Ethiopia Mini Demographic & Health Survey-2019

Publication date: 2021

Ethiopia Mini Demographic and Health Survey 2019 E thiopia 2019 M ini D em ographic and H ealth S urvey FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA Mini Demographic and Health Survey 2019 Ethiopian Public Health Institute Addis Ababa Federal Ministry of Health Addis Ababa The DHS Program ICF Rockville, Maryland, USA May 2021 The 2019 Ethiopia Mini Demographic and Health Survey (2019 EMDHS) was implemented by the Ethiopian Public Health Institute (EPHI), in partnership with the Central Statistical Agency (CSA) and the Federal Ministry of Health (FMoH), under the overall guidance of the Technical Working Group (TWG). Data collection lasted from March to June 2019. Funding for the 2019 EMDHS was provided by the World Bank, the United States Agency for International Development (USAID), and the United Nations Children’s Fund (UNICEF). ICF provided technical assistance through The DHS Program, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Additional information about the 2019 EMDHS may be obtained from the Ethiopian Public Health Institute (EPHI), Gulele Arbegnoch Street, Gulele Sub City, Addis Ababa, Ethiopia; telephone: +251-11-275-4647; fax: +251-11-275-4744; website: http://www.ephi.gov.et. Information about The DHS Program may be obtained from ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; telephone: +1-301-407-6500; fax: +1-301-407-6501; email: info@DHSprogram.com; internet: www.DHSprogram.com. The contents of this report are the sole responsibility of EPHI and ICF and do not necessarily reflect the views of USAID, the United States Government, or other donor agencies. Cover photo: “Ethiopian gazelles obviously concerned by the foreign intruder.” © 2008 Ralf Steinberger, used under Creative Commons CC BY 2.0 license. https://flic.kr/p/21K5LMm Suggested citation: Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. Contents • iii CONTENTS TABLES AND FIGURES . v FOREWORD . ix ACKNOWLEDGEMENTS . xi ACRONYMS AND ABBREVIATIONS . xiii READING AND UNDERSTANDING TABLES FROM THE 2019 EMDHS . xv 1 INTRODUCTION AND SURVEY METHODOLOGY . 1 1.1 Survey Objectives . 1 1.2 Sample Design . 1 1.3 Questionnaires . 2 1.4 Anthropometry . 3 1.5 Training of Trainers . 3 1.6 Training of Field Staff . 3 1.7 Fieldwork . 4 1.8 Health Facility Visits . 4 1.9 Data Processing . 4 1.10 Response Rates . 5 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 7 2.1 Drinking Water Sources and Treatment . 7 2.2 Sanitation . 8 2.3 Household Wealth . 9 2.3.1 Other Housing Characteristics . 10 2.3.2 Household Durable Goods . 10 2.4 Household Status and Resiliency . 10 2.4.1 Bank Account or Microfinance Account . 10 2.4.2 Productive Safety Net Programme . 10 2.4.3 Health Insurance Coverage . 11 2.4.4 Household Ownership Status . 11 2.5 Household Population and Composition . 11 2.6 Education . 12 3 CHARACTERISTICS OF RESPONDENTS . 23 3.1 Basic Background Characteristics of Survey Respondents . 23 3.2 Education and Literacy . 24 3.3 Marital Status . 25 4 FERTILITY DETERMINANTS . 29 4.1 Children Ever Born and Living . 29 4.2 Birth Intervals . 29 4.3 Age at First Birth . 30 5 FAMILY PLANNING . 37 5.1 Contraceptive Knowledge and Use . 37 5.2 Source of Modern Contraceptive Methods . 39 iv • Contents 6 INFANT AND CHILD MORTALITY . 47 6.1 Infant and Child Mortality . 48 6.2 High-risk Fertility Behaviour . 49 7 MATERNAL HEALTH CARE . 55 7.1 Antenatal Care Coverage and Content . 56 7.1.1 Skilled Providers . 56 7.1.2 Timing and Number of ANC Visits . 56 7.2 Components of ANC . 57 7.3 Delivery Services . 57 7.3.1 Institutional Deliveries . 57 7.3.2 Skilled Assistance during Delivery . 58 7.3.3 Delivery by Caesarean Section . 59 7.4 Postnatal Care . 59 7.4.1 Postnatal Health Check for Mothers . 59 7.4.2 Postnatal Health Check for Newborns . 60 8 CHILDHOOD VACCINATIONS . 75 8.1 Vaccination of Children . 75 8.2 Uptake of the Recently Introduced Vaccines . 77 8.3 Possession and Observation of Vaccination Cards in Households . 78 8.4 Observation of Vaccination Cards in Health Facilities . 78 9 NUTRITION OF CHILDREN . 85 9.1 Nutritional Status of Children . 85 9.1.1 Anthropometry Training and Data Collection . 87 9.1.2 Levels of Child Malnutrition . 87 9.2 Infant and Young Child Feeding Practices . 88 9.2.1 Early Initiation of Breastfeeding . 88 9.2.2 Exclusive Breastfeeding . 89 9.2.3 Median Duration of Breastfeeding . 90 9.2.4 Introduction of Complementary Foods . 90 9.2.5 Minimum Dietary Diversity and Minimum Meal Frequency . 91 9.2.6 Minimum Acceptable Diet . 92 9.3 Micronutrient Intake and Supplementation among Children . 92 9.4 Micronutrient Supplementation during Pregnancy . 93 REFERENCES. 103 Appendix A SAMPLE DESIGN . 105 A.1 Introduction . 105 A.2 Sample Frame . 105 A.3 Sample Design and Implementation . 106 A.4 Sample Probabilities and Sampling Weights . 107 Appendix B ESTIMATES OF SAMPLING ERRORS . 111 Appendix C DATA QUALITY TABLES . 129 Appendix D EMDHS CONTRIBUTORS . 135 Appendix E QUESTIONNAIRES . 141 Tables and Figures • v TABLES AND FIGURES 1 INTRODUCTION AND SURVEY METHODOLOGY . 1 Table 1.1 Results of the household and individual interviews . 5 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 7 Table 2.1.1 Household drinking water . 14 Table 2.1.2 Drinking water according to region and wealth . 15 Table 2.2.1 Household sanitation facilities . 16 Table 2.2.2 Sanitation facility type according to region and wealth . 17 Table 2.3 Wealth quintiles . 17 Table 2.4 Household characteristics . 18 Table 2.5 Household possessions . 19 Table 2.6 Household status and resiliency . 19 Table 2.7 Household population by age, sex, and residence . 20 Table 2.8 Household composition . 20 Table 2.9 Educational attainment of the female household population . 21 Figure 2.1 Household drinking water by residence . 8 Figure 2.2 Household sanitation facilities by residence . 9 Figure 2.3 Household wealth by residence. 10 Figure 2.4 Population pyramid . 12 3 CHARACTERISTICS OF RESPONDENTS . 23 Table 3.1 Background characteristics of respondents . 26 Table 3.2 Educational attainment: Women . 27 Table 3.3 Literacy: Women . 28 Table 3.4 Current marital status . 28 Figure 3.1 Education of survey respondents . 24 Figure 3.2 Education of survey respondents by residence . 24 Figure 3.3 Marital status . 25 4 FERTILITY DETERMINANTS . 29 Table 4.1 Children ever born and living . 33 Table 4.2 Birth intervals . 34 Table 4.3 Age at first birth . 35 Table 4.4 Median age at first birth . 35 Figure 4.1 Birth intervals . 30 Figure 4.2 Median age at first birth by residence . 31 Figure 4.3 Median age at first birth by education . 31 5 FAMILY PLANNING . 37 Table 5.1 Knowledge of contraceptive methods . 41 Table 5.2 Knowledge of contraceptive methods according to background characteristics . 42 Table 5.3 Current use of contraception by age . 43 Table 5.4 Current use of contraception according to background characteristics . 44 Table 5.5 Source of modern contraceptive methods . 45 vi • Tables and Figures Figure 5.1 Contraceptive use . 38 Figure 5.2 Trends in contraceptive use . 38 Figure 5.3 Use of modern methods by household wealth . 39 Figure 5.4 Source of modern contraceptive methods . 39 6 INFANT AND CHILD MORTALITY . 47 Table 6.1 Early childhood mortality rates . 51 Table 6.2 Five-year early childhood mortality rates according to background characteristics . 51 Table 6.3 Ten-year early childhood mortality rates according to additional characteristics . 52 Table 6.4 High-risk fertility behaviour . 53 Figure 6.1 Trends in early childhood mortality rates . 48 Figure 6.2 Under-5 mortality by household wealth . 49 Figure 6.3 Childhood mortality by previous birth interval . 49 7 MATERNAL HEALTH CARE . 55 Table 7.1 Antenatal care . 62 Table 7.2 Number of antenatal care visits and timing of first visit . 63 Table 7.3 Components of antenatal care . 64 Table 7.4 Maternal care indicators . 65 Table 7.5 Place of delivery . 66 Table 7.6 Assistance during delivery . 67 Table 7.7 Caesarean section . 68 Table 7.8 Timing of first postnatal check for the mother . 69 Table 7.9 Type of provider of first postnatal check for the mother . 70 Table 7.10 Timing of first postnatal check for the newborn . 71 Table 7.11 Type of provider of first postnatal check for the newborn . 72 Table 7.12 Content of postnatal care for newborns . 73 Figure 7.1 Trends in antenatal care coverage . 56 Figure 7.2 Components of antenatal care . 57 Figure 7.3 Trends in place of birth . 58 Figure 7.4 Home births by birth order . 58 Figure 7.5 Assistance during delivery . 58 Figure 7.6 Skilled assistance at delivery by education . 59 8 CHILDHOOD VACCINATIONS . 75 Table 8.1 Vaccinations by source of information . 80 Table 8.2 Vaccinations by background characteristics . 81 Table 8.3 Possession and observation of vaccination cards, according to background characteristics . 82 Table 8.4 Observation of vaccination history at health facilities: Children age 0-35 months . 83 Table 8.5 Observation of vaccination history at health facilities: Children age 12-35 months . 84 Figure 8.1 Childhood vaccinations . 76 Figure 8.2 Trends in childhood vaccinations . 77 Figure 8.3 Vaccination coverage by mother’s education . 77 Tables and Figures • vii 9 NUTRITION OF CHILDREN . 85 Table 9.1 Nutritional status of children . 95 Table 9.2 Initial breastfeeding . 96 Table 9.3 Breastfeeding status by age . 97 Table 9.4 Infant and young child feeding (IYCF) indicators on breastfeeding status . 97 Table 9.5 Median duration of breastfeeding . 98 Table 9.6 Foods and liquids consumed by children in the day or night preceding the interview . 99 Table 9.7 Minimum acceptable diet . 100 Table 9.8 Micronutrient intake among children . 101 Table 9.9 Iron tablets during mother’s pregnancy . 102 Figure 9.1 Trends in nutritional status of children . 87 Figure 9.2 Trends in stunting . 87 Figure 9.3 Stunting in children by mother’s education . 88 Figure 9.4 Breastfeeding practices by age . 89 Figure 9.5 IYCF indicators on minimum acceptable diet . 92 Appendix A SAMPLE DESIGN . 105 Table A.1 Distribution of residential households by region and type of residence . 105 Table A.2 Enumeration areas and households . 106 Table A.3 Sample allocation of clusters and households . 107 Table A.4 Sample allocation of expected number of completed interviews with women measured children . 107 Table A.5 Sample implementation: Women . 109 Appendix B ESTIMATES OF SAMPLING ERRORS . 111 Table B.1 List of selected variables for sampling errors, Ethiopia Mini-DHS 2019 . 113 Table B.2 Sampling errors: Total sample, Ethiopia Mini-DHS 2019 . 114 Table B.3 Sampling errors: Urban sample, Ethiopia Mini-DHS 2019 . 115 Table B.4 Sampling errors: Rural sample, Ethiopia Mini-DHS 2019 . 116 Table B.5 Sampling errors: Tigray sample, Ethiopia Mini-DHS 2019 . 117 Table B.6 Sampling errors: Afar sample, Ethiopia Mini-DHS 2019 . 118 Table B.7 Sampling errors: Amhara sample, Ethiopia Mini-DHS 2019 . 119 Table B.8 Sampling errors: Oromia sample, Ethiopia Mini-DHS 2019 . 120 Table B.9 Sampling errors: Somali sample, Ethiopia Mini-DHS 2019 . 121 Table B.10 Sampling errors: Benishangul-Gumuz sample, Ethiopia Mini-DHS 2019 . 122 Table B.11 Sampling errors: SNNPR sample, Ethiopia Mini-DHS 2019 . 123 Table B.12 Sampling errors: Gambela sample, Ethiopia Mini-DHS 2019 . 124 Table B.13 Sampling errors: Harari sample, Ethiopia Mini-DHS 2019 . 125 Table B.14 Sampling errors: Addis Ababa sample, Ethiopia Mini-DHS 2019 . 126 Table B.15 Sampling errors: Dire Dawa sample, Ethiopia Mini-DHS 2019 . 127 Appendix C DATA QUALITY TABLES . 129 Table C.1 Household age distribution . 129 Table C.2 Age distribution of eligible and interviewed women . 129 Table C.3 Completeness of reporting . 130 Table C.4 Births by calendar years . 130 Table C.5 Reporting of age at death in days . 131 Table C.6 Reporting of age at death in months . 131 Table C.7 Height and weight data completeness and quality for children . 132 Table C.8 Number of enumeration areas completed by month, according to region, Ethiopia Mini-DHS 2019 . 133 Foreword • ix FOREWORD he 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) is the second EMDHS and the fifth DHS implemented in Ethiopia. The Ethiopian Public Health Institute (EPHI) conducted the survey in collaboration with the Central Statistical Agency (CSA) and the Federal Ministry of Health (FMoH), with technical assistance from ICF and financial as well as technical support from development partners. The 2019 EMDHS generates data for measuring the progress of the health sector goals set under the Growth and Transformation Plan (GTP), which is closely aligned to the Sustainable Development Goals (SDG). The survey was conducted from March 21, 2019, to June 28, 2019, based on a nationally representative sample that provided estimates at the national and regional levels and for urban and rural areas. The survey interviewed 8,855 women of reproductive age (age 15-49) from a nationally representative sample of 8,663 households. Detailed information was collected on respondents’ background characteristics, fertility determinants, marriage, awareness and use of family planning methods, child feeding practices, nutritional status of children, childhood mortality, and height and weight of children age 0-59 months. This report presents comprehensive outcomes of the survey at the national level and for Ethiopia’s nine regional states and two city administrations. The success of the 2019 EMDHS was made possible through the active participation of government, nongovernmental, and international development partners. In this regard, EPHI is grateful for the commitment of the government of Ethiopia, the United States Agency for International Development (USAID), the World Bank, and the United Nations Children’s Fund (UNICEF). Special thanks go to the Federal Ministry of Health and its allies. We would like to extend our gratitude to the Central Statistical Agency for providing technical support on survey design and for its involvement in the entire survey process. Also, we are grateful to the Survey Steering Committee and Technical Working Group members, who were instrumental in guiding the resource mobilisation process, the survey implementation, and technical aspects of the survey. Similarly, we wish to express appreciation to ICF for its technical assistance in all stages of the survey. EPHI greatly acknowledges the principal survey coordinators and technical team members; the finance, procurement, human resources, and operation units; and others for their management of the technical, administrative, and logistical phases of the survey. We are also thankful to the EPHI staff, field staff, and data processing specialists. In particular, we thank the survey respondents, who generously provided data without which it would have been impossible to produce this report. Ebba Abate - PhD Director General Ethiopian Public Health Institute T Acknowledgments • xi ACKNOWLEDGMENTS e wish to acknowledge and thank the World Bank and United States Agency for International Development (USAID) for their financial and technical support in all phases of this survey. In addition, the technical assistance provided by ICF, the Central Statistical Authority (CSA), the Ministry of Health, the United Nations Children’s Fund (UNICEF), the Bill and Melinda Gates Foundation (BMGF), and DFID was key in ensuring the success of the survey. We appreciate the contributions of members of the Steering Committee and Technical Committee, who were drawn from the following organizations: USAID, CSA, the World Bank, ICF, BMGF, DFID, the Ministry of Finance and Economic Cooperation, and UNICEF. We extend sincere appreciation to all people not mentioned in this document but who provided suggestions at different stages during the process and conduct of the survey. We would like to especially thank the individual volunteers and households in the various regions of Ethiopia who provided valuable information. W Acronyms and Abbreviations • xiii ACRONYMS AND ABBREVIATIONS AMIYCN Adolescent, Maternal, Infant, and Young Child Nutrition ANC antenatal care BCG bacille Calmette-Guérin BMGF Bill and Melinda Gates Foundation CAPI computer-assisted personal interview CBHI community-based health insurance CPR contraceptive prevalence rate CSA Central Statistical Agency CSPro Census and Survey Processing DHS Demographic and Health Survey DPT diphtheria, pertussis, tetanus vaccine EA enumeration area EDHS Ethiopia Demographic and Health Survey EMDHS Ethiopia Mini Demographic and Health Survey EPHC Ethiopian Population and Housing Census EPHI Ethiopia Public Health Institute EPI Expanded Programme for Immunisation ESPES Enhancing Shared Prosperity through Equitable Services FDRE Federal Democratic Republic of Ethiopia FMoH Federal Ministry of Health FP2020 Family Planning 2020 HepB hepatitis B HEW health extension worker Hib Haemophilus influenzae type B HSTP Health Sector Transformation Plan IFSS internet file streaming system IUD intrauterine device IYCF infant and young child feeding LAM lactational amenorrhoea method LPG liquified petroleum gas MCV measles-containing vaccine NNP National Nutrition Programme OPV oral polio vaccine xiv • Acronyms and Abbreviations PBS Promoting Basic Services PCV pneumococcal conjugate vaccine PSNP Productive Safety Net Programme PSU primary sampling unit RV rotavirus vaccine SD standard deviation SDGs Sustainable Development Goals SDM standard days method SNNPR Southern Nations, Nationalities, and Peoples’ Region UNICEF United Nations Children’s Fund USAID United States Agency for International Development VAD vitamin A deficiency VIP ventilated improved pit WHO World Health Organization Reading and Understanding Tables from the 2019 EMDHS • xv READING AND UNDERSTANDING TABLES FROM THE 2019 ETHIOPIA MINI DEMOGRAPHIC AND HEALTH SURVEY (EMDHS) he 2019 Ethiopia Mini DHS final report is based on approximately 83 tables of data. For quick reference, they are located at the end of each chapter and can be accessed through links in the pertinent text (electronic version). Additionally, this more reader-friendly version features about 31 figures that clearly highlight trends, subnational patterns, and background characteristics. The text has been simplified to highlight key points in bullets and to clearly identify indicator definitions in boxes. While the text and figures featured in each chapter highlight some of the most important findings from the tables, not every finding can be discussed or displayed graphically. For this reason, EMDHS data users should be comfortable reading and interpreting tables. The following pages provide an introduction to the organization of EMDHS tables, the presentation of background characteristics, and a brief summary of sampling and understanding denominators. In addition, this section provides some exercises for users as they practice their new skills in interpreting EMDHS tables. T xvi • Reading and Understanding Tables from the 2019 EMDHS Example 1: Literacy: Women A Question Asked of All Survey Respondents Table 3.3 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Ethiopia Mini-DHS 2019 Higher than secondary schooling No schooling, primary or secondary school Total Percentage literate1 Number of women Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/visually impaired Age 15-24 7.4 42.7 18.3 28.8 2.8 0.1 100.0 68.4 3,691 15-19 3.1 49.1 19.7 25.0 3.0 0.1 100.0 71.9 2,210 20-24 13.9 33.2 16.2 34.4 2.4 0.0 100.0 63.2 1,481 25-29 7.8 28.0 11.9 50.4 1.9 0.0 100.0 47.6 1,667 30-34 5.1 14.1 11.1 67.8 1.9 0.0 100.0 30.3 1,160 35-39 2.3 9.1 11.1 76.0 1.5 0.0 100.0 22.5 1,065 40-44 1.7 13.6 10.2 73.8 0.6 0.1 100.0 25.5 739 45-49 1.6 12.2 10.1 75.1 0.5 0.5 100.0 23.9 563 Residence Urban 13.4 39.8 13.6 31.0 2.2 0.0 100.0 66.8 2,861 Rural 2.1 22.2 14.3 59.4 1.9 0.1 100.0 38.6 6,024 Region Tigray 12.6 36.8 10.2 40.3 0.0 0.1 100.0 59.6 629 Afar 2.5 7.9 9.4 78.7 1.5 0.0 100.0 19.8 85 Amhara 5.0 34.7 10.1 50.0 0.0 0.2 100.0 49.8 2,026 Oromia 3.2 28.8 15.2 52.8 0.1 0.0 100.0 47.1 3,347 Somali 1.9 5.3 5.0 58.3 29.4 0.0 100.0 12.3 420 Benishangul-Gumuz 9.6 18.8 17.2 52.6 1.8 0.0 100.0 45.5 98 SNNPR 3.6 17.1 21.4 56.1 1.7 0.0 100.0 42.2 1,705 Gambela 12.6 16.6 9.0 27.7 34.1 0.0 100.0 38.2 40 Harari 15.3 28.8 9.7 46.2 0.0 0.0 100.0 53.8 27 Addis Ababa 26.5 45.6 11.8 14.9 1.2 0.0 100.0 84.0 442 Dire Dawa 17.6 32.4 10.1 38.6 1.3 0.0 100.0 60.1 64 Wealth quintile Lowest 0.2 11.6 11.5 70.2 6.4 0.0 100.0 23.3 1,437 Second 0.5 17.1 12.6 68.1 1.6 0.2 100.0 30.1 1,615 Middle 1.5 24.2 16.5 56.8 1.0 0.0 100.0 42.2 1,671 Fourth 4.0 32.2 16.5 46.1 1.1 0.1 100.0 52.7 1,874 Highest 17.3 44.8 13.0 23.8 1.0 0.0 100.0 75.2 2,287 Total 5.7 27.8 14.1 50.3 2.0 0.1 100.0 47.6 8,885 1 Refers to women who attended schooling higher than the secondary level and women who can read a whole sentence or part of a sentence Step 1: Read the title and subtitle, highlighted in orange in the table above. They tell you the topic and the specific population group being described. In this case, the table is about women age 15-49 by their level of education and level of literacy. All eligible female respondents age 15-49 were asked these questions. Step 2: Scan the column headings—highlighted in green in Example 1. They describe how the information is categorized. In this table, the first column of data shows women with higher than secondary education. The second through sixth columns show women with no schooling, primary, or secondary school by their ability to read a sentence. The seventh column is the total or sum of the previous six columns totaling up to a 100% percent distribution. The eighth column shows the percentage of women age 15-49 who are literate (a sum of the first three columns). The last column lists the number of women age 15-49 interviewed in the survey. Step 3: Scan the row headings—the first vertical column highlighted in blue in Example 1. These show the different ways the data are divided into categories based on population characteristics. In this case, the table presents women’s literacy by age, urban-rural residence, region, and wealth quintile. Most of the tables in the EMDHS report will be divided into these same categories. Step 4: Look at the row at the bottom of the table highlighted in red. These percentages represent the totals of all women age 15-49 and their level of schooling and level of literacy. In this case, 47.6%* of women age 15-49 are literate. 