Ghana - Demographic and Health Survey - 2004

Publication date: 2004

Ghana Demographic and Health Survey 2003 G h an a 2003 D em ographic and H ealth Survey The 2003 Ghana Demographic and Health Survey (GDHS) is part of the worldwide MEASURE DHS project. The survey and this publication were made possible through support provided by the U.S. Agency for International Development, under the terms of contract No. HRN-C-00-97-0019-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. Ghana Demographic and Health Survey 2003 Ghana Statistical Service Accra, Ghana Noguchi Memorial Institute for Medical Research Legon, Ghana ORC Macro Calverton, Maryland, USA September 2004 Ghana Statistical Service Noguchi Memorial Institute for Medical Research MEASURE DHS+ This report highlights the findings of the 2003 Ghana Demographic and Health Survey (GDHS), a nationally representative survey of 5,691 women age 15-49 and 5,015 men age 15-59. The primary pur- pose of the GDHS is to generate recent and reliable information on fertility, family planning, infant and child mortality, maternal and child health, and nutrition. In addition, the survey collected information on malaria treatment and prevention, anaemia and HIV prevalence. This information is essential for making informed policy decisions, planning, monitoring, and evaluating programmes on health in general and reproductive health in particular, at both the national and regional levels. This survey is the fourth in a series of population and health surveys conducted in Ghana as part of the global Demographic and Health Surveys (DHS) programme. The 2003 GDHS was implemented by the Ghana Statistical Service (GSS) in collaboration with the Noguchi Memorial Institute for Medical Research (NMIMR) and the Ghana Health Service. Technical assistance was provided by ORC Macro through the MEASURE DHS programme. Financial support for the survey was provided by the U.S. Agency for International Development (USAID) and the Govern- ment of Ghana. Additional information about the GDHS may be obtained from the Ghana Statistical Service, P.O. Box 1098, Accra, Ghana (Telephone: (233-21) 671-732 and Fax: (233-21) 671-731). Information about the DHS project may be obtained from ORC Macro, 11785 Beltsville Drive, Calverton, MD (Telephone: 301-572-0200; Fax: 301-572-0999; E-mail: reports@orcmacro.com; Internet: http://www.measuredhs.com). Recommended citation: Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research (NMIMR), and ORC Macro. 2004. Ghana Demographic and Health Survey 2003. Calverton, Maryland: GSS, NMIMR, and ORC Macro. Contents | iii CONTENTS Tables and Figures . ix Foreword. xvii Contributors . xix Summary of Findings . xxi Map of Ghana .xxviii CHAPTER 1 INTRODUCTION .1 1.1 Geography, History, and Economy . 1 1.1.1 Geography.1 1.1.2 History.1 1.1.3 Economy .2 1.2 Demographic Profile. 2 1.3 Population Policy and Reproductive Health Programmes. 3 1.4 Objectives and Organisation of the Survey. 4 1.5 Sample Design. 4 1.6 Questionnaires . 5 1.7 Haemoglobin and HIV Testing. 5 1.7.1 Haemoglobin Testing.6 1.7.2 HIV/AIDS Testing.6 1.8 Pretest, Training, and Fieldwork. 7 1.8.1 Pretest .7 1.8.2 Training and Fieldwork .8 1.9 Data Processing . 8 1.10 Response Rates. 8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS .11 2.1 Household Population by Age and Sex . 11 2.2 Household Composition . 13 2.3 Educational Attainment of Household Members . 14 2.4 Housing Characteristics. 19 2.5 Household Durable Goods . 22 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS.23 3.1 Background Characteristics of Respondents . 23 iv | Contents 3.2 Educational Attainment and Literacy. 25 3.3 Access to Mass Media . 29 3.4 Employment . 32 3.4.1 Employment Status .32 3.4.2 Occupation .35 3.4.3 Type of Employer, Form of Earnings, and Continuity of Employment .38 3.4.4 Control Over Earnings and Women’s Contribution to Household Expenditures.40 3.5 Women’s Empowerment . 43 3.5.1 Women’s Participation in Decisionmaking.43 3.5.2 Attitudes toward Wife-beating .46 3.5.3 Attitudes toward Refusing Sex.49 CHAPTER 4 FERTILITY .53 4.1 Fertility Levels and Trends. 53 4.1.1 Fertility Levels.53 4.1.2 Differentials in Current and Completed Fertility .54 4.1.3 Trends in Fertility.56 4.2 Children Ever Born and Children Surviving . 58 4.3 Birth Intervals . 59 4.4 Age at First Birth . 61 4.5 Median Age at First Birth by Background Characteristics . 61 4.6 Teenage Fertility . 62 CHAPTER 5 FAMILY PLANNING .65 5.1 Knowledge of Contraceptive Methods . 65 5.2 Ever Use of Contraception . 68 5.3 Current Use of Contraceptive Methods. 70 5.4 Trends in the Use of Family Planning . 74 5.5 Current Use of Contraception by Women’s Status . 75 5.6 Number of Children at First Use of Contraception . 77 5.7 Use of Social Marketing Brands. 77 5.8 Knowledge of Fertile Period. 79 5.9 Source of Supply . 80 5.10 Informed Choice . 81 5.11 Future Use of Contraception. 84 5.12 Reasons for Not Intending to Use Contraception . 84 5.13 Preferred Method of Contraception for Future Use . 85 5.14 Exposure to Family Planning Messages. 86 5.15 Exposure to Specific Radio Messages on Family Planning . 89 Contents | v 5.16 Contact of Non-users with Family Planning Providers. 91 5.17 Discussion about Family Planning with Husband . 92 5.18 Attitudes of Men towards Family Planning . 93 5.19 Attitudes of Couples towards Family Planning . 94 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY .99 6.1 Current Marital Status . 99 6.2 Polygyny. 100 6.3 Age at First Marriage . 102 6.4 Age at First Sexual Intercourse . 104 6.5 Recent Sexual Activity. 107 6.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 110 6.7 Menopause . 112 CHAPTER 7 FERTILITY PREFERENCES. 113 7.1 Desire For More Children . 113 7.2 Need For Family Planning Services . 116 7.3 Ideal Family Size. 118 7.4 Fertility Planning . 121 7.5 Ideal Family Size And Unmet Need By Women’s Status . 122 CHAPTER 8 INFANT AND CHILD MORTALITY . 125 8.1 Definition, Data Quality and Methodology . 125 8.2 Levels and Trends in Infant and Child Mortality . 127 8.3 Socio-economic Diffferentials in Mortality . 129 8.4 Demographic Characteristics and Child Mortality. 131 8.5 Women’s Status and Child Mortality . 134 8.6 Perinatal Mortality . 135 8.7 High-Risk Fertility Behaviour. 136 CHAPTER 9 MATERNAL AND CHILD HEALTH. 137 9.1 Maternity Care . 137 9.1.1 Antenatal Care. 137 9.1.2 Delivery Care . 144 9.1.3 Postnatal Care . 148 9.2 Reproductive Health Care and Women’s Status. 150 9.3 Child health. 151 9.3.1 Vaccination of Children . 151 9.3.2 Acute Respiratory Infections . 155 9.3.3 Diarrhoeal Diseases . 157 vi | Contents 9.4 Child Health Care and Women’s Status . 163 9.5 Women’s Perceptions of Problems in Obtaining Health Care. 164 9.6 Use of Smoking Tobacco . 165 CHAPTER 10 NUTRITION . 169 10.1 Breastfeeding. 169 10.1.1 Initiation of Breastfeeding . 169 10.1.2 Age Pattern of Breastfeeding . 171 10.2 Complementary Feeding. 175 10.2.1 Types of Complementary Foods. 175 10.2.2 Frequency of Foods Consumed by Children . 176 10.3 Micronutrients . 179 10.3.1 Iodisation of Household Salt . 179 10.3.2 Micronutrient Intake among Children . 179 10.3.3 Micronutrient Intake Among Mothers . 182 10.3.4 Prevalence of Anaemia in Children. 184 10.3.5 Prevalence of Anaemia in Women. 184 10.3.6 Prevalence of Anaemia in Children by Anaemia Status of Mother . 187 10.4 Nutritional Status of Children under Age Five. 187 10.4.1 Measures of Nutritional Status in Childhood . 187 10.4.2 Trends in Children’s Nutritional Status . 191 10.5 Nutritional Status of Women . 191 CHAPTER 11 MALARIA . 195 11.1 Mosquito Nets . 195 11.1.1 Ownership of Mosquito Nets . 195 11.1.2 Use of Mosquito Nets by Children . 196 11.1.3 Use of Mosquito Nets by Pregnant Women . 198 11.2 Exposure to Media Messages on Malaria . 199 11.3 Malaria Diagnosis, Case Management, and Treatment . 200 11.3.1 Malaria Prophylaxis during Pregnancy. 200 11.3.2 Prevalence and Management of Childhood Malaria . 202 Contents | vii CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 207 12.1 HIV/AIDS–Related Knowledge and Attitudes. 207 12.2 Knowledge of Prevention Methods . 208 12.3 Beliefs about AIDS. 210 12.4 Stigma and Discrimination Associated with HIV/AIDS . 213 12.5 Knowledge of Prevention of Mother-to-Child Transmission . 216 12.6 HIV Testing. 219 12.7 Counselling and Testing Pregnant Women. 221 12.8 Attitudes towards Negotiating Safer Sex . 222 12.9 Higher-Risk Sex and Condom Use . 224 12.10 Paid Sex . 227 12.11 Self-Reporting of Sexually Transmitted Infections and Symptoms . 227 12.12 STI Treatment-Seeking Behaviour . 229 12.13 Sexual Behaviour among Young Women and Men . 229 12.14 Orphanhood and Children’s Living Arrangements. 235 CHAPTER 13 HIV PREVALENCE AND ASSOCIATED FACTORS . 239 13.1 Coverage of HIV Testing . 240 13.2 HIV Prevalence. 243 13.2.1 HIV Prevalence by Socioeconomic Characteristics . 243 13.2.2 HIV Prevalence by Other Socio-demographic Characteristics. 246 13.2.3 HIV Prevalence by Sexual Risk Behaviour . 247 13.2.4 HIV Prevalence by Other Characteristics Related to HIV Risk. 249 13.2.5 HIV Prevalence and Male Circumcision . 250 13.2.6 Prevalence among Couples. 251 13.3 Distribution of the HIV Burden in Ghana. 253 REFERENCES . 255 APPENDIX A SAMPLE IMPLEMENTATION . 257 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 263 APPENDIX C DATA QUALITY TABLES . 281 APPENDIX D PERSONS INVOLVED IN THE 2003 GHANA DEMOGRAPHIC AND HEALTH SURVEY . 287 APPENDIX E QUESTIONNAIRES . 291 Tables and Figures | ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators.2 Table 1.2 Results of the household and individual interviews .9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence .12 Table 2.2 Household composition.13 Table 2.3.1 Educational attainment of household population: women .15 Table 2.3.2 Educational attainment of household population: men .16 Table 2.4 School attendance ratios.18 Table 2.5 Household characteristics .20 Table 2.6 Household durable goods.22 Figure 2.1 Population Pyramid .12 Figure 2.2 Age-Specific Attendance Rates.19 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents .24 Table 3.2.1 Educational attainment by background characteristics: women.25 Table 3.2.2 Educational attainment by background characteristics: men.26 Table 3.3.1 Literacy: women.28 Table 3.3.2 Literacy: men .29 Table 3.4.1 Exposure to mass media: women.30 Table 3.4.2 Exposure to mass media: men .31 Table 3.5.1 Employment status: women.33 Table 3.5.2 Employment status: men .34 Table 3.6.1 Occupation: women.36 Table 3.6.2 Occupation: men .37 Table 3.7.1 Type of employment: women.39 Table 3.7.2 Type of employment: men .39 Table 3.8 Decision on use of earnings and contribution of earnings to household expenditures.41 Table 3.9 Women's control over earnings .42 Table 3.10 Women's participation in decisionmaking .43 Table 3.11 Women's participation in decisionmaking by background characteristics.45 Table 3.12.1 Women's attitude toward wife-beating.47 Table 3.12.2 Men's attitude toward wife-beating .48 Table 3.13.1 Women's attitude toward wives refusing sex with husbands .50 Table 3.13.2 Men's attitude toward wives refusing sex with husbands.51 Table 3.14 Men's attitudes towards justifiable actions if wife refuses sex .52 x | Tables and Figures Figure 3.1 Occupation of Women Age 15-49 and Men Age 15-59.38 Figure 3.2 Type of Earnings of Employed Women Age 15-49 and Men Age 15-59 .40 Figure 3.3 Women’s Participation in Decisionmaking: Number of Decisions in Which Women Participate in the Final Say, Based on Five Household Decisions .44 CHAPTER 4 FERTILITY Table 4.1 Current fertility .54 Table 4.2 Fertility by background characteristics.55 Table 4.3 Trends in age-specific fertility rates .56 Table 4.4 Trends in fertility.57 Table 4.5 Children ever born and living.58 Table 4.6 Birth intervals.60 Table 4.7 Age at first birth .61 Table 4.8 Median age at first birth by background characteristics.62 Table 4.9 Teenage pregnancy and motherhood .63 Figure 4.1 Total Fertility Rates, Ghana and Selected Sub-Saharan Countries .54 Figure 4.2 Total Fertility Rate by Background Characteristics .56 Figure 4.3 Trends in Total Fertility Rate, Ghana 1988-2003.57 CHAPTER 5 FAMILY PLANNING Table 5.1.1 Knowledge of contraceptive methods: women .66 Table 5.1.2 Knowledge of contraceptive methods: men .67 Table 5.2.1 Ever use of contraception: women.69 Table 5.2.2 Ever use of male method of contraception: men.70 Table 5.3 Current use of contraception .71 Table 5.4 Current use of contraception by background characteristics .72 Table 5.5 Trends in the use of family planning.74 Table 5.6 Current use of contraception by women's status.76 Table 5.7 Number of children at first use of contraception .77 Table 5.8 Pill brand and cost .78 Table 5.9 Condom brand and cost .79 Table 5.10 Knowledge of fertile period.80 Table 5.11 Source of contraception.81 Table 5.12 Informed choice .83 Table 5.13 Future use of contraception .84 Table 5.14 Reason for not intending to use contraception .85 Table 5.15 Preferred method of contraception for future use .86 Table 5.16.1 Exposure to family planning messages: women .87 Table 5.16.2 Exposure to family planning messages: men.88 Table 5.17 Exposure to specific radio shows on family planning .90 Table 5.18 Contact of non-users with family planning providers .91 Table 5.19 Discussion of family planning with husband.92 Table 5.20 Men's attitudes towards contraception .93 Tables and Figures | xi Table 5.21.1 Approval of family planning: women .95 Table 5.21.2 Approval of family planning: men .96 Table 5.22 Wife's perception of husband's attitude toward family planning .97 Figure 5.1 Current Use of Family Planning Among Currently Married Women Age 15-49 .74 Figure 5.2 Trends in Current Use of Contraceptive Methods, Ghana, 1988-2003.75 Figure 5.3 Trends in Source of Modern Contraceptive Methods, Ghana 1988-2003.83 Figure 5.4 Percentage of Women and Men Exposed to Family Planning Messages in the Media.90 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status.99 Table 6.2 Polygyny. 101 Table 6.3 Age at first marriage . 103 Table 6.4 Median age at first marriage. 104 Table 6.5 Age at first sexual intercourse. 105 Table 6.6 Median age at first intercourse . 106 Table 6.7.1 Recent sexual activity: women. 108 Table 6.7.2 Recent sexual activity: men . 109 Table 6.8 Postpartum amenorrhea, abstinence and insusceptibility . 110 Table 6.9 Median duration of postpartum insusceptibility by background characteristics . 111 Table 6.10 Menopause . 112 Figure 6.1 Percentage of Married Men with Two or More Wives, by Region. 102 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children. 114 Table 7.2 Desire to limit childbearing. 115 Table 7.3 Need for family planning . 117 Table 7.4 Ideal number of children . 119 Table 7.5 Mean ideal number of children by background characteristics . 120 Table 7.6 Fertility planning status . 121 Table 7.7 Wanted fertility rates . 122 Table 7.8 Ideal number of children and unmet need by women's status . 123 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates. 127 Table 8.2 Trends in early childhood mortality rates . 128 Table 8.3 Early childhood mortality rates by socio-economic characteristics . 129 Table 8.4 Early childhood mortality rates by demographic characteristics . 131 Table 8.5 Early childhood mortality rates by women's status . 132 Table 8.6 Perinatal mortality . 134 Table 8.7 High-risk fertility behaviour. 135 xii | Tables and Figures Figure 8.1 Trends in Infant and Under-five Mortality Rates, Ghana 1988-2003 . 128 Figure 8.2 Under-Five Mortality by Background Characteristics . 130 Figure 8.3 Under-Five Mortality by Socio-Economic Characteristics. 131 CHAPTER 9 MATERNAL AND CHILD HEALTH Table 9.1 Antenatal care . 138 Table 9.2 Number of antenatal care visits and timing of first visit . 140 Table 9.3 Components of antenatal care . 142 Table 9.4 Tetanus toxoid injections . 143 Table 9.5 Place of delivery . 145 Table 9.6 Assistance during delivery . 146 Table 9.7 Delivery characteristics . 147 Table 9.8 Postnatal care by background characteristics. 149 Table 9.9 Reproductive health care by women's status . 150 Table 9.10 Vaccinations by source of information . 152 Table 9.11 Vaccinations by background characteristics. 154 Table 9.12 Vaccinations in first year of life. 155 Table 9.13 Prevalence and treatment of symptoms of ARI 156 Table 9.14 Hand-washing materials in household. 158 Table 9.15 Disposal of children's stools. 159 Table 9.16 Prevalence of diarrhoea . 160 Table 9.17 Knowledge of ORS packets . 161 Table 9.18 Diarrhoea treatment . 162 Table 9.19 Feeding practices during diarrhoea . 163 Table 9.20 Children’s health care by women's status . 164 Table 9.21 Problems in accessing health care . 166 Table 9.22 Use of smoking tobacco. 167 Figure 9.1 Trends in Maternity Care Indicators, Ghana 1988-2003. 139 Figure 9.2 Number of Antenatal Care Visits . 140 Figure 9.3 Percentage of Children Age 12-23 Months with Specific Vaccinations. 152 Figure 9.4 Trends in Vaccination Coverage, Ghana 1988-2003 . 153 CHAPTER 10 NUTRITION Table 10.1 Initial breastfeeding . 170 Table 10.2 Breastfeeding status by age . 172 Table 10.3 Median duration and frequency of breastfeeding. 174 Table 10.4 Foods consumed by children in the day or night preceding the interview . 176 Table 10.5 Frequency of foods consumed by children in the day or night preceding the interview . 177 Table 10.6 Frequency of foods consumed by children in preceding seven days . 178 Table 10.7 Iodisation of household salt . 180 Table 10.8 Micronutrient intake among children . 181 Table 10.9 Micronutrient intake among mothers . 183 Table 10.10 Prevalence of anaemia in children . 185 Tables and Figures | xiii Table 10.11 Prevalence of anaemia in women . 186 Table 10.12 Prevalence of anaemia in children by anaemia status of mother. 187 Table 10.13 Nutritional status of children. 190 Table 10.14 Nutritional status of women by background characteristics. 193 Figure 10.1 Breastfeeding Practices by Age, Ghana 2003 . 173 Figure 10.2 Frequency of Meals Consumed by Children under 36 Months of Age Living with Their Mother, by Breastfeeding Status, Ghana 2003. 178 Figure 10.3 Stunting, Wasting, and Underweight by Age, Ghana . 191 CHAPTER 11 MALARIA Table 11.1 Ownership of mosquito nets. 196 Table 11.2 Use of mosquito nets by children. 197 Table 11.3 Use of mosquito nets by pregnant women . 198 Table 11.4. Exposure to messages on malaria . 199 Table 11.5 Use of Intermittent Preventive Treatment (IPT) by pregnant women. 201 Table 11.6 Use of Fansidar for Intermittent Preventive Treatment (IPT) . 202 Table 11.7 Prevalence and prompt treatment of fever . 203 Table 11.8 Type and timing of anti-malarial drugs . 205 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 12.1 Knowledge of AIDS. 208 Table 12.2 Knowledge of HIV prevention methods . 209 Table 12.3.1 Beliefs about AIDS: women . 211 Table 12.3.2 Beliefs about AIDS: men. 212 Table 12.4.1 Accepting attitudes towards those living with HIV: women . 214 Table 12.4.2 Accepting attitudes towards those living with HIV: men . 215 Table 12.5.1 Knowledge of prevention of mother to child transmission of HIV: women. . 217 Table 12.5.2 Knowledge of prevention of mother to child transmission of HIV: men . 218 Table 12.6 Women and men who had an HIV test and received test results. 220 Table 12.7 Pregnant women counselled and tested for HIV. 221 Table 12.8 Attitudes towards negotiating safer sex with husband . 223 Table 12.9 Higher-risk sex and condom use at last higher-risk sex among women and men age 15-49 . 225 Table 12.10 Multiple sex partners among women and men. 226 Table 12.11 Paid sex in past year . 227 Table 12.12 Self-reportiing of sexually transmitted infection (STI) and STI symptoms . 228 Table 12.13 Women and men seeking treatment for STIs. 229 Table 12.14 Age at first sex among young women and men . 230 Table 12.15 Knowledge of a source for condoms among young women and men . 231 Table 12.16 Condom use at first sex among young women and men . 232 Table 12.17 Premarital sex and use of condom among young women and men. 233 Table 12.18 Higher-risk sex and condom use at last higher-risk sex . 234 Table 12.19 Age discontinuity in sexual relationships . 236 Table 12.20 Children's living arrangements and orphanhood. 237 xiv | Tables and Figures Figure 12.1 Reason for Getting HIV Test among Women and Men Age 15-49 Who Have Ever Been Tested. 222 Figure 12.2 Abstinence, Being Faithful, and Using Condoms Among Women and Men Age 15-24 . 235 CHAPTER 13 HIV PREVALENCE AND ASSOCIATED FACTORS Table 13.1 Coverage of HIV testing . 240 Table 13.2 Coverage of HIV testing, by background characteristics. 242 Table 13.3 HIV prevalence by age. 243 Table 13.4 HIV prevalence by background characteristics . 245 Table 13.5 HIV prevalence by selected socio-demographic characteristics. 246 Table 13.6 HIV prevalence by sexual behaviour characteristics . 248 Table 13.7 HIV prevalence by other indicators . 249 Table 13.8 HIV prevalence by prior HIV testing. 250 Table 13.9 HIV prevalence among men by circumcision status. 251 Table 13.10 HIV prevalence among couples . 252 Figure 13.1 HIV Prevalence by Age Group and Sex . 244 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample implementation: women . 257 Table A.2 Sample implementation: men. 258 Table A.3 Coverage of HIV testing among interviewed women by socio-demographic characteristics . 259 Table A.4 Coverage of HIV testing among interviewed men by socio-demographic characteristics . 260 Table A.5 Coverage of HIV testing by sexual behaviour characteristics: women . 261 Table A.6 Coverage of HIV testing by sexual behaviour characteristics: men. 262 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Ghana 2003. 266 Table B.2 Sampling errors for total sample, Ghana 2003. 267 Table B.3 Sampling errors for urban sample, Ghana 2003 . 268 Table B.4 Sampling errors for rural sample, Ghana 2003 . 269 Table B.5 Sampling errors for Western sample, Ghana 2003 . 270 Table B.6 Sampling errors for Central sample, Ghana 2003 . 271 Table B.7 Sampling errors for Greater Accra sample, Ghana 2003 . 272 Table B.8 Sampling errors for Volta sample, Ghana 2003 . 273 Table B.9 Sampling errors for Eastern sample, Ghana 2003 . 274 Table B.10 Sampling errors for Ashanti sample, Ghana 2003 . 275 Table B.11 Sampling errors for Brong Ahafo sample, Ghana 2003 . 276 Table B.12 Sampling errors for Northern sample, Ghana 2003 . 277 Table B.13 Sampling errors for Upper East sample, Ghana 2003 . 278 Tables and Figures | xv Table B.14 Sampling errors for Upper West sample, Ghana 2003. 279 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution. 281 Table C.2 Age distribution of eligible and interviewed women and men . 282 Table C.3 Completeness of reporting . 283 Table C.4 Births by calendar years . 284 Table C.5 Reporting of age at death in days . 285 Table C.6 Reporting of age at death in months . 286 Foreword | xvii FOREWORD The 2003 Ghana Demographic and Health Survey (GDHS) is a nationwide sample survey carried out to provide information on population, family planning, maternal and child health, nutrition, childhood mortality, and AIDS and sexually transmitted infections (STIs). This is the fourth survey of its kind to be undertaken in Ghana, others being in 1988, 1993, and 1998. This latest GDHS included, for the first time, testing of blood samples to provide national rates of anaemia and HIV. All four demographic and health surveys have been implemented by the Ghana Statistical Service, in close collaboration with other stake- holders. The Statistical Service of Ghana acknowledges the invaluable assistance given by a number of organisations and individuals both local and international towards the successful implementation of the 2003 GDHS. The Service is grateful to the Ministry of Health and the Ghana Health Service for releasing nurses for the survey fieldwork and personnel for training the interviewers. Our appreciation also goes to the Ghana AIDS Commission for their support at the time of training and in helping to set up VCT cen- tres as a follow-on to the HIV testing in the survey. We sincerely thank the Ghana Registered Midwives Association (GRMA) and the National Popu- lation Council (NPC) for providing vehicles for the data collection. We are very grateful to all members of the National Steering Committee, the Ethics Committee and the project personnel for their immense support and contribution during the different phases of the survey. We appreciate the work done by the Noguchi Memorial Institute for Medical Research on HIV testing, and especially commend the laboratory team assigned to work on the blood samples for their tire- less efforts in getting the testing done successfully. The Service is particularly thankful to the United States Agency for International Development (USAID) for funding the survey through its mission in Ghana, and to ORC Macro for providing technical assistance. We thank the authors of this report. They are mentioned specifically by name at the beginning of this report. We owe an immense gratitude to the field coordinators, interviewers, nurses, laboratory person- nel, supervisors, field editors, regional statisticians, and drivers for their hard work and dedication. We have printed the names of all survey personnel in Appendix D as a sign of our appreciation for their valu- able assistance. Most of all, we truly appreciate the co-operation of all survey respondents in making the 2003 GDHS a success. Dr. Grace Bediako, Government Statistician, Ghana Statistical Service Contributors | xix CONTRIBUTORS This report was authored by the following persons: Dr. Clement Ahiadeke, Institute for Social, Statistical and Economic Research Mrs. Faustina Ainguah, Ghana Statistical Service Dr. William Ampofo, Noguchi Memorial Institute for Medical Research Mr. Jacob Arthur-Quarm, Noguchi Memorial Institute for Medical Research Dr. Amanua Chinbuah, Ghana Health Service, Health Research Unit Dr. Agnes Dzokoto, National AIDS Control Programme Dr. Pav Govindasamy, ORC Macro Mr. Steve Grey, National Population Council Dr. Steven O. Kwankye, Regional Institute for Population Studies Mr. Emmanual Larbi, Ghana AIDS Commission Mrs. Edith Mote, Ghana Statistical Service Dr. Gloria Quansah-Asare, Ghana Health Service, Maternal and Child Health/Family Planning Unit Dr. Isabella Sagoe-Moses, Ghana Health Service, Nutrition Unit Mrs. Jasbir Sangha, ORC Macro Dr. Tesfay Teklu, Regional Institute for Population Studies Summary of Findings | xxi SUMMARY OF FINDINGS The 2003 Ghana Demographic and Health Survey (2003 GDHS) is a nationally representa- tive survey of 5,691 women age 15-49 and 5,015 men age 15-59 from 6,251 households covering 412 sample points (clusters) throughout Ghana. This survey is the fourth in a series of national- level population and health survey conducted as part of the global Demographic and Health Sur- veys (DHS) program and is designed to provide data to monitor the population and health situa- tion in Ghana as a follow-up of the 1988, 1993 and 1998 GDHS surveys. The survey utilised a two-stage sample based on the 2000 Population and Housing Census and was designed to pro- duce separate estimates for key indicators for each of the ten regions in Ghana. Data collection took place over a three-month period, from late July to late October 2003. The survey obtained detailed information on fertility levels, marriage, sexual activity, fer- tility preferences, awareness and use of family planning methods, breastfeeding practices, nutri- tional status of women and young children, childhood mortality, maternal and child health, awareness and behaviour regarding HIV/AIDS, and other sexually transmitted infections (STIs). In addition, the 2003 GDHS collected informa- tion on malaria and use of mosquito nets, and carried out anaemia testing in children and women and HIV testing in adults. The 2003 GDHS was implemented by the Ghana Statistical Service (GSS) in collaboration with the Noguchi Memorial Institute for Medical Research (NMIMR) and the Ghana Health Ser- vice. Technical assistance was provided by ORC Macro through the MEASURE DHS pro- gramme. Financial support for the survey was provided by the U.S. Agency for International Development (USAID) and the Government of Ghana. FERTILITY Fertility Levels and Trends. Comparison of the data from the 2003 GDHS with the three earlier DHS surveys indicates that the dramatic decline in fertility experienced in the eighties and nineties appears to have slowed down. The TFR, estimated for the three years preceding each survey, declined dramatically from 6.4 children per woman in 1988 to 5.2 children per woman in 1993, and to 4.4 children in 1998, a nearly 2-child drop in fertility over the decade. However, the demographic transition experi- enced in Ghana seems to have stalled in the last three years even though contraceptive use has continued to rise. Nevertheless, with a current TFR of 4.4, Ghana’s fertility rate is one of the lowest in sub-Saharan Africa. Fertility Differentials. Differentials by background characteristics are marked. Rural women have nearly twice as many children (5.6 children per woman) as urban women (3.1 chil- dren per woman). The total fertility rate is high- est in the Northern Region (7.0 children per woman) and lowest in Greater Accra (2.9 chil- dren per woman). As expected, women’s educa- tion is strongly associated with lower fertility, decreasing from 6.0 children per woman among those with no education to 2.5 children per woman among those with at least secondary education. Similar differentials are observed by wealth quintile, with TFR decreasing from 6.4 children per woman among women in the lowest wealth quintile to 2.8 children per woman among those in the highest wealth quintile. Unplanned Fertility. Despite a steady rise in the level of contraceptive use over the last fifteen years, the 2003 GDHS data indicate that unplanned pregnancies are common in Ghana. Overall, 16 percent of births in Ghana are un- wanted, while 24 percent are mistimed (wanted later). The proportion of unplanned births de- clined slightly from 42 percent in 1993 to 36 percent in 1998 but rose again to 40 percent in 2003. What is more troubling, however, is the fact that the proportion of births that are un- wanted has increased rather dramatically from the 1993 level of 9 percent to 16 percent in 2003. xxii | Summary of Findings Fertility Preferences. There is consider- able desire among currently married Ghanaians to control the timing and number of births. Thirty-eight percent of currently married women would like to wait for two years or more for the next birth, and 36 percent do not want to have another child. About a fifth (18 percent) would like to have a child soon (within two years). A comparison of the data over the four DHS sur- veys show that the desire to space births among currently married women has declined in the last 15 years, from 45 percent in 1988 to 38 percent in 2003. On the other hand, the desire to limit has increased from 23 percent in 1988 to 34 per- cent in 2003. However, this change has been minimal in the last ten years. There has been a decline in ideal family size among currently married women over time, from a mean of 5.5 children in 1988 to 4.8 chil- dren in 2003. There has been little change in the ideal number of children over the last 10 years. FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is nearly universal, with 98 percent of all women age 15 to 49 and 99 per- cent of all men age 15 to 59 knowing at least one modern method of family planning. Among all women, the most widely known methods of family planning are the male condom (95 per- cent), injectables (89 percent), the pill (88 per- cent) and female condom (83 percent). Seventy percent of all women have heard of female ster- ilisation, while 61-65 percent have heard of the IUD, implants, and periodic abstinence. There has been an increase in levels of awareness of contraceptive methods over time. Among all women, the proportions who know any method has risen since 1988 for all methods (from 76 percent in 1988, 91 percent in 1993, 93 percent in 1998 and 98 percent in 2003). The proportions who know of implants has risen steeply since 1993 (from 4 percent in 1993, 21 percent in 1998 and 62 percent in 2003). A simi- lar trend is seen among men with remarkable increases in knowledge of IUD, male sterilisa- tion and LAM. Use of Contraception. The contraceptive prevalence rate among married women is 25 percent. The most commonly used modern method among married women is the pill (6 per- cent), followed closely by injectables (5 per- cent). Male condoms and female sterilisation are used by 3 percent and 2 percent of married women, respectively, while implants and IUD are used by 1 percent each. The most commonly used traditional method is periodic abstinence, used by 5 percent of married women. Trends in Contraceptive Use. Current use of contraception by married women has in- creased from 13 percent in 1988, 20 percent in 1993, 22 percent in 1998 and 25 percent in 2003. There has been a steady increase in the use of modern methods from 5 percent in 1988 to 19 percent in 2003. However, while there was an increase in the use of traditional methods from 8 percent in 1988 to 10 percent in 1993, use of these methods have since decreased to 9 percent in 1998 and to 7 percent in 2003. Use of male condoms, pills, injectables and implants has in- creased. Differentials in Contraceptive Use. Women in urban areas are more likely to use contraceptive methods (31 percent) than their rural counterparts (21 percent). Male condoms, IUD, and female sterilisation use in urban areas is two to three times higher than in rural Ghana. The more urbanised regions such as Greater Ac- cra and Brong-Ahafo have contraceptive preva- lence rates above 30 percent. Two of the three northern regions (Upper East and Northern) re- port low levels of contraceptive use (12 percent each). Women with at least some secondary education are more than twice as likely to use contraception as women with no education. The proportion currently using contraception gener- ally increases with increasing number of chil- dren. Fourteen percent of women without chil- dren are currently using contraceptive methods, compared with 26 percent of women with five or more children. Wealth and current use of contra- ception is positively related, increasing from 14 percent among currently married women in the lowest quintile to 35 percent in the highest quin- tile. Summary of Findings | xxiii Source of Modern Methods. In Ghana, both the public and private sectors are important sources of supply for users of modern methods (41 percent and 54 percent, respectively). The most common public sector source are govern- ment hospitals and polyclinics, which provide most of the services (26 percent), while govern- ment health centres and family planning clinics provide 11 percent and 4 percent of users, re- spectively. In the last five years, there has been a shift in the source of modern contraceptive methods from the public to the private sector. The propor- tion of current users relying on private medical sources has increased from 45 percent in 1998 to 54 percent in 2003, while the reliance on public sources for all modern methods decreased from 47 percent in 1998 to 41 percent in 2003. Unmet Need for Family Planning. Thirty- four percent of married women have an unmet need for family planning. Unmet need for spac- ing is higher than unmet need for limiting chil- dren (22 percent and 12 percent, respectively), unchanged since 1998. Only 43 percent of the demand for family planning is currently being met, implying that the needs of more than one in two Ghanaian women are currently not being met. MATERNAL HEALTH Antenatal Care. A relatively high percent- age of women received antenatal care from a trained health professional (21 percent from a doctor and 71 percent from a nurse/midwife). One percent of mothers received antenatal care from a traditional birth attendant (TBA) and 6 percent received no antenatal care. A compari- son of the 2003 GDHS data with data from the three earlier DHS surveys show that there has been an improvement in the utilization of ante- natal services in the last fifteen years from 82 percent of mothers receiving care for their most recent birth in the five-year period preceding the survey in 1988, to 92 percent in 2003. Half of women received at least two doses of tetanus toxoid for their most recent birth in the five years preceding the survey, a third of women received only one tetanus toxoid injec- tion and 14 percent received none. The data show that there has been an improvement in tetanus toxoid coverage, for the most recent birth in the five years preceding the survey, over the last fifteen years, from 70 percent in 1988 to 83 percent in 2003. With regard to anti-malarial indicators, the data show that 10 percent of pregnant women slept under a net, 4 percent slept under an ever- treated net, and 3 percent slept under an insecti- cide treated net (ITN), the night before the inter- view with no difference in the use of nets be- tween pregnant and non-pregnant women. The data show that 58 percent of mothers reported that they received anti-malarial drugs for the prevention of malaria during pregnancy. It also shows that chloroquine is more frequently (12 percent) taken than SP/Fansidar (1 percent), pre- sumably because the old programme was still in force during the fielding of the survey. The 1 percent of women who used SP/Fansidar re- ceived the drug during an antenatal visit. Delivery Care. Nationally, 46 percent of births in the last five years are delivered in health facilities, with 36 percent in public health facilities and 9 percent in private health facili- ties. About half of births (53 percent) occur at home. The data also show that medically trained providers assisted with 47 percent of deliveries, TBAs assisted with 31 percent of deliveries and relatives or friends attended 19 percent of deliv- eries. Medically assisted deliveries continue to be low in Ghana, with less than fifty percent benefiting from professional delivery assistance over the last fifteen years. Postnatal Care. One in four women who had a non-institutional live birth in the five years preceding the survey received postnatal care within two days of delivery, one in ten women received postnatal care 3-6 days after delivery and one in eight received postnatal care 7-41 days after delivery. More than half of women who had a non-institutional birth in the five years preceding the survey did not receive post- natal care at all. xxiv | Summary of Findings CHILD HEALTH Childhood Mortality. Data from the 2003 GDHS show that there has been a slowing down in the mortality decline over the last five years. Data for the most recent five-year period sug- gests that one in every nine Ghanaian children dies before reaching age five. Nearly three in five of these deaths occur in the first year of life―infant mortality is 64 deaths per 1,000 live births and child mortality is 50 deaths per 1,000 children age one. Neonatal mortality is 43 deaths per 1,000 live births in the most recent five-year period, while postneonatal mortality is 21 deaths per 1,000 live births. Neonatal deaths account for two-thirds of the deaths in infancy. Childhood Vaccination Coverage. Sixty- nine percent of Ghanaian children age 12-23 months are fully immunised, while 5 percent received no vaccinations at all. Nine in ten chil- dren have received the BCG and first dose of DPT and polio vaccines. While the coverage for the first dose of DPT and polio is high, coverage declines for subsequent doses of DPT and polio, with only about 80 percent of children receiving the recommended three doses of these vaccines. Eighty-three percent of children received the measles vaccine and 77 percent have been vac- cinated against yellow fever. The percentage of children age 12-23 months who have been fully vaccinated has increased over the last twenty years, from 47 percent in 1988 to 69 percent in 2003. Child Illness and Treatment. Among chil- dren under five years of age, 10 percent were reported to have had symptoms of acute respira- tory illness in the two weeks preceding the sur- vey. Of these, 44 percent were taken to a health facility or provider for treatment. Fifteen percent of children under five years had diarrhoea in the two weeks preceding the survey. Twenty-six percent of children with diarrhoea were taken to a health provider. Just over a third of children with diarrhoea (39 percent) were given a solu- tion made from oral rehydration salts (ORS), 11 percent received recommended home fluids (RHF) and 40 percent were given increased flu- ids. Overall, 63 percent received ORS, RHF, or increased fluids. Twenty-one percent of children under five years had a fever in the two weeks preceding the survey. Of these, 63 percent took an anti- malarial drug. Forty-four percent of children took the anti-malarial drug on the same day or the next after the onset of the illness. Chloro- quine is by far the most common anti-malarial drug taken for fever (59 percent), followed by Amodiaquine and Quinine (2 percent each) and SP/Fansidar (less than 1 percent). NUTRITION Breastfeeding Practices. The data indicate that almost all (97 percent) Ghanaian children are breastfed for some period of time. Forty-six percent of infants were put to the breast within one hour of birth, and 75 percent started breast- feeding within the first day. The data from 2003 can be compared with similar data collected five years ago. The data show that over the last five years, there was little difference in the percent of children ever breastfed. The 2003 GDHS data indicate that supple- mentary feeding of children begins early. For example, among newborns less than two months of age, 38 percent are receiving supplementary foods or liquids other than water. The median duration of breastfeeding in Ghana is 23 months. Twelve percent of children under six months are given a feeding bottle with a nipple. Bottle-feeding reaches its peak (15 percent) at age 4-5 months. The percentage of young chil- dren bottle-fed has declined markedly over the last five years. Iodisation of household salt. Ninety per- cent of the households interviewed in the 2003 GDHS had their salt tested for iodine, while 9 percent had no salt available in the household. Fifty-nine percent of households are consuming salt that is not iodised, 13 percent of households are consuming inadequately iodised salt (<15 ppm) and only 28 percent are consuming adequately iodised salt (15+ ppm). Intake of Vitamin A. Ensuring that chil- dren between six months and 59 months receive enough vitamin A may be the single most effec- Summary of Findings | xxv tive child survival intervention, since deficien- cies in this micronutrient can cause blindness and can increase the severity of infections, such as measles and diarrhoea. Seventy-eight percent of children 6-59 months are reported to have received a vitamin A supplement in the 6 months preceding the survey. Forty-one percent of children under three who live with their mothers consume fruits and vegetables rich in vitamin A. Forty-three percent of mothers with a birth in the last five years reported receiving a vitamin A dose postpartum. Eight percent of interviewed women reported night blindness during preg- nancy. When adjusted for blindness not attrib- uted to vitamin A deficiency during pregnancy, the data show only two percent of women re- ported night blindness during their last preg- nancy. Prevalence of anaemia. Iron-deficiency anaemia is a major threat to maternal health and child health. Overall, more than three-quarters of Ghanaian children 6-59 months old have some level of anaemia, including 23 percent of children who are mildly anaemic, 47 percent who are moderately anaemic and 6 percent who are severely anaemic. The prevalence of anaemia is less pro- nounced among women than among children. Forty-five percent of Ghanaian women age 15- 49 are anaemic, with 35 percent mildly anaemic, 9 percent moderately anaemic, and less than 1 percent severely anaemic. Nutritional Status of Children. Accord- ing to the 2003 GDHS, 30 percent of children under five are stunted and 11 percent severely stunted. Seven percent of children under five are wasted and 1 percent severely wasted. Weight-for-age results show that 22 percent of children under five are underweight, with 5 per- cent severely underweight. Children whose bio- logical mothers were not in the household are more likely to be malnourished (34 percent stunted, and 25 percent underweight) than chil- dren whose mothers were interviewed. The proportion of children under five who are stunted has increased from 26 percent in 1998 to 30 percent in 2003. The proportion un- derweight decreased from 10 percent in 1998 to 7 percent in 2003. The proportion of children who are wasted also decreased from 25 percent in 1998 to 22 percent in 2003. Nutritional Status of Women. The mean height of Ghanaian women is 159 centimetres, which is above the critical height of 145 centi- metres. Only 1 percent are below 145 centime- tres. Nine percent of women were found to be chronically malnourished (BMI less than 18.5), while 25 percent are overweight or obese. There has been little change in the percentage of moth- ers whose height is below 145 centimetres and in the mean BMI over the last ten years from 1993 to 2003. HIV/AIDS Awareness of AIDS. Almost all (98 per- cent) women and men (99 percent) have heard of AIDS indicating that awareness of AIDS in Ghana is universal. Thirty-seven percent of women and 38 percent of men age 15-49, know someone personally who has the virus that causes AIDS or who has died of AIDS. Seventy- three percent of women and 82 percent of men know that condom use is a major prevention method. Eighty-six percent and 90 percent of women and men, respectively, know that limit- ing sex to only one uninfected partner is vital to the prevention of HIV. Sixty-nine percent of women and 78 percent of men know that these two preventive measures in combination can reduce the risk of HIV infection. In addition, 79 percent of women and 83 percent of men know that abstinence can prevent HIV infection. About four in five women and men cor- rectly know that a healthy looking person can have the AIDS virus. Fifty-five percent of women and sixty percent of men know that AIDS cannot be transmitted through mosquito bites. Less than half of women and three-fifths of men know that AIDS cannot be transmitted by supernatural means. More than 70 percent of women and men know that a person cannot be- xxvi | Summary of Findings come infected with HIV/AIDS by sharing food with someone who has AIDS. General knowledge on HIV transmission during pregnancy, delivery and breastfeeding is relatively high and ranges between 69 and 75 percent among women and 74 to 82 percent among men. However, few women and men (16 percent each) know that the risk of MTCT can be reduced if a mother takes special drugs dur- ing her pregnancy. Attitudes Towards People Living with HIV/AIDS. It is encouraging to see that more than two-thirds of women and men age 15-49 are willing to care for a family member with HIV in their own household, and that three-fifths of women and two-thirds of men do not believe that the HIV positive status of a family member should be kept a secret. Two-fifths of women and half of men also believe that an HIV posi- tive female teacher should be allowed to con- tinue teaching. However, only one in four women and one in three men say that they would buy fresh vegetables from a vendor with AIDS. HIV-Related Behavioural Indicators. One of the strategies for reducing the risk of contracting an STI is for young persons to delay the age at which they become sexually active. Seven percent of women and 4 percent of men had sex by exact age 15. Forty-six percent of women and 27 percent of men first had sex by exact age 18. Sexual intercourse with a non-marital or non-cohabiting partner is associated with an in- creased risk of contracting sexually transmitted diseases. One in five women and two in five men age 15-49 reported engaging in higher-risk sexual behaviour. Even more disturbing is the fact that half of women age 15-24 and more than four-fifths of men in the same age cohort engage in risky sexual behaviour. Sexual intercourse with more than one partner is also associated with a high risk of ex- posure to sexually transmitted diseases. One percent of women and 10 percent of men age 15- 49 report having had sexual intercourse with more than one partner in the twelve months prior to the survey. Promoting the use of condoms is an impor- tant strategy in the fight against HIV/AIDS transmission. Overall, only 28 percent of women and 45 percent of men age 15-49 used a condom during their last episode of higher-risk sex. HIV Prevalence. HIV tests were conducted for 89 percent of the 5,949 eligible women and 80 percent of the 5,345 eligible men. Results from the 2003 GDHS indicate that 2 percent of Ghanaian adults are HIV positive. HIV preva- lence in women age 15-49 is nearly 3 percent, while for men 15-59, it is under 2 percent. This female-to-male ratio of 1.8 to 1 is higher than that found in most population-based studies in Africa and implies that young women are par- ticularly vulnerable to HIV infection compared with young men. Prevalence among females is consistently higher than among males at all age groups except at ages 40-44, where male preva- lence is higher. The female-male gap is particu- larly large among women and men age 25-29, where women are nearly three and a half times as likely to be HIV positive as men. The peak prevalence among women is at age 35-39 (5 percent), while prevalence rises gradually with age among men to peak at age 40-44 (4 percent). Patterns of HIV Prevalence. Urban resi- dents have only a slightly higher risk of being HIV positive than rural residents with the urban- rural difference among women slightly higher than among men. Overall prevalence is highest in the Eastern Region (4 percent), followed by the Western and Brong Ahafo regions (3 percent each). Prevalence is lowest in the Northern, Cen- tral and Volta regions (1 percent each). Gender differences are apparent in all the regions. Those who have completed primary and mid- dle/JSS education are more likely to be HIV positive than those with either no education or at least secondary education. Work status is related to HIV prevalence among both women and men, with prevalence twice as high among those cur- rently working than those not currently working. Prevalence is highest among both women and men in the middle wealth quintile. Summary of Findings | xxvii Prevalence is significantly higher among widowed women (7 percent), followed closely by divorced or separated women (6 percent). Among men, prevalence is markedly higher among divorced or separated men (6 percent). Results from the 2003 GDHS indicate that, for the vast majority (96 percent) of cohabiting couples, both partners are HIV negative, while only in 1 percent of couples, are both partners HIV positive. There is discordance in the HIV positive status in under 2 percent of couples, where one partner is infected and the other is not. xxviii | Map of Ghana GHANA Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geography The Republic of Ghana is centrally located in West Africa and has a total land area of 238,537 square kilometres. It is bordered by French-speaking countries, on the east by the Republic of Togo, on the north and northwest by Burkina Faso, and on the west by Côte d’Ivoire. The Gulf of Guinea lies to the south and stretches across the 560 kilometres of the country’s coastline. Ghana is a lowland country, except for a range of hills that lie on the eastern border and Mt. Afadjato, the highest point of about 884 metres above sea level, which is to the west of the Volta River. Ghana can be divided into three distinguishable ecological zones: the sandy coastline backed by a coastal plain that is crossed by several rivers and streams; the middle belt and western parts of the country, heavily forested with many streams and rivers; and an undulating savannah to the north that is drained mainly by the Black and White Volta Rivers. The Volta Lake, created as a result of a hydroelectric dam in the east, is one of the largest artificial lakes in the world. The climate of Ghana is tropical, but temperatures and rainfall vary by distance from the coast and elevation. The average annual temperature is about 26ºC (79º F). There are two distinct rainy seasons, April to June and September to November. In the north, however, the rainy season begins in March and lasts until September. Annual rainfall ranges from about 1,015 millimetres (40 inches) in the north to about 2,030 millimetres (80 inches) in the southwest. The harmattan, a dry desert wind, blows from the northeast between December and March, lowering the humidity and creating very warm days and cool nights in the north. In the south, the effects of the harmattan are felt mainly in January. 1.1.2 History Ghana gained its independence from British rule on 6 March 1957, and on 1 July 1960 became a sovereign state in the British Commonwealth of Nations. The administrative and political capital of the country is Accra, with a population of 1.7 million (GSS, 2002). Ghana is a constitutional democracy and currently operates a multi-party democratic presidential system of government following the promulgation of the 1992 fourth Republic Constitution of Ghana. The country has an Executive Presidency elected for four years with a maximum of two terms. There is a parliament elected every four years, an independent judiciary, and a vibrant media. The population is made up of several ethnic groups. The Akans constitute the largest ethnic group (49 percent) followed by the Mole-Dagbon (17 percent), Ewe (13 percent), and Ga/Dangme (8 percent). Various smaller ethnic groups can also be found in many parts of the country (GSS, 2002). Ghana is divided into 10 administrative regions, Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West. The regions are further divided into 138 districts to ensure efficient and effective administration at the local levels. 2 | Introduction 1.1.3 Economy The structure of the economy has not changed much over the past two decades. Agriculture, mining, logging, and retail trade are still the most important areas of economic activity. Agriculture is the main sector and employs about 50 percent of the population (GSS, 2002). High proportions of the working population in Ghana are concentrated in the informal sector, made up largely of self-employed persons. The leading exports of the country are cocoa, gold, and timber. In recent times, the economy has diversified and includes exports of non-traditional commodities such as pineapples, bananas, yams, and cashew nuts. Tourism is fast gaining prominence as a foreign exchange earner. The overriding objective of the Government of Ghana’s (GoG) economic development programme is poverty reduction and general improvement in the welfare of all Ghanaians. In 1995, the GoG developed the Vision 2020 strategy for poverty reduction, which emphasises economic growth, integrated rural development, expansion of employment opportunities, and improved access, especially by the rural and urban poor, to basic public services such as education, health care, water and sanitation, and family planning services (World Bank, 2003). Under this strategy, it is envisaged that national income will grow by at least 8 percent from the current 4-5 percent. 