longer period of time while that of Dhaka division for a shorter period of time. And so are those with mothers having lower levels of education or belonging to poorer households. Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Bangladesh, 2012-2013 Median duration (in months) of Number of children age 0-35 monthsAny breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Median 32.1 3.1 4.9 12,265 Sex Male 33.8 3.1 4.7 6,219 Female 31.5 3.2 5.2 6,046 Region Barisal 33.3 3.8 5.1 729 Chittagong 25.1 4.6 7.7 2,866 Dhaka 33.0 2.3 3.8 3,843 Khulna ≥36.0 2.5 4.3 1,170 Rajshahi ≥36.0 2.5 4.1 1,384 Rangpur 33.9 4.0 5.5 1,337 Sylhet 29.7 2.7 5.4 936 Area Urban 28.2 2.7 4.4 2,535 Rural 33.1 3.2 5.1 9,730 Mother’s education None 33.1 3.5 5.5 2,431 Primary incomplete ≥36.0 3.6 5.5 1,665 Primary complete 32.6 2.4 4.9 1,913 Secondary incomplete 31.5 3.2 4.8 4,538 Secondary complete or higher 29.5 2.8 4.3 1,717 32 l PROGOTIR PATHEY 2012-2013 Table NU.5: continued Median duration (in months) of Number of children age 0-35 monthsAny breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Wealth index quintile Poorest 33.5 3.4 5.6 2,876 Second ≥36.0 3.8 5.8 2,478 Middle 31.8 2.8 4.6 2,292 Fourth 32.5 2.9 4.7 2,238 Richest 27.5 2.7 4.2 2,382 [1] MICS indicator 2.11 - Duration of breastfeeding The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breastmilk and solid, semi-solid or soft food. The table shows that in Bangladesh, disparities in age appropriate feeding exist mainly in different divisions. For example, in Dhaka, 46.2 per cent children age 0-5 months are exclusively breastfed, whilst in Chittagong, 69.4 per cent of them are exclusively breastfed. For children age 6-23 months, these two divisions are also very different - 72 per cent in Dhaka compared to 55 per cent in Chittagong. As a result of feeding patterns, only 69.7 per cent of children age 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children age 0-23 months drops to 66.5 per cent. A wide variation is observed across divisions (Table NU.6), with the Rangpur showing the highest percentage of under 24 month children appropriately fed (76.8 per cent) and Chittagong the lowest (58.3 per cent). Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Bangladesh, 2012- 2013 Children age 0-5 months Children age 6-23 months Children age 0-23 months Per cent exclusively breastfed [1] Number of children Per cent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Per cent appropriately breastfed [2] Number of children Total 56.4 1,981 69.7 6,095 66.5 8,076 Sex Male 55.9 974 69.6 3,131 66.4 4,105 Female 56.8 1,007 69.9 2,965 66.6 3,971 Division Barisal 65.0 127 60.9 360 62.0 487 Chittagong 69.4 440 55.0 1,476 58.3 1,916 Dhaka 46.2 639 72.0 1,890 65.5 2,529 Khulna 50.5 167 83.3 605 76.2 772 Rajshahi 50.1 193 79.4 679 72.9 872 Rangpur 67.7 235 80.0 661 76.8 896 Sylhet 52.2 179 67.6 425 63.0 603 Area Urban 52.7 380 66.4 1,311 63.3 1,691 Rural 57.3 1,601 70.6 4,785 67.3 6,386 Mother’s education None 59.3 356 67.7 1,144 65.7 1,500 Primary incomplete 59.5 273 71.1 766 68.0 1,039 Primary complete 49.0 300 67.5 955 63.0 1,256 Secondary incomplete 57.7 767 70.8 2,319 67.6 3,085 Secondary complete or higher 53.9 285 70.9 911 66.8 1,196 Nutrition l 33 Table NU.6: continued Children age 0-5 months Children age 6-23 months Children age 0-23 months Per cent exclusively breastfed [1] Number of children Per cent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Per cent appropriately breastfed [2] Number of children Wealth index quintile Poorest 58.5 449 70.7 1,391 67.7 1,840 Second 62.3 436 70.9 1,198 68.6 1,634 Middle 53.8 373 70.0 1,150 66.0 1,523 Fourth 53.3 330 71.5 1,109 67.3 1,439 Richest 52.4 393 65.7 1,248 62.5 1,640 [1] MICS indicator 2.7 - Exclusive breastfeeding under 6 months [2] MICS indicator 2.12 - Age-appropriate breastfeeding Overall, 42.4 per cent of infants aged 6-8 months in Bangladesh received solid, semi-solid, or soft foods at least once during the previous day (Table NU.7). Among currently breastfeeding infants this percentage is 41.6 while it is 67.7 among infants currently not breastfeeding. There is little difference between boys and girls who are currently breastfeeding and receiving solid, semi-solid or soft foods, but boys and girls who are currently not breastfeeding are very different with boys much more likely to be receiving solid, semi-solid or soft foods. Again, children living in urban areas are more likely to receive them than those living in rural areas Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Bangladesh, 2012-2013 Currently breastfeeding Currently not breastfeeding All Per cent receiving solid, semi-solid or soft foods Number of children age 6-8 months Per cent receiving solid, semi-solid or soft foods Number of children age 6-8 months Per cent receiving solid, semi-solid or soft foods [1] Number of children age 6-8 months Total 41.6 987 (67.7) 35 42.4 1,022 Sex Male 41.9 522 (*) 20 43.2 542 Female 41.2 465 (*) 15 41.6 479 Area Urban 48.5 195 (*) 14 51.2 209 Rural 39.9 792 (*) 21 40.2 813 [1] MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle-feeding is still prevalent in Bangladesh. 12.1 per cent of children 0-23 months are fed using a bottle with a nipple. This figure increases to 17.2 per cent in children age 6-11, although declines to 8.9 in children age 12-23. The higher the mother’s education or the richer the household, the higher the proportion of children fed with a bottle with nipple (5.4 per cent in the poorest quintile and 21.9 per cent in the richest quintile). Wide gap also exist between divisions. 