1 2 3 4 5 Reading and Understanding Tables from the 2019 EMDHS • xvii Step 5: To find out what percentage of women in the lowest wealth quintile are literate, draw two imaginary lines, as shown on the table. This shows that 23.3% of women age 15-49 in the lowest wealth quintile are literate. By looking at patterns by background characteristics, we can see how literacy varies across Ethiopia. Knowing how literacy varies among different groups can help program planners and policy makers determine how to most effectively communicate health messages, for instance, and reach their target populations. *For the purpose of this document data are presented exactly as they appear in the table including decimal places. However, the text in the remainder of this report rounds data to the nearest whole percentage point. Practice: Use the table in Example 1 to answer the following questions: a) Which age group of women are most likely to be literate? b) Compare women in urban areas to women in rural areas – which group is more likely to be literate? c) What are the lowest and highest percentages (range) of women who are literate by region? d) Is there a clear pattern in literacy by wealth quintile? Answers: a) Women age 15-19: 71.9% of women in this age group are literate. b) Women in urban areas: 66.8% of women in urban areas are literate, compared to 38.6% of women in rural areas. c) Literacy among women ranges from a low of 12.3% in Somali to a high of 84.0% in Addis Ababa. d) Yes. Literacy increases as household wealth increases; 23.3% of women from the lowest wealth quintile are literate, compared to 75.2% of women from the highest wealth quintile. xviii • Reading and Understanding Tables from the 2019 EMDHS Example 2: Observation of Vaccination History at Health Facilities A Question Asked of a Subgroup of Survey Respondents Table 8.4 Observation of vaccination history at health facilities: Children age 0-35 months Percentage of children age 0-35 months who did not have a vaccination card seen during the home visit, and among children age 0-35 months without a vaccination card seen during the home visit, percentage who received at least one vaccination at a health facility, percentage with mother’s consent for visiting health facilities, percentage with vaccination history searched at health facilities, and percentage with vaccination history found and seen by the interviewer at health facilities, according to background characteristics, Ethiopia Mini-DHS 2019 Percentage of children who did not have vaccination card during home visit1 Number of children Among children who did not have vaccination card during home visit Background characteristic Percentage who received at least one vaccination at a health facility Percentage with mother’s consent for visiting health facilities Percentage with vaccination history searched at health facilities1 Percentage with vaccination history found and seen by interviewer Number of children Age in months <6 54.5 554 31.8 29.3 16.9 14.8 302 6-11 53.2 485 48.7 47.8 32.6 29.1 258 12-23 58.7 1,028 57.2 56.2 37.6 34.8 603 24-35 73.6 1,027 59.1 55.5 35.7 30.1 756 Sex Male 64.1 1,562 56.6 54.9 37.3 32.8 1,002 Female 59.9 1,532 48.7 45.8 28.2 25.0 918 Birth order 1 55.6 707 60.9 59.7 36.5 31.3 393 2-3 57.2 996 54.4 51.6 33.9 31.2 570 4-5 61.8 683 50.3 49.0 33.4 29.5 422 6+ 75.4 708 47.1 44.0 29.0 24.8 534 Residence Urban 45.5 802 49.9 44.9 28.6 25.1 365 Rural 67.8 2,292 53.5 51.9 34.0 30.0 1,554 Region Tigray 28.6 213 72.0 72.0 57.2 46.1 61 Afar 80.2 49 21.8 19.8 8.7 7.6 39 Amhara 51.8 614 69.3 69.3 37.1 37.1 318 Oromia 68.6 1,236 56.2 53.2 38.3 35.2 847 Somali 78.6 201 24.3 24.3 11.2 11.2 158 Benishangul-Gumuz 62.0 37 57.2 56.2 42.3 41.8 23 SNNPR 72.5 609 43.4 40.0 26.0 16.7 442 Gambela 48.6 14 53.1 53.1 18.0 18.0 7 Harari 53.5 9 45.9 43.7 15.9 9.4 5 Addis Ababa 12.6 95 * * * * 12 Dire Dawa 42.5 17 84.3 83.6 40.0 40.0 7 Mother’s education No education 72.0 1,533 46.2 43.6 27.4 24.9 1,104 Primary 56.2 1,161 58.6 57.2 39.0 34.1 652 Secondary 43.5 268 71.3 67.4 53.3 45.0 116 More than secondary 35.7 132 (81.2) (79.8) (27.4) (18.5) 47 Wealth quintile Lowest 81.6 693 39.1 39.1 23.1 20.6 565 Second 69.3 662 56.6 53.8 36.2 31.7 458 Middle 66.2 598 59.3 57.0 41.4 37.6 396 Fourth 56.8 513 61.0 58.0 35.1 27.2 291 Highest 33.2 628 57.6 51.9 33.5 32.6 208 Total 62.0 3,094 52.8 50.6 32.9 29.1 1,919 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Vaccination card, booklet, or other home-based record Step 1: Read the title and subtitle. In this case, the table is about two separate groups of children age 0-35 months: all children age 0-35 months (a) and children age 0-35 months who did not have a vaccination card during home visit (b). Step 2: Identify the two panels. First, identify the columns that refer to all children age 0-35 months (a), and then isolate the columns that refer only to children who did not have a vaccination card during home visit (b). 1 2 3 4 a b Reading and Understanding Tables from the 2019 EMDHS • xix Step 3: Look at the first panel. What percentage of children age 0-35 months did not have a vaccination card during home visit? It’s 62.0%. Now look at the second panel. How many children are there who did not have a vaccination card during home visit? It’s 1,919 children or 62.0% of the 3,094 children age 0-35 months. The second panel is a subset of the first panel. Step 4: Sixty-two percent of children age 0-35 months did not have a vaccination card during home visit. Once these children are further divided into the background characteristic categories, there may be too few cases for the percentages to be reliable. • What percentage of children who did not have a vaccination card during home visit whose mothers have more than a secondary education received at least one vaccination at a health facility? 81.2%. This percentage is in parentheses because there are between 25 and 49 children (unweighted) in this category. Readers should use this number with caution—it may not be reliable. (For more information on weighted and unweighted numbers, see Example 3.) • What percentage of children who did not have a vaccination card during home visit in Addis Ababa received at least one vaccination at a health facility? There is no number in this cell— only an asterisk. This is because there are fewer than 25 unweighted cases. Results for this group are not reported. The subgroup is too small, and therefore the data are not reliable. Note: When parentheses or asterisks are used in a table, the explanation will be noted under the table. If there are no parentheses or asterisks in a table, you can proceed with confidence that enough cases were included in all categories that the data are reliable. xx • Reading and Understanding Tables from the 2019 EMDHS Example 3: Understanding Sampling Weights in EMDHS Tables A sample is a group of people who have been selected for a survey. In the EMDHS, the sample is designed to represent the national population age 15-49. In addition to national data, most countries want to collect and report data on smaller geographical or administrative areas. However, doing so requires a large enough sample size in each area. For the 2019 EMDHS, the survey sample is representative at the national and regional levels, and for urban and rural areas. To generate statistics that are representative of the country as a whole and the 11 regions, the number of women surveyed in each region should contribute to the size of the total (national) sample in proportion to size of the region. However, if some regions have small populations, then a sample allocated in proportion to each region’s population may not include sufficient women from each region for analysis. To solve this problem, regions with small populations are oversampled. For example, let’s say that you have enough money to interview 8,885 women and want to produce results that are representative of Ethiopia as a whole and its regions (as in modified Table 3.1). However, the total population of Ethiopia is not evenly distributed among the regions: some regions, such as Oromia, are heavily populated while others, such as Harari are not. Thus, Harari must be oversampled. A sampling statistician determines how many women should be interviewed in each region in order to get reliable statistics. The blue column (1) in the table at the right shows the actual number of women interviewed in each region. Within the regions, the number of women interviewed ranges from 640 in Somali to 1,052 in Oromia. The number of interviews is sufficient to get reliable results in each region. With this distribution of interviews, some regions are overrepresented and some regions are underrepresented. For example, the population in Oromia is about 37.7% of the population in Ethiopia, while Harari’s population contributes only 0.3% of the population in Ethiopia. But as the blue column shows, the number of women interviewed in Oromia accounts for only about 11.9% of the total sample of women interviewed (1,052 / 8,885) and the number of women interviewed in Harari accounts for 8.6% of the total sample of women interviewed (763 / 8,885). This unweighted distribution of women does not accurately represent the population. In order to get statistics that are representative of Ethiopia, the distribution of the women in the sample needs to be weighted (or mathematically adjusted) such that it resembles the true distribution in the country. Women from a small region, like Harari, should only contribute a small amount to the national total. Women from a large region, like Oromia, should contribute much more. Therefore, DHS statisticians mathematically calculate a “weight” which is used to adjust the number of women from each region so that each region’s contribution to the total is proportional to the actual population of the region. The numbers in the purple column (2) represent the “weighted” values. The weighted values can be smaller or larger than the unweighted values at the regional level. The total national sample size of 8,885 women has not changed after weighting, but the distribution of the women in the regions has been changed to represent their contribution to the total population size. How do statisticians weight each category? They take into account the probability that a woman was selected in the sample. If you were to compare the green column (3) to the actual population distribution of Ethiopia, you would see that women in each region are contributing to the total sample with the same weight that they contribute to the population of the country. The weighted number of women in the survey Table 3.1 Background characteristics of respondents Percent distribution of women age 15-49 by selected background characteristics, Ethiopia Mini-DHS 2019 Number of women Background characteristic Weighted percent Weighted number Unweighted number Region Tigray 7.1 629 733 Afar 1.0 85 641 Amhara 22.8 2,026 948 Oromia 37.7 3,347 1,052 Somali 4.7 420 640 Benishangul- Gumuz 1.1 98 747 SNNPR 19.2 1,705 1,008 Gambela 0.5 40 723 Harari 0.3 27 763 Addis Ababa 5.0 442 818 Dire Dawa 0.7 64 812 Total 15-49 100.0 8,885 8,885 1 2 3 Reading and Understanding Tables from the 2019 EMDHS • xxi now accurately represents the proportion of women who live in Oromia and the proportion of women who live in Harari. With sampling and weighting, it is possible to interview enough women to provide reliable statistics at national and regional levels. In general, only the weighted numbers are shown in each of the EMDHS tables, so don’t be surprised if these numbers seem low: they may actually represent a larger number of women interviewed. Introduction and Survey Methodology • 1 INTRODUCTION AND SURVEY METHODOLOGY 1 he 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) is the second Mini Demographic and Health Survey conducted in Ethiopia. The Ethiopian Public Health Institute (EPHI) implemented the survey at the request of the Federal Ministry of Health (FMoH). Data collection took place from March 21, 2019, to June 28, 2019. Financial support for the 2019 EMDHS was provided by the government of Ethiopia, the World Bank via the Ministry of Finance and Economic Development’s Enhancing Shared Prosperity through Equitable Services (ESPES) and Promoting Basic Services (PBS) projects, the United Nations Children’s Fund (UNICEF), and the United States Agency for International Development (USAID). ICF provided technical assistance through The DHS Program, which is funded by USAID and offers support and technical assistance for the implementation of population and health surveys in countries worldwide. 1.1 SURVEY OBJECTIVES The primary objective of the 2019 EMDHS is to provide up-to-date estimates of key demographic and health indicators. Specifically, the main objectives of the survey are: ▪ To collect high-quality data on contraceptive use; maternal and child health; infant, child, and neonatal mortality levels; child nutrition; and other health issues relevant to achievement of the Sustainable Development Goals (SDGs) ▪ To collect information on health-related matters such as breastfeeding, maternal and child care (antenatal, delivery, and postnatal), children’s immunisations, and childhood diseases ▪ To assess the nutritional status of children under age 5 by measuring weight and height Four full-scale DHS surveys were conducted in 2000, 2005, 2011, and 2016. The first Ethiopia Mini-DHS, or EMDHS, was conducted in 2014. The 2019 EMDHS provides valuable information on trends in key demographic and health indicators over time. The information collected through the 2019 EMDHS is intended to assist policymakers and programme managers in evaluating and designing programmes and strategies for improving the health of the country’s population. The current survey included a health facility component that, combined with the household data obtained, helped facilitate collection of additional information on children’s vaccinations. 1.2 SAMPLE DESIGN The sampling frame used for the 2019 EMDHS is a frame of all census enumeration areas (EAs) created for the 2019 Ethiopia Population and Housing Census (EPHC) and conducted by the Central Statistical Agency (CSA). The census frame is a complete list of the 149,093 EAs created for the 2019 EPHC. An EA is a geographic area covering an average of 131 households. The sampling frame contains information about EA location, type of residence (urban or rural), and estimated number of residential households. Administratively, Ethiopia is divided into nine geographical regions and two administrative cities. The sample for the 2019 EMDHS was designed to provide estimates of key indicators for the country as a whole, for urban and rural areas separately, and for each of the nine regions and the two administrative cities. T 2 • Introduction and Survey Methodology The 2019 EMDHS sample was stratified and selected in two stages. Each region was stratified into urban and rural areas, yielding 21 sampling strata. Samples of EAs were selected independently in each stratum in two stages. Implicit stratification and proportional allocation were achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection, according to administrative units in different levels, and by using a probability proportional to size selection at the first stage of sampling. To ensure that survey precision was comparable across regions, sample allocation was done through an equal allocation wherein 25 EAs were selected from eight regions. However, 35 EAs were selected from each of the three larger regions: Amhara, Oromia, and the Southern Nations, Nationalities, and Peoples’ Region (SNNPR). In the first stage, a total of 305 EAs (93 in urban areas and 212 in rural areas) were selected with probability proportional to EA size (based on the 2019 EPHC frame) and with independent selection in each sampling stratum. A household listing operation was carried out in all selected EAs from January through April 2019. The resulting lists of households served as a sampling frame for the selection of households in the second stage. Some of the selected EAs for the 2019 EMDHS were large, with more than 300 households. To minimise the task of household listing, each large EA selected for the 2019 EMDHS was segmented. Only one segment was selected for the survey, with probability proportional to segment size. Household listing was conducted only in the selected segment; that is, a 2019 EMDHS cluster is either an EA or a segment of an EA. In the second stage of selection, a fixed number of 30 households per cluster were selected with an equal probability systematic selection from the newly created household listing. All women age 15-49 who were either permanent residents of the selected households or visitors who slept in the household the night before the survey were eligible to be interviewed. In all selected households, height and weight measurements were collected from children age 0-59 months, and women age 15-49 were interviewed using the Woman’s Questionnaire. 1.3 QUESTIONNAIRES Five questionnaires were used for the 2019 EMDHS: (1) the Household Questionnaire, (2) the Woman’s Questionnaire, (3) the Anthropometry Questionnaire, (4) the Health Facility Questionnaire, and (5) the Fieldworker’s Questionnaire. These questionnaires, based on The DHS Program’s standard questionnaires, were adapted to reflect the population and health issues relevant to Ethiopia. They were shortened substantially to collect data on indicators of particular relevance to Ethiopia and donors to child health programmes. Input was solicited from various stakeholders representing government ministries and agencies, nongovernmental organisations, and international donors. After the questionnaires were finalised in English, they were translated into Amarigna, Tigrigna, and Afaan Oromo. The Household Questionnaire was used to list all of the usual members of and visitors to selected households. Basic demographic information was collected on the characteristics of each person listed, including his or her age, sex, education, and relationship to the head of the household. The data on age and sex of household members obtained in the Household Questionnaire were used to identify women who were eligible for individual interviews. The Household Questionnaire was also used to collect information on characteristics of the household’s dwelling unit, such as source of water, type of toilet facilities, materials used for the floor of the dwelling unit, and ownership of various durable goods. The Woman’s Questionnaire was used to collect information from all eligible women age 15-49. These women were asked questions on the following main topics: background characteristics, reproduction, contraception, pregnancy and postnatal care, child nutrition, childhood immunisations, and health facility information. Introduction and Survey Methodology • 3 In the Anthropometry Questionnaire, height and weight measurements were recorded for eligible children age 0-59 months in all interviewed households. The Health Facility Questionnaire was used to record vaccination information for all children without a vaccination card seen during the mother’s interview. The Fieldworker’s Questionnaire collected background information about interviewers and other fieldworkers who participated in the 2019 EMDHS data collection. The 2019 EMDHS interviewers used tablet computers to record responses during the interviews. The tablets were equipped with Bluetooth technology to enable remote electronic transfer of files within the computer-assisted personal interviewing (CAPI) system, including transfer of assignments from supervisors to interviewers and transfer of completed questionnaires from interviewers to supervisors. The electronic data collection system deployed in the 2019 EMDHS was developed by The DHS Program using the mobile version of the Census and Survey Processing (CSPro) System. The CSPro software was developed jointly by the U.S. Census Bureau, The DHS Program, and CSPro. 1.4 ANTHROPOMETRY In all households, height and weight measurements were recorded for children age 0-59 months. Weight measurements were obtained using lightweight, electronic SECA 874 scales with a digital screen and the mother and child function. Height measurements were performed using measuring boards donated by UNICEF. Children younger than age 24 months were measured lying down (recumbent) on the board, while standing height was measured for older children. In contrast with the data collection procedures for the household and individual interviews, anthropometry data were initially recorded on the paper-based Anthropometry Questionnaire and subsequently entered into interviewers’ tablet computers. 1.5 TRAINING OF TRAINERS The training of trainers for the 2019 EMDHS was conducted from February 11-20, 2019, in Adama. It consisted of paper- and CAPI-based in-class training, anthropometry training including standardisation, and field practice. The field practice was conducted in Adama in clusters that were not included in the 2019 EMDHS sample. A total of 17 trainees attended the training of trainers. Trainees all had some experience with household surveys, either involvement in previous Ethiopian DHS surveys or involvement in surveys with similar procedures. Following field practice, a debriefing session was held with the trainee field staff, and lessons learned from the exercise were incorporated into the questionnaires for the main training. 1.6 TRAINING OF FIELD STAFF The EMDHS main training was conducted from February 27 to March 19, 2019, at Central Hotel in Hawassa. EPHI recruited and trained 151 health professional field staff for the main fieldwork to serve as female interviewers, female anthropometrists, female CAPI supervisors, field supervisors, regional coordinators, and their respective reserves. The objective of the training was to enable participants to administer both paper- and CAPI-based questionnaires and to take anthropometric measurements. The training course consisted of instructions regarding interviewing techniques and field procedures, a detailed review of questionnaire content, instructions on how to administer the paper and CAPI questionnaires, mock interviews between participants in the classroom, and practice interviews with real respondents in areas outside the survey sample. During the main training, all anthropometrists underwent a rigorous standardisation process to ensure the accuracy and precision of their anthropometric measurements. Practice standardisation exercises were conducted with children age 0-59 months. The paper-based field practice was conducted for 3 days and included the anthropometry component. Debriefing sessions were held with the field staff, and modifications to the paper questionnaires were made based on lessons drawn from the exercise. Teams carried out CAPI field practice over 4 days, also including the anthropometry component. Furthermore, regional coordinators, field supervisors, and CAPI supervisors were trained in data quality control procedures and fieldwork coordination. 4 • Introduction and Survey Methodology In addition, field supervisors were trained to administer the Health Facility Questionnaire and to perform as assistants to the anthropometrists. Both the anthropometrists and the field supervisors learned how to calibrate the digital scales and height boards and how to monitor the technical aspects of the anthropometry data collection using a system of checklists. 1.7 FIELDWORK Twenty-five interviewing teams carried out data collection for the 2019 EMDHS. Each team consisted of one field supervisor, one female CAPI supervisor, two female interviewers, and one female anthropometrist. In addition to the field teams, 11 regional coordinators were assigned, one for each region. The regional coordinator regularly visited and remained with respective teams throughout the fieldwork period to supervise and monitor their work and progress. Moreover, 10 staff members from EPHI coordinated and supervised fieldwork activities. EPHI researchers, an ICF technical specialist, a consultant, and representatives from other organisations, including CSA, FMoH, the World Bank, and USAID, supported the fieldwork monitoring. Data collection took place over a 3-month period, from March 21, 2019, to June 28, 2019. 1.8 HEALTH FACILITY VISITS In the 2019 EMDHS, data on vaccination coverage were obtained from health facility records in addition to information written on vaccination records, including the infant immunisation card and other health cards, and information gathered from mothers’ verbal reports. During the individual interview, mothers were asked to report vaccinations received by their children born in the last 3 years. For each child born in the 3 years before the survey, mothers were asked to show the interviewer the infant immunisation card or health card used to record the child’s immunisations. If the infant immunisation card or other health card was available, the interviewer copied the dates of each vaccination received in the respective section of the Woman’s Questionnaire. If a vaccination was not recorded on the infant immunisation card or the health card, the mother was asked to recall whether that particular vaccination had been administered. If the mother was not able to present the child’s infant immunisation card, she was asked to recall whether the child had received the BCG, polio, DPT-HepB- Hib, measles, pneumococcal, and rotavirus vaccines. If she indicated that the child had received the polio, DPT-HepB-Hib, pneumococcal, measles, or rotavirus vaccine, she was asked the number of doses that the child received. If the mother did not have the infant immunisation card or health card available and the child had visited a health facility, the field supervisor went to the health facility to collect the relevant vaccination records. The purpose of obtaining information at the health facility was to complement the immunisation information based on mothers’ recall. 