1.2 DEMOGRAPHIC PROFILE Ghana has undertaken four censuses since independence in 1957. The first was conducted in 1960, recording a population of 6.7 million. The 1970 Census reported Ghana’s population as 8.6 million with an intercensal growth rate of 2.4 percent. The 1984 and 2000 censuses put the population at 12.3 million and 18.9 million, respectively, with an average growth rate of 2.7 percent between the two census periods (Table 1.1). The population density per square kilometre has more than doubled from 36 persons in 1970 to 79 persons in 2000. The proportion urban increased significantly from 29 percent in 1970 to 44 percent in 2000. The sex ratio over the last 30 years has fallen slightly from 98.5 males per 100 females in 1970 to 97.9 in 2000. The proportion of the population under 15 years however, has decreased from 47 percent in 1970 to 41 percent in 2000, while the proportion 65 years and older increased from less than 4 percent to a little more than 5 percent over the same period. The changes observed in the age structure may be attributed to Table 1.1 Basic demographic indicators Selected demographic indicators for Ghana, 1970, 1984, 2000 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Indicator 1970 1984 2000 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Population (millions) 8.6 12.3 18.9 Intercensal growth rate (percent) 2.4 2.6 2.7 Density (pop./km2) 36.0 52.0 79.3 Percent urban 28.9 32.0 43.8 Sex ratio 98.5 97.3 97.9 Proportion age 0-14 years 46.9 45.0 41.3 Proportion age 65+ 3.6 4.0 5.3 Life expectancy (years) Male u 50.3 55.4 Female u 53.8 59.6 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– u=Unknown (Not available) Source: GSO, 1979; GSS, 1985; GSS, 2002 Introduction | 3 declining fertility and improvements in the health conditions of the people. Life expectancy at birth has increased from 50 years among males in 1984 to 55 years in 2000 and among females from 54 years to 60 years over the same period. 1.3 POPULATION POLICY AND REPRODUCTIVE HEALTH PROGRAMMES Ghana’s population policy was formulated and adopted in 1969 in recognition of the high population growth and fertility rates observed at the time. After 25 years of implementation, however, the 1969 population policy made only a modest impact. It was therefore revised in 1994 to take into account emerging issues such as HIV/AIDS, population and the environment, concerns about the elderly and children, and also to develop new strategies that would ensure the achievement of the revised policy objectives. This meant ensuring the systematic integration of population issues in all areas of development planning. Major targets aimed at achieving these objectives include the following: the reduction of the total fertility rate from 5.5 in 1993 to 5.0 by the year 2000; the achievement of a contraceptive prevalence rate of 15 percent for modern methods by the year 2000, and 50 percent by the year 2020; and the reduction in the annual population growth rate from about 3 percent per annum to 2 percent by the year 2020 (World Bank, 2003). The attainment of these policy goals is recognised as integral components of the national strategy to accelerate the pace of economic development, eradicate poverty, and enhance the quality of life of all citizens as outlined in the Vision 2020 Plan of Action. It is expected that these goals would propel Ghana into middle- income country status by the year 2020. The National Population Council and its Secretariat were established in 1992 as the highest statutory body to advise the government on population related issues as well as to facilitate, monitor, coordinate, and evaluate the implementation of population programmes of other organisations both public and private within the country. Ghana, in collaboration with the United Nations Fund for Population Activities (UNFPA), the United States Agency for International Development (USAID), the World Bank, and other development partners, has implemented several projects aimed at reducing reproductive health problems among the population. The support from these agencies is geared towards strategies on policy coordination and implementation as well as service delivery. The government is committed to improving access and equity of access to essential health care, and ensuring that the health sector plays a key role in the Ghana Poverty Reduction Strategy (GPRS). The priority health intervention areas identified include addressing the problems of HIV/AIDS and other sexually transmitted infections (STIs), malaria, tuberculosis, guinea worm disease, poliomyelitis, reproductive health, maternal and child health, accidents and emergencies, non-communicable diseases, oral health and eye care, and specialised services. The spread of HIV/AIDS is currently receiving considerable attention from the government and its development partners, with the immediate challenges including ensuring implementation of the Ghana HIV/AIDS Strategic Framework: 2001-2005 (World Bank, 2003). The objectives of the framework include reducing new HIV infections among the 15-49 age group and other vulnerable groups, and especially among the youth by the year 2005, improving service delivery and mitigating the impact of HIV/AIDS on individuals, the family, and the community by the year 2005, reducing individual and societal vulnerability and susceptibility to HIV/AIDS through the creation of an enabling environment for the implementation of the national response, and establishing a well managed multi-sectoral and multi-disciplinary institutional framework for the coordination and implementation of HIV/AIDS programmes in the country. 4 | Introduction The government recognises that a critical constraint to poverty reduction is the limited choice of contraceptives especially to poor families. A two-pronged strategy will be employed to address this issue. The first is to decentralise service delivery and expand the sale of contraceptives through community agents, including maternity homes and field workers. The second, a national campaign on fertility regulation, will be instituted and will include a comprehensive, systematic, and culturally sensitive information, education, and communication programme to promote the use of family planning (World Bank, 2003). In addition, the GPRS emphasises cost-effective interventions on immunisations and supervised delivery; a high impact and rapid delivery programme to reduce under-five and maternal mortality and malnutrition, especially in the three northern and central regions of the country; prevention and effective treatment of malaria and the availability and use of insecticide-treated bed nets; and the eradication of guinea worm (World Bank, 2003). 1.4 OBJECTIVES AND ORGANISATION OF THE SURVEY The principal objective of the 2003 Ghana Demographic and Health Survey (GDHS) is to provide data to monitor the population and health situation in the country. This is the fourth round in a series of national-level population and health surveys conducted in Ghana under the worldwide Demographic and Health Surveys Program. The primary objective is to provide current and reliable data on fertility and family planning behaviour, infant and child mortality, breastfeeding, antenatal care, children’s immunisations and childhood diseases, nutritional status of mothers and children, use of maternal and child health services, and awareness and behaviour regarding AIDS and other STIs. New features of the 2003 GDHS include the collection of information on female and male circumcision, information on malaria and ownership and use of insecticide-treated bed nets, and haemoglobin and HIV testing. The long-term objective of the survey includes strengthening the technical capacity of major government institutions, including the Ghana Statistical Service (GSS). The 2003 GDHS also provides comparable data for long-term trend analyses in Ghana, since the surveys were implemented by the same organisation, using similar data collection procedures. It also contributes to the ever-growing international database on demographic and health-related information. The 2003 GDHS was conducted by the Ghana Statistical Service in collaboration with the Noguchi Memorial Institute for Medical Research (NMIMR) and the Ghana Health Service. ORC Macro provided technical support for the survey through the MEASURE DHS+ programme. Funding for the survey came from the U.S. Agency for International Development (USAID), through its office in Ghana, and the Government of Ghana. 1.5 SAMPLE DESIGN The sample for the 2003 GDHS covered the population residing in private households in the country. A representative probability sample of about 6,600 households was selected nationwide. The list of enumeration areas (EAs) from the 2000 Ghana Population and Housing Census was used as a frame for the sample. The frame was first stratified into the 10 administrative regions in the country, then into rural and urban EAs. The sample was selected in such a manner as to allow for separate estimates for key indicators for the country as a whole, for each of the 10 regions in Ghana, as well as for urban and rural areas separately. The 2003 GDHS used a two-stage stratified sample design. At the first stage of sampling, 412 sample points or EAs were selected, each with probability proportional to size, based on the number of households. A complete household listing exercise was carried out between May and June 2003 within all the selected EAs (clusters). The second stage of selection involved systematic sampling of households from this list. The sample selected per EA varied by region depending on the population size. Fifteen households per EA were Introduction | 5 selected in all the regions except in Brong Ahafo, Upper East, and Upper West regions, where 20 households per EA were selected, and in the Northern region, where 16 households per EA were selected. The objective of this exercise was to ensure adequate numbers of complete interviews to provide estimates for important population characteristics with acceptable statistical precision. Due to the disproportional number of EAs and different sample sizes selected per EA among regions, the household sample for the 2003 GDHS is not self- weighted at the national level. The sample design is discussed in detail in Appendix A, and the methodology used in estimating sampling errors together with a list of sampling errors for key variables are provided in Appendix B. 1.6 QUESTIONNAIRES All women age 15-49 and all men age 15-59 who were either usual residents of the households in the GDHS sample or visitors present in the household the night before the survey were eligible to be interviewed in the survey. Three questionnaires were used for the 2003 GDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. The contents of these questionnaires were based on the model questionnaires developed by the MEASURE DHS+ programme and were designed to provide information needed by health and family planning programme managers and policymakers. The questionnaires were adapted to the Ghanaian situation and a number of questions pertaining to ongoing health, HIV, and family planning programmes were added. These questionnaires were translated from English into the five major languages (Akan, Nzema, Ewe, Ga, and Dagbani). The questionnaires are attached in Appendix E. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Information was collected on the characteristics of each person listed, including the age, sex, education, and relationship to the head of household. The main purpose of the Household Questionnaire was to identify eligible women and men for the individual interview. The Household Questionnaire collected information on characteristics of the household’s dwelling unit, such as the source of drinking water, type of toilet facilities, flooring materials, ownership of various consumer goods, and ownership and use of mosquito nets. It was also used to record height and weight measurements of women 15-49 and children under the age of 5, and to record the respondents’ consent to the haemoglobin and HIV testing. The Women’s Questionnaire was used to collect information from all women age 15-49. These women were asked questions on the following topics: respondent’s background characteristics, such as education, residential history, media exposure, knowledge and use of family planning methods, fertility preferences, antenatal and delivery care, breastfeeding and infant and child feeding practices, vaccinations and childhood illnesses, childhood mortality, marriage and sexual activity, woman’s work and husband’s background characteristics, and awareness and behaviour regarding AIDS and other STIs. The Men’s Questionnaire was administered to all men age 15-59 in every household in the GDHS sample. The Men’s Questionnaire collected much of the same information found in the Women’s Questionnaire, but was shorter because it did not contain a reproductive history or questions on maternal and child health and nutrition. 1.7 HAEMOGLOBIN AND HIV TESTING In all households selected for the 2003 GDHS, women age 15-49 and children under age 5 were tested for anaemia. In addition, all eligible women and men were tested for HIV. Anaemia and HIV testing were only carried out if consent was provided by the respondents and in the case of a minor, by the parent or guardian. The protocol for haemoglobin and HIV testing was approved by the Ghana Health Service Ethical Review Committee in Accra and the ORC Macro Institutional Review Board in Calverton, Maryland, USA. 6 | Introduction 1.7.1 Haemoglobin Testing Haemoglobin testing is the primary method of anaemia diagnosis. In the GDHS, testing was done using the HemoCue system. A consent statement was read to the eligible woman and to the parent or responsible adult for young children and women age 15-17. This statement explained the purpose of the test, informed prospective subjects tested and/or their caretakers that the results would be made available as soon as the test was completed, and also requested permission for the test to be carried out, as well as the consent to report their names to health personnel in the local health facility if their haemoglobin level was low (severe). Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then the palm side of the end of a finger (in case of adults and children six months of age and older) was punctured with a sterile, non-reusable, self-retractable lancet and a drop of blood collected on a HemoCue microcuvette and placed in a HemoCue photometer, which displays the result. For children under six months of age (or for children under one year of age who were particularly undernourished and bony) a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure, which was given to each woman, parent, or responsible adult, that explained what the results meant. For each person whose haemoglobin level was low (severe), and who agreed to have the condition reported, a referral was given to the respondent to be taken to a health facility. 1.7.2 HIV/AIDS Testing All eligible women and men who were interviewed were asked to voluntarily provide a few drops of blood for HIV testing. The protocol for the blood specimen collection and analysis was based on the anonymous linked protocol developed for DHS. The protocol allows for the merging of the HIV results to the socio-demographic data collected in the individual questionnaires, provided that information that could potentially identify an individual is destroyed before the linking takes place. This required that identification codes be deleted from the data file and that the back page of the Household Questionnaires that contain the bar code labels and names of respondents be destroyed prior to merging the HIV results with the individual data file. If, after explaining the procedure, the confidentiality of the data, and the fact that the test results would not be made available to the subject, a respondent consented to the HIV testing, a dried blood spot (DBS) specimen was obtained from a finger prick. Each respondent who consented to being tested for HIV was given an information brochure on AIDS, a list of fixed sites providing voluntary counseling and testing (VCT) services throughout the country, and a voucher to access free VCT services at any of these sites for the respondent and/or the partner. Each DBS sample was given a bar code label, with a duplicate label attached to the Household Questionnaire on the line showing consent for that respondent. A third copy of the same bar code label was affixed to a Blood Sample Transmittal Form in order to track the blood samples from the field to the laboratory. Filter papers were dried overnight in a plastic drying box, after which the nurse packed them in individual Ziploc bags for that particular sample point. Blood samples were periodically collected in the field along with the completed questionnaires and transported to the GSS headquarters in Accra for logging in, after which they were taken to the Noguchi Memorial Institute for Medical Research (NMIMR) at Legon, for HIV testing. In preparation for carrying out the HIV testing, a consultant from the Kenya Medical Research Institute was contracted by ORC Macro to spend a couple of weeks at NMIMR to assess their equipment and staff capacity. In addition, an ORC Macro official worked with laboratory scientists at NMIMR to conduct a validation study and set up the dried blood spot methodology to test for HIV using two Enzyme-Linked Immunosorbent Assay (ELISA) tests from different manufacturers that would also allow for sero-typing. Introduction | 7 Several meetings with ORC Macro staff, NMIMR staff, and staff of GSS, were then held to discuss the monitoring of sample collection in the field, the collection of samples from the field, and the delivery of the samples to the laboratory, with built-in checks to verify the samples collected and delivered. It was also emphasized at the meeting that the period between the collecting of blood samples in the field and the time of refrigeration should not exceed 14 days. The DBS filter paper samples with bar codes were received by NMIMR. Upon receipt, the samples were counted and checked against the transmittal sheet to verify the bar code identifications and kept in a cold room at 4 degrees centigrade until testing was started in September. Samples were taken out of the cold room and kept for at least 30 minutes at room temperature before testing. One-quarter-inch disks were punched from the dried blot spots and were submerged in phosphate buffered saline and Tween 20 for overnight elution at 4 degrees centigrade. The following day, serum was eluted and appropriate dilutions were made according to the testing protocol for the test kits used in the GDHS. These dilutions were determined following the validation study on the same test kits for both the DBS and venous blood samples. Eluted serum was tested following the manufacturer’s recommendations for each of the test kits used in the GDHS. All specimens were tested with a screening test, Vironostika HIV Uni-Form Plus O (ELISA I). All samples positive on the first screening test as well as 10 percent of the negatives were further tested in parallel with Wellcozyme HIV-1 Recombinant and Murex HIV-2 (ELISA II) for serotyping. Results for all the ELISAs were obtained by relating the absorbance value or optical density (OD) of a specimen to the OD of the serum controls. According to the testing algorithm, samples positive on the first ELISA and positive on both the second ELISAs were regarded as postivie for HIV-1 and HIV-2; samples positive on the first ELISA and positive on Wellcozyme HIV-1 Recombinant and negative on Murex HIV-2 were categorized as positive for HIV-1; similarly, samples that were positive on the first ELISA and negative on Wellcozyme HIV-1 Recombinant and positive on Murex HIV-2 were categorized as positive for HIV-2. Samples negative on the first ELISA and negative on ELISAs for serotyping were regarded as negative. Samples that had discordant results on ELISA I and ELISA II were tested again with ELISA I and ELISA II. The results were obtained and interpreted in the same manner as indicated above for the repeat ELISA testing. Discordant samples from the repeat ELISAs, were tested with a confirmatory test, PEPTI-LAV 1-2. In addition, all samples that tested positive on ELISAs and samples whose repeat ELISA results were discordant were also tested with PEPTI-LAV 1-2. Samples with “grey zone” or discordant results on the two assays (i.e., repeat ELISA’s and PEPTI-LAV 1-2) were tested by immunoblotting (Western Blot) with NEW LAV-BLOT I and NEW LAV-BLOT II using appropriate interpretative criteria based on the test kit. There were some indeterminate samples from the first round of testing that were also included for immunoblotting. The result on immunoblotting (Western Blot) was regarded as the final result. 1.8 PRETEST, TRAINING, AND FIELDWORK 1.8.1 Pretest A pretest of the Household, Women’s, and Men’s questionnaires used in the GDHS was conducted in May 2003 in English and five major local languages. The pretest training was conducted by GSS staff for two weeks from 5-17 May 2003. In addition, nurses recruited from the Ghana Health Service were trained in testing for haemoglobin and collecting blood samples for HIV/AIDS. Five teams were formed to conduct the pretest. Each team consisted of a supervisor, four interviewers, and a nurse. Urban and rural areas were chosen for the pretest to get a better overall sense of the response level and acceptance of HIV/AIDS testing. The lessons learned from the pretest were used to finalize the survey instruments and logistical arrangements. 8 | Introduction 1.8.2 Training and Fieldwork A total of 102 interviewers, 23 nurses, and 12 data entry operators participated in the main survey training that took place from 6-27 July 2003. All participants were trained in interviewing techniques and the contents of the GDHS questionnaires. The training was conducted following the standard DHS training procedures, including class presentations, mock interviews, and tests using the Household, Women’s, and Men’s Questionnaires. All interviewers were trained in taking height and weight measurements. In addition to interviewer training, 23 persons (most of whom were nurses from the Ghana Health Service) were trained for a period of 10 days in anaemia testing, collection of blood samples for the HIV testing, and in informed consent procedures. An additional 20 interviewers were also trained in blood collecting techniques. In addition to in-class practice, the nurses were taken to the local health clinic to practice blood-collecting techniques on women, men, and children. Interviewers and nurses were selected based on their in-class participation, performance in the field practices, fluency in the Ghanaian languages, and assessment tests. The most experienced trainees, those who took part in the pretest, and those who did extremely well, were selected to be supervisors and editors. Trainees selected as supervisors and field editors were given an additional two-days training on how to supervise fieldwork and edit questionnaires. In addition, there was one standby supervisor and nine interviewers ready for relief assignment whenever necessary. Ten regional statisticians acted as regional coordinators, and GSS staff coordinated and supervised fieldwork activities. Fifteen teams were constituted for data collection. Each team was made up of a supervisor, an editor, a nurse, four interviewers, and a driver. Fieldwork lasted for three months from late July to late October. ORC Macro provided technical assistance on all aspects of the survey; staff from ORC Macro participated in field supervision of interviews, height and weight measurements, and blood sample collection. 1.9 DATA PROCESSING The processing of the GDHS results began shortly after the fieldwork commenced. Completed questionnaires were returned periodically from the field to the GSS headquarters in Accra, where they were entered and edited by data processing personnel who were specially trained for this task. Twelve data entry operators from GSS were trained for one week on data entry procedures using CSPro. All data were entered twice (100 percent verification). In addition, tables were run periodically to monitor the quality of the data collected. The concurrent processing of the data was an advantage for data quality because field coordinators were able to advise teams of problems detected during the data entry. The data entry and editing phase of the survey was completed in mid-December 2003. 1.10 RESPONSE RATES Table 1.2 shows response rates for the 2003 GDHS. Response rates are important because high non- response may affect the reliability of the results. A total of 6,628 households were selected in the sample, of which 6,333 were occupied at the time of fieldwork. The difference between selected and occupied households is largely due to structures being vacant or destroyed. Successful interviews were conducted in 6,251 households, yielding a response rate of 99 percent. Introduction | 9 In the households interviewed in the survey, a total of 5,949 eligible women age 15-49 were identified; interviews were completed with 5,691 of these women, yielding a response rate of 96 percent. In the same households, a total of 5,345 eligible men age 15-59 were identified and interviews were completed with 5,015 of these men, yielding a male response rate of 94 percent. The response rates are slightly lower for the urban than rural sample, and among men than women. The principal reason for non-response among both eligible women and men was the failure to find individuals at home despite repeated visits to the household. The lower response rate for men reflects the more frequent and longer absences of men from the household, principally related to their employment and life style. Response rates for the HIV testing component were lower than those for the interviews. Details of the HIV testing response rates are discussed in Chapter 13. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence ––––––––––––––––– Result Urban Rural Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Household interviews Households selected 2,720 3,908 6,628 Households occupied 2,571 3,762 6,333 Households interviewed 2,517 3,734 6,251 Household response rate 97.9 99.3 98.7 Interviews with women Number of eligible women 2,500 3,449 5,949 Number of eligible women interviewed 2,374 3,317 5,691 Eligible woman response rate 95.0 96.2 95.7 Interviews with men Number of eligible men 2,063 3,282 5,345 Number of eligible men interviewed 1,903 3,112 5,015 Eligible man response rate 92.2 94.8 93.8 Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter provides a descriptive summary of the social, economic, and demographic characteristics of households sampled in the survey with a focus on some basic background characteristics such as age, sex, education, place of residence, and socio-economic condition of households. This information is crucial for the interpretation of key demographic and health indicators from which to draw meaningful policies and programmes for intervention. This information is also a basis for gauging the representativeness of the survey. The basic characteristics of the sampled population, that is, age, sex, education, and place of residence, form the basis of the background information by which most key demographic and health indices are analysed throughout this report. New to the DHS in general, and the 2003 GDHS in particular, is the wealth quintile, which is an indicator of the level of wealth that is consistent with expenditure and income measures. The wealth quintile was constructed using information on household ownership of a number of consumer items, ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and type of material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardised in relation to a normal distribution with a mean of zero and standard deviation of one. Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural population. In the 2003 GDHS, a household is defined as a person or a group of persons, related or unrelated, who live together in the same house or compound, share the same housekeeping arrangements, and are catered for as one unit. The Household Questionnaire was used to collect information on all usual residents and visitors who spent the night preceding the survey in the household. This mode of data collection allows the analysis of either the de jure (usual residents) or de facto (those who are present at the time of the interview) populations. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important variables in analysing demographic trends. Table 2.1 presents the distribution of the de facto household population in the 2003 GDHS survey by five-year age groups, according to sex and urban-rural residence. Figure 2.1 and Table 2.1 show the population by sex for Ghana. The data show that there are slightly more women (53 percent) than men (47 percent) in the overall population. There is a slightly higher concentration of women in the urban than rural areas (55 and 51 percent). The age structure is typical of a young population characterised by high fertility. This type of population structure imposes a heavy burden on the social and economic assets of a country. Ghana’s population is still young, with 44 percent of the population under 15 years, with the percentage in the older age groups (65 years and above) constituting just 5 percent of the population. 12 | Household Population and Housing Characteristics Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 Age Male Percent Female GDHS 2003 Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Ghana 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban Rural Total ––––––––––––––––––––– –––––––––––––––––––– ––––––––––––––––––––– Age Male Female Total Male Female Total Male Female Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– <5 13.3 10.7 11.9 17.5 16.2 16.8 15.8 13.9 14.8 5-9 14.0 11.8 12.8 17.5 15.0 16.2 16.1 13.6 14.8 10-14 16.1 12.8 14.3 16.9 13.3 15.0 16.6 13.1 14.7 15-19 11.5 11.5 11.5 9.0 7.5 8.2 10.0 9.3 9.6 20-24 7.8 10.1 9.1 5.0 6.8 5.9 6.2 8.2 7.2 25-29 8.0 8.3 8.2 5.6 7.1 6.4 6.6 7.6 7.1 30-34 6.4 6.7 6.5 5.0 6.1 5.6 5.5 6.4 6.0 35-39 4.9 5.9 5.4 4.3 5.8 5.1 4.5 5.9 5.2 40-44 3.6 4.6 4.2 3.7 4.4 4.0 3.7 4.5 4.1 45-49 3.7 3.8 3.7 4.0 3.5 3.7 3.9 3.6 3.7 50-54 2.7 3.7 3.3 2.5 3.9 3.2 2.6 3.8 3.3 55-59 1.7 2.4 2.1 1.7 2.6 2.1 1.7 2.5 2.1 60-64 2.3 2.3 2.3 2.1 2.3 2.2 2.2 2.3 2.3 65-69 1.5 1.5 1.5 1.9 1.6 1.7 1.7 1.6 1.6 70-74 1.1 1.7 1.4 1.3 1.5 1.4 1.2 1.6 1.4 75-79 0.7 0.7 0.7 0.9 1.0 0.9 0.8 0.8 0.8 80 + 0.6 1.3 1.0 0.9 1.3 1.1 0.8 1.3 1.0 Don't know/missing 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,575 5,539 10,115 6,925 7,326 14,250 11,500 12,865 24,365 Household Population and Housing Characteristics | 13 Data from the GDHS show an excess of males in the 10-14 age group, and a deficit in the 20-24 and 40-44 age groups. The excess of males in the 10-14 age group could be the effect of age shifting by interviewers in the DHS, out of the eligible age range (15-59) for the individual interviews, to reduce their workload. This effect is also obvious for females in the 50-54 age group, who are not eligible for the individual interview. The deficit of males in the 20-24 and 40-44 age groups is also reflected in the 2000 Census (GSS, 2002), and may be attributable to differential outmigration of males in search of jobs. 2.2 HOUSEHOLD COMPOSITION The size and composition of households and the sex of the head of household are important aspects that impact on household welfare. Table 2.2 shows information collected in the 2003 GDHS on sex composition and household size. The mean household size is 4.0, with household size in rural areas (4.3) larger than in urban areas (3.6). Two-thirds (66 percent) of households are headed by males, while a third (34 percent) are headed by females. The percentage of female-headed households is higher in urban (40 percent) than in rural areas (29 percent). Single-person households are more common in urban (25 percent) than rural areas (18 percent). This may be due to an influx of unmarried young persons migrating to urban areas in search of employment or to further their education. Table 2.2 Household composition Percent distribution of households by sex of head of house- hold and by household size, according to residence, Ghana 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––– Residence ––––––––––––––––– Characteristic Urban Rural Total –––––––––––––––––––––––––––––––––––––––––––––––––––– Sex of head of household Male 60.3 71.1 66.2 Female 39.7 28.9 33.8 Total 100.0 100.0 100.0 Number of usual members 1 24.5 17.5 20.7 2 14.2 11.3 12.6 3 14.2 13.1 13.6 4 15.4 14.5 14.9 5 11.4 13.6 12.6 6 8.3 10.6 9.5 7 5.3 7.9 6.7 8 2.7 4.3 3.6 9+ 4.0 6.9 5.6 Total 100.0 100.0 100.0 Number of households 2,870 3,381 6,251 Mean size 3.6 4.3 4.0 –––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Table is based on de jure members, i.e., usual resi- dents. 14 | Household Population and Housing Characteristics 2.3 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Education is important in that it helps individuals to make informed decisions that impact their health and well-being. Ghana’s system of education has undergone several stages of restructuring over the past 25 years (Sedgwick, 2000). The current system of formal education was introduced in 1989. It is based on a three-tier system: six years of primary education, followed by three years of junior secondary school (JSS), and a further three years at the senior secondary school (SSS) level. From the mid-1970s till the introduction of the current system of education, the six years of primary education was followed by five years of secondary education―three years of JSS and two years of SSS. Prior to the mid-1970s, students who completed six years of primary education had a choice. They could attend four years of middle school or attend five years of secondary school with a small group having the further option to pursue an additional two years of pre-university education. Upon completion of formal schooling, a student could choose to further his or her education at the tertiary level. In addition to university education, there are a host of institutions offering vocational, technical, and professional training that may be tertiary or non-tertiary. The different systems of formal education have been taken into account in tabulating the educational attainment of women and men interviewed in the 2003 GDHS. Table 2.3.1 shows the percent distribution of the de facto female household population age six years and over by highest level of education attended or completed, according to background characteristics. Thirty-seven percent of women have never been to school, about 30 percent have some primary or have completed primary school, 31 percent have some secondary or have completed secondary school, and about 2 percent have more than secondary school education. The data reveal that the proportion of women with no education is higher among older women, suggesting some improvement in education over the years. This may be due to the impact of the Free Compulsory Universal Basic Education (fCUBE) programme introduced in 1996. Education varies by place of residence. Urban women are more likely to be educated than rural women. For example, 26 percent of urban females have no education, compared with 47 percent of rural females. The proportion of urban females with some secondary education or higher (47 percent) is more than twice as high as that of rural females (21 percent). It is notable that females in the northern half of the country (Northern, Upper East, and Upper West regions) are seriously disadvantaged educationally. More than two-thirds of women in these regions have never been to school, compared with one-fifth in the Greater Accra region. In addition, 13 percent of females in Greater Accra have completed secondary education or higher, compared with less than 2 percent in the Northern and Upper West regions. With the exception of the three northern regions, the majority of females in all regions have been to school. It is worth noting that the proportion of female household members who have never attended school decreases with higher wealth status. Sixty-five percent of women in the lowest wealth quintile have no education compared with only 15 percent in the highest quintile. Table 2.3.2 shows that 26 percent of males have never been to school, 33 percent have had some primary or have completed primary education, 37 percent have had some secondary or completed secondary education, and about 4 percent have more than secondary education. One-third of males in rural areas have no education compared with only 15 percent in urban areas. There is a marked urban- rural differential in secondary and higher education: 16 percent of males in urban areas have completed secondary or higher education compared with only 4 percent in rural areas. Household Population and Housing Characteristics | 15 Table 2.3.1 Educational attainment of household population: women Percent distribution of the de facto female household population age six and over by highest level of education attended or completed, according to background characteristics, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– More Median Some than Don’t years Background No Some Completed secon- Completed secon- know/ of characteristic education primary primary1 dary secondary2 dary missing Total Number schooling ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 6-9 47.5 51.6 0.0 0.0 0.0 0.0 0.9 100.0 1,457 0.0 10-14 15.2 65.0 6.3 13.3 0.0 0.0 0.3 100.0 1,685 3.0 15-19 14.7 15.3 7.5 58.3 3.9 0.1 0.1 100.0 1,191 6.8 20-24 21.6 11.8 6.3 44.8 11.5 3.9 0.0 100.0 1,053 8.0 25-29 33.9 11.3 6.1 36.5 9.8 2.3 0.1 100.0 981 5.7 30-34 35.5 13.1 4.5 41.0 2.6 3.3 0.0 100.0 821 5.3 35-39 41.6 14.2 5.7 33.6 2.7 2.2 0.1 100.0 756 3.0 40-44 35.3 12.9 3.9 41.6 3.0 2.6 0.7 100.0 577 5.4 45-49 40.2 15.4 2.0 37.5 0.7 4.0 0.1 100.0 465 3.3 50-54 61.3 8.5 2.6 23.5 0.4 2.6 1.1 100.0 492 0.0 55-59 68.0 9.3 1.4 16.4 1.1 2.5 1.4 100.0 320 0.0 60-64 81.1 3.7 2.6 11.2 0.0 1.0 0.4 100.0 297 0.0 65+ 86.6 5.2 0.2 6.6 0.3 0.9 0.4 100.0 674 0.0 Residence Urban 25.9 22.5 4.6 38.1 5.8 2.8 0.4 100.0 4,841 5.3 Rural 46.8 27.8 4.0 19.5 0.9 0.6 0.4 100.0 5,944 0.0 Region Western 29.5 30.8 5.7 29.0 2.8 2.0 0.1 100.0 960 3.3 Central 39.1 29.1 4.6 23.7 2.2 1.2 0.2 100.0 904 1.6 Greater Accra 20.3 21.9 4.6 40.1 9.2 3.6 0.2 100.0 1,547 6.4 Volta 31.2 33.0 4.8 26.9 2.3 1.6 0.3 100.0 1,023 2.5 Eastern 29.6 27.0 6.2 32.4 1.9 2.2 0.6 100.0 1,166 3.7 Ashanti 28.3 25.7 4.1 37.7 2.7 1.1 0.4 100.0 2,154 4.1 Brong Ahafo 37.0 27.5 5.2 27.4 1.8 0.6 0.4 100.0 1,061 2.4 Northern 74.4 16.4 1.3 6.2 0.9 0.7 0.1 100.0 989 0.0 Upper East 71.1 18.3 1.1 6.7 1.3 1.0 0.6 100.0 661 0.0 Upper West 66.1 19.2 2.8 8.7 1.5 0.3 1.3 100.0 321 0.0 Wealth quintile Lowest 65.1 22.7 2.5 8.8 0.2 0.1 0.6 100.0 1,992 0.0 Second 47.2 29.6 3.8 18.4 0.4 0.2 0.4 100.0 2,046 0.0 Middle 36.5 28.9 5.5 27.4 1.2 0.2 0.3 100.0 2,172 2.1 Fourth 28.0 26.3 5.4 35.9 3.2 0.9 0.3 100.0 2,204 4.1 Highest 15.4 20.1 3.9 44.8 9.5 6.0 0.3 100.0 2,372 7.9 Total 37.4 25.4 4.3 27.8 3.1 1.6 0.4 100.0 10,785 2.1 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 13 women with missing information on age who are not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Across the regions the pattern among the male population is similar to that exhibited by the females. Males in the three northern regions are disadvantaged, with 54-59 percent never having been to school compared with less than 20 percent in the other regions, except Brong Ahafo (24 percent) and the Central (21 percent) regions. The variation in education among the male population according to wealth quintile is similar to that among the female population. Wealthy males are less likely to have no education. For example, 7 percent of males in the highest wealth quintile have no education compared with 53 percent in the lowest. 16 | Household Population and Housing Characteristics Table 2.3.2 Educational attainment of household population: men Percent distribution of the de facto male household population age six and over by highest level of education attended or com- pleted, according to background characteristics, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– More Some than Don’t Median Background No Some Completed secon- Completed secon- know/ years of characteristic education primary primary1 dary secondary2 dary missing Total Number schooling ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 6-9 45.2 53.6 0.1 0.1 0.0 0.0 1.0 100.0 1,544 0.0 10-14 14.8 67.7 6.1 11.1 0.0 0.0 0.3 100.0 1,907 2.7 15-19 9.3 18.9 7.9 60.8 3.7 0.0 0.1 100.0 1,148 6.9 20-24 12.9 8.7 5.6 50.5 17.6 4.7 0.0 100.0 707 8.4 25-29 15.6 9.1 4.7 43.6 16.3 10.3 0.3 100.0 758 8.5 30-34 21.4 7.5 4.0 48.5 13.1 5.2 0.5 100.0 634 9.0 35-39 25.4 8.4 4.1 46.7 7.7 6.6 1.1 100.0 522 9.1 40-44 24.4 6.3 2.1 50.9 6.8 9.3 0.3 100.0 420 9.3 45-49 26.3 9.0 4.2 45.9 6.0 8.5 0.2 100.0 445 9.2 50-54 25.7 7.6 3.5 48.2 4.8 9.3 0.9 100.0 301 9.1 55-59 34.7 5.6 3.2 35.9 4.7 15.4 0.6 100.0 197 9.0 60-64 52.7 8.2 3.3 27.6 3.5 4.1 0.5 100.0 253 0.0 65+ 66.3 6.8 1.7 20.6 2.1 2.3 0.2 100.0 523 0.0 Residence Urban 15.2 25.5 4.4 38.1 9.7 6.6 0.5 100.0 3,865 6.9 Rural 33.3 31.4 4.0 26.9 2.5 1.5 0.4 100.0 5,511 2.2 Region Western 14.5 32.5 6.8 37.3 5.9 2.9 0.0 100.0 817 5.4 Central 21.0 34.4 3.7 35.1 2.6 3.2 0.0 100.0 719 4.1 Greater Accra 12.8 21.9 3.7 37.0 15.4 8.4 0.8 100.0 1,194 8.5 Volta 18.0 30.7 5.2 37.5 3.6 4.7 0.3 100.0 825 5.2 Eastern 18.9 28.0 6.7 37.9 3.2 4.6 0.8 100.0 1,031 5.4 Ashanti 16.4 29.1 3.0 43.0 5.6 2.4 0.4 100.0 1,773 5.8 Brong Ahafo 23.5 34.6 4.3 29.4 4.6 3.4 0.2 100.0 1,020 3.6 Northern 58.6 25.3 2.2 9.0 3.2 1.4 0.2 100.0 1,060 0.0 Upper East 54.1 28.3 3.8 10.2 1.6 0.6 1.3 100.0 651 0.0 Upper West 54.2 26.3 2.6 11.3 2.5 2.8 0.4 100.0 286 0.0 Wealth quintile Lowest 52.6 28.8 3.4 12.8 1.1 0.6 0.7 100.0 1,865 0.0 Second 30.4 35.3 4.8 26.6 1.7 0.7 0.5 100.0 1,899 2.3 Middle 22.5 33.4 5.0 35.3 2.3 1.1 0.3 100.0 1,911 3.8 Fourth 16.5 26.1 4.6 40.7 7.4 4.4 0.3 100.0 1,855 6.3 Highest 7.0 20.8 3.0 42.4 15.1 11.3 0.4 100.0 1,846 8.9 Total 25.9 29.0 4.2 31.5 5.5 3.6 0.4 100.0 9,376 3.9 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Total includes 18 men with missing information on age who are not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Men are more educated than women at all levels of education, implying that females continue to lag behind males in education. The median number of years of schooling completed is twice as high among men (3.9 years) as among women (2.1 years). It is disappointing to note that the level of education has deteriorated over the last five years for both women and men. The proportion of women with no education rose from 34 percent in 1998 (GSS and MI, 1999) to 37 percent in 2003, with the median number of years of schooling falling slightly from 2.3 to 2.1 over the five years. Similarly, the proportion Household Population and Housing Characteristics | 17 of men with no education rose from 21 percent (GSS and MI, 1999) to 26 percent with the median number of years of schooling falling from 4.9 to 3.9 over the last five years. Nevertheless, the male- female gap in educational attainment has narrowed over the same period. The 2003 GDHS collected information on school attendance among the population 6-24 years that allows the calculation of net attendance ratios (NARs) and gross attendance ratios (GARs). The NAR for primary school is the percentage of the primary-school-age (6-11 years) population that is attending primary school. The NAR for secondary school is the measure of the secondary-school-age (12-18 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR however, measures participation at each level of schooling among persons age 6-24. The GAR is almost always higher than the NAR for the same level because the GAR includes participation by those who may be older, because they may have started school late, may have repeated one or more grades in school, or may have dropped out of school and later returned, or may be younger than the official age range for that level. Table 2.4 presents data on NAR and GAR for the de jure household population by level of schooling and sex, according to place of residence and wealth quintile. Sixty percent of children age 6-11, who should be attending primary school, are currently doing so. At the same time, the GAR at the primary school level is 95 percent, indicating that more than a third (35 percent) of young Ghanaians attending primary school are above or below primary school age. Not surprisingly, both the NAR and GAR are much lower at the secondary than at the primary school level. Slightly more than one-third of students age 12-18 who should be attending secondary school are in school at that level. The GAR for secondary school is 41 percent, indicating that the proportion of underage or overage youths in secondary school is not so large. The results show similar proportions of NAR for females and males at primary and secondary school level, indicating that there is no gender gap in school attendance among the Ghanaian school age population who should be attending school at a given level. However, the GARs at primary and secondary school levels are slightly higher for males than females, indicating a relatively higher overage or underage attendance among males than females. As expected, school attendance ratios at both the primary and secondary levels are lower in rural than in urban areas. For instance, the NAR at the primary school level in rural areas is 56 percent compared with 68 percent in urban areas. Similarly, the GAR at secondary school is 31 percent in rural areas compared with 53 percent in urban areas. Regional differences are obvious for the NAR and GAR with attendance ratios notably lower among the three northern regions (Northern, Upper East, and Upper West) compared with all other regions, and especially in the case of the GAR at the primary school level. There is a strong relationship between household economic status and school attendance that can be seen at both the primary and secondary levels and among males and females. For example, the NAR increases from 43 percent among students from poorer households (lowest wealth quintile) in primary school to 78 percent among students from richer households (highest wealth quintile). Similarly, the GAR rises three-fold from 20 percent among secondary school attendees in the lowest wealth quintile to 63 percent among those in the highest wealth quintile. The Gender Parity Index (GPI) represents the ratio of the GAR for females to the GAR for males. It is presented at both the primary and secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI less than 1 indicates that a smaller proportion of females than males attend school. In Ghana, the GPI is slightly less than 1 (0.9) for both primary and secondary school attendance, indicating that the gender gap is relatively small. There are no marked differences in the GPI by place of residence. The Northern Region has the widest gap (0.8) for primary school attendance and the Brong Ahafo Region has the widest gap (0.7) for secondary school attendance. 18 | Household Population and Housing Characteristics Table 2.4 School attendance ratios Net attendance ratios (NAR), gross attendance ratios (GAR), and gender parity index for the de jure household population by level of schooling and sex, according to background characteristics, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Net attendance ratio1 Gross attendance ratio2 Gender Background –––––––––––––––––––––––––– ––––––––––––––––––––––––– parity characteristic Male Female Total Male Female Total index3 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PRIMARY SCHOOL ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 69.9 66.7 68.3 110.0 100.4 105.2 0.91 Rural 56.2 55.2 55.8 92.0 86.8 89.6 0.94 Region Western 70.6 68.2 69.4 109.3 102.8 106.1 0.94 Central 61.3 60.6 61.0 98.5 99.5 99.0 1.01 Greater Accra 72.3 71.1 71.7 108.9 102.9 105.9 0.95 Volta 60.7 66.1 63.5 106.9 107.0 106.9 1.00 Eastern 58.9 60.9 59.8 99.6 92.0 96.1 0.92 Ashanti 69.0 65.9 67.5 104.8 98.5 101.7 0.94 Brong Ahafo 66.3 56.5 62.0 119.8 109.0 115.1 0.91 Northern 47.4 39.5 43.8 70.8 55.1 63.7 0.78 Upper East 42.4 46.4 44.2 70.3 61.0 66.0 0.87 Upper West 41.9 41.2 41.5 74.9 68.2 71.5 0.91 Wealth quintile Lowest 43.8 41.8 42.9 72.6 66.7 69.9 0.92 Second 57.9 53.6 55.9 100.9 89.4 95.5 0.89 Middle 66.0 62.4 64.4 107.9 101.3 104.8 0.94 Fourth 67.6 68.3 67.9 109.2 101.5 105.4 0.93 Highest 78.9 77.0 77.9 109.2 105.7 107.4 0.97 Total 61.0 59.6 60.4 98.4 92.0 95.4 0.94 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– SECONDARY SCHOOL ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Urban 45.4 44.8 45.1 55.3 50.1 52.6 0.90 Rural 26.8 25.9 26.4 33.0 28.3 30.8 0.86 Region Western 36.8 41.9 39.3 41.9 44.3 43.1 1.06 Central 34.3 30.5 32.4 39.6 34.9 37.2 0.88 Greater Accra 47.7 48.6 48.2 59.2 56.6 57.7 0.96 Volta 36.2 35.4 35.8 50.5 38.7 44.6 0.77 Eastern 37.8 35.6 36.8 45.8 37.2 41.6 0.81 Ashanti 42.8 39.2 40.9 48.1 42.2 45.1 0.88 Brong Ahafo 32.8 26.6 30.0 40.5 29.9 35.7 0.74 Northern 17.4 15.8 16.7 24.6 19.2 22.4 0.78 Upper East 16.5 23.2 19.4 24.1 26.6 25.2 1.11 Upper West 20.2 22.5 21.2 27.4 26.4 27.0 0.96 Wealth quintile Lowest 15.4 15.2 15.3 22.1 17.0 19.8 0.77 Second 27.3 19.7 23.9 33.6 21.5 28.2 0.64 Middle 34.5 34.7 34.6 40.8 36.7 38.8 0.90 Fourth 40.4 42.3 41.4 51.0 47.1 49.0 0.92 Highest 57.5 53.6 55.3 66.6 60.8 63.3 0.91 Total 34.6 35.0 34.8 42.4 38.8 40.6 0.91 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 The NAR for primary school is the percentage of the primary-school age (6-11 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (12-18 years) population that is at- tending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official pri- mary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage stu- dents at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school GAR for females to the GAR for males. The Gender Parity Index for secondary school is the ratio of the secondary school GAR for females to the GAR for males. Household Population and Housing Characteristics | 19 Figure 2.2 shows the age-specific attendance rates (ASAR) for the de jure household population age 6-24 by sex. The ASAR shows participation in schooling at any level, from primary through higher education. The closer the ASAR is to 100, the higher the participation of a given age population at that level. Less than 50 percent of children age seven and below are attending school. School attendance rises markedly up to age 11, remains high up to age 14, and then gradually declines. There are no marked differences in the proportion of males and females attending school up to age 15, after which there are significantly higher proportions of males than females attending school. Figure 2.2 Age-Specific Attendance Rates 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Male Female GDHS 2003 2.4 HOUSING CHARACTERISTICS There is a strong correlation between the socio-economic condition of households and the vulnerability of its members, and especially children, to common diseases. The amenities and assets available to households are important in determining the general socio-economic status of the population. The GDHS included questions on a household’s access to electricity, source of drinking water, type of sanitation facilities, flooring materials, and ownership of durable goods. Table 2.5 presents the distribution of households by household characteristics, according to residence. One in two households in Ghana has electricity. Three-fourths of households in urban areas (77 percent) have electricity compared with one-fourth (24 percent) of rural households. The 2003 data show an increase in the use of electricity among rural households over the last five years (GSS and MI, 1999), while access to electricity in urban households has declined over the same time period. The decline in the use of electricity by urban households may be attributed to the rapid development in housing projects, some of which are not yet connected to the national power grid. The availability of and accessibility to potable water may, to a large extent, minimise the prevalence of water-borne diseases among household members, especially young children. The source of drinking water is important because potentially fatal diseases, such as diarrhoeal diseases, guinea worm, bilharzia, typhoid, cholera, and dysentery, are common in the country. The main sources of drinking water are piped, protected well or borehole, and rivers or streams. Sixteen percent of households have 20 | Household Population and Housing Characteristics access to piped water in their dwelling, yard or plot, while 23 percent access drinking water from a public tap. Twelve percent of households get their drinking water from open wells, and 28 percent obtain drinking water from protected wells or boreholes. Fourteen percent of households obtain drinking water from rivers and streams. Not surprisingly, rural households have less access to clean drinking water than urban households. For example, one in three urban households have piped water in their dwelling, yard or plot, compared with 2 percent of rural households. The major source of drinking water for rural households is a well or borehole. For example, two-fifths of rural households get their drinking water from a protected public well or borehole, compared with one-tenth of urban households. The overall access to piped drinking water has remained the same over the last five years (GSS and MI, 1999). It takes eight in ten urban households and about half of rural households less than 15 minutes to reach their nearest source of drinking water. The median time to source in urban households is 4 minutes compared with 14 minutes among rural households. The vast majority of households have access to water all the time. Rural households are more likely than urban households to have access to water all the time. The availability of toilet facilities in households ensures a more efficient and hygienic method of human waste disposal. Most households in Ghana (42 percent) have traditional pit latrines, 26 percent have improved ventilated pit latrines (KVIP), and 11 percent have flush toilets. One-fifth of households have no toilet facility. Lack of a toilet facility is more common in rural areas (31 percent) than in urban areas (7 percent). Two-fifths of urban households have KVIP toilets, compared with 14 percent of households in rural areas. Traditional pit toilets are twice as common in rural areas (54 percent) as in urban areas (27 percent). Flush toilets are more common in urban households Table 2.5 Household characteristics Percent distribution of households by household characteristics, according to residence, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Household ––––––––––––––––– characteristic Urban Rural Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Electricity Yes 76.9 24.1 48.3 No 23.1 75.8 51.6 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Source of drinking water Piped into dwelling 11.5 0.7 5.7 Piped into compound/plot 21.9 1.2 10.7 Public tap 39.1 8.9 22.8 Open well in dwelling/yard 2.5 1.3 1.9 Open public well 5.9 12.8 9.6 Protected well in dwelling/yard 2.4 1.7 2.0 Protected public well 7.8 41.1 25.8 Spring 0.3 0.9 0.6 River, stream 2.0 24.3 14.1 Pond, lake 0.5 2.4 1.5 Dam 0.1 3.7 2.0 Rainwater 0.5 0.2 0.3 Tanker truck 2.3 0.4 1.3 Satchel water 3.0 0.3 1.5 Other 0.4 0.0 0.2 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Time to water source Percentage <15 minutes 79.8 46.5 61.8 Median time to source 4.3 14.3 9.4 Water availability All the time 75.9 91.9 84.5 Several hours per day 11.4 4.8 7.8 A few times a week 9.1 1.7 5.1 Less frequently 2.7 1.0 1.8 Not at all 0.7 0.4 0.5 Don’t know 0.1 0.0 0.1 Missing 0.1 0.2 0.2 Total 100.0 100.0 100.0 Sanitation facility Flush toilet 21.2 1.7 10.7 Traditional pit toilet 26.7 54.0 41.5 Ventilated improved pit latrine 40.8 13.5 26.0 No facility, bush, field 6.7 30.6 19.6 Bucket, pan 4.5 0.2 2.2 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Sharing toilet facilities No 14.6 8.6 11.4 Yes 78.5 60.8 68.9 No facility 6.7 30.6 19.6 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Flooring material Earth/sand/mud 3.2 17.8 11.1 Mud mixed with dung 0.1 2.4 1.3 Wood/palm/bamboo/parquet 0.4 0.1 0.2 Linoleum 19.5 5.7 12.0 Ceramic tiles/terrazo 3.9 0.3 2.0 Cement 54.5 71.5 63.7 Carpet 18.4 2.1 9.6 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Continued… Household Population and Housing Characteristics | 21 (21 percent) than in rural households (2 percent). Access to flush toilets has risen over the last five years, from 8 percent in 1998 (GSS and MI, 1999) to 11 percent in 2003. The majority of households (69 percent) share toilet facilities with one or more households. The type of flooring material used in dwellings is a proxy indicator of the socio- economic status of the household as well as its likely exposure to disease-causing agents. Most households in Ghana (87 percent) have finished floors (terrazzo, tiles, cement, carpet, and linoleum), with only 12 percent of households having rudimentary or natural flooring material (earth, sand, mud or mud mixed with dung). There has been little change over the last five years in the percentage of households with finished flooring. Rural households are much more likely to have cement floors (72 percent) than urban households (55 percent). The second most common flooring material in rural areas is earth, sand, or mud (18 percent). About one-fifth of urban households have linoleum floors and almost the same proportion have carpeted floors. Two common sources of cooking fuel in the country are firewood (59 percent) and charcoal (30 percent). One in four urban households uses firewood, while 87 percent of rural households depend on firewood as their main source of cooking fuel. On the other hand, more than 50 percent of urban households use charcoal compared with 10 percent of rural households. Liquified petroleum gas (LPG) or natural gas is used more commonly by urban households (15 percent) than households in rural areas (1 percent). However, even in urban areas, few households use electricity for cooking (1 percent), presumably because of the higher cost. The GDHS also included questions pertaining to disposal of household waste, possibility of eviction, and membership in mutual health organisations (MHO) or health insurance schemes (HIS). Data on these are also shown in Table 2.5. The majority of households (62 percent) dispose of their household waste in the street or an empty plot, with a much higher proportion of rural households than urban households disposing of household waste in this manner. Fourteen percent of households have their waste collected by the government and this is predominantly done in urban areas. Seven percent of households burn their waste, 4 percent have their waste collected by a community association, 4 percent dump it in their compound, while 3 percent each bury or compost their household waste. When asked about the possibility of eviction, most household respondents said that this was not likely at all (71 percent). Twelve percent of households mentioned that it was very likely that they could Table 2.5—Continued ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Household ––––––––––––––––– characteristic Urban Rural Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Cooking fuel Electricity 0.6 0.1 0.3 LPG, natural gas 14.6 1.4 7.4 Biogas 0.7 0.0 0.3 Kerosene 1.3 0.4 0.8 Coal, lignite 0.7 0.0 0.3 Charcoal 54.1 10.1 30.3 Firewood, straw 25.6 87.4 59.0 Dung 0.0 0.1 0.1 Other 2.3 0.4 1.3 Total 100.0 100.0 100.0 Disposal of household waste Collected by government 30.6 0.4 14.2 Collected by community assoc. 