34 l PROGOTIR PATHEY 2012-2013 Table NU.8: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Bangladesh, 2012-2013 Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months Total 12.1 8,076 Sex Male 12.1 4,105 Female 12.1 3,971 Age 0-5 months 13.5 1,981 6-11 months 17.2 2,002 12-23 months 8.9 4,093 Division Barisal 10.2 487 Chittagong 11.1 1,916 Dhaka 17.4 2,529 Khulna 8.6 772 Rajshahi 15.5 872 Rangpur 5.4 896 Sylhet 4.5 603 Area Urban 17.1 1,691 Rural 10.8 6,386 Mother’s education None 7.0 1,500 Primary incomplete 7.8 1,039 Primary complete 10.5 1,256 Secondary incomplete 13.1 3,085 Secondary complete or higher 21.3 1,196 Wealth index quintile Poorest 5.4 1,840 Second 7.4 1,634 Middle 11.4 1,523 Fourth 15.5 1,439 Richest 21.9 1,640 [1] MICS indicator 2.18 - Bottle feeding Figure NU.4: Children age 0-23 months fed with a bottle with a nipple by background characteristics, Bangladesh, 2012-2013 Nutrition l 35 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Government of Bangladesh introduced the Iodine Deficiency Disease Prevention Law (‘Salt Law’) making it mandatory for all edible salt to be iodized during 1989. UNICEF is providing support to the Government since then for implementation of the national universal salt iodization programme. In 2013, Government revised Salt Law to harmonise standards and include iodisation of all salt including in processed food, industrial salt. In addition to legislation, apart from this, Government of Bangladesh has increased efforts on establishing sustainable infrastructure for salt iodization and monitoring, creating consumer demand for adequately iodized salt, raising awareness on the importance of adequately iodized salt and the dangers of Iodine Deficiency Disorders on growth and development with support from UNICEF and other partners. Table NU.9: Iodized salt consumption Per cent distribution of households by consumption of iodized salt, Bangladesh, 2012-2013 Per cent of households in which salt was tested Number of households Per cent of households with salt test result Total Number of households in which salt was tested or with no salt Per cent of households with no salt Not iodized 0 PPM >0 and <15 PPM 15+ PPM [1] Total 98.1 51,895 1.1 26.3 18.3 54.3 100.0 51,499 Division Barisal 99.4 3,155 0.2 12.7 24.7 62.4 100.0 3,143 Chittagong 98.4 9,278 0.6 19.5 20.6 59.3 100.0 9,188 Dhaka 98.2 16,556 1.1 21.9 12.4 64.6 100.0 16,428 Khulna 98.8 6,167 0.8 15.5 23.7 60.1 100.0 6,139 Rajshahi 98.2 7,449 0.9 42.8 20.1 36.3 100.0 7,381 Rangpur 96.9 6,454 2.8 46.8 16.6 33.8 100.0 6,435 Sylhet 96.9 2,836 1.4 22.2 25.7 50.7 100.0 2,786 Area Urban 98.6 11,144 0.5 11.1 12.2 76.1 100.0 11,049 Rural 98.0 40,751 1.3 30.4 20.0 48.4 100.0 40,450 Wealth index quintile Poorest 97.6 11,195 1.7 44.2 24.5 29.6 100.0 11,117 Second 97.8 10,510 1.5 37.1 23.3 38.2 100.0 10,434 Middle 98.2 10,163 1.1 26.6 21.1 51.2 100.0 10,086 Fourth 98.3 9,950 0.8 15.8 14.8 68.6 100.0 9,866 Richest 98.9 10,078 0.3 5.2 6.8 87.7 100.0 9,997 [1] MICS indicator 2.19 - Iodized salt consumption In about 98.1 per cent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate content. Table NU.9 shows that in a very small proportion of households (1.1 per cent), there was no salt available. In 54.3 per cent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of adequately iodized salt was particularly low in Rangpur and Rajshahi (33.8 and 36.3 per cent). More than three quarters (76.1 per cent) of urban households were found to be using adequately iodized salt as compared to only 48.4 per cent in rural areas. As expected, the difference between the richest and poorest households in terms of iodized salt consumption is significant (Figure NU.5). 36 l PROGOTIR PATHEY 2012-2013 Figure NU.5: Percentage of households consuming adequately iodized salt, Bangladesh MICS, 2012-2013 Child Health l 37 VI. Child Health Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. Following on the 42nd and 44th World Health Assembly calls for elimination of neonatal tetanus, the global community continues to work to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1,000 live births in every district by 2015. The strategy for preventing maternal and neonatal tetanus is to ensure that all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received at least two doses of tetanus toxoid during a particular pregnancy, she (and her newborn) are also considered to be protected against tetanus if the woman:  Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years;  Received at least 3 doses, the last within the previous 5 years;  Received at least 4 doses, the last within the previous 10 years;  Received 5 or more doses anytime during her life. To assess the status of tetanus vaccination coverage, women who had a live birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth, and if so, how many. Women who did not receive two or more tetanus toxoid vaccinations during this recent pregnancy were then asked about tetanus toxoid vaccinations they may have previously received. Interviewers also asked women to present their vaccination card on which dates of tetanus toxoid are recorded and referred to information from the cards when available. Table CH.1: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Bangladesh, 2012-2013 Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus [1] Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Total 39.2 22.7 6.2 9.9 2.8 80.8 7,950 Division Barisal 50.4 17.3 4.1 5.9 1.7 79.4 475 Chittagong 49.3 19.2 4.2 5.8 .8 79.4 1,851 Dhaka 40.0 21.0 7.2 11.3 3.0 82.5 2,503 Khulna 24.2 34.9 8.3 11.9 4.1 83.4 760 Rajshahi 36.9 26.3 6.2 11.4 4.2 85.0 850 Rangpur 36.4 27.8 5.9 9.9 3.4 83.4 86 Sylhet 22.4 17.6 8.0 14.4 4.4 66.7 625 Area Urban 45.4 21.1 4.3 8.4 2.6 81.8 1,681 Rural 37.5 23.2 6.7 10.3 2.9 80.5 6,268 Education None 36.0 16.6 3.8 7.7 3.6 67.7 1,460 Primary incomplete 38.9 21.5 4.8 10.1 3.1 78.4 1,056 Primary complete 39.7 22.4 7.9 8.8 3.2 81.9 1,231 Secondary incomplete 40.5 24.8 6.7 10.7 2.4 85.1 3,043 Secondary complete or higher 39.3 26.7 7.5 11.3 2.3 87.1 1,160 38 l PROGOTIR PATHEY 2012-2013 Table CH.1 : continued Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus [1] Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Wealth index quintile Poorest 36.0 21.0 4.7 10.4 2.8 74.9 1,828 Second 37.7 23.0 7.0 8.9 2.4 78.9 1,607 Middle 38.3 23.5 7.0 9.6 3.3 81.7 1,524 Fourth 38.9 26.2 6.3 9.2 3.2 83.8 1,415 Richest 45.4 20.6 6.4 11.1 2.5 86.0 1,575 [1] MICS indicator 3.9 - Neonatal tetanus protection Table CH.1 shows the protection status from tetanus of women who have had a live birth within the last 2 years. It indicates that about 80.8 per cent of women were adequately protected against tetanus. Protection levels are similar in most of the divisions, except in Sylhet, which lags behind other divisions in protection against tetanus (66.7 per cent). Overall, only about 4 in 10 women received at least two doses of Tetanus Toxoid during their last pregnancy. Protection against tetanus had a higher coverage among women who completed secondary school or higher (87.1 per cent) when compared to women with no education (67.7 per cent). The coverage also varied with the wealth levels (Figure CH.1). Figure CH.1: Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus by background characteristics, Bangladesh, 2012-2013 Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 202521. Table CH.2 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the 2 weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of those illnesses over a two-week time window. 