1.9 DATA PROCESSING All electronic data files were transferred via the secure internet file streaming system (IFSS) to the EPHI central office in Addis Ababa, where they were stored on a password-protected computer. The data processing operation included secondary editing, which required resolution of computer-identified inconsistencies and coding of open-ended questions. The data were processed by EPHI staff members and an ICF consultant who took part in the main fieldwork training. They were supervised remotely by staff from The DHS Program. Data editing was accomplished using CSPro System software. During the fieldwork, field-check tables were generated to check various data quality parameters, and specific feedback was given to the teams to improve performance. Secondary editing, double data entry from both the anthropometry and health facility questionnaires, and data processing were initiated in April 2019 and completed in July 2019. Introduction and Survey Methodology • 5 1.10 RESPONSE RATES Table 1.1 shows response rates for the 2019 EMDHS. A total of 9,150 households were selected for the sample, of which 8,794 were occupied. Of the occupied households, 8,663 were successfully interviewed, yielding a response rate of 99%. In the interviewed households, 9,012 eligible women were identified for individual interviews; interviews were completed with 8,885 women, yielding a response rate of 99%. Overall, there was little variation in response rates according to residence; however, rates were slightly higher in rural than in urban areas. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Ethiopia Mini-DHS 2019 Residence Total Result Urban Rural Household interviews Households selected 2,790 6,360 9,150 Households occupied 2,698 6,096 8,794 Households interviewed 2,645 6,018 8,663 Household response rate1 98.0 98.7 98.5 Interviews with women age 15-49 Number of eligible women 2,999 6,013 9,012 Number of eligible women interviewed 2,951 5,934 8,885 Eligible women response rate2 98.4 98.7 98.6 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 7 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 Key Findings ▪ Drinking water: In Ethiopia, 87% of urban households have access to an improved source of drinking water, as compared with 61% of rural households. ▪ Electricity: Eighty-three percent of urban households and 14% of rural households have access to electricity. ▪ Household population and composition: Forty-four percent of Ethiopians are under age 15, while 4% are age 65 and older. nformation on the socioeconomic characteristics of the household population in the 2019 EMDHS provides a context to interpret demographic and health indicators and can furnish an approximate indication of the representativeness of the survey. In addition, this information sheds light on the living conditions of the population. This chapter presents information on sources of drinking water, sanitation, wealth, household status and resiliency, household population and composition, and women’s educational attainment. 2.1 DRINKING WATER SOURCES AND TREATMENT Basic drinking water service Drinking water from an improved source, provided either water is on the premises or round-trip collection time is 30 minutes or less. Sample: De jure population Limited drinking water service Drinking water from an improved source, and round-trip collection time is more than 30 minutes. Sample: De jure population In Ethiopia, 69% of households have access to an improved source of drinking water, including 87% of urban households and 61% of rural households (Table 2.1.1). Urban and rural households rely on different sources of drinking water. The three most common sources of drinking water in urban households are water piped into the household’s dwelling, yard, or plot (40%); water piped into a public tap/standpipe (30%); and water piped to a neighbour (9%). By contrast, rural households obtain their drinking water mainly from public taps/standpipes (31%) and protected springs (13%) (Table 2.1.1 and Figure 2.1). I 8 • Housing Characteristics and Household Population In urban areas, 53% of households have water on their premises, as compared with 7% of rural households. Fetching drinking water is a chore of great cost to household members depending on the time spent to obtain it. Twenty- eight percent of rural households travel 30 minutes or longer, round trip, to fetch drinking water. Table 2.1.2 presents information on drinking water according to region and wealth. By region, the percentage of the population with an improved source of drinking water ranges from 47% in Somali to 99% in Addis Ababa. Access to an improved source of drinking water increases with increasing wealth, from 37% among those in the lowest wealth quintile to 93% among those in the highest quintile. Similarly, the percentage of the population with basic drinking water service ranges from 26% in Somali to 94% in Addis Ababa. Basic drinking water service also increases with increasing wealth. Twenty-five percent of those in the lowest wealth quintile have basic drinking water service, as compared with 87% of those in the highest quintile. 2.2 SANITATION Improved toilet facilities Include any non-shared toilet of the following types: flush/pour flush toilets to a piped sewer system, septic tank, pit latrine, or unknown destination; ventilated improved pit (VIP) latrines; pit latrines with slabs; and composting toilets. Sample: Households Unimproved toilet facilities Include any toilet of the following types shared by two or more households: flush/pour flush not to a sewer/septic tank/pit latrine, pit latrines without slabs/open pits, buckets, hanging toilets/hanging latrines, and other. Sample: Households Figure 2.1 Household drinking water by residence 18 49 4 31 30 31 5 2 6 10 2 13 31 13 39 Total Urban Rural Percent distribution of households by source of drinking water Unimproved source Protected spring Protected dug well Public tap/ standpipe Piped water into dwelling/yard/plot/ neighbour’s yard Housing Characteristics and Household Population • 9 Overall, 20% of Ethiopian households use improved toilet facilities (42% in urban areas and 10% in rural areas) (Table 2.2.1). More than half (56%) of rural households use unimproved toilet facilities. More than one in four households (27%) in Ethiopia have no toilet facility (35% in rural areas and 10% in urban areas) (Figure 2.2). Patterns by background characteristics ▪ By region, the percentage of households with an improved sanitation facility ranges from a low of 10% in SNNPR to a high of 82% in Addis Ababa (Table 2.2.2). Access to an improved sanitation facility increases with increasing wealth, from 5% among households in the lowest wealth quintile to 54% among those in the highest quintile. ▪ Open defecation is most prevalent in Afar (70%) and least prevalent in Addis Ababa (2%). ▪ The percentage of households with basic sanitation service rises from 6% in Somali to 49% in Addis Ababa. Basic sanitation service also increases with increasing wealth, from 3% in the lowest wealth quintile to 30% in the highest quintile. Similarly, households in the highest wealth quintile are more likely to have limited sanitation service (24%) than those in the lowest and middle quintiles (2% each). 2.3 HOUSEHOLD WEALTH Wealth index Households are given scores based on the number and kinds of consumer goods they own, ranging from a television to a bicycle or car, and housing characteristics such as source of drinking water, toilet facilities, and flooring materials. These scores are derived using principal component analysis. National wealth quintiles are compiled by assigning the household score to each usual (de jure) household member, ranking each person in the household population by her or his score, and then dividing the distribution into five equal categories, each comprising 20% of the population. Sample: Households Figure 2.2 Household sanitation facilities by residence 20 42 10 53 49 56 27 10 35 Total Urban Rural Percent distribution of households by type of toilet facilities No facility/ bush/field Unimproved facility Improved facility 10 • Housing Characteristics and Household Population Table 2.3 presents wealth quintiles according to residence and region. Included in the table is the Gini coefficient, which indicates the level of concentration of wealth. The Gini coefficient ranges from 0-1, with 0 representing an equal distribution and 1 representing a totally unequal distribution. The wealthiest households are concentrated in urban areas (62%) (Figure 2.3). Approximately half of the rural population (51%) falls into the lowest two wealth quintiles. By region, the wealthiest households are concentrated in Addis Ababa (99%) and the poorest households in Somali (70%) and Afar (66%). In Ethiopia, the Gini coefficient is 0.27 (0.26 in urban areas and 0.22 in rural areas). Tigray has the highest Gini coefficient (0.46), while Addis Ababa has the lowest (0.13) (Table 2.3). 2.3.1 Other Housing Characteristics The 2019 EMDHS also collected data on access to electricity and flooring materials. Thirty-five percent of households in Ethiopia have access to electricity (83% in urban areas and 14% in rural areas) (Table 2.4). Overall, the two most commonly used materials for flooring in Ethiopia are earth or sand (70%) and dung (10%). Flooring materials differ widely in urban and rural areas. Earth or sand (51%), cement (15%), carpet (14%), and vinyl or asphalt strips (11%) are most often used in urban households, whereas households in rural areas primarily use earth or sand (78%) and dung (14%). 2.3.2 Household Durable Goods In addition, the survey collected information on household effects, means of transportation, and ownership of agricultural land and farm animals. In general, urban households are more likely than rural households to possess household effects. The most commonly found item in households is a mobile phone (68%); 87% of urban households and 59% of rural households own a mobile phone. As expected, rural households are more likely than urban households to own agricultural land and farm animals. For example, 31% of urban households own farm animals, as compared with 85% of rural households (Table 2.5). 2.4 HOUSEHOLD STATUS AND RESILIENCY Table 2.6 presents information about household status and resiliency collected in the 2019 EMDHS. Questions on this topic included whether respondents have bank accounts, participate in government subsistence or health insurance programmes, and own or rent their homes. 2.4.1 Bank Account or Microfinance Account Among the 8,663 households surveyed, 4 out of 10 (41%) reported having bank or microfinance accounts (67% of urban households and 29% of rural households). At the population level, 39% of Ethiopians have a bank or microfinance account, and 62% do not. 2.4.2 Productive Safety Net Programme The Productive Safety Net Programme (PSNP) is a social protection programme that was initiated in Africa. It provides food and cash transfers to chronically insecure households and builds community assets through labour-intensive public works that also provide employment for the poor, especially in food- insecure parts of rural Ethiopia. Figure 2.3 Household wealth by residence 8 255 26 6 25 20 20 62 5 Urban Rural Percent distribution of de jure population by wealth quintiles Highest Fourth Middle Second Lowest Housing Characteristics and Household Population • 11 The 2019 EMDHS included one question at the household level to obtain data on whether a household was participating in the PSNP at the time of the survey. The results indicated that only 14% of households were participating in the programme. Ninety-one percent of urban households and 85% of rural households were not participating in the PSNP. At the population level, 15% of Ethiopians were participating in the programme (16% of the rural population and 11% of the urban population). 2.4.3 Health Insurance Coverage Ethiopia implemented the community-based health insurance (CBHI) scheme in 2011, aimed at reaching the very large rural agricultural sector and covering the small and informal sectors in urban settings. The overall objectives of insurance coverage are to promote equitable access to sustainable quality health care, increase financial protection, and enhance social inclusion for Ethiopian families via the health sector. The CBHI benefit package covers all outpatient and inpatient services at the health centre and hospital levels other than procedures related to dentures, eyeglasses, and cosmetics (USAID/HFG 2015). The 2019 EMDHS results show that 28% of households are enrolled in the community-based health insurance scheme. Rural households (32%) are more likely to be enrolled than urban households (19%). At the population level, 3 out of 10 (28%) Ethiopians are enrolled, while 72% are not. 2.4.4 Household Ownership Status The 2019 EMDHS also collected information on household ownership, whether free of charge, subsidised, or rented. Among the 8,663 households surveyed in Ethiopia, 80% are owned, 15% are rented, and 5% are free or subsidised. Thirty-nine percent of urban households are rented, as compared with just 4% of rural households. 2.5 HOUSEHOLD POPULATION AND COMPOSITION Household A person or group of related or unrelated persons who live together in the same dwelling unit(s), who acknowledge one adult male or female as the head of the household, who share the same housekeeping arrangements, and who are considered a single unit. De facto population All persons who stayed in the selected households the night before the interview (whether usual residents or visitors). De jure population All persons who are usual residents of the selected households, regardless of where they stayed the night before the interview. How data are calculated All tables are based on the de facto population, unless otherwise specified. Household composition and population data provide information on age, sex, and residence. They also provide information on dependency (or non-working) groups in Ethiopia that affect household wealth due to the nation’s age structure. 12 • Housing Characteristics and Household Population A total of 40,280 individuals stayed overnight in the 8,663 households interviewed in the 2019 EMDHS. About 50% of these individuals were female, and 50% were male (Table 2.7). Children under age 15 represent 44% of the population, while individuals age 15-64 represent 52%; 4% of Ethiopians are age 65 or older. The population pyramid in Figure 2.4 shows the population distribution by 5-year age groups, separately for males and females. The broad base of the pyramid indicates that Ethiopia’s population is young, which is typical of countries with low life expectancies and high fertility rates. The average household size in Ethiopia is 4.7 persons (Table 2.8). Urban households are slightly smaller than rural households (4.1 persons versus 5.0 persons). Men head most Ethiopian households (78%), with 22% headed by women. Trends: The age distribution of the household population differs from previous years. Children under age 15 represented 47% of the population in 2011 and 2016, as compared with 44% in 2019. No change occurred for individuals age 65 and older, who account for 4% of the population. Average household size remained nearly the same from 2000 to 2019 (4.8 persons versus 4.7 persons). The percentage of female- headed households decreased from 25% in 2016 to 22% in 2019. 2.6 EDUCATION Education is one of the most important aspects of social and economic development. Education improves capabilities and is strongly associated with various socioeconomic variables such as lifestyle, income, and fertility for both individuals and societies. Median educational attainment Half of the population has completed less than the median number of years of schooling, and half of the population has completed more than the median number of years of schooling. Sample: De facto female household population age 6 and older Overall, 43% of females age 6 and older have never attended school (Table 2.9). Among most of the female population, primary school is the highest level of schooling attended or completed; 43% of females age 6 or older have completed some primary schooling, and 4% have completed their primary education. Only 1% of women have completed secondary school, and 3% have more than a secondary education. The median number of years of education for Ethiopian women is 0.6 years. Trends: Female educational attainment has improved since the first Ethiopia DHS in 2000. The percentage of females age 6 and older with no education decreased from 77% in 2000 to 43% in 2019. Figure 2.4 Population pyramid 18 14 10 6 2 2 6 10 14 18 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age Percent distribution of the household population Male Female 18 14 10 6 2 Housing Characteristics and Household Population • 13 Patterns by background characteristics ▪ Urban residents are much more likely than rural residents to be educated. Thirty percent of females age 6 and older in urban areas have no education, as compared with 48% of females in rural areas. ▪ Addis Ababa has the lowest proportion of females with no education (19%), while Somali has the highest proportion (65%). ▪ Women in the highest wealth quintile (12%) are more likely than women in the lowest wealth quintile (<1%) to have more than a secondary education. Women with no education are more likely to live in poverty. Fifty-nine percent of women in the lowest wealth quintile have no education, compared with 24% of women in the highest quintile. LIST OF TABLES For more information on household population and housing characteristics, see the following tables: ▪ Table 2.1.1 Household drinking water ▪ Table 2.1.2 Drinking water according to region and wealth ▪ Table 2.2.1 Household sanitation facilities ▪ Table 2.2.2 Sanitation facility type according to region and wealth ▪ Table 2.3 Wealth quintiles ▪ Table 2.4 Household characteristics ▪ Table 2.5 Household possessions ▪ Table 2.6 Household status and resiliency ▪ Table 2.7 Household population by age, sex, and residence ▪ Table 2.8 Household composition ▪ Table 2.9 Educational attainment of the female household population 14 • Housing Characteristics and Household Population Table 2.1.1 Household drinking water Percent distribution of households and de jure population by source of drinking water and by time to obtain drinking water, percentage of households and de jure population with basic drinking water service, and percentage with limited drinking water service, according to residence, Ethiopia Mini-DHS 2019 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 87.3 60.5 68.7 85.2 60.7 67.3 Piped into dwelling/yard/plot 40.0 2.3 13.9 36.7 2.2 11.5 Piped to neighbour 8.5 1.7 3.8 6.9 1.4 2.9 Public tap/standpipe 30.4 30.8 30.7 32.9 30.8 31.4 Tube well or borehole 0.7 5.4 3.9 0.6 4.9 3.7 Protected dug well 1.5 6.4 4.9 1.9 6.6 5.3 Protected spring 2.1 13.2 9.8 2.0 14.0 10.8 Rainwater 0.2 0.5 0.4 0.2 0.6 0.5 Tanker truck/cart with small tank 1.1 0.2 0.5 1.7 0.2 0.6 Bottled water 2.8 0.0 0.9 2.2 0.0 0.6 Unimproved source 12.7 39.1 31.0 14.8 39.1 32.5 Unprotected dug well 1.9 5.9 4.6 2.8 6.0 5.2 Unprotected spring 3.9 18.0 13.7 4.6 17.3 13.9 Surface water 6.8 15.2 12.7 7.4 15.8 13.5 Other 0.0 0.4 0.3 0.0 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises1 52.8 6.6 20.8 47.3 6.2 17.3 30 minutes or less 31.7 64.7 54.6 34.8 63.3 55.6 More than 30 minutes 15.4 28.3 24.4 17.9 30.3 26.9 Don’t know/missing 0.0 0.3 0.2 0.0 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage with basic drinking water service2 78.7 47.3 56.9 75.3 46.4 54.2 Percentage with limited drinking water service3 8.6 13.1 11.7 9.8 14.3 13.0 Number of households/ population 2,664 5,999 8,663 11,051 29,878 40,929 1 Includes water piped to a neighbour and those reporting a round-trip collection time of zero minutes 2 Defined as drinking water from an improved source, provided either water is on the premises or round-trip collection time is 30 minutes or less. Includes safely managed drinking water, which is not shown separately. 3 Drinking water from an improved source, and round-trip collection time is more than 30 minutes. Housing Characteristics and Household Population • 15 Table 2.1.2 Drinking water according to region and wealth Percent distribution of de jure population by drinking water source, percentage of de jure population with basic drinking water service, and percentage with limited drinking water service, according to region and wealth quintile, Ethiopia Mini-DHS 2019 Background characteristic Improved source of drinking water1 Unimproved source of drinking water2 Other/missing Total Percentage with basic drinking water service3 Percentage with limited drinking water service4 Number of persons Region Tigray 75.4 24.6 0.0 100.0 65.5 10.0 2,509 Afar 54.5 45.3 0.2 100.0 38.7 15.2 418 Amhara 65.0 35.0 0.1 100.0 57.0 7.9 8,358 Oromia 65.2 34.4 0.3 100.0 51.5 13.7 16,575 Somali 47.1 52.7 0.1 100.0 25.6 21.0 2,531 Benishangul- Gumuz 82.9 17.1 0.0 100.0 73.8 9.0 439 SNNPR 71.4 28.6 0.0 100.0 54.2 17.2 8,243 Gambela 69.2 30.8 0.0 100.0 63.7 4.7 157 Harari 85.3 14.7 0.0 100.0 65.4 20.0 111 Addis Ababa 98.7 1.2 0.1 100.0 93.7 5.0 1,349 Dire Dawa 85.1 14.9 0.0 100.0 80.1 4.9 239 Wealth quintile Lowest 37.2 62.7 0.0 100.0 24.9 12.2 8,185 Second 58.1 41.9 0.0 100.0 42.9 15.1 8,187 Middle 69.7 30.3 0.0 100.0 54.5 15.2 8,188 Fourth 78.9 20.4 0.7 100.0 62.0 16.9 8,169 Highest 92.5 7.4 0.1 100.0 86.6 5.9 8,200 Total 67.3 32.5 0.2 100.0 54.2 13.0 40,929 1 See Table 2.1.1 for definition of an improved source. 2 See Table 2.1.1 for definition of an unimproved source. 3 Defined as drinking water from an improved source, provided either water is on the premises or round-trip collection time is 30 minutes or less. Includes safely managed drinking water, which is not shown separately. 4 Drinking water from an improved source, and round-trip collection time is more than 30 minutes. 16 • Housing Characteristics and Household Population Table 2.2.1 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, percent distribution of households and de jure population with a toilet/latrine facility by location of the facility, percentage of households and de jure population with basic sanitation services, and percentage with limited sanitation services, according to residence, Ethiopia Mini-DHS 2019 Type and location of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved sanitation facility 41.6 9.7 19.5 41.0 9.1 17.7 Flush/pour flush to piped sewer system 1.5 0.0 0.4 1.6 0.0 0.4 Flush/pour flush to septic tank 4.7 0.0 1.5 4.3 0.0 1.2 Flush/pour flush to pit latrine 5.2 3.7 4.1 4.2 3.4 3.6 Flush/pour flush, don’t know where 0.0 0.1 0.1 0.1 0.0 0.1 Ventilated improved pit (VIP) latrine 2.6 0.5 1.1 2.7 0.4 1.0 Pit latrine with slab 27.3 4.4 11.4 27.8 4.1 10.5 Composting toilet 0.3 1.1 0.9 0.3 1.1 0.9 Unimproved facility Unimproved sanitation facility 48.7 55.5 53.4 48.9 55.6 53.8 Flush/pour flush not to sewer/ septic tank/pit latrine 0.8 0.0 0.3 0.9 0.0 0.3 Pit latrine without slab/open pit 47.2 55.1 52.7 47.0 55.2 53.0 Bucket 0.1 0.0 0.0 0.1 0.0 0.0 Hanging toilet/hanging latrine 0.0 0.0 0.0 0.1 0.0 0.0 Other 0.7 0.3 0.4 0.9 0.3 0.5 Open defecation (no facility/ bush/field) 9.7 34.8 27.1 10.1 35.4 28.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population 2,664 5,999 8,663 11,051 29,878 40,929 Location of toilet facility In own dwelling 7.9 0.4 3.2 7.7 0.5 2.9 In own yard/plot 85.3 87.2 86.5 84.9 87.6 86.7 Elsewhere 6.8 12.4 10.3 7.4 11.9 10.