4.2 3.9 4.0 Collected by private company 4.8 0.3 2.3 Dumped in compound 2.5 5.9 4.3 Dumped in street/empty plot 47.3 74.0 61.7 Burned 7.7 6.4 7.0 Buried 2.5 3.5 3.0 Composted 0.2 5.3 3.0 Other 0.2 0.1 0.1 Missing 0.1 0.2 0.3 Total 100.0 100.0 100.0 Possibility of eviction Very likely 21.0 4.9 12.3 Somewhat likely 20.7 10.9 15.4 Not at all likely 56.7 83.6 71.3 Don’t know 1.5 0.6 1.0 Total 100.0 100.0 100.0 Member of HIS Yes 3.5 2.8 3.1 No 95.9 96.3 96.2 Don’t know 0.6 0.8 0.7 Missing 0.0 0.2 0.1 Total 100.0 100.0 100.0 Number of households 2,870 3,381 6,251 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– HIS = Health Insurance Scheme 22 | Household Population and Housing Characteristics be evicted, while 15 percent of households mentioned that it was somewhat likely. Urban households are more likely to report that they face possible eviction than rural households. A very small percentage of households in Ghana (3 percent) belong to an HIS. Among those who belong to an HIS, the majority belong to an MHO (43 percent) or have government health coverage (20 percent), with 29 percent belonging to a private health insurance scheme (data not shown). About half of those who belong to any kind of insurance scheme mentioned that they have benefited from it in the past, and a large majority (91 percent) of those who are not members of an insurance scheme indicate that they would consider joining one in the future (data not shown). 2.6 HOUSEHOLD DURABLE GOODS Respondents were asked about ownership of particular household goods such as radios and television sets (access to media), refrigerators (access to food storage), telephones (access to other means of communication), and modes of transport (bicycle, motorcycle, car, or truck). Ownership of these items is also indicative of the household’s social and economic well-being. Table 2.6 presents data on the percentage of households possessing various durable consumer goods, by residence. The results show that 71 percent of households own a radio, 26 percent have a television, 23 percent have bicycles, and 19 percent own refrigerators. It is striking to note that nearly one in four households possess none of the durable items identified. There has been a noticeable rise in ownership of consumer durable goods over the last five years, with the most marked increase in the ownership of refrigerators, which increased from 2 percent in 1998 (GSS and MI, 1999) to 19 percent in 2003. Table 2.6 Household durable goods Percentage of households possessing various durable consumer goods, by residence, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence ––––––––––––––––– Durable consumer goods Urban Rural Total ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Radio 76.1 66.6 71.0 Television 44.9 9.9 26.0 Telephone 14.3 0.7 6.9 Refrigerator 34.6 5.5 18.8 Video deck 20.6 2.2 10.6 Bicycle 16.0 29.1 23.1 Motorcycle 2.6 1.7 2.1 Car/truck 9.0 2.4 5.4 Tractor 0.4 0.2 0.3 Horse/cart 0.3 1.4 0.9 None of the above 18.3 27.1 23.1 Number of households 2,870 3,381 6,251 Sixty-seven percent of households in rural areas have a radio. Smaller proportions, however, own consumer items such as televisions, telephones, refrigerators, and cars. Twenty-nine percent of rural households own bicycles, compared with 16 percent of urban households. Televisions, refrigerators, telephones, and cars or trucks are mostly restricted to urban areas, presumably due to the lack of electricity or affordability in rural areas. Characteristics of Survey Respondents | 23 CHARACTERISTICS OF SURVEY RESPONDENTS 3 The purpose of this chapter is to provide a descriptive summary of the demographic and socio- economic profile of respondents in the 2003 GDHS. This basic information on women and men in the reproductive age group is crucial for the interpretation of the 2003 GDHS findings within the context of reproduction, health, and women’s status and empowerment. The percent distribution of respondents by the various demographic and socio-economic characteristics can also be used as an approximate indicator of the representativeness of the survey sample to the general population. The main background characteristics described in detail that will be used in subsequent chapters on reproduction and health are: age at the time of the survey, marital status, residence, education, and wealth quintiles. This chapter also includes information on literacy, exposure to mass media, employment and earnings, and women’s position and decisionmaking power in relation to others in the household. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 shows data on the background characteristics of the 5,691 female respondents age 15- 49 and the 5,015 male respondents age 15-59, interviewed in the 2003 GDHS, by background characteristics, including age, marital status, urban-rural residence, region, education, religion, and ethnicity. The age distribution shows that more than one in two females (55 percent) and males (51 percent) are under age 30. The proportion in each age group tends to decrease with increasing age for both sexes. The data show that most of the respondents are currently married or living together, although the proportion of women (62 percent) who are married or living together is higher than men (53 percent). Four in ten men (41 percent) have never married, compared with only about three in ten women (28 percent). Nine percent of women and 6 percent of men are divorced, separated, or widowed. The distribution of respondents by urban-rural residence shows that men are slightly more likely to live in rural areas (55 percent) than women (52 percent). By region, the distribution of respondents varies markedly. For example, about one-fifth of respondents are from the Ashanti Region, about one- sixth are from Greater Accra, and about one-tenth each are from the Western, Eastern, Brong Ahafo, and Northern regions. Less than 3 percent of women and men are from the Upper West Region. Twenty-eight percent of women and 18 percent of men have no education. About one-fifth of women and one-sixth of men have only primary education and two-fifths have only middle/JSS level of education. Men are twice as likely to have attained the secondary level of education as women (23 and 12 percent, respectively). The majority of respondents are Christians―77 percent of women and 70 percent of men. Sixteen percent of women and 19 percent of men are Moslems. The ethnic composition shows that Akans are the predominant group, with 51 percent of women and 47 percent of men, followed by the Mole Dagbon (13 percent of women and 18 percent of men). 24 | Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percentage distribution of women and men by background characteristics, Ghana 2003 Number of women Number of men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 20.2 1,148 1,113 22.1 1,107 1,095 20-24 17.8 1,012 997 13.6 684 692 25-29 16.7 951 966 15.0 754 727 30-34 14.1 802 818 12.6 633 633 35-39 12.7 722 724 9.9 498 518 40-44 10.2 579 572 8.2 412 411 45-49 8.4 477 501 8.8 441 441 50-54 na na na 5.9 294 300 55-59 na na na 3.8 192 198 Marital status Never married 28.4 1,616 1,509 40.7 2,042 2,002 Married 54.2 3,087 3,273 48.6 2,439 2,514 Living together 8.1 462 421 4.6 233 212 Divorced/separated 7.3 416 368 5.4 272 257 Widowed 1.9 110 120 0.6 29 30 Residence Urban 48.4 2,755 2,374 44.9 2,250 1,903 Rural 51.6 2,936 3,317 55.1 2,765 3,112 Region Western 9.7 553 524 9.5 476 457 Central 7.6 431 352 7.4 370 300 Greater Accra 16.6 942 835 14.6 733 621 Volta 8.6 492 442 8.8 440 386 Eastern 10.6 601 506 10.7 539 453 Ashanti 20.1 1,142 927 19.1 956 785 Brong Ahafo 10.0 569 638 10.5 528 593 Northern 8.8 499 610 10.5 527 638 Upper East 5.4 310 395 6.3 317 395 Upper West 2.7 153 462 2.6 130 387 Education No education 28.2 1,608 1,917 17.6 881 1,118 Primary 20.0 1,135 1,112 16.0 803 857 Middle/JSS 40.0 2,279 2,044 43.2 2,165 1,967 Secondary+ 11.8 669 618 23.2 1,165 1,073 Religion Roman Catholic 13.9 788 905 14.6 731 794 Anglican/Methodist/Presbyt. 17.8 1,016 907 15.9 799 709 Other Christian 45.6 2,597 2,352 39.4 1,978 1,785 Moslem 15.6 887 1,013 18.7 939 1,050 Traditional/spiritualist 2.7 152 210 4.7 238 317 No religion 4.4 250 302 6.5 327 355 Other/Missing 0.0 1 2 0.0 4 5 Ethnicity Akan 50.7 2,885 2,481 47.3 2,370 2,025 Ga/Dangme 8.2 465 437 7.5 374 338 Ewe 13.1 745 698 13.0 654 614 Guan 2.6 145 159 3.7 186 191 Mole-Dagbani 12.8 730 1,119 17.5 878 1,235 Grussi 2.4 134 171 2.4 121 157 Gruma 2.5 142 178 3.0 151 188 Hausa 1.3 74 62 1.1 56 50 Other 6.4 362 380 4.4 223 214 Missing 0.2 9 6 0.1 3 3 Total 100.0 5,691 5,691 100.0 5,015 5,015 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Survey Respondents | 25 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Education provides people with the knowledge and skills that can lead to a better quality of life. The level of education has been found to be highly associated with the health of mothers and their children and on their reproductive health behaviours. Tables 3.2.1 and 3.2.2 present the distribution of women and men by highest level of schooling attended or completed, and the median number of years of schooling, according to background characteristics. The data show that 28 percent of women have never been to school, 14 percent have some primary education only, while 6 percent have completed primary education. In addition, 44 percent have some secondary education, 8 percent have completed secondary school, with 3 percent having attained higher than secondary education. The data also show that men are more educated than women at all levels of education. For example, about twice as many men as women have completed secondary education or gone on to a higher level. On average, men have two more years of schooling than women—the median years of schooling among women and men is 6.2 and 8.3 years, Table 3.2.1 Educational attainment by background characteristics: women Percent distribution of women by highest level of schooling attended or completed, and median number of years of schooling, ac- cording to background characteristics, Ghana 2003 Highest level of schooling attended or completed Background characteristic No education Some primary Completed primary1 Some sec- ondary Completed secondary2 More than secondary Total Number of women Median years of schooling Age 15-19 12.3 15.7 7.7 59.4 4.8 0.1 100.0 1,148 6.9 20-24 19.6 13.8 6.4 45.5 9.6 5.1 100.0 1,012 8.0 25-29 32.2 11.9 6.9 38.0 8.9 2.1 100.0 951 5.8 30-34 33.9 15.3 5.4 39.6 2.7 3.2 100.0 802 5.1 35-39 40.4 12.7 5.5 36.4 2.4 2.6 100.0 722 4.2 40-44 35.9 12.3 4.6 42.8 2.2 2.2 100.0 579 5.4 45-49 39.9 15.7 3.0 36.0 1.3 4.1 100.0 477 3.4 Residence Urban 16.3 10.6 5.4 54.5 8.9 4.3 100.0 2,755 8.3 Rural 39.5 17.1 6.6 34.1 1.7 1.1 100.0 2,936 3.5 Region Western 22.3 17.3 7.2 45.8 4.5 2.9 100.0 553 6.5 Central 25.2 20.7 7.3 41.0 3.5 2.2 100.0 431 5.5 Greater Accra 12.4 11.2 5.2 54.0 12.0 5.2 100.0 942 8.5 Volta 20.7 21.9 5.4 44.2 5.1 2.8 100.0 492 6.3 Eastern 15.9 14.4 9.1 53.4 3.9 3.3 100.0 601 7.3 Ashanti 16.8 12.4 6.6 57.5 5.1 1.5 100.0 1,142 7.9 Brong Ahafo 27.4 15.5 7.4 45.3 2.7 1.7 100.0 569 6.0 Northern 78.8 6.2 2.3 9.2 2.0 1.5 100.0 499 0.0 Upper East 72.4 9.8 2.0 12.3 1.9 1.6 100.0 310 0.0 Upper West 63.3 11.5 3.7 18.3 2.3 0.8 100.0 153 0.0 Wealth quintile Lowest 63.6 14.1 4.8 16.5 0.6 0.3 100.0 970 0.0 Second 37.8 21.6 6.3 32.9 1.0 0.4 100.0 949 3.2 Middle 26.0 16.0 8.0 47.5 2.0 0.5 100.0 1,071 5.9 Fourth 18.6 14.0 6.9 53.9 5.3 1.3 100.0 1,245 7.6 Highest 8.4 7.2 4.4 58.5 13.2 8.3 100.0 1,457 9.0 Total 28.2 13.9 6.0 44.0 5.2 2.6 100.0 5,691 6.2 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level 26 | Characteristics of Survey Respondents respectively. High dropout of girls at primary and secondary levels may explain some of the differences in educational attainment between women and men. The Ghanaian government has been considering measures to enhance girls’ retention rates in schools. One such measure allows girls who drop out of school due to pregnancy to continue with their education after delivery. The data show that the educational attainment among both women and men has improved over time, as seen by the changes between age cohorts. For example, 40 percent of women in the oldest age cohort (45-49) have no education compared with 12 percent among those age 15-19, while the corresponding percentages for men are 35 and 8 percent, respectively. Table 3.2.2 Educational attainment by background characteristics: men Percent distribution of men by highest level of schooling attended or completed, and median number of years of schooling, according to background characteristics, Ghana 2003 Highest level of schooling attended or completed Background characteristic No educa- tion Some primary Completed primary1 Some sec- ondary Completed secondary2 More than secondary Total Number of men Median years of schooling Age 15-19 8.1 17.9 8.8 60.3 4.8 0.1 100.0 1,107 7.1 20-24 10.8 9.6 5.8 51.2 17.6 5.0 100.0 684 8.4 25-29 14.5 8.3 5.6 44.4 16.6 10.6 100.0 754 8.5 30-34 19.5 8.1 4.5 49.8 11.9 6.1 100.0 633 9.0 35-39 26.6 8.7 4.5 46.6 7.4 6.2 100.0 498 9.0 40-44 23.4 6.3 2.6 53.6 6.0 8.1 100.0 412 9.3 45-49 26.3 10.2 4.0 43.8 6.1 9.6 100.0 441 9.1 50-54 25.0 8.4 3.4 49.9 3.2 10.1 100.0 294 9.2 55-59 34.5 5.3 4.3 35.4 6.8 13.8 100.0 192 9.0 Residence Urban 8.0 6.3 4.9 54.6 15.7 10.4 100.0 2,250 9.2 Rural 25.4 13.9 6.0 47.0 4.8 2.9 100.0 2,765 6.7 Region Western 7.3 11.0 9.2 58.3 9.4 4.8 100.0 476 8.5 Central 9.3 14.8 5.8 60.3 4.6 5.2 100.0 370 8.3 Greater Accra 5.8 5.1 2.8 50.4 22.6 13.3 100.0 733 9.9 Volta 7.9 13.7 5.9 58.4 6.1 8.0 100.0 440 8.5 Eastern 7.9 8.9 8.5 62.3 5.0 7.4 100.0 539 8.8 Ashanti 9.4 7.0 5.0 63.8 10.6 4.2 100.0 956 8.7 Brong Ahafo 14.2 12.2 5.2 53.2 8.9 6.3 100.0 528 8.3 Northern 59.5 11.6 4.0 14.6 7.3 3.0 100.0 527 0.0 Upper East 48.9 18.8 5.6 21.7 3.6 1.4 100.0 317 0.0 Upper West 44.9 16.4 4.2 23.4 5.5 5.5 100.0 130 2.2 Wealth quintile Lowest 47.9 16.5 5.7 26.1 2.6 1.3 100.0 872 0.8 Second 22.2 18.4 6.9 47.6 3.6 1.2 100.0 903 6.2 Middle 14.7 10.6 7.7 60.5 4.4 2.0 100.0 975 8.0 Fourth 8.7 6.8 5.3 59.2 12.7 7.3 100.0 1,060 8.9 Highest 2.2 3.5 2.8 54.2 21.0 16.3 100.0 1,204 9.9 Total 17.6 10.5 5.5 50.4 9.7 6.3 100.0 5,015 8.3 1 Completed 6 grade at the primary level 2 Completed 12 grade at the secondary level Characteristics of Survey Respondents | 27 Tables 3.2.1 and 3.2.2 also show that educational attainment varies greatly by urban-rural residence. Respondents in rural areas have substantially lower levels of educational attainment than their urban counterparts. Forty percent of women and 25 percent of men in the rural areas have never been to school in contrast to 16 percent of women and 8 percent of men in urban areas. Educational attainment is highest in Greater Accra and lowest in the Northern region. This is not surprising because Greater Accra is the most urbanized region in the country and has better educational opportunities. Nevertheless, even in this region, twice as many women as men have no education. Not surprisingly, there is a direct relationship between educational attainment and wealth. Women and men in the highest wealth quintile are most educated, in contrast to respondents with little or no education who are concentrated in the lowest wealth quintile. For example, 8 percent of women and 2 percent of men from the highest wealth quintile have no education, in contrast to 64 and 48 percent of women and men, respectively, in the lowest wealth quintile. Literacy is widely acknowledged as benefiting both the individual and society and, in particular among women, is associated with a number of positive outcomes, including intergenerational health and nutrition benefits. In the 2003 GDHS, literacy was ascertained by a respondent’s ability to read none, part, or all of a simple statement in any language that the respondent is likely to be able to read. The questions on literacy were asked only of respondents who had not attended school or attended primary or middle/JSS only. Respondents for whom no card with the required language was available, and those who were blind or visually impaired, are excluded from the estimation of percent literate, because their literacy cannot be gauged. Tables 3.3.1 and 3.3.2 show the percent distribution of women and men by level of schooling attended and by level of literacy. More than half (55 percent) of women and nearly three-quarters (73 percent) of men are literate, while 45 percent of women and 27 percent of men cannot read at all. As in the case of educational attainment, men are more likely to be literate than women. Forty percent of rural women compared with 71 percent of urban women are literate. Similarly, 62 percent of rural men compared with 87 percent of urban men are literate. Regional variations in the level of literacy are marked, ranging from a high of 75 percent among women in Greater Accra to a low of 14 percent among women in the Northern region. Almost nine in ten men in Greater Accra (89 percent) are literate, compared with one in three in the Northern and Upper East regions. There is a strong relationship between wealth and literacy levels. Women (83 percent) and men (95 percent) categorised in the highest wealth quintile are literate compared with only 20 percent of women and 37 percent of men in the lowest wealth quintile. Four in five women and three in five men in the lowest quintile cannot read at all. 28 | Characteristics of Survey Respondents Table 3.3.1 Literacy: women Percent distribution of women by level of schooling attended and by level of literacy, and percent literate, according to back- ground characteristics, Ghana 2003 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card/ visually impaired Missing Total Number of women Percent literate1 Age 15-19 64.3 4.7 3.4 27.6 0.0 0.0 100.0 1,148 72.4 20-24 60.2 1.2 1.0 37.4 0.0 0.1 100.0 1,012 62.5 25-29 49.0 0.6 0.3 49.9 0.2 0.0 100.0 951 50.0 30-34 45.4 1.1 1.1 52.1 0.0 0.3 100.0 802 47.7 35-39 41.4 0.4 0.9 57.2 0.1 0.0 100.0 722 42.7 40-44 47.1 1.0 0.7 51.0 0.2 0.0 100.0 579 48.9 45-49 41.4 1.4 1.8 55.4 0.0 0.0 100.0 477 44.6 Residence Urban 67.7 2.0 1.2 28.9 0.1 0.0 100.0 2,755 71.0 Rural 36.9 1.4 1.6 60.1 0.0 0.1 100.0 2,936 39.9 Region Western 53.2 1.1 2.3 43.4 0.0 0.0 100.0 553 56.6 Central 46.7 2.0 1.4 49.9 0.0 0.0 100.0 431 50.1 Greater Accra 71.2 2.2 1.0 25.5 0.1 0.0 100.0 942 74.5 Volta 52.0 2.6 1.5 43.9 0.0 0.0 100.0 492 56.1 Eastern 60.6 2.0 1.5 35.9 0.0 0.0 100.0 601 64.1 Ashanti 64.2 1.5 1.5 32.6 0.0 0.1 100.0 1,142 67.4 Brong Ahafo 49.7 2.0 2.4 45.6 0.3 0.0 100.0 569 54.3 Northern 12.7 0.6 0.3 86.0 0.1 0.4 100.0 499 13.6 Upper East 15.8 0.7 0.1 83.4 0.0 0.0 100.0 310 16.6 Upper West 21.5 1.7 1.1 75.7 0.0 0.0 100.0 153 24.3 Wealth quintile Lowest 17.4 1.0 1.1 80.2 0.1 0.2 100.0 970 19.6 Second 34.3 1.3 2.0 62.3 0.2 0.0 100.0 949 37.6 Middle 50.0 1.3 1.6 47.1 0.0 0.0 100.0 1,071 52.9 Fourth 60.5 2.4 1.7 35.1 0.1 0.1 100.0 1,245 64.8 Highest 80.0 2.1 0.7 17.2 0.0 0.0 100.0 1,457 82.8 Total 51.8 1.7 1.4 45.0 0.1 0.1 100.0 5,691 55.0 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sen- tence Excludes from the denominator those women for whom no card with required language was available and those who are blind or visually impaired. Characteristics of Survey Respondents | 29 Table 3.3.2 Literacy: men Percent distribution of men by level of schooling attended and by level of literacy, and percent literate, according to back- ground characteristics, Ghana 2003 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card/ visually impaired Missing Total Number of men Percent literate1 Age 15-19 65.2 8.5 5.6 20.6 0.0 0.1 100.0 1,107 79.4 20-24 73.8 1.6 3.6 20.6 0.3 0.0 100.0 684 79.3 25-29 71.7 0.9 1.6 25.7 0.0 0.1 100.0 754 74.2 30-34 67.8 1.1 2.0 27.9 1.0 0.1 100.0 633 71.8 35-39 60.2 1.8 2.1 34.8 1.1 0.0 100.0 498 64.8 40-44 67.7 0.8 1.7 28.8 0.8 0.2 100.0 412 70.9 45-49 59.5 2.2 2.0 35.3 1.2 0.0 100.0 441 64.3 50-54 63.2 3.0 1.6 31.2 1.0 0.0 100.0 294 68.5 55-59 56.0 2.9 2.2 38.1 0.8 0.0 100.0 192 61.6 Residence Urban 80.7 2.4 3.1 13.0 0.8 0.0 100.0 2,250 86.9 Rural 54.8 3.7 2.8 38.3 0.3 0.1 100.0 2,765 61.5 Region Western 72.4 4.1 2.7 20.4 0.3 0.0 100.0 476 79.5 Central 70.1 2.6 2.5 24.9 0.0 0.0 100.0 370 75.1 Greater Accra 86.3 1.2 1.0 10.9 0.6 0.0 100.0 733 89.1 Volta 72.5 5.0 2.5 19.9 0.2 0.0 100.0 440 80.1 Eastern 74.8 3.4 3.2 18.7 0.0 0.0 100.0 539 81.3 Ashanti 78.6 2.4 3.0 15.9 0.1 0.0 100.0 956 84.1 Brong Ahafo 68.4 3.8 4.6 23.2 0.0 0.0 100.0 528 76.8 Northern 24.9 4.5 4.1 65.8 0.2 0.6 100.0 527 33.7 Upper East 26.7 2.2 2.9 62.5 5.8 0.0 100.0 317 33.7 Upper West 34.5 2.6 4.4 58.2 0.2 0.0 100.0 130 41.6 Wealth quintile Lowest 29.9 3.7 3.1 62.3 0.6 0.3 100.0 872 37.1 Second 52.5 5.4 3.5 38.3 0.3 0.0 100.0 903 61.6 Middle 67.0 3.1 3.5 25.9 0.6 0.0 100.0 975 74.0 Fourth 79.2 2.8 3.2 14.3 0.5 0.0 100.0 1,060 85.6 Highest 91.5 1.3 1.8 4.9 0.6 0.0 100.0 1,204 95.1 Total 66.4 3.1 2.9 27.0 0.5 0.1 100.0 5,015 72.9 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence. Excludes from the denominator those men for whom no card with required language was available and those who are blind or visually impaired. 3.3 ACCESS TO MASS MEDIA The 2003 GDHS collected information on respondents’ exposure to both broadcast and print media. This information is a means of assessing the potential effectiveness of using these media to broadcast messages on such important topics as reproductive health and HIV/AIDS. Tables 3.4.1 and 3.4.2 show that access to mass media, especially the broadcast media, is generally high in Ghana. Seventy-four percent of women and 89 percent of men listen to the radio at least once a week, and 44 percent of women and 51 percent of men watch television at least once a week. Exposure to the print 30 | Characteristics of Survey Respondents media is relatively low. Twelve percent of women and 28 percent of men read a newspaper at least once a week. Men are twice as likely as women to be exposed to all three media sources (23 and 10 percent, respectively). Media exposure is higher among younger women (age 15-24) than older women (25 years and above). However, among men, exposure is lowest among those age 15-19 and highest among those age 20-29. Urban women and men tend to have greater exposure to all three media sources than their rural counterparts. The high level of illiteracy among rural women is reflected in the lower proportion of these women (4 percent) exposed to the print media than urban women (21 percent). Table 3.4.1 Exposure to mass media: women Percentage of women who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Ghana 2003 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media No media Number of women Age 15-19 19.6 54.5 73.0 14.7 18.5 1,148 20-24 14.3 51.9 78.0 11.4 16.5 1,012 25-29 9.6 43.7 75.7 8.3 20.5 951 30-34 7.7 36.8 72.0 6.7 25.9 802 35-39 9.3 35.9 71.0 7.8 25.2 722 40-44 9.9 37.3 74.2 7.6 22.4 579 45-49 11.7 33.6 73.3 9.3 23.7 477 Residence Urban 21.3 66.0 80.9 17.6 12.2 2,755 Rural 4.0 23.1 67.7 2.6 29.6 2,936 Region Western 16.7 45.5 76.0 12.8 19.4 553 Central 7.5 35.2 61.2 4.7 31.5 431 Greater Accra 26.7 74.4 85.4 22.6 8.3 942 Volta 10.9 26.5 73.9 6.4 21.2 492 Eastern 10.3 44.5 80.4 8.8 15.9 601 Ashanti 12.9 54.0 81.6 10.6 13.2 1,142 Brong Ahafo 7.0 40.9 80.0 5.4 16.1 569 Northern 3.0 15.6 45.9 2.5 51.4 499 Upper East 2.3 16.8 62.6 2.1 34.7 310 Upper West 2.4 10.7 46.7 1.1 51.7 153 Education No education 0.0 18.4 56.7 0.0 40.1 1,608 Primary 1.4 34.4 70.6 0.6 24.8 1,135 Middle/JSS 12.6 56.1 82.8 9.4 11.8 2,279 Secondary+ 60.1 79.7 92.2 51.0 1.7 669 Wealth quintile Lowest 1.4 7.2 51.2 0.1 47.1 970 Second 1.9 16.5 69.0 1.2 29.0 949 Middle 4.3 33.4 74.2 2.5 22.0 1,071 Fourth 10.0 53.6 79.4 6.5 14.2 1,245 Highest 34.5 85.5 88.1 30.3 4.2 1,457 Total 12.4 43.9 74.1 9.9 21.2 5,691 Characteristics of Survey Respondents | 31 Table 3.4.2 Exposure to mass media: men Percentage of men who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Ghana 2003 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media No media Number of men Age 15-19 21.8 55.2 84.0 18.5 12.2 1,107 20-24 30.4 60.3 91.8 24.5 5.0 684 25-29 33.4 57.2 93.2 28.1 4.9 754 30-34 30.0 48.4 90.4 24.0 7.1 633 35-39 28.7 44.1 89.8 22.7 8.6 498 40-44 31.0 41.4 89.7 23.0 8.9 412 45-49 30.0 43.9 87.5 22.4 9.0 441 50-54 25.3 38.8 90.7 19.6 7.9 294 55-59 30.0 41.7 92.8 24.6 7.2 192 Residence Urban 46.4 76.3 92.4 40.7 3.7 2,250 Rural 13.8 29.7 86.9 8.4 11.7 2,765 Region Western 31.4 52.6 90.5 21.7 4.7 476 Central 21.4 37.3 82.3 12.2 13.2 370 Greater Accra 55.9 78.8 95.2 49.6 2.1 733 Volta 20.7 33.5 89.0 13.6 8.5 440 Eastern 27.2 53.6 95.9 23.3 2.8 539 Ashanti 35.8 66.8 97.5 30.3 1.6 956 Brong Ahafo 24.4 51.5 94.0 20.4 4.6 528 Northern 8.0 22.6 67.7 5.6 28.7 527 Upper East 8.1 28.9 80.9 6.1 14.5 317 Upper West 9.0 12.8 74.9 3.5 24.3 130 Education No education 0.4 17.8 75.4 0.4 22.9 881 Primary 3.6 34.0 82.0 2.2 14.5 803 Middle/JSS 25.5 56.2 94.0 19.7 3.5 2,165 Secondary+ 72.2 76.7 96.4 60.0 1.1 1,165 Wealth quintile Lowest 4.4 10.4 73.8 1.3 24.9 872 Second 8.9 20.4 89.2 3.7 9.7 903 Middle 16.0 44.5 91.6 9.5 5.0 975 Fourth 37.1 67.9 92.2 28.3 4.2 1,060 Highest 63.0 92.3 96.3 58.9 0.7 1,204 Total 28.4 50.6 89.3 22.9 8.1 5,015 More than one in five women and one in two men in Greater Accra are exposed to all three media sources. Media exposure is markedly lower in the three northern regions and is especially low in the Upper West, where only 1 percent of women and 4 percent of men are exposed to all three media sources. Exposure to mass media is closely related to the level of education of respondents. Half of all women and three-fifths of all men with at least secondary education are exposed to all three media sources. Three- fifths and nearly three-quarters of highly educated women and men read a newspaper at least once a week. 32 | Characteristics of Survey Respondents There is a high correlation between wealth and media exposure, with the gap between those in the highest quintile and all other quintiles being especially wide. For example, 30 percent of women in the highest wealth quintile are exposed to all three media compared with 7 percent or less of women in the other four quintiles. Since 1998, the proportions of both women and men who have no media exposure have declined markedly, from 30 percent to 21 percent among women and 15 percent to 8 percent among men (GSS and MI, 1999). However, the proportion of women and men who report reading the newspaper and watching television at least once a week has declined, while the proportion who reported listening to the radio has increased. Some of these reported differences by type of media source may be due to a change in the way the questions were worded between the two surveys. 3.4 EMPLOYMENT 3.4.1 Employment Status Tables 3.5.1 and 3.5.2 present the percent distribution of women and men by employment status, according to background characteristics. There is little difference in the overall employment status of women and men. Three-fourths of women and men reported being currently employed, while 3 percent reported being employed in the 12 months preceding the survey, but not employed at the time the survey was fielded. About one-fifth of women and men were not employed in the 12 months prior to the survey. Current employment increases with age from 33 and 26 percent among the youngest cohort of women and men, respectively, to about 95 percent among the oldest cohort of respondents. Low current employment among young women and men may be due to the fact that a proportionately larger number of young people are still in school. Currently and formerly married women are more likely to be currently employed than never married women. However, among men, married men are more likely to be employed than formerly married men and those never married. Current employment rises with the number of living children. For example, about one in two respondents with no children are currently employed compared with 94 percent of women and 98 percent of men with five or more children. Current employment is also higher among rural respondents than urban respondents. This could be due to the fact that it is easier to find employment in the largely informal sector in the rural areas than in urban areas. Unemployment could also be higher in the urban areas because there is greater demand for skilled labour, which is harder to acquire. There is little variation in employment status of respondents by region. More than 80 percent of women in the Upper West and Volta regions and men in the Upper East and Northern regions are currently employed compared with about 70-80 percent of respondents in all other regions. Current employment is inversely related to education, falling from 86 percent among women with no education to 60 percent among women with at least secondary education. The corresponding data for men is 97 and 67 percent, respectively. A similar pattern is seen by wealth quintile for both women and men. Characteristics of Survey Respondents | 33 Table 3.5.1 Employment status: women Percent distribution of women by employment status, according to background characteristics, Ghana 2003 Employed in the 12 months preceding the survey Background Characteristic Currently employed Not currently employed Not employed in the 12 months preced- ing the survey Total Number of women Age 15-19 33.0 3.3 63.6 100.0 1,148 20-24 66.5 4.7 28.8 100.0 1,012 25-29 86.8 2.6 10.5 100.0 951 30-34 90.4 2.1 7.4 100.0 802 35-39 94.7 1.5 3.6 100.0 722 40-44 92.3 1.9 5.8 100.0 579 45-49 94.8 0.5 4.7 100.0 477 Marital status Never married 42.0 3.8 54.2 100.0 1,616 Married or living together 88.3 2.2 9.4 100.0 3,549 Divorced/separated/widowed 87.7 2.4 10.0 100.0 526 Number of living children 0 48.2 3.7 48.1 100.0 1,872 1-2 82.2 3.3 14.6 100.0 1,602 3-4 91.3 1.5 7.0 100.0 1,227 5+ 94.3 1.3 4.4 100.0 990 Residence Urban 69.2 3.4 27.4 100.0 2,755 Rural 80.6 2.0 17.3 100.0 2,936 Region Western 72.3 1.1 26.6 100.0 553 Central 79.1 5.9 15.0 100.0 431 Greater Accra 71.1 4.2 24.7 100.0 942 Volta 82.2 1.2 16.6 100.0 492 Eastern 73.0 1.7 25.3 100.0 601 Ashanti 71.3 4.0 24.6 100.0 1,142 Brong Ahafo 79.2 1.1 19.7 100.0 569 Northern 79.5 0.8 19.7 100.0 499 Upper East 73.7 2.5 23.7 100.0 310 Upper West 85.1 1.0 13.9 100.0 153 Education No education 86.2 1.6 12.1 100.0 1,608 Primary 76.5 3.3 20.1 100.0 1,135 Middle/JSS 70.9 2.9 26.2 100.0 2,279 Secondary+ 60.3 3.3 36.4 100.0 669 Wealth quintile Lowest 83.5 1.3 15.0 100.0 970 Second 82.4 2.1 15.5 100.0 949 Middle 76.5 1.8 21.8 100.0 1,071 Fourth 71.9 3.8 24.3 100.0 1,245 Highest 66.4 3.7 29.9 100.0 1,457 Total 75.1 2.7 22.2 100.0 5,691 34 | Characteristics of Survey Respondents Table 3.5.2 Employment status: men Percent distribution of men by employment status, according to background characteristics, Ghana 2003 Employed in the 12 months preceding the survey Background characteristic Currently employed Not currently employed Not em- ployed in the 12 months pre- ceding the survey Missing/ don't know Total Number of men Age 15-19 26.0 4.3 68.3 1.5 100.0 1,107 20-24 66.8 5.5 27.4 0.3 100.0 684 25-29 88.8 4.6 6.6 0.0 100.0 754 30-34 94.8 2.6 2.4 0.2 100.0 633 35-39 97.0 1.6 1.4 0.0 100.0 498 40-44 97.7 0.9 1.4 0.0 100.0 412 45-49 96.7 1.4 1.9 0.0 100.0 441 50-54 96.7 2.1 1.2 0.0 100.0 294 55-59 94.4 1.0 4.6 0.0 100.0 192 Marital status Never married 45.9 5.3 47.9 0.9 100.0 2,042 Married or living together 96.9 1.6 1.5 0.0 100.0 2,671 Divorced/separated/widowed 88.1 4.5 7.4 0.0 100.0 302 Number of living children 0 50.8 5.3 43.1 0.8 100.0 2,300 1-2 95.1 2.2 2.7 0.0 100.0 981 3-4 96.4 1.6 1.8 0.1 100.0 816 5+ 98.3 0.8 0.9 0.0 100.0 917 Residence Urban 69.4 4.1 25.9 0.6 100.0 2,250 Rural 80.6 2.6 16.6 0.3 100.0 2,765 Region Western 73.3 3.8 22.7 0.2 100.0 476 Central 74.4 2.9 21.4 1.3 100.0 370 Greater Accra 72.3 5.2 21.9 0.6 100.0 733 Volta 73.3 2.7 23.6 0.4 100.0 440 Eastern 76.9 2.0 20.8 0.2 100.0 539 Ashanti 74.6 2.7 22.2 0.5 100.0 956 Brong Ahafo 70.6 3.3 25.8 0.3 100.0 528 Northern 85.6 2.7 11.6 0.0 100.0 527 Upper East 82.5 2.5 15.0 0.0 100.0 317 Upper West 78.3 6.2 15.4 0.0 100.0 130 Education No education 97.4 1.2 1.4 0.0 100.0 881 Primary 71.6 2.6 25.7 0.2 100.0 803 Middle/JSS 73.0 3.1 23.3 0.5 100.0 2,165 Secondary + 66.6 5.5 27.3 0.6 100.0 1,165 Wealth quintile Lowest 85.6 3.0 11.4 0.0 100.0 872 Second 80.4 2.1 17.4 0.1 100.0 903 Middle 74.6 2.4 22.3 0.7 100.0 975 Fourth 69.8 4.1 25.9 0.2 100.0 1,060 Highest 70.7 4.2 24.3 0.8 100.0 1,204 Total 75.6 3.3 20.8 0.4 100.0 5,015 Characteristics of Survey Respondents | 35 3.4.2 Occupation Tables 3.6.1 and 3.6.2 show data on employed women and men by their occupation, according to background characteristics. More than one-third of working women (36 percent) and half of men (50 percent) are employed in the agricultural (Figure 3.1). Four times as many women (42 percent) as men (11 percent) work in sales and services. Sixteen percent of employed women and 23 percent of employed men are skilled manual workers. Three times as many men (10 percent) as women (3 percent) are engaged in professional, technical, and managerial positions. Occupation varies by age groups. Among women, the proportion engaged in agriculture or in professional, technical, or managerial occupations, increases with age. For example, one in four working women age 15-19 are in agricultural occupations compared with nearly one in two women age 45-49. On the other hand, the proportion engaged in sales and services and in skilled manual labour decreases with age. A similar pattern is observed for men for skilled manual labour only. A higher proportion of never-married women than ever-married women are engaged in most occupations with the exception of agriculture, which accounts for two in five currently married women who are working compared with more than one in four formerly married women and 12 percent of never- married women. There is no clear pattern in occupation by marital status among men. Among working men, about half of those who are currently or formerly married are engaged in the agricultural sector compared to two in five never-married men. Three-tenths of never-married men are engaged as skilled manual labour, compared with one-fifth of ever married men. There is a direct relationship between the number of living children and agricultural occupation among both women and men. The proportion engaged in agriculture increases with the number of living children. Among women, the proportion engaged in all other occupations is higher among those with no children than among those with one or more children. Not surprisingly, most working women and men in rural areas are engaged in the agricultural sector, in contrast to women and men in urban areas, who are mostly engaged in sales and service and skilled manual work. Agriculture is the predominant occupation among women in the Northern, Upper East, Brong Ahafo, and Upper West regions. In addition to these regions, the majority of men in the Eastern, Volta, and Central regions are also employed in the agricultural sector. In contrast, the majority of working women living in Greater Accra, Ashanti, and Eastern regions are in sales and service jobs. Among working men, the highest proportions engaged in the professional, technical and managerial, clerical, sales and service, and skilled manual work are from Greater Accra. Education is related to the type of occupation of respondents. Fifty-nine percent of working women and 83 percent of working men who have never been to school are engaged in agriculture. On the other hand, the majority of women and men with secondary or higher education are employed in non- agricultural occupations. Women and men in the lowest quintile are predominantly engaged in agriculture, while those in the highest wealth quintile are mostly engaged in sales and service, skilled manual, or professional, technical, and managerial work. 36 | Characteristics of Survey Respondents Table 3.6.1 Occupation: women Percent distribution of women employed in the 12 months preceding the survey by occupation, according to background characteristics, Ghana 2003 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of women Age 15-19 0.6 1.5 50.2 21.2 0.0 25.9 0.5 100.0 417 20-24 1.9 3.8 46.2 20.8 0.0 26.6 0.8 100.0 721 25-29 2.4 1.2 43.6 18.3 0.8 33.2 0.6 100.0 851 30-34 3.3 0.9 43.3 14.2 0.7 37.1 0.5 100.0 743 35-39 4.1 1.2 40.5 14.0 0.1 39.1 0.9 100.0 694 40-44 4.1 1.0 36.5 13.9 0.4 43.2 0.9 100.0 545 45-49 5.6 1.0 31.8 12.0 0.1 48.0 1.6 100.0 455 Marital status Never married 4.0 4.7 55.2 22.3 0.6 12.2 0.9 100.0 740 Married or living together 2.9 1.0 38.0 14.6 0.3 42.4 0.8 100.0 3,213 Dvorced/separated/widowed 2.9 0.6 48.4 19.4 0.3 27.5 0.8 100.0 473 Number of living children 0 4.8 4.5 52.5 21.9 0.4 15.5 0.5 100.0 971 1-2 2.3 0.9 48.6 17.7 0.2 29.6 0.7 100.0 1,369 3-4 3.7 0.9 38.8 14.8 0.5 40.8 0.6 100.0 1,140 5+ 1.9 0.2 25.8 10.9 0.3 59.5 1.4 100.0 947 Residence Urban 4.5 3.1 61.3 21.0 0.3 9.4 0.4 100.0 2,001 Rural 1.9 0.2 26.1 12.7 0.4 57.5 1.1 100.0 2,425 Region Western 4.4 1.4 31.6 21.6 0.0 39.8 1.2 100.0 406 Central 1.9 0.3 40.7 19.6 0.0 37.5 0.0 100.0 366 Greater Accra 5.0 4.9 60.0 24.3 0.0 5.3 0.4 100.0 709 Volta 2.3 0.7 36.8 17.8 0.3 41.5 0.7 100.0 410 Eastern 4.7 1.5 50.8 9.4 0.3 33.3 0.0 100.0 449 Ashanti 2.3 1.5 52.3 13.1 0.5 28.2 2.1 100.0 860 Brong Ahafo 2.3 0.8 34.2 8.6 0.0 53.3 0.8 100.0 457 Northern 2.5 0.0 18.1 17.1 1.2 60.5 0.5 100.0 401 Upper East 2.0 0.0 30.6 12.3 0.0 55.1 0.0 100.0 236 Upper West 0.6 0.5 21.1 23.6 3.1 51.1 0.0 100.0 131 Education No education 0.1 0.0 24.4 14.8 0.6 59.1 0.9 100.0 1,412 Primary 0.3 0.1 41.3 15.7 0.1 41.6 0.8 100.0 906 Middle/JSS 1.7 0.6 56.8 18.8 0.3 21.2 0.8 100.0 1,683 Secondary+ 24.7 13.6 43.7 14.1 0.0 3.3 0.6 100.0 425 Wealth quintile Lowest 0.3 0.0 14.9 11.9 1.0 71.5 0.5 100.0 823 Second 1.0 0.0 24.3 11.0 0.2 63.1 0.5 100.0 802 Middle 1.6 0.4 36.8 16.0 0.0 43.7 1.4 100.0 838 Fourth 3.4 1.4 61.0 21.8 0.6 10.9 1.0 100.0 943 Highest 8.0 5.1 64.7 19.7 0.0 1.8 0.7 100.0 1,020 Total 3.1 1.5 42.0 16.4 0.3 35.8 0.8 100.0 4,426 Characteristics of Survey Respondents | 37 Table 3.6.2 Occupation: men Percent distribution of men employed in the 12 months preceding the survey by occupation, according to background characteristics, Ghana 2003 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of men Age 15-19 2.6 0.3 8.1 25.2 2.0 57.6 4.1 100.0 335 20-24 7.2 2.3 11.1 33.0 3.0 40.1 3.2 100.0 494 25-29 10.5 2.2 12.7 27.8 1.7 41.9 3.2 100.0 705 30-34 8.7 2.6 13.5 27.3 1.0 46.2 0.6 100.0 617 35-39 10.5 1.4 10.9 20.9 1.9 51.6 2.8 100.0 491 40-44 13.7 2.8 7.3 16.1 0.4 59.6 0.3 100.0 406 45-49 14.1 2.1 8.3 18.8 0.5 55.0 1.3 100.0 433 50-54 13.1 2.3 12.5 13.7 1.4 55.4 1.6 100.0 290 55-59 17.7 1.0 13.9 7.9 1.2 57.2 1.1 100.0 183 Marital status Never married 9.6 2.6 11.6 29.6 2.2 40.1 4.3 100.0 1,045 Married or living together 11.1 1.8 10.4 20.9 0.9 53.7 1.2 100.0 2,630 Divorced/separated/widowed 6.7 2.3 14.6 20.7 4.1 49.5 2.1 100.0 279 Number of living children 0 9.9 2.5 12.2 28.6 2.5 40.5 3.8 100.0 1,291 1-2 10.1 1.6 12.2 27.2 1.5 45.2 2.1 100.0 955 3-4 10.7 2.0 11.9 21.0 0.7 53.0 0.7 100.0 800 5+ 11.1 1.8 7.3 13.1 0.6 65.2 1.0 100.0 909 Residence Urban 18.0 3.8 21.4 36.4 2.1 14.9 3.5 100.0 1,654 Rural 4.9 0.7 3.5 13.7 1.1 74.9 1.1 100.0 2,300 Region Western 7.2 2.4 11.4 26.2 1.8 45.8 5.0 100.0 367 Central 9.5 1.4 4.5 29.5 1.0 52.0 2.0 100.0 286 Greater Accra 15.3 6.1 25.2 36.6 2.6 10.6 3.7 100.0 568 Volta 11.8 1.1 4.9 20.7 1.2 58.2 2.1 100.0 334 Eastern 14.0 1.3 9.0 21.7 0.5 52.5 0.9 100.0 425 Ashanti 12.6 1.8 11.5 31.7 3.0 37.6 1.9 100.0 739 Brong Ahafo 9.8 1.4 8.0 12.5 0.9 65.6 1.7 100.0 390 Northern 4.5 0.4 5.6 8.4 0.4 80.2 0.4 100.0 465 Upper East 4.0 0.7 12.2 13.0 0.0 69.0 1.1 100.0 270 Upper West 8.1 0.0 6.8 7.5 1.0 75.3 1.3 100.0 110 Education No education 0.5 0.3 7.4 6.5 0.8 83.1 1.3 100.0 869 Primary 0.8 0.7 4.8 22.1 0.7 67.1 3.8 100.0 595 Middle/JSS 4.8 1.7 11.3 33.7 2.5 43.7 2.3 100.0 1,649 Secondary+ 38.4 5.3 18.6 20.4 0.8 15.1 1.3 100.0 840 Wealth quintile Lowest 2.5 0.1 2.0 5.4 0.3 88.8 0.9 100.0 772 Second 2.8 0.3 2.6 9.3 0.7 82.8 1.5 100.0 745 Middle 5.6 0.7 6.0 20.2 1.7 63.3 2.6 100.0 751 Fourth 14.9 3.2 15.5 40.4 2.5 20.2 3.2 100.0 784 Highest 23.5 5.2 26.0 37.3 2.0 3.8 2.2 100.0 902 Total 10.4 2.0 11.0 23.2 1.5 49.8 2.1 100.0 3,954 38 | Characteristics of Survey Respondents Figure 3.1 Occupation of Women Age 15-49 and Men Age 15-59 GDHS 2003 Agriculture 36% Unskilled manual 2% Unskilled manual <1% Skilled manual 16% Agriculture 50% Professional/ technical/ managerial 3% Missing 2% Missing <1% Professional/ technical/ managerial 10% Sales and services 42% Clerical 2% Clerical 2% Sales and Skilled manual 23% services 11% 3.4.3 Type of Employer, Form of Earnings, and Continuity of Employment Tables 3.7.1, 3.7.2, and Figure 3.2, present data on women and men by type of employment. The majority of women and men (about 60 percent) who work receive cash earnings. A significant proportion of women (25 percent) and men (30 percent) receive earnings in cash and in-kind. Eight percent of women and 5 percent of men are not paid at all. Three-quarters of women in both agricultural and non-agricultural occupations are self-employed, 14 percent are employed by a non-family member, and 10 percent are employed by a family member. Three-quarters of employed women work all year, while one in five works seasonally. Most women in both agricultural and non-agricultural occupations work all year; however, one in three women who work in agriculture and 13 percent of women engaged in non-agricultural occupations work seasonally. Similar information was not collected for men. Characteristics of Survey Respondents | 39 Table 3.7.1 Type of employment: women Percent distribution of women employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Ghana 2003 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 30.9 78.2 61.0 Cash and in-kind 48.4 12.2 25.3 In-kind only 12.2 2.4 6.0 Not paid 8.5 7.3 7.7 Total 100.0 100.0 100.0 Type of employer Employed by family member 17.3 5.5 9.8 Employed by non-family member 5.5 18.1 13.9 Self-employed 77.0 75.8 75.9 Missing 0.2 0.6 0.5 Total 100.0 100.0 100.0 Continuity of employment All year 65.3 83.1 76.6 Seasonal 34.0 12.9 20.5 Occasional 0.6 3.9 2.8 Missing 0.1 0.0 0.1 Total 100.0 100.0 100.0 Number of women 1,583 2,809 4,426 Note: Total includes 30 women with missing information on type of employment who are not shown separately. Table 3.7.2 Type of employment: men Percent distribution of men employed in the 12 months preceding the survey by type of earnings, according to type of employment (agricul- tural or non-agricultural), Ghana 2003 Type of Earnings Agricultural work Non- agricultural work Total Cash only 36.0 84.3 60.2 Cash and in-kind 51.6 8.6 29.9 In-kind only 7.5 1.5 4.4 Not paid 5.0 5.7 5.2 Missing 0.0 0.0 0.2 Total 100.0 100.0 100.0 Number of men 1,970 1,901 3,954 Note: Total includes 78 men with missing information on type of employment who are not shown separately. 40 | Characteristics of Survey Respondents Figure 3.2 Type of Earnings of Employed Women Age 15-49 and Men Age 15-59 Women Men Cash only 61% Not paid 8% Cash and in-kind 25% Not paid 5% Cash only 60% In-kind only 6% Cash and in-kind 30% In-kind only 4% Note: Total may not add to 100 due to rounding. GDHS 2003 3.4.4 Control Over Earnings and Women’s Contribution to Household Expenditures Women’s autonomy is dependent not only on their access to income but also on the amount of control they have over their earnings. Employed women who earn cash were asked about who mainly decides how their income is used. Table 3.8 shows that women in Ghana have considerable autonomy over the use of their earnings. Nearly three-fourths of women who earn cash report that they are solely responsible for decisions on the use of their earnings, while 18 percent report that they jointly decide how the money should be spent either with their husband or someone else. Almost one in ten women stated that they have no say in how their earnings are spent. Sole decisionmaking rises with age. One in five never-married women have no say in how their earnings are used, while a similar proportion of currently married women report that they make joint decision. There is little difference in sole decisionmaking by the number of children, but joint decisionmaking rises with the number of children women have. On the other hand, there is an inverse relationship between the number of children women have and the percentage who have no say in how their earnings are spent. For example, twice as many women who have no children have no say in how their earnings are spent compared with women with one or more children. Autonomy over cash earnings is higher among urban than rural women, and relatively high among women residing in Greater Accra, Western, and Upper East regions, and lowest among women in the Central region. Education and wealth exert only a small influence on control over earnings. For example, 78 percent of women with at least secondary education or in the highest wealth quintile compared with 70 percent of women with no education or in the lowest wealth quintile have the sole say in how their earnings are spent. Characteristics of Survey Respondents | 41 Table 3.8 Decision on use of earnings and contribution of earnings to household expenditures Percent distribution of women employed in the 12 months preceding the survey receiving cash earnings by person who decides how earn- ings are to be used and by proportion of household expenditures met by earnings, according to background characteristics, Ghana 2003 Person who decides how earnings are used Proportion of household expenditures met by earnings Background characteristic Woman only Jointly1 Someone else only2 Total Almost none/none Less than half About half or more than half All Total Number of women Age 15-19 62.6 9.3 28.1 100.0 47.6 27.2 21.6 3.5 100.0 228 20-24 69.9 16.7 13.3 100.0 19.9 34.0 39.3 6.9 100.0 584 25-29 72.1 18.3 9.5 100.0 11.9 37.0 44.2 6.8 100.0 776 30-34 75.4 17.3 7.3 100.0 9.1 26.3 52.1 12.5 100.0 682 35-39 71.2 20.9 7.7 100.0 4.4 26.0 52.6 16.8 100.0 638 40-44 75.2 19.1 5.7 100.0 4.6 22.1 56.1 17.1 100.0 497 45-49 81.0 15.5 3.2 100.0 3.4 20.9 60.8 14.8 100.0 417 Marital status Never married 75.5 5.4 19.1 100.0 37.3 26.8 27.9 8.1 100.0 498 Married or living together 69.1 22.0 8.8 100.0 7.8 31.6 51.4 9.2 100.0 2,887 Divorced/separated/widowed 96.2 2.1 1.7 100.0 8.1 10.2 50.7 31.1 100.0 436 Number of living children 0 75.2 8.4 16.4 100.0 30.5 28.3 32.4 8.7 100.0 695 1-2 74.9 16.3 8.8 100.0 10.5 32.0 48.3 9.2 100.0 1,246 3-4 71.2 21.4 7.4 100.0 6.4 26.5 54.0 13.1 100.0 1,027 5+ 70.8 22.4 6.7 100.0 4.3 26.0 54.3 15.3 100.0 853 Residence Urban 78.0 12.9 9.0 100.0 14.5 27.9 46.1 11.5 100.0 1,782 Rural 68.7 21.7 9.6 100.0 9.1 29.1 50.2 11.5 100.0 2,039 Region Western 82.7 9.6 7.7 100.0 12.6 25.1 55.4 6.9 100.0 371 Central 54.0 34.9 11.1 100.0 11.7 21.8 45.4 21.0 100.0 308 Greater Accra 84.8 4.6 10.6 100.0 12.9 24.0 49.7 13.4 100.0 616 Volta 76.1 10.9 13.0 100.0 6.4 22.6 56.8 14.3 100.0 378 Eastern 77.3 19.0 3.7 100.0 7.5 14.9 60.0 17.7 100.0 418 Ashanti 66.1 25.3 8.4 100.0 16.4 34.1 42.3 7.2 100.0 791 Brong Ahafo 59.4 33.8 6.5 100.0 12.2 28.5 45.7 13.3 100.0 390 Northern 79.0 9.8 11.2 100.0 4.6 47.6 41.9 5.9 100.0 310 Upper East 82.1 3.7 14.2 100.0 19.2 45.5 30.6 4.7 100.0 165 Upper West 66.3 16.0 17.7 100.0 4.6 42.7 46.6 6.2 100.0 74 Education No education 70.3 18.9 10.8 100.0 8.3 32.9 49.1 9.7 100.0 1,144 Primary 72.7 18.1 9.1 100.0 12.0 25.0 50.5 12.4 100.0 785 Middle/JSS 73.9 17.5 8.3 100.0 13.5 26.4 46.9 13.1 100.0 1,499 Secondary+ 78.0 13.0 9.1 100.0 13.4 30.9 46.8 8.9 100.0 393 Wealth quintile Lowest 70.2 17.7 12.1 100.0 8.1 33.5 50.4 8.0 100.0 610 Second 63.8 24.6 11.4 100.0 10.3 29.0 49.5 11.0 100.0 707 Middle 74.6 17.9 7.5 100.0 10.7 27.1 48.0 14.3 100.0 746 Fourth 75.6 15.2 9.0 100.0 12.9 25.8 49.4 11.9 100.0 837 Highest 78.3 14.0 7.7 100.0 14.7 28.5 45.2 11.6 100.0 921 Total 73.0 17.6 9.3 100.0 11.6 28.5 48.3 11.5 100.0 3,821 Note: Percentages may not add to 100 due to the exclusion of women with missing information. 1 With husband or someone else 2 Includes husband 42 | Characteristics of Survey Respondents Information on the contribution of respondent’s income to household expenditures was also gathered in the 2003 GDHS. It is expected that employment and earnings are more likely to empower women if their earnings are important for meeting the needs of their households. However, often women’s income is so small that it can barely meet household needs. Table 3.8 shows that the earnings of very young women (age 15-19) are less likely to contribute a major share of household expenditures than those of older women (20-49). Not surprisingly, working women who are divorced, separated, or widowed tend to contribute to a major portion of household expenditure. Women’s contribution to household expenditure increases with the number of children they have. There is little difference between urban and rural women’s contribution to household expenditure. The majority of working women in all regions except Upper East, Northern, and Ashanti regions meet half or more or all of household expenditure with their earnings. There is no clear relationship between women’s contribution to household expenditure and education or wealth. Table 3.9 shows the relationship between women’s control over their earnings and their contribution to household expenditure by marital status. The table shows that women who are not currently married (that is, those who have never married, or are divorced, separated, or widowed) are somewhat more likely (85 percent) than currently married women (69 percent) to make sole decisions on how their earnings are spent. Nine percent of married women do not have a say in how their earnings are spent, with 8 percent reporting that their husbands alone decide on how their earnings are spent. On the other hand, 11 percent of unmarried women have no say in how their earnings are used. The data also show that among unmarried women earning cash, the greater a woman’s contribution to household expenditure, the more likely is she to make sole decisions on how her earnings are spent. Nevertheless, 8 percent of married women who contribute all of their earnings to household expenditure report that their husband or someone else makes sole decisions on how their earnings are spent, whereas only 3 percent of unmarried women who contribute all their earnings to household expenditure report that they have no say in how it is spent. Table 3.9 Women's control over earnings Percent distribution of women who received cash earnings for work in the past 12 months by person who decides how earnings are used, and the proportion of household expenditures met by earnings, according to current marital status, Ghana 2003 Currently married or living together Not married1 Contribution to household expenditures Woman only Jointly with husband Jointly with someone else Husband only Some- one else only Total Number of women Woman only Jointly with someone else Someone else only Total Number of women Almost none/ none 74.5 15.8 0.5 6.8 2.4 100.0 224 71.1 7.1 21.9 100.0 221 Less than half 66.9 22.8 0.3 9.3 0.6 100.0 912 84.0 3.6 12.4 100.0 178 Half or more 68.2 22.6 0.9 7.6 0.7 100.0 1,485 89.6 2.9 7.5 100.0 360 All 77.2 15.3 0.0 7.1 0.4 100.0 265 95.1 2.2 2.6 100.0 176 Total 69.1 21.4 0.6 8.0 0.8 100.0 2,887 85.2 3.9 10.9 100.0 934 Note: Total includes 1 woman (currently married or living together) with missing information on contribution to household expendi- tures, who is not shown separately. Percentages for currently married women may not add to 100 due to exclusion of women with missing information. 