21 World Health Organization/The United Nations Children’s Fund (UNICEF) 2013. “End preventable deaths: Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea”, 2013 Child Health l 39 The definition of a case of diarrhoea or fever, in this survey, was the mother’s or caretaker’s report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must consequently be interpreted with caution. For these reasons, although the period-prevalence over a two-week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. Table CH.2 Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea and/or symptoms of acute respiratory infection (ARI) in the last two weeks, Bangladesh, 2012-2013 Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhoea Symptoms of ARI Total 3.9 3.2 20,903 Sex Male 3.9 3.5 10,694 Female 4.0 2.9 10,209 Division Barisal 6.3 4.1 1,270 Chittagong 4.5 3.6 4,792 Dhaka 3.5 2.1 6,456 Khulna 3.3 4.3 2,014 Rajshahi 3.5 3.1 2,405 Rangpur 3.8 3.2 2,372 Sylhet 3.8 4.7 1,595 Area Urban 4.6 2.4 4,268 Rural 3.8 3.4 16,635 Age 0-11 months 5.4 4.5 3,983 12-23 months 7.7 4.1 4,093 24-35 months 3.3 3.0 4,189 36-47 months 2.2 2.5 4,332 48-59 months 1.4 2.1 4,306 Mother’s education None 3.8 2.9 4,700 Primary incomplete 4.7 3.8 2,944 Primary complete 3.6 3.2 3,256 Secondary incomplete 3.9 3.5 7,291 Secondary complete or higher 3.9 2.3 2,711 Wealth index quintile Poorest 4.8 3.8 5,105 Second 3.6 4.1 4,285 Middle 3.4 3.0 3,886 Fourth 3.7 2.8 3,750 Richest 4.0 2.0 3,877 Overall, 3.9 per cent of under five children were reported to have had diarrhoea in the two weeks preceding the survey, 3.2 per cent symptoms of ARI (Table CH.2). There are minor differences between urban and rural areas, particularly in the case of diarrhoea and ARI. 40 l PROGOTIR PATHEY 2012-2013 Diarrhoea Diarrhoea is a leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – mostly through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. In addition, provision of zinc supplements has been shown to reduce the duration and severity of the illness as well as the risk of future episodes. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. In the MICS, mothers or caretakers were asked whether their child under age five years had an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness, including what the child had been given to drink and eat during the episode and whether this was more or less than what was usually given to the child. The overall period-prevalence of diarrhoea in children under 5 years of age is 3.9 per cent (Table CH.2) and ranges from 3.3 per cent in Khulna division to 6.3 per cent in Barisal division. The highest period-prevalence is seen among children age 12-23 months which grossly corresponds to the weaning period. The spatial distribution of prevalence of diarrhoea in different districts is presented in Map CH.1. Map CH.1: Children age 0-59 months with diarrhoea in the last two weeks by district, Bangladesh, 2012-2013 Naoganon Dinajpur KurigramRangpur Joypurhat Gaibandha Nawabganj Rajshahi Bogra Jamalpur Sherpur Mymensingh Gazipur Tangail Netrokona Kishoreganj Maulvibazar SylhetSunamganj Sirajganj Narsingdi Brahmanbaria Habiganj ComillaMunshiganj Manikganj Dhaka Narayanganj Natore Pabna Kushtia Chandpur Lakshmipur Noakhali Faridpur Gopalganj Shariatpur Bagerhat Pirojpur Patuakhali Barguna Jhalokati Bhola Meherpur Rajbari Jhenaidah Magura Chuadanga Jessore Narail Satkhira Khulna Khagrachhari Feni Ramgamati Chittagong Bandarban Cox's Bazar Barisal Madaripur Thakurgaon Nilphamari Panchagarh Lalmonirhat Per cent Child Health l 41 Ta bl e CH .3 : F ee di ng p ra cti ce s du ri ng d ia rr ho ea Pe r ce nt d is tr ib uti on o f c hi ld re n ag e 0- 59 m on th s w it h di ar rh oe a in t he la st t w o w ee ks b y am ou nt o f l iq ui ds a nd fo od g iv en d ur in g ep is od e of d ia rr ho ea , B an gl ad es h, 2 01 2- 20 13 Ha d di ar rh oe a in la st tw o w ee ks Nu m be r o f ch ild re n ag e 0- 59 m on th s D rin ki ng p ra cti ce s du rin g di ar rh oe a: Ea tin g pr ac tic es d ur in g di ar rh oe a: Nu m be r o f ch ild re n ag ed 0- 59 m on th s w ith d ia rr ho ea Gi ve n m uc h le ss to dr in k Gi ve n so m ew ha t le ss to dr in k Gi ve n ab ou t th e sa m e to d rin k Gi ve n m or e to d rin k Gi ve n no th in g to d rin k M is si ng / D K To ta l Gi ve n m uc h le ss to ea t Gi ve n so m ew ha t le ss to e at Gi ve n ab ou t t he sa m e to ea t Gi ve n m or e to e at St op pe d fo od Ha d ne ve r be en giv en fo od M iss in g /D K To ta l To ta l 3. 9 20 ,9 03 15 .4 26 .8 32 .6 23 .0 1. 2 1. 1 10 0. 0 17 .4 38 .4 34 .6 6. 1 1. 4 0. 5 1. 7 10 0. 0 82 5 Se x M al e 3. 9 10 ,6 94 12 .8 29 .1 32 .0 23 .9 1. 7 0. 5 10 0. 0 15 .6 40 .8 34 .2 6. 3 1. 6 0. 4 1. 0 10 0. 0 42 1 Fe m al e 4. 0 10 ,2 09 18 .1 24 .5 33 .1 22 .0 0. 6 1. 7 10 0. 0 19 .3 35 .9 35 .0 5. 8 1. 2 0. 5 2. 4 10 0. 0 40 4 D iv is io n Ba ris al 6. 3 1, 27 0 13 .2 22 .3 34 .4 28 .8 0. 8 0. 4 10 0. 0 24 .9 34 .3 33 .4 6. 4 0. 5 0. 0 0. 4 10 0. 0 80 Ch itt ag on g 4. 5 4, 79 2 17 .8 32 .2 38 .0 11 .4 0. 1 0. 5 10 0. 0 8. 2 46 .4 37 .7 3. 0 4. 0 0. 1 0. 5 10 0. 0 21 8 Dh ak a 3. 5 6, 45 6 16 .3 22 .5 29 .7 28 .1 1. 9 1. 6 10 0. 0 21 .0 34 .4 35 .3 6. 5 0. 4 0. 4 2. 0 10 0. 0 22 4 Kh ul na 3. 3 2, 01 4 18 .9 30 .4 24 .0 20 .7 3. 9 2. 0 10 0. 0 22 .0 50 .0 21 .5 5. 1 0. 0 0. 0 1. 4 10 0. 0 67 Ra jsh ah i 3. 5 2, 40 5 10 .8 23 .3 29 .3 35 .4 0. 0 1. 3 10 0. 0 20 .3 27 .1 39 .2 10 .6 0. 0 0. 0 2. 9 10 0. 0 85 Ra ng pu r 3. 8 2, 37 2 12 .2 24 .5 35 .3 27 .6 0. 5 0. 0 10 0. 0 12 .9 32 .1 36 .2 12 .9 1. 2 1. 4 3. 3 10 0. 0 90 Sy lh et 3. 8 1, 59 5 13 .3 34 .0 31 .3 16 .5 2. 5 2. 4 10 0. 0 24 .3 41 .6 28 .1 0. 0 0. 9 2. 1 3. 0 10 0. 0 61 A re a U rb an 4. 6 4, 26 8 23 .2 23 .4 34 .6 18 .5 0. 0 0. 3 10 0. 0 16 .0 42 .1 37 .1 4. 6 0. 0 0. 0 0. 2 10 0. 0 19 8 Ru ra l 3. 8 16 ,6 35 12 .9 27 .9 31 .9 24 .4 1. 5 1. 3 10 0. 0 17 .8 37 .2 33 .8 6. 5 1. 9 0. 6 2. 2 10 0. 0 62 7 Ag e 0- 11 5. 4 3, 98 3 20 .8 31 .1 32 .2 14 .7 0. 8 0. 4 10 0. 0 22 .1 34 .0 33 .6 5. 7 2. 4 0. 7 1. 3 10 0. 0 21 3 12 -2 3 7. 7 4, 09 3 14 .4 26 .8 34 .9 20 .6 1. 6 1. 6 10 0. 0 15 .9 41 .6 33 .6 5. 6 1. 0 0. 4 1. 9 10 0. 0 31 5 24 -3 5 3. 3 4, 18 9 12 .6 21 .3 30 .7 33 .4 1. 1 0. 8 10 0. 0 17 .8 34 .5 36 .1 7. 7 2. 2 0. 0 1. 6 10 0. 0 14 0 36 -4 7 2. 2 4, 33 2 12 .5 26 .7 27 .5 31 .9 0. 0 1. 4 10 0. 0 10 .3 41 .5 39 .4 6. 2 0. 3 1. 0 1. 4 10 0. 0 97 48 -5 9 1. 4 4, 30 6 12 .6 24 .7 33 .9 26 .4 2. 0 0. 5 10 0. 0 18 .6 40 .5 32 .3 5. 9 0. 0 0. 0 2. 