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population with a toilet/latrine facility 2,406 3,910 6,316 9,932 19,313 29,245 Percentage with basic sanitation service1 18.7 6.5 10.2 21.7 6.7 10.8 Percentage with limited sanitation service2 22.8 3.1 9.2 19.1 2.3 6.9 Number of households/population 2,664 5,999 8,663 11,051 29,878 40,929 1 Defined as use of improved facilities that are not shared with other households. Includes safely managed sanitation service, which is not shown separately. 2 Defined as use of improved facilities shared by 2 or more households Housing Characteristics and Household Population • 17 Table 2.2.2 Sanitation facility type according to region and wealth Percent distribution of de jure population by type of sanitation, percentage of de jure population with basic sanitation service, and percentage with limited sanitation service, according to region and wealth quintile, Ethiopia Mini-DHS 2019 Type of sanitation Total Percentage with basic sanitation service3 Percentage with limited sanitation service4 Number of persons Background characteristic Improved sanitation facility1 Unimproved sanitation facility2 Open defecation Region Tigray 29.5 19.8 50.7 100.0 15.4 14.1 2,509 Afar 16.3 14.0 69.7 100.0 6.8 9.4 418 Amhara 17.7 48.0 34.3 100.0 12.4 5.2 8,358 Oromia 12.6 61.5 25.9 100.0 7.9 4.8 16,575 Somali 26.4 8.8 64.9 100.0 5.8 19.9 2,531 Benishangul- Gumuz 12.7 71.1 16.2 100.0 10.8 1.9 439 SNNPR 9.7 77.2 13.2 100.0 8.2 1.5 8,243 Gambela 14.6 40.1 45.3 100.0 6.8 7.7 157 Harari 41.1 36.9 22.1 100.0 22.7 17.9 111 Addis Ababa 82.1 15.9 2.1 100.0 49.1 33.0 1,349 Dire Dawa 70.5 11.1 18.4 100.0 37.3 33.1 239 Wealth quintile Lowest 5.2 26.7 68.1 100.0 3.2 1.9 8,185 Second 8.7 54.8 36.5 100.0 6.1 2.6 8,187 Middle 9.0 67.4 23.6 100.0 7.2 1.8 8,188 Fourth 11.9 77.6 10.5 100.0 7.4 4.4 8,169 Highest 53.7 42.2 4.1 100.0 29.9 23.6 8,200 Total 17.7 53.8 28.5 100.0 10.8 6.9 40,929 1 See Table 2.2.1 for definition of an improved facility. 2 See Table 2.2.1 for definition of an unimproved facility. 3 Defined as use of improved facilities that are not shared with other households. Includes safely managed sanitation service, which is not shown separately. 4 Defined as use of improved facilities shared by 2 or more households Table 2.3 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini coefficient, according to residence and region, Ethiopia Mini-DHS 2019 Residence/region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 7.5 4.8 5.7 20.3 61.7 100.0 11,051 0.26 Rural 24.6 25.6 25.3 19.8 4.6 100.0 29,878 0.22 Region Tigray 18.8 15.9 14.8 14.3 36.1 100.0 2,509 0.46 Afar 66.1 4.4 4.7 5.7 19.0 100.0 418 0.40 Amhara 13.9 24.1 25.0 18.7 18.3 100.0 8,358 0.42 Oromia 18.2 22.4 21.1 19.8 18.4 100.0 16,575 0.35 Somali 69.6 9.9 4.0 6.3 10.1 100.0 2,531 0.31 Benishangul-Gumuz 28.5 22.9 21.2 16.4 10.8 100.0 439 0.35 SNNPR 15.7 19.8 24.0 31.9 8.6 100.0 8,243 0.19 Gambela 21.8 16.0 12.2 19.6 30.4 100.0 157 0.44 Harari 5.2 11.4 11.2 15.7 56.5 100.0 111 0.42 Addis Ababa 0.0 0.0 0.0 1.0 99.0 100.0 1,349 0.13 Dire Dawa 16.2 7.6 2.1 3.9 70.2 100.0 239 0.29 Total 20.0 20.0 20.0 20.0 20.0 100.0 40,929 0.27 18 • Housing Characteristics and Household Population Table 2.4 Household characteristics Percent distribution of households and de jure population by housing characteristics, percentage using solid fuel for cooking, and percentage using clean fuel for cooking, according to residence, Ethiopia Mini-DHS 2019 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 82.9 13.7 35.0 81.2 12.4 31.0 No 17.1 86.3 65.0 18.8 87.6 69.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 51.3 77.6 69.5 52.2 78.7 71.6 Dung 2.7 13.9 10.4 1.9 12.8 9.9 Wood/planks 0.1 0.1 0.1 0.1 0.1 0.1 Palm/bamboo 1.4 1.1 1.2 1.7 1.3 1.4 Parquet or polished wood 0.9 0.0 0.3 0.9 0.0 0.2 Vinyl or asphalt strips 10.7 2.2 4.8 11.1 1.8 4.3 Ceramic tiles 4.1 0.1 1.4 4.2 0.1 1.2 Cement 15.0 3.3 6.9 14.6 3.4 6.5 Carpet 13.8 1.5 5.3 13.3 1.6 4.8 Other 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 66.3 71.2 69.7 55.2 66.4 63.4 Two 26.3 22.9 23.9 33.5 25.9 28.0 Three or more 7.4 5.9 6.3 11.3 7.6 8.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 28.8 36.2 33.9 24.8 35.5 32.6 In a separate building 49.9 47.8 48.4 56.9 48.5 50.8 Outdoors 18.6 15.4 16.4 17.2 15.9 16.2 No food cooked in household 2.6 0.6 1.2 1.1 0.1 0.4 Other 0.1 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 19.7 0.9 6.7 18.1 0.6 5.3 LPG/natural gas/biogas 0.6 0.1 0.3 0.3 0.1 0.1 Kerosene 0.6 0.2 0.3 0.4 0.1 0.1 Charcoal 23.0 2.0 8.5 19.9 1.4 6.4 Wood 53.1 91.1 79.4 59.9 92.9 84.0 Straw/shrubs/grass 0.0 0.6 0.4 0.0 0.6 0.5 Agricultural crop 0.0 0.8 0.5 0.0 0.8 0.6 Animal dung 0.3 3.6 2.6 0.2 3.4 2.6 Other 0.1 0.0 0.0 0.0 0.0 0.0 No food cooked in household 2.6 0.6 1.2 1.1 0.1 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 76.4 98.1 91.4 80.0 99.1 94.0 Percentage using clean fuel for cooking2 20.3 1.0 7.0 18.5 0.7 5.5 Number of households/ population 2,664 5,999 8,663 11,051 29,878 40,929 LPG = Liquefied petroleum gas 1 Includes charcoal, wood, straw/shrubs/grass, agricultural crops, and animal dung 2 Includes electricity, kerosene, and LPG/natural gas/biogas Housing Characteristics and Household Population • 19 Table 2.5 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals, by residence, Ethiopia Mini-DHS 2019 Residence Total Possession Urban Rural Household effects Radio 36.2 24.1 27.8 Television 47.3 3.3 16.8 Mobile phone 87.4 59.1 67.8 Computer 8.7 0.4 2.9 Non-mobile telephone 5.7 0.1 1.8 Refrigerator 20.5 0.9 7.0 Watch 38.0 18.0 24.1 Table 66.4 35.8 45.2 Chair 72.5 48.8 56.1 Bed with cotton/sponge/spring mattress 62.8 24.3 36.1 Electric mitad 19.1 1.4 6.9 Kerosene lamp/pressure lamp 6.2 7.8 7.3 Means of transport Bicycle 7.1 1.3 3.1 Animal-drawn cart 3.2 2.3 2.6 Motorcycle/scooter 2.9 1.6 2.0 Car/truck 4.1 0.4 1.5 Bajaj 2.3 0.4 1.0 Ownership of agricultural land 29.9 76.9 62.5 Ownership of farm animals1 31.0 84.6 68.1 Number 2,664 5,999 8,663 1 Cows, bulls, other cattle, horses, donkeys, mules, camels, goats, sheep, chickens or other poultry, and beehives Table 2.6 Household status and resiliency Percent distribution of households and de jure population with a bank account or microfinance savings account, and percent distribution of households and de jure population by Safety Net Programme participation, community-based health insurance scheme enrolment, and household ownership status, Ethiopia Mini-DHS 2019 Households Population Household status/resiliency Urban Rural Total Urban Rural Total Bank account or microfinance account Yes 67.1 29.0 40.7 67.8 27.7 38.5 No 32.9 71.0 59.3 32.2 72.3 61.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Safety Net Programme participation Yes 9.1 15.4 13.5 10.5 16.4 14.8 No 90.9 84.6 86.5 89.5 83.6 85.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Community-based health insurance scheme enrolment Yes 19.4 32.0 28.1 19.5 31.7 28.4 No 80.6 68.0 71.9 80.5 68.3 71.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Household ownership status Owned 55.7 91.2 80.3 65.2 94.1 86.3 Free of charge or subsidised 5.4 5.0 5.1 4.3 3.4 3.7 Rented 38.9 3.8 14.6 30.5 2.4 10.0 Other 0.0 0.1 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/ population 2,664 5,999 8,663 11,051 29,878 40,929 20 • Housing Characteristics and Household Population Table 2.7 Household population by age, sex, and residence Percent distribution of the de facto household population by various age groups, according to sex and residence, Ethiopia Mini-DHS 2019 Urban Rural Male Female Total Age Male Female Total Male Female Total <5 13.0 12.3 12.7 13.9 13.8 13.9 13.7 13.4 13.6 5-9 13.4 11.1 12.2 15.5 16.4 15.9 15.0 14.9 14.9 10-14 12.3 13.3 12.8 16.2 16.0 16.1 15.2 15.3 15.2 15-19 12.8 13.6 13.2 11.9 10.3 11.1 12.1 11.2 11.7 20-24 9.4 9.9 9.6 6.7 6.6 6.6 7.4 7.5 7.4 25-29 8.6 10.2 9.4 6.3 7.8 7.1 6.9 8.5 7.7 30-34 6.3 6.7 6.5 4.9 5.4 5.2 5.3 5.8 5.5 35-39 6.6 5.4 6.0 5.0 5.4 5.2 5.4 5.4 5.4 40-44 3.7 3.2 3.4 4.3 3.6 4.0 4.1 3.5 3.8 45-49 4.0 3.0 3.5 3.2 2.7 2.9 3.4 2.8 3.1 50-54 2.8 2.6 2.7 2.7 3.4 3.0 2.7 3.2 2.9 55-59 1.4 3.2 2.3 2.0 2.7 2.3 1.8 2.8 2.3 60-64 2.0 2.0 2.0 2.1 2.5 2.3 2.1 2.3 2.2 65-69 1.4 0.6 1.0 1.5 1.2 1.4 1.5 1.1 1.3 70-74 0.8 1.0 0.9 1.7 0.8 1.3 1.4 0.9 1.2 75-79 0.7 0.7 0.7 0.8 0.6 0.7 0.8 0.6 0.7 80+ 0.5 1.1 0.8 1.0 0.7 0.9 0.9 0.9 0.9 Don’t know/missing 0.2 0.2 0.2 0.4 0.1 0.2 0.3 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Dependency age groups 0-14 38.8 36.7 37.7 45.6 46.2 45.9 43.8 43.6 43.7 15-64 57.6 59.7 58.7 49.0 50.3 49.6 51.2 52.9 52.1 65+ 3.5 3.4 3.4 5.0 3.4 4.2 4.6 3.4 4.0 Don’t know/missing 0.2 0.2 0.2 0.4 0.1 0.2 0.3 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Child and adult populations 0-17 46.3 44.2 45.3 53.3 52.6 53.0 51.5 50.3 50.9 18+ 53.5 55.6 54.6 46.3 47.3 46.8 48.2 49.6 48.9 Don’t know/missing 0.2 0.2 0.2 0.4 0.1 0.2 0.3 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Adolescents 10-19 25.1 27.0 26.1 28.0 26.3 27.2 27.3 26.5 26.9 Number of persons 5,306 5,538 10,844 14,971 14,466 29,437 20,276 20,004 40,280 Table 2.8 Household composition Percent distribution of households by sex of head of household and by household size, and mean household size, according to residence, Ethiopia Mini-DHS 2019 Residence Total Characteristic Urban Rural Household headship Male 68.9 82.0 77.9 Female 31.1 18.0 22.1 Total 100.0 100.0 100.0 Number of usual members 0 0.0 0.1 0.1 1 10.4 4.6 6.4 2 16.8 9.8 12.0 3 17.6 14.2 15.3 4 16.3 16.7 16.6 5 14.5 14.9 14.7 6 9.7 14.7 13.2 7 6.2 10.8 9.4 8 3.4 7.6 6.3 9+ 5.1 6.6 6.2 Total 100.0 100.0 100.0 Mean size of households 4.1 5.0 4.7 Number of households 2,664 5,999 8,663 Note: Table is based on de jure household members, i.e., usual residents. Housing Characteristics and Household Population • 21 Table 2.9 Educational attainment of the female household population Percent distribution of the de facto female household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Ethiopia Mini-DHS 2019 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 53.7 46.3 0.0 0.0 0.0 0.0 0.0 100.0 2,540 0.0 10-14 12.1 85.7 1.0 1.1 0.0 0.1 0.0 100.0 3,057 2.3 15-19 9.6 57.9 9.2 19.8 0.3 3.2 0.0 100.0 2,243 5.5 20-24 18.7 38.1 11.2 16.4 1.8 13.8 0.0 100.0 1,497 6.0 25-29 37.9 34.0 6.7 13.0 0.8 7.7 0.0 100.0 1,694 2.9 30-34 61.1 24.1 3.7 4.8 1.5 4.8 0.0 100.0 1,153 0.0 35-39 67.1 24.1 2.2 2.8 1.1 2.7 0.0 100.0 1,076 0.0 40-44 67.8 25.0 2.9 2.0 0.8 1.5 0.0 100.0 704 0.0 45-49 69.7 24.4 1.1 1.1 1.9 1.6 0.2 100.0 554 0.0 50-54 84.0 9.9 1.6 2.7 0.9 0.7 0.1 100.0 630 0.0 55-59 84.7 11.0 1.9 0.0 0.4 1.9 0.0 100.0 566 0.0 60-64 93.6 4.2 0.0 1.4 0.4 0.3 0.0 100.0 470 0.0 65+ 95.2 3.3 0.1 0.2 0.2 1.0 0.0 100.0 678 0.0 Don’t know/ missing * * * * * * * 100.0 18 * Residence Urban 29.5 42.4 6.0 11.9 1.7 8.6 0.0 100.0 4,748 3.0 Rural 48.4 43.2 2.9 4.2 0.2 1.1 0.0 100.0 12,132 0.0 Region Tigray 38.9 35.6 4.7 11.9 1.4 7.4 0.1 100.0 1,062 1.8 Afar 57.6 36.2 1.1 2.7 0.4 1.9 0.1 100.0 152 0.0 Amhara 46.9 39.5 4.7 5.9 0.1 2.9 0.0 100.0 3,619 0.1 Oromia 41.2 47.0 3.7 6.0 0.3 1.7 0.0 100.0 6,695 0.7 Somali 65.4 27.8 2.3 3.3 0.4 0.8 0.0 100.0 970 0.0 Benishangul- Gumuz 40.5 46.3 2.9 4.9 0.1 5.3 0.0 100.0 183 0.6 SNNPR 42.5 47.5 2.6 5.1 0.4 1.8 0.0 100.0 3,340 0.5 Gambela 27.6 49.3 5.2 9.3 0.2 8.3 0.0 100.0 66 2.9 Harari 35.4 42.3 4.2 7.9 1.2 8.7 0.2 100.0 48 1.8 Addis Ababa 18.6 33.0 6.0 14.8 6.1 21.3 0.1 100.0 644 6.7 Dire Dawa 31.8 37.9 5.5 10.9 2.3 11.6 0.0 100.0 100 3.0 Wealth quintile Lowest 59.3 37.3 1.3 1.9 0.0 0.2 0.0 100.0 3,183 0.0 Second 50.9 44.4 2.4 2.0 0.0 0.2 0.0 100.0 3,310 0.0 Middle 46.7 44.9 2.8 4.5 0.2 0.8 0.0 100.0 3,336 0.1 Fourth 37.7 46.8 4.5 8.4 0.4 2.2 0.0 100.0 3,449 1.2 Highest 23.5 41.2 7.3 14.0 2.2 11.8 0.0 100.0 3,601 4.6 Total 43.1 43.0 3.8 6.4 0.6 3.2 0.0 100.0 16,879 0.6 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Completed 8th grade at the primary level 2 Completed 4th year at the secondary level Characteristics of Respondents • 23 CHARACTERISTICS OF RESPONDENTS 3 Key Findings ▪ Education: The percentage of women age 15-49 with no education has decreased since 2000, from 75% to 40%. ▪ Educational attainment: The percentage of women with some primary education increased from 14% in 2000 to 35% in 2019. Six percent of women have completed primary school, 11% have some secondary schooling, and 7% have completed secondary school or have more than a secondary education. ▪ Literacy: One in two (48%) women are literate, an increase from one in four (24%) women in 2000. ▪ Marital status: In Ethiopia, two in three (66%) women are currently in union (married or living together with a partner). his chapter presents information on demographic and socioeconomic characteristics of the survey respondents such as age, religion, marital status, education, and wealth status. This information is useful in understanding the factors that affect use of reproductive health services, contraceptive use, and other health behaviours. 3.1 BASIC BACKGROUND CHARACTERISTICS OF SURVEY RESPONDENTS The 2019 EMDHS interviewed 8,885 women age 15-49. Table 3.1 shows the percent distribution of women by background characteristics. The majority of women are under age 30 (60%). In general, the percentage of women in the various age groups decreases as age increases; this pattern reflects the comparatively young age structure in Ethiopia, which is a result of high fertility in past decades. The main religions in Ethiopia are Orthodox Christianity (42% of women) and Muslim (30%). Twenty- seven percent of women are Protestant. Sixty-six percent of women are currently married or living together with a partner. Twenty-six percent of women have never been married, while 6% are divorced or separated and 2% are widowed. A person’s place of residence determines her or his access to services and information about health and other aspects of life. Two-thirds of women live in rural areas (68%), and one-third live in urban areas. Eighty percent of women live in three major regions: Amhara, Oromia, and the Southern Nations, Nationalities, and Peoples’ Region (SNNPR). Four in 10 women (40%) age 15-49 have no formal education, a decrease of eight percentage points from the figure reported in 2016 (48%). T 24 • Characteristics of Respondents 3.2 EDUCATION AND LITERACY Literacy Respondents who had attended higher than secondary school were assumed to be literate. All other respondents, shown a typed sentence to read aloud, were considered literate if they could read all or part of the sentence. Sample: Women age 15-49 Education is an important factor influencing an individual’s attitudes and opportunities. Table 3.2 shows the distribution of women by highest level of schooling attended or completed, and median years completed, according to background characteristics. As noted, 40% of women have no formal education (Figure 3.1). Six percent of women have completed primary school, while 1% have completed a secondary education. Six percent of women have more than a secondary education. Trends: The percentage of women with no education has decreased over the years, from 75% in 2000 and 66% in 2005 to 51% in 2011, 48% in 2016, and 40% in 2019. Patterns by background characteristics ▪ Younger respondents are more likely to have attended school and reached higher levels of education than older respondents. The percentage of women with no education increases steadily by age group, from 11% among those age 15-19 to 74% among those age 45-49, suggesting an improvement in women’s education over time (Table 3.2). ▪ Urban women are better educated than rural women. Almost half (48%) of women in rural areas have never attended school, as compared with 25% of urban women. The urban-rural difference is more pronounced at the secondary and higher levels of education. Only 3% of women in rural areas have completed secondary schooling or higher, compared with 16% of women in urban areas (Figure 3.1). ▪ Educational attainment increases with increasing household wealth. About 6 in 10 (62%) women in the lowest wealth quintile have no education, as compared with 18% of women in the highest wealth quintile. Similarly, less than 1% of women in the lowest wealth quintile have completed secondary schooling or higher, compared with 20% of women in the highest quintile. Figure 3.1 Education of survey respondents Figure 3.2 Education of survey respondents by residence 40 35 6 11 16 Women Percent distribution of women age 15-49 by highest level of schooling attended or completed More than secondary Completed secondary Some secondary Primary complete Primary incomplete No education 40 25 48 35 33 36 6 9 511 18 8 7 16 3 Total Urban Rural Percent distribution of women age 15-49 by highest level of schooling attended or completed Completed secondary or more Some secondary Completed primary Some primary No education Figures do not = 100 due to rounding. Characteristics of Respondents • 25 ▪ Educational attainment varies across regions. Somali and Afar have the highest proportions of women with no education (72% and 64%, respectively), while Addis Ababa (13%) has the lowest proportion. ▪ Literacy among women decreases sharply with age, from 72% among those age 15-19 to 24% among those age 45-49 (Table 3.3). ▪ By region, the percentage of women who are literate is highest in Addis Ababa (84%) and lowest in Somali (12%). ▪ Literacy increases with increasing wealth, from 23% among women in the lowest wealth quintile to 75% among women in the highest quintile. 3.3 MARITAL STATUS Currently married Women who report being married or living together with a partner as though married at the time of the survey. Sample: Women age 15-49 Marriage helps determine the extent to which women are exposed to the risk of pregnancy and is an important determinant of fertility levels. In Ethiopia, two in three (66%) women are currently married or living together with a partner (Table 3.4 and Figure 3.2). One in four women (26%) have never been married, 6% are divorced or separated, and 2% are widowed. Trends: The percentage of women who are currently in a union (married or living together) has remained relatively constant over time (64% in 2016 and 66% in 2019). Patterns by background characteristics ▪ There are marked differences in marital status by age. The percentage of women who have never been married generally decreases as age increases, from 75% among those age 15-19 to 2% among those age 45-49. ▪ The percentage of women currently in a union peaks at 89% among those age 30-34 and falls to 81% among those age 45-49. ▪ In general, the proportion of women who are divorced, separated, or widowed increases with age. Four percent of women age 15-19 are divorced or separated, as compared with 8% of women age 45-49. Similarly, less than 1% of women age 15-19 are widowed, compared with 9% of women age 45-49. LIST OF TABLES For more information on the characteristics of survey respondents, see the following tables: ▪ Table 3.1 Background characteristics of respondents ▪ Table 3.2 Educational attainment: Women ▪ Table 3.3 Literacy: Women ▪ Table 3.4 Current marital status Figure 3.3 Marital status Never married 26% Married or living together 66% Divorced/ separated 6% Widowed 2% Percent distribution of women age 15-49 Women 26 • Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women age 15-49 by selected background characteristics, Ethiopia Mini-DHS 2019 Number of women Background characteristic Weighted percent Weighted number Unweighted number Age 15-19 24.9 2,210 2,100 20-24 16.7 1,481 1,578 25-29 18.8 1,667 1,752 30-34 13.1 1,160 1,166 35-39 12.0 1,065 1,037 40-44 8.3 739 714 45-49 6.3 563 538 Religion Orthodox 41.5 3,685 3,374 Catholic 0.5 47 78 Protestant 27.4 2,435 1,711 Muslim 29.5 2,619 3,635 Traditional 0.9 83 60 Other 0.2 15 27 Marital status Never married 26.2 2,325 2,300 Married 64.6 5,743 5,613 Living together 1.4 121 129 Divorced/separated 5.7 510 616 Widowed 2.1 185 227 Residence Urban 32.2 2,861 2,951 Rural 67.8 6,024 5,934 Region Tigray 7.1 629 733 Afar 1.0 85 641 Amhara 22.8 2,026 948 Oromia 37.7 3,347 1,052 Somali 4.7 420 640 Benishangul-Gumuz 1.1 98 747 SNNPR 19.2 1,705 1,008 Gambela 0.5 40 723 Harari 0.3 27 763 Addis Ababa 5.0 442 818 Dire Dawa 0.7 64 812 Education No education 40.4 3,589 3,640 Primary 41.7 3,701 3,345 Secondary 12.2 1,088 1,149 More than secondary 5.7 507 751 Wealth quintile Lowest 16.2 1,437 2,031 Second 18.2 1,615 1,341 Middle 18.8 1,671 1,268 Fourth 21.1 1,874 1,344 Highest 25.7 2,287 2,901 Total 15-49 100.0 8,885 8,885 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Characteristics of Respondents • 27 Table 3.2 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Ethiopia Mini-DHS 2019 Highest level of schooling Total Median years completed Number of women Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 14.2 49.0 10.1 18.4 0.9 7.4 100.0 5.7 3,691 15-19 10.7 56.9 9.3 19.7 0.4 3.1 100.0 5.5 2,210 20-24 19.5 37.1 11.3 16.4 1.8 13.9 100.0 5.9 1,481 25-29 39.9 32.1 6.5 12.8 0.8 7.8 100.0 2.7 1,667 30-34 60.6 24.5 3.7 4.6 1.5 5.1 100.0 0.0 1,160 35-39 70.9 20.8 2.2 2.8 1.0 2.3 100.0 0.0 1,065 40-44 70.9 23.3 1.7 1.9 0.6 1.7 100.0 0.0 739 45-49 74.1 20.2 1.1 1.0 1.9 1.6 100.0 0.0 563 Residence Urban 24.5 33.0 8.6 18.2 2.4 13.4 100.0 6.1 2,861 Rural 47.9 36.4 5.3 7.9 0.4 2.1 100.0 0.6 6,024 Region Tigray 34.8 23.7 7.1 19.7 2.2 12.6 100.0 5.4 629 Afar 64.3 27.0 1.1 4.4 0.8 2.5 100.0 0.0 85 Amhara 46.4 29.8 8.2 10.3 0.2 5.0 100.0 1.8 2,026 Oromia 37.2 41.6 6.5 10.8 0.7 3.2 100.0 2.5 3,347 Somali 71.7 15.0 4.5 6.5 0.4 1.9 100.0 0.0 420 Benishangul-Gumuz 39.8 36.6 5.0 8.8 0.2 9.6 100.0 2.9 98 SNNPR 40.7 41.7 4.1 9.0 0.8 3.6 100.0 2.1 1,705 Gambela 21.1 41.9 9.0 14.9 0.4 12.6 100.0 5.6 40 Harari 32.6 31.6 6.4 12.9 1.2 15.3 100.0 4.5 27 Addis Ababa 13.3 24.8 7.9 20.1 7.3 26.5 100.0 8.6 442 Dire Dawa 26.9 28.7 7.3 16.5 2.9 17.6 100.0 6.2 64 Wealth quintile Lowest 62.1 31.3 2.8 3.6 0.0 0.2 100.0 0.0 1,437 Second 53.8 37.6 4.3 3.7 0.0 0.5 100.0 0.0 1,615 Middle 45.2 38.8 5.4 8.8 0.4 1.5 100.0 1.5 1,671 Fourth 35.9 38.2 7.1 14.0 0.8 4.0 100.0 3.3 1,874 Highest 17.5 31.2 10.3 20.8 3.0 17.3 100.0 7.1 2,287 Total 40.4 35.3 6.4 11.2 1.0 5.7 100.0 2.5 8,885 1 Completed 8th grade at the primary level 2 Completed 4th year at the secondary level 28 • Characteristics of Respondents Table 3.3 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Ethiopia Mini-DHS 2019 Higher than secondary schooling No schooling, primary or secondary school Total Percentage literate1 Number of women Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/visually impaired Age 15-24 7.4 42.7 18.3 28.8 2.8 0.1 100.0 68.4 3,691 15-19 3.1 49.1 19.7 25.0 3.0 0.1 100.0 71.9 2,210 20-24 13.9 33.2 16.2 34.4 2.4 0.0 100.0 63.2 1,481 25-29 7.8 28.0 11.9 50.4 1.9 0.0 100.0 47.6 1,667 30-34 5.1 14.1 11.1 67.8 1.9 0.0 100.0 30.3 1,160 35-39 2.3 9.1 11.1 76.0 1.5 0.0 100.0 22.5 1,065 40-44 1.7 13.6 10.2 73.8 0.6 0.1 100.0 25.5 739 45-49 1.6 12.2 10.1 75.1 0.5 0.5 100.0 23.9 563 Residence Urban 13.4 39.8 13.6 31.0 2.2 0.0 100.0 66.8 2,861 Rural 2.1 22.2 14.3 59.4 1.9 0.1 100.0 38.6 6,024 Region Tigray 12.6 36.8 10.2 40.3 0.0 0.1 100.0 59.6 629 Afar 2.5 7.9 9.4 78.7 1.5 0.0 100.0 19.8 85 Amhara 5.0 34.7 10.1 50.0 0.0 0.2 100.0 49.8 2,026 Oromia 3.2 28.8 15.2 52.8 0.1 0.0 100.0 47.1 3,347 Somali 1.9 5.3 5.0 58.3 29.4 0.0 100.0 12.3 420 Benishangul-Gumuz 9.6 18.8 17.2 52.6 1.8 0.0 100.0 45.5 98 SNNPR 3.6 17.1 21.4 56.1 1.7 0.0 100.0 42.2 1,705 Gambela 12.6 16.6 9.0 27.7 34.1 0.0 100.0 38.2 40 Harari 15.3 28.8 9.7 46.2 0.0 0.0 100.0 53.8 27 Addis Ababa 26.5 45.6 11.8 14.9 1.2 0.0 100.0 84.0 442 Dire Dawa 17.6 32.4 10.1 38.6 1.3 0.0 100.0 60.1 64 Wealth quintile Lowest 0.2 11.6 11.5 70.2 6.4 0.0 100.0 23.3 1,437 Second 0.5 17.1 12.6 68.1 1.6 0.2 100.0 30.1 1,615 Middle 1.5 24.2 16.5 56.8 1.0 0.0 100.0 42.2 1,671 Fourth 4.0 32.2 16.5 46.1 1.1 0.1 100.0 52.7 1,874 Highest 17.3 44.8 13.0 23.8 1.0 0.0 100.0 75.2 2,287 Total 5.7 27.8 14.1 50.3 2.0 0.1 100.0 47.6 8,885 1 Refers to women who attended schooling higher than the secondary level and women who can read a whole sentence or part of a sentence Table 3.4 Current marital status Percent distribution of women age 15-49 by current marital status, according to age, Ethiopia Mini-DHS 2019 Marital status Total Percentage of respondents currently in union Number of respondents Age Never married Married Living together Divorced Separated Widowed 15-19 74.5 20.3 1.2 2.5 1.4 0.1 100.0 21.5 2,210 20-24 29.5 62.7 1.8 3.7 1.7 0.5 100.0 64.5 1,481 25-29 10.2 81.8 1.8 3.7 1.2 1.3 100.0 83.6 1,667 30-34 3.5 87.6 0.8 4.2 2.3 1.6 100.0 88.5 1,160 35-39 1.4 84.6 1.6 7.4 1.0 3.9 100.0 86.3 1,065 40-44 1.0 85.8 0.4 5.4 1.6 5.9 100.0 86.2 739 45-49 1.5 79.8 1.6 6.6 1.3 9.2 100.0 81.3 563 Total 15-49 26.2 64.6 1.4 4.2 1.5 2.1 100.0 66.0 8,885 Fertility Determinants • 29 FERTILITY DETERMINANTS 4 Key Findings ▪ Birth intervals: The median birth interval in Ethiopia is 35.8 months. The interval is longer in urban areas than in rural areas (38.6 months versus 35.1 months). ▪ Age at first birth: The median age at first birth among women age 25-49 is 18.7 years. he number of children that a woman bears depends on many factors, including the age she begins childbearing, how long she waits between births, and her fecundity. Postponing first births and extending the interval between births have played an important role in reducing fertility levels in many countries. These factors also have positive health consequences. In contrast, short birth intervals (of less than 24 months) can lead to harmful outcomes for both newborns and their mothers, such as preterm birth, low birth weight, and death. Childbearing at a very young age is associated with an increased risk of complications during pregnancy and childbirth and higher rates of neonatal mortality. This chapter describes fertility determinants in Ethiopia. It presents information on children ever born and living, birth intervals, and age at first birth. Information on the current level of fertility is not presented in this report. 