1 Never-married, divorced, separated, or widowed women Characteristics of Survey Respondents | 43 3.5 WOMEN’S EMPOWERMENT In addition to information on women’s education, employment status, and control over earnings, the 2003 GDHS collected information from both women and men on other measures of women’s empowerment. Respondents were asked about women’s role in household decisionmaking, their acceptance of wife-beating, and their opinions about whether a wife can deny sex to her husband for certain specified reasons. Such information provides insight into women’s control over their environment and their attitudes towards gender roles, both of which are relevant to understanding women’s ability to make independent decisions about their own health care and that of their children’s. 3.5.1 Women’s Participation in Decisionmaking In order to assess women’s weight in household decisionmaking, women were asked who in their family usually has the final say on five different types of decisions, namely: their own health care, large household purchases, daily household purchases, visits to family or relatives, and what food to cook each day. The percent distribution of women according to the person who usually has the final say in different decisions is shown in Table 3.10. The data are presented separately for women who are currently married and women who have never married or who are divorced, separated, or widowed. Table 3.10 Women's participation in decisionmaking Percent distribution of women by person who has the final say in making specific decisions, according to current marital status and type of decision, Ghana 2003 Currently married or living together Not married1 Decision Woman only Jointly with hus- band Jointly with some- one else Hus- band only Some- one else only Decision not made/not applica- ble Total Num- ber of women Woman only Jointly with some- one else Some- one else only Decision not made/not applicable Total Num- ber of women Own health care 37.0 20.6 0.9 34.9 6.6 0.0 100.0 3,549 33.1 7.3 58.6 1.0 100.0 2,142 Large household purchases 20.9 30.2 1.5 40.9 6.3 0.2 100.0 3,549 25.5 5.9 66.4 2.2 100.0 2,142 Daily household purchases 28.8 32.3 1.4 31.8 5.5 0.2 100.0 3,549 26.5 5.8 65.4 2.3 100.0 2,142 Visits to family or relatives 20.9 37.9 1.5 33.7 5.4 0.5 100.0 3,549 29.6 6.1 62.0 2.3 100.0 2,142 What food to cook each day 39.9 26.5 1.7 26.1 5.6 0.2 100.0 3,549 27.0 7.8 63.1 2.1 100.0 2,142 Note: Percentages may not add to 100 due to the exclusion of women with missing information. 1 Never-married, divorced, separated or widowed women The data show that the majority of Ghanaian women, irrespective of their marital status, do not have sole authority over any of the five main household decisions. Thirty-one percent of all women, irrespective of their marital status, have no final say in any of the decisions, while 35 percent of women have a final say in all the five decisions (Figure 3.3). Among unmarried women, decisionmaking is highly dominated by someone else (59-66 percent), while among married women, decisionmaking is somewhat dominated by husbands (26-41 percent). Married women also report that decisionmaking is made jointly with their husband (21-38 percent). Especially disconcerting is the fact that most women do not have sole authority over their own health care. Only about one-third of married and unmarried women make sole decisions about their own health care. A third of married women report that their husbands make sole decisions about their health care and three-fifths of unmarried women report that someone else makes 44 | Characteristics of Survey Respondents sole decisions about their health care. One-fifth of married women report that decisions on their own health care are made jointly with their husbands. Forty-one percent of married women report that their husbands alone decide on large household purchases compared with 21 percent of women who report that they alone are the sole decisionmakers on large household purchases, and 30 percent of women who report it to be a joint decision. Among the five decisions, married women seem to have the greatest say over what to cook each day (40 percent), while unmarried women have the greatest say over their own health care (33 percent). Joint decisions with husbands are especially important when it comes to visiting family or relatives (38 percent). Table 3.11 shows the percentage of women who say that they alone or jointly with someone else have the final say in the five specific household decisions, by background characteristics. More than one- third of women say that they alone or jointly with someone else have the final say in all five decisions. The data show that women’s participation in decisionmaking rises with age. Women who are divorced, separated, or widowed are more likely to participate in decisionmaking than currently married women. Decisionmaking among women also rises with the number of children she has, indicating her greater involvement in decisions that may have an impact on the welfare of her children. There are no significant differences in decisionmaking by urban-rural place of residence and women’s education. Women’s involvement in decisionmaking is highest in the Central region and lowest in the Upper East. Employed women who receive cash earnings are more likely to have a greater say in all five decisions than unemployed women and those who are employed but not for cash. Women in the lowest wealth quintile are least likely to report involvement in all five decisions, but beyond that there is little difference among higher wealth quintiles. 31 12 7 8 7 35 None 1 2 3 4 5 Number of decisions in which woman participates in final say 0 10 20 30 40 Pe rc en ta ge o f w om en Figure 3.3 Women’s Participation in Decisionmaking: Number of Decisions in Which Women Participate in the Final Say, Based on Five Household Decisions GDHS 2003 Characteristics of Survey Respondents | 45 Table 3.11 Women's participation in decisionmaking by background characteristics Percentage of women who say that they alone or jointly have the final say in specific decisions, by background characteristics, Ghana 2003 Alone or jointly has final say in: Background characteristic Own health care Making large pur- chases Making daily pur- chases Visits to family or relatives What food to cook each day All specified decisions None of the specified decisions Number of women Age 15-19 18.1 8.8 9.4 11.5 13.1 6.8 75.9 1,148 20-24 44.7 32.8 38.4 41.4 42.3 25.3 39.5 1,012 25-29 58.6 49.3 58.3 59.1 64.9 37.6 18.8 951 30-34 65.0 59.3 67.0 65.3 71.8 46.4 14.8 802 35-39 65.0 62.8 73.6 69.8 76.6 51.3 12.5 722 40-44 67.6 65.9 72.5 70.9 76.3 53.1 12.3 579 45-49 71.3 67.7 78.1 74.3 82.6 57.7 9.8 477 Marital status Never married 26.6 16.0 16.5 21.0 19.2 13.5 67.8 1,616 Married or living together 58.5 52.6 62.5 60.4 68.1 39.9 17.7 3,549 Divorced/separated/ widowed 82.8 78.4 80.9 80.8 82.4 72.6 9.8 526 Number of living children 0 30.9 20.1 22.5 26.5 25.2 16.7 60.5 1,872 1-2 58.1 52.0 59.4 58.3 64.9 40.5 21.6 1,602 3-4 63.5 58.5 67.5 63.9 72.0 44.9 14.5 1,227 5+ 65.8 61.6 71.7 70.0 77.2 50.9 12.2 990 Residence Urban 51.6 45.9 49.9 50.0 52.5 37.3 34.9 2,755 Rural 51.7 43.3 52.3 52.0 58.4 33.7 27.7 2,936 Region Western 51.4 43.3 50.3 52.4 63.2 35.4 27.6 553 Central 69.7 63.5 66.1 64.4 68.1 57.3 23.2 431 Greater Accra 49.1 45.5 48.8 51.0 50.4 38.9 39.8 942 Volta 27.2 32.9 41.3 43.2 44.0 17.7 40.6 492 Eastern 69.7 60.6 62.8 64.4 66.5 55.3 23.2 601 Ashanti 56.8 51.0 56.0 56.2 60.8 37.8 26.8 1,142 Brong Ahafo 53.1 51.9 54.9 54.8 55.8 43.9 36.5 569 Northern 34.9 26.9 49.8 43.9 53.4 13.6 28.6 499 Upper East 53.2 9.3 14.0 10.3 24.4 6.1 29.8 310 Upper West 32.7 18.5 42.8 35.9 47.0 13.7 40.7 153 Education No education 53.1 41.1 53.6 51.0 60.3 31.5 22.5 1,608 Primary 52.2 47.4 52.7 53.0 57.1 38.6 32.7 1,135 Middle/JSS 50.9 47.2 50.9 50.5 53.6 37.2 34.8 2,279 Secondary+ 49.8 39.2 43.4 49.7 47.7 33.4 37.4 669 Employment Not employed 27.0 17.1 19.5 23.9 25.8 13.5 62.4 1,412 Employed for cash 63.8 58.7 67.1 65.4 70.2 46.9 16.3 3,708 Employed not for cash 33.2 20.3 25.5 24.8 33.3 14.5 51.0 565 Wealth quintile Lowest 46.4 33.0 45.2 41.4 50.3 25.0 30.5 970 Second 53.5 46.5 54.6 55.2 61.2 36.8 27.6 949 Middle 55.4 47.7 52.9 53.7 58.0 37.5 28.9 1,071 Fourth 51.3 48.9 54.7 54.0 57.7 39.7 31.3 1,245 Highest 51.5 45.0 48.5 50.3 51.6 36.3 35.7 1,457 Total 51.7 44.6 51.2 51.1 55.5 35.4 31.2 5,691 Note: Total includes 6 women with missing information on employment who are not shown separately. 46 | Characteristics of Survey Respondents 3.5.2 Attitudes toward Wife-beating Violence against women is receiving considerable attention because it has serious consequences for mental and physical well-being, including their reproductive and sexual health (WHO, 1999). To assess the acceptability of domestic violence, respondents interviewed in the 2003 GDHS were asked whether they thought a husband is justified in hitting or beating his wife for any of the following reasons: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual relations with him. The data on attitude toward wife-beating are shown in Tables 3.12.1 and 3.12.2 for women and men, respectively. Nearly one in two women believe that a husband is justified in beating his wife for at least one of the specified reasons (Table 3.12.1). Thirty-seven percent of women believe that a husband is justified in beating his wife if she neglects the children, while one in three women think wife-beating is justified if a wife goes out without telling her husband, and 30 percent believe that wife-beating is justified if she argues with her husband. Twenty percent and 14 percent of women, respectively, believe that a man is justified in beating his wife if she burns the food or refuses to have sex with him. Surprisingly, younger women, who are presumably more educated, are more likely than older women to agree with at least one reason for wife-beating. Currently married women are slightly more likely than never-married or formerly married women to accept wife-beating. Women who reside in rural areas and in the more conservative northern regions are much more likely than urban women and women in the other regions to accept wife-beating for at least one reason. As a woman’s level of education or wealth rises, she is less likely to agree that wife-beating is justified for any reason. There is no clear relationship between attitudes towards wife-beating and women’s employment status or decisionmaking power. Men were also asked their opinions about wife-beating to understand attitudes that may prompt male violence against women (Table 3.12.2). Interestingly, men (32 percent) are less likely than women (49 percent) to feel that wife-beating is justified for at least one reason, and are much less likely to agree that wife-beating is justified for each of the five specific reasons. Characteristics of Survey Respondents | 47 Table 3.12.1 Women's attitude toward wife-beating Percentage of women who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteris- tics, Ghana 2003 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without tell- ing him Neglects the children Refuses to have sex with him Percentage who agree with at least one of the specified reasons Number of women Age 15-19 13.2 27.0 34.5 36.7 16.4 50.6 1,148 20-24 14.2 29.7 34.5 38.1 19.1 48.4 1,012 25-29 13.9 30.9 33.9 39.3 20.8 51.0 951 30-34 15.7 32.3 37.3 39.4 24.5 50.4 802 35-39 13.9 30.0 31.6 36.7 20.8 47.9 722 40-44 11.2 26.8 32.8 32.9 19.5 42.9 579 45-49 14.8 29.5 31.5 33.3 20.1 43.6 477 Marital status Never married 10.5 22.0 29.2 32.0 13.8 44.1 1,616 Married or living together 15.8 33.1 36.6 39.9 23.0 51.0 3,549 Divorced/separated/widowed 11.6 28.0 31.2 33.6 18.2 45.5 526 Number of living children 0 11.0 24.1 30.2 32.3 15.0 45.0 1,872 1-2 15.6 32.3 36.1 39.5 20.7 50.8 1,602 3-4 14.8 30.8 36.5 39.9 22.8 49.6 1,227 5+ 15.4 33.2 34.7 38.6 24.5 50.5 990 Residence Urban 8.9 24.3 28.4 30.8 15.5 41.6 2,755 Rural 18.5 34.3 39.2 42.9 24.1 55.1 2,936 Region Western 16.5 29.8 37.0 38.7 20.6 52.9 553 Central 6.1 39.9 38.7 48.0 19.8 56.2 431 Greater Accra 5.7 13.5 20.1 23.3 8.1 30.3 942 Volta 9.4 16.4 20.0 26.2 9.7 37.6 492 Eastern 12.7 28.3 30.6 31.3 14.6 46.4 601 Ashanti 7.5 27.9 30.5 33.5 17.8 44.2 1,142 Brong Ahafo 8.9 19.6 27.8 19.7 13.3 38.5 569 Northern 37.4 53.1 62.0 68.4 48.5 76.3 499 Upper East 41.3 56.7 61.5 70.0 50.7 81.2 310 Upper West 29.2 59.1 56.0 65.6 30.0 80.6 153 Education No education 23.9 43.4 46.7 51.4 33.0 62.3 1,608 Primary 15.4 30.8 37.8 40.6 20.3 54.4 1,135 Middle/JSS 8.9 23.3 29.0 31.0 13.9 42.8 2,279 Secondary+ 4.0 14.6 13.7 17.5 8.5 25.0 669 Employment Not employed 12.6 26.7 31.2 34.3 16.5 47.2 1,412 Employed for cash 13.2 29.4 33.2 36.0 19.9 46.9 3,708 Employed not for cash 21.6 36.9 46.2 51.3 28.2 62.9 565 Number of decisions in which woman has final say1 0 14.0 26.8 32.5 36.4 16.9 48.1 1,777 1-2 21.6 36.9 41.5 46.5 26.0 58.2 1,055 3-4 14.1 30.8 36.4 39.1 22.1 50.0 842 5 9.7 27.3 30.3 32.0 18.5 43.3 2,017 Wealth quintile Lowest 28.5 45.0 49.2 54.0 35.5 67.2 970 Second 17.3 32.3 40.4 41.7 22.4 55.2 949 Middle 12.9 29.8 33.8 37.7 18.8 49.6 1,071 Fourth 10.3 27.6 30.4 34.0 16.8 46.6 1,245 Highest 5.7 18.6 22.9 25.0 11.5 32.7 1,457 Total 13.9 29.5 34.0 37.1 19.9 48.5 5,691 Note: Total includes 6 women with missing information on employment who are not shown separately. 1 Either by herself or jointly with others 48 | Characteristics of Survey Respondents Table 3.12.2 Men's attitude toward wife-beating Percentage of men who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteris- tics, Ghana 2003 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without tell- ing him Neglects the children Refuses to have sex with him Percentage who agree with at least one of the specified reasons Number of men Age 15-19 12.3 21.4 26.3 32.6 14.3 43.8 1,107 20-24 9.8 17.0 21.0 23.9 12.0 34.7 684 25-29 6.4 16.2 21.1 26.2 8.7 34.1 754 30-34 8.3 14.2 18.9 21.4 9.3 28.7 633 35-39 5.7 12.6 16.6 21.1 7.8 27.5 498 40-44 4.0 11.7 12.7 14.9 6.5 21.8 412 45-49 6.2 12.7 15.8 17.4 8.0 23.3 441 50-54 4.9 11.7 15.3 17.7 8.3 23.6 294 55-59 5.6 14.0 15.6 15.0 9.4 24.3 192 Marital status Never married 9.9 18.2 22.2 26.8 12.1 36.7 2,042 Married or living together 6.9 14.4 18.3 21.6 9.1 28.9 2,671 Divorced/separated/widowed 4.8 12.2 16.8 19.0 6.2 28.3 302 Number of living children 0 9.8 17.9 22.3 27.2 12.3 36.8 2,300 1-2 6.9 14.8 19.6 21.8 7.9 30.5 981 3-4 5.0 11.8 15.5 19.5 7.4 24.9 816 5+ 7.4 15.2 17.7 19.8 9.4 27.9 917 Residence Urban 5.2 12.0 15.3 17.5 7.1 25.0 2,250 Rural 10.3 18.9 23.5 28.5 12.6 37.8 2,765 Region Western 12.7 25.3 25.1 30.7 14.2 41.7 476 Central 6.0 12.5 20.3 20.5 7.8 29.8 370 Greater Accra 3.0 7.9 9.1 12.0 4.7 16.5 733 Volta 4.8 6.6 10.3 12.7 3.5 18.5 440 Eastern 5.1 12.3 14.9 17.9 5.8 23.1 539 Ashanti 3.3 9.0 12.1 13.4 5.9 21.6 956 Brong Ahafo 5.0 13.0 19.5 18.0 6.2 29.8 528 Northern 22.9 34.4 45.7 54.8 32.0 65.4 527 Upper East 14.1 27.7 28.1 41.2 14.3 54.3 317 Upper West 19.0 37.8 44.5 59.0 20.8 69.2 130 Education No education 15.1 27.4 33.4 41.2 22.0 50.9 881 Primary 13.1 23.8 29.3 32.6 15.4 46.4 803 Middle/JSS 5.7 13.3 16.7 19.6 6.6 27.8 2,165 Secondary+ 3.4 6.2 8.6 11.3 4.0 15.7 1,165 Employment Not employed 8.9 15.3 20.0 25.7 11.0 35.4 1,224 Employed for cash 7.1 14.9 18.7 21.5 9.0 29.0 3,448 Employed not for cash 13.9 27.3 29.7 36.7 18.2 50.2 341 Number of decisions in which wife has say1 0 9.4 17.6 21.8 25.8 11.7 35.3 3,386 1-2 7.4 15.5 18.6 24.5 10.2 32.0 713 3-4 3.3 9.2 13.2 14.1 4.9 19.0 674 5 3.2 9.6 13.7 16.5 2.3 22.2 242 Wealth index Lowest 16.4 27.0 32.1 41.2 19.1 52.8 872 Second 8.5 17.3 22.7 25.4 12.3 35.0 903 Middle 8.9 16.8 23.3 25.0 9.9 33.8 975 Fourth 5.6 12.8 14.6 18.9 7.4 27.3 1,060 Highest 2.9 8.3 10.4 12.4 4.5 17.4 1,204 Total 8.0 15.8 19.8 23.6 10.1 32.0 5,015 Note: Total includes 2 men with missing information on employment who are not shown separately. 1 Either by herself or jointly with others Characteristics of Survey Respondents | 49 3.5.3 Attitudes toward Refusing Sex Women’s rights and control over their own sexuality are important aspects of their empowerment. In addition, their control over when and with whom they have sex has an impact on their health, especially with respect to the transmission of STIs such as HIV/AIDS. Respondents in the GDHS were asked whether a wife is justified in refusing sex when: she knows that her husband has a sexually transmitted disease; she knows that her husband has sex with other women; she has recently given birth; and when she is tired or not in the mood for sex. Tables 3.13.1 and 3.13.2 show the percentage of women and men who believe that a wife is justified in refusing to have sex with her husband for these specified reasons, by background characteristics. Sexual autonomy is relatively high among Ghanaian women. Nearly two-thirds of women and men agree that women are justified in denying sex to their husbands for all four reasons, with little variation between women and men by background characteristics. Women and men who reside in rural areas, those who live in the Upper West region, poorly educated respondents, and respondents from the lowest wealth quintile are somewhat less likely than their counterparts to agree that a woman is justified in refusing sex with her husband for all four reasons. There is no clear relationship between women’s sexual autonomy and her decisionmaking power or beliefs about wife-beating. Male respondents in the 2003 GDHS were also asked whether they thought that a husband had the right to take specific actions—get angry and reprimand her, to refuse to give her money or other means of financial support, to use force and have sex with her even if she does not want to, and to have sex with another woman—if his wife refused to have sex with him. Table 3.14 shows that one in four men agree with at least one of the four specified actions. Fifteen percent of men say it is justifiable for men to get angry and reprimand the wife, 12 percent say it is okay to have sex with another woman, 10 percent say it is justifiable to refuse financial support, and 5 percent say it is acceptable to use force if she refuses to have sex with him. Differences by background characteristics are not large. However, men in the youngest cohort (15-19), rural men, men in the Upper West and Northern regions, men with no education, men who are employed but not for cash, and men in the lowest wealth quintile are less tolerant of women’s sexual autonomy than other men. 50 | Characteristics of Survey Respondents Table 3.13.1 Women's attitude toward wives refusing sex with husbands Percentage of women who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteris- tics, Ghana 2003 Wife is justified in refusing sex with husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has sex with other women Has recently given birth Is tired or not in the mood Percentage who agree with all of the speci- fied reasons Percentage who agree with none of the specified reasons Number of women Age 15-19 84.7 79.1 79.1 73.1 63.0 9.8 1,148 20-24 86.5 81.8 85.0 75.2 62.5 6.2 1,012 25-29 86.4 78.8 84.4 74.4 62.4 8.0 951 30-34 84.9 76.8 84.5 74.9 61.1 6.0 802 35-39 86.5 76.7 82.8 72.6 62.1 8.7 722 40-44 88.6 79.7 86.4 76.8 65.9 6.2 579 45-49 87.4 79.4 86.1 74.7 63.4 7.6 477 Marital status Never married 86.0 80.2 80.3 72.7 62.7 8.8 1,616 Married or living together 85.8 77.8 84.1 74.4 61.8 7.5 3,549 Divorced/separated/widowed 89.6 83.5 90.3 79.6 69.6 4.8 526 Number of living children 0 86.4 80.8 82.3 74.0 63.3 7.8 1,872 1-2 85.8 78.3 84.3 75.5 62.1 7.2 1,602 3-4 86.1 77.9 84.1 73.3 62.2 7.9 1,227 5+ 86.6 78.0 84.1 74.7 63.5 7.8 990 Residence Urban 88.1 81.2 84.4 76.3 63.9 6.6 2,755 Rural 84.4 76.9 82.8 72.6 61.7 8.6 2,936 Region Western 92.3 85.3 90.4 79.4 68.9 2.8 553 Central 87.4 88.5 87.2 60.9 51.9 4.6 431 Greater Accra 87.7 81.5 86.0 77.9 67.5 7.2 942 Volta 82.9 76.3 76.9 74.5 61.3 12.8 492 Eastern 80.3 81.2 83.7 75.8 66.3 10.0 601 Ashanti 85.9 74.7 81.2 74.6 62.1 9.4 1,142 Brong Ahafo 84.4 80.4 83.8 78.6 67.6 8.2 569 Northern 83.3 72.9 79.7 68.8 54.5 7.7 499 Upper East 95.5 72.9 88.0 79.2 63.1 0.9 310 Upper West 83.7 73.5 74.9 57.8 45.5 8.3 153 Education No education 84.5 73.2 81.7 69.4 56.0 8.2 1,608 Primary 83.3 78.9 82.1 74.2 63.0 9.8 1,135 Middle/JSS 88.0 82.0 84.6 77.2 66.5 6.9 2,279 Secondary+ 88.8 82.6 87.0 77.0 65.9 4.9 669 Employment Not employed 86.7 80.8 82.9 75.1 63.6 7.3 1,412 Employed for cash 86.3 79.5 84.6 75.1 63.6 7.5 3,708 Employed not for cash 84.2 71.3 78.6 67.8 55.2 8.9 565 Number of decisions in which woman has final say1 0 84.9 78.2 79.8 73.6 62.8 9.5 1,777 1-2 84.4 73.0 83.2 72.0 57.8 7.9 1,055 3-4 87.0 78.6 81.8 70.3 59.2 7.4 842 5 87.9 83.0 87.8 78.0 66.9 5.9 2,017 Number of reasons wife-beating is justified 0 85.3 79.5 83.4 74.5 64.5 8.9 2,928 1-2 85.8 77.0 81.3 73.5 59.7 7.7 1,279 3-4 88.2 77.1 85.4 72.2 58.0 4.7 1,047 5 88.4 85.7 87.3 81.1 71.5 5.9 437 Wealth quintile Lowest 86.2 75.3 83.6 73.0 60.7 7.1 970 Second 83.7 76.0 80.7 72.4 62.0 9.7 949 Middle 83.5 80.0 81.8 72.2 62.1 9.4 1,071 Fourth 86.2 79.5 82.8 74.7 62.0 8.0 1,245 Highest 89.7 82.2 87.4 78.0 65.8 5.0 1,457 Total 86.2 79.0 83.6 74.4 62.8 7.6 5,691 Note: Total includes 6 women with missing information on employment who are not shown separately. 1 Either by herself or jointly with others Characteristics of Survey Respondents | 51 Table 3.13.2 Men's attitude toward wives refusing sex with husbands Percentage of men who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteristics, Ghana 2003 Wife is justified in refusing sex with husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has sex with other women Has recently given birth Is tired or not in the mood Percentage who agree with all of the speci- fied reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 85.8 78.9 82.4 73.6 60.3 5.8 1,107 20-24 91.6 80.8 87.1 78.2 63.4 3.9 684 25-29 91.9 85.2 91.1 83.1 68.8 1.5 754 30-34 93.4 86.9 90.7 84.4 73.0 2.2 633 35-39 93.2 82.7 89.2 81.8 68.4 1.4 498 40-44 95.3 86.2 90.8 80.8 68.7 0.9 412 45-49 88.0 82.0 88.3 82.3 66.2 2.9 441 50-54 90.9 80.3 88.4 82.6 68.5 3.0 294 55-59 89.1 81.7 90.0 76.1 66.1 4.1 192 Marital status Never married 88.5 81.0 85.1 76.2 62.9 4.6 2,042 Married or living together 92.1 84.1 90.1 82.5 69.2 2.0 2,671 Divorced/separated/widowed 91.3 79.2 88.1 80.6 63.9 3.1 302 Number of living children 0 89.1 81.1 85.7 76.7 62.7 4.1 2,300 1-2 92.3 83.2 89.6 82.6 69.5 2.4 981 3-4 93.1 84.7 91.3 84.0 71.4 1.3 816 5+ 90.4 83.4 88.7 80.8 67.4 3.0 917 Residence Urban 92.1 84.4 89.6 83.2 69.9 2.5 2,250 Rural 89.4 81.0 86.5 77.1 63.4 3.6 2,765 Region Western 88.2 81.4 87.9 79.7 63.4 2.9 476 Central 95.0 83.4 86.9 77.6 64.9 3.3 370 Greater Accra 93.0 86.4 92.7 84.4 73.5 2.3 733 Volta 92.2 80.4 90.2 78.7 61.1 1.3 440 Eastern 89.2 88.2 94.1 88.1 78.9 3.1 539 Ashanti 90.8 82.1 87.0 83.6 70.4 3.1 956 Brong Ahafo 89.3 83.9 87.9 76.4 64.5 3.2 528 Northern 88.8 77.9 80.1 69.6 55.6 5.8 527 Upper East 88.3 79.9 84.5 79.7 60.9 2.9 317 Upper West 90.5 69.5 77.7 57.8 40.0 3.5 130 Education No education 88.1 76.5 83.4 71.8 57.7 4.5 881 Primary 88.2 78.6 83.5 74.0 60.2 4.6 803 Middle/JSS 90.6 84.3 89.3 81.7 68.0 2.8 2,165 Secondary+ 94.1 86.5 91.9 86.3 73.9 1.6 1,165 Employment Not employed 88.6 81.9 85.8 77.2 64.1 3.6 1,224 Employed for cash 91.8 83.5 89.2 81.4 68.2 2.6 3,448 Employed not for cash 85.0 75.6 82.3 72.8 55.9 6.7 341 Number of decisions in which woman has final say1 0 89.3 81.1 85.6 77.7 63.6 3.9 3,386 1-2 92.1 80.6 91.0 78.3 63.6 1.9 713 3-4 94.0 88.9 93.9 88.9 78.2 1.0 674 5 94.6 90.4 94.8 88.1 78.5 0.8 242 Number of reasons wife-beating is justified 0 91.6 84.1 89.9 83.6 70.5 2.8 3,409 1-2 88.8 77.9 83.6 72.2 56.9 3.5 930 3-4 87.4 80.5 83.3 70.6 55.2 3.2 516 5 91.3 84.0 85.0 73.5 66.7 5.8 160 Wealth quintile Lowest 86.3 77.9 82.6 72.8 58.7 5.9 872 Second 90.8 82.2 87.2 76.7 64.3 2.9 903 Middle 91.0 82.7 86.9 78.6 64.9 2.4 975 Fourth 89.5 82.3 86.7 80.1 65.7 3.6 1,060 Highest 94.1 86.2 94.2 88.0 75.0 1.4 1,204 Total 90.6 82.5 87.9 79.8 66.3 3.1 5,015 Note: Total includes 2 men with missing information on employment who are not shown separately. 1 Either by herself or jointly with others 52 | Characteristics of Survey Respondents Table 3.14 Men's attitudes towards justifiable actions if wife refuses sex Percentage of men who believe a wife's refusal of sex justifies specific actions, by background characteristics, Ghana 2003 Husband's justifiable actions if wife refuses sex: Background characteristic Getting angry Refusing money Using force Having sex with another woman Percentage who agree with at least one of the speci- fied reasons Number of men Age 15-19 16.4 12.6 5.4 14.6 29.2 1,107 20-24 15.3 7.5 3.3 10.6 25.2 684 25-29 14.2 9.6 4.1 11.6 23.0 754 30-34 16.2 9.0 4.6 9.2 25.4 633 35-39 13.8 7.3 6.3 9.3 22.6 498 40-44 15.6 9.1 3.2 10.7 24.8 412 45-49 15.6 9.2 3.7 10.8 25.1 441 50-54 14.6 10.4 5.2 11.9 24.6 294 55-59 14.2 6.0 7.0 12.8 24.3 192 Marital status Never married 15.7 10.2 4.4 12.5 26.1 2,042 Married or living together 15.1 9.1 5.0 10.7 24.9 2,671 Divorced/separated/ widowed 15.0 8.0 2.6 12.6 25.1 302 Number of living children 0 15.5 9.7 4.4 12.1 25.7 2,300 1-2 16.1 8.7 4.3 10.6 25.8 981 3-4 14.2 9.8 5.1 11.3 24.6 816 5+ 15.1 9.5 5.1 11.3 25.0 917 Residence Urban 12.5 6.7 2.6 8.7 20.0 2,250 Rural 17.6 11.8 6.3 13.8 29.8 2,765 Region Western 23.2 10.4 3.5 11.9 31.4 476 Central 9.6 4.2 1.7 7.9 15.4 370 Greater Accra 12.0 5.0 1.9 5.5 17.1 733 Volta 17.3 6.6 1.1 9.5 25.1 440 Eastern 10.4 8.2 5.9 10.7 18.1 539 Ashanti 8.2 9.3 2.8 8.3 18.7 956 Brong Ahafo 15.5 11.2 8.5 18.3 35.5 528 Northern 27.0 18.1 12.1 22.6 41.4 527 Upper East 17.0 12.4 5.4 10.9 28.4 317 Upper West 35.7 14.1 5.0 17.7 47.2 130 Education No education 20.6 15.7 9.5 17.6 35.0 881 Primary 19.1 11.4 6.9 15.4 32.3 803 Middle/JSS 13.4 8.5 3.4 9.7 22.8 2,165 Secondary + 12.3 5.4 1.7 7.6 18.3 1,165 Employment Not employed 14.5 10.2 3.4 12.6 26.2 1,224 Employed for cash 14.8 8.8 4.8 10.5 24.1 3,448 Employed not for cash 23.3 14.5 6.9 17.9 35.3 341 Wealth quintile Lowest 22.0 15.8 9.6 18.3 37.8 872 Second 16.3 12.2 6.1 13.2 29.6 903 Middle 15.5 9.4 4.2 11.4 25.2 975 Fourth 12.3 7.9 2.4 10.7 20.8 1,060 Highest 12.3 4.4 2.2 6.2 17.5 1,204 Total 15.3 9.5 4.6 11.5 25.4 5,015 Note: Total includes 2 men with missing information on employment who are not shown separately. Fertility | 53 FERTILITY 4 One of the main challenges facing Ghana in the 1950s was high fertility. Ghana introduced its first Population Policy in 1969 to address the problem of high fertility and escalating growth rates in the face of declining mortality. After 25 years of little progress, the Population Policy was revised in 1994 to include a systematic integration of population in development planning with renewed emphasis on fertility deceleration to keep pace with resource generation. Since then, Ghana has made significant progress in reducing its fertility. An important aspect of the demographic and health surveys conducted in the country has been the collection of birth history information to enhance data availability for monitoring the progress in fertility decline. This chapter presents the 2003 GDHS results on fertility levels, trends, and differentials. The analysis is based on the birth histories collected from women age 15-49 interviewed during the survey. To obtain this information, women were first asked a series of questions to determine the total number of live births they had in their lifetime. For each live birth, information was then collected on the age, sex, and survival status of the child. For dead children, age at death was recorded. Information from the birth history is used to assess current and completed fertility and to look at other factors related to fertility, including age at first birth, birth intervals, and teenage childbearing. The following measures of current fertility are derived from birth history data: • Age-specific fertility rates (ASFR) are expressed as the number of births per thousand women in the age group and represent a valuable measure for assessing the current age pattern of childbearing. They are defined in terms of the number of live births during a specified period to women in the particular age group divided by the number of woman-years lived in that age group during the specified period. • Total fertility rate (TFR) is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed rates of age-specific fertility. The TFR is obtained by summing the age- specific fertility rates and multiplying by five. • General fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women age 15-44. • Crude birth rate (CBR) is the number of births per 1,000 population during a specified period. The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to the calendar period 2001-2003. A three-year period was chosen because it reflects the current situation, while also allowing the rates to be calculated on a sufficient number of cases so as not to compromise the statistical precision of estimates. 4.1 FERTILITY LEVELS AND TRENDS 4.1.1 Fertility Levels Table 4.1 presents information on the current fertility levels for Ghana as a whole and for urban and rural areas. The table shows that the prime reproductive years among Ghanaian women are during 54 | Fertility their twenties and early thirties. Urban-rural differences in childbearing rates are evident for all age groups, but are especially large in the 20s. With a TFR of 4.4, Ghana’s fertility rate is one of the lowest in sub-Saharan Africa, as the comparison in Figure 4.1 indicates. On average, a Ghanaian woman who is at the beginning of her childbearing years will give birth to 4.4 children by the end of her reproductive period if fertility levels remain constant at the levels observed in the three-year period before the 2003 GDHS. The TFR for rural areas (5.6 births) is more than two births higher than the rate for urban areas (3.1 births). The general fertility rate is 146. This means that there were 146 births for every 1,000 women during the three-year period preceding the survey. The table also shows a crude birth rate of 33 per 1,000 population for the period under review. Figure 4.1 Total Fertility Rates, Ghana and Selected Sub-Saharan Countries 7.2 6.9 6.4 6.3 5.9 5.7 5.5 5.5 5.2 5.2 5.0 4.8 4.4 4.2 4.0 2.9 Ni ge r 1 99 8 Ug an da 20 00 Bu rki na Fa so 19 98 -9 9 M ala wi 20 00 Za mb ia 20 01 -0 2 Ni ge ria 20 03 Eth iop ia 20 00 Gu ine a 1 99 9 Cô te d’I vo ire 19 98 -9 9 To go 19 98 Ke ny a 2 00 3 Ca me roo n 1 99 8 Gh an a 2 00 3 Ga bo n 2 00 0 Zim ba bw e 1 99 9 So uth A fric a 1 99 8 4.1.2 Differentials in Current and Completed Fertility Table 4.2 presents differentials in the TFR and the percentage of women who are currently preg- nant, by key background characteristics. The percentage currently pregnant provides a useful measure of Table 4.1 Current fertility Age-specific and cumulative fertility rates, the general fer- tility rate, and the crude birth rate for the three years pre- ceding the survey, by urban-rural residence, Ghana 2003 Residence Age group Urban Rural Total 15-19 42 113 74 20-24 128 225 176 25-29 157 256 210 30-34 145 213 182 35-39 95 179 141 40-44 39 95 70 45-49 18 49 36 TFR 3.1 5.6 4.4 GFR 102 188 146 CBR 26.6 36.7 32.6 Note: Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate for ages 15-49, expressed per woman GFR: General fertility rate (births divided by the number of women age 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility | 55 current fertility. However, it may not capture all pregnant women since some women may be unaware of their pregnancy, or reluctant to disclose a pregnancy in its early stages. The table also shows differentials in the mean number of children ever born to women age 40-49, that is, to women who are at the end of their childbearing years, which is a measure of completed or past fertility. The mean number of children ever born can be com- pared with the current TFR in order to assess the extent of fertility change over the last two decades in Ghana. Table 4.2 and Figure 4.2 show that regional variations in fertility are marked, ranging from a high of 7.0 births in the Northern region to a low of 2.9 births in Greater Accra. The TFR is inversely related to the level of education. On average, women with no education (6.0) give birth to more than twice as many children as women with at least secondary education (2.5). Fertility also decreases with increasing wealth, from 6.4 births among women in the lowest wealth quintile to 2.8 births among women in the highest wealth quintile. Seven percent of women are cur- rently pregnant. Rural women are almost twice as likely to be pregnant at the time of the interview as urban women. Current preg- nancy is highest in the Northern region and lowest in Greater Accra. The percentage of women currently pregnant declines as level of education rises and is highest among the poorest segment of women and lowest among the richest. Women age 40-49 have given birth to an average of 5.5 children. A comparison of the TFR and cumulative fertility indicates that there has been a decrease in fertility over time among women in all groups except among women in the Northern region and women in the lowest wealth quintile. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, per- centage of women 15-49 currently pregnant, and mean num- ber of children ever born to women age 40-49 years, by back- ground characteristics, Ghana 2003 Background characteristic Total fertil- ity rate1 Percentage currently pregnant1 Mean num- ber of chil- dren ever born to women age 40-49 Residence Urban 3.1 5.1 4.8 Rural 5.6 9.5 6.1 Region Western 4.5 7.1 5.5 Central 5.0 8.3 6.5 Greater Accra 2.9 4.0 3.9 Volta 4.4 6.9 5.3 Eastern 4.3 7.3 5.8 Ashanti 4.1 7.6 5.7 Brong Ahafo 4.8 7.0 5.6 Northern 7.0 13.0 6.7 Upper East 4.7 7.9 5.7 Upper West 5.5 8.7 6.4 Education No education 6.0 10.1 6.3 Primary 5.3 8.3 6.0 Middle/JSS 3.5 6.1 5.0 Secondary+ 2.5 3.6 3.1 Wealth quintile Lowest 6.4 10.5 6.3 Second 5.9 8.1 6.6 Middle 4.9 9.3 5.9 Fourth 3.3 6.8 5.3 Highest 2.8 3.9 3.8 Total 4.4 7.4 5.5 1 Women age 15-49 years 56 | Fertility 4.4 3.1 5.6 4.5 5.0 2.9 4.4 4.3 4.1 4.8 7.0 4.7 5.5 6.0 5.3 3.5 2.5 GHANA RESIDENCE Urban Rural REGION Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West EDUCATION No education Primary Middle/JSS Secondary+ 0.0 2.0 4.0 6.0 8.0 Number of births Figure 4.2 Total Fertility Rate by Background Characteristics GDHS 2003 4.1.3 Trends in Fertility Besides the comparison of current and completed fertility, fertility trends in Ghana can be assessed in sev- eral other ways. Fertility trends can be observed using retrospective data from the birth histories collected from respondents in a single survey. The TFR from the 2003 GDHS can also be compared with estimates obtained in earlier surveys or censuses. Table 4.3 presents the trend in age-specific fertil- ity rates for successive five-year periods before the sur- vey, generated from the birth history data collected in the 2003 GDHS. The numerators of the births are classified by five-year segments of time preceding the survey and the mother’s age at the time of birth. Because women 50 years and over were not interviewed in the survey, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years and more prior to the sur- vey, because women in that age group would have been 50 years or older at the time of the survey. Par- tially truncated rates are enclosed in brackets in the table. Table 4.3 confirms the substantial decline in fertility over the last two decades. This decline is most obvious in the last three five-year periods preceding the survey, with the largest decline observed between the 10-14 year and 5-9 year periods before the survey. Fertility decline was steepest among the youngest cohort. Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Ghana 2003 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 74 84 117 116 20-24 183 200 228 242 25-29 214 227 253 244 30-34 183 208 233 (239) 35-39 146 162 (201) 40-44 77 (101) 45-49 (40) Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Fertility | 57 A comparison of the TFRs ob- tained from the three earlier GDHS surveys conducted in 1988, 1993, and 1998, with the TFR obtained from the 2003 GDHS is shown in Table 4.4 and Figure 4.3. Direct estimates of fertility for the three years preceding the sur- vey have been used in this compari- son, because a three-year rate is more robust than rates based on a shorter period of time. Hence, these rates may be slightly different from published rates for 1988, 1993, and 1998, which are based on the five years preceding the survey. Fertility trends have to be interpreted within the context of data quality and sample size. A discussion of these issues in relation to earlier surveys is beyond the scope of this report. As such, the fertility trend shown in Figure 4.3 and Table 4.4 should be interpreted with caution. The TFR has declined dramatically from 6.4 children per woman in 1988 to 5.2 children per woman in 1993, and to 4.4 children in 1998, a nearly 2-child drop in fertility over the decade. However, the demographic transition experienced in Ghana in the 1980s and 1990s seems to have slowed in the last three years even though contraceptive use has continued to rise. Further investigation, outside the scope of this report, is necessary to examine the underlying causes for this unexpected trend. Table 4.4 shows that since 1988, fertility has fallen in every age group, with fertility levels among women under age 35 declining by around 25 percent during the decade between the 1988 and 1998 surveys. Figure 4.3 Trends in Total Fertility Rate Ghana 1988-2003 6.4 5.2 4.4 4.4 GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Bi rth s pe r w om an GDHS 1988-2003 Note: Rates are per 1,000 women and refer to the three-year period preceding the survey. Table 4.4 Trends in fertility Age-specific fertility rates and total fertility rates for GDHS surveys, 1988-2003 Age group GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 15-19 125 116 88 74 20-24 260 221 197 176 25-29 280 233 203 210 30-34 249 209 177 182 35-39 189 143 136 141 40-44 117 87 74 70 45-49 61 22 11 36 15-49 6.4 5.2 4.4 4.4 Note: Rates are per 1,000 women and refer to the three-year period preceding the survey 58 | Fertility 4.2 CHILDREN EVER BORN AND CHILDREN SURVIVING Table 4.5 presents the distribution of all women and currently married women by the mean number of children ever born and the mean number of children surviving, by five-year age groups. Lifetime fertility reflects the accumulation of births over the past 30 years and, therefore, its relevance to the current situation is limited; nevertheless, information on the mean number of children ever born is useful in examining the variation among different age groups. The distribution of children ever born by age shows that early childbearing is not common in Ghana; nearly 90 percent of women age 15-19 have never given birth. However, this proportion declines to 18 percent for women age 25-29, and to 7 percent or less among women age 30 and older. Ghanaian women attain a parity of 5.9 children by the end of their reproductive age, which is 1.5 children more than the total fertility rate, a difference brought about by the dramatic decline in fertility in the 1980s and 1990s. Although the pattern is similar for currently married women, less than half (44 percent) of women age 15-19 have not borne a child, and this proportion declines rapidly to less than 4 percent by age 30-34. This discrepancy between all women and currently-married women is attributable to the sizeable proportion of young and unmarried women in the former category who exhibit lower fertility. Currently married women reported higher fertility at all ages, and especially at younger ages, and have had an average of 3.5 children compared with 2.5 children among all women. Nevertheless, this one-child difference between currently married women and all women indicates that childbearing outside of marriage is not uncommon in Ghana. Consonant with expectations, the mean number of children ever born and mean number of living children rise monotonically with increasing age of women, thus presupposing minimal or no recall lapse, which heightens confidence in the birth history reports. Table 4.5 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born and mean number of living children, according to age group, Ghana 2003 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean number of children ever born Mean number of living children ALL WOMEN 15-19 89.7 9.7 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,148 0.11 0.10 20-24 47.2 30.5 18.2 3.6 0.4 0.1 0.0 0.0 0.0 0.0 0.0 100.0 1,012 0.80 0.72 25-29 18.1 21.1 25.8 20.5 8.7 4.0 1.4 0.3 0.2 0.0 0.0 100.0 951 2.01 1.81 30-34 7.0 10.4 16.5 23.7 18.1 12.9 7.7 1.8 1.7 0.2 0.1 100.0 802 3.26 2.90 35-39 5.1 6.1 8.4 14.4 18.6 16.2 14.5 9.2 4.4 2.6 0.6 100.0 722 4.38 3.84 40-44 2.8 2.9 6.3 13.3 14.7 16.4 14.4 12.8 8.2 4.6 3.6 100.0 579 5.18 4.41 45-49 1.6 4.3 6.6 8.2 10.6 11.0 14.7 12.9 13.5 9.9 6.8 100.0 477 5.88 5.00 Total 31.6 13.8 12.2 11.3 8.8 7.1 5.8 3.8 2.8 1.7 1.0 100.0 5,691 2.53 2.22 CURRENTLY MARRIED WOMEN 15-19 44.0 53.2 2.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 137 0.59 0.54 20-24 18.0 43.7 31.0 6.8 0.5 0.1 0.0 0.0 0.0 0.0 0.0 100.0 530 1.28 1.17 25-29 7.0 20.8 30.1 24.7 10.9 4.3 1.6 0.4 0.2 0.0 0.0 100.0 739 2.34 2.11 30-34 3.4 8.4 15.9 25.4 19.2 14.6 9.0 2.1 1.7 0.2 0.1 100.0 671 3.52 3.13 35-39 2.6 5.4 7.7 15.0 19.0 16.9 15.3 9.8 4.7 2.9 0.7 100.0 621 4.58 4.03 40-44 1.8 2.7 5.3 12.6 13.2 16.7 15.5 14.0 9.0 5.4 3.9 100.0 473 5.41 4.65 45-49 0.9 3.1 5.5 7.7 9.6 11.0 16.2 13.5 15.8 8.5 8.3 100.0 377 6.14 5.24 Total 7.3 16.1 16.6 16.1 12.1 10.0 8.5 5.5 4.1 2.2 1.5 100.0 3,549 3.54 3.11 Fertility | 59 Voluntary childlessness is uncommon and currently married women with no live births are likely to be those who are unable to bear children. The level of childlessness among married women at the end of their reproductive lives can be used as an indicator of the level of primary sterility. In Ghana, primary sterility among older currently married women is less than 2 percent. 4.3 BIRTH INTERVALS Information on birth intervals provides valuable insight into birth spacing patterns. Short birth in- tervals, that is, births that occur less than 24 months apart, are detrimental to the health of both the mother and her child. Table 4.6 shows the distribution of non-first births in the five years preceding the survey by the number of months since the previous birth, according to selected demographic and socio-economic vari- ables. First births are omitted from the table because there is no prior birth with which to measure an in- terval. Fourteen percent of all non-first births occur less than 24 months after an earlier birth. The median birth interval is 38 months, that is, half of non-first births to women in Ghana occur more than three years after a previous birth. There has been little change in birth spacing patterns over the last five years. The median birth interval increases with age from 35 months for births to women age 20-29 to 46 months for births to women age 40-49. The longer birth interval among older women may be attributed to the decline in fecundity as women grow older. There are no significant differences in the median birth interval by birth order and sex of the child. However, the median birth interval is markedly shorter if the previous child has died. Among births following a child who has died, 34 percent occur at intervals of less than 24 months. This may be due to the desire of parents to replace dead children, as well as the impact of the loss of the fertility-delaying effects of breastfeeding. The median interval between births to urban women is seven months longer (44 months) than for rural women (37 months). The median birth interval ranges from a low of 34 months in the Western region to 42 months in Greater Accra and Upper East regions. Education and wealth status are not strongly related to median birth interval, except for births to the most educated and the wealthiest group of women. The median birth interval is longer among non-first births to women with at least secondary education than among women with lower levels of education, and among women in the highest wealth quintile than women in the other wealth quintiles. 60 | Fertility Table 4.6 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to background characteristics, Ghana 2003 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48+ Total Number of non-first births Median number of months since preceding birth Age 20-29 6.9 8.7 37.0 24.7 22.7 100.0 983 35.1 30-39 4.1 9.1 28.3 23.3 35.2 100.0 1,375 39.8 40-49 3.0 7.1 23.2 21.0 45.5 100.0 445 45.5 Birth order 2-3 5.1 8.5 29.3 22.9 34.3 100.0 1,259 38.8 4-6 5.0 8.2 29.8 24.9 32.2 100.0 1,100 38.7 7+ 4.3 11.0 35.5 21.5 27.8 100.0 449 35.7 Sex of preceding birth Male 4.1 8.8 29.3 24.2 33.6 100.0 1,453 39.0 Female 5.8 8.7 31.7 22.6 31.1 100.0 1,354 37.9 Survival of preceding birth Living 3.2 8.1 30.8 24.0 33.9 100.0 2,517 39.1 Dead 19.9 14.2 27.5 18.5 19.8 100.0 290 31.5 Residence Urban 5.2 7.0 25.2 20.5 42.1 100.0 856 43.6 Rural 4.8 9.5 32.8 24.8 28.1 100.0 1,951 37.2 Region Western 4.5 13.3 37.3 16.9 27.9 100.0 280 33.9 Central 2.9 12.0 35.6 24.4 25.2 100.0 239 35.8 Greater Accra 4.3 7.5 24.4 21.3 42.4 100.0 278 41.8 Volta 3.4 4.6 29.5 25.0 37.6 100.0 217 40.7 Eastern 4.0 9.7 36.4 12.2 37.7 100.0 281 36.0 Ashanti 7.5 9.7 27.3 23.8 31.8 100.0 536 38.6 Brong Ahafo 6.1 8.8 29.1 22.8 33.1 100.0 284 37.7 Northern 5.1 7.6 29.9 29.1 28.3 100.0 420 39.1 Upper East 1.6 2.9 27.8 34.9 32.8 100.0 177 41.9 Upper West 6.4 7.9 29.8 30.2 25.7 100.0 95 37.6 Education No education 4.5 8.0 31.8 26.4 29.3 100.0 1,258 38.2 Primary 6.6 10.4 31.3 22.2 29.5 100.0 641 36.6 Middle/JSS 4.0 8.7 28.3 21.1 37.9 100.0 802 39.8 Secondary+ 6.0 8.4 26.3 14.3 45.0 100.0 106 43.6 Wealth quintile Lowest 4.0 6.2 33.4 28.7 27.7 100.0 778 38.3 Second 4.7 14.6 31.8 22.5 26.5 100.0 665 35.7 Middle 6.7 6.7 30.9 22.5 33.2 100.0 536 38.1 Fourth 4.7 7.5 28.3 24.3 35.3 100.0 443 39.6 Highest 5.0 8.1 24.4 14.7 47.8 100.0 385 46.0 Total 4.9 8.7 30.5 23.4 32.4 100.0 2,807 38.4 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. Total includes 6 non-first births to women age 15-19, which are not shown separately. Fertility | 61 4.4 AGE AT FIRST BIRTH One of the factors that determines the level of fertility in a population is the age at first birth. Women who marry early are typically exposed to the risk of pregnancy for a longer period, especially when there is little or no contraceptive use. Thus, early childbearing generally leads to a larger family size than later onset of childbearing. A rise in the median age at first birth is typically a sign of transition from high to low fertility. Table 4.7 shows the percentage of women who have given birth by specific ages and the median age at first birth, according to current age. Table 4.7 Age at first birth Percentage of women who gave birth by specific exact ages, and median age at first birth, by current age, Ghana 2003 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 0.6 na na na na 89.7 1,148 a 20-24 1.4 14.9 34.6 na na 47.2 1,012 a 25-29 3.3 22.0 40.8 56.4 76.2 18.1 951 21.1 30-34 4.7 28.6 47.6 65.5 80.5 7.0 802 20.2 35-39 4.1 24.2 44.4 64.4 82.1 5.1 722 20.5 40-44 4.4 28.2 48.5 70.8 84.1 2.8 579 20.1 45-49 3.4 24.7 44.9 67.7 85.8 1.6 477 20.4 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group The median age at first birth for the youngest cohort of women age 25-29, for whom a median could be calculated, is 21. For all other age groups, the median age at first birth is around 20 years, suggesting that age at first birth has increased in the most recent period. Further evidence of this trend is observed by the fact that the percentage of first births occurring at age 18 or less has fallen from 25 percent among the oldest cohort of women (age 45-49) to 15 percent among the youngest cohort for whom complete information is available (age 20-24). This reduction in the percentage of women giving birth early implies that more young women are postponing childbearing. A comparison of data from the 1993, 1998, and 2003 GDHS for the same age groups reinforces the conclusion that there has been a trend towards a rising age at first birth. 4.5 MEDIAN AGE AT FIRST BIRTH BY BACKGROUND CHARACTERISTICS Age at first birth tends to vary by demographic and socio-economic characteristics of women. Table 4.8 shows the median age at first birth among women by selected background characteristics. The median age at first birth for women age 25-49 in Ghana is 20.5 years. Urban women have their first birth a year later than their rural counterparts. Across regions, the median age at first birth ranges from a low of 19.9 years in the Upper East to a high of 21.8 years in Greater Accra. Age at first birth by education does not appear to vary substantially between education categories, although the median age at first birth for the highest level of education (Middle/JSS) for which a median could be estimated is somewhat higher than that at lower levels. The data also show that women who belong to the wealthiest quintile have their first child about two years later than women in all the other wealth quintiles. 62 | Fertility Table 4.8 Median age at first birth by background characteristics Median age at first birth among women age 25-49 years, by current age and background characteristics, Ghana 2003 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women age 25-49 Residence Urban 22.9 21.1 21.2 20.0 20.3 21.1 Rural 20.1 19.8 20.0 20.3 20.5 20.1 Region Western 21.6 19.4 21.2 (18.7) (19.1) 20.0 Central 19.8 (19.4) (20.3) (19.9) (20.6) 20.1 Greater Accra 23.6 22.6 21.5 20.9 20.9 21.8 Volta 22.4 20.3 20.3 19.6 (21.2) 20.7 Eastern 20.7 19.6 20.2 21.0 (20.4) 20.3 Ashanti 20.8 19.7 20.6 20.3 19.5 20.2 Brong Ahafo 20.8 21.3 19.2 19.1 21.1 20.2 Northern 20.9 20.7 21.4 (21.3) (22.0) 21.1 Upper East 18.7 19.5 (19.9) (20.2) (21.4) 19.9 Upper West 21.0 21.0 19.9 (21.2) 20.3 20.5 Education No education 19.8 19.7 20.2 20.1 20.4 20.1 Primary 19.4 19.8 19.7 19.0 19.7 19.5 Middle/JSS 22.0 20.3 20.6 20.2 20.3 20.6 Secondary+ a 25.8 (25.2) (23.3) (21.7) a Wealth quintile Lowest 20.0 20.0 20.0 20.2 21.2 20.2 Second 19.5 19.3 20.0 20.0 20.3 19.7 Middle 20.7 19.5 20.0 20.2 19.7 19.9 Fourth 21.5 20.0 20.1 19.3 19.7 20.2 Highest 23.9 23.5 22.4 21.0 21.1 22.6 Total 21.1 20.2 20.5 20.1 20.4 20.5 Note: Figures in parentheses are based on 25-49 unweighted cases. a = Omitted because less than 50 percent of women had a birth before reaching the begin- ning of the age group 4.6 TEENAGE FERTILITY Adolescent childbearing has potentially negative demographic and social consequences. Births that occur to teenage mothers (less than 20 years) have been found to have the highest infant and child mortality in Ghana (GSS and MI, 1994 and 1999). This may be due to the fact that teenage mothers are more likely to suffer from pregnancy and delivery complications than older mothers, resulting in higher morbidity and mortality for both themselves and their children. In addition, early childbearing may foreclose a teenager’s ability to pursue educational or job opportunities. Table 4.9 shows the percentage of adolescent women (age 15-19) who are mothers or pregnant with their first child, by background characteristics. One in ten teenagers has already had a child (10 percent) and another 4 percent are pregnant with their first child. Fertility | 63 Urban teenagers differ substantially from their rural counterparts with respect to childbearing. Seven percent of adolescents in urban areas have begun childbearing, compared with 22 percent of their counterparts residing in rural areas. By region, the percentage of women age 15-19 who have begun childbearing ranges from a low of 10 percent in the Greater Accra, Upper West, and Ashanti regions to a high of 24 percent in the Central and Northern regions. It is also clear that childbearing among adolescents decreases with higher education (26 percent among adolescents with no education and 3 percent among those with at least secondary education). Childbearing decreases from 26 percent among adolescents in the lowest wealth quintile to just 2 percent among those in the highest wealth quintile. Poverty is quite plausibly an important consideration in understanding adolescent childbearing in Ghana (Nabila and Fayorsey, 1996). There has been no change in the overall percentage of teenage women who have begun childbearing over the last five years (GSS and MI, 1999). Table 4.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who are mothers or pregnant with their first child, by background characteristics, Ghana 2003 Percentage who are: Background characteristic Mothers Pregnant with first child Percentage who have begun childbearing Number of women Age 15 0.6 2.7 3.3 238 16 3.9 2.5 6.4 243 17 9.8 2.0 11.8 229 18 16.5 8.0 24.5 250 19 23.0 1.8 24.8 188 Residence Urban 5.7 1.5 7.2 629 Rural 15.8 6.0 21.8 519 Region Western 10.2 4.0 14.2 122 Central 13.7 10.5 24.1 93 Greater Accra 8.4 1.1 9.5 203 Volta 14.3 2.7 17.1 88 Eastern 9.5 3.7 13.2 108 Ashanti 8.1 2.2 10.3 255 Brong Ahafo 10.7 2.9 13.6 112 Northern 15.7 7.9 23.6 76 Upper East 9.1 3.5 12.6 62 Upper West 8.5 1.3 9.8 29 Education No education 19.1 6.8 26.0 141 Primary 15.5 5.3 20.8 269 Middle/JSS 7.6 2.8 10.4 588 Secondary+ 3.0 0.0 3.0 150 Wealth quintile Lowest 18.5 7.6 26.1 166 Second 16.6 6.3 23.0 170 Middle 15.0 5.1 20.1 221 Fourth 7.4 2.3 9.7 261 Highest 1.9 0.0 1.9 331 Total 10.3 3.5 13.8 1,148 Family Planning | 65 FAMILY PLANNING 5 This chapter presents the 2003 GDHS findings on contraceptive knowledge and use, attitudes, and sources, as well as exposure to media messages about family planning. The information is particularly useful for policymakers, programme managers, and researchers in population and family planning, and provides a means to assess the success of the Ghanaian family planning programme. Although the focus is on women, some results from the male survey are also presented, since men play an important role in realising women’s reproductive goals. Comparisons are also made, where feasible, with findings from previous surveys in order to evaluate trends occurring in Ghana over the last fifteen years. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge about fertility control is an important step toward gaining access to and then using a suitable contraceptive method in a timely and effective manner. Information on knowledge of contraception was collected in two ways. Respondents were asked to mention all ways or methods couples can use to avoid or delay pregnancy. When a respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent knew of it. Using this approach, information was collected for 12 modern family planning methods: female and male sterilisation, the pill, the IUD, injectables, implants, male and female condoms, diaphragm, foam tablets and jelly, the lactational amenorrhoea method (LAM), and emergency contraception. Information was also collected on two traditional methods: rhythm or periodic abstinence, and withdrawal. Provision was also made in the questionnaire to record any other methods named spontaneously by respondents and this was coded as “folk methods.” This report combines both prompted and unprompted knowledge. Thus, knowledge of a family planning method in the GDHS is defined simply as having heard of a method. Tables 5.1.1 and 5.1.2 show the percentage of women age 15-49 and men age 15-59 who have heard of contraceptive methods among all women and men, currently married women and men, sexually active unmarried women and men, sexually inactive unmarried women and men, and for unmarried women and men with no sexual experience, by specific method. The data show that knowledge of any contraceptive method is almost universal in Ghana, with 98 percent of all women and 99 percent of all men knowing at least one method of contraception. Modern methods are more widely known than traditional methods. Ninety-eight percent of all women know of a modern method compared with 75 percent who know of a traditional method. Among women, the male condom is the most commonly known (95 percent), followed by injectables (89 percent), the pill (88 percent), and the female condom (83 percent). Emergency contraception is the least known, reported by 28 percent of all women. Among the traditional methods, periodic abstinence is the most commonly known (65 percent), followed closely by withdrawal (61 percent), a small proportion (4 percent) mentioned folk methods. Currently married women have a somewhat similar pattern of knowledge, especially with regard to level of knowledge. Among currently married women, 98 percent know at least one method of contraception or a modern method, and 78 percent know a traditional method. Among modern methods, the most commonly known method is the male condom (95 percent), followed by injectables (92 percent), the pill (90 percent), and the female condom (82 percent). Emergency contraception is the least known modern method (29 percent). 66 | Family Planning Table 5.1.1 Knowledge of contraceptive methods: women Percentage of all women, of currently married women, of sexually active unmarried women, of sexu- ally inactive unmarried women, and of women with no sexual experience who know any contracep- tive method, by specific method, Ghana 2003 Unmarried women who have ever had sex Method All women Currently married women Sexually active1 Not sexually active2 Unmarried women who have never had sex Any method 97.7 98.0 99.5 99.2 94.2 Any modern method 97.5 97.8 99.5 99.2 94.0 Female sterilisation 70.2 74.3 70.7 69.9 53.9 Male sterilisation 42.8 45.4 41.7 44.1 31.1 Pill 87.5 89.7 90.1 89.9 75.0 IUD 61.3 65.1 62.2 64.1 42.4 Injectables 88.9 91.8 91.7 90.5 74.5 Implants 61.5 66.7 62.5 61.8 39.8 Male condom 95.3 94.7 98.9 98.3 93.1 Female condom 83.2 81.6 88.5 90.0 80.1 Diaphragm 35.4 38.4 38.3 37.3 20.7 Foam/jelly 40.1 42.9 47.8 43.6 22.6 Lactational amenorrhoea (LAM) 32.1 37.3 26.2 30.3 14.9 Emergency contraception 28.2 28.8 36.5 33.1 17.5 Any traditional method 75.4 77.6 84.1 83.9 54.2 Periodic abstinence 65.4 67.1 71.8 72.5 48.7 Withdrawal 61.3 65.2 73.7 70.3 31.4 Folk method 3.8 4.3 3.9 4.1 1.2 Mean number of methods known 8.6 8.9 9.0 9.0 6.5 Number of women 5,691 3,549 257 1,002 884 1 Had sexual intercourse in the month preceding the survey 2 Did not have sexual intercourse in the month preceding the survey Contraceptive knowledge is highest among sexually active unmarried women (almost 100 percent) and lowest among unmarried women who have never had sex (94 percent). Unmarried women reported the male condom to be the most commonly known method and are more likely to report knowledge of emergency contraception than LAM, regardless of their sexual activity status. Among the unmarried women who have never had sex, the female condom was the second most frequently mentioned method (80 percent) after the male condom (93 percent). Knowledge of contraception is higher among men―99 percent know of at least one method of contraception (Table 5.1.2). Like women, a larger proportion of men (99 percent) know a modern method than a traditional method (80 percent). The most commonly known modern method is the male condom (98 percent). Similarly, periodic abstinence is the most commonly known traditional method (71 percent). It is worth noting that knowledge of implants and IUD is lower for men than for women. Family Planning | 67 Table 5.1.2 Knowledge of contraceptive methods: men Percentage of all men, of currently married men, of sexually active unmarried men, of sexually inac- tive unmarried men, and of men with no sexual experience who know any contraceptive method, by specific method, Ghana 2003 Unmarried men who have ever had sex Method All men Currently married men Sexually active1 Not sexually active2 Unmarried men who have never had sex Any method 98.9 99.6 99.6 99.4 96.6 Any modern method 98.9 99.6 99.6 99.4 96.5 Female sterilisation 73.3 80.2 75.6 75.7 54.7 Male sterilisation 53.5 59.6 58.8 56.4 35.6 Pill 86.8 92.1 87.3 89.7 72.5 IUD 56.6 63.5 56.3 57.4 40.3 Injectables 86.8 93.1 88.0 86.3 72.0 Implants 50.0 58.0 48.0 47.0 33.9 Male condom 98.0 98.7 99.3 98.9 95.2 Female condom 86.2 87.9 91.5 91.1 77.2 Diaphragm 36.5 41.0 39.0 37.3 24.5 Foam/jelly 47.5 55.1 52.2 48.2 27.6 Lactational amenorrhoea (LAM) 32.1 39.6 29.8 30.2 16.7 Emergency contraception 29.7 33.6 31.1 36.8 16.0 Any traditional method 79.7 88.0 85.4 86.6 53.8 Periodic abstinence 71.2 79.9 74.6 76.3 46.4 Withdrawal 68.1 76.6 81.3 77.3 37.3 Folk method 1.9 2.4 2.0 1.6 1.0 Mean number of methods known 8.8 9.6 9.1 9.1 6.5 Number of men 5,015 2,671 485 707 1,154 1 Had sexual intercourse in the month preceding the survey 2 Did not have sexual intercourse in the month preceding the survey Looking at the number of methods known, it is clear that knowledge of specific methods is lowest among both women and men who never had sex. For example, while married women have heard of an average of 8.9 methods and married men 9.6 methods, unmarried women and unmarried men who have never had sex report knowing only an average of 6.5 methods. There has been an increase in levels of awareness of contraceptive methods over time. Among all women, the proportion who know any method has risen since 1988 for all methods (from 76 percent in 1988, 91 percent in 1993, 93 percent in 1998, to 98 percent in 2003), with the exception of knowledge of the diaphragm, which is no longer available in the country. The proportion who know of implants has risen steeply since 1993 (from 4 percent in 1993, 21 percent in 1998, to 62 percent in 2003). There is a similar trend for men. There are also remarkable increases in knowledge of IUD, male sterilisation, and LAM by men. The mean number of methods known has increased since 1998 from 5.8 to 8.6 for women and from 5.6 to 8.8 for men. This increase could be attributed partly to the fact that female condoms and injectables and training on emergency contraception were introduced into the national family planning programme in 2000. 68 | Family Planning 5.2 EVER USE OF CONTRACEPTION All women interviewed in the survey who said they had heard of a method of family planning were asked whether they had ever used that method. Men were asked if they had ever used “male- oriented” methods, i.e., male sterilisation, condoms, rhythm method, and withdrawal. Tables 5.2.1 and 5.2.2 show the percentages of women and men who have ever used family planning by specific method and age. Forty-seven percent of all women report having used a method of contraception at some time, 39 percent have used a modern method, and 26 percent have used a traditional method. Of the modern methods, the male condom (18 percent) is the most commonly used method, followed by the pill (16 percent). Diaphragm and male sterilisation are the least used methods, with less than 1 percent reporting use of these methods. Of the traditional methods, periodic abstinence (19 percent) is the method most commonly used followed by withdrawal (14 percent). Emergency contraception has been used by 1 percent of all women. Fifty-five percent of currently married women have used a method of contraception at some time, 45 percent have used a modern method, while 30 percent have used a traditional method. The pill is the most commonly used method (20 percent) followed by the male condom (17 percent) and injectables (13 percent). Use is particularly high among sexually active unmarried women, 73 percent of whom have used contraception. Sexually active unmarried women tend to use temporary methods of contraception rather than long-term or permanent methods. Forty-five percent of these women have used a male condom compared with only 17 percent of married women. Also, compared with currently married women, ever use of emergency contraception, the pill and the female condom is higher among sexually active unmarried women. Table 5.2.2 shows the percentage of all men, currently married men and sexually active unmarried men who reported having ever used one of four male methods of contraception―male sterilisation, male condom, periodic abstinence or withdrawal. The most popular male method, the condom, has been used by 39 percent of all men, 47 percent of currently married men, and 70 percent of sexually active unmarried men. Male sterilisation is practically non-existent in Ghana. Of the two traditional methods, periodic abstinence is reported as used more often than withdrawal by all men (30 percent) and currently married men (43 percent) but is less popular than withdrawal among sexually active unmarried men (36 percent). Family Planning | 69 Table 5.2.1 Ever use of contraception: women Percentage of all women, of currently married women, and of sexually active unmarried women who have ever used any contraceptive method, by specific method and age, Ghana 2003 Modern method Traditional method Age Any method Any modern method Female sterili- sation Male sterili- sation Pill IUD Inject- ables Im- plants Male con- dom Female condom Dia- phragm Foam/ jelly LAM Emer- gency contra- ception Any tradi- tional method Peri- odic absti- nence With- drawal Folk meth- od Number of women ALL WOMEN 15-19 19.4 16.1 0.0 0.0 2.8 0.0 0.5 0.0 14.0 0.8 0.0 0.4 0.1 0.7 9.7 6.9 5.3 0.3 1,148 20-24 51.1 42.1 0.4 0.0 14.3 0.3 5.4 1.0 28.6 1.9 0.2 1.4 1.8 1.8 30.9 22.3 18.9 1.0 1,012 25-29 58.0 46.8 0.0 0.0 19.9 1.2 11.4 1.0 24.1 0.9 0.4 3.7 5.4 1.3 34.4 24.0 18.8 2.1 951 30-34 60.0 50.2 0.9 0.0 22.3 3.1 15.1 2.2 18.7 1.7 1.0 4.7 6.6 1.0 31.2 21.3 17.1 2.1 802 35-39 53.4 44.3 1.6 0.0 22.0 4.7 13.5 1.1 13.6 0.4 0.7 4.2 6.4 0.9 27.0 19.7 14.5 1.7 722 40-44 54.3 44.9 4.2 0.1 20.0 5.0 13.1 1.4 12.4 0.1 0.5 6.2 6.3 1.3 27.3 20.6 12.0 1.0 579 45-49 47.2 36.2 5.3 0.1 16.2 4.2 12.0 1.5 8.9 0.6 0.2 4.4 4.6 0.3 25.2 20.9 9.1 1.4 477 Total 47.4 38.9 1.3 0.0 15.8 2.1 9.1 1.1 18.3 1.0 0.4 3.2 4.0 1.1 25.9 18.7 13.8 1.3 5,691 CURRENTLY MARRIED WOMEN 15-19 38.7 33.6 0.0 0.0 8.6 0.0 2.8 0.2 26.5 0.0 0.0 3.6 1.0 1.8 17.3 11.5 9.1 0.8 137 20-24 54.4 43.3 0.8 0.0 17.2 0.4 8.7 1.4 25.9 1.3 0.5 1.8 3.0 1.7 34.0 24.2 20.2 1.1 530 25-29 58.5 46.8 0.0 0.0 21.8 1.5 13.8 1.2 20.4 0.5 0.2 3.5 6.5 1.0 34.1 23.3 16.7 2.5 739 30-34 60.8 51.3 0.9 0.0 23.1 3.2 16.2 2.2 17.9 1.8 1.0 4.7 7.3 1.1 31.3 21.4 17.0 2.3 671 35-39 54.4 45.6 1.9 0.0 21.5 5.1 13.6 1.3 12.8 0.5 0.8 4.0 6.8 0.9 27.4 19.6 14.9 1.9 621 40-44 55.3 45.7 4.9 0.1 20.3 6.2 13.9 1.5 12.2 0.0 0.2 7.1 5.8 1.6 27.9 20.8 12.1 1.3 473 45-49 47.6 38.6 5.6 0.1 17.4 5.0 12.8 1.7 9.0 0.7 0.2 4.9 5.5 0.3 24.3 20.3 8.7 1.5 377 Total 55.3 45.4 1.9 0.0 20.1 3.2 12.9 1.5 17.3 0.8 0.5 4.2 5.8 1.1 29.9 21.3 15.2 1.8 3,549 SEXUALLY ACTIVE UNMARRIED WOMEN1 Total 72.6 64.4 0.0 0.0 26.6 3.0 7.3 1.3 44.9 4.9 0.5 4.2 1.2 3.2 38.3 29.6 24.5 1.0 257 LAM = Lactational amenorrhoea method 1 Women who had sexual intercourse in the month preceding the survey 70 | Family Planning Table 5.2.2 Ever use of male method of contraception: men Percentage of all men, of currently married men, and of sexually active unmarried men who have ever used a male method of contraception, by specific method and age, Ghana 2003 Modern method Traditional method Age Any method Any modern method Male sterilisation Male con- dom Any traditional method Periodic abstinence With- drawal Number of men ALL MEN 15-19 12.8 10.5 0.0 10.5 6.2 4.1 3.9 1,107 20-24 54.7 48.0 0.0 48.0 32.9 22.2 25.0 684 25-29 72.6 60.0 0.0 60.0 51.4 40.1 34.7 754 30-34 71.7 55.7 0.0 55.7 53.5 39.6 35.3 633 35-39 63.4 45.8 0.0 45.8 50.0 40.3 31.1 498 40-44 69.8 46.0 0.0 46.0 55.7 44.9 35.9 412 45-49 59.5 36.8 0.3 36.5 50.4 40.9 32.2 441 50-54 57.5 29.6 0.2 29.6 44.9 37.4 27.7 294 55-59 55.0 29.4 0.0 29.4 44.1 36.8 19.1 192 Total 53.0 39.3 0.0 39.3 38.6 29.8 25.2 5,015 CURRENTLY MARRIED MEN 15-19 * * * * * * * 7 20-24 73.7 63.8 0.0 63.8 55.0 41.4 36.3 128 25-29 76.6 61.4 0.0 61.4 58.4 45.5 36.1 398 30-34 72.8 55.1 0.0 55.1 54.8 42.9 35.2 500 35-39 64.7 46.9 0.0 46.9 50.6 41.4 30.3 424 40-44 70.2 45.6 0.0 45.6 57.7 46.7 37.3 375 45-49 61.4 37.8 0.3 37.5 52.6 42.9 32.8 396 50-54 58.2 30.2 0.2 30.2 45.3 38.1 27.5 272 55-59 56.8 30.7 0.0 30.7 46.3 38.2 21.4 171 Total 67.6 47.2 0.1 47.1 53.3 42.8 32.9 2,671 SEXUALLY ACTIVE UNMARRIED MEN1 Total 81.3 70.0 0.0 70.0 52.5 35.9 42.0 485 Note: Male respondents were not asked about methods that are female controlled, such as the pill or IUD. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who had sexual intercourse in the month preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS The level of current use of contraceptive methods is one of the indicators most frequently used to assess the success of family planning programme activities. It is also widely used as a measure in analysing the determinants of fertility. This section focuses on the levels and differentials in current use of family planning. Table 5.3 shows the percent distribution of women who are currently using specific family planning methods by age. One in five women is currently using any contraceptive method. The use of any contraceptive method increases with age, reaching its peak at age group 30-34 (28 percent), and then starts to decline. Modern methods are used by 15 percent of women, while only 5 percent are using traditional methods. Male condoms, pills, and injectables are the most commonly used methods (4 percent each). Female sterilisation, implants, and IUD are used by roughly 1 percent each, while female Family Planning | 71 condoms, foam/jelly, and diaphragms1 are the least used modern methods (less than 1 percent each). Of the traditional methods, periodic abstinence is the most commonly used (4 percent), while withdrawal is used by 1 percent. Less than 1 percent use folk methods. The contraceptive prevalence rate among currently married women is 25 percent. Among currently married women, the pill (6 percent) is the most commonly used modern method, followed closely by injectables (5 percent). Male condoms and female sterilisation are used by 3 percent and 2 percent of currently married women, respectively, while implants and IUD are used by 1 percent each. The most commonly used traditional method is periodic abstinence, used by 5 percent of currently married women. After the male condom (18 percent), the most commonly used modern method among sexually active unmarried women is the pill (8 percent), while periodic abstinence (9 percent) is the most widely used traditional method. Sexually active unmarried women are nearly twice as likely to report use of both any modern and any traditional method than currently married women. The difference may be due to the greater use of male condoms by sexually active unmarried women. This group is six times as likely to use male condoms as currently married women. Table 5.4 and Figure 5.1 show the percent distribution of currently married women by current use of family planning methods, according to background characteristics. Current use of contraception varies 1 Diaphragms are no longer available in Ghana. Table 5.3 Current use of contraception Percent distribution of all women, of currently married women, and of sexually active unmarried women by contraceptive method currently used, according to age, Ghana 2003 Modern method Traditional method Age Any method Any modern method Female sterili- sation Pill IUD In- ject- ables Im- plants Male con- dom Female con- dom Dia- phragm Foam/ jelly LAM Any tradi- tional method Peri- odic absti- nence With- drawal Folk meth- od Not currently using Total Number of women ALL WOMEN 15-19 8.5 6.4 0.0 1.0 0.0 0.1 0.0 5.2 0.1 0.0 0.0 0.0 2.1 1.6 0.3 0.2 91.5 100.0 1,148 20-24 21.4 15.4 0.4 3.3 0.2 2.9 0.6 7.7 0.3 0.0 0.0 0.1 6.0 4.7 0.9 0.4 78.6 100.0 1,012 25-29 25.4 18.5 0.0 6.9 0.2 5.5 0.5 5.0 0.1 0.0 0.1 0.2 6.8 5.2 1.1 0.5 74.6 100.0 951 30-34 27.5 20.6 0.9 5.7 0.8 6.4 1.4 3.7 0.4 0.1 0.5 0.6 6.9 5.0 1.3 0.7 72.5 100.0 802 35-39 26.1 19.6 1.6 6.5 1.3 4.9 0.7 3.1 0.0 0.1 1.0 0.3 6.6 5.1 0.7 0.8 73.9 100.0 722 40-44 24.7 18.6 4.2 4.6 1.9 4.9 1.0 1.3 0.0 0.1 0.2 0.3 6.1 5.1 0.6 0.4 75.3 100.0 579 45-49 14.5 10.5 5.3 1.1 0.6 2.2 1.1 0.2 0.0 0.0 0.0 0.0 4.0 3.4 0.4 0.2 85.5 100.0 477 Total 20.7 15.3 1.3 4.1 0.6 3.7 0.7 4.3 0.2 0.0 0.2 0.2 5.4 4.2 0.8 0.4 79.3 100.0 5,691 CURRENTLY MARRIED WOMEN 15-19 8.4 6.9 0.0 3.3 0.0 0.8 0.0 2.7 0.0 0.0 0.0 0.0 1.6 0.6 0.2 0.8 91.6 100.0 137 20-24 22.8 16.9 0.8 4.1 0.3 4.8 1.1 5.6 0.0 0.0 0.0 0.1 6.0 4.7 0.8 0.4 77.2 100.0 530 25-29 25.8 18.7 0.0 7.4 0.3 7.0 0.6 3.3 0.0 0.0 0.0 0.3 7.1 5.3 1.1 0.6 74.2 100.0 739 30-34 29.7 22.3 0.9 6.6 0.7 7.0 1.5 3.7 0.5 0.1 0.6 0.7 7.4 5.5 1.1 0.8 70.3 100.0 671 35-39 28.1 20.9 1.9 6.8 1.5 5.2 0.8 3.1 0.0 0.1 1.2 0.3 7.2 5.5 0.8 1.0 71.9 100.0 621 40-44 28.7 21.6 4.9 5.4 2.4 5.4 1.1 1.6 0.0 0.1 0.3 0.4 7.1 6.1 0.6 0.4 71.3 100.0 473 45-49 16.0 11.5 5.6 1.2 0.8 2.5 1.1 0.3 0.0 0.0 0.0 0.0 4.5 4.0 0.2 0.2 84.0 100.0 377 Total 25.2 18.7 1.9 5.5 0.9 5.4 1.0 3.1 0.1 0.1 0.4 0.3 6.5 5.1 0.8 0.6 74.8 100.0 3,549 SEXUALLY ACTIVE UNMARRIED WOMEN1 Total 43.4 31.6 0.0 8.2 1.1 3.5 0.3 18.0 0.5 0.0 0.0 0.0 11.8 8.7 3.1 0.0 56.6 100.0 257 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method 1 Women who have had sexual intercourse in the month preceding the survey 72 | Fam ily Planning Table 5.4 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Ghana 2003 Modern method Traditional method Background characteristic Any method Any modern method Female sterili- sation Pill IUD Inject- ables Implants Male condom Female condom Dia- phragm Foam/ jelly LAM Any tradi- tional method Periodic absti- nence With- drawal Folk method Not cur- rently using Total Number of women Residence Urban 31.4 24.2 2.8 6.5 1.5 6.0 1.3 5.2 0.2 0.1 0.4 0.3 7.2 6.1 0.9 0.2 68.6 100.0 1,436 Rural 20.9 14.9 1.2 4.9 0.5 5.1 0.8 1.7 0.1 0.1 0.3 0.4 6.0 4.4 0.7 0.9 79.1 100.0 2,113 Region Western 28.2 17.7 1.9 4.3 1.0 3.7 0.9 3.1 0.0 0.0 2.0 0.7 10.6 7.3 2.3 0.9 71.8 100.0 319 Central 15.2 13.2 0.0 2.3 0.0 5.8 2.1 3.0 0.0 0.0 0.0 0.0 2.0 0.9 1.0 0.0 84.8 100.0 274 Greater Accra 34.0 26.0 3.6 5.2 1.3 6.8 1.0 6.4 0.0 0.0 1.0 0.7 8.0 6.0 1.6 0.4 66.0 100.0 476 Volta 23.6 19.3 0.8 3.6 0.2 9.9 1.0 3.7 0.0 0.0 0.0 0.0 4.3 4.1 0.0 0.3 76.4 100.0 304 Eastern 27.1 21.5 2.7 7.7 0.7 4.2 1.5 3.5 0.3 0.2 0.4 0.3 5.6 4.6 1.0 0.0 72.9 100.0 354 Ashanti 29.7 21.0 3.7 8.7 1.6 2.8 0.3 2.8 0.4 0.1 0.0 0.5 8.8 8.0 0.4 0.4 70.3 100.0 643 Brong Ahafo 33.0 24.8 1.1 10.0 1.8 7.7 1.0 3.0 0.0 0.1 0.0 0.0 8.2 7.2 0.9 0.1 67.0 100.0 398 Northern 12.1 7.7 0.4 2.6 0.4 2.5 1.0 0.8 0.0 0.0 0.0 0.0 4.4 1.1 0.3 3.1 87.9 100.0 431 Upper East 11.9 9.7 0.0 2.0 0.4 6.4 0.0 0.9 0.0 0.0 0.0 0.0 2.2 2.2 0.0 0.0 88.1 100.0 236 Upper West 26.3 19.5 0.9 1.6 0.0 11.1 2.4 2.2 0.0 0.0 0.2 1.0 6.9 6.2 0.4 0.3 73.7 100.0 113 Education No education 15.3 11.0 0.9 3.0 0.5 4.6 0.6 1.0 0.1 0.0 0.2 0.1 4.2 2.6 0.6 1.1 84.7 100.0 1,354 Primary 26.1 20.7 2.2 6.3 1.0 6.5 0.7 2.7 0.0 0.2 0.9 0.2 5.3 3.8 0.8 0.7 73.9 100.0 710 Middle/JSS 32.4 23.9 1.8 8.2 1.2 6.1 1.3 4.1 0.2 0.0 0.3 0.5 8.6 7.3 1.1 0.2 67.6 100.0 1,205 Secondary+ 39.8 28.1 5.8 4.4 1.2 4.0 2.3 9.9 0.0 0.0 0.0 0.6 11.7 11.0 0.7 0.0 60.2 100.0 280 Number of living children 0 14.4 8.6 0.0 1.2 0.0 0.6 0.5 6.4 0.0 0.0 0.0 0.0 5.8 4.4 1.0 0.4 85.6 100.0 307 1-2 22.7 17.0 0.7 5.1 0.3 5.7 0.7 4.1 0.0 0.0 0.2 0.3 5.7 4.5 0.7 0.4 77.3 100.0 1,280 3-4 30.5 22.1 2.5 7.4 1.8 6.6 0.9 1.9 0.3 0.1 0.5 0.2 8.4 6.7 1.0 0.7 69.5 100.0 1,073 5+ 26.1 20.4 3.5 5.5 1.1 5.3 1.7 2.0 0.0 0.1 0.5 0.6 5.7 4.1 0.7 0.9 73.9 100.0 888 Wealth quintile Lowest 14.0 8.6 0.4 2.3 0.0 4.0 0.5 0.7 0.0 0.1 0.5 0.0 5.4 3.3 0.5 1.5 86.0 100.0 753 Second 24.0 19.1 1.5 5.8 0.6 6.4 0.9 2.9 0.0 0.1 0.2 0.6 4.8 3.5 0.8 0.5 76.0 100.0 687 Middle 24.9 18.6 1.8 7.1 0.5 5.2 1.6 1.5 0.3 0.0 0.2 0.3 6.3 5.0 0.7 0.7 75.1 100.0 692 Fourth 29.0 21.3 2.3 6.6 1.2 5.5 0.8 4.3 0.0 0.1 0.3 0.1 7.7 6.4 1.0 0.3 71.0 100.0 695 Highest 34.6 26.3 3.4 6.1 2.2 6.0 1.1 6.2 0.2 0.0 0.5 0.6 8.3 7.2 1.0 0.0 65.4 100.0 721 Total 25.2 18.7 1.9 5.5 0.9 5.4 1.0 3.1 0.1 0.1 0.4 0.3 6.5 5.1 0.8 0.6 74.8 100.0 3,549 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method Family Planning | 73 31 21 28 15 34 24 27 30 33 12 12 26 15 26 32 40 14 24 25 29 35 RESIDENCE Urban Rural REGION Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West EDUCATION No education Primary Middle/JSS Secondary+ WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 10 20 30 40 50 Percent Modern methods Traditional methods Figure 5.1 Current Use of Family Planning Among Currently Married Women Age 15-49 GDHS 2003 with urban-rural and regional residence, education level, and number of living children. Women in urban areas are more likely to use contraceptive methods (31 percent) than their rural counterparts (21 percent). Male condoms, IUD, and female sterilisation use in urban areas is two to three times higher than in rural Ghana. The more urbanised regions such as Greater Accra, Brong-Ahafo, and Ashanti, have contraceptive prevalence rates of 30-34 percent. Two of the three northern regions (Upper East and Northern) and Central Region report the lowest levels of contraceptive use (12 percent each in the Northern and Upper East regions, and 15 percent in the Central Region). Women with at least some secondary education are more than twice as likely to use contraception as women with no education. Use of female sterilisation, implants, male condoms, IUD, LAM, and periodic abstinence all increase with education. The proportion currently using contraception generally increases with increasing number of children. Fourteen percent of women without children are currently using contraceptive methods, compared with 26 percent of women with five or more children. Current use of contraception is, however, highest among women who have three or four children (31 percent). Use of female sterilisation, implants, and LAM increases with increasing number of children. Wealth and current use of contraception is positively related, increasing from 14 percent among currently married women in the lowest quintile to 35 percent in the highest quintile. The gap in use is especially large between women in the lowest wealth quintile and all other wealth quintiles, and is obvious for all methods with the exception of female sterilisation, which shows an isotonic increase from lowest to highest wealth quintile. The pattern of current use of modern and traditional methods of contraception is generally similar across subgroups. Use of both modern and traditional methods are more common in urban than rural areas, increases with increasing education and wealth quintile. 74 | Family Planning 5.4 TRENDS IN THE USE OF FAMILY PLANNING Table 5.5 and Figure 5.2 show the trend in the use of family planning among currently married women based on data from the 1988, 1993, 1998, and 2003 GDHS surveys. Table 5.5 Trends in the use of family planning Percentage of currently married women age 15-49 who are currently using specific family planning methods, Ghana 1988, 1993, 1998, 2003 Method GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 Any method 12.9 20.3 22.0 25.2 Any modern method 5.2 10.1 13.3 18.7 Pill 1.8 3.2 3.9 5.5 IUD 0.5 0.9 0.7 0.9 Injectable 0.3 1.6 3.1 5.4 Diaphragm/foam/Jelly 1.3 1.2 0.9 0.5 Male condom 0.3 2.2 2.7 3.1 Female condom u u u 0.1 Female sterilisation 1.0 0.9 1.3 1.9 Implants u 0.0 0.1 1.0 LAM u u 0.5 0.3 Any traditional method 7.7 10.1 8.7 6.5 Periodic abstinence 6.2 7.5 6.6 5.1 Withdrawal 0.9 2.1 1.5 0.8 Other 0.6 0.5 0.6 0.6 Number of women 3,156 3,204 3,131 3,549 u = Unknown (not available) GDHS 1988-2003 Figure 5.2 Trends in Current Use of Contraceptive Methods Ghana, 1988-2003 13 5 8 20 10 10 22 13 9 25 19 7 Any method Any modern method Any traditional method 0 5 10 15 20 25 30 Pe rc en ta ge c ur r e nt ly m ar rie d w om en 1988 1993 1998 2003 Family Planning | 75 The current use of contraception among currently married women shows an increase from 13 percent in 1988, 20 percent in 1993, 22 percent in 1998, to 25 percent in 2003. There has been a steady increase in the use of modern methods from 5 percent in 1988, 10 percent in 1993, 13 percent in 1998 to 19 percent in 2003. However, while there was an increase in the use of traditional methods from 8 percent in 1988 to 10 percent in 1993, use of these methods have since decreased to 9 percent in 1998 and 7 percent in 2003. Use of male condoms, pills, injectables, and implants have increased markedly. For example, pill use more than doubled, use of injectables increased from less than 1 percent to 5 percent, and male condom use increased from less than 1 percent to 3 percent, between 1988 and 2003. A major IEC campaign called Life Choices, which aimed at repositioning family planning (from being a purely clinical or health issue to being a choice one makes in life according to personal reproductive goals), may have contributed significantly to the increased use of modern methods. 5.5 CURRENT USE OF CONTRACEPTION BY WOMEN’S STATUS Women’s status plays a very important role in access to and use of family planning services as well as other reproductive and child health services and is a determinant of contraceptive use. Table 5.6 presents the distribution of currently married women by contraceptive method currently used, according to selected indicators of women’s status. A woman’s desire and ability to manage her fertility and her choice of contraceptive methods are in part affected by her status, self-image, and sense of empowerment. A woman who feels that she does not have much control over basic aspects of her life may be less likely to feel she can make and carry out decisions about her fertility. She may also feel the need to choose methods that are less obvious or that do not depend on her husband’s cooperation. There does not appear to be a clear relationship between the three measures of women’s status and current contraceptive use among currently married women. Nevertheless, women who believe that wife-beating is not justified for any reason at all seem to be slightly more likely to use contraceptives than other women. 76 | Fam ily Planning Table 5.6 Current use of contraception by women's status Percent distribution of currently married women by contraceptive method currently used, according to indicators of women's status, Ghana 2003 Modern method Traditional method Women’s status indicator Any method Any modern method Female sterili- sation Pill IUD Inject- ables Implants Male condom Female condom Dia- phragm Foam/ jelly LAM Any traditional method Periodic absti- nence With- drawal Folk method Not currently using Total Number of women Number of decisions in which woman has final say1 0 23.6 19.4 0.8 4.4 1.0 6.6 1.3 4.3 0.0 0.0 0.4 0.6 4.3 3.2 0.7 0.3 76.4 100.0 630 1-2 19.5 14.3 1.4 3.7 0.3 4.9 0.7 2.8 0.0 0.2 0.2 0.0 5.3 3.9 0.5 0.9 80.5 100.0 760 3-4 28.6 18.8 1.3 8.2 1.1 4.3 1.3 1.5 0.3 0.0 0.4 0.4 9.8 7.7 0.9 1.3 71.4 100.0 742 5 27.1 20.6 3.0 5.7 1.0 5.7 0.8 3.6 0.1 0.1 0.4 0.3 6.4 5.1 1.0 0.3 72.9 100.0 1,417 Number of reasons to refuse sex with husband 0 23.5 18.7 0.5 9.0 0.1 3.4 2.3 2.3 0.5 0.0 0.5 0.0 4.9 4.2 0.0 0.7 76.5 100.0 267 1-2 25.0 17.6 1.6 4.5 1.8 4.0 1.1 2.7 0.5 0.0 0.3 1.1 7.4 6.4 0.5 0.5 75.0 100.0 461 3-4 25.4 18.8 2.0 5.4 0.8 5.8 0.8 3.2 0.0 0.1 0.4 0.2 6.5 4.9 0.9 0.6 74.6 100.0 2,821 Number of reasons wife - beating is justified 0 27.5 19.8 2.3 6.2 0.8 4.9 1.3 3.5 0.1 0.1 0.3 0.3 7.6 6.4 0.8 0.4 72.5 100.0 1,738 1-2 22.3 16.9 1.4 5.5 1.3 5.4 0.8 2.1 0.2 0.0 0.2 0.1 5.4 4.1 0.7 0.6 77.7 100.0 755 3-4 26.0 19.9 1.9 4.7 1.2 7.0 0.8 3.3 0.0 0.0 0.6 0.5 6.1 4.0 0.9 1.2 74.0 100.0 717 5 18.0 14.0 0.9 4.2 0.0 5.1 0.4 2.6 0.0 0.0 0.4 0.5 4.0 2.5 0.7 0.8 82.0 100.0 339 Total 25.2 18.7 1.9 5.5 0.9 5.4 1.0 3.1 0.1 0.1 0.4 0.3 6.5 5.1 0.8 0.6 74.8 100.0 3,549 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method 1 Either by herself or jointly with others Family Planning | 77 5.6 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION The decision to initiate family planning use differs according to the circumstances of couples and individuals concerned. Contraceptive methods may be used for limiting births when they have already had the desired number of children (i.e., to stop having children), or spacing births (i.e., to delay the interval between births), or postpone a first birth. In the 2003 GDHS, women were asked how many children they had at the time they first used a method of family planning. The number of living children at the time of first use of contraception is a measure of willingness to postpone the first birth and of a deliberate effort at spacing births. Thus, differences in fertility-controlling behaviour of different cohorts of women can be observed by examining the number of living children at first use of contraceptives by age of the woman. Table 5.7 shows the percent distribution of women who have ever used contraception by number of living children at the time of first use of contraception, according to current age. Two in five women age 15-49 years report first use of contraception before the birth of their first child. Younger women (age 15-34) reported first use of contraceptives at lower parities than older women. Among older women, those who ever used contraception tended to start only when they had at least four children. In contrast, younger users tend to start when they had only one child or none. For example, 93 percent of women 15- 19 who have used contraception started before they had any children, compared with 12 percent of women age 45-49. In a culture where smaller family size is becoming a norm, young women adopt family planning at an earlier age than their older counterparts. The data suggests a move towards the early use of contraceptives among younger Ghanaian women to delay childbearing. On the other hand, older women initiate contraceptive use at a later age primarily to limit rather than space births. Table 5.7 Number of children at first use of contraception Percent distribution of women who have ever used contraception by number of living children at the time of first use of contraception, according to current age, Ghana 2003 Number of living children at time of first use of contraception Current age 0 1 2 3 4+ Missing Total Number of women 15-19 92.9 6.8 0.3 0.0 0.0 0.0 100.0 222 20-24 68.7 24.2 5.6 1.0 0.0 0.5 100.0 518 25-29 38.2 31.9 17.7 8.0 3.2 1.0 100.0 551 30-34 21.4 29.1 21.4 12.1 15.7 0.2 100.0 481 35-39 15.2 18.9 17.2 18.5 29.8 0.4 100.0 385 40-44 13.7 18.2 10.4 14.7 42.2 0.8 100.0 315 45-49 12.3 15.6 12.4 10.9 47.7 1.0 100.0 225 Total 37.3 23.0 13.3 9.3 16.6 0.6 100.0 2,698 5.7 USE OF SOCIAL MARKETING BRANDS It is important for programme purposes to get a sense of whether the social marketing of contraceptives is successful. Questions on social marketing in Ghana were restricted to the use of the pill and condom, since they are the most commonly used modern methods of contraception. Pill and condom users were asked for the brand name and the cost. Secure is the brand of oral contraceptive pill that is socially marketed by the Ghana Social Marketing Foundation (GSMF). Ovrette, Microgynon, Micronor, and Lo-femenal are brands provided by the public sector and at the Planned Parenthood Association of Ghana (PPAG) clinics. The other brands 78 | Family Planning are mainly sold in the private commercial sector. Table 5.8 shows that the brand marketed by GSMF is by far the most popular brand of pill used in Ghana. One in two women use Secure, compared with one in eight women using brands marketed by the public sector. The most common, Lo-femenal, is used by 8 percent of pill users. One in six women use brands marketed by the private sector―the most common, Duofem, is used by 7 percent of pill users. Table 5.8 also shows the average cost of a cycle of pills by brand name for women who know the cost. The average cost of a cycle of pills is 1,366 cedis2 irrespective of the brand, but cost varies markedly by the brand type, ranging from a high of 1,667 cedis for Micronor to a low of 935 cedis for Ovrette. Table 5.8 Pill brand and cost Percent distribution of pill users and average cost per cycle, by brand of pill according to source, Ghana 2003 Brand by source Users Cost per cycle (cedis1) GSMF Secure 50.3 1,087 Public Ovrette 3.1 935 Microgynon 0.8 1,000 Lo-femenal 8.4 1,252 Micronor 0.4 1,667 Private Duofem 6.5 999 Other 10.5 2,800 Don’t know/Missing 19.9 1,616 Average cost per cycle na 1,366 Total 100.0 na Number 235 216 1One US$ is equivalent to 8,992 cedis. Excludes users who don’t know cost. GSMF = Ghana Social Marketing Foundation na=Not applicable As seen in Table 5.9, GSMF plays an important role in the marketing of condoms too. Sixty- three percent of men who report use of condom mention using brands marketed by GSMF (Protector, Champion, and Panther), 16 percent use a privately marketed brand (Rough Rider or other), and 4 percent used a brand marketed by the public sector (no brand name/no logo). Table 5.9 also shows the average cost of condoms by brand name among men who knew the cost of condoms. The most popular condom, Champion, is also the cheapest. Condoms marketed by the private sector are much more expensive than those marketed by GSMF or the public sector. 2 One US$ is equivalent to 8,992 cedis. Family Planning | 79 Table 5.9 Condom brand and cost Percent distribution of condom users and average cost per con- dom by brand of condom according to source, Ghana 2003 Brand name Users Cost per condom (cedis1) GSMF Protector 5.6 388 Champion 35.5 254 Panther 21.8 322 Public No brand name/no logo 3.6 260 Private Rough rider 1.3 1,266 Other 15.1 649 Don’t know/Missing 17.0 358 Average cost per condom na 368 Total 100.0 na Number 1,981 1,838 1One US$ is equivalent to 8,992 cedis. Excludes users who don’t know cost. GSMF = Ghana Social Marketing Foundation na=Not applicable The market share of socially marketed pills and condoms has increased in the last five years. GSMF brands of pills and condoms increased by 35 percent and 27 percent, respectively, in the five years between 1998 and 2003. In 1998, pills marketed by GSMF accounted for 37 percent of current users, while condoms sold by GSMF accounted for 50 percent of current users (GSS and MI, 1999). 5.8 KNOWLEDGE OF FERTILE PERIOD A basic knowledge of reproductive physiology is especially useful for the successful practice of coitus-related methods such as withdrawal, condom, vaginal methods, and other fertility-awareness-based methods collectively called periodic abstinence. Knowledge of the fertile period is particularly critical in the case of periodic abstinence. The successful practice of natural family planning depends on an understanding of when during the menstrual cycle a woman is most likely to conceive. All women and men in the 2003 GDHS were asked about their knowledge of a woman’s fertile period. The results are presented in Table 5.10 for users and non-users of periodic abstinence. Only about three-tenths of all women and all men (29 and 28 percent, respectively) reported correct knowledge of a woman’s fertile period, that is, that a woman is most likely to conceive half way between two periods. Users of natural family planning methods are more knowledgeable about their ovulatory cycle; 62 percent of female users of natural family planning correctly identified the middle of the cycle as the fertile time compared with 28 percent of non-users of the method. Knowledge of the fertile period among men was lower than for women. Forty-five percent of male users of natural family planning correctly identified the middle of the cycle as the fertile time, compared with 27 percent of non-users of the method. One-third of women wrongly reported that the fertile period occurs right after a woman’s period has ended, with 30 percent of users of periodic abstinence reporting so. Nineteen percent reported not having any knowledge of the fertile period. This is an improvement over the results of the 1993 GDHS, 80 | Family Planning where nearly half of all women did not have correct knowledge of the fertile period. In that survey, 28 percent of all women and 55 percent of users of periodic abstinence correctly knew of the fertile period, while 20 percent of all women reported that the fertile period is right after the period has ended. Comparable data were not available for the 1998 GDHS. Table 5.10 Knowledge of fertile period Percent distribution of women and men by knowledge of the fertile period during the ovulatory cycle, according to current use/non-use of periodic abstinence, Ghana 2003 Women Men Perceived fertile period Users of periodic abstinence Non-users of periodic abstinence All women Users of periodic abstinence Nonusers of periodic abstinence All men Just before her period begins 4.1 4.8 4.7 7.5 7.0 7.0 During her period 0.6 2.1 2.1 3.2 3.9 3.9 Right after her period has ended 30.0 35.2 35.0 41.0 27.8 28.4 Halfway between two periods 62.1 28.0 29.4 45.1 27.2 28.1 Other 0.0 0.1 0.1 0.0 0.1 0.1 No specific time 0.3 9.7 9.3 0.2 12.9 12.3 Don't know 3.0 20.0 19.2 2.6 20.8 19.9 Missing 0.0 0.2 0.2 0.4 0.2 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 238 5,453 5,691 261 4,754 5,015 5.9 SOURCE OF SUPPLY Information on sources of modern contraception is important to family planning programme management. In Ghana, both public and private sectors are strategically important in the provision of family planning services. Non-clinical short-term methods such as the pill and condoms are widely distributed by the private sector. Ghana has a vibrant social marketing programme that networks with pharmacies and chemical sellers, private clinics and maternity homes as well as major NGOs, such as the PPAG, which provide both clinical and non-clinical methods. The public sector provides the full range of clinical and non-clinical methods mainly through health facilities and also supports major partners such as PPAG. In the 2003 GDHS, all current users of modern contraceptive methods were asked the most recent source of their methods. Interviewers were instructed to record the name of the source or facility, because respondents may not always be able to accurately categorise a source as public or private. Supervisors and editors then verified this information. This procedure helped in improving the accuracy of the information. The results are shown in Table 5.11 and Figure 5.3 and indicate that in Ghana both the public and private sectors are important sources of supply for users of modern methods (41 and 54 percent, respectively). The most common public sector sources are government hospitals and polyclinics, which provide most of the services (26 percent), while government health centres and family planning clinics provide 11 and 4 percent, respectively. Within the private sector, pharmacies, chemists, and drug stores are the largest source, supplying 43 percent of all current users. Seven percent of users also mentioned private hospitals or clinics and 3 percent mentioned maternity homes and PPAG clinics. Other sources such as family, relatives, and shops are the least common (2 percent). Family Planning | 81 Table 5.11 Source of contraception Percent distribution of current users of modern contraceptive methods by most recent source of method, ac- cording to specific method, Ghana 2003 Source Female sterilisation Pill IUD Inject- ables Implants Male condom Total Public sector 68.9 19.5 (78.2) 86.9 (92.0) 5.2 41.0 Government hospital/ polyclinic 67.5 9.9 (63.6) 43.6 (69.0) 3.3 25.7 Government health centre 0.0 7.0 (7.0) 31.1 (18.0) 0.2 10.6 FP clinic 1.4 2.3 (7.5) 9.5 (2.9) 0.4 3.6 Mobile clinic 0.0 0.0 (0.0) 0.4 (0.0) 0.0 0.1 Fieldworker 0.0 0.3 (0.0) 1.0 (2.0) 1.2 0.8 Other 0.0 0.0 (0.0) 1.4 (0.0) 0.0 0.3 Private medical sector 29.3 76.8 (21.8) 12.6 (8.0) 82.4 53.7 Private hospital/clinic 29.3 4.2 (12.6) 6.2 (5.9) 1.7 6.5 Private doctor 0.0 0.6 (0.0) 0.0 (0.0) 0.0 0.2 Pharmacy/chemist/ drug store 0.0 66.1 (0.0) 0.9 (0.0) 80.0 43.1 Mobile clinic 0.0 0.5 (0.0) 0.0 (0.0) 0.0 0.1 Fieldworker 0.0 1.1 (0.0) 0.0 (0.0) 0.7 0.7 FP/PPAG clinic 0.0 1.4 (3.1) 2.6 (2.1) 0.0 1.3 Maternity home 0.0 2.8 (6.1) 3.0 (0.0) 0.0 1.7 Other 0.0 0.2 (0.0) 0.0 (0.0) 0.0 0.0 Other source 0.0 1.3 (0.0) 0.0 (0.0) 6.1 2.4 Shop 0.0 0.0 (0.0) 0.0 (0.0) 1.0 0.3 Friend/relative 0.0 1.3 (0.0) 0.0 (0.0) 5.2 2.1 Other 0.0 2.4 (0.0) 0.5 (0.0) 2.7 1.7 Missing 1.8 0.0 (0.0) 0.0 (0.0) 3.5 1.2 Total 100.0 100.0 (100.0) 100.0 (100.0) 100.0 100.0 Number of women 72 235 35 208 37 246 858 Note: Table excludes lactational amenorrhoea method (LAM). Figures in parentheses are based on 25-49 un- weighted cases. Total includes 7 users of female condom, 3 users of the diaphragm and 12 users of foam/jelly. In the last fifteen years, there has been a shift in the source of modern contraceptive methods from the public to the private sector (Figure 5.3). The proportion of current users relying on private medical sources has increased from 43 percent in 1988 to 52 percent in 1993, declined to 45 percent in 1998 and then increased to 54 percent in 2003. Reliance on public sources for all modern methods increased from 35 percent in 1988, 43 percent in 1993, to 47 percent in 1998, with a decline (41 percent) in 2003. There are differences by method among the sectors. Male condoms and pills are commonly obtained from private sources (82 and 77 percent, respectively), while clinic-based methods such as IUD, injectables, and implants are provided predominantly by public facilities. Female sterilisation requires medical personnel and is available mostly in public sector hospitals (69 percent) and some private hospitals and clinics (29 percent). 5.10 INFORMED CHOICE Informed choice is an important aspect of the delivery of family planning services. Family planning providers should inform all method users of potential side effects, what they should do if they 82 | Family Planning encounter signs of a problem, and alternate options. This information assists users in coping with side effects and decreases unnecessary discontinuation of temporary methods. Table 5.12 shows that about half of family planning clients receive relevant information to make informed choices. Health providers are somewhat more likely to inform users of modern methods about side effects or problems of method used (54 percent) and about what other methods could be used (53 percent) than about what to do if they experienced side effects (50 percent). Information varies by type of method, being least likely to be provided to users of female sterilization (24 percent). Public sector clients received more information than private sector clients (seven and four in ten, respectively). Pharmacy, chemist, and drug store clients received the least information (three in ten). Slightly higher proportions of urban residents received relevant information than their rural counterparts, particularly with respect to information on other methods that could be used (59 and 48 percent, respectively). Most of the regional information is based on small numbers of users. There appears to be no major differentials in informed choice by educational level. Among wealth quintiles the least informed are women in the middle quintile with the women from the highest quintile receiving the most information. Figure 5.3 Trends in Source of Modern Contraceptive Methods, Ghana 1988-2003 35 43 47 4143 52 45 54 GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 0 20 40 60 80 100 Pe rc en ta ge o f w om en Public Private GDHS 1988-2003 Family Planning | 83 Table 5.12 Informed choice Among current users of modern contraceptive methods who adopted the current method in the five years preceding the survey, percentage who were informed about the side effects of the method used, percentage who were informed what to do if side effects were experienced, and percentage who were informed of other methods that could be used for contraception, by specific method, initial source of method, and background characteristics, Ghana 2003 Method/source/ background characteristic Informed about side effects or problems of method used1 Informed what to do if ex- perienced side effects1 Informed of other meth- ods that could be used2 Method Female sterilisation 23.2 20.1 23.7 Pill 40.7 37.3 43.5 IUD (51.6) (52.7) (50.8) Injectables 74.1 68.0 73.5 Implants (79.9) (82.5) (79.2) Other3 na na (36.9) Initial source of method4 Public sector 71.3 65.4 72.1 Government hospital/polyclinic 66.1 63.7 68.1 Government health centre 77.9 64.6 78.9 FP clinic (79.5) (71.3) (78.1) Private medical sector 41.0 39.7 42.2 Private hospital/clinic (49.6) (44.8) (57.4) Pharmacy/chemist/drug store 31.3 29.7 28.4 Residence Urban 58.2 54.1 59.0 Rural 48.8 45.6 47.9 Region Western (69.1) (67.3) 61.7 Central (66.4) (70.1) (75.5) Greater Accra 47.8 39.9 48.7 Volta (58.2) (49.7) (54.8) Eastern 41.1 44.2 47.5 Ashanti 51.0 46.5 47.4 Brong Ahafo 57.6 59.2 60.9 Northern (41.4) (38.2) (44.8) Upper East (63.9) (33.3) (50.6) Upper West 49.7 46.0 49.2 Education No education 56.4 49.7 56.0 Primary 55.3 50.9 52.8 Middle/JSS 51.3 48.3 51.8 Secondary+ (52.0) (55.1) 56.4 Wealth quintile Lowest 54.6 46.0 49.4 Second 53.7 48.7 54.0 Middle 49.5 46.0 48.6 Fourth 52.6 50.5 49.3 Highest 56.8 54.7 61.7 Total 53.5 49.8 53.4 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indictes that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Among users of female sterilisation, pill, IUD, injectables and implants 2 Among users of female sterilisation, pill, IUD, injectables, implants, female condom, diaphragm, foam or jelly, and lactational amenorrhoea method (LAM) 3 Female condom, diaphragm, foam, jelly and lactational amenorrhoea method (LAM) 4 Source at start of current episode of use 84 | Family Planning 5.11 FUTURE USE OF CONTRACEPTION Intention to use family planning is an important indicator of the potential demand for services. Currently married women who were not using contraceptives at the time of the survey were asked about their intention to use family planning in the future. The results are shown in Table 5.13. The table reveals that of the currently married female non-users, 54 percent intend to use a method of contraception in the future, while 42 percent have no intention to use any method. Four percent are not sure of their contraceptive use intention. Table 5.13 Future use of contraception Percent distribution of currently married women who are not using a contraceptive method by intention to use in the future, according to number of living children, Ghana 2003 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 56.6 59.3 54.9 58.2 49.0 54.1 Unsure 5.2 4.6 4.8 5.5 2.8 4.1 Does not intend to use 38.2 36.0 39.7 35.8 48.1 41.5 Missing 0.0 0.2 0.6 0.5 0.2 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 190 491 488 451 1,035 2,655 1 Includes current pregnancy There has been an increase in the percentage of currently married non-users who intend to use family planning in the future (including those who intend to use but are not sure of timing), from 37 percent in 1988, to 51 percent in 1993, followed by a slight decline to 48 percent in 1998, and then an increase to 58 percent in 2003. 5.12 REASONS FOR NOT INTENDING TO USE CONTRACEPTION Table 5.14 presents the main reasons for not intending to use contraception given by currently married women age 15-29 and 30-49 years who do not intend to use a contraceptive method in the future. The main reasons for not intending to use any contraception in the future among currently married women are fertility-related issues (41 percent), followed by method-related reasons (37 percent). Among fertility-related reasons, 17 percent of younger women state that they want as many children as possible, while older women (20 percent) do not intend to use because they are subfecund or infecund. Fear of side effects was the most cited method-related reason for non-use among all women (26 percent). This reason is particularly cited by younger women (34 percent) than women 30 years and older (23 percent). This calls for a continued intensification of information and counseling on side effects of contraceptive methods by the family planning programme in Ghana. Younger women are also more likely to be opposed to family planning than older women (9 and 5 percent, respectively). Fear of side effects has increased in importance as a reason for non-use since 1998, from 18 to 26 percent. Family Planning | 85 Table 5.14 Reason for not intending to use contraception Percent distribution of currently married women who are not using a contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, Ghana 2003 Age Reason 15-29 30-49 Total Fertility-related reasons 20.3 47.7 40.5 Infrequent sex/no sex 1.4 7.0 5.5 Menopausal/had hysterectomy 0.0 8.5 6.3 Subfecund/infecund 1.4 19.7 14.9 Wants as many children as possible 17.4 12.5 13.8 Opposition to use 16.9 10.7 12.3 Respondent opposed 8.9 4.7 5.8 Husband/partner opposed 3.3 2.9 3.0 Religious prohibition 4.7 3.1 3.5 Lack of knowledge 8.5 4.7 5.7 Knows no method 5.9 3.9 4.4 Knows no source 2.6 0.8 1.3 Method-related reasons 47.5 33.8 37.3 Health concerns 9.1 7.0 7.6 Fear of side effects 34.2 22.5 25.6 Lack of access/too far 0.8 0.5 0.6 Costs too much 1.5 1.1 1.2 Inconvenient to use 1.0 1.0 1.0 Interferes with body's normal processes 0.9 1.6 1.4 Other 2.1 1.2 1.4 Don’t know 3.0 1.6 2.0 Missing 1.8 0.4 0.8 Total 100.0 100.0 100.0 Number of women 288 815 1,102 5.13 PREFERRED METHOD OF CONTRACEPTION FOR FUTURE USE Asking non-users who say they intend to use a family planning method in the future for the type of method they would prefer to use is a way to assess the potential demand for specific methods of family planning. Table 5.15 shows that among currently married women, the contraceptive method most commonly preferred for future use is injectables (43 percent), followed by the pill (15 percent) and implants (11 percent). There has been a slight change in the order of preferred methods by currently married women since the 1998 GDHS. The proportion of non-users preferring the injectable increased from 36 percent in 1998 to 43 percent in 2003, while the proportion of non-users who prefer to use the pill has decreased from 21 percent in 1998 to 15 percent in 2003. Preference for implants increased from 4 percent in 1998 to 11 percent in 2003. Intention to use the IUD also increased from 2 percent in 1998 to 4 percent in 2003 and is the same among both younger and older women. Older respondents are more likely to intend to use permanent methods than younger ones. For example, among respondents in the age group 30-49, 5 percent say they would prefer female sterilisation compared with 2 percent among those in the age group 15-29. 