8 10 0. 0 61 M ot he r’ s ed uc ati on N on e 3. 8 4, 70 0 15 .6 25 .6 30 .4 22 .3 3. 5 2. 6 10 0. 0 18 .0 32 .9 39 .3 4. 4 1. 5 0. 9 2. 9 10 0. 0 18 0 Pr im ar y in co m pl et e 4. 7 2, 94 4 14 .5 31 .0 32 .9 17 .6 2. 1 2. 0 10 0. 0 17 .3 46 .3 25 .6 3. 8 3. 3 0. 4 3. 3 10 0. 0 13 9 Pr im ar y co m pl et e 3. 6 3, 25 6 13 .4 27 .8 31 .6 27 .2 0. 0 0. 0 10 0. 0 21 .0 33 .5 33 .1 11 .2 1. 1 0. 0 0. 2 10 0. 0 11 8 Se co nd ar y in co m pl et e 3. 9 7, 29 1 19 .4 24 .5 30 .5 25 .0 0. 2 0. 5 10 0. 0 19 .2 39 .2 33 .0 5. 8 1. 1 0. 2 1. 4 10 0. 0 28 2 Se co nd ar y co m pl et e or hi gh er 3. 9 2, 71 1 7. 8 28 .6 42 .5 21 .2 0. 0 0. 0 10 0. 0 7. 6 40 .4 44 .3 6. 8 0. 0 0. 9 0. 0 10 0. 0 10 6 W ea lt h in de x qu in ti le Po or es t 4. 8 5, 10 5 13 .1 33 .1 24 .0 26 .8 1. 1 2. 0 10 0. 0 16 .0 39 .0 33 .3 6. 3 1. 6 0. 6 3. 1 10 0. 0 24 6 Se co nd 3. 6 4, 28 5 14 .8 22 .9 36 .8 22 .0 1. 6 1. 9 10 0. 0 24 .0 32 .0 35 .8 3. 2 0. 7 0. 8 3. 5 10 0. 0 15 5 M id dl e 3. 4 3, 88 6 13 .3 24 .1 42 .2 19 .5 0. 9 0. 0 10 0. 0 14 .6 31 .4 42 .2 5. 9 5. 2 0. 7 0. 0 10 0. 0 13 0 Fo ur th 3. 7 3, 75 0 13 .6 26 .0 33 .0 25 .0 2. 3 0. 0 10 0. 0 20 .0 43 .2 26 .8 9. 9 0. 0 0. 0 0. 0 10 0. 0 13 9 Ri ch es t 4. 0 3, 87 7 23 .0 23 .8 33 .5 19 .0 0. 0 0. 7 10 0. 0 12 .9 45 .1 36 .1 5. 3 0. 0 0. 0 0. 7 10 0. 0 15 5 42 l PROGOTIR PATHEY 2012-2013 Table CH.3 provides statistics on drinking and feeding practices during diarrhoea. Less than one quarter (23 per cent) of children under age 5 with diarrhoea were given more than the usual amount to drink, while about one in every three children (32.6 per cent) was given the same amount. Resulting that four in every 10 children were given less than usual amount to drink during the episode. Among children of different ages, the youngest, of age 0-11 months, were least likely to be given more than usual amount to drink (14.7 per cent). Nearly four in every ten (38.4 per cent) with diarrhoea were given somewhat less to eat than normal with another 2 in 10 (19.3 per cent) given much less or nothing to eat. More than every 1 in two children under 5, suffering from diarrhoea were given less to eat than normal during the latest episode. Table CH.4: Oral rehydration solutions and recommended homemade fluids Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, Bangladesh, 2012-2013 Had diarrhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea Recommended homemade fluids Any recommended homemade fluid ORS or any recommended homemade fluid ORS (Fluid from ORS packet or pre- packaged ORS fluid) Sugar and salt solution Green coconut water Rice water Boiled rice water Total 3.9 20,903 73.0 14.5 10.2 11.4 9.8 29.4 78.8 825 Sex Male 3.9 10,694 72.2 17.1 9.4 12.0 10.5 29.8 78.7 421 Female 4.0 10,209 73.7 11.8 11.0 10.7 9.0 29.0 78.9 404 Division Barisal 6.3 1,270 64.6 16.9 16.7 7.1 12.6 31.1 69.5 80 Chittagong 4.5 4,792 70.5 20.3 19.0 12.1 11.9 38.9 79.8 218 Dhaka 3.5 6,456 81.5 10.7 7.4 9.7 9.0 23.3 84.4 224 Khulna 3.3 2,014 79.7 9.1 3.6 17.9 6.0 27.1 81.8 67 Rajshahi 3.5 2,405 67.1 9.9 4.5 5.6 9.9 25.3 73.5 85 Rangpur 3.8 2,372 69.3 21.5 4.6 22.4 10.3 34.7 76.0 90 Sylhet 3.8 1,595 67.8 6.7 3.9 4.7 5.0 16.6 74.8 61 Area Urban 4.6 4,268 77.5 8.7 6.2 9.5 3.0 20.9 81.5 198 Rural 3.8 16,635 71.5 16.4 11.5 12.0 11.9 32.1 77.9 627 Age 0-11 months 5.4 3,983 71.1 6.8 2.3 8.1 3.9 15.0 73.8 213 12-23 months 7.7 4,093 73.6 18.4 11.8 14.5 11.3 35.6 80.1 315 24-35 months 3.3 4,189 69.5 16.7 17.7 13.2 15.8 38.7 78.9 140 36-47 months 2.2 4,332 77.9 16.3 10.6 7.4 6.9 26.7 82.9 97 48-59 months 1.4 4,306 76.1 13.8 11.9 8.5 13.5 30.6 82.4 61 Mother’s education None 3.8 4,700 65.2 11.5 10.8 7.3 12.8 27.2 73.7 180 Primary incomplete 4.7 2,944 73.5 12.1 10.4 9.1 11.1 28.1 78.3 139 Primary complete 3.6 3,256 80.5 13.1 14.4 10.9 9.9 27.9 81.5 118 Secondary incomplete 3.9 7,291 76.4 17.6 10.5 16.5 10.1 33.3 81.0 282 Secondary complete or higher 3.9 2,711 68.0 16.1 3.4 8.2 2.1 26.1 79.0 106 Wealth index quintile Poorest 4.8 5,105 67.8 14.8 10.9 9.5 12.6 31.9 76.7 246 Second 3.6 4,285 68.3 15.7 10.8 14.9 15.5 35.5 72.8 155 Middle 3.4 3,886 71.4 10.4 6.9 8.0 8.4 22.6 76.9 130 Fourth 3.7 3,750 84.8 18.7 15.8 11.7 8.8 31.1 88.8 139 Richest 4.0 3,877 76.5 12.6 6.1 13.3 1.7 23.5 80.7 155 Child Health l 43 Table CH.4 shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. As high as 73 per cent received fluids from ORS packets or pre-packaged ORS fluids and 29.4 per cent received recommended homemade fluids. Approximately 79 per cent of children with diarrhoea received ORS or any recommended homemade fluid. The influence of wealth and education is not clear but urban children were more likely to receive ORS or any recommended homemade fluid (81.5 per cent in urban areas versus 77.9 per cent in rural areas). Divisions vary significantly (see Figure CH.2 below); Dhaka division had very high proportion of children under 5 receiving ORS or any recommended fluid (84.4 per cent), whereas Barisal had much smaller percentages (69.5 per cent). Figure CH.2: Children under-5 with diarrhoea who received ORS or recommended homemade liquids, Bangladesh, 2012-2013 44 l PROGOTIR PATHEY 2012-2013 Ta bl e CH .5 : O ra l r eh yd ra ti on t he ra py w it h co nti nu ed fe ed in g an d ot he r tr ea tm en ts Pe rc en ta ge o f c hi ld re n ag e 0- 59 m on th s w it h di ar rh oe a in t he la st t w o w ee ks w ho w er e gi ve n or al r eh yd ra ti on t he ra py w it h co nti nu ed fe ed in g an d pe rc en ta ge w ho w er e gi ve n ot he r tr ea tm en ts , Ba ng la de sh , 2 01 2- 20 13 Ch ild re n w ith d ia rr ho ea w ho w er e gi ve n: No t gi ve n an y tre at m en t or d ru g Nu m be r o f ch ild re n ag ed 0- 59 m on th s w ith di ar rh oe a OR S or in cr ea se d flu id s O RT (O RS o r re co m m en de d ho m em ad e flu id s or in cr ea se d flu id s) O RT w ith co nti nu ed fe ed in g [1 ] Ot he r t re at m en ts Pi ll or sy ru p In je cti on In tra ve no us Ho m e re m ed y He rb al m ed ici ne Ot he r An tib io tic An tim oti lit y Zi nc Ot he r U nk no w n An tib io tic N on -a nti bi oti c U nk no w n To ta l 77 .1 81 .5 64 .6 18 .8 2. 4 11 .8 1. 4 17 .6 1. 4 0. 4 0. 5 0. 1 1. 7 5. 1 11 .0 82 5 Se x M al e 77 .0 82 .4 66 .3 19 .9 2. 7 10 .8 2. 0 20 .4 1. 9 0. 0 0. 7 0. 0 1. 6 5. 1 11 .5 42 1 Fe m al e 77 .2 80 .7 62 .7 17 .6 2. 1 12 .8 0. 8 14 .7 0. 9 0. 7 0. 3 0. 2 1. 8 5. 0 10 .4 40 4 D iv is io n Ba ris al 72 .4 76 .4 59 .5 12 .9 0. 0 5. 5 0. 7 27 .1 0. 0 0. 0 0. 0 0. 0 0. 0 4. 4 16 .4 80 Ch itt ag on g 71 .5 79 .9 68 .7 24 .2 4. 5 10 .8 0. 5 9. 8 3. 1 0. 0 0. 4 0. 0 0. 