4.1 CHILDREN EVER BORN AND LIVING The 2019 EMDHS collected information on the number of children ever born to women age 15-49 and those still surviving at the time of the survey. On average, women age 45-49 have given birth to 6.7 children, of whom 5.6 survived to the time of the survey (a difference of 1.1). Of the 7.0 children on average born to currently married women age 45-49, 5.9 survived to the time of the survey. In Ethiopia, 2% of currently married women age 45-49 have never given birth. Since voluntary childlessness is rare, this is often viewed as a measure of primary sterility (Table 4.1). 4.2 BIRTH INTERVALS Median birth interval Number of months since the preceding birth by which half of children are born. Sample: Non-first births in the 5 years before the survey T 30 • Fertility Determinants Short birth intervals, particularly those less than 24 months, place both newborns and their mothers at increased health risk. The median birth interval in Ethiopia is 35.8 months; thus, half of non-first births occur within 3 years of the first birth (Table 4.2). About one in four births (28%) occur within 24-35 months of the previous birth, and one in five births (20%) occur within 36-47 months of the previous birth (Figure 4.1). Trends: There have been no substantial differences in median birth intervals over the last 20 years. From 2000 to 2019, the median birth interval increased slightly but steadily. Median intervals were 33.6 months in 2000, 33.8 months in 2005, 33.9 months in 2011, 34.5 months in 2016, and 35.8 months in 2019. Patterns by background characteristics ▪ Births to older women occur after longer intervals than births to younger women. The median birth interval among women age 40-49 is nearly 14 months longer than the median birth interval among women age 15-19 (41.0 months versus 27.3 months) (Table 4.2). ▪ The median birth interval is 15 months longer if the child from the preceding birth is living than if the child has died (36.5 months versus 21.6 months). In contrast, there is little difference (less than 1 month) in the median birth interval by sex of the preceding child. ▪ The median birth interval is 3.5 months longer in urban areas than in rural areas (38.6 versus 35.1 months). ▪ The median birth interval increases from 34.8 months among women with no education to 43.8 months among women with a secondary education before decreasing to 39.3 months among women with more than a secondary education. ▪ Median birth intervals increase with increasing wealth. The birth interval among women in the highest quintile is more than 12 months longer than the interval among women in the lowest quintile (43.3 months versus 30.9 months). 4.3 AGE AT FIRST BIRTH Median age at first birth Age by which half of women have had their first child. Sample: Women age 20-49 and 25-49 Figure 4.1 Birth intervals 7-17 9% 18-23 14% 36-47 20% 48-59 12% 60+ 18% Percent distribution of non-first births by number of months since the preceding birth 24-35 28% Note: Percentages do not sum to 100 due to rounding. Fertility Determinants • 31 The age at which childbearing commences is an important determinant of the overall level of fertility as well as the health and well-being of the mother and child. In Ethiopia, the median age at first birth among women age 25-49 is 18.7 years. This means that half of women age 25-49 give birth for the first time before age 19 (Table 4.3). Trends: The median age at first birth increased slightly from 19.0 years in 2005 to 19.2 years in 2011 and 2016 before decreasing to 18.7 years in 2019. Patterns by background characteristics ▪ Urban women age 25-49 begin childbearing 1.9 years later than their counterparts in rural areas (20.0 versus 18.1 years) (Figure 4.2 and Table 4.4). ▪ By region, median age at first birth ranges from 17.5 years among women in Gambela to 21.5 years among women in Dire Dawa. ▪ Women with a secondary education begin childbearing almost 5 years later than women with no education (22.6 years versus 17.9 years) (Figure 4.3). Figure 4.2 Median age at first birth by residence Figure 4.3 Median age at first birth by education 18.7 20.0 18.1 Total Urban Rural Median age at first birth among women age 25-49 17.9 18.8 22.6 No education Primary Secondary Median age at first birth among women age 25-49 32 • Fertility Determinants LIST OF TABLES For more information on fertility levels and some of the determinants of fertility, see the following tables: ▪ Table 4.1 Children ever born and living ▪ Table 4.2 Birth intervals ▪ Table 4.3 Age at first birth ▪ Table 4.4 Median age at first birth Fertility Determinants • 33 Table 4.1 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Ethiopia Mini-DHS 2019 Number of children ever born Total Number of women Mean number of children ever born Mean number of living children Age 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 89.7 8.6 1.5 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,210 0.12 0.11 20-24 44.1 29.6 17.1 6.2 2.3 0.7 0.0 0.0 0.0 0.0 0.0 100.0 1,481 0.95 0.89 25-29 16.2 16.2 25.3 16.6 11.7 6.8 4.4 2.5 0.2 0.0 0.1 100.0 1,667 2.44 2.26 30-34 4.8 5.7 15.2 17.8 16.1 15.0 11.4 9.1 2.4 1.9 0.7 100.0 1,160 4.04 3.75 35-39 3.5 4.2 8.0 11.1 16.9 14.3 16.0 10.4 6.2 5.3 4.3 100.0 1,065 5.05 4.60 40-44 2.1 2.6 3.2 5.6 11.3 13.3 13.7 14.5 12.6 8.3 12.8 100.0 739 6.32 5.36 45-49 3.0 2.6 4.0 5.6 6.2 11.3 10.7 17.1 13.0 10.8 15.6 100.0 563 6.69 5.61 Total 34.1 11.7 11.4 8.6 8.0 6.9 6.1 5.2 3.0 2.3 2.7 100.0 8,885 2.73 2.44 CURRENTLY MARRIED WOMEN 15-19 60.5 33.2 5.6 0.5 0.2 0.0 0.0 0.0 0.0 0.0 0.0 100.0 475 0.47 0.42 20-24 20.7 40.7 25.0 8.9 3.4 1.2 0.1 0.0 0.0 0.0 0.0 100.0 955 1.37 1.29 25-29 7.3 16.1 28.3 18.3 13.3 8.0 5.2 3.0 0.3 0.0 0.1 100.0 1,394 2.77 2.56 30-34 2.1 4.2 13.9 17.7 17.3 16.7 12.7 9.8 2.6 2.1 0.7 100.0 1,026 4.31 4.00 35-39 2.6 3.0 6.7 10.6 16.9 14.7 17.3 10.7 6.9 5.7 4.9 100.0 919 5.29 4.85 40-44 1.6 1.9 2.1 3.9 11.4 13.2 13.3 16.7 13.9 8.6 13.3 100.0 637 6.55 5.61 45-49 1.9 2.7 1.8 5.3 5.9 10.1 11.1 19.5 12.6 11.5 17.8 100.0 458 7.03 5.91 Total 11.1 14.8 15.1 11.4 11.1 9.5 8.5 7.4 4.1 3.1 3.8 100.0 5,864 3.76 3.38 34 • Fertility Determinants Table 4.2 Birth intervals Percent distribution of non-first births in the 5 years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Ethiopia Mini-DHS 2019 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Mother’s age 15-19 14.3 30.2 34.2 3.4 8.1 9.9 100.0 41 27.3 20-29 11.1 16.0 28.1 21.2 12.0 11.7 100.0 1,863 33.4 30-39 6.9 12.2 28.6 19.3 12.1 20.9 100.0 1,929 37.0 40-49 8.5 10.7 22.0 19.4 12.7 26.7 100.0 473 41.0 Sex of preceding birth Male 8.7 13.4 27.6 20.2 13.7 16.5 100.0 2,126 36.2 Female 9.1 14.3 27.8 19.8 10.5 18.4 100.0 2,179 35.4 Survival of preceding birth Living 7.1 13.2 28.7 20.8 12.4 17.9 100.0 4,038 36.5 Dead 36.9 24.3 12.3 7.9 7.3 11.2 100.0 268 21.6 Birth order 2-3 7.6 14.3 24.4 19.8 13.2 20.8 100.0 1,755 37.7 4-6 9.7 12.5 28.5 19.6 11.2 18.5 100.0 1,727 35.7 7+ 10.1 15.6 33.0 21.3 11.6 8.3 100.0 824 32.5 Residence Urban 8.1 12.2 23.0 22.3 11.5 23.0 100.0 970 38.6 Rural 9.2 14.3 29.1 19.3 12.2 15.9 100.0 3,335 35.1 Region Tigray 3.7 6.0 32.9 20.5 14.1 22.8 100.0 275 38.7 Afar 20.9 17.3 32.1 15.2 6.2 8.4 100.0 67 27.2 Amhara 3.2 8.5 19.1 18.2 16.5 34.5 100.0 775 48.6 Oromia 9.7 16.5 31.1 20.6 9.7 12.5 100.0 1,741 32.5 Somali 22.1 18.8 37.2 12.8 6.7 2.3 100.0 359 26.0 Benishangul-Gumuz 6.1 9.9 30.3 21.1 13.4 19.2 100.0 53 37.6 SNNPR 8.3 14.0 23.4 24.0 14.4 15.9 100.0 893 37.6 Gambela 7.8 7.3 18.8 19.4 21.0 25.7 100.0 18 46.5 Harari 12.5 15.1 30.1 20.6 8.0 13.7 100.0 13 33.3 Addis Ababa 6.5 12.8 20.4 13.8 13.9 32.6 100.0 90 44.7 Dire Dawa 11.3 12.8 30.9 21.9 11.8 11.3 100.0 21 33.6 Mother’s education No education 10.1 14.2 29.3 19.6 10.8 16.0 100.0 2,683 34.8 Primary 7.3 14.1 26.0 20.9 15.8 16.0 100.0 1,304 36.8 Secondary 7.1 10.2 16.7 19.5 6.6 39.8 100.0 230 43.8 More than secondary 4.1 9.8 31.6 19.9 9.5 25.0 100.0 89 39.3 Wealth quintile Lowest 13.7 17.4 31.4 17.8 12.3 7.5 100.0 1,146 30.9 Second 8.1 15.0 27.7 21.9 13.6 13.7 100.0 979 35.6 Middle 6.6 12.3 28.9 20.1 12.4 19.7 100.0 809 37.3 Fourth 8.6 9.4 27.7 20.7 11.3 22.2 100.0 716 37.6 Highest 5.2 12.6 19.7 20.1 9.8 32.6 100.0 656 43.3 Total 8.9 13.8 27.7 20.0 12.1 17.5 100.0 4,306 35.8 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Fertility Determinants • 35 Table 4.3 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Ethiopia Mini-DHS 2019 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 1.1 na na na na 89.7 2,210 a 20-24 6.3 22.2 39.0 na na 44.1 1,481 a 25-29 15.3 35.0 51.1 63.6 78.7 16.2 1,667 19.9 30-34 20.7 48.1 66.3 76.8 87.6 4.8 1,160 18.2 35-39 21.4 48.1 64.5 77.0 87.9 3.5 1,065 18.2 40-44 31.1 52.3 69.2 81.3 89.3 2.1 739 17.7 45-49 22.0 48.3 60.3 73.0 84.4 3.0 563 18.3 20-49 17.5 39.6 56.0 na na 15.7 6,675 19.3 25-49 20.7 44.5 60.8 72.8 84.7 7.6 5,194 18.7 na = Not applicable due to censoring a = Omitted because less than 50% of women had a birth before reaching the beginning of the age group Table 4.4 Median age at first birth Median age at first birth among women age 20- 49 and age 25-49, according to background characteristics, Ethiopia Mini-DHS 2019 Women age 20-49 Women age 25-49 Background characteristic Residence Urban a 20.0 Rural 18.7 18.1 Region Tigray 20.0 19.6 Afar 19.1 19.4 Amhara 19.1 18.2 Oromia 18.8 18.2 Somali 19.9 19.6 Benishangul-Gumuz 18.6 18.0 SNNPR 19.0 18.5 Gambela 17.9 17.5 Harari a 19.6 Dire Dawa a 21.5 Education No education 17.9 17.9 Primary 19.4 18.8 Secondary a 22.6 Wealth quintile Lowest 18.8 18.7 Second 18.7 18.2 Middle 18.5 18.0 Fourth 18.6 17.9 Highest a 20.6 Total 19.3 18.7 a = Omitted because less than 50% of the women had a birth before reaching the beginning of the age group Family Planning • 37 FAMILY PLANNING 5 Key Findings ▪ Contraceptive knowledge: Knowledge of family planning is nearly universal in Ethiopia, with 96% of currently married women having heard of at least one modern method. ▪ Modern contraceptive use: Modern contraceptive use among currently married women has increased steadily since 2005, from 14% to 41%. ▪ Methods used: Injectables are the most commonly used method among currently married women (27%), followed by implants (9%). ▪ Sources of modern methods: The most common source of modern contraception is the public sector (87%); only 12% of women obtain their method from private sector sources. ouples can use contraceptive methods to limit or space the number of children they have. This chapter presents information on knowledge, use, and sources of contraceptive methods. Family planning helps women avoid unplanned or unwanted pregnancies and prevent unsafe abortions. Additionally, contraceptive use helps women space the births of their children, which benefits the health of the mother and child. Although previous surveys gathered data on family planning from both women and men, the 2019 Ethiopia Mini-DHS was limited to only women. In line with Ethiopia’s Family Planning 2020 (FP2020) commitments, the Ministry of Health (MoH) developed the health sector transformation plan of 2015, which aimed to increase the contraceptive prevalence rate (CPR) to 55%. This would mean reaching an additional 6.2 million women and adolescent girls with family planning services by 2020 (MOH 2015). 5.1 CONTRACEPTIVE KNOWLEDGE AND USE Knowledge of contraceptive methods is virtually universal in Ethiopia, with 96% of currently married women age 15-49 knowing at least one method of contraception. The most well-known methods for currently married women are injectables (93%), implants (87%) and pills (83%). Among all women, male sterilisation is the least-known modern contraceptive method (13%). On average, currently married women know of six contraceptive methods (Table 5.1). Knowledge of contraceptive methods varies the most by a respondent’s region. Almost all currently married women in Addis Ababa know at least one method of contraception, while in Somali only 67% of currently married women know at least one method of contraception (Table 5.2). Contraceptive prevalence rate: Percentage of women who use any contraceptive method Sample: All women age 15-49 and currently married women age 15-49 C 38 • Family Planning The contraceptive prevalence rate (CPR) among currently married women age 15-49 in Ethiopia is 41%. Many currently married women use a modern method (41%), while only 1% use a traditional method (Table 5.3). Modern methods Include male and female sterilisation, injectables, intrauterine devices (IUDs), contraceptive pills, implants, female and male condoms, the Standard Days Method and emergency contraception The most commonly used modern contraceptive methods among currently married women in Ethiopia are injectables (27%), followed by implants (9%), and the pill and IUD (2% each) (Figure 5.1). Trends: Modern contraceptive use among currently married women has steadily increased over the last 15 years, from 14% in 2005 to 41% in 2019 (Figure 5.2). The largest increases have been in the use of injectables (from 10% in 2005 to 27% in 2019) and implants (from less than 1% in 2005 to 9% in 2019). Figure 5.2 Trends in contraceptive use Patterns by background characteristics ▪ Modern contraceptive use is higher among currently married women with one or two living children (53%) than among those with five or more living children (31%) (Table 5.4). ▪ Urban women (48%) are more likely than rural women (38%) to use modern methods. 6 14 27 35 41 2 1 <1 1 1 2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS 2019 EMDHS Percentage of currently married women currently using a contraceptive method Any traditional method Any modern method Figure 5.1 Contraceptive use 41 41 27 9 2 2 1 Any method Any modern method Injectables Implants Pill IUD Traditional method Percentage of currently married women age 15-49 currently using a contraceptive method Family Planning • 39 ▪ Modern contraceptive use generally increases with increasing household wealth, from 27% among women in the lowest wealth quintile to 51% among those in the highest quintile (Figure 5.3). ▪ The percentage of women using a modern method is higher among those with a secondary education (56%) than among those with no education (32%) (Table 5.4). ▪ The percentages of women using modern methods are lowest in Somali (3%) and Afar (13%) and highest in Amhara (50%) and Addis Ababa (48%). 5.2 SOURCE OF MODERN CONTRACEPTIVE METHODS Source of modern contraceptives The place where the modern method currently being used was obtained the last time it was acquired. Sample: Women age 15-49 currently using a modern contraceptive method Information on current sources of modern contraceptive methods is important for family planners and programme implementers. The most common source of modern contraception is the public sector (87%), followed by the private sector (12%). In the public sector, government health stations/centres (47%) and government health posts (34%) are the most common sources (Figure 5.4 and Table 5.5). Patterns by background characteristics ▪ The main source of injectables is the public sector (85%), primarily government health stations/centres (41%) and government health posts (42%). Only 13% of women using injectables obtained their method from the private sector, mainly private clinics (12%). ▪ Almost all implant and IUD users obtained their method from the public sector (96% and 94%, respectively). ▪ Sixty-eight percent of pill users obtained their method from the public sector, mainly through a government health station/centre (30%) or public pharmacy (18%). Thirty-two percent of pill users obtained their method from the private sector, primarily from a private clinic or private pharmacy (15% each). Figure 5.3 Use of modern methods by household wealth Figure 5.4 Source of modern contraceptive methods 27 35 45 43 51 Lowest Second Middle Fourth Highest Percentage of currently married women age 15-49 Poorest Wealthiest Public sector 87% Private sector 12% NGO 1% Percent distribution of current users of modern methods age 15-49 by most recent source of method 40 • Family Planning LIST OF TABLES For more information on family planning, see the following tables: ▪ Table 5.1 Knowledge of contraceptive methods ▪ Table 5.2 Knowledge of contraceptive methods according to background characteristics ▪ Table 5.3 Current use of contraception by age ▪ Table 5.4 Current use of contraception according to background characteristics ▪ Table 5.5 Source of modern contraceptive methods Family Planning • 41 Table 5.1 Knowledge of contraceptive methods Percentage of all women and currently married women age 15-49 who know any contraceptive method, by specific method, Ethiopia Mini-DHS 2019 Method All women Currently married women Any method 95.2 96.2 Any modern method 95.0 96.1 Female sterilisation 30.7 32.1 Male sterilisation 13.2 12.8 Pill 81.0 83.0 IUD 50.5 52.3 Injectables 91.0 92.5 Implants 84.3 87.1 Male condom 70.9 68.7 Female condom 24.7 22.3 Emergency contraception 27.2 25.0 Standard days method 19.2 20.3 Lactational amenorrhoea (LAM) 42.1 46.9 Any traditional method 51.5 51.9 Rhythm 46.7 46.7 Withdrawal 24.0 24.7 Other traditional method 0.2 0.2 Mean number of methods known by respondents 15-49 6.1 6.1 Number of respondents 8,885 5,864 42 • Family Planning Table 5.2 Knowledge of contraceptive methods according to background characteristics Percentage of currently married women age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method, by background characteristics, Ethiopia Mini-DHS 2019 Background characteristic Heard of any method Heard of any modern method1 Number of women Age 15-19 94.8 94.8 475 20-24 97.1 97.1 955 25-29 97.2 97.0 1,394 30-34 96.6 95.9 1,026 35-39 95.9 95.9 919 40-44 95.6 95.6 637 45-49 93.7 93.7 458 Residence Urban 98.2 98.0 1,627 Rural 95.5 95.3 4,237 Region Tigray 98.4 98.2 370 Afar 86.3 86.1 64 Amhara 96.2 96.2 1,313 Oromia 98.5 98.2 2,306 Somali 66.7 66.5 284 Benishangul-Gumuz 95.4 95.3 67 SNNPR 98.3 98.2 1,177 Gambela 94.7 94.4 25 Harari 98.2 98.2 16 Addis Ababa 99.4 99.4 206 Dire Dawa 95.5 95.5 36 Education No education 94.0 93.7 3,025 Primary 98.2 98.1 2,119 Secondary 99.9 99.9 470 More than secondary 99.9 99.9 250 Wealth quintile Lowest 89.2 88.9 1,069 Second 96.5 96.4 1,138 Middle 97.0 96.9 1,154 Fourth 98.3 98.3 1,220 Highest 99.1 98.8 1,283 Total 96.2 96.1 5,864 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, emergency contraception, standard days method (SDM), lactational amenorrhoea method (LAM), and other modern methods Family Planning • 43 Table 5.3 Current use of contraception by age Percent distribution of all women and currently married women age 15-49 by contraceptive method currently used, according to age, Ethiopia Mini-DHS 2019 Any method Any modern method Modern method Any tradi- tional method Traditional method Not current- ly using Total Number of women Age Female sterili- sation Pill IUD Inject- ables Im- plants Male condom Emer- gency contra- ception SDM LAM Other Rhythm With- drawal Other ALL WOMEN 15-19 9.4 9.4 0.0 0.5 0.1 6.5 1.9 0.2 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 90.6 100.0 2,210 20-24 36.2 34.7 0.0 1.4 0.2 26.1 6.2 0.1 0.1 0.0 0.6 0.0 1.5 1.5 0.0 0.0 63.8 100.0 1,481 25-29 41.4 40.5 0.0 1.9 2.0 26.7 9.0 0.1 0.0 0.2 0.6 0.0 0.9 0.5 0.4 0.0 58.6 100.0 1,667 30-34 40.3 39.5 0.1 2.3 1.6 26.4 8.7 0.2 0.0 0.0 0.2 0.0 0.8 0.5 0.2 0.0 59.7 100.0 1,160 35-39 34.6 34.1 0.8 2.2 1.9 20.7 7.7 0.2 0.0 0.4 0.1 0.0 0.5 0.1 0.4 0.0 65.4 100.0 1,065 40-44 27.6 26.9 1.5 2.0 1.1 14.7 6.4 0.3 0.0 0.0 0.7 0.2 0.8 0.1 0.6 0.0 72.4 100.0 739 45-49 14.4 13.7 0.7 0.0 0.4 8.4 3.4 0.0 0.0 0.1 0.7 0.0 0.8 0.8 0.0 0.0 85.6 100.0 563 Total 28.8 28.1 0.3 1.4 1.0 18.7 6.0 0.2 0.0 0.1 0.4 0.0 0.7 0.5 0.2 0.0 71.2 100.0 8,885 CURRENTLY MARRIED WOMEN 15-19 36.5 36.4 0.0 1.7 0.0 27.4 5.9 0.4 0.0 0.2 0.7 0.0 0.0 0.0 0.0 0.0 63.5 100.0 475 20-24 52.5 50.6 0.0 2.2 0.4 37.8 9.1 0.1 0.2 0.0 0.9 0.0 1.9 1.9 0.0 0.0 47.5 100.0 955 25-29 48.1 47.1 0.0 2.2 2.4 31.4 10.2 0.0 0.0 0.2 0.7 0.0 1.0 0.5 0.4 0.0 51.9 100.0 1,394 30-34 43.9 43.0 0.1 2.4 1.9 29.0 9.3 0.0 0.0 0.0 0.2 0.0 0.9 0.6 0.3 0.0 56.1 100.0 1,026 35-39 39.3 38.8 0.9 2.5 2.3 23.4 8.9 0.2 0.0 0.5 0.1 0.0 0.5 0.1 0.4 0.0 60.7 100.0 919 40-44 30.1 29.2 1.0 2.1 1.2 16.8 6.8 0.2 0.0 0.0 0.8 0.3 0.9 0.1 0.7 0.0 69.9 100.0 637 45-49 17.5 16.6 0.9 0.0 0.3 10.3 4.2 0.0 0.0 0.1 0.8 0.0 0.9 0.9 0.0 0.0 82.5 100.0 458 Total 41.4 40.5 0.3 2.0 1.5 27.2 8.5 0.1 0.0 0.2 0.6 0.0 1.0 0.7 0.3 0.0 58.6 100.0 5,864 Note: If more than one method is used, only the most effective method is considered in this tabulation. SDM = Standard days method LAM = Lactational amenorrhoea method 4 4 • F a m il y P la n n in g T a b le 5 .4 C u rr e n t u s e o f c o n tr a c e p ti o n a c c o rd in g t o b a c k g ro u n d c h a ra c te ri s ti c s P e rc e n t d is tr ib u ti o n o f c u rr e n tl y m a rr ie d w o m e n a g e 1 5 -4 9 b y c o n tr a c e p ti v e m e th o d c u rr e n tl y u s e d , a c c o rd in g t o b a c k g ro u n d c h a ra c te ri s ti c s , E th io p ia M in i- D H S 2 0 1 9 A n y m e th o d A n y m o d e rn m e th o d M o d e rn m e th o d A n y t ra d i- ti o n a l m e th o d T ra d it io n a l m e th o d N o t c u rr e n tl y u s in g T o ta l N u m b e r o f w o m e n B a c k g ro u n d c h a ra c te ri s ti c F e m a le s te ri li - s a ti o n P il l IU D In je c t- a b le s Im p la n ts M a le c o n d o m E m e r- g e n c y c o n tr a - c e p ti o n S D M L A M O th e r R h y th m W it h - d ra w a l O th e r N u m b e r o f li v in g c h il d re n 0 2 8 .2 2 5 .6 0 .0 2 .8 0 .7 1 8 .2 3 .5 0 .4 0 .0 0 .1 0 .0 0 .0 2 .6 2 .6 0 .0 0 .0 7 1 .8 1 0 0 .0 6 9 4 1 -2 5 3 .7 5 2 .9 0 .1 3 .4 1 .3 3 5 .5 1 1 .5 0 .1 0 .1 0 .1 0 .7 0 .0 0 .9 0 .5 0 .3 0 .0 4 6 .3 1 0 0 .0 1 ,8 5 7 3 -4 4 3 .7 4 3 .5 0 .3 1 .3 1 .4 3 0 .2 9 .1 0 .0 0 .0 0 .3 1 .0 0 .0 0 .2 0 .1 0 .1 0 .0 5 6 .3 1 0 0 .0 1 ,4 6 3 5 + 3 2 .2 3 1 .1 0 .8 1 .0 2 .0 1 9 .9 6 .8 0 .0 0 .0 0 .2 0 .4 0 .1 1 .0 0 .5 0 .5 0 .0 6 7 .8 1 0 0 .0 1 ,8 5 0 R e s id e n c e U rb a n 4 9 .7 4 7 .7 0 .3 5 .2 1 .5 3 0 .7 9 .2 0 .2 0 .0 0 .2 0 .5 0 .0 2 .0 1 .9 0 .1 0 .0 5 0 .3 1 0 0 .0 1 ,6 2 7 R u ra l 3 8 .2 3 7 .7 0 .4 0 .8 1 .5 2 5 .8 8 .2 0 .1 0 .0 0 .2 0 .6 0 .0 0 .6 0 .2 0 .4 0 .0 6 1 .8 1 0 0 .0 4 ,2 3 7 R e g io n T ig ra y 3 7 .3 3 6 .3 0 .0 3 .8 1 .0 1 5 .0 1 5 .4 0 .4 0 .0 0 .0 0 .7 0 .0 0 .9 0 .6 0 .4 0 .0 6 2 .7 