86 | Family Planning Table 5.15 Preferred method of contraception for future use Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to age, Ghana 2003 Age Method 15-29 30-49 Total Female sterilisation 2.0 5.3 3.6 Pill 17.2 13.4 15.4 IUD 3.9 3.9 3.9 Injectables 45.8 39.0 42.5 Implants 10.1 12.1 11.1 Condom 3.0 2.9 2.9 Female condom 0.6 0.7 0.6 Diaphragm 0.2 0.9 0.5 Foam/jelly 0.0 0.1 0.1 Lactational amenorrhoea method (LAM) 0.2 0.2 0.2 Periodic abstinence 4.3 4.5 4.4 Withdrawal 0.2 0.2 0.2 Other 2.5 2.3 2.4 Unsure 10.3 14.4 12.3 Total 100.0 100.0 100.0 Number of women 748 689 1,437 5.14 EXPOSURE TO FAMILY PLANNING MESSAGES The media is seen as an effective means to disseminate family planning information. To assess the extent to which media serve as sources of family planning messages, respondents were asked whether they had heard or seen a message about family planning on the radio, television, newspapers or magazines, posters, leaflets or brochures, from health workers, and community meetings in the few months preceding the survey. The results are shown in Table 5.16.1 for women and Table 5.16.2 for men and in Figure 5.4. Radio is the most frequent source of family planning messages for both women (77 percent) and men (86 percent). Fifty-two percent of women and 58 percent of men saw a family planning message on the television in the few months preceding the survey. About half of women and men are also exposed to family planning messages through posters. Health workers are also mentioned as an important source by 47 percent of women and 44 percent of men, while 34 percent of women and 36 percent of men mentioned hearing about family planning at community meetings. Newspapers and magazines are the least common source of family planning messages for both women (20 percent) and men (33 percent). About one in five women and one in nine men were not exposed to a family planning message through the radio, television, or newspaper/magazine in the few months prior to the survey. Thirteen percent of women and 9 percent of men have had no exposure to family planning messages from any media source. Exposure to family planning messages is more common among men than women and in urban than rural areas, and increases with increasing level of education and wealth quintile. Among the regions, women in the Upper East, Brong-Ahafo, Eastern, and Ashanti regions and men in the Western, Central and Greater Accra regions have by far the highest exposure to family planning messages through any media, while respondents in the Upper West and Northern regions have the lowest. Family Planning | 87 Table 5.16.1 Exposure to family planning messages: women Percentage of women who heard or saw a family planning message on various media sources in the past few months, according to back- ground characteristics, Ghana 2003 Background characteristic Radio Television Newspaper/ magazine None of the three media sources Poster Leaflet/ brochure Health worker Community meetings No expo- sure to any source of media Number of women Age 15-19 67.3 55.3 21.5 25.1 47.2 20.4 26.7 24.9 18.4 1,148 20-24 75.5 59.9 22.3 19.2 49.0 23.0 45.3 31.5 11.7 1,012 25-29 80.0 51.3 18.4 17.7 51.9 22.0 54.6 36.6 11.0 951 30-34 81.2 48.2 18.0 17.6 50.3 19.6 57.1 34.6 9.6 802 35-39 78.0 49.0 15.8 20.2 46.3 17.7 55.5 37.4 12.0 722 40-44 80.9 49.0 19.9 15.9 49.9 19.3 54.3 35.1 10.0 579 45-49 80.6 46.2 19.2 18.4 49.5 19.1 49.4 44.0 11.5 477 Residence Urban 82.7 73.9 30.8 11.7 59.8 28.8 46.4 36.2 7.5 2,755 Rural 71.1 31.9 9.1 27.0 39.0 12.6 48.2 31.2 17.2 2,936 Region Western 72.6 54.1 16.2 21.9 58.3 20.4 53.6 36.4 12.1 553 Central 71.6 47.2 9.6 23.4 52.1 13.2 35.8 26.4 14.7 431 Greater Accra 79.4 77.3 33.9 13.9 57.3 29.3 36.8 33.7 10.8 942 Volta 63.4 27.7 15.7 31.2 44.0 16.5 61.6 28.4 17.0 492 Eastern 88.7 59.3 18.9 9.7 40.4 18.7 59.1 47.8 7.0 601 Ashanti 84.7 65.5 27.1 12.1 66.5 29.7 44.5 36.4 8.9 1,142 Brong Ahafo 87.4 58.1 21.0 11.1 59.9 27.4 58.2 46.5 6.2 569 Northern 51.0 16.1 4.4 47.6 18.1 3.2 42.7 18.1 32.5 499 Upper East 87.1 23.6 5.5 11.6 10.8 3.7 31.1 20.4 5.1 310 Upper West 48.8 11.9 2.8 50.2 15.9 1.3 57.7 12.7 25.1 153 Education No education 65.4 24.9 2.3 32.9 24.3 4.7 40.6 21.5 21.6 1,608 Primary 75.0 44.3 7.7 22.5 42.1 11.1 44.0 27.9 15.0 1,135 Middle/JSS 82.7 66.4 24.6 12.6 61.9 26.7 50.8 39.7 7.4 2,279 Secondary+ 86.2 83.4 64.1 6.8 76.8 52.9 57.3 51.6 3.6 669 Wealth quintile Lowest 60.8 15.0 3.3 38.0 22.8 5.4 44.1 22.0 23.3 970 Second 73.4 27.0 5.5 25.1 38.2 10.5 46.3 28.9 16.9 949 Middle 77.3 45.5 11.5 20.2 47.4 15.4 51.1 37.6 13.1 1,071 Fourth 80.9 65.6 21.3 14.9 55.7 23.1 48.3 36.2 8.6 1,245 Highest 85.4 87.1 44.0 7.4 69.3 38.5 46.4 39.3 5.3 1,457 Total 76.7 52.3 19.6 19.6 49.1 20.4 47.3 33.6 12.5 5,691 88 | Family Planning Table 5.16.2 Exposure to family planning messages: men Percentage of men who heard or saw a family planning message on the radio or television, or in a newspaper/magazine in the past few months, according to background characteristics, Ghana 2003 Background characteristic Radio Television Newspaper/ magazine None of the three media sources Poster Leaflet/ brochure Health worker Community meetings No expo- sure to any source of media Number of men Age 15-19 74.7 56.7 23.2 19.5 49.8 17.5 28.4 21.0 16.5 1,107 20-24 84.4 66.0 36.2 11.8 56.1 27.7 45.3 36.5 8.6 684 25-29 90.8 66.0 38.3 6.9 60.9 27.7 45.1 40.2 5.3 754 30-34 90.5 60.5 35.5 8.3 59.1 26.3 50.6 42.5 5.5 633 35-39 88.1 52.7 34.7 11.4 57.2 26.4 50.2 42.1 7.2 498 40-44 89.6 50.9 36.3 8.7 55.8 26.1 51.0 44.7 6.4 412 45-49 89.1 56.1 36.4 9.1 56.2 28.1 52.9 41.9 8.0 441 50-54 89.1 52.9 35.2 9.4 59.2 23.2 52.3 40.3 7.8 294 55-59 85.8 50.2 35.9 13.3 45.1 26.9 46.9 38.8 11.4 192 Residence Urban 87.6 78.6 48.1 8.4 67.4 34.6 44.1 39.4 6.5 2,250 Rural 83.8 42.1 21.4 14.4 46.2 16.8 44.4 34.0 11.3 2,765 Region Western 83.9 66.7 34.0 10.6 65.3 26.5 46.8 38.9 7.1 476 Central 88.6 55.4 22.8 9.1 43.0 15.5 29.2 21.1 7.7 370 Greater Accra 90.3 82.2 55.7 6.8 68.1 38.5 38.0 38.9 5.4 733 Volta 81.4 50.2 29.0 14.7 59.6 24.6 49.8 42.5 10.6 440 Eastern 92.0 62.5 32.6 6.6 53.2 27.3 42.0 48.3 5.5 539 Ashanti 87.2 67.0 44.2 8.9 65.8 33.4 48.2 41.1 8.2 956 Brong Ahafo 91.7 62.7 32.4 7.3 72.7 22.3 47.6 26.9 6.5 528 Northern 71.6 25.0 10.7 26.7 30.6 6.0 40.5 26.7 19.3 527 Upper East 83.1 38.9 16.6 14.7 24.4 13.8 59.8 42.1 10.2 317 Upper West 67.6 17.4 10.1 31.3 18.1 6.8 39.9 16.2 26.6 130 Education No education 75.9 22.5 5.3 23.4 22.2 3.2 36.0 22.1 18.1 881 Primary 77.6 42.6 11.4 18.9 35.9 8.8 34.5 25.0 15.8 803 Middle/JSS 88.7 65.4 32.6 8.4 62.8 25.3 43.7 36.2 6.7 2,165 Secondary+ 92.4 83.6 71.1 4.0 81.5 51.1 58.3 55.5 2.4 1,165 Wealth quintile Lowest 74.3 21.6 10.1 24.7 28.7 7.6 43.2 26.4 18.3 872 Second 87.4 36.4 19.2 11.7 44.9 14.2 39.8 30.7 9.8 903 Middle 86.8 55.7 22.9 10.8 53.8 18.2 43.2 34.6 8.3 975 Fourth 86.9 74.4 39.1 9.5 63.7 29.9 45.0 39.1 8.0 1,060 Highest 90.0 89.8 64.2 5.0 77.8 45.8 48.7 47.1 3.7 1,204 Total 85.5 58.4 33.4 11.7 55.7 24.8 44.3 36.4 9.2 5,015 Family Planning | 89 Figure 5.4 Percentage of Women and Men Exposed to Family Planning Messages in the Media 77 52 20 13 86 58 33 9 Radio Television Newspaper/ magazine No media sources 0 20 40 60 80 100 Pe rc en ta ge o f w om en /m en Women Men GDHS 2003 Note: No media sources refers to nonexposure to radio, television, newspaper/magazine, poster, leaflet/brochure, health worker, and community meetings. 5.15 EXPOSURE TO SPECIFIC RADIO MESSAGES ON FAMILY PLANNING The 2003 GDHS survey collected information from women and men about whether they had heard specific radio adverts and slogans on family planning from the Life Choices campaign in the few months before the survey. The slogans included the following: Life Choices: It’s your life, it’s your choice; Make the choice that is best for you; Contraceptives are safe and effective; and Obra ni wora bo3. Table 5.17 shows the percentages of women and men who have heard the specific radio messages and slogans of Life Choices in the few months preceding the survey, by background characteristics. Of the four slogans asked about, the most common is Obra ni wora bo, heard by 68 percent of women and 75 percent of men. The remaining messages were heard in the following order: Life Choices: It’s your life. It’s your choice, “Make the choice that is best for you” with “Contraceptives are safe and effective” being the least heard message, by both sexes. Men are more likely than women to have heard each of the messages. The percentage of women and men who have been exposed to specific radio messages generally decreases with age, is higher among urban residents than rural residents, and increases with increasing level of education and wealth. Never-married women and, in some cases, men are more likely to have heard specific slogans on family planning than those currently in union or formerly married. The national-level campaign was launched in Greater Accra in 2001, followed by the regional campaigns. Exposure to the first three specific radio messages is highest in Greater Accra, while exposure to Obra ni wora bo is highest in the Ashanti Region and in the other predominantly Akan-speaking regions. Exposure to family planning messages and specifically these four messages is particularly low in the three northern regions. 3 Obra ni wora bo is an Akan phrase that translates to “Life is what you make of it.” In terms of the Life Choices campaign, therefore, it implies “Your (reproductive) life depends on the choices you make.” 90 | Family Planning Table 5.17 Exposure to specific radio shows on family planning Percentage of all women and men who have heard specific radio shows on family planning, by background characteristics, Ghana 2003 Women Men Background characteristic Life Choices: It's your life. It's your choice. Make the choice that is best for you Contra- ceptives are safe and effective Obra ni wora bo Number of respondents Life Choices: It's your life. It's your choice. Make the choice that is best for you Contra- ceptives are safe and effective Obra ni wora bo Number of respondents Age 15-19 64.4 52.6 41.8 71.5 1,148 67.0 53.4 44.2 72.0 1,107 20-24 60.1 50.6 42.6 72.1 1,012 76.5 65.3 56.6 76.7 684 25-29 51.6 44.5 39.5 67.3 951 72.1 62.1 54.4 80.1 754 30-34 44.1 37.4 33.6 64.6 802 70.3 64.3 54.0 77.4 633 35-39 41.3 34.8 31.1 63.5 722 63.3 58.8 54.7 74.0 498 40-44 44.7 38.6 35.8 67.9 579 69.2 58.7 58.0 75.1 412 45-49 41.2 38.1 30.8 63.7 477 60.0 55.5 53.5 71.3 441 50-54 na na na na na 64.9 59.9 53.9 72.8 294 55-59 na na na na na 59.6 52.5 46.9 73.7 192 Residence Urban 68.3 58.4 52.3 81.1 2,755 81.6 70.3 65.1 84.1 2,250 Rural 36.2 30.2 23.7 55.5 2,936 57.4 50.1 41.9 67.7 2,765 Region Western 57.0 40.9 35.7 79.8 553 70.5 60.7 53.2 89.6 476 Central 40.4 33.1 27.3 80.8 431 64.5 56.8 45.6 85.5 370 Greater Accra 74.3 61.7 59.1 82.5 942 82.5 71.4 69.2 86.6 733 Volta 46.5 42.9 35.8 40.2 492 69.8 58.9 48.0 44.4 440 Eastern 60.4 58.1 35.0 81.8 601 75.8 64.3 54.4 91.3 539 Ashanti 57.1 48.0 42.9 86.2 1,142 76.6 66.1 59.9 92.0 956 Brong Ahafo 58.1 52.8 50.7 80.9 569 75.0 66.4 59.2 90.8 528 Northern 15.6 13.5 11.1 14.8 499 33.8 30.1 27.3 29.2 527 Upper East 25.3 16.2 8.3 21.0 310 60.5 54.6 44.1 52.6 317 Upper West 16.3 13.2 10.8 14.6 153 24.3 20.7 17.1 14.6 130 Education No education 16.0 10.5 9.0 37.7 1,608 30.1 23.3 19.7 43.9 881 Primary 40.5 33.1 26.0 67.7 1,135 45.8 37.4 28.9 67.3 803 Middle/JSS 70.3 60.4 50.6 82.8 2,279 78.3 67.3 57.4 84.2 2,165 Secondary + 93.5 86.0 80.7 89.7 669 93.9 86.4 83.7 86.9 1,165 Current marital status Never in union 71.8 61.0 50.3 78.4 1,616 71.7 59.1 51.3 75.0 2,042 Currently in un- ion 43.3 36.7 32.1 62.5 3,549 66.0 59.4 53.2 74.9 2,671 Formerly in union 46.8 39.7 34.5 72.0 526 64.8 57.9 52.0 77.0 302 Wealth index Poorest 17.9 15.0 11.6 31.3 970 39.5 34.5 28.1 46.3 872 Poorer 34.1 28.8 22.0 57.7 949 58.2 49.6 40.4 72.9 903 Middle 47.8 39.2 29.4 69.4 1,071 66.8 55.4 47.0 77.4 975 Richer 59.9 50.8 44.5 77.5 1,245 77.8 66.9 59.5 81.3 1,060 Richest 81.7 70.3 64.9 89.6 1,457 89.5 80.7 76.9 90.1 1,204 Total 51.7 43.9 37.5 67.9 5,691 68.3 59.2 52.3 75.1 5,015 na = Not applicable Family Planning | 91 5.16 CONTACT OF NON-USERS WITH FAMILY PLANNING PROVIDERS In the 2003 GDHS, women who were not using contraception were asked whether they had attended a health facility in the last year for any reason and, if so, whether a staff person at that facility spoke to them about family planning methods. This information is important for determining whether non-users of family planning in Ghana have had an opportunity to receive information about family planning from providers. Table 5.18 shows that 15 percent of non-users reported that they had visited a health facility and discussed family planning, while 11 percent of women were visited by a fieldworker who discussed Table 5.18 Contact of non-users with family planning providers Percentage of women who are not using contraception who were visited by a fieldworker who discussed family planning, who visited a health facility and discussed family planning, and who visited a health facility but did not discuss family planning, in the 12 months preceding the survey, by background char- acteristics, Ghana 2003 Background characteristic Women who were visited by a fieldworker who discussed family planning Women who visited a health facility and discussed fam- ily planning Women who visited a health facility and did not discuss family planning Women who did not discuss family plan- ning with a fieldworker or at a health facility Number of women Age 15-19 4.7 3.2 19.6 92.9 1,050 20-24 10.3 15.0 30.8 78.3 796 25-29 12.5 20.7 31.6 72.9 710 30-34 13.6 20.3 28.9 71.6 582 35-39 13.6 22.5 28.5 69.0 533 40-44 15.0 18.4 26.0 73.6 436 45-49 12.7 10.8 26.0 80.3 408 Residence Urban 8.6 13.0 29.8 81.5 2,126 Rural 12.8 16.1 24.3 76.1 2,388 Region Western 7.9 12.2 29.0 81.4 436 Central 5.4 7.6 37.7 87.3 371 Greater Accra 8.6 13.7 37.2 81.1 721 Volta 23.5 28.8 24.6 59.6 394 Eastern 9.4 9.8 20.6 83.7 468 Ashanti 6.4 13.0 25.2 82.3 869 Brong Ahafo 11.9 13.7 14.6 78.3 413 Northern 19.5 20.7 28.0 69.5 445 Upper East 12.1 12.9 18.0 79.9 278 Upper West 8.5 21.0 27.6 74.3 120 Education No education 12.9 17.2 23.4 75.8 1,389 Primary 9.3 12.5 27.2 82.0 907 Middle/JSS 9.9 14.2 26.7 78.9 1,735 Secondary+ 11.2 13.3 37.1 79.5 483 Wealth quintile Lowest 14.0 18.1 22.2 74.7 848 Second 11.1 12.6 22.8 79.8 747 Middle 12.5 15.6 26.5 75.9 860 Fourth 10.7 14.1 24.3 79.5 961 Highest 7.0 13.2 36.0 82.2 1,099 Total 10.8 14.7 26.9 78.6 4,514 92 | Family Planning family planning in the 12 months preceding the survey. Roughly one in four women (27 percent) visited a health facility but did not discuss family planning. The majority of the women did not discuss family planning with a fieldworker or at a health facility. Women age 20-44 are more likely to have discussed family planning at a health facility than women age 15-19 and 45-49. Urban women are less likely to have discussed family planning with health staff than rural women, as are highly educated women compared with women with no education, and women in the highest wealth quintile as compared with women in the lowest wealth quintile. It could be that these groups are already using the methods or already have information and therefore do not feel the need to discuss family planning with providers or are less likely to have visited a facility. Discussion of family planning with staff at health facilities or in the field is highest in the Volta region (29 and 24 percent, respectively) and lowest in the Central region (8 and 5 percent, respectively). 5.17 DISCUSSION ABOUT FAMILY PLANNING WITH HUSBAND Although discussion of family planning between husband and wife is not a precondition for adoption of contraception, its absence may be an impediment to use. Inter-spousal communication is thus an important intermediate step along the path to eventual adoption and especially continuation of contraceptive use. Lack of discussion may reflect a lack of personal interest, hostility to the subject, or customary reticence in talking about sex-related matters. To explore this subject, women interviewed in the 2003 GDHS were asked the number of times they discussed family planning with their husband in the 12 months preceding the survey. Table 5.19 provides in- formation for currently married women who know of at least one contraceptive method about the number of times family planning was discussed with their husbands in the past year, according to age. The data indicate that 37 percent of women reported having dis- cussed family planning with their husbands once or twice, and 21 percent discussed family planning with their husbands at least three times. About two in five (41 per- cent) never discussed family planning with their husbands in the past year. Women age 25-29 are the most likely to report frequent discussions (three or more times) with their husbands (25 percent), while women 15-19 are least likely (9 percent). The results indicate that there has been an increase over the past ten years in the proportion of couples who discuss family planning. The proportion of couples who discussed family planning at least once has increased steadily from 42 percent in 1988, 46 percent in 1993, 54 percent in 1998, to 58 percent in 2003. Table 5.19 Discussion of family planning with husband Percent distribution of currently married women who know a contraceptive method by the number of times they discussed family planning with their husband in the past year, according to current age, Ghana 2003 Number of times family planning was discussed with husband Age Never One or two Three or more Missing Total Number of women 15-19 59.8 30.7 8.8 0.7 100.0 133 20-24 39.8 39.0 20.7 0.6 100.0 517 25-29 33.9 40.4 24.9 0.8 100.0 724 30-34 36.6 38.8 24.1 0.5 100.0 657 35-39 40.0 37.4 21.6 1.0 100.0 614 40-44 44.3 37.5 17.1 1.1 100.0 466 45-49 55.9 29.2 14.6 0.3 100.0 367 Total 41.1 37.4 20.8 0.7 100.0 3,479 Family Planning | 93 5.18 ATTITUDES OF MEN TOWARDS FAMILY PLANNING The 2003 GDHS included questions in the male survey to illicit information on men’s atti- tudes towards contraception in general. This information is useful in formulating family planning programmes and policies because men play a key role in their own as well as in women’s reproductive health and behaviour. This infor- mation is useful in formulating educational activities geared to- wards addressing some misconcep- tions and fears. It will be useful in the future to examine men’s atti- tude towards male methods. To get a sense of their atti- tudes toward contraception in gen- eral, men were asked their opinion on a number of questions pertain- ing to contraception and its use. The questions addressed whether men perceived contraception to be a woman’s business, whether women who use contraception may become promiscuous, and whether a woman should be sterilised be- cause she is the one who gets pregnant. Table 5.20 presents the results by background characteris- tics. About one in three men (35 percent) consider contraception to be a woman’s business, while roughly half of the men (53 per- cent) feel that women who use contraception may become pro- miscuous, and 41 percent of men feel that a woman should get steril- ised since she is the one who be- comes pregnant. There is no uniform pat- tern in men’s attitudes about fam- ily planning by background char- acteristics. However, some general comments can be made. Men in the youngest cohort (15-19), never- married men, men in the Volta re- Table 5.20 Men's attitudes towards contraception Percentage of men 15-59 who know of a method of family planning and who agree with specific statements about contraceptive use, by background characteristics, Ghana 2003 Background characteristic Contra- ception is women's business Women who use contra- ception may become promiscuous A woman should get sterilised be- cause she is the one who be- comes pregnant Number of men Age 15-19 32.3 48.0 35.4 1,071 20-24 36.3 52.8 44.1 680 25-29 37.1 55.4 42.0 751 30-34 34.6 54.6 41.6 630 35-39 37.1 50.5 43.6 495 40-44 31.2 57.5 43.0 411 45-49 35.4 52.4 39.5 439 50-54 38.4 60.7 44.5 292 55-59 33.6 53.2 40.4 191 Marital status Never married 31.2 48.0 35.9 1,997 Married 36.1 55.2 43.6 2,429 Living together 47.0 61.2 53.3 233 Divorced/separated 41.8 60.4 41.6 272 Widowed (33.5) (75.8) (51.7) 29 Residence Urban 33.5 53.3 38.9 2,244 Rural 36.1 52.7 42.5 2,716 Region Western 40.2 61.1 46.9 474 Central 23.0 63.7 36.6 368 Greater Accra 18.2 40.8 26.2 729 Volta 14.9 25.4 30.5 434 Eastern 40.4 59.9 42.0 533 Ashanti 55.9 78.8 52.6 952 Brong Ahafo 29.5 47.8 32.0 525 Northern 31.5 33.5 46.5 508 Upper East 53.2 53.6 57.5 308 Upper West 27.6 31.9 32.8 127 Education No education 40.6 45.1 47.7 858 Primary 39.4 52.2 41.6 779 Middle/JSS 37.6 58.2 44.1 2,157 Secondary+ 22.8 49.7 29.5 1,165 Wealth quintile Lowest 36.1 42.2 43.4 839 Second 36.4 55.3 42.9 891 Middle 40.5 56.6 42.1 970 Fourth 36.4 59.3 42.4 1,057 Highest 27.4 50.4 35.4 1,203 Total 35.0 53.0 40.9 4,960 Note: Figures in parentheses are based on 25-49 unweighted cases. 94 | Family Planning gion, men with secondary education and higher, and men in the highest wealth quintile are generally less likely to have negative attitudes about family planning than other men. The results indicate a larger scope for dissemination of family planning messages to improve men’s attitude towards family planning. 5.19 ATTITUDES OF COUPLES TOWARDS FAMILY PLANNING When couples have a positive attitude towards family planning, they are more likely to adopt a family planning method. In the 2003 GDHS, married women were asked whether they approved of couples using family planning and what they perceived as their husband’s attitude towards family planning. Men were also asked whether they approved of couples using family planning. This information is important in the formulation of family planning policies because it indicates the extent to which further education and publicity are needed to increase acceptance of family planning. Tables 5.21.1 and 5.21.2 show the percent distribution of currently married women and men who know a contraceptive method, by approval of family planning, according to background characteristics. An overwhelming majority of married women and men (87 and 89 percent, respectively) approve of family planning. Eleven percent of women and 10 percent of men disapprove of couples using family planning, while 2 percent each of women and men are unsure about their attitude towards use of family planning by couples. Approval of family planning among respondents is higher in urban than rural areas and increases with increasing level of education and wealth. Table 5.21.1 also shows women’s perception of their husband’s attitude towards family planning, Two-thirds of married women who approve of family planning believe that their husband also approves. Women in the youngest cohort, rural women, women from the Northern region, women with no education, and women in the poorest wealth quintile are more likely than other women to not know their husbands’ attitudes towards family planning. Family Planning | 95 Table 5.21.1 Approval of family planning: women Percent distribution of currently married women who know a method of family planning by approval of family planning and their perception of their husband's attitude toward family planning, according to background char- acteristics, Ghana 2003 Woman approves of family planning Woman disapproves of family planning Background characteristic Husband approves Husband disapproves Husband's attitude unknown, missing Husband approves Husband disapproves Husband's attitude unknown, missing Woman unsure1 Total Number of women Age 15-19 56.4 6.1 20.2 0.9 5.9 5.3 5.2 100.0 133 20-24 68.5 5.9 14.4 2.2 4.9 2.0 2.1 100.0 517 25-29 70.7 9.9 8.6 0.9 5.3 2.5 2.0 100.0 724 30-34 64.7 11.5 10.7 2.0 7.4 1.7 2.1 100.0 657 35-39 65.3 10.9 11.4 0.5 7.4 2.6 1.9 100.0 614 40-44 62.8 10.0 11.6 1.4 8.8 2.3 3.1 100.0 466 45-49 55.4 14.4 13.7 1.9 9.2 3.3 2.1 100.0 367 Residence Urban 69.6 9.8 9.2 1.4 6.1 1.9 2.1 100.0 1,430 Rural 61.9 10.4 13.5 1.4 7.5 2.9 2.5 100.0 2,049 Region Western 66.6 7.0 15.7 1.4 3.7 2.9 2.8 100.0 317 Central 70.6 8.5 16.2 0.4 2.2 0.8 1.2 100.0 274 Greater Accra 59.1 9.7 14.0 2.5 7.9 2.6 4.0 100.0 473 Volta 57.7 12.3 14.7 3.2 5.2 3.0 3.9 100.0 300 Eastern 76.4 6.4 7.7 0.4 5.6 1.1 2.4 100.0 350 Ashanti 73.7 10.8 4.5 0.6 8.2 1.6 0.5 100.0 637 Brong Ahafo 82.8 5.9 4.1 1.3 4.7 0.2 1.0 100.0 387 Northern 41.6 10.1 22.4 2.0 12.0 7.9 4.1 100.0 400 Upper East 57.5 20.9 10.3 0.5 9.1 1.3 0.4 100.0 230 Upper West 45.1 19.3 17.2 2.1 9.3 3.0 3.9 100.0 110 Education No education 51.5 12.8 14.9 1.3 11.2 4.2 4.1 100.0 1,290 Primary 67.0 8.7 14.0 2.0 4.5 1.7 2.1 100.0 705 Middle/JSS 76.9 8.0 7.6 0.9 4.4 1.4 0.8 100.0 1,204 Secondary+ 71.6 10.6 9.3 2.5 4.1 0.8 1.1 100.0 280 Wealth quintile Lowest 53.5 12.1 15.5 1.4 9.9 3.5 4.0 100.0 713 Second 65.8 8.9 12.1 1.0 7.4 2.7 2.0 100.0 666 Middle 67.3 8.9 11.6 1.7 5.5 2.6 2.4 100.0 687 Fourth 69.2 9.3 11.2 1.4 5.5 2.2 1.3 100.0 693 Highest 69.8 11.3 8.4 1.6 6.1 1.2 1.8 100.0 720 Total 65.1 10.1 11.7 1.4 6.9 2.5 2.3 100.0 3,479 1 Includes missing 96 | Family Planning Table 5.21.2 Approval of family planning: men Percent distribution of currently married men who know a method of family planning by approval of family planning, according to background characteristics, Ghana 2003 Background characteristic Approves of family planning Disapproves of family planning Unsure Total Number of men Age 15-19 100.0 0.0 0.0 100.0 7 20-24 94.3 3.4 2.3 100.0 127 25-29 90.1 8.6 1.2 100.0 397 30-34 90.7 8.3 1.0 100.0 498 35-39 89.2 8.9 1.9 100.0 422 40-44 87.1 10.4 2.5 100.0 375 45-49 89.3 9.9 0.8 100.0 395 50-54 84.5 12.9 2.6 100.0 270 55-59 80.9 17.2 1.9 100.0 171 Marital status Married 88.1 10.1 1.8 100.0 2,429 Living together 93.7 6.0 0.4 100.0 233 Residence Urban 91.3 7.5 1.2 100.0 1,042 Rural 86.9 11.2 1.9 100.0 1,621 Region Western 96.0 4.0 0.0 100.0 254 Central 90.2 9.0 0.8 100.0 195 Greater Accra 88.8 8.5 2.7 100.0 345 Volta 87.1 12.5 0.3 100.0 227 Eastern 91.0 7.5 1.5 100.0 305 Ashanti 93.7 5.6 0.7 100.0 500 Brong Ahafo 90.2 9.8 0.0 100.0 270 Northern 76.3 19.8 3.9 100.0 323 Upper East 85.9 10.9 3.2 100.0 171 Upper West 72.1 20.0 7.9 100.0 73 Education No education 78.4 17.3 4.3 100.0 631 Primary 85.8 13.3 0.9 100.0 350 Middle/JSS 91.8 7.2 1.0 100.0 1,113 Secondary + 95.3 4.3 0.4 100.0 568 Wealth index Lowest 77.6 18.7 3.7 100.0 507 Second 90.9 8.4 0.7 100.0 525 Middle 90.3 8.8 0.9 100.0 531 Fourth 90.6 7.0 2.4 100.0 516 Highest 92.8 6.5 0.7 100.0 583 Total 88.6 9.8 1.6 100.0 2,662 From data gathered in the 2003 GDHS survey, information on attitude towards family planning can be tabulated for the 1,949 couples. Table 5.22 shows the percent distribution of couples by husband’s actual attitude towards family planning according to wife’s perception of husband’s attitude and is a Family Planning | 97 measure of the percentage of couples with discordant attitudes towards family planning and of the extent of knowledge of each other’s attitude. The data indicate that wives are generally accurate when they report on their husband’s approval of family planning. Wives’ perceptions of their husbands’ approval of family planning is consistent with husbands’ actual attitudes in the majority of cases (88 percent). However, in 78 percent of cases when the wife reported that her husband disapproved of family planning, the opposite was true and the husband actually approved. At the same time, in 8 percent of cases the wife perceived that her husband approved of family planning when he actually disapproved. This information reinforces the importance of spousal communication and shows that there is a potential for the Ghanaian family planning programme to benefit from greater male involvement. Table 5.22 Wife's perception of husband's attitude toward family planning Percent distribution of couples by husband’s actual attitude toward family planning, according to wife’s perception of husband’s attitude, Ghana 2003 Husband's actual attitude towards family planning Wife's perception of husband's attitude towards family planning Approves Disapproves Don't know Total Number of couples Approves 91.3 7.9 0.8 100.0 1,509 Disapproves 77.7 19.3 3.0 100.0 335 Don't know (79.8) (11.5) (8.7) 100.0 26 Total 88.3 10.2 1.5 100.0 1,949 Note: Figures in parentheses are based on 25-49 unweighted cases. Other Proximate Determinants of Fertility │ 99 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter addresses the principal factors, other than contraception, which affect a woman’s risk of becoming pregnant. These factors include marriage, polygyny, sexual intercourse, postpartum amenorrhoea, abstinence from sexual relations, and termination of exposure to pregnancy. Direct measures of the onset of exposure to the risk of pregnancy and the level of exposure are also discussed in this chapter. 6.1 CURRENT MARITAL STATUS Table 6.1 shows data on the current marital status of women and men interviewed in the 2003 GDHS. In this report, the term “currently married” refers to both women in a formal union and women in an informal union. Marriage and cohabitation are generally considered to be primary indicators of exposure to the risk of pregnancy. In Ghana, however, a union is not a prerequisite to childbearing as some childbearing occurs outside union. Table 6.1 shows that 28 percent of women age 15-49 have never married, 54 percent are formally married, 8 percent are living together, and 9 percent are divorced, separated, or widowed. Marriage occurs relatively early in Ghana, and two in every five women age 20-24 are currently married. Less than 1 percent of women age 40 and over have never married. The proportion separated is highest among women age 30-34. The proportion divorced or widowed generally increases with age. Table 6.1 Current marital status Percent distribution of women and men by current marital status, according to age, Ghana 2003 Marital status Age Never married Married Living together Divorced Separated Widowed Total Number of women/men WOMEN 15-19 86.3 7.3 4.7 0.0 1.7 0.0 100.0 1,148 20-24 42.1 40.2 12.1 0.9 4.6 0.1 100.0 1,012 25-29 14.4 66.4 11.3 2.4 4.9 0.6 100.0 951 30-34 5.1 75.4 8.2 4.1 5.5 1.8 100.0 802 35-39 2.3 79.0 7.1 4.6 4.4 2.6 100.0 722 40-44 0.6 76.4 5.3 8.4 4.2 5.1 100.0 579 45-49 0.4 72.9 6.3 8.3 3.7 8.4 100.0 477 Total 28.4 54.2 8.1 3.3 4.0 1.9 100.0 5,691 MEN 15-19 99.0 0.3 0.4 0.0 0.4 0.0 100.0 1,107 20-24 75.8 11.5 7.2 0.2 5.1 0.2 100.0 684 25-29 39.2 42.2 10.6 1.0 6.9 0.1 100.0 754 30-34 13.5 71.5 7.5 3.0 4.1 0.5 100.0 633 35-39 5.6 81.0 4.2 4.7 3.9 0.5 100.0 498 40-44 2.1 88.8 2.2 2.4 3.0 1.5 100.0 412 45-49 1.7 87.3 2.6 5.1 2.5 0.8 100.0 441 50-54 0.6 88.9 3.7 2.6 2.2 2.0 100.0 294 55-59 0.0 88.9 0.3 5.1 2.5 3.2 100.0 192 Total 40.7 48.6 4.6 2.0 3.4 0.6 100.0 5,015 100 │ Other Proximate Determinants of Fertility A greater proportion of men (41 percent) than women (28 percent) have never married. Almost half of men (49 percent) are married, 5 percent are living together, and another 6 percent are divorced, separated, or widowed. Men tend to marry at older ages than women. While two in three women age 25- 29 are married, the proportion of men married in the same age group is two in five. Data from earlier DHS surveys show that there has been a noticeable increase in the proportion of women and men never married. Twenty percent of women age 15-49 were never married in 1993 (GSS and MI, 1994) and 24 percent in 1998 (GSS and MI, 1999) compared with 28 percent in 2003. Even more impressive is the marked increase in the percentage of women never-married in the cohort age 20-24, from 29 percent in 1998 to 42 percent in 2003. The proportion of never-married men age 15-59 increased only between 1993 and 1998, with little difference between 1998 and 2003. The proportion divorced has decreased for women over the past five years, from 5 percent in 1998 (GSS and MI, 1999) to 3 percent in 2003, while the proportion separated decreased from 5 percent in 1998 to 4 percent in 2003. 6.2 POLYGYNY Polygyny (the practice of having more than one wife at the same time) has implications for the frequency of sexual activity and fertility. Married women were asked whether their husbands had other wives and, if so, how many. Married men were asked whether they had one or more wives or partners. Table 6.2 shows that 23 percent of married women in Ghana are in polygynous unions compared with 13 percent of men. Ten percent of women say they have one co-wife, while 13 percent say they have two or more co-wives. Married men are less likely to report having multiple wives. This discrepancy between the number of wives and co-wives reported by men and women may be due to definitional or conceptual problems of who is a wife. By definition, it is higher among women than men because if a man has two wives, both have co-wives, while he is only one man reporting more than one wife. Conceptual differences may arise because of the tendency for women to describe their husband’s mistresses or girlfriends as wives, whereas men are less likely to classify girlfriends as wives. The level of polygyny increases with age for both women and men. Rural women and men are more likely to be in polygynous unions than their urban counterparts. Regional variations are also noticeable. Women and men in the Northern, Upper East, and Upper West regions are more likely to report being in a polygynous union than those in other regions (Figure 6.1). Married women in Greater Accra (13 percent) and married men in the Ashanti Region (7 percent) are least likely to be in a polygynous union. There is an inverse relationship between respondent’s education and polygyny. Thirty-six percent of women with no education are in a polygynous union compared with 9 percent of women with secondary and higher education. The corresponding data for men are 28 percent and 7 percent, respectively. The level of polygyny among women has decreased from 28 percent in 1993 (GSS and MI, 1994) to 23 percent in both 1998 and 2003. Comparable information for men is not available for 1993, but data for 1998 (13 percent) show that there has been no change in the percentage of men who report being in a polygynous relationship over the last five years. Other Proximate Determinants of Fertility │ 101 Table 6.2 Polygyny Percent distribution of currently married women by number of cowives and currently married men by number of wives, according to background characteristics, Ghana 2003 Women Men Number of cowives Number of wives Background characteristic 0 1 2+ Missing Total Number of women 1 2+ Total Number of men Age 15-19 90.1 5.8 4.1 0.0 100.0 137 * * * 7 20-24 85.1 7.5 6.6 0.8 100.0 530 94.1 5.9 100.0 128 25-29 84.2 6.9 8.3 0.6 100.0 739 92.5 7.5 100.0 398 30-34 78.3 12.4 9.4 0.0 100.0 671 92.0 8.0 100.0 500 35-39 69.5 10.2 19.7 0.6 100.0 621 88.7 11.3 100.0 424 40-44 71.8 11.1 17.1 0.0 100.0 473 86.1 13.9 100.0 375 45-49 62.8 13.5 22.7 1.0 100.0 377 79.6 20.4 100.0 396 50-54 na na na na na na 82.8 17.2 100.0 272 55-59 na na na na na na 78.1 21.9 100.0 171 Residence Urban 82.7 6.4 10.1 0.8 100.0 1,436 91.9 8.1 100.0 1,042 Rural 73.0 12.2 14.6 0.2 100.0 2,113 84.1 15.9 100.0 1,629 Region Western 82.6 6.4 11.1 0.0 100.0 319 90.4 9.6 100.0 255 Central 84.3 10.1 5.3 0.3 100.0 274 89.4 10.6 100.0 195 Greater Accra 84.6 4.4 8.7 2.3 100.0 476 92.5 7.5 100.0 345 Volta 73.2 14.4 12.0 0.5 100.0 304 89.0 11.0 100.0 227 Eastern 86.0 1.1 12.5 0.3 100.0 354 92.3 7.7 100.0 306 Ashanti 83.9 6.6 9.5 0.0 100.0 643 93.4 6.6 100.0 500 Brong Ahafo 81.9 6.4 11.4 0.2 100.0 398 92.3 7.7 100.0 271 Northern 56.1 17.1 26.6 0.2 100.0 431 71.2 28.8 100.0 328 Upper East 55.0 27.3 17.8 0.0 100.0 236 69.5 30.5 100.0 171 Upper West 59.6 22.7 17.0 0.6 100.0 113 70.0 30.0 100.0 74 Education No education 63.2 16.5 19.9 0.4 100.0 1,354 72.0 28.0 100.0 638 Primary 81.2 8.0 10.5 0.2 100.0 710 88.9 11.1 100.0 352 Middle/JSS 86.8 4.9 7.8 0.5 100.0 1,205 92.2 7.8 100.0 1,113 Secondary+ 89.4 3.3 5.8 1.5 100.0 280 93.5 6.5 100.0 568 Wealth quintile Lowest 63.0 19.8 16.9 0.3 100.0 753 74.9 25.1 100.0 514 Second 75.3 9.4 15.1 0.2 100.0 687 87.1 12.9 100.0 527 Middle 75.1 9.9 14.8 0.2 100.0 692 86.9 13.1 100.0 531 Fourth 83.6 5.9 10.5 0.0 100.0 695 92.7 7.3 100.0 516 Highest 88.2 3.5 6.6 1.7 100.0 721 93.4 6.6 100.0 583 Total 76.9 9.8 12.8 0.5 100.0 3,549 87.2 12.8 100.0 2,671 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 102 │ Other Proximate Determinants of Fertility 13 10 11 8 11 8 7 8 29 31 30 GHANA Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West 0 10 20 30 40 Percent Figure 6.1 Percentage of Married Men with Two or More Wives, by Region GDHS 2003 REGION 6.3 AGE AT FIRST MARRIAGE Marriage marks the point in a woman’s life at which childbearing becomes socially acceptable in Ghana. Marriage is, therefore, closely associated with fertility because women who marry early will, on average, have a longer exposure to the probability of becoming pregnant. Early age at first marriage is an important fertility indicator because it not only affects the length of time a woman is exposed to the risk of pregnancy, but also tends to lead to early childbearing and to higher fertility. Information on age at first marriage was obtained by asking respondents the month and year, or age, at which they started living with their first partner. Older respondents are less likely to recall with accuracy marriage dates and ages, therefore, the data for older respondents should be interpreted with caution. Table 6.3 shows that the median age at marriage among women age 20-49 is 19.6, a slight increase over the past five years from 19.1 years. There is a general trend towards later marriage. More than one-third of women (35 percent) age 25-49 are married by exact age 18 compared with 38 percent of women in the same age group five years ago (GSS and MI, 1999). By age 20, more than half (56 percent) of women age 25-49 were married and by age 25 the proportion married among the same age group is 85 percent. It is to be noted that the median age at first marriage for women age 25-49 is 19.4 years and is only slightly lower (0.5 years) among women age 45-49 years than among those age 25-29 years. Table 6.3 also provides information about age at first marriage among men. Men tend to marry at a later age than women. For example, the median age at first marriage for those age 30-34 years is 25.0 years compared with 19.1 years for women in the same age group. About half of men are married by age 25 compared with more than four in five (85 percent) women. Other Proximate Determinants of Fertility │ 103 Table 6.3 Age at first marriage Percentage of women and men who were first married by specific exact ages and median age at first marriage, according to current age, Ghana 2003 WOMEN Percent first married by exact age: Current age 15 18 20 22 25 Percentage never married Number of women Median age at first marriage 15-19 2.5 na na na na 86.3 1,148 a 20-24 5.9 27.9 46.8 na na 42.1 1,012 a 25-29 7.6 31.3 50.4 65.7 82.1 14.4 951 20.0 30-34 10.2 40.5 59.5 71.3 83.7 5.1 802 19.1 35-39 9.3 34.9 56.8 71.0 84.2 2.3 722 19.4 40-44 10.6 37.7 62.1 75.3 89.0 0.6 579 19.0 45-49 10.0 33.1 53.7 71.6 86.7 0.4 477 19.5 20-49 8.6 33.8 54.1 na na 13.8 4,543 19.6 25-49 9.3 35.4 56.1 70.4 84.6 5.6 3,531 19.4 MEN Percent first married by exact age: Current age 20 22 25 28 30 Percentage never married Number of men Median age at first marriage 20-24 13.3 na na na na 75.8 684 a 25-29 13.9 27.6 49.5 na na 39.2 754 a 30-34 15.8 27.7 49.6 70.9 80.4 13.5 633 25.0 35-39 16.2 28.4 51.9 71.6 79.8 5.6 498 24.7 40-44 17.6 35.3 58.7 75.2 84.5 2.1 412 23.9 45-49 15.2 30.0 57.2 74.4 82.6 1.7 441 24.3 50-54 11.3 26.4 49.7 69.1 77.2 0.6 294 25.0 55-59 6.9 15.5 40.2 62.7 74.0 0.0 192 26.1 25-59 14.6 28.2 51.6 na na 13.2 3,224 24.8 30-59 14.9 28.4 52.2 71.5 80.5 5.3 2,470 24.7 Note: The age at first marriage is defined as the age at which the respondent began living with first spouse/partner. na = Not applicable a = Omitted because less than 50 percent of the respondents began living with their first spouse/partner for the first time before reaching the beginning of the age group Table 6.4 examines differences in the median age at first marriage for women and men by background characteristics. Rural women and men marry about one year earlier than urban women and men. Regional differentials show that women in the Upper East Region and men in the Volta Region marry about three years earlier than women and men in Greater Accra. Education has a marked impact on the age at marriage. For example, women age 25-49 with no education marry six years earlier than women with at least some secondary education. The same pattern is observed for men, although the educational difference among men is not as marked as among women. Women and men in the highest wealth quintile tend to marry later than their counterparts in the lower wealth quintiles. 104 │ Other Proximate Determinants of Fertility Table 6.4 Median age at first marriage Median age at first marriage among women age 20-49, by current age and background characteristics, and among men age 30-59, Ghana 2003 Age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Men age 30-59 Residence Urban 21.7 20.0 20.1 19.2 19.9 a 20.2 25.5 Rural 19.0 18.3 18.7 18.8 19.3 18.8 18.8 24.1 Region Western 21.1 18.3 20.3 (18.7) (18.5) 19.7 19.5 23.7 Central 19.1 (18.7) (18.9) (18.5) (20.6) 18.8 19.1 23.9 Greater Accra 22.8 21.2 20.4 20.0 20.4 a 20.9 26.5 Volta 20.3 18.8 19.0 18.9 (20.5) 19.7 19.5 23.6 Eastern 19.9 19.2 20.1 19.6 (20.4) a 19.8 24.9 Ashanti 19.3 18.6 19.1 19.1 18.6 19.3 18.9 24.5 Brong Ahafo 20.0 19.7 18.4 17.9 19.2 19.0 18.9 24.8 Northern 19.4 18.7 19.2 (19.5) (18.9) 18.9 19.2 25.7 Upper East 17.6 18.1 (18.2) (18.2) (20.0) 18.5 18.3 24.1 Upper West 19.5 19.5 19.0 (19.1) 18.3 19.2 19.1 25.2 Education No education 18.8 18.1 19.2 18.6 v19.5 18.7 18.8 24.6 Primary 18.6 19.1 18.2 18.2 18.8 18.7 18.6 25.2 Middle/JSS 20.5 19.1 19.6 18.9 19.1 19.8 19.5 23.8 Secondary+ a 26.5 (25.0) (23.1) (22.7) a 24.8 26.6 Wealth quintile Lowest 18.6 18.7 18.5 18.5 19.6 18.6 18.7 24.8 Second 18.7 17.9 19.3 18.9 18.8 18.8 18.7 23.9 Middle 19.3 18.2 19.0 19.0 19.8 19.0 18.9 23.9 Fourth 20.5 18.8 19.1 18.3 18.9 19.6 19.3 24.6 Highest 22.7 22.4 21.3 19.9 21.1 a 21.7 26.2 All women 20.0 19.1 19.4 19.0 19.5 19.6 19.4 na All men a 25.0 24.7 23.9 24.3 na na 24.7 Note: The age at first marriage is defined as the age at which the respondent began living with first spouse/partner. Figures in parentheses are based on 25-49 unweighted cases. a = Omitted because less than 50 percent of the respondents began living with their first spouse/partner for the first time before reaching the beginning of the age group na = Not applicable 6.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is sometimes seen as a proxy for a woman’s first exposure to intercourse but the two events need not occur at the same time. Since women and men may engage in sexual relations prior to marriage, the age at first sexual intercourse is a more reliable estimate of a woman’s exposure to the risk of pregnancy. In the survey, women and men were asked how old they were when they first had sexual intercourse. Table 6.5 shows that the median age at first sexual intercourse for women age 25-49 years is 18.2 years and for men age 25-59 years it is 20.2 years. Nine percent of women and 4 percent of men reported having sexual intercourse by age 15. By age 18, almost half of women (48 percent) and one-fourth of men (25 percent) have had sexual intercourse. Sixty-one percent of women and 80 percent of men age 15-19 Other Proximate Determinants of Fertility │ 105 have never had sex. After age 24, nearly all women are sexually active. The 2003 GDHS data indicate that there has been little change over time in the median age at first sexual intercourse among women. However, age at first sexual intercourse among men has decreased. For example, the cohort of men age 20-24 had first sexual intercourse two years earlier (19.6 years) than the cohort of men age 55-59 (21.8 years). Table 6.5 Age at first sexual intercourse Percentage of women and men who had first sexual intercourse by specific exact ages and median age at first intercourse, according to current age, Ghana 2003 Percentage who had first sexual intercourse by exact age Current age 15 18 20 22 25 Percentage who never had intercourse Number of respondents Median age at first intercourse WOMEN 15-19 7.4 na na na na 61.0 1,148 a 20-24 7.5 43.1 70.5 na na 15.7 1,012 18.4 25-29 8.2 45.4 69.3 82.9 89.4 2.1 951 18.3 30-34 10.5 51.3 71.5 83.5 88.2 0.3 802 17.9 35-39 10.5 49.3 73.0 83.6 87.9 0.3 722 18.0 40-44 10.4 47.1 69.5 82.3 86.8 0.1 579 18.2 45-49 7.0 44.3 68.9 82.0 88.2 0.0 477 18.4 20-49 9.0 46.7 70.5 na na 4.0 4,543 18.2 25-49 9.4 47.7 70.6 83.0 88.2 0.7 3,531 18.2 MEN 15-19 3.9 na na na na 80.0 1,107 a 20-24 3.9 25.7 54.5 na na 29.2 684 19.6 25-29 6.2 29.2 53.9 73.5 86.5 7.3 754 19.6 30-34 4.4 25.4 48.9 69.2 83.1 1.5 633 20.1 35-39 5.5 27.7 49.4 68.6 83.4 0.5 498 20.0 40-44 3.1 21.6 44.7 70.9 85.1 0.0 412 20.3 45-49 3.4 21.4 43.2 65.9 82.2 0.0 441 20.4 50-54 2.7 18.5 37.4 61.5 77.6 0.3 294 20.8 55-59 0.6 17.3 31.3 51.2 75.1 0.0 192 21.8 20-59 4.2 24.7 48.1 na na 6.9 3,908 a 25-59 4.3 24.5 46.7 68.1 83.1 2.1 3,224 20.2 na = Not applicable a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Table 6.6 shows differentials in median age at first sex by background characteristics. Urban women experience sexual intercourse for the first time about one year after their rural counterparts, but there is no difference in age at first sexual intercourse between urban and rural men. Women and men living in the Upper West Region experience first sexual intercourse at a later age than their counterparts in the other regions. Educated women and men and women who fall in the highest wealth quintile are also seen to initiate sexual intercourse at a later age than women and men with little or no education and women in the other wealth quintiles. In contrast, there is little difference in the age at first sexual intercourse among men by wealth quintile. 106 │ Other Proximate Determinants of Fertility Table 6.6 Median age at first intercourse Median age at first sexual intercourse among women age 20-49, by current age and background characteristics, and median age among men age 25-59, by background characteristics, Ghana 2003 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Men age 25-29 Residence Urban 19.0 18.9 18.3 18.6 18.5 18.5 18.7 18.6 20.3 Rural 17.7 17.7 17.6 17.5 18.0 18.3 17.8 17.8 20.1 Region Western 18.6 18.1 16.7 17.8 17.6 (18.4) 17.9 17.7 20.0 Central 17.6 18.4 16.9 (17.1) (16.8) (17.4) 17.5 17.5 19.5 Greater Accra a 18.9 18.6 19.0 19.4 18.7 19.1 18.9 19.6 Volta 17.6 18.1 17.6 16.9 17.4 (18.6) 17.7 17.8 19.5 Eastern 18.4 18.8 18.0 18.1 18.5 (18.3) 18.4 18.3 20.0 Ashanti 18.7 18.0 17.9 18.4 18.4 18.3 18.3 18.2 20.4 Brong Ahafo 18.1 18.0 18.5 17.7 17.8 (18.5) 18.1 18.1 20.5 Northern 17.1 18.4 18.2 18.0 (18.8) (18.5) 18.1 18.3 20.9 Upper East 18.5 17.0 17.5 (16.5) (17.8) (17.9) 17.6 17.4 20.9 Upper West 18.5 19.6 20.3 19.7 (19.0) (20.2) 19.3 19.6 22.2 Education No education 17.3 17.6 17.4 17.6 18.0 18.4 17.7 17.7 20.7 Primary 17.6 17.6 18.0 17.0 17.5 17.4 17.5 17.5 20.0 Middle/JSS 18.4 18.6 17.9 18.5 18.3 18.6 18.4 18.4 20.0 Secondary+ a 20.1 19.7 (19.9) (20.1) (19.7) a 20.0 20.2 Wealth quintile Lowest 17.2 17.2 18.0 17.2 17.8 18.5 17.6 17.6 20.3 Second 17.8 17.8 17.1 17.9 17.9 18.1 17.7 17.7 20.2 Middle 18.0 17.8 17.8 17.5 18.0 18.1 17.9 17.8 20.0 Fourth 18.3 18.6 17.6 18.0 17.5 18.4 18.2 18.2 20.3 Highest a 19.2 18.8 18.9 19.2 18.7 19.3 19.0 20.2 All women 18.4 18.3 17.9 18.0 18.2 18.4 18.2 18.2 na All men 19.6 19.6 20.1 20.0 20.3 20.4 na na 20.2 Note: Figures in parentheses are based on 25-49 unweighted cases. a = Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group na = Not applicable Other Proximate Determinants of Fertility │ 107 6.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the frequency of inter- course. Information on sexual activity, therefore, can be used to refine measures of exposure to pregnancy. Women and men were asked how long ago their last sexual activity occurred, to assess whether they had a sexual encounter in the last four weeks. The results are shown in Table 6.7.1 for women and Table 6.7.2 for men. About two in five women age 15-49 were sexually active in the four weeks before the survey, 26 percent had been sexually active in the previous year but not in the previous month, and 13 percent had not been sexually active for one or more years. An additional 16 percent of women have never had sex. The proportion of women who were sexually active in the four weeks before the survey increases with age from 14 percent at age 15-19 to 56 percent by age 40-44 and decreases thereafter to 48 percent among women age 45-49. Teenagers and women who are not currently in a marital union were less likely to be sexually active in the four weeks preceding the survey than older women and women who are married or living with a man. Three in five women who have been married 10 to 24 years were sexually active in the past four weeks. The proportion is slightly lower for those married less than 10 years or 25 or more years. Women who have been married more than once are more likely to have been sexually active in the past four weeks than women who have been married only once. Women in urban areas are less likely to be sexually active over the past four weeks (38 percent) than those in rural areas (46 percent). The proportion of women who are sexually active in the four weeks preceding the survey is highest in the Eastern Region (48 percent) and lowest in Greater Accra (36 percent). Women with at least some secondary education are less likely to be sexually active than less educated women. As expected, women who are using a contraceptive method are more likely to be sexually active than women who are not using any method. Obviously, women who are sexually active are more likely to use a method, but it is also true that those who are using contraception probably feel freer to engage in sex because they are at a lower risk of pregnancy. Women in the highest wealth quintile are least likely to be sexually active in the past four weeks. Almost half (45 percent) of the men interviewed were sexually active in the four weeks before the survey, while 22 percent had sex in the previous year but not in the previous month (Table 6.7.2). Ten percent had not been sexually active in the previous year and 23 percent had never had sex. As with women, sexual activity increases with age among men, with the highest level among men in their mid-40s and early 50s. Men in union are much more likely to be sexually active than those never in union. Fewer urban men (41 percent) reported recent sexual activity than rural men (48 percent). Recent sexual activity is highest in the Eastern Region (51 percent) and lowest in the Upper East (31 percent). Education and wealth do not appear to be related to recent sexual activity. A comparison of data between the 2003 GDHS and the 1998 GDHS (GSS and MI, 1999) shows that there has been a decline in recent sexual activity among young men age 15-24 but an increase in recent sexual activity among older men. There has been little change in recent sexual activity among women over the past five years. 108 │ Other Proximate Determinants of Fertility Table 6.7.1 Recent sexual activity: women Percent distribution of women by timing of last sexual intercourse, according to background characteristics, Ghana 2003 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within the past year1 One or more years Missing Never had sexual intercourse Total Number of women Age 15-19 14.1 17.7 6.3 0.9 61.0 100.0 1,148 20-24 36.8 31.2 13.0 3.3 15.7 100.0 1,012 25-29 48.8 32.8 12.9 3.4 2.1 100.0 951 30-34 54.8 26.3 14.4 4.2 0.3 100.0 802 35-39 55.2 28.1 12.9 3.5 0.3 100.0 722 40-44 55.6 23.7 18.4 2.2 0.1 100.0 579 45-49 48.2 24.8 25.9 1.1 0.0 100.0 477 Marital status Never married 11.4 21.0 12.1 0.9 54.6 100.0 1,616 Married or living together 60.0 28.4 8.4 3.1 0.0 100.0 3,549 Divorced/separated/widowed 14.0 29.2 51.3 5.5 0.0 100.0 526 Marital duration2 Married only once 0-4 years 55.0 33.4 7.0 4.6 0.1 100.0 645 5-9 years 56.7 31.2 9.0 3.0 0.0 100.0 562 10-14 years 62.8 26.2 7.6 3.4 0.0 100.0 489 15-19 years 60.4 25.8 9.8 4.1 0.0 100.0 397 20-24 years 62.3 25.1 11.8 0.8 0.0 100.0 301 25+ years 56.8 22.6 18.0 2.6 0.0 100.0 227 Married more than once 64.0 27.8 5.6 2.6 0.0 100.0 929 Residence Urban 38.0 24.7 14.4 2.0 20.9 100.0 2,755 Rural 45.7 27.9 12.6 3.3 10.5 100.0 2,936 Region Western 42.2 26.6 11.4 2.7 17.0 100.0 553 Central 46.8 22.9 13.2 2.8 14.4 100.0 431 Greater Accra 35.7 27.3 13.9 1.4 21.7 100.0 942 Volta 40.6 30.7 12.3 2.9 13.5 100.0 492 Eastern 47.6 25.3 11.5 3.1 12.5 100.0 601 Ashanti 41.6 25.8 13.5 2.1 17.0 100.0 1,142 Brong Ahafo 46.1 28.3 9.8 2.9 12.8 100.0 569 Northern 42.6 26.9 17.0 5.5 8.1 100.0 499 Upper East 40.0 21.2 19.6 2.9 16.4 100.0 310 Upper West 37.2 25.6 18.6 3.3 15.4 100.0 153 Education No education 46.4 28.1 15.6 4.5 5.3 100.0 1,608 Primary 44.9 24.5 12.4 2.9 15.4 100.0 1,135 Middle/JSS 40.9 25.8 12.1 1.9 19.3 100.0 2,279 Secondary+ 29.8 27.3 14.5 1.0 27.5 100.0 669 Current contraceptive method Female sterilisation 68.6 17.8 11.1 2.6 0.0 100.0 72 Pill 81.7 16.2 1.5 0.7 0.0 100.0 235 IUD (91.0) (5.3) (3.7) (0.0) (0.0) (100.0) 35 Condom 53.6 45.6 0.7 0.0 0.0 100.0 246 Periodic abstinence 65.9 28.3 5.0 0.6 0.2 100.0 238 Other method 75.1 19.0 5.1 0.8 0.0 100.0 351 No method 34.6 26.6 16.0 3.2 19.6 100.0 4,514 Wealth quintile Lowest 40.9 27.9 16.6 4.9 9.7 100.0 970 Second 47.7 29.9 10.0 2.9 9.5 100.0 949 Middle 44.6 27.9 12.3 3.2 12.0 100.0 1,071 Fourth 42.5 25.9 12.3 2.1 17.2 100.0 1,245 Highest 36.5 22.3 15.5 1.2 24.4 100.0 1,457 Total 42.0 26.4 13.4 2.7 15.5 100.0 5,691 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes women who had sexual intercourse within the past 4 weeks 2 Excludes women who are not currently married Other Proximate Determinants of Fertility │ 109 Table 6.7.2 Recent sexual activity: men Percent distribution of men by timing of last sexual intercourse, according to background characteristics, Ghana 2003 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within the past year1 One or more years Missing Never had sexual intercourse Total Number of men Age 15-19 6.1 8.6 5.3 0.0 80.0 100.0 1,107 20-24 27.5 29.0 14.2 0.1 29.2 100.0 684 25-29 51.1 27.8 13.8 0.0 7.3 100.0 754 30-34 58.8 27.9 11.8 0.0 1.5 100.0 633 35-39 65.1 24.3 10.0 0.2 0.5 100.0 498 40-44 67.4 23.3 9.3 0.0 0.0 100.0 412 45-49 67.1 22.4 10.5 0.0 0.0 100.0 441 50-54 70.9 21.0 7.8 0.0 0.3 100.0 294 55-59 60.2 24.8 14.8 0.2 0.0 100.0 192 Marital status Never married 13.6 17.3 12.6 0.0 56.4 100.0 2,042 Married or living together 70.2 24.3 5.3 0.0 0.1 100.0 2,671 Divorced/separated/widowed 26.1 33.9 39.8 0.2 0.0 100.0 302 Marital duration2 Married only once 0-4 years 62.6 32.3 4.8 0.0 0.3 100.0 429 5-9 years 65.2 27.3 7.3 0.0 0.1 100.0 394 10-14 years 71.2 22.2 6.3 0.3 0.0 100.0 324 15-19 years 71.2 24.0 4.8 0.0 0.0 100.0 250 20-24 years 73.2 22.1 4.7 0.0 0.0 100.0 237 25+ years 73.7 19.8 6.4 0.1 0.0 100.0 200 Married more than once 74.2 21.4 4.4 0.0 0.0 100.0 836 Residence Urban 40.9 23.0 11.8 0.0 24.3 100.0 2,250 Rural 47.5 21.3 9.2 0.0 22.0 100.0 2,765 Region Western 44.9 24.6 8.6 0.0 22.0 100.0 476 Central 48.9 18.4 7.1 0.0 25.5 100.0 370 Greater Accra 45.6 21.4 13.0 0.1 19.8 100.0 733 Volta 48.5 21.1 6.6 0.0 23.8 100.0 440 Eastern 50.7 23.7 6.0 0.0 19.7 100.0 539 Ashanti 46.6 21.1 10.2 0.0 22.2 100.0 956 Brong Ahafo 41.8 23.8 8.1 0.0 26.3 100.0 528 Northern 38.5 24.0 15.7 0.1 21.7 100.0 527 Upper East 31.4 21.4 17.1 0.0 30.1 100.0 317 Upper West 39.2 17.1 14.0 0.3 29.3 100.0 130 Education No education 47.3 23.0 16.3 0.2 13.2 100.0 881 Primary 37.7 20.3 7.4 0.0 34.6 100.0 803 Middle/JSS 46.5 19.7 8.6 0.0 25.1 100.0 2,165 Secondary+ 43.5 26.8 11.1 0.0 18.6 100.0 1,165 Wealth quintile Lowest 41.1 22.5 11.8 0.0 24.6 100.0 872 Second 48.4 20.3 8.2 0.0 23.1 100.0 903 Middle 46.4 21.6 8.5 0.0 23.4 100.0 975 Fourth 42.0 22.5 12.2 0.0 23.3 100.0 1,060 Highest 44.8 22.9 10.9 0.1 21.3 100.0 1,204 Total 44.5 22.0 10.4 0.0 23.0 100.0 5,015 1 Excludes men who had sexual intercourse within the past 4 weeks 2 Excludes men who are not currently married 110 │ Other Proximate Determinants of Fertility 6.