1 5. 5 10 .0 21 8 Dh ak a 85 .6 86 .2 64 .2 14 .0 1. 5 18 .1 1. 5 19 .0 0. 9 0. 0 0. 7 0. 0 3. 3 2. 5 8. 9 22 4 Kh ul na 81 .5 83 .6 65 .1 17 .9 1. 2 3. 7 0. 0 18 .2 0. 6 1. 0 1. 7 0. 0 2. 5 8. 4 6. 9 67 Ra jsh ah i 77 .1 81 .8 65 .2 24 .4 1. 7 10 .5 1. 5 13 .2 1. 5 2. 7 0. 0 0. 0 3. 0 3. 2 12 .1 85 Ra ng pu r 75 .2 81 .2 67 .6 10 .9 1. 4 8. 9 0. 7 28 .2 0. 8 0. 0 0. 3 0. 0 0. 4 10 .0 14 .2 90 Sy lh et 70 .1 74 .8 51 .6 29 .3 5. 6 15 .7 7. 7 17 .8 1. 2 0. 0 0. 0 1. 2 3. 0 5. 2 12 .8 61 A re a Ur ba n 79 .2 81 .7 67 .1 16 .0 0. 4 20 .5 0. 5 10 .0 0. 7 0. 0 1. 2 0. 0 2. 2 6. 9 12 .3 19 8 Ru ra l 76 .4 81 .5 63 .7 19 .7 3. 1 9. 1 1. 7 20 .0 1. 7 0. 5 0. 3 0. 1 1. 5 4. 5 10 .6 62 7 Ag e 0- 11 m on th s 72 .9 75 .6 55 .2 21 .3 4. 6 17 .5 0. 6 17 .9 0. 3 0. 0 0. 3 0. 0 2. 2 5. 6 12 .5 21 3 12 -2 3 m on th s 77 .2 81 .6 65 .8 20 .2 1. 9 14 .4 1. 5 18 .0 2. 7 0. 9 0. 6 0. 2 2. 3 5. 6 10 .9 31 5 24 -3 5 m on th s 76 .2 84 .3 66 .9 19 .6 1. 1 5. 7 1. 1 16 .2 1. 4 0. 0 0. 3 0. 0 0. 1 2. 3 10 .8 14 0 36 -4 7 m on th s 82 .7 86 .8 76 .6 14 .0 0. 0 6. 5 3. 6 16 .3 0. 0 0. 0 0. 9 0. 0 0. 3 5. 1 9. 4 97 48 -5 9 m on th s 84 .2 87 .3 66 .5 8. 4 4. 5 1. 1 1. 1 19 .9 1. 1 0. 0 0. 0 0. 0 2. 8 6. 7 9. 0 61 M ot he r’ s ed uc ati on No ne 70 .9 76 .4 59 .3 13 .9 4. 5 7. 1 1. 3 17 .1 0. 0 0. 4 0. 8 0. 0 2. 0 6. 9 16 .3 18 0 Pr im ar y in co m pl et e 76 .8 80 .5 61 .6 16 .9 0. 0 3. 2 0. 9 17 .5 1. 0 1. 7 0. 1 0. 0 2. 2 7. 1 10 .6 13 9 Pr im ar y co m pl et e 85 .1 86 .1 67 .5 17 .9 4. 7 11 .2 1. 1 20 .6 2. 2 0. 0 0. 6 0. 6 0. 2 2. 1 8. 1 11 8 Se co nd ar y in co m pl et e 80 .8 83 .9 65 .0 19 .3 2. 2 16 .1 1. 8 16 .2 2. 5 0. 0 0. 6 0. 0 1. 5 4. 1 8. 7 28 2 Se co nd ar y co m pl et e or h ig he r 69 .3 80 .3 72 .9 29 .2 0. 0 20 .4 1. 5 18 .8 0. 7 0. 0 0. 0 0. 0 2. 7 5. 2 11 .5 10 6 W ea lt h in de x qu in ti le Po or es t 74 .5 80 .1 63 .1 17 .7 5. 1 6. 7 1. 7 19 .5 0. 3 1. 2 0. 5 0. 0 0. 6 7. 4 12 .8 24 6 Se co nd 71 .6 76 .2 56 .1 13 .6 1. 6 11 .6 1. 7 16 .3 1. 3 0. 0 0. 6 0. 0 3. 8 3. 2 15 .6 15 5 M id dl e 76 .2 81 .0 61 .9 20 .3 2. 2 6. 8 2. 3 21 .5 1. 9 0. 0 0. 3 0. 6 2. 7 5. 6 8. 0 13 0 Fo ur th 88 .1 91 .5 74 .6 25 .1 0. 6 12 .8 0. 5 20 .9 1. 9 0. 0 1. 1 0. 0 0. 5 3. 7 3. 2 13 9 Ri ch es t 77 .6 80 .7 68 .5 18 .7 1. 0 23 .5 0. 7 9. 7 2. 7 0. 0 0. 0 0. 0 1. 7 4. 0 12 .8 15 5 [1 ] M IC S in di ca to r 3 .1 2- D ia rr ho ea tr ea tm en t w ith o ra l r eh yd ra tio n th er ap y (O RT ) a nd c on tin ue d fe ed in g Child Health l 45 Table CH.5 provides the proportion of children aged 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments. Overall, 77.1 per cent of children with diarrhoea received ORS or increased fluids, 81.5 per cent received ORT (ORS or recommended homemade fluids or increased fluids). Use of ORS and ORT increased with the age of the child and was also higher among those living in the Dhaka division (86.2 per cent) as compared to other divisions, with Sylhet having the lowest levels of ORT use at 75.4 per cent. As is reflected from the table, 64.6 per cent of children received both oral rehydration therapy (ORT) and continued feeding, as per the recommendation. There were some differences in the home management of diarrhoea by background characteristics. Boys, as compared to girls, and children living in urban areas were more likely to receive ORT together with continued feeding. Geographical variation also existed with children in Sylhet division much less likely to receive such treatment (51.6 per cent) as compared to other areas (60 per cent or more). Figure CH.3: Children under-5 with diarrhoea who received oral rehydration therapy (ORT) and continued feeding, Bangladesh, 2012-2013 0 10 20 30 40 50 60 70 80 Division Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Area Urban Rural Mother’s Education None Primary incomplete Primary complete Secondary incomplete Secondary complete or higher Bangladesh Per cent Acute Respiratory Infections Symptoms of ARI are collected during the Bangladesh MICS 2012-2013 to capture pneumonia disease, the leading cause of death in children under five. Once diagnosed, pneumonia is treated effectively with antibiotics. Studies have shown a limitation in the survey approach of measuring pneumonia because many of the suspected cases identified through surveys are in fact, not true pneumonia.22 While this limitation does not affect the level and patterns of care-seeking for suspected pneumonia, it limits the validity of the level of treatment of pneumonia with antibiotics, as reported through household surveys. The treatment indicator described in this report must therefore be taken with caution, keeping in mind that the accurate level is likely higher. 22 Campbell H, el Arifeen S, Hazir T, O’Kelly J, Bryce J, et al. (2013) Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatment. PLoS Med 10(5): e1001421. doi:10.1371/journal.pmed.1001421 46 l PROGOTIR PATHEY 2012-2013 Ta bl e CH .6 : C ar e- se ek in g fo r an d an ti bi oti c tr ea tm en t of s ym pt om s of a cu te r es pi ra to ry in fe cti on (A R I) Pe rc en ta ge o f c hi ld re n ag e 0- 59 m on th s w ith sy m pt om s of A RI in th e la st tw o w ee ks w ho w er e ta ke n to a h ea lth p ro vi de r a nd p er ce nt ag e of c hi ld re n w ho w er e gi ve n an tib io tic s, B an gl ad es h, 2 01 2- 20 13 Ha d su sp ec te d pn eu m on ia in th e la st tw o w ee ks Nu m be r o f ch ild re n ag e 0- 59 m on th s Pu bl ic s ec to r: Go ve rn m en t ho sp ita l Ch ild re n w ith s us pe ct ed p ne um on ia w ho w er e ta ke n to : An y ap pr op ria te pr ov id er [1 ] Pe rc en ta ge of ch ild re n w ith su sp ec te d pn eu m on ia w ho re ce ive d an tib io tic s in th e la st tw o w ee ks [2 ] Nu m be r of ch ild re n ag e 0- 59 m on th s w ith su sp ec te d pn eu m on ia in th e la st tw o w ee ks Pu bl ic s ec to r: Go ve rn m en t ho sp ita l Pu bl ic s ec to r: Go ve rn m en t he al th ce nt er Pu bl ic s ec to r: Go ve rn m en t he al th p os t Pu bl ic se ct or : Vi lla ge he al th w or ke r Pu bl ic se ct or : M ob ile / Ou tre ac h cli ni c Ot he r pu bl ic Pr iva te ho sp ita l / cli ni c Pr iva te ph ys ici an Pr iva te ph ar m ac y M ob ile cli ni c Ot he r pr iva te m ed ica l Re la tiv e / Fr ie nd Sh op Tr ad iti on al pr ac titi on er Ot he r To ta l 3. 2 20 ,9 03 13 .2 2. 8 0. 7 3. 4 0. 0 0. 5 5. 6 9. 1 15 .9 0. 5 0. 9 0. 5 6. 8 23 .0 3. 7 35 .8 74 .3 67 0 Se x M al e 3. 5 10 ,6 94 13 .6 2. 8 1. 3 3. 7 0. 0 0. 3 6. 6 10 .0 14 .7 0. 1 1. 6 0. 6 5. 9 21 .8 3. 3 38 .8 76 .1 37 5 Fe m al e 2. 9 10 ,2 09 12 .6 2. 8 0. 0 3. 1 0. 0 0. 