1 0 0 .0 3 7 0 A fa r 1 2 .7 1 2 .7 0 .0 2 .5 0 .9 7 .0 1 .6 0 .0 0 .0 0 .0 0 .7 0 .0 0 .0 0 .0 0 .0 0 .0 8 7 .3 1 0 0 .0 6 4 A m h a ra 4 9 .5 4 9 .5 0 .2 1 .7 1 .2 3 6 .1 1 0 .1 0 .0 0 .0 0 .0 0 .3 0 .0 0 .0 0 .0 0 .0 0 .0 5 0 .5 1 0 0 .0 1 ,3 1 3 O ro m ia 4 0 .7 3 8 .9 0 .7 2 .0 1 .6 2 6 .1 7 .4 0 .0 0 .0 0 .2 0 .9 0 .1 1 .8 1 .2 0 .5 0 .0 5 9 .3 1 0 0 .0 2 ,3 0 6 S o m a li 3 .4 3 .4 0 .0 0 .3 0 .0 2 .0 0 .4 0 .0 0 .0 0 .0 0 .7 0 .0 0 .0 0 .0 0 .0 0 .0 9 6 .6 1 0 0 .0 2 8 4 B e n is h a n g u l- G u m u z 3 8 .5 3 6 .7 0 .0 1 .0 2 .2 1 6 .8 1 5 .8 0 .0 0 .0 0 .8 0 .0 0 .0 1 .8 1 .5 0 .2 0 .1 6 1 .5 1 0 0 .0 6 7 S N N P R 4 5 .0 4 4 .6 0 .2 1 .3 1 .5 3 3 .5 7 .7 0 .2 0 .1 0 .1 0 .0 0 .0 0 .4 0 .1 0 .3 0 .0 5 5 .0 1 0 0 .0 1 ,1 7 7 G a m b e la 3 3 .8 3 3 .2 0 .0 2 .2 0 .4 2 9 .5 1 .0 0 .2 0 .0 0 .0 0 .0 0 .0 0 .6 0 .6 0 .0 0 .0 6 6 .2 1 0 0 .0 2 5 H a ra ri 3 2 .4 3 0 .3 0 .2 3 .5 1 .4 1 0 .4 1 1 .0 0 .8 0 .2 0 .0 2 .8 0 .0 2 .1 2 .1 0 .0 0 .0 6 7 .6 1 0 0 .0 1 6 A d d is A b a b a 4 9 .9 4 7 .6 0 .0 8 .6 5 .2 1 7 .0 1 3 .3 1 .1 0 .0 1 .2 1 .2 0 .0 2 .4 2 .4 0 .0 0 .0 5 0 .1 1 0 0 .0 2 0 6 D ir e D a w a 3 0 .5 3 0 .3 0 .4 4 .9 0 .9 8 .2 1 2 .6 0 .5 0 .0 0 .3 2 .5 0 .0 0 .1 0 .1 0 .0 0 .0 6 9 .5 1 0 0 .0 3 6 E d u c a ti o n N o e d u c a ti o n 3 2 .3 3 2 .0 0 .4 0 .9 0 .9 2 2 .1 6 .7 0 .0 0 .0 0 .1 0 .9 0 .0 0 .3 0 .1 0 .2 0 .0 6 7 .7 1 0 0 .0 3 ,0 2 5 P ri m a ry 4 9 .0 4 7 .5 0 .4 1 .7 1 .4 3 3 .8 9 .7 0 .2 0 .0 0 .1 0 .2 0 .1 1 .5 0 .9 0 .6 0 .0 5 1 .0 1 0 0 .0 2 ,1 1 9 S e c o n d a ry 5 7 .2 5 5 .8 0 .0 7 .1 3 .5 3 2 .7 1 1 .5 0 .1 0 .3 0 .5 0 .1 0 .0 1 .5 1 .5 0 .0 0 .0 4 2 .8 1 0 0 .0 4 7 0 M o re t h a n s e c o n d a ry 5 7 .5 5 3 .8 0 .0 9 .7 6 .0 2 2 .3 1 4 .1 0 .6 0 .0 0 .8 0 .4 0 .0 3 .8 3 .7 0 .0 0 .0 4 2 .5 1 0 0 .0 2 5 0 W e a lt h q u in ti le L o w e s t 2 7 .0 2 6 .7 0 .1 0 .5 0 .3 1 9 .5 4 .8 0 .3 0 .0 0 .3 0 .8 0 .0 0 .3 0 .0 0 .3 0 .0 7 3 .0 1 0 0 .0 1 ,0 6 9 S e c o n d 3 5 .3 3 5 .1 0 .2 0 .8 0 .7 2 4 .1 8 .5 0 .0 0 .0 0 .0 0 .6 0 .2 0 .2 0 .1 0 .1 0 .0 6 4 .7 1 0 0 .0 1 ,1 3 8 M id d le 4 5 .2 4 4 .6 0 .1 0 .2 1 .9 3 2 .1 9 .3 0 .1 0 .1 0 .3 0 .5 0 .0 0 .6 0 .1 0 .4 0 .0 5 4 .8 1 0 0 .0 1 ,1 5 4 F o u rt h 4 4 .0 4 2 .9 0 .7 1 .6 1 .6 2 8 .8 9 .6 0 .0 0 .0 0 .0 0 .6 0 .0 1 .0 0 .7 0 .3 0 .0 5 6 .0 1 0 0 .0 1 ,2 2 0 H ig h e s t 5 3 .0 5 0 .6 0 .5 6 .6 2 .6 3 0 .5 9 .6 0 .2 0 .0 0 .2 0 .4 0 .0 2 .4 2 .1 0 .3 0 .0 4 7 .0 1 0 0 .0 1 ,2 8 3 T o ta l 4 1 .4 4 0 .5 0 .3 2 .0 1 .5 2 7 .2 8 .5 0 .1 0 .0 0 .2 0 .6 0 .0 1 .0 0 .7 0 .3 0 .0 5 8 .6 1 0 0 .0 5 ,8 6 4 N o te : If m o re t h a n o n e m e th o d i s u s e d , o n ly t h e m o s t e ff e c ti v e m e th o d i s c o n s id e re d i n t h is t a b u la ti o n . S D M = S ta n d a rd d a y s m e th o d L A M = L a c ta ti o n a l a m e n o rr h o e a m e th o d Family Planning • 45 Table 5.5 Source of modern contraceptive methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Ethiopia Mini-DHS 2019 Source IUD Injectables Implants Pill Male condom Total Public sector 93.7 85.4 95.5 68.1 (30.7) 86.6 Government hospital 9.4 1.9 4.9 6.6 (0.0) 3.8 Government health station/ centre 66.5 40.8 69.8 29.9 (9.2) 46.9 Government health post 17.8 41.7 20.8 13.3 (4.5) 34.1 Public pharmacy 0.0 1.0 0.0 18.4 (17.0) 1.7 Other public sector 0.0 0.0 0.0 0.0 (0.0) 0.0 NGO health facility 2.2 0.9 1.0 0.2 (0.0) 1.1 Other NGO 0.0 0.1 0.0 0.0 (0.0) 0.1 Private sector 4.1 13.3 3.5 31.7 (50.1) 11.8 Private hospital 4.1 1.0 0.3 1.5 (0.0) 1.0 Private clinic 0.0 11.5 3.2 15.2 (16.2) 9.3 Private pharmacy 0.0 0.9 0.0 15.0 (33.9) 1.5 Other private medical 0.0 0.0 0.0 0.0 (0.0) 0.0 Other source 0.0 0.2 0.0 0.0 (19.2) 0.3 Shop 0.0 0.0 0.0 0.0 (19.2) 0.1 Friend/relative 0.0 0.2 0.0 0.0 (0.0) 0.2 Other 0.0 0.1 0.0 0.0 (0.0) 0.2 Don’t know 0.0 0.0 0.0 0.0 (0.0) 0.0 Missing 0.0 0.0 0.0 0.0 (0.0) 0.0 Total 100.0 100.0 100.0 100.0 (100.0) 100.0 Number of women 90 1,658 533 127 14 2,459 Note: Total includes other modern methods (female sterilisation, emergency contraception, standard days method, and lactational amenorrhoea method). Figures in parentheses are based on 25-49 unweighted cases. Infant and Child Mortality • 47 INFANT AND CHILD MORTALITY 6 Key Findings ▪ Current levels: For the 5-year period preceding the survey, the infant mortality rate was 47 deaths per 1,000 live births and the under-5 mortality rate was 59 deaths per 1,000 live births. This means that 1 in 17 children in Ethiopia die before reaching age 5. ▪ Trends: There has been a slight increase in neonatal mortality since 2016, from 29 to 33 deaths per 1,000 live births. ▪ High-risk fertility behaviour: Seventy-three percent of currently married women are in a high-risk birth category. In the 5 years preceding the survey, 60% of infants were at elevated odds of dying from avoidable risks; 39% fell into a single high-risk category, and 21% fell into a multiple high- risk category. Only 23% of births were not in any high-risk category. nformation on infant and child mortality is relevant to a demographic assessment of a country’s population and is an important indicator of the country’s socioeconomic development and quality of life. It can also help estimate how many children may be at higher risk of death and support the development of strategies to reduce this risk, such as promoting birth spacing. This chapter presents information on levels, trends, and differentials in neonatal, postneonatal, infant, child, and under-5 mortality rates. It also examines biodemographic factors and fertility behaviours that increase mortality risks for infants and children. The information was collected during a retrospective birth history in which female respondents listed all of the children born to them, along with each child’s date of birth, survivorship status, and current age or age at death. The quality of mortality estimates calculated from birth histories depends on the mother’s ability to recall all of the children to whom she has given birth, as well as their birth dates and ages at death. Potential data quality problems include: ▪ The selective omission from birth histories of those births that did not survive, which can result in underestimation of childhood mortality. ▪ The displacement of birth dates, which may distort mortality trends. This can occur if an interviewer knowingly records a birth as occurring in a different year than the one in which it occurred. This may happen if an interviewer is trying to cut down on his or her overall workload, because live births occurring during the 5 years before the interview are the subject of a lengthy set of additional questions. ▪ Inaccurate reporting of age at death. Misreporting the child’s age at death may distort the age pattern of mortality, especially if the net effect of the age misreporting is to transfer deaths from one age bracket to another. I 48 • Infant and Child Mortality Any method of measuring childhood mortality that relies on mothers’ reports (e.g., birth histories) assumes that female adult mortality is not high or, if it is high, that there is little or no correlation between the mortality risks of mothers and those of their children. Selected indicators of the quality of the mortality data on which the estimates of mortality in this chapter are based are presented in Appendix C, Tables C.3- C.6. 6.1 INFANT AND CHILD MORTALITY Neonatal mortality: The probability of dying within the first month of life. Postneonatal mortality: The probability of dying between the first month of life and the first birthday (computed as the difference between infant and neonatal mortality). Infant mortality: The probability of dying between birth and the first birthday. Child mortality: The probability of dying between the first and the fifth birthday. Under-5 mortality: The probability of dying between birth and the fifth birthday. The 2019 EMDHS results show that the neonatal, infant, and under-5 mortality rates for the 5 years before the survey were 33, 47, and 59 deaths per 1,000 live births, respectively. In other words, 1 in every 30 children in Ethiopia die within the first month, 1 in every 21 die before their first birthday, and 1 in every 17 die before their fifth birthday (Table 6.1). Trends: Under-5 mortality declined from 123 deaths per 1,000 live births in 2005 to 59 deaths per 1,000 live births in 2019, a 52% decrease. Over the same period, infant mortality declined from 77 to 47 deaths per 1,000 live births, a 39% reduction. Neonatal mortality declined from 39 deaths per 1,000 live births in 2005 to 29 deaths per 1,000 live births in 2016 before increasing to 33 deaths per 1,000 births in 2019 (an overall reduction of 15% over the past 14 years) (Figure 6.1). Figure 6.1 Trends in early childhood mortality rates 123 88 67 59 77 59 48 47 39 37 29 33 2005 EDHS 2011 EDHS 2016 EDHS 2019 EMDHS Deaths per 1,000 live births in the 5-year period before the survey Under-5 mortality Infant mortality Neonatal mortality Infant and Child Mortality • 49 Patterns by background characteristics ▪ The 5-year infant mortality rate is higher in rural areas than in urban areas (51 versus 32 deaths per 1,000 live births) (Table 6.2). ▪ The under-5 mortality rate decreases with increasing household wealth. Under-5 mortality is 77 deaths per 1,000 live births in the poorest households and 46 deaths per 1,000 live births in the wealthiest households (Figure 6.2). ▪ In general, childhood mortality rates decrease as the length of previous birth intervals increases (Figure 6.3). Figure 6.3 Childhood mortality by previous birth interval 6.2 HIGH-RISK FERTILITY BEHAVIOUR Findings from scientific studies have confirmed a strong relationship between a child’s chance of dying and specific fertility behaviours, meaning that the survival of infants and children depends in part on the demographic and biological characteristics of their mothers. The probability of children dying in infancy is much greater among children born to mothers who are too young (under age 18) or too old (over age 34), children born after a short birth interval (less than 24 months after the preceding birth), and children born to mothers of high parity (more than three children). The risk is elevated when a child is born to a mother who has a combination of these risk characteristics. Table 6.4 presents the percentage distribution of children born in the 5 years preceding the survey who fall into different risk categories: not in any high-risk category, in an unavoidable risk category, in a single high-risk category, or in a multiple high-risk category. Patterns by background characteristics ▪ Overall, 73% of currently married women have the potential for a high-risk birth, with 32% falling into a single high-risk category and 41% falling into a multiple high-risk category. ▪ In the 5 years before the survey, 60% of infants in Ethiopia were at elevated odds of dying from avoidable risks: 39% were in a single high-risk category, and 21% were in a multiple high-risk 91 116 43 58 30 3430 36 Infant mortality Under-5 mortality Previous birth interval: Deaths per 1,000 live births for the 10-year period before the survey <2 years 2 years 3 years 4+ years Figure 6.2 Under-5 mortality by household wealth 77 73 72 62 46 Lowest Second Middle Fourth Highest Deaths per 1,000 live births for the 10-year period before the survey Poorest Wealthiest 50 • Infant and Child Mortality category. Twenty-three percent of births were not in any high-risk category, while 17% were in the unavoidable risk category. ▪ In general, risk ratios are higher for children in a multiple high-risk category than for children in a single high-risk category. The risk ratio is highest (6.18) for births to women less than 34 years old in which the birth interval was less than 24 months and the birth order was higher than three. LIST OF TABLES For more information on infant and child mortality, see the following tables: ▪ Table 6.1 Early childhood mortality rates ▪ Table 6.2 Five-year early childhood mortality rates according to background characteristics ▪ Table 6.3 Ten-year early childhood mortality rates according to additional characteristics ▪ Table 6.4 High-risk fertility behaviour Infant and Child Mortality • 51 Table 6.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for 5-year periods preceding the survey, Ethiopia Mini-DHS 2019 Years preceding the survey Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 33 14 47 13 59 5-9 38 23 61 15 76 10-14 38 30 68 34 100 1 Computed as the difference between the infant and neonatal mortality rates Table 6.2 Five-year early childhood mortality rates according to background characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 5-year period preceding the survey, according to background characteristics, Ethiopia Mini- DHS 2019 Background characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 37 15 53 15 67 Female 28 12 40 11 51 Residence Urban 21 11 32 14 46 Rural 37 14 51 13 64 Total 33 14 47 13 59 1 Computed as the difference between the infant and neonatal mortality rates 52 • Infant and Child Mortality Table 6.3 Ten-year early childhood mortality rates according to additional characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, according to additional characteristics, Ethiopia Mini-DHS 2019 Characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Mother’s age at birth <20 55 20 75 11 86 20-29 26 16 43 13 55 30-39 42 19 61 19 79 40-49 (36) * * * * Birth order 1 49 14 62 10 72 2-3 30 16 46 13 58 4-6 29 16 44 10 54 7+ 44 36 80 33 110 Previous birth interval2 <2 years 56 35 91 27 116 2 years 28 15 43 16 58 3 years 19 11 30 4 34 4+ years 18 12 30 6 36 Region Tigray 28 10 38 6 43 Afar 22 24 46 13 58 Amhara 46 12 58 11 69 Oromia 39 23 62 11 72 Somali 45 27 71 32 101 Benishangul-Gumuz 55 19 74 17 90 SNNPR 22 15 37 20 56 Gambela 33 17 50 38 86 Harari 37 13 49 16 64 Addis Ababa (17) (4) (21) (5) (26) Dire Dawa 31 30 61 20 79 Mother’s education No education 34 22 56 15 70 Primary 40 13 53 15 68 Secondary 34 16 50 (1) (51) More than secondary (10) (7) (17) (1) (19) Wealth quintile Lowest 34 24 58 20 77 Second 41 21 62 12 73 Middle 40 17 57 16 72 Fourth 36 12 49 14 62 Highest 24 15 39 7 46 Note: Figures in parentheses are based on 250-499 unweighted person-years of exposure to the risk of death. An asterisk indicates that a figure is based on fewer than 250 unweighted person-years of exposure to the risk of death and has been suppressed. 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births Infant and Child Mortality • 53 Table 6.4 High-risk fertility behaviour Percent distribution of children born in the 5 years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Ethiopia Mini-DHS 2019 Births in the 5 years preceding the survey Percentage of currently married women1 Risk category Percentage of births Risk ratio Not in any high-risk category 23.1 1.00 18.3a Unavoidable risk category First-order births between age 18 and age 34 17.0 2.04 8.9 In any avoidable high-risk category 59.9 2.30 72.8 Single high-risk category Mother’s age <18 only 5.7 2.99 1.5 Mother’s age >34 only 1.1 0.93 3.0 Birth interval <24 months only 6.2 3.33 9.2 Birth order >3 only 25.6 1.11 18.3 Subtotal 38.6 1.73 32.0 Multiple high-risk category Age <18 and birth interval <24 months2 0.8 1.18 0.2 Age >34 and birth interval <24 months 0.1 * 0.3 Age >34 and birth order >3 9.7 2.65 27.6 Age >34 and birth interval <24 months and birth order >3 1.9 6.18 4.2 Birth interval <24 months and birth order >3 8.9 3.56 8.5 Subtotal 21.3 3.33 40.8 Total 100.0 na 100.0 Subtotals by individual avoidable high-risk category Mother’s age <18 6.4 2.77 1.6 Mother’s age >34 12.8 3.10 35.1 Birth interval <24 months 17.8 3.71 22.4 Birth order >3 46.1 2.11 58.7 Number of births/women 5,527 na 5,864 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilised women Maternal Health Care • 55 MATERNAL HEALTH CARE 7 Key Findings ▪ Antenatal care: 74% of women age 15-49 with a live birth in the 5 years before the survey received antenatal care (ANC) from a skilled provider for their most recent birth. 43% of women had at least four ANC visits during their last pregnancy. ▪ Components of antenatal care: 88% of women who received ANC had their blood pressure measured, 79% had a blood sample taken, 74% had a urine sample taken, and 71% received nutritional counselling. ▪ Delivery: Almost half (48%) of live births in the 5 years preceding the survey occurred in a health facility. Institutional deliveries increased from 26% in 2016 to 48% in 2019, while home deliveries decreased from 73% to 51% over the same period. ▪ Postnatal care: Thirty-four percent of women and 35% of newborns received a postnatal check within the first 2 days after birth. ealth care services during pregnancy and after delivery are important for the survival and well- being of both the mother and the infant. Skilled care during pregnancy, childbirth, and the postpartum period is critical in reducing maternal and neonatal morbidity and mortality. As highlighted in the 2015-16 Health Sector Transformation Plan (HSTP), maternal and newborn health are priorities for the government of Ethiopia (FMoH 2015). The key components of the HSTP are delivery at a health facility, with skilled medical attention and hygienic conditions; reductions in complications and infections during labour and delivery; timely postnatal care that treats complications from delivery; and education of the mother on care for herself and her infant. The goal of the reproductive health programme is to reduce the maternal mortality ratio to 199 maternal deaths per 100,000 live births and the neonatal mortality rate to 10 deaths per 1,000 live births by 2020. This chapter presents information on antenatal care (ANC) and its main components: the number and timing of ANC visits, blood pressure measurement, blood and urine sampling, and nutritional counselling. The chapter also presents information on childbirth and postnatal care such as place of delivery, assistance during delivery, caesarean delivery, and postnatal health checks for mothers and newborns. H 56 • Maternal Health Care 7.1 ANTENATAL CARE COVERAGE AND CONTENT 7.1.1 Skilled Providers Antenatal care (ANC) from a skilled provider Pregnancy care received from skilled providers, such as doctors, nurses/midwives, health officers, and health extension workers. Sample: Women age 15-49 who had a live birth in the 5 years before the survey The 2019 EMDHS results show that 74% of women who had a live birth in the 5 years before the survey received ANC from a skilled provider for their last birth (Table 7.1). Trends: The proportion of women age 15-49 who received ANC from a skilled provider has increased over time, from 28% in 2005 and 34% in 2011 to 62% in 2016 and 74% in 2019 (Figure 7.1). Patterns by background characteristics ▪ ANC from a skilled provider varies by mother’s age, from a high of 77% among women age 20- 34 to a low of 59% among women age 35-49. ▪ ANC from a skilled provider is lowest for sixth- or higher-order births (58%) and highest for first-order births (83%). ▪ Urban women are more likely than rural women to receive ANC from a skilled provider (85% and 70%, respectively). ▪ Regionally, ANC coverage from a skilled provider is highest in Addis Ababa (97%) and lowest in Somali (30%). ▪ ANC from a skilled provider increases with increasing mother’s education, from 62% among women with no education to nearly 100% among women with more than a secondary education. ▪ Women in the highest wealth quintile (95%) are more likely than those in the lowest quintile (47%) to receive ANC from a skilled provider. 7.1.2 Timing and Number of ANC Visits Forty-three percent of women in Ethiopia had at least four ANC visits during their last pregnancy, while 26% of women had no ANC visits (Table 7.2). Rural women (29%) were more likely than urban women (15%) to have no ANC visits. Only 28% of women had their first ANC visit during the first trimester, while 32% had their first visit during the fourth or fifth month of pregnancy and 12% had their first visit during the sixth or seventh month. Two percent of women did not receive any ANC until the eight month of pregnancy or later (Table 7.2). Forty-three percent of women in urban areas received ANC within their first trimester of pregnancy, as compared with 22% of those in rural areas (Table 7.2). Figure 7.1 Trends in antenatal care coverage 28 34 62 74 12 19 32 43 6 11 20 28 2005 EDHS 2011 EDHS 2016 EDHS 2019 EMDHS Percentage of women age 15-49 who had a live birth in the 5 years before the survey (for the most recent birth) Received any ANC from skilled provider Had 4+ ANC visits Had ANC in first trimester Maternal Health Care • 57 Trends: The proportion of women with the recommended four or more ANC visits increased from 12% in 2005 to 43% in 2019. During this same time period, the proportion of women who received ANC in the first trimester increased from 6% to 28% (Figure 7.1). 7.2 COMPONENTS OF ANC Standard guidelines for ANC in Ethiopia emphasise that every pregnant woman should receive ANC from a skilled provider that includes a thorough physical examination, blood tests for infection screening, and a urine test. Among women who received ANC, 88% had their blood pressure measured, 79% had a blood sample taken, and 74% had a urine sample taken as part of an ANC visit (Table 7.3 and Figure 7.2). Seventy- one percent of women received nutritional counselling during ANC. Women living in urban areas, highly educated women, and women in the highest wealth quintile were more likely than their counterparts to receive each service. Trends: The proportion of pregnant women who had a urine sample collected during an ANC visit increased from 27% in 2005 to 74% in 2019. Similarly, the proportion who had a blood sample taken increased from 26% to 79%, and the proportion who had their blood pressure measured increased from 62% to 88%. 7.3 DELIVERY SERVICES 7.3.1 Institutional Deliveries Institutional deliveries Deliveries that occur in a health facility. Sample: All live births in the 5 years before the survey Increasing institutional deliveries is important for reducing maternal and neonatal mortality. However, access to health facilities is more difficult in rural areas than in urban areas because of distance, scarce transport, and a lack of appropriate facilities. Although institutional delivery has been promoted in Ethiopia, home delivery is still common, primarily in hard-to-reach areas. Forty-eight percent of live births in the 5 years before the survey were delivered in a health facility (Table 7.4). Figure 7.2 Components of antenatal care 71 74 79 88 Nutritional counselling Urine sample taken Blood sample taken Blood pressure measured Among women who received ANC for their most recent birth, the percentage with selected services 58 • Maternal Health Care Trends: Institutional deliveries increased from 5% in 2005 to 26% in 2016 and 48% in 2019. During the same period, there was a sharp decline in home deliveries (94% in 2005, 73% in 2016, and 51% in 2019) (Figure 7.3). Patterns by background characteristics ▪ Sixth- and higher-order births are more likely than first-order births to be delivered at home (67% versus 30%) (Figure 7.4 and Table 7.5). ▪ Seventy-four percent of births to mothers who attended four or more ANC visits were delivered in a health facility, as compared with 14% of births to mothers with no ANC visits. ▪ Ninety-three percent of births to mothers with more than a secondary education were delivered in a health facility, compared with 33% of births to mothers with no education. ▪ The percentage of public sector deliveries is lowest in Somali (17%) and Afar (27%) and highest in Tigray (72%). ▪ Births to women in the lowest wealth quintile are more likely to be delivered at home (79%) than births to women in the highest wealth quintile (14%). 