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is the interval between the birth of a child and the return of the menstrual cycle. It is the period during which the woman becomes temporarily and involuntarily infecund following childbirth. Postpartum protection from conception can be prolonged by breastfeeding, which can lengthen the duration of amenorrhoea. Delaying the resumption of postpartum sexual relations can also prolong protection. The period of voluntary sexual inactivity after childbirth is referred to as postpartum abstinence. A woman is said to be insusceptible to the risk of pregnancy if she is either amenorrhoeic or abstaining from sexual intercourse following childbirth. Women who gave birth during the three years prior to the survey were asked about their breastfeeding practices, the duration of amenorrhoea, and postpartum sexual abstinence. Table 6.8 shows that the median duration of amenorrhoea is 11 months, of abstinence 9 months, and of insusceptibility 14 months. The data show that all women are insusceptible to pregnancy during the first two months after a birth due to both postpartum amenorrhoea and postpartum abstinence. However, the contribution of abstinence to the period of insusceptibility starts decreasing after the second month after birth. At 10 to 11 months after birth, about half of all women are still amenorrhoeic, but only 41 percent are abstaining. By 14 to 15 months, a third of women are still amenorrhoeic, another third are abstaining, and only half are insusceptible because of the reduced combined effect of amenorrhoea and abstinence. At 20 to 21 months postpartum, mothers are just amenorrhoeic in one in ten births and the number abstaining is about a quarter (23 percent). By 34-35 months, the effect of postpartum amenorrhoea is almost completely wiped out and insusceptibility to pregnancy becomes low. Table 6.8 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Ghana 2003 Percentage of births for which the mother is: Months since birth Amenorrhoeic Abstaining Insusceptible Number of births < 2 98.1 100.0 100.0 97 2-3 87.6 86.8 95.5 95 4-5 77.5 71.1 87.1 136 6-7 60.3 61.5 74.6 152 8-9 67.4 49.9 76.6 108 10-11 49.9 40.8 64.8 137 12-13 40.7 38.7 55.8 128 14-15 32.2 34.7 48.6 148 16-17 24.8 20.8 36.0 129 18-19 13.4 21.3 28.7 111 20-21 13.3 22.9 29.3 114 22-23 6.1 20.4 22.4 90 24-25 5.0 11.8 15.5 104 26-27 3.3 10.1 11.7 138 28-29 4.3 11.6 15.0 120 30-31 5.3 10.8 13.8 106 32-33 3.5 8.2 9.6 104 34-35 1.2 4.5 4.5 114 Total 33.3 34.7 44.4 2,130 Median 10.8 8.8 13.8 na Mean 12.1 12.8 16.0 na Note: Estimates are based on status at the time of the survey. na = Not applicable Other Proximate Determinants of Fertility │ 111 A comparison of data from the 1993, 1998, and 2003 GDHS surveys indicates that the median duration of postpartum amenorrhoea, abstinence, and insusceptibility decreased between 1993 (GSS and MI, 1994) and 1998 (GSS and MI, 1999) but remained unchanged between 1998 and 2003. Table 6.9 shows the median durations of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics. Postpartum insusceptibility is shorter among urban than rural women. Postpartum insusceptibility is highest among women in the Upper East Region, due more to postpartum abstinence than amenorrhoea. In contrast, women from the Central Region are postpartum insusceptible primarily due to amenorrhoea rather than abstinence. There is an inverse relationship between the level of education and wealth on the one hand and women’s insusceptibility to pregnancy on the other. Table 6.9 Median duration of postpartum insusceptibility by background characteristics Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Ghana 2003 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility Number of births Age 15-29 9.6 8.9 14.1 1,129 30-49 11.7 8.7 13.6 1,001 Residence Urban 7.8 7.2 11.3 722 Rural 11.7 9.7 15.7 1,408 Region Western 8.4 7.3 13.1 206 Central 16.8 7.9 17.4 181 Greater Accra 8.6 7.1 10.1 225 Volta 10.8 11.0 12.6 180 Eastern 11.5 6.5 13.3 211 Ashanti 7.5 6.2 10.0 404 Brong Ahafo 9.0 6.6 12.4 234 Northern 14.5 15.8 21.6 291 Upper East 13.7 22.7 23.0 129 Upper West 13.2 15.6 19.8 68 Education No education 13.6 13.6 17.7 848 Primary 9.9 8.0 12.5 497 Middle/JSS 7.6 7.3 11.3 662 Secondary+ 7.4 4.4 7.5 123 Wealth quintile Lowest 13.8 14.9 17.7 535 Second 10.7 9.0 14.7 469 Middle 10.3 8.5 13.0 438 Fourth 8.0 7.4 12.6 356 Highest 8.1 4.4 9.3 333 Total 10.8 8.8 13.8 2,130 Note: Medians are based on current status. 112 │ Other Proximate Determinants of Fertility 6.7 MENOPAUSE Menopause marks the onset of infecundity and is another factor influencing the risk of pregnancy. Women are considered menopausal if they are neither pregnant nor postpartum amenorrhoeic, and have not had a menstrual period in the six months preceding the survey (Table 6.10). Nine percent of women age 30 and over are menopausal. As expected, the proportion of women who are menopausal increases with age from 2 percent among women age 30-34 to 47 percent among women age 48-49. The prevalence of menopause increases sharply after age 43. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Ghana 2003 Age Percentage menopausal1 Number of women 30-34 2.2 802 35-39 1.2 722 40-41 3.7 269 42-43 11.3 233 44-45 22.8 223 46-47 32.6 179 48-49 46.5 151 Total 9.4 2,580 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 113 FERTILITY PREFERENCES 7 Information on the fertility preferences of men and women provide a measure of the overall atti- tude of society towards childbearing and the general course of future fertility. This type of data is useful for family planning programmers to assess the need for contraception and the extent of unwanted and mistimed pregnancies. Data on fertility preferences can also be used to facilitate the objectives of the Ghana National Family Planning Programme, which was established to promote and facilitate couples’ desires for the number of children they want to bear, with births spaced according to their preferences (Republic of Ghana, 1969). In the 2003 GDHS, both women and men were asked a series of questions to ascertain their fertil- ity preferences. Specific questions were asked about the desire to have another child, the length of time they would like to wait before having another child, and what they considered to be the ideal number of children. The information collected makes it possible to quantify fertility preferences and, in combination with data on contraceptive use, allow the estimation of unmet need for family planning, both for spacing and for limiting births. 7.1 DESIRE FOR MORE CHILDREN Table 7.1 shows fertility preferences among currently married women and men by the number of living children at the time of the survey. There is considerable desire among currently married Ghanaians to control the timing and number of births. Thirty-eight percent of currently married women would like to wait for two years or more for the next birth, and 36 percent do not want to have another child or are ster- ilised. About a fifth (18 percent) would like to have a child soon (within two years). The remaining women are uncertain about their fertility desires or say they are unable to get pregnant (infecund). A simi- lar pattern is observed for currently married men. Table 7.1 also shows that fertility preferences are closely related to the number of children a woman has. The vast majority (63 percent) of currently married women without a child would like to have one soon. Nevertheless, they show a greater interest in controlling the pace of childbearing once they have a child; almost two-thirds (63 percent) of women with one child want to delay their next birth. Inter- est in controlling the number of births grows rapidly as the number of children increases; the proportion of married women wanting no more children or who are sterilised rises from 4 percent among women with one child to 75 percent among women with six or more children. Men without a child are twice as likely to want a child later than women. At the same time, women who have not started childbearing are much more likely to want a child within two years than men (63 and 47 percent, respectively). 114 | Fertility Preferences Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and men by desire for children, according to number of living children, Ghana 2003 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total WOMEN Have another soon2 62.8 26.4 19.0 16.7 9.7 7.0 4.9 18.0 Have another later3 22.5 62.8 55.6 40.9 28.7 23.6 7.8 37.5 Have another, undecided when 9.5 4.1 3.7 1.0 0.5 0.3 0.5 2.4 Undecided 1.3 1.8 1.7 5.0 4.9 3.5 3.8 3.2 Want no more 1.3 3.4 17.6 33.9 48.9 58.9 71.7 34.1 Sterilised 0.0 0.4 1.0 1.8 3.0 2.8 3.7 1.9 Declared infecund 2.6 0.9 1.3 0.8 4.4 3.9 7.6 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 234 618 652 623 495 369 558 3,549 MEN Have another soon2 46.7 25.6 21.2 16.0 10.3 14.4 12.6 19.0 Have another later3 43.5 65.0 53.8 40.7 33.0 23.1 17.7 38.5 Have another, undecided when 1.4 2.0 1.1 1.7 1.4 0.8 1.3 1.4 Undecided 4.4 1.8 4.5 6.7 7.0 4.3 4.9 4.8 Want no more 2.4 5.2 17.2 33.2 45.3 54.4 59.2 33.8 Declared infecund 1.3 0.3 1.9 1.6 2.7 3.0 4.1 2.3 Missing 0.3 0.0 0.2 0.2 0.4 0.0 0.3 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 214 388 424 426 330 286 603 2,671 1 Includes current pregnancy 2 Wants next birth within two years 3 Wants to delay next birth for two or more years A comparison of the data over the four GDHS surveys show that the desire to space births among currently married women has declined in the past 15 years, from 45 percent in 1988 (GSS and IRD, 1989) to 38 percent in 2003. However, this change has been minimal in the past ten years. On the other hand, the desire to limit (excluding sterilised women) has increased from 23 percent in 1988 to 34 percent in 2003. Again this change has been minimal over the past ten years. Table 7.2 shows the percentage of currently married women and men who want no more children (or are sterilised) by the number of living children and background characteristics. Urban women are more likely than rural women to want no more children regardless of the number of children they already have, although the overall urban-rural difference is slightly less then one percentage point, a pattern that is similar for men as well. Fertility Preferences | 115 Table 7.2 Desire to limit childbearing Percentage of currently married women and men who want no more children, by number of living children and background char- acteristics, Ghana 2003 Number of living children1 Background characteristic 0 1 2 3 4 5 6+ Total WOMEN Residence Urban 2.3 4.3 23.6 46.6 60.8 74.6 76.8 36.4 Rural 0.0 3.6 14.0 28.0 45.8 55.6 74.9 35.6 Region Western * 2.6 15.7 32.1 (58.5) (70.0) 75.2 37.6 Central * (2.6) (11.1) (48.9) (69.6) * (100.0) 43.7 Greater Accra (6.8) 9.7 36.3 56.7 80.8 (91.6) * 45.7 Volta * 3.8 31.5 (39.7) (64.3) (81.7) (87.7) 45.6 Eastern * (8.9) (23.3) 53.9 (54.7) (79.8) 80.7 46.7 Ashanti (0.0) 1.1 13.8 35.9 53.9 65.2 74.0 37.1 Brong Ahafo (0.0) 3.4 16.8 29.6 57.3 (56.7) 79.3 33.5 Northern (0.0) 1.3 0.9 10.9 17.9 24.4 51.3 15.1 Upper East * (0.0) (7.4) 14.4 24.5 (48.6) (50.7) 21.9 Upper West * 0.0 7.9 (8.1) 20.3 (50.4) 65.0 23.2 Education No education 0.0 4.9 8.7 17.1 35.8 49.1 68.7 31.5 Primary (0.0) 5.0 19.7 40.1 62.7 63.2 81.3 40.5 Middle/JSS 0.0 3.7 23.2 44.6 62.4 78.9 82.7 38.2 Secondary+ (6.6) 0.0 30.2 69.0 * * * 36.7 Wealth quintile Lowest (0.0) 4.1 8.0 13.5 28.4 45.5 61.5 26.4 Second (0.0) 3.5 16.5 29.8 45.3 62.0 78.7 40.0 Middle (0.0) 3.3 22.3 36.2 59.3 61.7 77.3 40.8 Fourth (0.0) 3.7 18.7 43.9 60.4 73.4 85.1 36.6 Highest 3.9 4.7 24.6 52.4 69.3 (78.2) (88.1) 36.8 Total 1.3 3.9 18.6 35.7 51.9 61.7 75.4 36.0 MEN Residence Urban 2.6 5.4 24.7 44.8 53.5 64.8 65.9 36.3 Rural 2.2 5.0 11.7 23.3 40.6 48.1 56.9 32.1 Region Western * (4.0) (18.4) (39.2) (52.1) (63.6) 78.5 42.4 Central * * (19.2) * * * (74.9) 45.6 Greater Accra (7.4) (1.9) 34.7 62.1 (78.7) * (83.5) 46.1 Volta * (3.9) (22.2) * (57.9) (65.6) (68.3) 38.8 Eastern * (3.1) (18.4) 46.3 (57.2) (59.9) 68.8 42.6 Ashanti (3.8) 7.7 14.6 25.5 40.9 50.1 59.5 32.3 Brong Ahafo * 11.4 (9.6) (29.3) (37.6) (65.5) 78.0 37.3 Northern (2.3) 3.1 (0.0) 4.0 (4.9) (8.4) (23.4) (8.3) Upper East * (2.7) (1.5) (2.1) * * (30.6) (15.2) Upper West * (0.0) (0.0) * * (31.9) (30.6) (15.6) Education No education 0.0 2.1 1.1 7.7 11.8 15.7 36.3 16.7 Primary (0.0) 0.3 9.1 25.0 (43.1) 43.2 59.9 27.0 Middle/JSS 1.9 9.9 22.9 37.2 55.7 68.7 72.8 42.0 Secondary+ 6.1 3.2 23.9 52.9 66.5 (80.4) 78.4 41.0 Wealth quintile Lowest 0.0 9.6 0.0 7.4 14.7 30.0 40.8 19.1 Second (3.0) 5.3 6.9 25.0 41.8 47.8 57.0 33.9 Middle (4.1) 4.8 18.2 25.8 55.1 56.1 67.1 38.4 Fourth 2.8 5.1 24.7 36.0 (43.2) (55.7) 72.9 34.9 Highest 2.4 2.3 28.3 55.2 65.9 79.0 72.0 41.3 Total 2.4 5.2 17.2 33.2 45.3 54.4 59.2 33.8 Note: Women and men who have been sterilised are considered to want no more children. An asterisk indicates that a figure is based on fewer than 25 un-weighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes current pregnancy 116 | Fertility Preferences Women and men residing in the Eastern, Volta, Greater Accra, Central, and Western regions are more likely than women and men in the other regions to want to limit the number of children they have (38-47 percent). The desire to limit childbearing among women is lowest in the Northern Region (15 percent). The percentage of men who do not want any more children increases with the level of education. For example, the desire to limit childbearing rises from 17 percent among men with no education to more than 40 percent among men with at least Middle/JSS education; however, educational difference among women is marked only between women with no education (32 percent) and those with some education (37-41 percent). Educational differences among women are, however, striking when the number of living children is taken into account. For example, among women with three children, only 17 percent of women with no education want no more children compared with 69 percent of women with secondary or higher schooling. A similar male-female pattern is observed by wealth quintiles. In general, women and men who are from the lowest wealth quintile are least likely to want to limit the number of children that they want, with quintile differentials more striking among men than women. 7.2 NEED FOR FAMILY PLANNING SERVICES Currently married women who say that they do not want any more children or that they want to wait two or more years before having another child, but are not using contraception, are considered to have an unmet need for family planning. Women who are using family planning methods are said to have a met need for family planning. Women with unmet need and met need together constitute the total de- mand for family planning. Table 7.3 shows the need for family planning among currently married women by background characteristics. Thirty-four percent of married women have an unmet need for family planning. Unmet need for spacing is higher than unmet need for limiting children (22 and 12 percent, respectively). Table 7.3 also shows that one in four currently married women is using a method of contraception, with 14 per- cent using for spacing and 11 percent using for limiting. The total demand for family planning among women is 59 percent, 36 percent with a need for spacing and 24 percent with a need for limiting. Forty- three percent of the demand for family planning is currently being met, implying that the needs of more than one in two women are currently not being met. Comparison of data from the 1998 and 2003 GDHS surveys suggests that there has been little change in the unmet need among currently married women over the past five years. The total demand for family planning and the percentage of demand satisfied increased by 7 percent, each, over the five-year period. Fertility Preferences | 117 Table 7.3 Need for family planning Percentage of currently married women with unmet need for family planning, with met need for family planning, and the total demand for family planning, by background characteristics, Ghana 2003 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percentage of demand satisfied Number of women Age 15-19 52.9 3.9 56.8 8.4 0.0 8.4 61.3 3.9 65.2 12.9 137 20-24 39.2 2.0 41.1 21.1 1.7 22.8 60.2 3.7 63.9 35.7 530 25-29 28.9 7.0 36.0 22.0 3.8 25.8 50.9 10.8 61.8 41.8 739 30-34 20.3 10.4 30.7 19.6 10.0 29.7 39.9 20.5 60.4 49.1 671 35-39 14.7 18.1 32.8 8.4 19.8 28.1 23.1 37.9 61.0 46.1 621 40-44 7.3 22.1 29.5 3.3 25.4 28.7 10.6 47.6 58.2 49.4 473 45-49 3.9 21.6 25.5 0.6 15.4 16.0 4.5 37.0 41.5 38.6 377 Residence Urban 17.3 10.7 28.0 17.6 13.8 31.4 34.8 24.5 59.4 52.9 1,436 Rural 24.7 13.4 38.1 11.1 9.8 20.9 35.9 23.2 59.1 35.5 2,113 Region Western 22.6 10.1 32.7 13.0 15.3 28.2 35.6 25.4 61.0 46.3 319 Central 31.2 18.6 49.9 6.4 8.7 15.2 37.7 27.4 65.0 23.3 274 Greater Accra 14.6 16.7 31.2 15.1 18.9 34.0 29.6 35.6 65.2 52.1 476 Volta 21.1 19.4 40.5 13.3 10.3 23.6 34.5 29.6 64.1 36.8 304 Eastern 17.5 16.3 33.9 13.2 13.9 27.1 30.7 30.2 60.9 44.4 354 Ashanti 17.6 11.0 28.5 17.3 12.4 29.7 34.9 23.4 58.2 51.0 643 Brong Ahafo 22.5 8.9 31.4 19.5 13.5 33.0 41.9 22.4 64.4 51.2 398 Northern 28.8 5.0 33.8 8.9 3.2 12.1 37.7 8.2 46.0 26.4 431 Upper East 29.1 10.0 39.1 8.6 3.3 11.9 37.7 13.3 51.0 23.3 236 Upper West 19.7 4.8 24.5 19.2 7.1 26.3 38.9 12.0 50.9 51.7 113 Education No education 24.1 11.1 35.1 7.8 7.5 15.3 31.8 18.6 50.4 30.3 1,354 Primary 24.3 15.3 39.6 13.6 12.4 26.1 37.9 27.7 65.6 39.7 710 Middle/JSS 19.3 12.5 31.8 18.6 13.8 32.4 37.9 26.3 64.2 50.5 1,205 Secondary+ 14.2 9.9 24.1 21.9 17.8 39.8 36.2 27.7 63.9 62.2 280 Wealth quintile Lowest 29.6 11.1 40.7 8.7 5.3 14.0 38.3 16.5 54.8 25.6 753 Second 23.7 14.1 37.7 12.2 11.7 24.0 35.9 25.8 61.7 38.9 687 Middle 21.9 12.6 34.5 11.9 13.0 24.9 33.8 25.7 59.4 41.9 692 Fourth 20.3 12.8 33.0 17.0 12.0 29.0 37.3 24.7 62.0 46.8 695 Highest 12.8 11.0 23.9 19.1 15.5 34.6 31.9 26.5 58.4 59.1 721 Total 21.7 12.3 34.0 13.7 11.4 25.2 35.5 23.7 59.2 42.5 3,549 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrhoeic women who are not using family planning and whose last birth was mistimed, and fecund women who are neither pregnant nor amenorrhoeic and who are not using any method of family plan- ning and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth unless they say it would not be a problem if they discovered they were pregnant in the next few weeks. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeic women whose last child was unwanted, and fecund women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are pregnant and amenorrhoeic women who became pregnant while using a method (these women are in need of a better method of contraception). 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 118 | Fertility Preferences Unmet need generally declines with age, with the decline sharper among younger (15-29) than older (35-49) women. As can be seen from the table, younger women have a higher unmet need for spac- ing, while older women have a greater unmet need for limiting. Rural women have a higher unmet need for family planning than their urban counterparts (38 percent compared with 28 percent). It is also inter- esting to note that rural women have higher unmet need for both spacing and limiting than their urban counterparts. Unmet need is highest in the Central Region (50 percent) and lowest in the Upper West (25 percent). Not surprisingly, the percentage of demand satisfied is highest in Greater Accra (52 percent) and lowest in the Upper East and Central regions (23 percent each). With the exception of Greater Accra, the unmet need for spacing is higher than the unmet need for limiting in all regions. Women with secondary or higher education have a lower unmet need for family planning (24 percent) than women with primary education and those with no education whose unmet need for fam- ily planning is 40 and 35 percent, respectively. Total demand for family planning is highest for women with primary education rather than women with no education, 66 percent compared with 50 percent. The percentage of demand satisfied ranges from 30 percent among women with no education to 62 percent for women with secondary or higher level education. The unmet need for family planning is highest among women in the lowest wealth quintile and lowest among women in the highest wealth quintile (41 and 24 percent, respectively). For all the five wealth quintiles, the unmet need for spacing is higher than the unmet need for limiting. Also, the percent- age of demand satisfied ranges from 26 percent for women in the lowest wealth quintile to 59 percent for women in the highest wealth quintile. 7.3 IDEAL FAMILY SIZE Information on what men and women believe to be their ideal family size was elicited through two questions. Respondents who had no living children were asked, “If you could choose exactly the number of children to have in your whole life, how many would that be?” Respondents who had children were asked, “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” These questions are based on hypothetical situations; therefore, the responses to them are expected to in part reflect societal norms prevalent in the past as well as at present. Nevertheless, even though these questions are based on hypo- thetical situations, they give an idea of the total number of children women who have not started child- bearing will have in the future, while among older and high parity women, these data provide a measure of the level of unwanted fertility. Table 7.4 shows that 98 percent of women and men gave a numeric response to the questions on ideal number. Fertility Preferences | 119 Table 7.4 Ideal number of children Percent distribution of all women and all men by ideal number of children, and mean ideal number of children for all women and men and for currently married women and men, according to number of living children, Ghana 2003 Number of living children1 Ideal number of children 0 1 2 3 4 5 6+ Total WOMEN 0 0.8 0.2 0.1 0.3 0.5 0.2 0.9 0.5 1 0.4 0.9 0.8 0.4 0.7 0.1 0.0 0.5 2 14.8 10.6 6.2 3.8 4.3 3.7 3.5 8.6 3 32.3 30.0 19.3 15.8 7.0 6.8 6.0 20.9 4 32.4 36.8 45.7 40.3 37.7 25.5 28.1 35.4 5 9.2 8.0 11.3 13.7 11.6 17.9 8.1 10.6 6+ 8.1 12.1 16.1 24.4 35.7 41.0 50.0 21.5 Non-numeric responses 1.9 1.4 0.5 1.3 2.4 4.7 3.3 2.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,774 848 766 710 562 412 618 5,691 Mean ideal number of children for:2 All women 3.7 4.0 4.3 4.7 5.1 5.5 5.8 4.4 Number 1,740 836 763 701 548 393 597 5,579 Currently married women 4.1 4.1 4.3 4.7 5.1 5.6 5.7 4.8 Number 227 609 648 614 483 351 539 3,471 MEN 0 0.7 0.2 0.4 0.1 0.4 0.3 0.2 0.4 1 0.7 0.2 0.6 0.4 0.4 0.5 0.3 0.5 2 12.5 9.0 6.0 5.0 6.9 4.6 3.7 8.9 3 28.2 29.1 19.8 17.1 8.9 12.1 7.6 21.6 4 29.0 35.1 39.2 28.5 29.4 15.4 22.2 28.9 5 13.5 11.6 13.9 21.8 15.3 21.7 12.2 14.6 6+ 13.9 13.4 19.2 25.4 35.5 42.4 48.3 22.9 Non-numeric responses 1.6 1.4 0.9 1.7 3.1 3.0 5.5 2.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 2,300 510 471 458 358 300 617 5,015 Mean ideal number of children for:2 All men 4.1 4.4 4.7 5.0 5.2 6.2 7.1 4.8 Number 2,264 503 467 450 347 291 583 4,906 Currently married men 4.4 4.5 4.7 5.1 5.1 6.2 7.2 5.4 Number 211 383 420 418 319 278 570 2,599 1 Includes current pregnancy 2 Means are calculated excluding the women and men giving non-numeric responses The mean ideal number of children for all women is 4.4, while for men it is 4.8, indicating that men’s ideal number of children is slightly larger than women’s. Both currently married women and men prefer a larger ideal family size than all women and men. There may be two principal reasons for this pat- tern. To the extent that women and men are able to implement their fertility desires, those who want smaller families will tend to achieve smaller families. Some women and men who have children may have difficulty admitting that they would like to have fewer children than they actually have and are likely to report their actual number of children as their preferred number. For the most part, the pattern in expressed desire by ideal number is similar among women and men. However, the percentages for 120 | Fertility Preferences women and men diverge beyond an ideal number of three children. Thirty-five percent of all women ex- press a desire for four children compared with 29 percent of all men. On the other hand 11 percent of women prefer an ideal number of 5 children compared with 15 percent of men. The preference for a larger number of children is higher for men than women irrespective of the number of living children. Ideal number increases with the number of living children and ranges from 3.7 for all women without any children to 5.8 for those with at least 6 children. As with women, the mean ideal number of children among all men increases with the number of children and ranges from 4.1 among those without a child to 7.1 among those who already have 6 or more children. Data from GDHS surveys conducted over the past 15 years shows that, although there has been a decline in ideal family size among currently married women over time, from a mean of 5.5 children in 1988 (GSS and MI, 1989) to 4.8 children in 2003, there has been little change in the past 10 years. In fact, there appears to be a slight increase in the ideal family size desired by both women and men over the past five years (GSS and MI, 1999). Table 7.5 shows the mean ideal number of chil- dren for all women and men by age according to back- ground characteristics. The ideal family size increases with age, from 3.8 children among women age 15-19 to 5.4 among women age 45- 49. For men in these age groups, the mean ideal num- ber ranges from 4.2 to 6.1. This pattern suggests a trend towards lower ideal family size. The ideal family size for both women and men is higher in rural than urban areas. The ideal size is high- est in the Northern Region (6.9 for women and 8.2 for men) and relatively high for the other two northern re- gions. This confirms the findings that women and men residing in the three northern regions have a preference for large families. Women and men residing in Greater Accra have the low- est ideal family size. There are also variations in the ideal family size by level of education. Across all age groups, the ideal family size decreases with increasing Table 7.5 Mean ideal number of children by background characteristics Mean ideal number of children for all women, by age and mean ideal number of children for all men, according to background characteristics, Ghana 2003 Age Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 All women 15-49 All men 15-59 Residence Urban 3.5 3.4 3.8 4.0 4.2 4.5 5.0 3.9 4.1 Rural 4.1 4.2 4.9 5.3 5.5 5.6 5.7 4.9 5.5 Region Western 3.8 3.7 4.1 4.6 4.7 (4.8) (4.9) 4.2 4.3 Central 3.4 3.6 4.2 (3.9) (4.1) (4.2) (4.5) 3.9 4.1 Greater Accra 3.2 3.1 3.2 3.8 3.6 4.5 3.8 3.5 3.4 Volta 3.0 3.3 3.6 4.0 4.2 4.5 (4.3) 3.8 4.4 Eastern 3.7 3.4 3.8 4.1 4.4 3.9 (5.1) 4.0 4.3 Ashanti 3.8 3.7 4.3 4.9 5.2 5.4 5.7 4.5 4.6 Brong Ahafo 3.7 3.8 4.1 4.4 4.9 5.4 (6.1) 4.4 4.5 Northern 6.1 5.9 6.5 7.2 7.4 (8.3) (8.1) 6.9 8.2 Upper East 4.9 5.6 5.8 5.8 (6.0) (6.3) (6.9) 5.8 7.0 Upper West 4.2 5.0 6.0 5.4 6.1 (6.9) 6.2 5.6 6.2 Education No education 5.0 5.0 5.5 5.8 6.0 6.2 6.5 5.7 7.8 Primary 3.9 3.9 4.3 4.6 4.7 4.7 4.9 4.3 5.0 Middle/JSS 3.6 3.5 3.8 4.1 4.0 4.5 4.8 3.9 4.2 Secondary + 3.2 3.2 3.1 3.7 (3.6) (3.8) (4.0) 3.3 3.8 Wealth quintile Lowest 4.9 5.0 5.8 6.2 6.2 6.3 6.7 5.8 6.9 Second 3.9 4.2 4.8 5.1 5.5 5.3 5.5 4.8 5.3 Middle 3.9 3.7 4.5 4.5 5.0 5.2 5.2 4.5 4.7 Fourth 3.6 3.7 3.8 4.2 4.4 4.7 5.4 4.0 4.3 Highest 3.3 3.2 3.5 3.9 3.8 4.3 4.4 3.6 3.7 All women 3.8 3.8 4.3 4.7 4.9 5.1 5.4 4.4 na All men 4.2 4.1 4.4 4.9 5.1 5.5 6.1 na 4.8 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable Fertility Preferences | 121 levels of education. A similar pattern is observed by wealth quintiles. 7.4 FERTILITY PLANNING Wanted fertility can be measured in two ways. Responses to a question about children born in the five years preceding the survey (and any current pregnancy) are used to determine whether the pregnancy was planned (wanted then), wanted but at a later time (mistimed), or unwanted (not wanted at all). The answers to these questions provide some insight into the degree to which couples are able to control fertil- ity. Wanted fertility is calculated in the same manner as the actual total fertility rate, but unwanted births are excluded from the numerator. Table 7.6 shows the percent distribution of births (including current pregnancy) in the five years preceding the survey by fertility planning status, according to birth order and mother’s age at birth. The data show that two-fifths of births in the five years preceding the survey are unplanned―24 percent were mistimed (wanted later) and 16 percent were unwanted. The proportion of planned births increases be- tween the first and second birth and then declines for subsequent births. Table 7.6 Fertility planning status Percent distribution of births in the five years preceding the survey (including current pregnancy), by fertility planning status, according to birth order and mother's age at birth, Ghana 2003 Planning status of birth Birth order and mother’s age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 57.9 25.7 16.2 0.2 100.0 910 2 66.3 25.8 7.3 0.6 100.0 785 3 63.1 26.2 9.4 1.3 100.0 640 4+ 55.8 21.7 21.7 0.8 100.0 1,723 Mother’s age at birth <20 42.0 37.0 20.7 0.3 100.0 458 20-24 58.9 29.8 10.7 0.5 100.0 989 25-29 66.9 21.6 11.1 0.5 100.0 1,025 30-34 64.4 21.7 13.2 0.7 100.0 772 35-39 58.1 16.8 23.8 1.3 100.0 546 40-44 50.8 12.7 35.0 1.5 100.0 222 45-49 53.0 12.8 32.1 2.1 100.0 47 Total 59.4 24.1 15.7 0.7 100.0 4,058 The proportion of unplanned births has slightly decreased from 42 percent in 1993 to 36 percent in 1998 but increased to 40 percent in 2003. What is more troubling, however, is the fact that the propor- tion of births that are unwanted has increased rather dramatically from the 1993 and 1998 level of 9 per- cent to 16 percent in 2003. Table 7.7 provides information on total wanted fertility rates and the actual total fertility rates for the three years preceding the survey, by select background characteristics. Unwanted births are defined as births that exceed the number considered ideal. Women who did not report a numeric ideal family size were assumed to want all their births. The total wanted fertility rate represents the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births were prevented. A 122 | Fertility Preferences comparison of the total wanted fertility and actual total fertility rate suggests the potential demographic impact of the elimination of unwanted births. The total wanted fertility rate, which stood at 4.2 in 1993, fell to 3.7 in 1998 and remained at 3.7 in the three years preceding the 2003 survey. During the same period, the total fertility rate fell from 5.2 children per woman in 1993 to 4.4 in 1998 and remained unchanged at 4.4 in 2003 suggesting a narrowing between desired and actual fertility over the past 10 years. The wanted fertility rate in rural areas is two chil- dren more than in urban areas. The gap between wanted and realised fertility in rural areas is larger than in urban areas, suggesting that urban women may be better able to translate their ideal family size to realised family size. At the regional level, women in Greater Accra de- sire the least number of children (2.4) in contrast to their counterparts in the Northern Region who want 6.5 chil- dren. However, the gap between desired and actual fertil- ity is the same between these two regions. The largest gap between wanted and realised fertility is observed in the Central and Eastern regions (about 1.5 children), suggest- ing that women in these regions are less able to translate their desired family size in practice. Women’s education has an inverse relationship with levels of both wanted and actual fertility, although the difference between the two is higher among those with primary education (1.3) than among those with no educa- tion (0.8). There is also an inverse relationship between wealth and wanted fertility, with the gap between wanted and actual fertility widest among women who belong to the second wealth quintile. 7.5 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS An increase in women’s status and empowerment is recognised as important in the effort to re- duce fertility through at least two main pathways: its association with desired family size and its positive association with women’s ability to meet their own family-size goals through the effective use of contra- ception. Table 7.8 shows how women’s ideal family size and their unmet need for contraception vary by the three indicators of women’s empowerment―number of decisions in which the respondent has final say, number of reasons for which a woman can refuse to have sexual relations with her husband, and number of reasons for which the respondent feels a husband is justified in beating his wife. Table 7.8 shows that the mean ideal number of children is lowest among women who believe that wife-beating is not justified for any reason at all and progressively increases with the number of reasons women believe that it can be justified. Unmet need is also lowest among women who believe that wife- Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Ghana 2003 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 2.6 3.1 Rural 4.6 5.6 Region Western 3.5 4.5 Central 3.5 5.0 Greater Accra 2.4 2.9 Volta 3.3 4.4 Eastern 2.9 4.3 Ashanti 3.5 4.1 Brong Ahafo 3.8 4.8 Northern 6.5 7.0 Upper East 4.5 4.7 Upper West 5.0 5.5 Education No education 5.2 6.0 Primary 4.0 5.3 Middle/JSS 2.7 3.5 Secondary+ 2.3 2.5 Wealth quintile Lowest 5.7 6.4 Second 4.4 5.9 Middle 4.1 4.9 Fourth 2.6 3.3 Highest 2.4 2.8 Total 3.7 4.4 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Fertility Preferences | 123 beating is not justified for any reason at all. There is no clear pattern between ideal family size or unmet need and the other two measures of women’s status. Table 7.8 Ideal number of children and unmet need by women's status Mean ideal number of children and unmet need for spacing and limiting among all women, by women's status indicators, Ghana 2003 Unmet need for family planning2 Women's status indicator Mean ideal number of children1 Number of women For spacing For limiting Total Number of women Number of decisions in which oman has final say3 0 4.9 611 24.9 8.1 33.0 630 1-2 5.0 734 27.6 11.1 38.6 760 3-4 5.1 723 19.2 9.2 28.4 742 5 4.5 1,403 18.5 16.4 35.0 1,417 Number of reasons to refuse sex with husband 0 4.9 262 25.9 14.9 40.9 267 1-2 5.3 431 20.7 10.1 30.8 461 3-4 4.7 2,778 21.5 12.4 33.9 2,821 Number of reasons wife-beating is justified 0 4.5 1,709 17.8 13.7 31.5 1,738 1-2 4.8 733 25.3 13.5 38.9 755 3-4 5.2 698 24.5 9.3 33.8 717 5 5.8 331 27.9 8.7 36.6 339 Total 4.8 3,471 21.7 12.3 34.0 3,549 1 Totals are calculated excluding the women giving non-numeric responses 2 See Table 7.3 for definition of unmet need for family planning 3 Either by herself or jointly with others Infant and Child Mortality | 125 INFANT AND CHILD MORTALITY 8 Chapter 8 deals with levels, trends, and differentials in neonatal, postneonatal, infant, child, and under-five mortality in Ghana. The data used in measuring these childhood mortality rates were collected from the birth history section of the Women’s Questionnaire in the 2003 GDHS. Women of reproductive age (15-49) were asked the number of biological sons and daughters who live with them, the number living elsewhere, and the number who have died. In addition, for each live birth, women were asked for the sex, date of birth, whether the birth was single or multiple, and the survival status. Information about age for living children, and for deceased children, age at death, was also collected. Measures of childhood mortality are used for a number of purposes. For instance, childhood mortality in general and infant mortality in particular are often used as broad indicators of social development or as more specific indicators of health status. Measures of childhood mortality are also useful in population projections. Studies of its characteristics such as age pattern and socio-economic and demographic differentials are used to highlight factors that promote child survival as well as those that are detrimental to it. Consequently, mortality analyses are helpful in identifying promising directions for health programmes and advancing child survival efforts. 8.1 DEFINITION, DATA QUALITY AND METHODOLOGY Childhood mortality estimates measure the risk of dying from birth up to age five. The rates of childhood mortality presented in this chapter are defined as follows: Neonatal mortality (NN): the probability of dying between birth and the first month of life Postneonatal mortality (PNN): the difference between infant and neonatal mortality Infant mortality (1q0): the probability of dying between birth and exact age one Child mortality (4q1): the probability of dying between exact ages one and five Under-five mortality (5q0): the probability of dying between birth and exact age five. All rates are expressed per 1,000 live births, except child mortality, which is expressed per 1,000 children surviving to 12 months of age. The reliability of mortality estimates depends on the sampling variability of the estimates and on nonsampling errors. Sampling errors are presented in Appendix B. Nonsampling errors arise from problems associated with the quality of data collection and include the completeness with which births and deaths are reported and recorded. The most common problems are misreporting of age at death, misreporting of dates of birth, and event underreporting (of both the birth and death of a child). The possible occurrence of these data problems in the 2003 GDHS is discussed with reference to the data quality tables in Appendix C. A typical problem with survey data is the misreporting of infant deaths, that occur in the late postneonatal period, as deaths at 12 months or one year of age (digit preference in the reporting of age). Such misreporting results in underestimation of the infant mortality rates and overestimation of child mortality rates. Table C.6 in Appendix C displays some digit preferences in reported deaths at 12 months 126 | Infant and Child Mortality or one year. This “heaping” took place in spite of the care taken in the GDHS to minimise errors of this nature by insisting that age at death be recorded in days if the death took place within one month after birth, in months if the child died within 24 months of birth, and in years if the child died between ages two and five. Nevertheless, age heaping at 12 months is not markedly different from the level seen in the data collected in the previous GDHS surveys. Misreporting of the date of birth of children is common in many surveys that include both demographic and health information for children born since a specified date. The effect of such an error is to distort time trends in fertility and mortality. In the 2003 GDHS, the cutoff date for asking health questions was 1998, that is, for births since January 1998. An examination of Table C.4 suggests that there is evidence of misreporting of dates of birth for both living and deceased children. The calendar year ratios for living and deceased children are 82 and 48 percent, respectively, for 1998, compared with 116 and 153 percent, respectively, in 1997. The deficit in calendar year 1998 is believed to be the result of “aging” of children by interviewers who want to avoid collecting health data information for children. The transference of children and especially deceased children out of the five-year period preceding the survey is likely to understate the true level of childhood mortality for that period. The data also show heaping in 1999 and 2000, although this is not as severe as in 1997. Event underreporting is usually more severe for deaths that occur early in infancy. Omission of deaths may also be more common among women who have had several children, or in cases where the death took place a long time ago. In order to assess the impact of omission on measures of child mortality, two indicators are used: the percentage of deaths that occurred under seven days to the number that occurred under one month and the percentage of neonatal to infant deaths. It is hypothesised that omission will be more prevalent among those who died immediately after birth than those who lived longer and that it will be more serious for events that took place in the distant past rather than those in the more recent past. Table C.5 shows that the percentage of early neonatal deaths ranges from 77 percent for the 15-19 years prior to the survey to 85 percent for the 5-9 years before the survey and 83 percent for the period 0-4 years before the survey. These results are similar to those found in the 1988 (GSS and MI, 1998), 1993 (GSS and MI, 1994), and 1998 (GSS and MI, 1999) GDHS surveys. Similarly, Table C.6 shows that neonatal deaths comprise 57 to 69 percent of all infant deaths. This is considered plausible.1 Over time, the figures vary within a narrow range for the 20 years prior to the survey, suggesting that there has not been selective omission of early infant deaths. In addition to recall errors for the more distant retrospective periods, there are structural reasons for limiting mortality estimation to recent periods, preferably to the 0-4, 5-9, and 10-14 years before the survey. In fact, except for the first period, the others are slightly biased estimates because they are based on child mortality experience of women age 15-44 and 15-39 respectively instead of women age 15-49 as in the 0-4 years prior to the survey period. Therefore, estimating mortality for the periods further than 10- 15 years before the survey is not advisable. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 shows mortality rates for the 15 years preceding the survey in three five-year periods. Under-five mortality in Ghana is 111 deaths per 1,000 live births in the most recent five-year period. This means one in every nine Ghanaian children dies before reaching age five. Nearly three in five of these deaths occur in the first year of life―infant mortality is 64 deaths per 1,000 live births and child mortality 1 There are no model mortality patterns for the neonatal period. However, one review of data from several developing countries concluded that at levels of neonatal mortality of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). Infant and Child Mortality | 127 is 50 deaths per 1,000 children age one year. Neonatal mortality is 43 deaths per 1,000 live births in the most recent five-year period, while postneonatal mortality is 21 deaths per 1,000 live births. Neonatal deaths account for two-thirds of the deaths in infancy. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Ghana 2003 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 43 21 64 50 111 5-9 39 26 65 46 108 10-14 38 26 64 43 104 1 Computed as the difference between the infant and neonatal mortality rates Mortality trends can be examined in two ways: by comparing mortality rates for three five-year periods preceding a single survey, and by comparing mortality estimates obtained from various surveys. However, mortality data have to be interpreted with caution since sampling errors associated with mortality estimates are large. Data from the 2003 GDHS show that infant mortality has remained constant over the 15-year period preceding the survey at about 64-65 deaths per 1,000 live births. However, there is substantial variation when the infant mortality rates are split into their component neonatal and postneonatal mortality rates. Postneonatal mortality declined slightly from 26 per 1,000 in the 5-14 years before the survey to 21 per 1,000 live births in the 0-4 years before the survey. Over the same period, neonatal mortality increased from 38 per 1,000 live births to 43 per 1,000 live births. Both child mortality and under-five mortality increased from 43 per 1,000 children to 50 per 1,000 children, and from 104 per 1,000 births to 111 per 1,000 births, over the same period, respectively. All these changes are very small and are not statistically significant. In other words, according to these figures, childhood mortality has remained more or less constant over the 1988 to 2003 period. With declining infant mortality, the proportion of neonatal to infant mortality is expected to increase. However, in the case of the 2003 GDHS data, contrary to expectation, infant mortality remained constant over the 15-year period, while the proportion of neonatal to infant mortality increased. A reduction in postneonatal mortality may reflect an improvement in the socio-economic situation of the population, leading to increased vaccination coverage and improved maternal and child health care. The deterioration in neonatal mortality is, however, more difficult to explain. When data from the four GDHS surveys (conducted in 1988, 1993, 1998, and 2003) are compared (Table 8.2 and Figure 8.1), for the most recent five-year period, the marked decline in both infant and under-five mortality observed in the three earlier surveys (1984-1998) appears to have halted during the period 1999-2003. This is caused principally by an increase in the neonatal mortality rate from about 30 per 1,000 for the 0-4 years preceding the 1998 GDHS to 43 per 1,000 during the same period prior to the 2003 GDHS (GSS and MI, 1999). It is reassuring that the under-five mortality rate for the period 5-9 years before the 2003 GDHS (108) is identical to the rate 0-4 years before the 1998 GDHS. The apparent slowing down in mortality decline signifies the difficulties the socio-economic situation in general and the health system in particular are facing in achieving the Ghana Poverty Reduction Strategy, which targets an infant mortality rate of 50 per 1,000 and an under-five mortality rate of 95 by 2005 (World Bank, 2003). 128 | Infant and Child Mortality Table 8.2 Trends in early childhood mortality rates Infant and under-five mortality, Ghana 1983-2003 Survey year Approximate calendar period Infant mortality (1q0) Under-five mortality (5q0) 1988 1983-1987 77 155 1993 1989-1993 66 119 1998 1994-1998 57 108 2003 1999-2003 64 111 8.3 SOCIO-ECONOMIC DIFFFERENTIALS IN MORTALITY Table 8.3 and Figure 8.2 show differentials in childhood mortality by four socio-economic variables: residence, region, mother’s education, and wealth quintile. When interpreting mortality data, it is useful to bear in mind that sampling errors are quite large. To ensure a sufficient number of cases for statistical reliability, mortality rates are calculated for a ten-year period. Socio-economic characteristics are highly correlated with one another and with bio-behavioural characteristics, and their impact is better analysed within a multivariate framework. However, such an analysis is beyond the scope of this report. Therefore, caution must be exercised in interpreting the bivariate results shown in Table 8.3. Place of residence, whether urban or rural, is defined at the time of interview. Where internal migration is high, births of migrants may have occurred in the place of previous residence. The mortality estimates of the current place of residence are, therefore, likely to be slightly biased. In the absence of data that would allow the classification of exposure and deaths according to the place of residence at the time of the event, the assumption is made that the extent of bias is marginal. Infant and Child Mortality | 129 Table 8.3 Early childhood mortality rates by socio-economic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by background characteristic, Ghana 2003 Background characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 38 17 55 40 93 Rural 43 27 70 52 118 Region Western 37 30 66 46 109 Central (37) (13) (50) (41) (90) Greater Accra 29 16 45 31 75 Volta 44 31 75 41 113 Eastern 42 22 64 33 95 Ashanti 57 22 80 40 116 Brong Ahafo 36 22 58 35 91 Northern 38 32 69 90 154 Upper East 22 11 33 48 79 Upper West 62 43 105 115 208 Mother’s education No education 37 29 66 63 125 Primary 49 27 76 48 120 Middle/JSS 43 18 60 34 92 Secondary+ (27) (2) (29) (5) (34) Wealth quintile Lowest 37 25 61 70 128 Second 40 23 64 44 105 Middle 49 25 73 40 111 Fourth 38 28 66 45 108 Highest 42 15 58 33 88 Note: Rates based on 250 to 499 exposed persons are in parentheses. 1 Computed as the difference between the infant and neonatal mortality rates Mortality levels in rural areas are considerably and consistently higher than in urban areas. For instance, under-five mortality in rural areas is 118 per 1,000 live births compared with 93 for urban areas. The urban-rural gap is most notable for postneonatal mortality, which is considerably higher in rural areas (27 per 1,000 births) than in urban areas (17 per 1,000 births). Marked regional differentials in under-five mortality are also observed in Table 8.3. For example, under-five mortality ranges from a low of 75 per 1,000 live births in Greater Accra to a high of 208 per 1,000 live births in the Upper West Region. As expected, mother’s education is inversely related to a child’s risk of dying. Under-five mortality among mothers with no education (125 per 1,000 live births) is noticeably higher than among women with middle/JSS level of education (92 per 1,000 live births). The direct association observed between education and under-five mortality is, however, not reproduced at the infant mortality level. Children of women with no education appear to have a lower risk of dying than those with primary education. 130 | Infant and Child Mortality 93 118 109 90 75 113 95 116 91 154 79 208 125 120 92 34 128 105 111 108 88 RESIDENCE Urban Rural REGION Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West MOTHER'S EDUCATION No education Primary Middle/JSS Secondary+ WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 50 100 150 200 250 Deaths per 1,000 live births Figure 8.2 Under-Five Mortality by Background Characteristics GDHS 2003Note: Rates are for the 10-year period preceding the survey. Children in the highest wealth quintile exhibit the lowest mortality rate for all categories of mortality, with the exception of neonatal mortality, which is lowest among the poorest segment of the population. 8.4 DEMOGRAPHIC CHARACTERISTICS AND CHILD MORTALITY Studies have shown that a number of demographic factors are strongly associated with the survival chances of young children. These factors include sex of the child, age of the mother at birth, birth order, length of the preceding birth interval, and the size of the child at birth. Table 8.4 shows the relationship between childhood mortality and these demographic variables. Again, for all variables except birth size, mortality estimates are calculated for a ten-year period before the survey to reduce sampling variability. However, mortality rates by birth size are for the five years preceding the survey since information on birth size was collected only for children born in the last five years. Childhood mortality rates are generally higher for males than females (Figure 8.3). With the exception of child mortality, male mortality exceeds female mortality at all levels (Table 8.4). Data from World Fertility Surveys and DHS surveys indicate that births to young mothers (under age 20 years) and older mothers (35 years and over) experience an elevated risk of mortality. Data from the 2003 GDHS confirm the expected curvilinear relationship between mother’s age at birth and mortality. First births and higher order births generally face an elevated risk of mortality. Data from the 2003 GDHS confirm this pattern for the most part. With the exception of postneonatal mortality, births of order seven and higher experience the highest levels of childhood mortality. Neonatal, infant, and under- five mortality is lowest for second and third order births. Mortality among children is negatively associated with the length of the previous birth interval and this is especially the case when the birth interval is less than two years. As seen from the data, this is Infant and Child Mortality | 131 111 108 131 103 108 128 192 110 82 86 SEX OF CHILD Male Female AGE OF MOTHER <20 20-29 30-39 40-49 PREVIOUS BIRTH INTERVAL <2 2 Years 3 Years 4+ Years 0 50 100 150 200 250 Deaths per 1,000 live births Figure 8.3 Under-Five Mortality by Socio-Economic Characteristics GDHS 2003 Note: Previous birth interval excludes first-order births; rates are for the 10-year period preceding the survey. Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by demographic characteristics, Ghana 2003 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 46 24 70 44 111 Female 36 23 59 52 108 Mother's age at birth <20 54 23 77 58 131 20-29 35 25 61 45 103 30-39 42 22 64 48 108 40-49 (62) (19) (81) (51) (128) Birth order 1 46 20 66 42 105 2-3 34 21 55 43 96 4-6 40 29 69 50 116 7+ 56 23 79 72 145 Previous birth interval2 <2 83 48 131 69 192 2 years 28 26 53 60 110 3 years 25 18 43 41 82 4+ years 40 15 55 32 86 Birth size3 Small/very small 61 19 81 na na Average or larger 33 21 54 na na Note: Rates based on 250 to 499 exposed persons are in parentheses. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey 132 | Infant and Child Mortality true at all levels of mortality. For example, neonatal mortality for children born at less than a two-year interval is two to three times higher than for children born after an interval of two years or more. A child’s size at birth has often been found to be an important determinant of its survival chances in infancy. The majority of births in Ghana take place outside a health facility. Babies born in a non- institutional setting are seldom weighed at birth, and the only measure of their size at birth is the mother’s assessment of their size. The data show that infant mortality is 50 percent higher among babies assessed as small or very small than babies assessed as average or larger at birth. The difference in infant mortality is predominantly due to neonatal mortality, which is almost twice as high among small or very small babies as among average or larger babies. 8.5 WOMEN’S STATUS AND CHILD MORTALITY In Ghana, as in most societies, women are the primary child caregivers. As such, their status can have a direct impact on the health status and survival of their children. Empowered women are in a better position to make informed decisions about their own and their children’s health. The 2003 GDHS included three proxy measures of women’s status: their participation in household decisionmaking, their attitude towards a woman’s ability to refuse sex with her husband, and their attitude towards wife-beating. Table 8.5 shows childhood mortality rates tabulated by the three measures of women’s status. Mortality rates are consistently higher for children whose mothers have no say in any household decision- making. For example, under-five mortality is 133 deaths per 1,000 births among women who have no say in any household decisions compared with 104 deaths per 1,000 births among women who have a say in all five household decisions. Infant mortality and its two component rates are higher among women who believe that a wife cannot refuse sex with her husband for any reason, but this relationship is not clear for Table 8.5 Early childhood mortality rates by women's status Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by women's status indicators, Ghana 2003 Women's status indicator Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which woman has final say2 0 46 31 77 61 133 1-2 31 24 56 43 96 3-4 44 22 66 56 118 5 42 21 63 43 104 Number of reasons to refuse sex with husband 0 54 28 82 42 121 1-2 40 20 59 69 124 3-4 40 24 64 45 106 Number of reasons wife- beating is justified 0 41 20 61 39 98 1-2 46 27 73 42 112 3-4 41 28 69 61 126 5 32 23 55 76 126 1 Computed as the difference between the infant and neonatal mortality rates 2 Alone or jointly with others Infant and Child Mortality | 133 child and under-five mortality. Postneonatal, child, and under-five mortality rates are also clearly lower among women who believe that wife-beating is not justified for any reason at all, but this relationship is not clear for neonatal and infant mortality. 