7 4. 3 8. 1 17 .5 1. 1 0. 0 0. 4 8. 0 24 .4 4. 2 31 .9 71 .9 29 5 D iv is io n Ba ris al 4. 1 1, 27 0 12 .2 5. 5 0. 0 3. 8 0. 0 0. 0 3. 8 0. 8 25 .3 0. 0 0. 0 0. 0 6. 1 28 .0 2. 3 26 .1 78 .4 51 Ch itt ag on g 3. 6 4, 79 2 8. 1 1. 1 2. 5 2. 2 0. 0 0. 7 3. 0 8. 5 15 .6 2. 1 2. 2 0. 2 9. 2 24 .1 2. 9 30 .0 66 .8 17 3 Dh ak a 2. 1 6, 45 6 17 .3 3. 7 0. 5 4. 2 0. 0 0. 8 6. 3 7. 7 17 .4 0. 0 0. 0 0. 0 7. 5 18 .8 1. 4 37 .8 82 .3 13 3 Kh ul na 4. 3 2, 01 4 17 .1 3. 8 0. 0 3. 7 0. 0 0. 0 16 .2 5. 5 7. 8 0. 0 0. 0 1. 0 0. 0 24 .5 1. 9 46 .2 76 .4 86 Ra jsh ah i 3. 1 2, 40 5 16 .8 3. 1 0. 0 1. 6 0. 0 0. 0 5. 8 6. 6 17 .8 0. 0 1. 1 0. 0 0. 0 31 .7 8. 5 35 .0 69 .4 75 Ra ng pu r 3. 2 2, 37 2 11 .8 0. 9 0. 0 6. 1 0. 0 0. 0 3. 5 15 .0 8. 4 0. 0 1. 6 3. 2 10 .0 24 .1 3. 3 37 .7 72 .8 76 Sy lh et 4. 7 1, 59 5 11 .4 3. 7 0. 0 3. 5 0. 0 1. 2 1. 1 19 .7 22 .8 0. 0 0. 0 0. 0 11 .9 12 .6 8. 1 39 .2 78 .6 75 Ar ea Ur ba n 2. 4 4, 26 8 7. 2 5. 0 0. 0 1. 3 0. 0 3. 1 4. 8 17 .6 21 .6 3. 1 3. 1 0. 3 6. 2 12 .4 1. 7 44 .1 81 .5 10 1 Ru ra l 3. 4 16 ,6 35 14 .2 2. 4 0. 9 3. 8 0. 0 0. 0 5. 7 7. 6 14 .9 0. 1 0. 5 0. 6 6. 9 24 .8 4. 0 34 .3 73 .0 56 9 Ag e 0- 11 4. 5 3, 98 3 16 .2 2. 2 0. 4 6. 0 0. 0 0. 6 5. 5 13 .3 15 .2 0. 0 1. 7 1. 6 7. 1 23 .3 4. 6 44 .0 74 .9 17 8 12 -2 3 4. 1 4, 09 3 9. 2 3. 5 0. 0 2. 9 0. 0 0. 5 6. 5 6. 8 10 .9 2. 0 0. 4 0. 4 6. 9 22 .9 6. 5 31 .4 74 .1 17 0 24 -3 5 3. 0 4, 18 9 14 .8 2. 1 0. 0 1. 1 0. 0 0. 9 4. 7 8. 1 19 .5 0. 1 0. 0 0. 0 8. 6 27 .8 1. 4 30 .8 79 .5 12 6 36 -4 7 2. 5 4, 33 2 14 .7 3. 0 4. 1 3. 3 0. 0 0. 0 3. 7 6. 4 13 .2 0. 0 1. 9 0. 0 6. 6 23 .5 2. 1 37 .1 71 .7 10 7 48 -5 9 2. 1 4, 30 6 10 .4 3. 4 0. 0 2. 9 0. 0 0. 0 7. 6 10 .0 25 .0 0. 0 0. 0 0. 0 3. 7 15 .0 1. 8 33 .2 69 .1 90 M ot he r’s ed uc ati on No ne 2. 9 4, 70 0 12 .0 3. 2 3. 2 4. 4 0. 0 0. 9 2. 9 9. 5 16 .0 0. 0 0. 9 0. 2 5. 4 20 .1 1. 5 35 .9 75 .6 13 5 Pr im ar y in co m pl et e 3. 8 2, 94 4 17 .6 2. 9 0. 6 3. 9 0. 0 0. 8 2. 4 4. 6 16 .5 0. 0 0. 6 0. 0 7. 0 24 .7 1. 8 32 .5 67 .4 11 1 Pr im ar y co m pl et e 3. 2 3, 25 6 7. 2 3. 0 0. 0 3. 1 0. 0 0. 0 2. 9 4. 9 21 .3 0. 3 0. 0 0. 0 10 .9 29 .1 3. 6 20 .7 76 .7 10 3 Se co nd ar y in co m pl et e 3. 5 7, 29 1 15 .6 2. 8 0. 0 2. 3 0. 0 0. 4 8. 0 10 .4 15 .5 0. 0 1. 5 1. 3 6. 2 22 .0 5. 9 40 .0 75 .0 25 7 Se co nd ar y co m pl et e or h igh er 2. 3 2, 71 1 7. 6 1. 5 0. 0 5. 6 0. 0 0. 0 11 .4 17 .8 7. 7 4. 9 0. 0 0. 0 5. 0 20 .0 2. 9 48 .7 76 .7 64 W ea lth in de x qu in til e Po or es t 3. 8 5, 10 5 15 .3 4. 0 0. 3 2. 1 0. 0 0. 6 3. 0 6. 9 16 .2 0. 0 1. 0 0. 8 3. 6 27 .3 3. 0 32 .3 68 .3 19 6 Se co nd 4. 1 4, 28 5 12 .5 2. 8 2. 5 5. 2 0. 0 0. 0 5. 4 7. 1 14 .0 0. 2 0. 0 0. 5 8. 1 23 .0 2. 7 34 .0 70 .7 17 5 M id dl e 3. 0 3, 88 6 15 .0 3. 2 0. 0 3. 9 0. 0 0. 0 3. 3 11 .8 15 .3 0. 1 0. 0 0. 0 8. 7 23 .5 6. 4 37 .3 80 .1 11 7 Fo ur th 2. 8 3, 75 0 12 .6 1. 3 0. 0 1. 1 0. 0 0. 0 6. 5 10 .2 21 .2 3. 0 3. 8 1. 0 8. 0 16 .8 3. 9 37 .9 82 .9 10 5 Ri ch es t 2. 0 3, 87 7 7. 2 1. 3 0. 0 5. 3 0. 0 2. 5 14 .6 14 .1 13 .3 0. 0 0. 0 0. 0 7. 5 19 .5 3. 3 43 .6 77 .0 77 [1 ] M IC S in di ca to r 3 .1 3 - C ar e- se ek in g fo r c hi ld re n w ith a cu te re sp ira to ry in fe cti on (A RI ) s ym pt om s [2 ] M IC S in di ca to r 3 .1 4 - A nti bi oti c tr ea tm en t f or c hi ld re n w ith A RI sy m pt om s Child Health l 47 Table CH.6 presents the percentage of children with symptoms of ARI in the two weeks preceding the survey for whom care was sought, by source of care and the percentage who received antibiotics. Nationally, 3.2 per cent of children age 0-59 months were suspected to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, only 35.8 per cent were taken to an appropriate provider and 23 per cent were taken to traditional practitioners and another 15.9 per cent to the private pharmacy. Boys were more likely to be taken to an appropriate provider than girls (38.8 per cent against 31.9 per cent). Table CH.6 also shows the point of treatment among children with symptoms of ARI who were treated with antibiotics. About 3 in every 4 under 5 year old children with symptoms of ARI received antibiotics in the two weeks prior to the survey. Taking antibiotic treatment differed between rural and urban areas – 73 per cent as compared to 81.5 per cent. Children in Dhaka, Sylhet and Barisal divisions were more likely to receive antibiotic treatment as compared to the remaining four divisions. 48 l PROGOTIR PATHEY 2012-2013 Ta bl e CH .7 : K no w le dg e of t he t w o da ng er s ig ns o f p ne um on ia Pe rc en ta ge o f w om en a ge 1 5- 49 y ea rs w ho a re m ot he rs o r ca re ta ke rs o f c hi ld re n un de r ag e 5 by s ym pt om s th at w ou ld c au se to ta ke a c hi ld c hi ld u nd er a ge 5 im m ed ia te ly to a h ea lt h fa ci lit y, a nd pe rc en ta ge o f m ot he rs w ho r ec og ni ze fa st o r di ffi cu lt b re at hi ng a s si gn s fo r se ek in g ca re im m ed ia te ly , B an gl ad es h, 2 01 2- 20 13 Pe rc en ta ge o f m ot he rs / c ar et ak er s w ho t hi nk t ha t a ch ild s ho ul d be t ak en im m ed ia te ly t o a he al th fa ci lit y if th e ch ild : M ot he rs /c ar et ak er s w ho re co gn iz e at le as t on e of th e tw o da ng er s ig ns o f pn eu m on ia (f as t an d/ or di ffi cu lt b re at hi ng ) N um be r of m ot he rs / ca re ta ke rs o f c hi ld re n ag e 0- 59 m on th s Is n ot a bl e to dr in k or br ea stf ee d Be co m es sic ke r De ve lo ps a fe ve r Ha s f as t br ea th in g H as d iffi cu lt y br ea th in g Ha s b lo od in st oo l Is d rin ki ng po or ly Ha s o th er sy m pt om s To ta l 8. 1 28 .1 79 .3 24 .8 32 .9 7. 8 5. 2 21 .9 46 .9 17 ,7 82 D iv is io n Ba ris al 4. 8 21 .2 79 .7 29 .3 25 .1 3. 9 1. 5 19 .3 41 .2 1, 09 1 Ch itt ag on g 3. 8 28 .0 63 .8 27 .8 32 .0 7. 0 4. 0 7. 3 49 .8 3, 90 4 Dh ak a 11 .9 30 .1 83 .3 20 .9 27 .8 5. 0 7. 1 25 .9 39 .0 5, 53 5 Kh ul na 9. 6 24 .0 86 .7 27 .7 43 .8 13 .5 2. 3 19 .3 55 .8 1, 80 7 Ra jsh ah i 4. 3 23 .0 86 .3 14 .9 34 .0 3. 9 1. 8 42 .8 44 .6 2, 10 4 Ra ng pu r 10 .4 21 .6 84 .5 23 .2 41 .0 13 .3 8. 1 22 .5 53 .7 2, 08 9 Sy lh et 7. 2 51 .3 79 .2 43 .5 34 .5 15 .0 9. 4 20 .0 57 .4 1, 25 0 A re a U rb an 11 .1 31 .1 79 .0 25 .4 31 .4 8. 1 7. 7 18 .8 46 .7 3, 63 9 Ru ra l 7. 3 27 .4 79 .4 24 .6 33 .3 7. 7 4. 6 22 .7 46 .9 14 ,1 42 Ed uc ati on N on e 6. 4 28 .9 77 .9 23 .5 30 .4 8. 3 4. 9 20 .7 43 .3 3, 79 1 Pr im ar y in co m pl et e 7. 2 25 .1 79 .6 23 .7 31 .1 6. 2 4. 3 24 .4 45 .3 2, 52 4 Pr im ar y co m pl et e 8. 3 30 .4 79 .7 24 .4 32 .3 8. 2 4. 5 19 .1 45 .7 2, 75 2 Se co nd ar y in co m pl et e 7. 8 27 .6 80 .3 25 .0 33 .4 7. 