7.3.2 Skilled Assistance during Delivery Skilled assistance during delivery Births delivered with the assistance of doctors, nurses/midwives, health officers, and health extension workers. Sample: All live births in the 5 years before the survey In the 5 years before the survey, 50% of births were delivered by a skilled provider (Figure 7.5 and Table 7.6). Most births were attended by nurses or midwives (36%), followed by traditional birth attendants (31%) and doctors (8%). Trends: The percentage of births delivered by a skilled provider increased from 11% in 2011 and 28% in 2016 to 50% in 2019. Patterns by background characteristics ▪ Skilled providers delivered 76% of births to mothers who attended four or more ANC visits, as compared with 15% of births to mothers with no ANC visits (Table 7.6). Figure 7.3 Trends in place of birth Figure 7.4 Home births by birth order Figure 7.5 Assistance during delivery 5 10 26 48 94 90 73 51 2005 EDHS 2011 EDHS 2016 EDHS 2019 EMDHS Percentage of live births in the 5 years before the survey Delivered in health facility Delivered at home 30 48 61 67 1 2 3 4 Percentage of live births in the 5 years before the survey that were delivered at home Birth order Nurse/ midwife 36% Doctor 8% Health officer 2% Health extension worker 4% Traditional birth attendant 31% Relative/ other 6% No one 13% Percent distribution of births in the 5 years before the survey Maternal Health Care • 59 ▪ Births to mothers in urban areas (72%) are more likely than births to mothers in rural areas (43%) to be assisted by a skilled provider. ▪ Ninety-three percent of births to mothers with more than a secondary education are assisted by a skilled provider, compared with 35% of births to mothers with no education (Figure 7.6 and Table 7.6). ▪ The proportion of births assisted by skilled providers ranges from 26% in Somali to 96% in Addis Ababa. ▪ Births to mothers in the highest wealth quintile (87%) are almost four times more likely to be assisted by a skilled provider than births to mothers in the lowest quintile (22%). 7.3.3 Delivery by Caesarean Section Access to caesarean sections (C-sections) can reduce maternal and neonatal mortality and complications such as obstetric fistula. However, use of caesarean sections without medical need can put women at risk of both short-term and long-term health problems. The World Health Organization advises that C-sections be performed only when medically necessary. According to WHO, population-level reductions in maternal and newborn mortality are not associated with C-section rates higher than 10%. The 2019 EMDHS results showed that 5% of live births in the 5 years before the survey were delivered by C-section (Table 7.7). Trends: The rate of caesarean sections increased from 2% in 2016 to 5% in 2019. Patterns by background characteristics ▪ Caesarean section deliveries are more common among mothers age 35-49 (7%) than among mothers less than age 20 (3%). ▪ The caesarean section rate in urban areas (10%) is more than twice that in rural areas (4%). ▪ Women with more than a secondary education (19%) are more likely to undergo C-sections than women with a secondary education (13%), primary education (6%), or no education (3%). 7.4 POSTNATAL CARE 7.4.1 Postnatal Health Check for Mothers A large proportion of maternal and neonatal deaths occur during the first 24 hours after delivery. For both the mother and the infant, prompt postnatal care is important in treating complications that arise from delivery and providing the mother with important information on caring for herself and her baby. In Ethiopia, 34% of women age 15-49 who gave birth in the 2 years before the survey had a postnatal check during the first 2 days after birth, while 64% did not receive a postnatal check (Table 7.8). Patterns by background characteristics ▪ Women who delivered in a health facility were 20 times more likely to have a postnatal health check within 2 days of delivery than those who delivered elsewhere (60% versus 3%). Figure 7.6 Skilled assistance at delivery by education 35 61 84 93 No education Primary Secondary More than secondary Percentage of live births in the 5 years before the survey assisted by a skilled provider 60 • Maternal Health Care ▪ Forty-eight percent of urban women received a postnatal check-up within 2 days, as compared with 29% of rural women. ▪ The proportion of women who received postnatal check-ups in the 2 days after delivery varies widely by region, from 10% in Somali to 74% in Addis Ababa. Type of Provider The skills of the provider determine the provider’s ability to diagnose problems and recommend appropriate treatment or referral. Thirty percent of women received a postnatal check from a doctor, nurse, or midwife. Only 3% of women received a check from a health officer, and another 2% received a check from a health extension worker (HEW) (Table 7.9). 7.4.2 Postnatal Health Check for Newborns The first 48 hours is a vulnerable phase in the life of a newborn baby and a period in which many neonatal deaths occur. Lack of postnatal health checks during this period can delay identification of newborn complications and initiation of appropriate care and treatment. Table 7.10 shows that only 35% of newborns had a postnatal check within the first 2 days after birth, while 63% received no postnatal check. Patterns by background characteristics ▪ Newborns delivered in a health facility were much more likely to receive a postnatal health check from a skilled provider within 2 days than those delivered elsewhere (62% versus 2%). ▪ Infants born to urban women (48%) were more likely than those born to rural women (30%) to receive a check-up within the first 2 days of birth. ▪ The percentage of newborns receiving check-ups within the first 2 days increases with increasing mother’s education. Twenty-two percent of babies born to women with no education received a postnatal check-up, as compared with 70% of babies born to women with more than a secondary education. Type of Provider Thirty percent of newborns received a postnatal check-up within 2 days from a doctor, nurse, or midwife, while 3% received a check-up from a health officer, 1% from an HEW, and less than 1% from a traditional birth attendant (Table 7.11). Other Components of Newborn Postnatal Care The survey also collected data on other components of postnatal care such as whether selected signal functions were performed within 2 days of birth, including measuring the newborn’s temperature and informing the mother about danger signs in newborns. Forty percent of newborns in the 2 years before the survey had at least two signal functions performed within 2 days after birth (Table 7.12). LIST OF TABLES For more information on maternal health care, see the following tables: ▪ Table 7.1 Antenatal care ▪ Table 7.2 Number of antenatal care visits and timing of first visit ▪ Table 7.3 Components of antenatal care ▪ Table 7.4 Maternal care indicators ▪ Table 7.5 Place of delivery ▪ Table 7.6 Assistance during delivery Maternal Health Care • 61 ▪ Table 7.7 Caesarean section ▪ Table 7.8 Timing of first postnatal check for the mother ▪ Table 7.9 Type of provider of first postnatal check for the mother ▪ Table 7.10 Timing of first postnatal check for the newborn ▪ Table 7.11 Type of provider of first postnatal check for the newborn ▪ Table 7.12 Content of postnatal care for newborns 62 • Maternal Health Care Table 7.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the 5 years preceding the survey by antenatal care (ANC) provider during the pregnancy for the most recent birth and percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Ethiopia Mini- DHS 2019 Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Background characteristic Doctor Nurse/ midwife Health officer Health extension worker Traditional birth attendant Other Age at birth <20 7.3 52.0 3.1 10.5 0.1 0.5 26.6 100.0 72.8 529 20-34 8.4 47.9 5.2 15.0 0.2 0.8 22.5 100.0 76.5 2,840 35-49 5.7 35.6 5.3 12.7 0.2 0.4 40.1 100.0 59.4 557 Birth order 1 12.6 56.2 5.9 8.7 0.2 0.2 16.3 100.0 83.3 841 2-3 11.0 51.6 4.7 13.2 0.1 0.9 18.6 100.0 80.5 1,268 4-5 5.0 40.4 7.1 18.8 0.3 1.5 26.8 100.0 71.4 853 6+ 2.2 37.5 2.5 15.6 0.3 0.1 41.7 100.0 57.8 965 Residence Urban 21.2 49.8 5.7 7.9 0.0 0.3 15.1 100.0 84.5 1,026 Rural 3.2 45.6 4.7 16.2 0.3 0.8 29.3 100.0 69.7 2,900 Region Tigray 22.0 52.3 10.7 9.0 0.4 0.2 5.3 100.0 94.0 287 Afar 10.3 44.3 5.3 2.7 0.3 0.0 37.1 100.0 62.7 51 Amhara 7.9 58.2 9.4 7.1 0.2 2.1 15.1 100.0 82.6 839 Oromia 5.0 40.7 3.1 22.0 0.0 0.0 29.2 100.0 70.8 1,519 Somali 5.1 21.7 2.2 1.2 0.0 0.2 69.6 100.0 30.2 218 Benishangul-Gumuz 9.5 46.5 2.4 24.8 0.0 0.0 16.7 100.0 83.3 47 SNNPR 3.1 49.6 2.3 14.5 0.6 1.0 29.0 100.0 69.4 787 Gambela 25.8 53.0 5.1 1.8 0.0 0.7 13.7 100.0 85.7 19 Harari 28.7 46.7 3.3 2.1 0.0 0.0 19.3 100.0 80.7 11 Addis Ababa 35.7 55.1 6.0 0.0 0.0 0.0 3.1 100.0 96.9 127 Dire Dawa 27.4 39.2 8.7 8.2 0.3 0.7 15.5 100.0 83.5 21 Education No education 2.5 39.3 5.1 15.2 0.4 1.3 36.3 100.0 62.0 2,014 Primary 8.1 54.6 4.6 14.2 0.0 0.1 18.5 100.0 81.4 1,415 Secondary 21.6 58.8 5.5 11.2 0.0 0.0 2.9 100.0 97.1 345 More than secondary 46.8 43.2 5.5 4.4 0.0 0.0 0.2 100.0 99.8 153 Wealth quintile Lowest 1.1 29.5 3.1 13.6 0.1 1.0 51.6 100.0 47.3 825 Second 2.1 43.9 5.2 19.8 0.2 0.3 28.6 100.0 71.0 822 Middle 2.9 50.8 5.7 16.2 0.4 1.3 22.7 100.0 75.6 761 Fourth 5.9 54.5 4.0 16.3 0.2 1.0 18.0 100.0 80.7 705 Highest 27.1 56.2 6.8 4.6 0.1 0.0 5.3 100.0 94.6 813 Total 7.9 46.7 5.0 14.0 0.2 0.7 25.6 100.0 73.6 3,927 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, health officer, and health extension worker. Maternal Health Care • 63 Table 7.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the 5 years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Ethiopia Mini-DHS 2019 Number of ANC visits and timing of first visit Residence Total Urban Rural Number of ANC visits None 15.1 29.3 25.6 1 1.9 3.8 3.3 2-3 23.6 29.4 27.9 4+ 58.7 37.4 43.0 Don’t know/missing 0.6 0.1 0.3 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 15.1 29.3 25.6 <4 43.4 22.3 27.8 4-5 32.3 32.2 32.2 6-7 6.4 13.5 11.6 8+ 2.3 2.0 2.1 Don’t know/missing 0.5 0.8 0.7 Total 100.0 100.0 100.0 Number of women 1,026 2,900 3,927 Median months pregnant at first visit (for those with ANC) 4.0 4.7 4.5 Number of women with ANC 871 2,052 2,923 64 • Maternal Health Care Table 7.3 Components of antenatal care Among women age 15-49 receiving antenatal care (ANC) for the most recent live birth in the 5 years preceding the survey, percentage receiving specific antenatal services, according to background characteristics, Ethiopia Mini-DHS 2019 Background characteristic Blood pressure measured Urine sample taken Blood sample taken Nutritional counselling Number of women with ANC for their most recent birth Age at birth <20 90.8 71.3 78.3 68.7 388 20-34 87.6 74.5 79.2 71.7 2,201 35-49 88.2 72.6 77.0 69.3 334 Birth order 1 91.7 81.1 84.7 73.1 704 2-3 88.8 77.5 81.1 71.2 1,032 4-5 87.4 68.3 76.6 74.9 624 6+ 83.0 64.4 69.9 63.8 563 Residence Urban 96.9 87.7 90.7 75.8 871 Rural 84.4 68.0 73.8 69.0 2,052 Region Tigray 91.3 85.5 87.7 74.9 271 Afar 94.5 87.3 87.8 67.0 32 Amhara 93.6 83.8 87.0 77.9 713 Oromia 82.8 65.5 71.6 63.3 1,076 Somali 90.5 79.2 80.9 62.2 66 Benishangul-Gumuz 88.5 66.4 74.9 71.1 39 SNNPR 86.2 64.2 72.4 72.5 559 Gambela 92.5 88.4 94.2 74.4 16 Harari 95.2 89.7 90.5 73.0 9 Addis Ababa 99.5 98.6 97.9 89.6 123 Dire Dawa 94.8 91.6 91.8 68.8 18 Education No education 83.2 67.6 74.0 69.1 1,282 Primary 90.4 74.0 79.0 68.4 1,153 Secondary 94.5 86.5 88.8 83.2 335 More than secondary 97.6 98.0 96.9 80.3 152 Wealth quintile Lowest 81.7 59.3 67.7 59.2 399 Second 78.9 60.0 68.0 66.9 587 Middle 85.9 69.9 75.5 73.7 589 Fourth 90.5 75.6 80.1 70.9 578 Highest 98.3 93.8 94.6 78.4 770 Total 88.1 73.9 78.9 71.0 2,923 Maternal Health Care • 65 Table 7.4 Maternal care indicators Among women age 15-49 who had a live birth in the 5 years preceding the survey, percentage who received antenatal care (ANC) from a skilled provider for the most recent live birth and percentage with four or more ANC visits for the most recent live birth; among all live births in the 5 years before the survey, percentage delivered by a skilled provider and percentage delivered in a health facility; and among women age 15-49 who had a live birth in the 2 years preceding the survey, percentage who received a postnatal check during the first 2 days after giving birth, according to background characteristics, Ethiopia Mini-DHS 2019 Women who had a live birth in the 5 years preceding the survey Live births in the 5 years preceding the survey Women who had a live birth in the 2 years preceding the survey Background characteristic Percentage receiving antenatal care from a skilled provider1 Percentage with 4+ ANC visits Number of women Percentage delivered by a skilled provider1 Percentage delivered in a health facility Number of births Percentage with a postnatal check during the first 2 days after birth2 Number of women Age at birth <20 72.8 36.4 529 55.8 53.6 751 34.5 316 20-34 76.5 45.7 2,840 49.9 47.8 4,069 34.1 1,504 35-49 59.4 35.5 557 43.0 39.7 707 31.6 285 Residence Urban 84.5 58.7 1,026 72.1 70.4 1,367 47.6 553 Rural 69.7 37.4 2,900 42.5 40.0 4,160 28.9 1,552 Region Tigray 94.0 63.9 287 73.3 72.4 371 63.3 155 Afar 62.7 31.1 51 30.6 28.3 86 23.5 31 Amhara 82.6 50.8 839 55.7 54.2 1,050 39.8 433 Oromia 70.8 40.6 1,519 43.7 41.0 2,211 26.1 825 Somali 30.2 11.1 218 26.0 23.3 409 10.3 132 Benishangul-Gumuz 83.3 55.9 47 65.0 63.7 67 45.0 24 SNNPR 69.4 34.1 787 50.1 47.5 1,106 32.0 411 Gambela 85.7 31.8 19 69.9 70.3 25 55.1 10 Harari 80.7 38.8 11 64.7 63.8 16 45.1 6 Addis Ababa 96.9 81.8 127 95.7 94.8 156 73.5 64 Dire Dawa 83.5 61.5 21 70.8 69.2 30 48.2 13 Education No education 62.0 32.4 2,014 35.2 32.7 2,962 21.8 977 Primary 81.4 47.0 1,415 60.5 57.8 1,956 36.9 840 Secondary 97.1 72.5 345 83.6 83.8 415 62.4 182 More than secondary 99.8 78.9 153 93.1 93.1 194 70.6 105 Wealth quintile Lowest 47.3 20.1 825 22.1 19.7 1,321 12.8 460 Second 71.0 37.7 822 40.6 38.5 1,198 21.3 449 Middle 75.6 39.0 761 47.5 43.3 1,044 27.8 392 Fourth 80.7 48.7 705 63.1 61.5 960 48.5 364 Highest 94.6 70.4 813 86.9 85.9 1,005 61.7 438 Total 73.6 43.0 3,927 49.8 47.5 5,527 33.8 2,105 Note: If more than one source of assistance was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, health officer, and health extension worker. 2 Includes women who received a check from a doctor, nurse, midwife, health officer, health extension worker, or traditional birth attendant 66 • Maternal Health Care Table 7.5 Place of delivery Percent distribution of live births in the 5 years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Ethiopia Mini-DHS 2019 Health facility Home Other Total Percentage delivered in a health facility Number of births Background characteristic Public sector Private sector NGO Mother’s age at birth <20 52.7 0.5 0.4 45.8 0.5 100.0 53.6 751 20-34 45.2 1.4 1.2 51.1 1.1 100.0 47.8 4,069 35-49 38.1 1.1 0.4 59.1 1.2 100.0 39.7 707 Birth order 1 65.7 1.9 1.4 30.0 0.9 100.0 69.1 1,221 2-3 47.7 2.0 1.1 48.1 1.0 100.0 50.9 1,755 4-5 37.4 0.6 0.5 60.5 1.0 100.0 38.5 1,244 6+ 30.7 0.2 0.7 67.2 1.2 100.0 31.6 1,306 Antenatal care visits1 None 13.3 0.0 0.3 85.8 0.7 100.0 13.6 1,004 1-3 50.7 0.8 0.6 47.3 0.7 100.0 52.0 1,225 4+ 69.8 2.5 1.4 25.0 1.4 100.0 73.6 1,688 Don’t know/missing * * * * * * * 10 Residence Urban 63.2 3.7 3.5 29.2 0.4 100.0 70.4 1,367 Rural 39.5 0.4 0.1 58.7 1.2 100.0 40.0 4,160 Region Tigray 72.0 0.0 0.4 26.5 1.1 100.0 72.4 371 Afar 27.1 0.0 1.2 71.6 0.2 100.0 28.3 86 Amhara 53.3 0.1 0.8 44.4 1.4 100.0 54.2 1,050 Oromia 39.7 0.7 0.6 57.8 1.2 100.0 41.0 2,211 Somali 16.7 1.3 5.2 76.0 0.8 100.0 23.3 409 Benishangul-Gumuz 63.4 0.0 0.3 31.3 5.0 100.0 63.7 67 SNNPR 47.3 0.0 0.2 52.1 0.4 100.0 47.5 1,106 Gambela 58.2 0.9 11.2 29.3 0.4 100.0 70.3 25 Harari 56.0 6.8 1.1 35.5 0.6 100.0 63.8 16 Addis Ababa 66.8 26.2 1.9 4.8 0.4 100.0 94.8 156 Dire Dawa 56.5 12.6 0.0 30.3 0.6 100.0 69.2 30 Mother’s education No education 31.8 0.3 0.6 66.0 1.3 100.0 32.7 2,962 Primary 56.1 0.5 1.1 41.4 0.8 100.0 57.8 1,956 Secondary 76.3 5.1 2.3 15.5 0.7 100.0 83.8 415 More than secondary 77.3 14.2 1.6 6.9 0.0 100.0 93.1 194 Wealth quintile Lowest 19.0 0.3 0.4 79.2 1.1 100.0 19.7 1,321 Second 38.2 0.0 0.3 60.4 1.0 100.0 38.5 1,198 Middle 42.9 0.0 0.3 55.3 1.4 100.0 43.3 1,044 Fourth 60.4 0.1 0.9 37.3 1.3 100.0 61.5 960 Highest 76.5 6.2 3.2 13.7 0.4 100.0 85.9 1,005 Total 45.3 1.2 1.0 51.4 1.0 100.0 47.5 5,527 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes only the most recent birth in the 5 years preceding the survey Maternal Health Care • 67 Table 7.6 Assistance during delivery Percent distribution of live births in the 5 years preceding the survey by person providing assistance during delivery and percentage of births assisted by a skilled provider, according to background characteristics, Ethiopia Mini-DHS 2019 Person providing assistance during delivery Percentage delivered by a skilled provider1 Number of births Background characteristic Doctor Nurse/ midwife Health officer Health extension worker Traditional birth attendant Relative/ other No one Total Mother’s age at birth <20 5.5 45.0 1.6 3.7 29.9 7.3 7.0 100.0 55.8 751 20-34 8.8 35.4 2.0 3.7 31.1 5.4 13.5 100.0 49.9 4,069 35-49 9.7 26.6 1.4 5.4 31.8 5.9 19.2 100.0 43.0 707 Birth order 1 15.1 49.5 2.4 3.1 21.0 5.1 3.8 100.0 70.1 1,221 2-3 9.3 38.5 2.0 3.1 29.5 6.2 11.4 100.0 52.9 1,755 4-5 6.3 27.8 1.9 4.9 36.7 5.8 16.6 100.0 40.8 1,244 6+ 3.1 26.2 1.2 4.7 37.1 5.8 21.9 100.0 35.3 1,306 Antenatal care visits2 None 2.3 10.3 0.6 1.6 55.8 7.1 22.3 100.0 14.8 1,004 1-3 6.5 41.4 2.1 5.6 22.8 6.5 15.1 100.0 55.6 1,225 4+ 14.9 54.2 2.2 4.7 14.1 4.7 5.2 100.0 76.0 1,688 Don’t know/missing * * * * * * * * * 10 Place of delivery Health facility 17.4 72.5 3.8 5.9 0.0 0.2 0.2 100.0 99.6 2,628 Public facility 15.1 74.4 3.8 6.2 0.1 0.2 0.2 100.0 99.5 2,506 Private facility 83.5 16.5 0.0 0.0 0.0 0.0 0.0 100.0 100.0 68 NGO 38.9 52.2 8.9 0.0 0.0 0.0 0.0 100.0 100.0 54 Elsewhere 0.3 2.2 0.1 2.1 59.1 10.8 25.3 100.0 4.7 2,899 Residence Urban 21.6 47.0 2.2 1.2 19.4 2.5 6.0 100.0 72.1 1,367 Rural 4.1 31.9 1.8 4.8 34.8 6.8 15.8 100.0 42.5 4,160 Region Tigray 15.3 50.9 5.2 1.8 8.7 15.9 2.1 100.0 73.3 371 Afar 5.7 23.5 0.9 0.5 60.8 3.7 4.9 100.0 30.6 86 Amhara 10.4 40.2 2.2 2.8 26.0 7.1 11.3 100.0 55.7 1,050 Oromia 5.0 31.4 1.5 5.8 33.1 2.4 20.7 100.0 43.7 2,211 Somali 5.9 17.0 2.7 0.3 71.4 0.6 2.0 100.0 26.0 409 Benishangul-Gumuz 12.5 42.5 0.5 9.5 8.3 3.9 22.8 100.0 65.0 67 SNNPR 5.5 39.9 0.9 3.7 27.8 10.9 11.2 100.0 50.1 1,106 Gambela 25.6 38.2 3.6 2.4 20.4 6.7 3.0 100.0 69.9 25 Harari 23.1 39.9 1.2 0.6 29.8 0.7 4.8 100.0 64.7 16 Addis Ababa 46.4 47.5 1.8 0.0 3.2 0.8 0.3 100.0 95.7 156 Dire Dawa 27.4 39.6 1.8 2.0 21.5 2.9 4.8 100.0 70.8 30 Mother’s education No education 3.3 26.4 1.2 4.2 39.9 6.4 18.5 100.0 35.2 2,962 Primary 11.2 42.9 2.5 3.9 24.4 5.7 9.5 100.0 60.5 1,956 Secondary 16.8 59.9 3.7 3.2 11.7 2.8 1.9 100.0 83.6 415 More than secondary 40.1 50.7 1.7 0.6 3.9 3.0 0.0 100.0 93.1 194 Wealth quintile Lowest 1.5 15.7 0.9 4.0 49.9 7.8 20.3 100.0 22.1 1,321 Second 2.7 32.1 1.8 4.0 36.8 5.3 17.3 100.0 40.6 1,198 Middle 4.9 33.8 2.2 6.7 34.2 6.5 11.7 100.0 47.5 1,044 Fourth 7.3 49.8 2.1 3.9 18.4 7.3 11.2 100.0 63.1 960 Highest 29.1 54.4 2.5 0.8 8.3 1.5 3.4 100.0 86.9 1,005 Total 8.4 35.6 1.9 3.9 31.0 5.8 13.4 100.0 49.8 5,527 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Skilled provider includes doctor, nurse, midwife, health officer, and health extension worker. 2 Includes only the most recent birth in the 5 years preceding the survey 68 • Maternal Health Care Table 7.7 Caesarean section Percentage of live births in the 5 years preceding the survey delivered by caesarean section (C-section), according to background characteristics, Ethiopia Mini- DHS 2019 Background characteristic Percentage delivered by C-section Number of births Mother’s age at birth <20 2.8 751 20-34 5.6 4,069 35-49 7.0 707 Birth order 1 9.0 1,221 2-3 4.8 1,755 4-5 4.7 1,244 6+ 3.6 1,306 Antenatal care visits1 None 1.1 1,004 1-3 6.6 1,225 4+ 9.0 1,688 Don’t know/missing * 10 Place of delivery Health facility 11.4 2,628 Public facility 10.8 2,506 Private facility 42.2 68 NGO 3.0 54 Residence Urban 10.1 1,367 Rural 3.9 4,160 Region Tigray 6.9 371 Afar 2.7 86 Amhara 7.4 1,050 Oromia 4.1 2,211 Somali 1.1 409 Benishangul-Gumuz 6.2 67 SNNPR 4.6 1,106 Gambela 3.8 25 Harari 8.2 16 Addis Ababa 24.1 156 Dire Dawa 15.6 30 Mother’s education No education 2.9 2,962 Primary 6.4 1,956 Secondary 12.6 415 More than secondary 19.3 194 Wealth quintile Lowest 1.6 1,321 Second 3.6 1,198 Middle 4.5 1,044 Fourth 4.7 960 Highest 14.3 1,005 Total 5.4 5,527 Note: The question on C-section was asked only of women who delivered in a health facility. In this table, it is assumed that women who did not give birth in a health facility did not receive a C-section. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes only the most recent birth in the 5 years preceding the survey Maternal Health Care • 69 Table 7.8 Timing of first postnatal check for the mother Among women age 15-49 giving birth in the 2 years preceding the survey, percent distribution of the mother’s first postnatal check for the most recent live birth by time after delivery, and percentage of women with a live birth during the 2 years preceding the survey who received a postnatal check in the first 2 days after giving birth, according to background characteristics, Ethiopia Mini-DHS 2019 Time after delivery of mother’s first postnatal check1 No postnatal check2 Total Percentage of women with a postnatal check during the first 2 days after birth1 Number of women Background characteristic Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Age at birth <20 29.3 4.7 0.5 0.0 0.4 0.0 65.1 100.0 34.5 316 20-34 29.2 2.9 2.0 1.1 0.9 0.7 63.3 100.0 34.1 1,504 35-49 28.3 3.1 0.2 0.3 0.0 2.1 66.1 100.0 31.6 285 Birth order 1 39.4 3.2 2.2 1.5 0.5 0.0 53.2 100.0 44.7 507 2-3 30.8 5.0 1.5 0.0 0.3 0.1 62.3 100.0 37.3 716 4-5 25.3 1.8 1.7 1.6 1.3 2.5 65.9 100.0 28.8 447 6+ 18.3 1.6 0.6 0.4 1.0 1.1 77.0 100.0 20.5 435 Place of delivery Health facility 52.3 5.4 2.6 0.8 0.7 1.1 37.2 100.0 60.2 1,137 Elsewhere 1.9 0.6 0.3 0.7 0.6 0.5 95.4 100.0 2.8 968 Residence Urban 39.4 4.6 3.6 1.9 0.3 0.9 49.3 100.0 47.6 553 Rural 25.4 2.7 0.8 0.4 0.8 0.8 69.2 100.0 28.9 1,552 Region Tigray 56.1 4.9 2.3 2.7 1.0 0.6 32.4 100.0 63.3 155 Afar 19.8 3.3 0.4 0.8 0.4 1.0 74.3 100.0 23.5 31 Amhara 34.4 4.6 0.8 2.1 0.6 1.2 56.4 100.0 39.8 433 Oromia 22.9 2.4 0.9 0.0 0.8 1.2 71.9 100.0 26.1 825 Somali 8.5 0.8 1.0 0.4 0.0 0.0 89.3 100.0 10.3 132 Benishangul-Gumuz 36.2 4.7 4.1 1.1 1.8 0.4 51.7 100.0 45.0 24 SNNPR 26.6 2.7 2.7 0.5 0.7 0.0 66.8 100.0 32.0 411 Gambela 52.3 1.8 0.9 0.6 1.3 0.6 42.4 100.0 55.1 10 Harari 30.6 10.7 3.8 1.2 1.8 1.1 50.8 100.0 45.1 6 Addis Ababa 63.2 5.5 4.8 0.0 0.0 1.0 25.5 100.0 73.5 64 Dire Dawa 35.3 10.4 2.5 1.4 2.3 2.5 45.7 100.0 48.2 13 Education No education 19.6 1.3 0.9 0.2 0.2 0.6 77.1 100.0 21.8 977 Primary 29.6 5.4 2.0 1.3 1.0 1.2 59.6 100.0 36.9 840 Secondary 57.9 1.0 3.5 1.6 2.3 0.0 33.7 100.0 62.4 182 More than secondary 63.5 6.1 0.9 0.0 0.1 1.0 28.3 100.0 70.6 105 Wealth quintile Lowest 11.3 0.8 0.7 0.3 0.3 0.8 85.8 100.0 12.8 460 Second 18.6 2.3 0.4 1.4 0.5 0.0 76.8 100.0 21.3 449 Middle 25.3 2.4 0.1 0.7 0.9 1.2 69.4 100.0 27.8 392 Fourth 42.6 2.8 3.2 0.1 1.5 0.0 49.9 100.0 48.5 364 Highest 50.7 7.5 3.5 1.3 0.5 2.0 34.6 100.0 61.7 438 Total 29.1 3.2 1.5 0.8 0.7 0.8 63.9 100.0 33.8 2,105 1 Includes women who received a check from a doctor, midwife, nurse, health officer, health extension worker, or traditional birth attendant 2 Includes women who received a check after 41 days 70 • Maternal Health Care Table 7.9 Type of provider of first postnatal check for the mother Among women age 15-49 giving birth in the 2 years preceding the survey, percent distribution by type of provider of the mother’s first postnatal health check during the 2 days after the most recent live birth, according to background characteristics, Ethiopia Mini-DHS 2019 Type of health provider of mother’s first postnatal check No postnatal check during the first 2 days after birth Total Number of women Background characteristic Doctor/nurse/ midwife Health officer Health extension worker Traditional birth attendant Age at birth <20 30.5 2.0 1.8 0.3 65.5 100.0 316 20-34 29.2 3.4 1.5 0.0 65.9 100.0 1,504 35-49 30.1 0.5 1.0 0.0 68.4 100.0 285 Birth order 1 41.9 2.0 0.8 0.0 55.3 100.0 507 2-3 31.7 3.7 1.7 0.1 62.7 100.0 716 4-5 23.2 3.6 1.9 0.0 71.2 100.0 447 6+ 17.8 1.2 1.4 0.0 79.5 100.0 435 Place of delivery Health facility 53.3 4.5 2.3 0.0 39.8 100.0 1,137 Elsewhere 1.5 0.7 0.5 0.1 97.2 100.0 968 Residence Urban 44.7 2.1 0.7 0.0 52.4 100.0 553 Rural 24.1 3.0 1.7 0.0 71.1 100.0 1,552 Region Tigray 53.2 7.8 1.9 0.4 36.7 100.0 155 Afar 22.0 1.0 0.0 0.5 76.5 100.0 31 Amhara 34.5 4.1 1.2 0.0 60.2 100.0 433 Oromia 22.6 1.9 1.6 0.0 73.9 100.0 825 Somali 9.4 0.5 0.4 0.0 89.7 100.0 132 Benishangul-Gumuz 35.4 2.3 7.2 0.0 55.0 100.0 24 SNNPR 27.9 2.5 1.7 0.0 68.0 100.0 411 Gambela 51.9 3.0 0.0 0.3 44.9 100.0 10 Harari 41.8 2.7 0.0 0.6 54.9 100.0 6 Addis Ababa 72.9 0.6 0.0 0.0 26.5 100.0 64 Dire Dawa 46.3 1.5 0.4 0.0 51.8 100.0 13 Education No education 18.6 1.5 1.6 0.0 78.2 100.0 977 Primary 32.3 3.7 0.8 0.1 63.1 100.0 840 Secondary 51.8 6.1 4.4 0.0 37.6 100.0 182 More than secondary 69.5 1.0 0.0 0.0 29.4 100.0 105 Wealth quintile Lowest 10.6 0.7 1.5 0.0 87.2 100.0 460 Second 17.1 2.4 1.9 0.0 78.7 100.0 449 Middle 23.6 2.7 1.5 0.0 72.2 100.0 392 Fourth 40.7 5.7 2.2 0.0 51.5 100.0 364 Highest 58.1 3.0 0.4 0.2 38.3 100.0 438 Total 29.5 2.8 1.5 0.0 66.2 100.0 2,105 Maternal Health Care • 71 Table 7.10 Timing of first postnatal check for the newborn Percent distribution of most recent live births in the 2 years preceding the survey by time after birth of first postnatal check, and percentage of births with a postnatal check during the first 2 days after birth, according to background characteristics, Ethiopia Mini-DHS 2019 Time after delivery of newborn’s first postnatal check1 No postnatal check2 Total Percentage of births with a postnatal check during the first 2 days after birth1 Number of births Background characteristic Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know Mother’s age at birth <20 27.9 7.9 0.6 0.4 2.7 0.7 59.9 100.0 36.7 316 20-34 23.6 7.7 1.8 1.6 1.1 1.0 63.3 100.0 34.6 1,504 35-49 21.5 8.0 1.6 0.8 0.3 2.2 65.7 100.0 31.8 285 Birth order 1 35.5 9.5 1.0 1.3 2.8 0.8 49.2 100.0 47.3 507 2-3 24.9 6.4 2.2 1.1 0.4 1.1 63.9 100.0 34.6 716 4-5 19.0 9.9 1.5 2.6 1.9 1.4 63.7 100.0 33.1 447 6+ 13.9 5.6 1.2 0.4 0.2 1.5 77.3 100.0 21.1 435 Place of delivery Health facility 43.6 13.5 2.7 2.1 1.6 1.8 34.6 100.0 61.9 1,137 Elsewhere 0.8 0.9 0.3 0.3 0.8 0.3 96.5 100.0 2.3 968 Residence Urban 31.2 11.6 2.9 2.7 2.1 1.0 48.5 100.0 48.4 553 Rural 21.3 6.3 1.1 0.8 0.9 1.2 68.3 100.0 29.6 1,552 Region Tigray 45.5 8.2 1.5 0.4 1.4 4.3 38.7 100.0 55.5 155 Afar 16.7 5.6 2.7 0.8 0.4 1.0 72.8 100.0 25.8 31 Amhara 27.1 11.9 1.9 0.8 2.1 2.9 53.3 100.0 41.7 433 Oromia 19.5 6.5 1.2 1.0 1.1 0.4 70.4 100.0 28.1 825 Somali 7.9 2.1 2.4 0.5 0.0 0.4 86.7 100.0 13.0 132 Benishangul-Gumuz 30.7 10.3 3.0 0.7 0.0 0.0 55.3 100.0 44.7 24 SNNPR 19.2 6.4 1.2 3.2 1.3 0.0 68.7 100.0 30.0 411 Gambela 46.7 5.9 3.1 0.3 1.3 0.0 42.8 100.0 56.0 10 Harari 33.7 5.9 5.7 1.6 2.4 2.0 48.7 100.0 46.9 6 Addis Ababa 65.1 15.4 2.7 1.1 0.9 1.0 13.7 100.0 84.4 64 Dire Dawa 33.8 8.1 5.9 0.0 0.0 1.7 50.5 100.0 47.8 13 Mother’s education No education 14.8 5.4 0.9 1.0 0.6 1.8 75.4 100.0 22.1 977 Primary 28.5 7.3 1.7 1.9 2.0 0.5 58.1 100.0 39.4 840 Secondary 37.3 17.5 2.8 0.7 1.6 0.8 39.3 100.0 58.3 182 More than secondary 49.6 16.1 4.0 0.1 0.0 0.9 29.3 100.0 69.8 105 Wealth quintile Lowest 8.4 4.1 0.5 0.2 0.9 1.3 84.6 100.0 13.3 460 Second 18.6 6.0 0.5 0.3 1.3 1.2 72.1 100.0 25.4 449 Middle 23.2 7.9 0.6 1.7 0.8 1.0 64.8 100.0 33.4 392 Fourth 29.8 9.9 2.7 0.7 1.1 0.4 55.3 100.0 43.2 364 Highest 41.5 11.3 3.7 3.5 2.0 1.7 36.3 100.0 60.1 438 Total 23.9 7.7 1.6 1.3 1.2 1.1 63.1 100.0 34.5 2,105 1 Includes newborns who received a check from a doctor, midwife, nurse, health officer, health extension worker, or traditional birth attendant 2 Includes newborns who received a check after the first week of life 72 • Maternal Health Care Table 7.11 Type of provider of first postnatal check for the newborn Percent distribution of most recent live births in the 2 years preceding the survey by type of provider of the newborn’s first postnatal health check during the 2 days after the most recent live birth, according to background characteristics, Ethiopia Mini-DHS 2019 Type of health provider of newborn’s first postnatal check No postnatal check during the first 2 days after birth Total Number of births Background characteristic Doctor/ nurse/ midwife Health officer Health extension worker Traditional birth attendant Mother’s age at birth <20 31.4 3.2 2.0 0.1 63.3 100.0 316 20-34 30.0 2.7 1.5 0.4 65.4 100.0 1,504 35-49 29.8 1.6 0.2 0.2 68.2 100.0 285 Birth order 1 43.6 2.8 0.9 0.0 52.7 100.0 507 2-3 30.3 2.8 1.5 0.1 65.4 100.0 716 4-5 26.0 3.5 2.9 0.7 66.9 100.0 447 6+ 18.7 1.4 0.4 0.7 78.9 100.0 435 Place of delivery Health facility 55.0 4.6 2.3 0.0 38.1 100.0 1,137 Elsewhere 1.0 0.3 0.3 0.7 97.7 100.0 968 Residence Urban 46.4 1.9 0.1 0.0 51.6 100.0 553 Rural 24.4 2.9 1.9 0.4 70.4 100.0 1,552 Region Tigray 46.8 6.9 1.0 0.8 44.5 100.0 155 Afar 24.1 1.0 0.2 0.4 74.2 100.0 31 Amhara 38.0 2.5 0.9 0.4 58.3 100.0 433 Oromia 23.9 2.7 1.6 0.0 71.9 100.0 825 Somali 11.2 1.8 0.0 0.0 87.0 100.0 132 Benishangul-Gumuz 36.0 2.3 6.4 0.0 55.3 100.0 24 SNNPR 25.0 1.9 2.2 0.9 70.0 100.0 411 Gambela 52.9 3.1 0.0 0.0 44.0 100.0 10 Harari 42.3 3.3 0.0 1.3 53.1 100.0 6 Addis Ababa 83.8 0.6 0.0 0.0 15.6 100.0 64 Dire Dawa 45.2 2.0 0.0 0.6 52.2 100.0 13 Mother’s education No education 18.6 1.2 1.9 0.4 77.9 100.0 977 Primary 34.5 3.8 0.8 0.3 60.6 100.0 840 Secondary 50.1 5.8 2.3 0.0 41.7 100.0 182 More than secondary 68.7 1.0 0.0 0.0 30.2 100.0 105 Wealth quintile Lowest 10.3 1.1 1.1 0.8 86.7 100.0 460 Second 19.9 2.3 2.9 0.3 74.6 100.0 449 Middle 27.9 3.0 2.1 0.4 66.6 100.0 392 Fourth 37.9 4.6 0.7 0.0 56.8 100.0 364 Highest 57.3 2.7 0.1 0.0 39.9 100.0 438 Total 30.2 2.6 1.4 0.3 65.5 100.0 2,105 Maternal Health Care • 73 Table 7.12 Content of postnatal care for newborns Among most recent live births in the 2 years preceding the survey, percentage for whom selected functions were performed during the first 2 days after birth and percentage with at least two signal functions performed during the first 2 days after birth, according to background characteristics, Ethiopia Mini- DHS 2019 Among most recent live births in the 2 years preceding the survey, percentage for whom the selected function was performed during the first 2 days after birth: Percentage with at least two signal functions performed during the first 2 days after birth Number of births Background characteristic Cord examined Temperature measured Counselling on danger signs Counselling on breastfeeding Observation of breastfeeding Mother’s age at birth <20 24.5 21.5 19.1 31.3 32.7 36.7 316 20-34 26.4 26.8 21.9 39.1 35.2 40.4 1,504 35-49 28.9 25.2 19.4 36.3 30.9 38.2 285 Birth order 1 31.6 32.1 24.2 44.1 45.7 49.5 507 2-3 26.6 25.6 22.7 41.2 36.8 41.8 716 4-5 27.0 25.6 21.1 32.7 26.0 33.4 447 6+ 19.5 18.9 15.0 29.0 25.2 30.6 435 Place of delivery Health facility 42.8 44.1 34.0 59.9 58.5 66.0 1,137 Elsewhere 7.2 4.2 6.0 11.3 5.8 8.5 968 Residence Urban 36.9 40.1 30.7 54.7 50.2 57.7 553 Rural 22.7 20.7 17.7 31.5 28.6 33.1 1,552 Region Tigray 50.5 50.6 40.7 61.3 59.6 69.7 155 Afar 22.5 17.1 21.9 34.3 29.7 32.0 31 Amhara 26.5 28.9 19.6 48.7 41.0 49.2 433 Oromia 22.7 19.9 16.7 27.7 26.4 29.8 825 Somali 11.8 13.6 6.5 18.6 14.6 17.9 132 Benishangul-Gumuz 38.4 37.2 30.9 48.6 52.1 52.7 24 SNNPR 20.9 20.6 20.2 34.6 31.6 35.6 411 Gambela 46.4 57.1 46.8 48.0 53.8 64.6 10 Harari 35.9 28.5 15.1 35.7 39.4 42.9 6 Addis Ababa 70.5 70.4 69.4 85.7 78.6 89.5 64 Dire Dawa 50.3 39.5 20.6 39.4 33.7 52.6 13 Mother’s education No education 20.4 21.3 16.3 27.0 24.0 30.3 977 Primary 27.2 23.4 19.2 41.3 38.2 43.1 840 Secondary 49.5 46.1 41.7 64.8 57.8 60.5 182 More than secondary 36.5 50.4 45.7 58.9 57.1 61.8 105 Wealth quintile Lowest 10.5 11.1 9.3 19.2 17.7 19.8 460 Second 23.2 19.6 15.0 30.2 30.8 35.2 449 Middle 25.1 20.8 22.8 33.7 26.3 34.4 392 Fourth 30.0 26.2 20.0 41.0 34.7 41.6 364 Highest 44.7 51.6 39.3 65.0 61.9 67.8 438 Total 26.4 25.8 21.1 37.6 34.3 39.6 2,105 Childhood Vaccinations • 75 CHILDHOOD VACCINATIONS 8 Key Findings ▪ Vaccinations: 44% of children age 12-23 months have received all basic vaccinations at some time, and 40% received these vaccinations by the appropriate age. The percentage of children who received all basic vaccinations has increased by 5 percentage points since 2016 (from 39% to 44%). ▪ Vaccination cards in households: A vaccination card, booklet, or other home-based record was seen for 41% of children age 12-23 months and 26% of children age 24-35 months. ▪ Vaccination history missing but sought at health facilities: 62% of children age 0-35 months did not have a vaccination card seen during the home visit. Vaccination history was sought at a health facility for 33% of children and obtained for 29% of children. 8.1 VACCINATION OF CHILDREN All basic vaccinations coverage Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card, health facility visit, or the mother’s report). To have received all basic vaccinations, a child must receive at least: ▪ One dose of BCG vaccine, which protects against tuberculosis ▪ Three doses of DPT-HepB-Hib, which protects against diphtheria, pertussis (whooping cough), tetanus, hepatitis B, and Haemophilus influenzae type b ▪ Three doses of polio vaccine ▪ One dose of measles vaccine Sample: Living children age 12-23 months he Expanded Programme for Immunisation (EPI) in Ethiopia, launched in 1980, has been one of the core priorities in past Health Sector Development Programmes (HSDPs) and the current Health Sector Transformation Plan (HSTP) (FMoH 2015). The country has mobilised volunteers, health extension workers, and health facilities to deliver immunisation services. Improved district planning and management were initiated in 2011 with the goal of reaching every district. Static, outreach, and mobile are the three important service delivery platforms for vaccination services. In addition, several campaigns provide polio, measles, and other antigens to children. Universal immunisation of children against the six common vaccine-preventable diseases, namely tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, and measles, is crucial in reducing infant and child mortality. Other childhood vaccines given in Ethiopia protect against hepatitis B and Haemophilus influenzae type b (Hib). Unlike previous EDHS surveys, this survey also captured information related to the second dose of measles vaccine (MCV 2), an effort launched in early 2019. T 76 • Childhood Vaccinations According to the guidelines developed by the World Health Organization (WHO), children are considered to have received all basic vaccinations if they have received a vaccination against tuberculosis (also known as BCG), three doses of the DPT-HepB-Hib (also called pentavalent) vaccine, and vaccinations against polio and measles. The BCG vaccine is usually given at birth or at first clinical contact, while the DPT- HepB-Hib and polio vaccines are given at approximately age 6, 10, and 14 weeks. Measles vaccinations should be given at or soon after age 9 months. The EPI in Ethiopia considers a child to have received all basic vaccinations if the child has also received three doses of the pneumococcal conjugate vaccine (PVC) (at age 6, 10, and 14 weeks) and two doses of the rotavirus vaccine (at age 6 and 10 weeks). Information on vaccination coverage was obtained in three ways in the 2019 EMDHS: from written vaccination records, including the infant immunisation card and other health cards; from mothers’ verbal reports; and from health facility records. For each child born in the 3 years before the survey, mothers were asked to show the interviewer the infant immunisation card or health card used to record the child’s immunisations. If the infant immunisation card or other health card was available, the interviewer copied the dates of each vaccination received in the respective section of the Woman’s Questionnaire. If a vaccination was not recorded on the infant immunisation card or the health card, the mother was asked to recall whether that particular vaccination had been given. If the mother was not able to present the child’s infant immunisation card, she was asked to recall whether the child had received the BCG, polio, DPT- HepB-Hib, measles, pneumococcal, and rotavirus vaccines. If she indicated that the child had received the polio, DPT-HepB-Hib, pneumococcal, measles, or rotavirus vaccine, she was asked the number of doses that the child received. In addition, for any children missing vaccination data who also visited a health facility, the field supervisor visited the health facility to collect the relevant vaccination records. The purpose of obtaining information at the health facility was to complement the immunisation information based on mothers’ recall. Data on vaccination coverage among children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s recall) showed that only 4 out of 10 children (44%) have received all basic vaccinations at some time, and 40% received these vaccinations before their first birthday (Figure 8.1 and Table 8.1). Fifty-nine percent of children in this age group received a measles vaccination (MCV 1), and 19% received no vaccinations. Figure 8.1 Childhood vaccinations Coverage rates decline for subsequent doses of these vaccines, with 61% of children age 12-23 months receiving the recommended three doses of DPT-HepB-Hib vaccine and 60% receiving all three doses of the polio vaccine. There is a 15 percentage-point dropout rate within this age group from the first to the third dose of the DPT-HepB-Hib vaccine and an 18 percentage-point dropout rate from the first to the third dose of the polio vaccine. Only 9 percent of children age 24-35 months received the second dose of the measles vaccine (MCV 2). 73 76 71 61 78 72 60 59 44 19 BCG 1 2 3 1 2 3 Measles All basic None Percentage of children age 12-23 months vaccinated at any time before the survey PolioDPT/pentavalent Childhood Vaccinations • 77 8.2 UPTAKE OF THE RECENTLY INTRODUCED VACCINES The government of Ethiopia introduced the pneumococcal conjugate vaccine (PCV) and monovalent human rotavirus vaccine (RV) into the national infant immunisation programme in November 2011 and October 2012, respectively. PCV protects against Streptococcus pneumoniae bacteria, which cause severe pneumonia, meningitis, and other illnesses. Rotavirus causes gastroenteritis, an inflammation of the stomach and intestines. If left untreated, rotavirus can lead to severe dehydration and death. Among children age 12-23 months, 74% received the first dose of PCV and 60% received the third dose (Table 8.2). Seventy-three percent of children received the first dose of RV, while 67% received the second dose. Trends: There has been steady progress in EPI coverage over the years. The percentage of children age 12-23 months who received all basic vaccinations increased from 20% in 2005 and 24% in 2011 to 39% in 2016 and 44% in 2019. Also, the proportion of children with no vaccinations decreased from 24% in 2005 to 19% in 2019 (Figure 8.2). Patterns by background characteristics ▪ Vaccination coverage among children age 12-23 months generally declines as birth order increases, from 44% among first-order births to 37% among sixth- or higher-order births (Table 8.2). ▪ Children in urban areas are more likely to receive all basic vaccinations than children in rural areas (62% versus 36%). ▪ At the regional level, coverage of all basic vaccinations is highest in Addis Ababa (83%) and Tigray (73%) and lowest in Somali (19%) and Afar (20%). ▪ Children are more likely to receive all basic vaccinations if their mothers have more than a secondary education (65%) than if their mothers have no education (33%) (Figure 8.3). ▪ Children from households in the highest wealth quintile are more likely to receive all basic vaccinations than children from households in the lowest quintile (67% versus 26%) (Table 8.2). Figure 8.2 Trends in childhood vaccinations Figure 8.3 Vaccination coverage by mother’s education 20 24 39 44 24 15 16 19 2005 EDHS 2011 EDHS 2016 EDHS 2019 EMDHS Percentage of children age 12-23 months who received all basic vaccines at any time before the survey All basic vaccinations No vaccinations 33 50 59 65 No education Primary Secondary More than secondary Percentage of children age 12-23 months who received all basic vaccines at any time before the survey 78 • Childhood Vaccinations 8.3 POSSESSION AND OBSERVATION OF VACCINATION CARDS IN HOUSEHOLDS Vaccination cards in households Percentage of children age 12-23 months and children age 24-35 who ever had a vaccination card (or booklet or other home-based record) that was seen during a home visit. Sample: Children under age 3 with vaccination cards in the household Vaccination cards are critical tools in ensuring that children receive all recommended vaccinations according to schedule. In Ethiopia, 45% of children age 12-23 months and 31% of children age 24-35 months were reported to have ever had a vaccination card. Interviewers were able to see a vaccination card, booklet, or other home-based record for 41% of children age 12-23 months and 26% of children age 24-35 months (Table 8.3). 8.4 OBSERVATION OF VACCINATION CARDS IN HEALTH FACILITIES Vaccination cards in health facilities Percentage of children age 0-35 months and children age 12-35 months with vaccination history found and seen at a health facility. Sample: Children under age 3 with vaccination cards in a health facility Table 8.4 presents information on observation of vaccination history at health facilities for children age 0-35 months. Sixty-two percent of children in this age group did not have a vaccination card seen during home visits. Of these children, 53% received at least one vaccination at a health facility. For 51% of the children, interviewers were able to obtain the mother’s consent to search for the health record at a health facility. Vaccination history was sought at a health facility for 33% of children and found for 29% of children. Table 8.5 presents results from health facility visits for children age 12-35 months. Sixty-six percent did not have a vaccination card during their home visit. Among these children, 58% received at least one vaccination at a health facility. Interviewers obtained the mother’s consent to search for the health record at a health facility for 56% of the children. Supervisors and field teams searched for the vaccination history at health facilities for 37% of children and located the history for 32% of children. Trends: The percentage of children age 0-35 months with no vaccination card during their home visit declined from 71% in 2016 to 62% in 2019. Over the same period, the percentage of children age 12-23 months who ever had a vaccination card decreased slightly from 46% to 45%, while the percentage among children age 24-35 months decreased from 35% to 31%. Childhood Vaccinations • 79 LIST OF TABLES For more information on childhood vaccinations, observation of vaccination cards, and observation of vaccination history at health facilities, see the following tables: ▪ Table 8.1 Vaccinations by source of information ▪ Table 8.2 Vaccinations by background characteristics ▪ Table 8.3 Possession and observation of vaccination cards, according to background characteristics ▪ Table 8.4 Observation of vaccination history at health facilities: Children age 0-35 months ▪ Table 8.5 Observation of vaccination history at health facilities: Children age 12-35 months 80 • Childhood Vaccinations Table 8.1 Vaccinations by source of information Percentage of children age 12-23 months and children age 24-35 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage who received specific vaccines by the appropriate age, Ethiopia Mini-DHS 2019 Children age 12-23 months Children age 24-35 months Vaccine Vaccination card1 Health facility Mother’s report Any source Vaccinated by appropriate age2,3 Vaccination card1 Health facility Mother’s report Any source Vaccinated by appropriate age3,4 BCG 37.2 27.7 8.0 73.0 70.4 24.7 32.0 6.2 63.0 62.6 DPT-HepB-Hib 1 40.1 28.0 8.2 76.3 75.1 26.2 32.8 5.4 64.4 63.3 2 38.2 26.5 6.6 71.3 70.3 24.6 30.1 4.4 59.1 58.4 3 35.6 22.5 3.1 61.1 60.3 22.7 24.9 2.3 50.0 49.0 Polio 0 (birth dose) 16.2 13.6 2.2 31.9 31.6 11.9 18.9 2.1 32.9 32.3 1 39.7 28.5 9.7 77.9 76.7 26.0 34.4 8.2 68.7 67.5 2 38.0 27.0 6.6 71.5 70.6 23.9 32.1 5.7 61.6 60.9 3 34.5 23.1 2.4 59.9 58.4 22.3 26.2 1.6 50.2 49.2 IPV 24.8 22.3 7.5 54.6 53.3 15.4 28.6 4.6 48.5 47.7 Pneumococcal 1 39.9 26.1 7.5 73.6 72.5 25.7 31.6 5.2 62.6 61.5 2 37.7 24.4 6.3 68.4 67.5 23.9 29.0 3.7 56.6 56.0 3 34.7 22.1 3.1 59.8 58.6 21.6 25.2 1.2 48.0 47.0 Rotavirus 1 39.3 26.2 7.0 72.5 71.4 25.4 29.8 6.0 61.3 60.3 2 36.9 23.8 6.0 66.8 65.6 23.5 27.8 4.0 55.3 53.8 Measles-containing vaccine 1 29.0 22.8 6.7 58.5 54.8 19.0 29.7 6.2 54.9 49.9 2 na na na na na 1.9 6.6 0.6 9.1 6.9 All basic vaccinations5 26.1 17.7 0.2 44.1 40.2 17.6 20.9 1.0 39.5 36.3 All age-appropriate vaccinations6 9.9 8.3 0.0 18.2 18.1 1.4 2.5 0.0 3.9 1.6 No vaccinations 0.0 3.7 15.5 19.2 na 0.0 5.4 23.6 29.0 na Number of children 425 338 265 1,028 1,028 271 415 341 1,027 1,027 na = Not applicable BCG = Bacille Calmette-Guérin DPT = Diphtheria-pertussis-tetanus HepB = Hepatitis B Hib = Haemophilus influenzae type b IPV = inactivated polio vaccine 1 Vaccination card, booklet, or other home-based record 2 Received by age 12 months 3 For children whose vaccination information is based on the mother’s report, date of vaccination is not collected. The proportions of vaccinations given during the first and second years of life are assumed to be the same as for children with a written record of vaccination. 4 Received by age 12 months for all vaccines except measles-containing vaccine 2, which should be received by age 24 months 5 BCG, three doses of DPT-HepB-Hib, three doses of oral polio vaccine (excluding polio vaccine given at birth), and one dose of measles-containing vaccine 6 For children age 12-23 months: BCG, three doses of DPT-HepB-Hib, four doses of oral polio vaccine, IPV, three doses of pneumococcal vaccine, two doses of rotavirus vaccine, and one dose of measles-containing vaccine. For children age 24-35 months, all of the just-mentioned vaccinations plus a second dose of measles-containing vaccine. C h il d h o o d V a c c in a ti o n s • 8 1 T a b le 8 .2 V a c c in a ti o n s b y b a c k g ro u n d c h a ra c te ri s ti c s P e rc e n ta g e o f c h il d re n a g e 1 2 -2 3 m o n th s a n d c h il d re n a g e 2 4 -3 5 m o n th s w h o r e c e iv e d s p e c if ic v a c c in e s a t a n y t im e b e fo re t h e s u rv e y ( a c c o rd in g t o a v a c c in a ti o n c a rd o r th e m o th e r’ s r e p o rt ), p e rc e n ta g e w it h a ll b a s ic v a c c in a ti o n s , a n d p e rc e n ta g e w it h a ll a g e -a p p ro p ri a te v a c c in a ti o n s , b y b a c k g ro u n d c h a ra c te ri s ti c s , E th io p ia M in i- D H S 2 0 1 9 C h il d re n a g e 1 2 -2 3 m o n th s C h il d re n a g e 2 4 -3 5 m o n th s B C G D P T -H e p B -H ib P o li o 1 P n e u m o c o c c a l R o ta v ir u s M C V 1 A ll b a s ic v a c c i- n a ti o n s 2 A ll a g e - a p p ro - p ri a te v a c c i- n a ti o n s 3 N o v a c c i- n a ti o n s N u m b e r o f c h il d re n M C V 2 A ll a g e - a p p ro - p ri a te v a c c i- n a ti o n s 4 N u m b e r o f c h il d re n B a c k g ro u n d c h a ra c te ri s ti c 1 2 3 0 ( b ir th d o s e ) 1 2 3 IP V 1 2 3 1 2 S e x M a le 7 4 .1 7 9 .0 7 2 .1 6 3 .3 3 2 .4 7 9 .9 7 3 .1 6 2 .4 5 3 .2 7 5 .3 7 0 .5 6 2 .8 7 3 .2 6 7 .6 5 7 .6 4 5 .5 1 7 .4 1 7 .7 4 9 5 7 .8 4 .0 5 1 4 F e m a le 7 1 .9 7 3 .8 7 0 .4 5 9 .1 3 1 .5 7 6 .0 7 0 .1 5 7 .7 5 5 .9 7 2 .0 6 6 .3 5 7 .1 7 1 .9 6 6 .0 5 9 .4 4 2 .8 1 8 .9 2 0 .6 5 3 3 1 0 .5 3 .7 5 1 4 B ir th o rd e r 1 7 9 .7 8 0 .6 7 4 .9 5 6 .4 3

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