5 5. 2 22 .8 47 .9 6, 32 0 Se co nd ar y co m pl et e or h ig he r 12 .0 28 .9 78 .4 27 .6 38 .4 8. 6 7. 6 22 .0 52 .8 2, 39 4 W ea lt h in de x qu in ti le Po or es t 6. 0 26 .1 78 .7 21 .9 31 .1 6. 4 3. 0 24 .4 44 .3 4, 14 8 Se co nd 7. 1 26 .6 80 .4 23 .7 33 .5 7. 9 4. 6 23 .4 46 .7 3, 63 7 M id dl e 7. 6 27 .2 81 .0 25 .7 34 .1 9. 2 4. 8 21 .2 47 .7 3, 38 3 Fo ur th 8. 1 30 .4 79 .3 25 .8 32 .2 6. 9 6. 0 19 .6 46 .8 3, 24 9 Ri ch es t 12 .0 31 .1 77 .4 27 .6 34 .1 8. 7 8. 5 20 .2 49 .5 3, 36 5 Child Health l 49 Mothers’ knowledge of danger signs is an important determinant of care-seeking behaviour. In the MICS, mothers or caretakers were asked to report symptoms that would cause them to take a child under-five for care immediately at a health facility. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7. Overall, 46.9 per cent of women of age 15-49 years knew of at least one of the two danger signs of pneumonia – fast breathing and difficulty in breathing. The most commonly identified symptom for taking a child to a health facility was fever (79.3 per cent). About a quarter (24.8 per cent) of mothers identified fast breathing and 32.9 per cent identified difficult breathing as symptoms for taking children immediately to a health care provider. Wide variations are observed on knowledge levels among the divisions. It ranged from 39 per cent in Dhaka to 57.4 per cent in Sylhet. Mothers from the richer households and those with higher education level showed, in general, higher levels of knowledge in this regard. Solid Fuel Use More than 3 billion people around the world rely on solid fuels for their basic energy needs, including cooking and heating. Solid fuels include biomass fuels, such as wood, charcoal, crops or other agricultural waste, dung, shrubs and straw, and coal. Cooking and heating with solid fuels leads to high levels of indoor smoke which contains a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is their incomplete combustion, which produces toxic elements such as carbon monoxide, polyaromatic hydrocarbons, and sulphur dioxide (SO2), among others. Use of solid fuels increases the risks of incurring acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, asthma, or cataracts, and may contribute to low birth weight of babies born to pregnant women exposed to smoke. The primary indicator for monitoring use of solid fuels is the proportion of the population using solid fuels as the primary source of domestic energy for cooking, shown in Table CH.8. 50 l PROGOTIR PATHEY 2012-2013 Ta bl e CH .8 : S ol id fu el u se Pe r ce nt d is tr ib uti on o f ho us eh ol d m em be rs a cc or di ng t o ty pe o f co ok in g fu el u se d by t he h ou se ho ld , a nd p er ce nt ag e of h ou se ho ld m em be rs li vi ng in h ou se ho ld s us in g so lid f ue ls fo r co ok in g, Ba ng la de sh , 2 01 2- 20 13 Pe rc en ta ge o f h ou se ho ld m em be rs in h ou se ho ld s us in g: So lid fu el s fo r c oo ki ng [1 ] N um be r o f ho us eh ol d m em be rs El ec tr ic ity Li qu efi ed Pe tr ol eu m G as (L PG ) N at ur al ga s Bi og as Ke ro se ne Co al / Li gn ite Ch ar co al W oo d St ra w / Sh ru bs / Gr as s An im al du ng Ag ric ul tu ra l cr op re sid ue N o fo od co ok ed in h ou se ho ld O th er M iss in g To ta l To ta l 0. 1 0. 8 8. 8 0. 1 0. 1 0. 0 0. 2 67 .6 1. 8 4. 9 13 .6 0. 1 1. 7 0. 1 10 0. 0 88 .2 23 7, 39 6 D iv is io n Ba ris al 0. 2 0. 7 0. 0 0. 0 0. 0 0. 0 0. 1 92 .2 3. 0 0. 4 2. 6 0. 0 0. 8 0. 1 10 0. 0 98 .3 15 ,0 28 Ch itt ag on g 0. 0 0. 8 7. 9 0. 0 0. 1 0. 0 0. 2 89 .1 0. 1 0. 1 1. 6 0. 0 0. 0 0. 0 10 0. 0 91 .1 47 ,7 25 Dh ak a 0. 1 0. 7 21 .2 0. 1 0. 1 0. 0 0. 1 60 .0 1. 1 3. 5 11 .3 0. 1 1. 8 0. 1 10 0. 0 75 .9 72 ,9 91 Kh ul na 0. 2 1. 0 0. 2 0. 2 0. 0 0. 0 0. 6 65 .2 7. 3 13 .9 8. 8 0. 1 2. 3 0. 0 10 0. 0 95 .9 26 ,5 08 Ra jsh ah i 0. 3 1. 3 1. 1 0. 1 0. 2 0. 0 0. 1 32 .6 2. 9 13 .9 43 .3 0. 1 4. 0 0. 1 10 0. 0 92 .9 30 ,9 23 Ra ng pu r 0. 2 0. 8 0. 0 0. 2 0. 0 0. 0 0. 1 73 .7 0. 4 1. 1 20 .5 0. 3 2. 4 0. 0 10 0. 0 95 .9 28 ,2 34 Sy lh et 0. 1 0. 1 8. 5 0. 1 0. 0 0. 2 0. 1 76 .1 0. 8 5. 0 8. 9 0. 0 0. 0 0. 1 10 0. 0 91 .1 15 ,9 87 A re a U rb an 0. 5 3. 0 36 .6 0. 3 0. 3 0. 0 0. 3 50 .5 1. 2 2. 3 4. 0 0. 0 0. 9 0. 0 10 0. 0 58 .3 49 ,2 49 Ru ra l 0. 0 0. 2 1. 6 0. 0 0. 1 0. 0 0. 2 72 .1 2. 0 5. 6 16 .1 0. 1 1. 9 0. 1 10 0. 0 96 .0 18 8, 14 7 Ed uc ati on of ho us eh ol d he ad N on e 0. 0 0. 1 3. 5 0. 0 0. 0 0. 0 0. 1 68 .0 2. 3 5. 8 17 .8 0. 1 2. 1 0. 0 10 0. 0 94 .1 10 0, 95 7 Pr im ar y in co m pl et e 0. 1 0. 0 5. 9 0. 0 0. 1 0. 0 0. 2 69 .1 2. 0 5. 9 14 .6 0. 1 2. 0 0. 0 10 0. 0 91 .8 31 ,2 73 Pr im ar y co m pl et e 0. 0 0. 3 8. 5 0. 0 0. 0 0. 0 0. 1 70 .1 1. 7 4. 5 12 .8 0. 2 1. 6 0. 2 10 0. 0 89 .2 27 ,3 98 Se co nd ar y in co m pl et e 0. 2 0. 7 10 .2 0. 1 0. 2 0. 0 0. 3 70 .3 1. 5 4. 9 10 .1 0. 0 1. 4 0. 0 10 0. 0 87 .1 40 ,3 19 Se co nd ar y co m pl et e or h ig he r 0. 6 3. 9 24 .6 0. 4 0. 2 0. 0 0. 2 60 .5 1. 0 2. 1 5. 7 0. 0 0. 6 0. 0 10 0. 0 69 .6 37 ,2 61 M is si ng /D K 0. 0 0. 0 6. 1 0. 0 0. 0 0. 0 0. 0 71 .5 0. 0 3. 5 18 .9 0. 0 0. 0 0. 0 10 0. 0 93 .9 18 7 W ea lt h in de x qu in ti le Po or es t 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 1 59 .7 2. 9 5. 8 27 .8 0. 2 3. 3 0. 0 10 0. 0 96 .5 47 ,4 80 Se co nd 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 1 71 .2 2. 2 5. 8 18 .0 0. 1 2. 2 0. 1 10 0. 0 97 .4 47 ,4 82 M id dl e 0. 0 0. 0 0. 5 0. 0 0. 0 0. 0 0. 2 76 .0 1. 8 6. 6 13 .2 0. 1 1. 6 0. 0 10 0. 0 97 .8 47 ,4 79 Fo ur th 0. 0 0. 1 7. 3 0. 1 0. 1 0. 0 0. 2 77 .6 1. 5 4. 8 7. 1 0. 1 1. 0 0. 0 10 0. 0 91 .3 47 ,4 78 Ri ch es t 0. 6 3. 9 36 .4 0. 3 0. 3 0. 0 0. 2 53 .4 0. 7 1. 7 2. 0 0. 0 0. 3 0. 1 10 0. 0 58 .0 47 ,4 78 [1 ] M IC S in di ca to r 3. 15 - U se o f s ol id fu el s fo r co ok in g Child Health l 51 Overall, a majority of households in Bangladesh were using solid fuels for cooking (88.2 per cent), use of wood playing a major role (67.6 per cent). Use of solid fuels was much lower in urban areas (58.3 per cent) than in rural areas, where almost all households (96 per cent) use solid fuels. Dhaka division shows much lower use of solid fuels for cooking by households, 75.9 per cent, which may be due to a bigger proportion of richer class in the urban population as it covers Dhaka city, and availability of other fuels in this division. Almost all households in Barisal division (98.3 per cent) use solid fuel for cooking. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Table CH.9: Solid fuel use by place of cooking Per cent distribution of household members in households using solid fuels by place of cooking, Bangladesh, 2012-2013 Place of cooking: Number of household members in households using solid fuels for cooking In a separate room used as kitchen Elsewhere in the house In a separate building Outdoors Other Missing Total Total 16.7 3.9 57.8 21.2 0.3 0.1 100.0 209,384 Division Barisal 16.8 6.1 63.7 13.2 0.1 0.0 100.0 14,769 Chittagong 31.5 4.6 43.4 19.1 1.2 0.1 100.0 43,465 Dhaka 22.5 1.5 56.5 19.4 0.1 0.1 100.0 55,390 Khulna 5.7 4.1 83.3 6.8 0.1 0.0 100.0 25,419 Rajshahi 0.9 1.5 53.6 43.8 0.1 0.0 100.0 28,714 Rangpur 3.0 1.2 70.1 25.6 0.0 0.0 100.0 27,070 Sylhet 26.7 18.6 39.8 14.4 0.4 0.0 100.0 14,557 Area Urban 20.6 7.0 53.4 18.0 0.9 0.1 100.0 28,726 Rural 16.1 3.4 58.5 21.7 0.3 0.0 100.0 180,659 Education of household head None 16.4 3.9 53.4 26.0 0.3 0.1 100.0 95,026 Primary incomplete 16.0 4.5 57.5 21.7 0.2 0.0 100.0 28,706 Primary complete 16.9 4.5 59.0 18.8 0.8 0.0 100.0 24,437 Secondary incomplete 17.5 3.5 62.5 16.2 0.3 0.0 100.0 35,112 Secondary complete or higher 17.7 3.6 66.6 11.6 0.4 0.1 100.0 25,928 Missing/DK 10.7 0.0 57.3 32.1 0.0 0.0 100.0 176 Wealth index quintile Poorest 14.7 5.7 44.6 34.4 0.5 0.0 100.0 45,809 Second 14.2 3.6 58.1 24.0 0.2 0.0 100.0 46,263 Middle 16.1 2.6 61.5 19.6 0.2 0.1 100.0 46,453 Fourth 18.3 3.0 64.6 13.6 0.4 0.1 100.0 43,330 Richest 23.2 5.3 62.1 8.9 0.5 0.0 100.0 27,530 Use of solid fuel by place of cooking is depicted in Table CH.9. The presence and extent of indoor pollution are dependent on cooking practices, places used for cooking, as well as types of fuel used. According to the Bangladesh MICS 2012-2013, among those using solid fuels, about 3 in every 5 households (57.8 per cent) used a separate building as place for cooking, and 16.7 per cent used a separate room as kitchen. Another 1 in every 5 (21.2 per cent) households cooked outdoors. The divisions vary substantially in use of a separate kitchen with Rajshahi having only 0.9 per cent of households using solid fuels and having a separate kitchen and Chittagong having 31.5 per cent households in this category. 52 l PROGOTIR PATHEY 2012-2013 © U N IC EF /B A N A 20 14 -0 06 72 /H aq ue Water and Sanitation l 53 VII. Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, and physical contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances23. Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio and is an important determinant for stunting. Improved sanitation can reduce diarrheal disease by more than a third24, and can significantly lessen the adverse health impacts of other disorders responsible for death and disease among millions of children in developing countries. The MDG target(7, C) is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The indicators currently used to monitor progress are the population using an improved source of drinking water and the population using an improved sanitation facility. For more details on water and sanitation and to access some reference documents, please visit the UNICEF childinfo website25 or the website of the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation26. Use of Improved Water Sources The distribution of the population by main source of drinking water is shown in Table WS.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, compound, yard or plot, to neighbour, public tap/standpipe), tubewell/borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for handwashing and cooking. 23 WHO/UNICEF 2012 Progress on Drinking water and Sanitation: 2012 update 24 Cairncross S., Hunt C., Boisson S., et al. 2010. Water, sanitation and hygiene for the prevention of diarrhoea. International Journal of Epidemiology. 39: i193-i205. 25 http://www.childinfo.org/wes.html 26 http://www.wssinfo.org © U N IC EF /B A N A 20 14 -0 06 72 /H aq ue 54 l PROGOTIR PATHEY 2012-2013 Ta bl e W S. 1: U se o f i m pr ov ed w at er s ou rc es Pe r ce nt d is tr ib uti on o f h ou se ho ld p op ul ati on a cc or di ng to m ai n so ur ce o f d ri nk in g w at er a nd p er ce nt ag e of h ou se ho ld p op ul ati on u si ng im pr ov ed d ri nk in g w at er s ou rc es , B an gl ad es h, 2 01 2- 20 13 M ai n so ur ce o f d rin ki ng w at er Im pr ov ed so ur ce s Un im pr ov ed so ur ce s To ta l Pe rc en ta ge us in g im pr ov ed so ur ce s o f dr in kin g w at er [1 ] Nu m be r o f ho us eh ol d m em be rs Pi pe d w at er Tu be w el l, Bo re ho le Pr ot ec te d w el l Pr ot ec te d sp rin g Ra in w at er co lle cti on Bo tt le d w at er [a ] Un pr ot ec te d w el l Un pr ot ec te d sp rin g Ta nk er - tru ck Ca rt w ith sm al l t an k / dr um Su rfa ce w at er (r iv er , st re am , da m , la ke , po nd , c an al , irr ig ati on ch an ne l) Bo tt le d w at er [a ] Ot he r M iss in g Pi pe d in to dw el lin g Pi pe d in to co m po un d, ya rd o r p lo t Pi pe d to ne igh bo ur Pu bl ic ta p / sta nd pi pe To ta l 3. 1 2. 5 0. 2 1. 2 90 .6 0. 3 0. 0 0. 1 0. 0 0. 3 0. 1 0. 0 0. 0 1. 4 0. 0 0. 3 0. 0 10 0. 0 97 .9 23 7, 39 6 D iv is io n Ba ris al 0. 3 0. 0 0. 0 0. 4 94 .4 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 3. 4 0. 0 1. 3 0. 0 10 0. 0 95 .3 15 ,0 28 Ch itt ag on g 1. 2 0. 6 0. 3 1. 5 92 .5 0. 8 0. 1 0. 1 0. 0 1. 1 0. 4 0. 0 0. 0 1. 4 0. 0 0. 0 0. 0 10 0. 0 97 .0 47 ,7 25 Dh ak a 8. 4 6. 8 0. 2 1. 1 83 .4 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 10 0. 0 99 .9 72 ,9 91 Kh ul na 0. 1 0. 3 0. 3 1. 6 91 .8 0. 0 0. 0 0. 3 0. 1 0. 0 0. 0 0. 0 0. 0 4. 4 0. 0 1. 0 0. 0 10 0. 0 94 .4 26 ,5 08 Ra jsh ah i 0. 6 1. 5 0. 1 2. 0 94 .7 0. 3 0. 0 0. 0 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 0 0. 4 0. 0 10 0. 0 99 .3 30 ,9 23 Ra ng pu r 0. 3 0. 0 0. 0 0. 4 99 .0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 10 0. 0 99 .9 28 ,2 34 Sy lh et 1. 8 0. 7 0. 2 0. 8 89 .9 0. 4 0. 0 0. 0 0. 0 0. 7 0. 0 0. 0 0. 0 5. 5 0. 0 0. 0 0. 0 10 0. 0 93 .8 15 ,9 87 Ar ea Ur ba n 14 .0 9. 7 0. 6 4. 4 70 .1 0. 2 0. 0 0. 0 0. 1 0. 1 0. 0 0. 0 0. 0 0. 6 0. 0 0. 1 0. 0 10 0. 0 99 .1 49 ,2 49 Ru ra l 0. 2 0. 6 0. 1 0. 4 96 .0 0. 3 0. 0 0. 1 0. 0 0. 4 0. 1 0. 0 0. 0 1. 6 0. 0 0. 3 0. 0 10 0. 0 97 .6 18 8, 14 7 Ed uc ati on o f ho us eh ol d he ad No ne 0. 5 1. 8 0. 2 0. 5 94 .3 0. 3 0. 0 0. 0 0. 0 0. 4 0. 2 0. 0 0. 0 1. 4 0. 0 0. 2 0. 0 10 0. 0 97 .7 10 0, 95 7 Pr im ar y in co m pl et e 1. 0 2. 9 0. 2 1. 2 91 .3 0. 4 0. 0 0. 1 0. 0 0. 7 0. 1 0. 0 0. 0 1. 8 0. 0 0. 4 0. 0 10 0. 0 97 .1 31 ,2 73 Pr im ar y co m pl et e 1. 5 3. 6 0. 3 0. 9 91 .5 0. 2 0. 0 0. 0 0. 0 0. 3 0. 0 0. 0 0. 0 1. 5 0.

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