8.6 PERINATAL MORTALITY Women in the 2003 GDHS were asked to report on any pregnancy loss that occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of pregnancy was recorded. In this report, perinatal deaths include pregnancy losses of at least seven months’ gestation (stillbirths) and deaths to live births within the first seven days of life (early neonatal deaths). The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. Information on stillbirths and deaths to infants within the first week of life are highly susceptible to omission and misreporting. Nevertheless, retrospective surveys in developing countries provide more representative and accurate perinatal death rates than the vital registration system. The perinatal mortality rate serves as a good indicator of the state of health in general and at delivery in particular. It reflects the level of utilisation of health services and the ability to cope with demands of childbirth and thereby delivery of a healthy baby. Data in Table 8.6 show that out of the 3,679 reported pregnancies of at least seven months’ gestation, 40 were stillbirths and 129 were early neonatal deaths, yielding an overall perinatal mortality rate of 46 per 1,000 pregnancies. Perinatal mortality is highest among mothers age 30-39 (58 per 1,000 pregnancies) and lowest among mothers age 20-29 (37 per 1,000 pregnancies). Perinatal mortality is also relatively higher among teenage mothers (52 per 1,000 pregnancies). The higher perinatal mortality among both young and older women may be a reflection of accessing antenatal services later rather than early in their pregnancy, women’s inability to use antenatal services effectively either because they lack the social and financial means to enable them to use the existing facilities, or in the case of very young women, because they are less biologically ready for safe childbearing. Perinatal mortality is highest when the previous pregnancy interval is less than 15 months (90 per 1,000 pregnancies). Perinatal mortality is also higher among women residing in rural than urban areas (51 and 37 per 1,000 pregnancies, respectively). A wide regional variation in perinatal mortality is also evident with women in the Western, Ashanti, Volta, and Central regions experiencing levels higher than the national average. Surprisingly, women in the Upper East and Northern regions reported the lowest rates (26 and 29 per 1,000 pregnancies, respectively). Contrary to expectations, there is no clear relationship between perinatal mortality and women’s education or the wealth index. 8.7 HIGH-RISK FERTILITY BEHAVIOUR Children’s survival chances are associated with certain characteristics of fertility behaviour. These characteristics are of particular importance in this section because they are easily avoidable at a relatively low cost. Infants and children have an elevated risk of dying if their mothers are too young (under 18 years of age) or too old (over 35 years old), if they are born after too short a birth interval (less than 24 months), and if they are of high birth order (has three or more children). Although first births are commonly associated with higher mortality risk, they are not included in the high-risk category because the risks associated with first births are unavoidable. Table 8.7 shows the percent distribution of children born in the five years preceding the survey and the percent distribution of currently married women, by risk factors. The table also shows the risk ratio of dying for children, by comparing the proportion of dead children in each risk category with the proportion of dead children not in any high-risk category. 134 | Infant and Child Mortality Table 8.6 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Ghana 2003 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 8 13 52 420 20-29 12 54 37 1,826 30-39 18 51 58 1,190 40-49 2 10 49 244 Previous pregnancy interval in months First pregnancy 13 23 47 762 <15 1 13 90 162 15-26 8 22 52 573 27-38 5 21 29 896 39+ 14 49 49 1,287 Residence Urban 11 34 37 1,215 Rural 30 95 51 2,465 Region Western 11 14 66 378 Central 6 11 55 310 Greater Accra 5 9 37 395 Volta 1 16 58 300 Eastern 0 11 30 362 Ashanti 9 33 61 694 Brong Ahafo 3 14 43 404 Northern 3 12 29 502 Upper East 0 6 26 215 Upper West 1 4 40 119 Mother's education No education 8 45 36 1,474 Primary 9 40 58 853 Middle/JSS 18 39 49 1,157 Secondary+ 5 5 51 196 Wealth quintile Lowest 8 26 36 949 Second 5 30 44 815 Middle 15 33 64 735 Fourth 5 16 34 622 Highest 7 24 56 558 Total 40 129 46 3,679 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months 2 Early neonatal deaths are deaths at age 0-6 days among live-born children 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months' duration Infant and Child Mortality | 135 The first column in Table 8.7 shows the percentage of births occurring in the five years before the survey that fall into the various risk categories. Slightly more than half (53 percent) of births in Ghana have elevated mortality risks, which are avoidable, and almost three in ten (28 percent) were not in any high-risk category. Among those who are at risk, 31 percent of births are in a single high-risk category, Table 8.7 High-risk fertility behaviour Percent distribution of children born in the five 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, Ghana 2003 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high-risk category 28.4 1.00 20.6a Unavoidable risk category First order births between ages 18 and 34 years 18.7 1.25 5.8 Single high-risk category Mother’s age <18 3.8 1.36 0.6 Mother’s age >34 1.8 1.95 5.3 Birth interval <24 months 4.4 2.05 9.0 Birth order >3 20.7 1.35 13.4 Subtotal 30.8 1.49 28.3 Multiple high-risk category Age <18 & birth interval <24 months2 0.1 0.00 0.3 Age >34 & birth interval <24 months 0.2 0.00 0.1 Age >34 & birth order >3 16.0 1.33 30.6 Age >34 & birth interval <24 months & birth order >3 1.8 3.67 6.0 Birth interval <24 months & birth order >3 4.1 2.07 8.3 Subtotal 22.1 1.64 45.3 In any avoidable high-risk category 52.9 1.55 73.6 Total 100.0 na 100.0 Number of births 3,639 na 3,549 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. 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 136 | Infant and Child Mortality while 22 percent of births are in a multiple high-risk category. In general, risk ratios are higher for children in a multiple high-risk category than for those in a single high-risk category. The most vulnerable births are those to women who are age 35 or older, with a birth interval less than 24 months and birth order three or higher. These children are nearly four times more likely to die than children not in any high-risk category. Fortunately, less than 2 percent of births fall into this category. Twenty-one percent of births occur to mothers who have three or more births, and another 16 percent of births occur to mothers who are 35 years or older and have had three or more children. These children are about one and a half times as likely to die as children without any risk. The last column of Table 8.7 shows the distribution of currently married women who have the potential for having a high-risk birth by category. This column is purely hypothetical and does not take into consideration the protection provided by family planning, postpartum insusceptibility, and prolonged abstinence. However, it provides an insight into the magnitude of high-risk fertility behaviour. Three in four women are potentially at risk of giving birth to a child with an elevated risk of mortality. Nearly one in three of these women is or would be too old, and have or would have too many children. A substantially higher proportion of women have the potential of having a birth in a multiple high-risk category than in a single high-risk category. Maternal and Child Health | 137 MATERNAL AND CHILD HEALTH 9 This chapter presents findings from the 2003 GDHS in three areas of importance to maternal and child health, including information on antenatal, delivery, and postnatal care, children’s vaccinations, and common childhood illnesses and their treatment. Combined with information on childhood mortality, this information can be used to identify subgroups of women and children who face increased risk because of non-use of maternal and child health (MCH) services, and to provide information to assist in the planning of appropriate improvements in services. Data were obtained for all live births that occurred in the five years preceding the survey. Wherever possible, data from the 2003 GDHS are compared with data from the three earlier DHS surveys in Ghana, conducted in 1988, 1993, and 1998. However, analysis of trends in maternity care indicators is complicated by the fact that previous GDHS surveys asked questions on antenatal care and tetanus injections for all births, whereas the 2003 survey confined these questions to only the most recent birth. In addition, the questions on maternity care and children’s health referred to varying periods (sometimes five and sometimes three years) preceding the survey. While it is possible to adjust for some of these inconsistencies, it is not possible to correct them all. Caution has to be exercised in interpreting trend data. 9.1 MATERNITY CARE Early and regular checkups by health professionals are very important in assessing the physical status of women during pregnancy and ensuring appropriate interventions during delivery. The 2003 GDHS obtained information from women on both the coverage of antenatal care and of key elements of the care received for the last birth during the five-year period before the survey. 9.1.1 Antenatal Care Antenatal Care Coverage Table 9.1 shows the percent distribution of women who had a live birth in the five years preced- ing the survey by the source of antenatal care for the most recent birth. In obtaining the information on source, interviewers recorded all persons a woman had seen for antenatal care. However, for cases where more than one person was seen, only the provider with the highest qualifications was considered in the analysis. Table 9.1 indicates that a relatively high percentage of women received antenatal care from a trained health professional, that is, a doctor, nurse, midwife or auxiliary midwife (21 percent from a doc- tor and 71 percent from a nurse/midwife). One percent of mothers received antenatal care from a tradi- tional birth attendant (TBA) and 6 percent received no antenatal care. Older women are less likely to receive antenatal care from a trained health professional than younger women. Women are also less likely to obtain care from a trained health professional for births of order six and higher. Ninety-eight percent of urban residents and 89 percent of rural residents got antena- tal care from a trained heath professional. Urban residents are also more likely to receive antenatal care from doctors (34 percent) than rural residents (14 percent). Regional variations in antenatal care from a health professional is marked. Care from a doctor, for example, ranges from a high of 45 percent in Greater Accra to a low of 3 percent in the Upper East. In fact, less than 10 percent of women living in the three northern regions received antenatal care from a doctor, and one in six mothers in the Northern Re- gion and one in seven mothers in the Upper East did not receive any antenatal care. Nevertheless, care from a nurse/midwife is encouragingly high in these regions 138 | Maternal and Child Health Table 9.1 Antenatal care Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth, according to background characteristics, Ghana 2003 Background characteristic Doctor Nurse/ midwife/ auxiliary midwife Traditional birth atten- dant/ other No one Missing Total Number of women Age at birth <20 17.8 76.0 1.6 4.4 0.1 100.0 297 20-34 21.6 71.1 0.9 5.9 0.4 100.0 1,762 35-49 20.4 68.2 1.6 8.4 1.4 100.0 586 Birth order 1 21.8 73.8 0.8 3.5 0.1 100.0 565 2-3 23.9 69.2 1.1 5.0 0.8 100.0 940 4-5 21.3 69.8 1.0 6.7 1.3 100.0 582 6+ 14.5 72.6 1.8 11.0 0.1 100.0 558 Residence Urban 33.7 64.2 0.4 1.2 0.6 100.0 946 Rural 13.7 74.9 1.6 9.2 0.6 100.0 1,699 Region Western 21.6 73.3 1.5 3.6 0.0 100.0 246 Central 19.8 74.8 0.8 4.6 0.0 100.0 211 Greater Accra 45.1 51.2 0.6 2.8 0.3 100.0 303 Volta 22.5 67.0 0.6 9.6 0.3 100.0 220 Eastern 20.2 71.5 3.2 4.0 1.0 100.0 266 Ashanti 28.3 65.9 1.2 3.5 1.2 100.0 507 Brong Ahafo 12.7 83.0 1.7 1.7 0.9 100.0 297 Northern 8.4 74.3 0.7 16.3 0.2 100.0 346 Upper East 2.6 82.8 0.0 13.5 1.2 100.0 166 Upper West 3.7 87.2 0.0 8.5 0.6 100.0 83 Education No education 11.4 74.7 0.7 12.5 0.7 100.0 1,025 Primary 17.4 75.2 1.8 5.0 0.6 100.0 589 Middle/JSS 28.6 68.3 1.4 1.1 0.6 100.0 879 Secondary+ 53.5 46.5 0.0 0.0 0.0 100.0 153 Wealth quintile Lowest 8.8 74.5 1.4 14.3 0.9 100.0 648 Second 10.8 80.5 1.3 6.9 0.4 100.0 557 Middle 19.0 75.7 0.6 4.4 0.3 100.0 534 Fourth 24.1 71.2 2.2 2.1 0.3 100.0 474 Highest 50.6 47.6 0.0 0.6 1.2 100.0 433 Total 20.9 71.0 1.2 6.3 0.6 100.0 2,645 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Women’s education is strongly associated with receipt of antenatal care from a health profes- sional. As a woman’s education increases, the likelihood that she will receive antenatal care from a health professional increases from 86 percent among women with no education to 100 percent among women Maternal and Child Health | 139 with at least some secondary. More than half (54 percent) of women with secondary and higher education saw a doctor for antenatal care compared with 11 percent of women with no education. A comparison of the 2003 GDHS data with data from the three earlier GDHS surveys show that there has been an 11 percent improvement in the utilization of antenatal services in the past 15 years (Fig- ure 9.1) from 82 percent of mothers receiving care for their most recent birth in the five-year period pre- ceding the survey in 1988, to 92 percent in 2003. Figure 9.1 Trends in Maternity Care Indicators Ghana 1988-2003 82 70 40 86 77 44 89 81 44 92 84 47 Antenatal care from health professional One or more tetanus toxoid injections Medically assisted delivery 0 20 40 60 80 100 Pe rc en ta ge o f b irt hs 1988 1993 1998 2003 GDHS 1988-2003 Note: Data for 1988, 1993, and 1998 are with reference to births, whereas data for antenatal care and tetanus toxoid for 2003 are with reference to women who had a live birth. The reference period is five years preceding the survey except for 1993, which refers to the three years preceding the survey. Women who had a live birth in the five years preceding the survey were also asked about the source of antenatal care for their most recent birth. The majority of women (88 percent) seek antenatal care from a public source (data not shown). Government hospitals and clinics are by far the most common source providing antenatal care to 62 percent of women, followed by health centres, 25 percent. Twelve percent of women received antenatal care from a private facility, with most of them receiving care from private hospitals or clinics (9 percent). Number and Timing of Antenatal Care Visits Antenatal care can be more effective in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and continued through to delivery. Obstetricians generally recommend that expec- tant mothers should begin antenatal attendance as early as possible in the first trimester. Monthly antena- tal visits are recommended up to the seventh month of pregnancy, after which visits every two weeks are recommended up to the eighth month, when the visits should be weekly until delivery. If the first antena- tal visit is made at the third month of pregnancy, this optimum schedule translates to a total of at least 12- 13 visits during the duration of the pregnancy. The World Health Organisation (WHO) recommends a minimum of four visits per pregnancy. Early detection of problems in pregnancy leads to more timely referrals in case of complications and this is of particular importance in some remote regions of Ghana, where basic health services are few and present a challenge to the health care delivery system. Women who do not receive antenatal care during pregnancy are at a higher risk of obstetric emergencies and ad- 140 | Maternal and Child Health verse outcomes. In an effort to bridge the gap and provide health care as close to the family as possible, the Dis- trict Health Management Teams have trained traditional birth attendants to recognise the danger signs during pregnancy and refer women early to health centres. This may explain the high percentage receiving antenatal care through facility-based health pro- fessionals. Table 9.2 provides the per- centage distribution of women who had a live birth in the five years pre- ceding the survey by the number of antenatal care (ANC) visits for the most recent birth, and by the timing of the first visit, according to residence. Most women (69 percent) have made at least four ANC visits for their most recent birth in the five years preceding the survey (Figure 9.2). Eighty-four percent of urban Ghana- ians and 61 percent of rural Ghanaians report visiting antenatal clinics at least four times during their pregnancy. The median number of months pregnant at first visit among women who received antenatal care is 3.8 among urban residents and 4.2 among rural residents. More than half the women in urban areas and about two-fifths of women in rural areas make their first antenatal visit before their fourth month of pregnancy, while 34 percent of urban women and 35 percent of rural women make their first visit between the fourth and fifth month of pregnancy. Figure 9.2 Number of Antenatal Care Visits No visits 6% 1 visit 4% 2-3 visits 17% 4+ visits 69% Don't know missing 4% GDHS 2003 Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent birth, and by the timing of the first visit according to resi- dence, Ghana 2003 Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 1.2 9.2 6.3 1 0.9 5.7 4.0 2-3 8.3 21.3 16.7 4+ 84.3 61.0 69.4 Don't know/missing 5.3 2.8 3.7 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.2 9.2 6.3 <4 56.0 41.0 46.4 4-5 34.4 34.9 34.7 6-7 7.7 12.4 10.7 8+ 0.2 1.7 1.2 Don't know/missing 0.5 0.8 0.7 Total 100.0 100.0 100.0 Median months pregnant at first visit (for those with ANC) 3.8 4.2 4.0 Number of women 946 1,699 2,645 Maternal and Child Health | 141 Components of Antenatal Care Complications during pregnancy are an important cause of maternal and child morbidity and mor- tality. Detecting and monitoring these complications is a crucial component of safe motherhood. In order to gauge the quality of care received during pregnancy, the 2003 GDHS questioned women on whether ANC services included information about signs of pregnancy complications, blood pressure measure- ment, the testing of urine and blood samples, and the provision of iron supplements and anti-malarial pro- phylaxis tablets. Some caution should be exercised in considering the information on the content of antenatal care. The information is dependent on a woman’s understanding of the questions, for example, her understand- ing of what blood pressure measurement involves. It is also dependent on her recall of events during ante- natal visits that may have taken place a number of years before the interview. Nonetheless, the results are useful in providing insights into the content of antenatal care for Ghanaian women. Table 9.3 shows the percentage of women with a live birth in the five years preceding the survey who received antenatal care for the most recent birth, by content of antenatal care, and percentage of women with a live birth in the five years preceding the survey who received iron tablets or anti-malarial drugs for the most recent birth by background characteristics. As discussed earlier, antenatal care from a health professional is high in Ghana, and this may be reflected in the quality of care that expectant moth- ers receive. Three in five women (61 percent) are informed about the signs of complications during preg- nancy. In addition, more than four in five women have their weight, blood pressure, and heights measured and have urine and blood samples taken. Although encouraging, programme managers need to ensure that all women coming for ANC services receive the full benefit of the services. Four in five women (whether or not they received ANC) are given iron tablets and three in five (58 percent) receive antimalarial drugs. In general, the quality of antenatal care varies little by background characteristics, with the sharp- est variation seen by education level and wealth status. Women with secondary education or higher (75 percent) are more likely than women with less education to be informed about signs of complications as are women in the highest wealth quintile (74 percent). Women with no education are also less likely to have a blood or urine sample taken or receive iron tablets than women with at least some education. For example, only 71 percent of women with no education received iron tablets compared with 85 percent of women with middle school education or higher. Tetanus Toxoid Immunisation An important component of antenatal care in Ghana is ensuring that pregnant women and chil- dren are adequately protected against tetanus. Tetanus toxoid injections are given during pregnancy for prevention of neonatal tetanus, an important cause of death among infants. Five doses given at specified periods provide lifetime protection. However, for full antenatal protection, a pregnant woman should re- ceive two doses of tetanus toxoid. If a woman has been vaccinated during a previous pregnancy, then she may only require one dose during the current pregnancy. Table 9.4 shows the percent distribution of women who had a live birth in the five years preced- ing the survey by number of tetanus toxoid injections received during the most recent pregnancy, accord- ing to background characteristics. The data show that half of women received at least two doses of tetanus toxoid, a third of women received only one tetanus toxoid injection, and 14 percent received none. There is little variation in tetanus toxoid coverage by age at birth and birth order. Urban women are three times as likely as rural women to have received tetanus toxoid injections. 142 | Maternal and Child Health Table 9.3 Components of antenatal care Percentage of women with a live birth in the five years preceding the survey who received antenatal care for the most recent birth, by content of ante- natal care, and percentage of women with a live birth in the five years preceding the survey who received iron tablets or anti-malarial drugs for the most recent birth, according to background characteristics, Ghana 2003 Women who received antenatal care Background characteristic Informed of signs of pregnancy complica- tions Weight measured Height measured Blood pressure measured Urine sample taken Blood sample taken Number of women Received iron tablets Received anti-malarial drugs Number of women Age at birth <20 55.3 93.4 85.1 94.7 81.8 84.6 283 79.9 57.1 297 20-34 62.6 94.2 84.8 95.9 86.0 86.8 1,650 79.7 58.5 1,762 35-49 60.3 95.9 88.3 96.3 83.4 88.2 529 76.6 57.6 586 Birth order 1 60.8 93.8 84.5 96.3 87.1 88.9 544 82.0 61.0 565 2-3 62.1 94.9 85.9 95.6 87.1 86.9 886 80.2 57.7 940 4-5 61.3 94.2 86.0 95.8 83.8 85.5 535 77.7 58.7 582 6+ 60.2 94.7 85.6 95.7 80.2 85.8 496 75.6 55.4 558 Residence Urban 69.3 97.1 88.4 98.2 95.6 95.5 929 85.1 66.7 946 Rural 56.4 92.9 83.8 94.4 78.5 81.5 1,532 75.7 53.4 1,699 Region Western 59.9 89.1 83.6 92.1 88.6 90.9 237 77.1 54.7 246 Central 71.4 91.5 81.2 95.2 86.6 84.4 202 82.6 67.9 211 Greater Accra 61.7 97.2 84.4 97.4 96.3 95.1 293 82.2 65.4 303 Volta 41.0 96.9 83.1 99.0 89.8 89.9 199 84.4 66.3 220 Eastern 60.5 86.7 81.2 90.7 87.2 88.0 253 76.2 46.9 266 Ashanti 74.6 96.9 90.3 97.3 94.4 93.4 483 83.5 64.3 507 Brong Ahafo 68.6 97.0 92.1 97.0 97.1 96.8 289 91.4 72.0 297 Northern 47.3 95.3 81.7 95.5 54.8 66.4 289 65.2 39.7 346 Upper East 59.0 97.1 88.0 97.7 63.9 71.8 141 72.6 58.7 166 Upper West 37.6 95.0 84.5 95.5 53.3 61.9 76 59.0 20.5 83 Education No education 54.8 94.2 84.4 95.6 72.3 78.1 890 70.6 47.9 1,025 Primary 59.8 92.1 83.6 94.2 87.7 87.3 556 82.0 59.1 589 Middle/JSS 66.4 95.7 87.4 96.3 93.8 93.5 863 86.0 68.1 879 Secondary+ 75.0 97.7 89.3 100.0 98.8 97.9 153 84.6 65.9 153 Wealth quintile Lowest 51.5 92.8 82.0 93.4 64.7 71.9 550 68.1 45.1 648 Second 55.0 93.2 82.8 95.3 83.1 84.6 516 79.4 58.7 557 Middle 61.1 93.7 85.7 94.3 88.5 89.5 509 82.3 57.1 534 Fourth 68.5 96.0 89.3 97.9 95.4 94.4 463 83.9 67.5 474 Highest 73.9 97.4 89.3 99.1 97.8 97.2 425 85.7 68.1 433 Total 61.3 94.5 85.6 95.8 85.0 86.8 2,462 79.1 58.1 2,645 Maternal and Child Health | 143 Table 9.4 Tetanus toxoid injections Percent distribution of women who had a live birth in the five years preceding the survey by num- ber of tetanus toxoid injections received during pregnancy for the most recent birth, according to background characteristics, Ghana 2003 Background characteristic No injections One injection Two or more injections Don't know/ missing Total Number of women Age at birth <20 15.4 33.4 48.6 2.6 100.0 297 20-34 14.1 33.4 50.5 2.0 100.0 1,762 35-49 14.4 31.9 50.9 2.9 100.0 586 Birth order 1 11.6 31.1 54.4 2.9 100.0 565 2-3 14.4 32.1 51.1 2.4 100.0 940 4-5 14.6 34.4 48.5 2.5 100.0 582 6+ 16.5 35.3 47.0 1.1 100.0 558 Residence Urban 5.6 33.8 56.8 3.7 100.0 946 Rural 19.1 32.6 46.8 1.4 100.0 1,699 Region Western 10.6 36.8 51.6 1.0 100.0 246 Central 11.9 28.3 59.3 0.5 100.0 211 Greater Accra 9.5 33.3 51.8 5.4 100.0 303 Volta 16.9 32.3 49.3 1.5 100.0 220 Eastern 16.7 35.2 43.0 5.1 100.0 266 Ashanti 11.2 38.7 49.0 1.0 100.0 507 Brong Ahafo 8.0 33.1 57.1 1.9 100.0 297 Northern 25.9 24.3 47.7 2.1 100.0 346 Upper East 18.7 34.3 45.6 1.5 100.0 166 Upper West 18.7 27.7 50.0 3.6 100.0 83 Education No education 21.5 33.5 43.0 2.0 100.0 1,025 Primary 14.7 31.0 51.9 2.4 100.0 589 Middle/JSS 7.5 34.5 55.8 2.3 100.0 879 Secondary+ 3.8 29.8 63.0 3.4 100.0 153 Wealth quintile Lowest 22.6 33.5 42.0 1.8 100.0 648 Second 18.2 33.0 47.4 1.4 100.0 557 Middle 14.0 32.7 52.7 0.6 100.0 534 Fourth 7.5 35.2 54.6 2.7 100.0 474 Highest 4.5 30.7 59.2 5.6 100.0 433 Total 14.3 33.1 50.4 2.3 100.0 2,645 Coverage among mothers residing in the Northern, Upper West, and Upper East regions is lower than coverage in the other regions. Education is positively related to tetanus toxoid coverage — women with at least secondary education are six times more likely to have received tetanus toxoid injections as women with no education. GDHS data show that there has been an improvement in tetanus toxoid coverage, for the most re- cent birth in the five years preceding the survey, from 70 percent in 1988 to 84 percent in 2003 (Figure 9.1). 144 | Maternal and Child Health 9.1.2 Delivery Care Place of Delivery Traditionally, children in Ghana are delivered at home with the assistance of birth attendants or elderly women of the community. An important component of efforts to reduce the health risks of moth- ers and children is to increase the proportion of babies delivered under medical supervision. Proper medi- cal attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause the death or serious illness of the mother and or the baby. Women interviewed in the 2003 GDHS were asked to report the place of birth of all children born in the five years before the survey. Table 9.5 shows the percent distribution of live births in the five years preceding the survey by place of delivery according to background characteristics. Nationally, 46 percent of births are delivered in health facilities, with 36 percent in public health facilities and 9 percent in private health facilities. More than half of births (53 percent) occur at home. Mother’s age at birth does not affect the place of delivery. First births and births of order two and three are more likely than higher order births to be delivered in a health facility. A child born in an urban area is two and a half times more likely to have been delivered at a health facility than a rural-born child. Four in five births in Greater Accra are delivered in a health facil- ity compared with one in six births in the Northern region. As expected, a woman’s education and wealth are strong determinants of institutional deliveries. For example, 89 percent of births to women with at least secondary education occurred in a health facility compared with 28 percent of births to women with no education. Eighty-nine percent of women in the highest wealth quintile had an institutional delivery compared with 19 percent of women in the lowest wealth quintile. Antenatal care attendance has an impact on the proportion of births delivered in a health facility. Only 10 percent of births to women who did not receive antenatal care were delivered at a health facility compared with 59 percent of those to women with four or more antenatal visits. Assistance at Delivery The level of assistance a woman receives during the birth of her child also has important health consequences for both mother and child. Births delivered at home are more likely to be delivered without professional assistance, whereas births delivered at a health facility are more likely to be delivered by trained medical personnel. Table 9.6 shows the percent distribution of live births in the five years preced- ing the survey by the person who provided assistance during delivery according to background character- istics of the woman. The data show that medically trained providers assisted with 47 percent of deliveries, traditional birth attendants (TBA) assisted with 31 percent of deliveries, and relatives or friends attended 19 percent of deliveries. First births are more likely to be delivered by a medically trained provider than those of second or higher order. Urban births are more likely (80 percent) to receive assistance from a medically trained pro- vider compared with rural births (31 percent). Most births in Greater Accra (81 percent) receive assistance from medical personnel. Also, as seen with place of delivery, births to educated and wealthy women are more likely to be assisted at delivery by a medically trained professional. Medically assisted deliveries continue to be low in Ghana, with less than 50 percent benefiting from professional delivery assistance over the past 15 years (Figure 9.1). The 2003 GDHS included a question to determine if births in Ghana are registered with the gov- ernment or local authority. The majority of births in the five years before the survey were not registered (54 percent), 44 percent were registered with the government or local authority, and the status was not known for 2 percent of births (data not shown). Maternal and Child Health | 145 Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics, Ghana 2003 Health facility Background characteristic Public sector Private sector Home Other Missing Total Number of births Mother's age at birth <20 35.7 10.9 52.8 0.3 0.4 100.0 411 20-34 36.7 9.5 52.9 0.4 0.5 100.0 2,507 35-49 35.1 8.0 55.4 0.3 1.2 100.0 720 Birth order 1 45.7 12.6 41.2 0.3 0.2 100.0 820 2-3 35.7 11.1 51.8 0.4 0.9 100.0 1,271 4-5 33.2 7.5 58.2 0.1 1.1 100.0 822 6+ 30.1 4.8 64.4 0.6 0.1 100.0 726 Residence Urban 61.0 17.6 20.4 0.4 0.6 100.0 1,204 Rural 24.0 5.3 69.7 0.3 0.6 100.0 2,435 Region Western 24.0 11.4 63.9 0.7 0.0 100.0 367 Central 27.7 10.1 61.6 0.5 0.0 100.0 304 Greater Accra 58.5 21.1 19.6 0.2 0.5 100.0 390 Volta 40.8 4.1 54.6 0.3 0.2 100.0 298 Eastern 36.3 7.9 54.1 0.7 1.0 100.0 362 Ashanti 46.3 13.7 38.8 0.3 0.9 100.0 685 Brong Ahafo 47.0 9.0 42.6 0.2 1.1 100.0 401 Northern 14.7 1.7 83.1 0.1 0.5 100.0 500 Upper East 23.2 2.5 73.3 0.0 1.0 100.0 215 Upper West 32.0 1.6 65.0 0.5 0.8 100.0 118 Mother's educa- tion No education 22.9 4.9 71.0 0.5 0.7 100.0 1,466 Primary 35.4 7.5 56.4 0.2 0.5 100.0 843 Middle/JSS 50.1 13.3 35.5 0.3 0.8 100.0 1,139 Secondary+ 60.2 28.8 11.0 0.0 0.0 100.0 191 Antenatal care visits1 None 8.1 2.3 89.0 0.5 0.0 100.0 167 1-3 16.4 4.3 78.9 0.4 0.0 100.0 546 4+ 46.5 12.7 40.5 0.3 0.0 100.0 1,834 Wealth quintile Lowest 17.0 2.4 79.6 0.3 0.7 100.0 941 Second 24.1 6.0 69.0 0.6 0.4 100.0 809 Middle 32.8 7.9 58.5 0.2 0.7 100.0 721 Fourth 57.3 15.5 26.4 0.6 0.2 100.0 617 Highest 68.0 21.4 9.2 0.0 1.4 100.0 551 Total 36.3 9.4 53.4 0.4 0.6 100.0 3,639 1 Includes only the most recent birth in the five years preceding the survey 146 | Maternal and Child Health Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, according to background characteristics, Ghana 2003 Background characteristic Doctor Nurse/ midwife/ auxiliary midwife Traditional birth attendant Relative/ other No one Don't know/ missing Total Number of births Mother's age at birth <20 6.1 42.3 30.1 20.4 0.8 0.4 100.0 411 20-34 6.5 41.2 30.7 18.7 2.4 0.6 100.0 2,507 35-49 7.1 36.9 32.5 20.1 2.1 1.3 100.0 720 Birth order 1 8.7 51.2 24.3 15.1 0.4 0.3 100.0 820 2-3 7.3 40.9 30.5 18.4 1.9 0.9 100.0 1,271 4-5 4.8 36.8 33.1 20.7 3.3 1.2 100.0 822 6+ 5.0 31.8 36.8 23.2 3.2 0.1 100.0 726 Residence Urban 14.6 65.1 12.1 6.2 1.5 0.6 100.0 1,204 Rural 2.6 28.3 40.3 25.5 2.5 0.7 100.0 2,435 Region Western 3.5 35.1 47.0 12.6 1.8 0.0 100.0 367 Central 3.5 34.9 55.7 3.5 2.4 0.0 100.0 304 Greater Accra 24.0 57.4 10.6 6.3 1.1 0.5 100.0 390 Volta 7.4 37.6 19.0 33.1 2.6 0.2 100.0 298 Eastern 2.6 43.9 42.0 9.5 0.6 1.3 100.0 362 Ashanti 8.4 51.5 25.8 11.8 1.6 0.9 100.0 685 Brong Ahafo 4.3 54.1 19.2 18.9 2.5 1.1 100.0 401 Northern 2.3 16.0 43.3 33.8 4.1 0.5 100.0 500 Upper East 0.5 27.3 15.9 54.6 0.4 1.2 100.0 215 Upper West 3.4 29.9 25.7 32.9 6.9 1.1 100.0 118 Mother's education No education 3.5 26.2 35.6 30.8 3.0 0.8 100.0 1,466 Primary 6.8 37.6 38.5 15.1 1.5 0.5 100.0 843 Middle/JSS 7.9 56.4 23.1 9.9 1.9 0.8 100.0 1,139 Secondary+ 21.3 68.1 8.5 2.1 0.0 0.0 100.0 191 Wealth quintile Lowest 1.6 19.0 37.8 37.5 3.3 0.8 100.0 941 Second 3.0 28.9 44.3 21.1 2.4 0.4 100.0 809 Middle 3.4 39.9 37.2 16.7 2.0 0.8 100.0 721 Fourth 10.5 62.6 19.2 5.9 1.7 0.2 100.0 617 Highest 20.2 70.2 4.7 2.9 0.6 1.4 100.0 551 Total 6.6 40.5 31.0 19.1 2.2 0.7 100.0 3,639 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Maternal and Child Health | 147 Delivery Characteristics The 2003 GDHS enquired about some characteristics related to delivery. Table 9.7 shows the percentage of live births in the five years preceding the survey delivered by caesarean section and the per- cent distribution of the babies by birth weight and by mother’s estimate of baby’s size at birth, according to background characteristics. Only 4 percent of live births are delivered by caesarean section. This has not changed since 1998 (GSS and MI, 1999). Caesarean sections (C-sections) are highest among births to mothers in the oldest age cohort, first order births, urban births, births in Greater Accra, births to mothers who have at least secondary education, and births to mothers in the highest wealth quintile. Table 9.7 Delivery characteristics Percentage of live births in the five years preceding the survey delivered by caesarean section, and percent distribution by birth weight and by mother's estimate of baby's size at birth, according to background characteristics, Ghana 2003 Birth weight Size of child at birth Background characteristic Delivery by C- section Not weighed Less than 2.5 kg 2.5 kg or more Don't know/ missing Total Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 3.2 58.8 2.4 22.6 16.3 100.0 9.3 13.6 76.7 0.4 100.0 411 20-34 3.3 56.7 2.0 27.3 14.0 100.0 6.3 11.5 80.9 1.4 100.0 2,507 35-49 5.2 56.7 1.9 25.0 16.3 100.0 6.2 10.4 81.8 1.5 100.0 720 Birth order 1 5.2 49.2 3.2 31.5 16.1 100.0 8.4 13.6 77.4 0.6 100.0 820 2-3 4.7 55.9 1.8 28.0 14.3 100.0 5.5 10.6 82.3 1.6 100.0 1,271 4-5 2.0 59.0 1.7 25.2 14.1 100.0 5.9 11.5 80.7 1.9 100.0 822 6+ 2.2 65.2 1.6 18.7 14.4 100.0 7.5 10.8 81.0 0.8 100.0 726 Residence Urban 7.6 28.8 3.1 48.3 19.8 100.0 6.2 8.3 84.6 1.0 100.0 1,204 Rural 1.8 70.9 1.5 15.4 12.2 100.0 6.9 13.1 78.6 1.4 100.0 2,435 Region Western 2.2 70.5 1.2 16.4 12.0 100.0 9.3 9.3 81.2 0.3 100.0 367 Central 1.0 78.2 0.4 11.5 9.8 100.0 3.4 13.8 79.1 3.8 100.0 304 Greater Accra 12.0 20.7 3.2 51.9 24.2 100.0 5.0 6.4 87.1 1.5 100.0 390 Volta 3.7 65.0 2.2 17.1 15.7 100.0 2.4 6.6 89.9 1.0 100.0 298 Eastern 3.9 46.7 2.8 36.4 14.1 100.0 6.6 14.0 78.1 1.4 100.0 362 Ashanti 4.4 42.6 4.1 38.1 15.2 100.0 6.2 14.9 77.7 1.2 100.0 685 Brong Ahafo 2.6 48.0 1.7 32.1 18.1 100.0 9.5 10.5 78.4 1.6 100.0 401 Northern 1.6 78.4 0.4 8.8 12.4 100.0 6.8 11.1 81.7 0.5 100.0 500 Upper East 0.5 80.4 0.0 14.0 5.5 100.0 13.2 13.9 71.9 1.0 100.0 215 Upper West 1.8 71.3 2.2 11.3 15.3 100.0 3.1 16.2 80.1 0.5 100.0 118 Mother's education No education 1.7 72.3 1.3 13.4 13.0 100.0 7.2 12.5 79.3 1.0 100.0 1,466 Primary 2.9 57.1 1.5 24.9 16.6 100.0 6.6 12.4 79.7 1.3 100.0 843 Middle/JSS 4.9 43.2 2.6 37.7 16.5 100.0 6.1 10.0 82.3 1.6 100.0 1,139 Secondary+ 15.9 20.5 6.4 64.5 8.7 100.0 6.0 9.2 83.8 0.9 100.0 191 Wealth quintile Lowest 1.5 79.8 1.3 7.9 11.1 100.0 6.8 13.9 78.3 1.0 100.0 941 Second 1.7 70.5 1.8 17.6 10.1 100.0 5.0 13.3 80.8 0.9 100.0 809 Middle 1.9 61.9 1.0 22.8 14.4 100.0 10.2 11.0 77.4 1.4 100.0 721 Fourth 4.1 36.6 2.4 39.7 21.3 100.0 6.8 10.3 81.6 1.2 100.0 617 Highest 12.2 14.6 4.6 60.1 20.6 100.0 4.0 6.7 87.1 2.2 100.0 551 Total 3.7 57.0 2.0 26.3 14.7 100.0 6.6 11.5 80.6 1.3 100.0 3,639 148 | Maternal and Child Health Babies weighing less than 2.5 kilogrammes at birth are regarded as small or of low birth weight. Information on birth weight is known for only 28 percent of babies born in the five years preceding the survey. In the 2003 GDHS, 2 percent of all births weighed less than 2.5 kilogrammes at birth. Since many respondents did not deliver in health facilities and would not have had their babies weighed at birth, women were also asked for their own subjective assessment of whether their babies were average or larger than average, smaller than average, or very small at birth. Although information of this type is subject to considerable error for individual births, in general, the proportion of births reported as very small or smaller than average has a high correlation to the prevalence of low birth weight. About one in five babies was assessed by their mothers as being very small or smaller than average. Births to mothers age less than 20 at birth, first order births, rural births, births in the Upper East Region, births to mothers with little or no education, and births to mothers in the lowest and middle wealth quintiles, are more likely to be reported as very small or smaller than average. 9.1.3 Postnatal Care Another crucial component of safe motherhood is postnatal care. Postnatal check-ups provide an opportunity to assess and treat delivery complications and to counsel new mothers on how to care for themselves and their children. The timing of postnatal care is important. Since most maternal and neona- tal deaths occur within two days of delivery, postnatal care should be received immediately following the birth, during this critical period. In the 2003 GDHS, questions on postnatal check-ups were asked only of women who had a non-institutional delivery, as it is assumed that women who delivered within a medical facility would have received care within the crucial first two days following delivery. Table 9.8 shows the percent distribution of women who had a non-institutional live birth in the five years preceding the survey by timing of postnatal care for the most recent non-institutional birth, ac- cording to background characteristics. One in four women received postnatal care within two days of de- livery, one in ten women received postnatal care 3-6 days after delivery, and one in eight received postna- tal care 7-41 days after delivery. More than half of women who had a noninstitutional birth in the five years preceding the survey did not receive postnatal care. There is little variation by mother’s age at birth and urban-rural residence in postnatal care re- ceived; however, mothers of second and third order births, mothers with some education, and mothers in the middle and higher wealth quintiles are more likely than their counterparts to receive postnatal care. Wide regional variation also exists. Mothers residing in Greater Accra, Volta, Upper East, and Upper West regions are less likely than mothers residing in the other regions to have received postnatal care. The surprisingly low percentage in Greater Accra may be due to the small number of mothers with a noninsti- tutional delivery. Maternal and Child Health | 149 Table 9.8 Postnatal care by background characteristics Percent distribution of women who had a non-institutional live birth in the five years preceding the survey by timing of postnatal care for the most recent non-institutional birth, according to background characteristics, Ghana 2003 Timing of first postnatal check-up Background characteristic Within 2 days of delivery 3-6 days after delivery 7-41 days after delivery Don't know/ missing Did not receive post- natal checkup1 Total Number of women Age at birth <20 26.2 12.1 13.0 0.7 47.9 100.0 153 20-34 25.4 8.8 13.5 0.3 52.0 100.0 896 35-49 23.8 9.0 7.9 0.5 58.8 100.0 334 Birth order 1 23.5 12.5 14.0 0.5 49.5 100.0 226 2-3 28.9 9.8 11.8 0.4 49.0 100.0 466 4-5 22.0 8.3 12.7 0.0 56.9 100.0 329 6+ 24.0 7.0 10.8 0.8 57.4 100.0 362 Residence Urban 26.3 10.0 23.4 0.9 39.4 100.0 200 Rural 24.9 9.0 10.2 0.4 55.5 100.0 1,184 Region Western 43.5 7.2 14.8 0.0 34.5 100.0 156 Central 32.1 27.8 19.4 0.0 20.7 100.0 130 Greater Accra 17.3 6.1 7.0 2.0 67.5 100.0 57 Volta 10.1 7.4 3.3 0.0 79.2 100.0 118 Eastern 28.5 8.3 9.7 0.6 52.9 100.0 140 Ashanti 33.0 7.0 15.5 0.6 43.9 100.0 181 Brong Ahafo 23.9 4.4 18.9 0.0 52.8 100.0 129 Northern 24.1 7.6 9.5 0.6 58.2 100.0 294 Upper East 7.9 9.6 10.3 0.8 71.5 100.0 124 Upper West 9.4 6.0 8.5 0.3 75.8 100.0 54 Education No education 19.8 8.1 11.2 0.4 60.5 100.0 729 Primary 28.6 12.6 10.3 0.3 48.1 100.0 332 Middle/JSS 33.1 8.4 14.3 0.3 44.0 100.0 307 Secondary+ * * * * * 100.0 16 Wealth quintile Lowest 21.4 7.3 7.6 0.2 63.4 100.0 530 Second 23.0 10.4 15.8 0.0 50.9 100.0 381 Middle 31.4 10.8 11.1 1.6 45.1 100.0 300 Fourth 29.0 11.2 17.8 0.0 42.0 100.0 128 Highest (33.5) (4.2) (24.7) (0.0) (37.5) 100.0 44 Total 25.1 9.2 12.1 0.4 53.2 100.0 1,383 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes women who received the first postnatal checkup after 41 days 150 | Maternal and Child Health 9.2 REPRODUCTIVE HEALTH CARE AND WOMEN’S STATUS A woman’s status has a direct impact on her health and health-seeking behaviour. Table 9.9 shows the percentage of woman with a live birth in the five years preceding the survey who received an- tenatal care from health professionals, the percentage of women who received postnatal care within the first two days of delivery, and the percentage of births for whom mothers received delivery care from a trained health professional, according to three measures of women’s status: number of decisions in which a woman, either alone or jointly with others, has a final say; number of reasons women believe that a woman can refuse sex with her husband; and the number of reasons a woman believes that wife-beating is justified. In general, women’s status is positively related to women’s reproductive health. However, infor- mation from the data gives a mixed picture. Table 9.9 shows that there is a clear positive relationship be- tween qualified reproductive health care and women’s attitude towards wife-beating. Women who believe that wife-beating is not justified for any reason are most likely to have received professional medical as- sistance for antenatal and delivery care and to have received postnatal care within the first two days of delivery. The percentage of women who receive reproductive health care from medical professionals de- clines as the number of reasons women believe wife-beating is justified increases. Table 9.9 also shows that women who have the final say in all five household decisionmaking processes are most likely to have received maternity care from a health professional. However, the differences are less obvious for antena- Table 9.9 Reproductive health care by women's status Percentage of women with a live birth in the five years preceding the survey who received antenatal and postnatal care from a health professional for the most recent birth, and percentage of births in the five years preceding the sur- vey for which mothers received professional delivery care, by women's status indicators, Ghana 2003 Women's status indicator Percentage of women who received antena- tal care from doctor, nurse/midwife or aux- iliary midwife Percentage of women who re- ceived postnatal care within first two days of delivery1 Number of women Percentage of births for which mother received delivery care from doctor, nurse/ midwife or auxiliary midwife Number of births Number of decisions in which woman has final say2 0 92.1 61.1 523 47.6 694 1-2 86.9 49.1 578 38.2 809 3-4 91.9 58.0 510 42.8 726 5 94.7 68.6 1,034 54.1 1,410 Number of reasons to refuse sex with husband 0 93.2 59.7 219 44.3 314 1-2 88.7 52.6 352 40.7 476 3-4 92.3 62.3 2,074 48.4 2,849 Number of reasons wife- beating is justified 0 94.2 69.4 1,208 56.4 1,636 1-2 91.3 56.6 614 43.9 873 3-4 90.6 54.5 554 39.9 759 5 86.1 45.0 269 28.2 371 Total 91.9 60.8 2,645 47.1 3,639 1 Includes mothers who delivered in a health facility 2 Either by herself or jointly with others Maternal and Child Health | 151 tal care than for delivery and postnatal care. In addition, this relationship does not hold true for all the subcategories of decisionmaking. For example, a higher percentage of women who have no say in any of the five major household decisions have received medical reproductive health care than their counterparts who have a say in one to four of the five decisions. This same pattern is also observed for women who believe that a woman is justified in refusing sex with her husband. 9.3 CHILD HEALTH 9.3.1 Vaccination of Children The 2003 GDHS collected information on immunisation coverage for all children born in the five years before the survey. The Government of Ghana has adopted the World Health Organisation (WHO) and UNICEF guidelines for vaccinating children. According to these guidelines, to be considered fully vaccinated, a child should receive the following vaccinations: one dose each of BCG and measles, three doses of the polio vaccine, and three doses of DPT. In addition, in Ghana a vaccine against yellow fever is also recommended for children. BCG, which protects against tuberculosis, should be given at birth or at first clinical contact. DPT protects against diphtheria, pertussis (whooping cough), and tetanus. A dose of polio vaccine is given at birth (Polio 0) or within 13 days of birth. DPT and polio vaccine guidelines re- quire three vaccinations at approximately 6, 10, and 14 weeks of age. The measles and yellow fever vac- cines should be given at nine months of age. Currently, the pentavalent vaccine “DPT/HepB/HiB”, intro- duced in 2002, has replaced the DPT vaccine. This vaccine contains in addition to DPT, the hepatitis B vaccine and a vaccine against Haemophilus influenza type B. It is recommended that children receive the complete schedule of vaccinations before 12 months of age. In the GDHS, information on vaccination coverage was obtained in two ways—from health cards and from mother’s verbal reports. All mothers were asked to show the interviewer the health cards on which the child’s immunisations are recorded. If the card was available, the interviewer copied the dates on which each vaccination was received. If a vaccination was not recorded on the card, the mother was asked to recall whether that particular vaccination had been given. If the mother was not able to present a card for a child at all, she was asked to recall whether the child had received BCG, polio, DPT, measles, and yellow fever vaccinations. If she recalled that the child had received the polio or DPT vaccines, she was asked about the number of doses that the child received. The data presented here are for children age 12-23 months, the youngest cohort of children who have reached the age by which they should be fully vaccinated, and are restricted to children who were alive at the time of the survey. Table 9.10 shows the percentage of children age 12-23 months who re- ceived specific vaccines at any time before the survey by source of information. Sixty-nine percent of Ghanaian children age 12-23 months are fully immunised, while 5 percent received no vaccinations1 (Figure 9.3). Fifty-eight percent of children 12-23 months were fully vaccinated by 12 months of age. 1 Data for polio vaccinations were adjusted for a likely underreporting. It appeared that for some children who did not receive polio at birth, interviewers may have mistakenly written the date polio 1 was given in the space for recording the date of polio 0. To correct for any such errors, the total number of doses of DPT and polio was checked, since the two vaccines are usually given at the same time. For children reported as having received all three doses of DPT and polio 0, polio 1, and polio 2 only, it was assumed that polio 0 was in fact polio 1, polio 1 was in fact polio 2, and polio 2 was in fact polio 3. 152 | Maternal and Child Health Table 9.10 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Ghana 2003 DPT Polio1 Source of of information BCG 1 2 3 0 1 2 3 Measles All2 Yellow fever No vacci- nations Number of chil- dren Vaccinated at any time before survey Vaccination card 79.2 80.5 77.7 74.5 49.6 81.5 79.1 74.3 74.0 66.5 68.6 0.0 577 Mother's report 12.0 10.4 8.8 5.0 4.1 11.5 9.6 4.9 9.2 2.9 8.0 4.8 118 Either source 91.1 90.8 86.5 79.5 53.7 93.0 88.7 79.2 83.2 69.4 76.6 4.8 695 Vaccinated by 12 months of age3 90.0 90.0 85.3 76.9 53.6 92.2 87.2 75.9 68.8 58.0 58.5 6.1 695 1 Polio 0 is the polio vaccination given at birth 2 BCG, measles and three doses each of DPT (DPT/HepB/HiB) and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination Figure 9.3 Percentage of Children Age 12-23 Months with Specific Vaccinations 91 91 87 80 54 93 89 79 83 69 77 5 BCG 1 2 3 0 1 2 3 Measles Yellow fever No vacci- nations 0 20 40 60 80 100 Pe rc en t a ge v ac ci na te d by a ge 1 2 m on th s Note: Based on health cards and mothers' reports 1 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio 0) DPT Polio 1 All GDHS 2003 Nine in ten children received the BCG and first dose of DPT and polio vaccines at some time be- fore the survey. While the coverage for the first dose of DPT and polio is high, coverage declines for sub- sequent doses of DPT and polio, with only about 80 percent of children receiving the recommended three doses of these vaccines. The drop-out rate represents the proportion of children who receive the first dose of a vaccine but do not go on to get the third dose. Dropout rates are 12 percent and 15 percent for DPT and polio, respectively. This is an improvement from 1998 when drop-out rates for DPT and polio were 19 percent and 22 percent, respectively (GSS and MI, 1999). Eighty-three percent of children received the measles vaccine and 77 percent have been vaccinated against yellow fever. Ideally, measles and yellow fever should be given on the same day and the difference in vaccination coverage poses a challenge for Maternal and Child Health | 153 health professionals. The percentage of children age 12-23 months who have been fully vaccinated has increased over the past fifteen years, from 47 percent in 1988 (GSS and IRD, 1989), to 69 percent in 2003 (Figure 9.4). Figure 9.4 Trends in Vaccination Coverage, Ghana 1988-2003 47 55 62 69 GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 0 20 40 60 80 100 Pe rc en t a ge o f c hi ld re n ag e 12 - 2 3 m on th s Note: Children age 12-23 months fully vaccinated, i.e., have received BCG, measles, and three doses of DPT and polio (excluding polio 0). GDHS 1988-2003 Table 9.11 shows the percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and the percentage with a vaccination card by background characteristics. The gender and birth order of the child has little effect on vaccination status. Urban children are more likely than their rural counterparts to be fully immunised. Apart from the Northern region, where less than half of the children are fully immunised, at least three in five children in each of the other re- gions are fully immunised. Children of women with no education were less likely (57 percent) to be fully immunised than children of educated mothers. Similarly, children in households in the lowest wealth quintile (54 percent) are least likely to be fully immunised. Table 9.12 provides the percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and the percentage with a vaccination card, by current age of child. Half of the children received all vaccines by 12 months of age. Children in the older cohort (48-59 months) were less likely (42 percent) to have received all their vaccines compared with those age 12-23 months (58 percent). This pattern was consistent for each vaccine but more marked when all the vaccines are considered together. This corroborates the trend towards higher immunisation coverage in 2003 than in 1998. 154 | Maternal and Child Health Table 9.11 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Ghana 2003 DPT Polio1 Background characteristic BCG 1 2 3 0 1 2 3 Measles All2 Yellow fever No vacci- nations Percen- tage with a vac- cina- tion card seen Number of chil- dren Sex Male 92.5 91.6 87.3 81.3 50.9 93.8 89.7 80.4 83.2 70.3 77.3 4.3 84.9 375 Female 89.5 90.0 85.6 77.3 57.0 92.0 87.6 77.7 83.2 68.3 75.9 5.4 80.7 321 Birth order 1 91.0 94.3 90.9 81.3 61.1 94.5 89.2 77.2 85.7 70.6 80.9 3.8 81.5 159 2-3 89.5 88.0 83.5 77.5 52.0 91.1 87.2 78.7 82.1 67.1 74.3 5.7 82.4 257 4-5 92.3 92.8 88.8 83.0 56.0 94.3 89.9 82.3 83.0 71.7 74.3 3.4 86.0 150 6+ 93.3 89.9 84.3 77.1 45.3 93.1 89.8 78.8 82.7 69.8 78.8 5.9 82.2 129 Residence Urban 95.9 94.0 91.5 86.2 77.6 95.1 91.4 82.8 85.8 75.5 83.0 3.3 84.6 248 Rural 88.5 89.1 83.7 75.8 40.4 91.8 87.3 77.1 81.8 66.0 73.1 5.6 82.0 447 Region Western 92.5 91.1 86.7 78.9 44.3 95.7 93.2 83.7 76.4 60.4 76.6 4.3 87.4 59 Central 95.2 95.2 92.6 87.9 25.5 95.2 95.2 89.0 86.5 82.1 70.7 2.6 84.0 68 Greater Accra 91.0 91.4 84.5 78.7 81.7 90.3 87.0 77.4 87.8 69.1 73.7 4.5 82.6 75 Volta 91.2 95.6 91.4 89.3 47.5 95.6 91.4 90.3 89.4 82.3 86.4 4.4 85.5 66 Eastern 88.8 91.8 82.5 77.0 57.0 89.9 79.5 73.1 79.1 65.6 73.9 8.2 84.8 77 Ashanti 92.8 91.7 90.7 82.4 60.0 94.5 89.8 79.7 82.2 71.6 78.7 5.5 76.5 123 Brong Ahafo 91.1 91.5 89.5 85.3 70.0 94.0 91.7 83.4 87.1 79.0 82.4 4.5 87.5 75 Northern 84.1 77.9 70.0 62.2 48.6 87.3 81.4 62.5 76.0 48.0 68.6 5.1 80.9 92 Upper East 97.8 99.1 97.8 77.8 30.0 97.8 95.0 84.1 91.2 77.0 82.7 0.9 87.9 39 Upper West 91.4 89.7 87.8 75.5 49.9 93.0 89.9 74.1 79.5 60.3 75.4 7.0 75.6 21 Education No education 89.2 86.7 78.7 68.5 46.1 91.1 84.9 69.8 78.2 57.3 71.3 5.1 80.5 244 Primary 88.5 87.5 85.2 77.1 42.5 89.8 85.2 75.9 79.5 66.8 71.8 8.7 75.9 155 Middle/JSS 93.6 95.7 93.5 89.2 61.6 96.5 93.6 88.4 88.0 79.2 81.5 2.5 88.5 256 Secondary+ (97.6) (97.6) (94.3) (94.3) (93.5) (94.3) (94.3) (90.6) (97.6) (90.6) (96.8) (2.4) (90.6) 39 Wealth quintile Lowest 86.5 83.8 75.3 64.5 35.0 88.4 81.1 67.8 75.0 53.7 68.6 7.5 79.7 177 Second 90.8 91.9 87.8 81.4 41.2 92.9 89.9 81.1 82.8 72.4 77.8 4.9 83.8 153 Middle 90.3 95.1 91.6 85.8 53.8 96.1 92.6 86.0 87.2 74.2 76.6 3.1 86.9 122 Fourth 96.2 91.4 90.4 84.7 63.1 96.1 92.3 81.7 86.1 73.9 77.4 2.9 79.8 121 Highest 94.1 94.9 92.0 87.4 86.8 93.4 90.9 84.0 88.8 79.1 85.9 4.4 85.8 123 Total 91.1 90.8 86.5 79.5 53.7 93.0 88.7 79.2 83.2 69.4 76.6 4.8 83.0 695 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Polio 0 is the polio vaccination given at birth 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Maternal and Child Health | 155 Table 9.12 Vaccinations in first year of life Percentage of children age 12-59 at the time of the survey who received specific vaccines by 12 months of age, and per- centage with a vaccination card, by current age of child, Ghana 2003 DPT Polio1 Current age of child in months BCG 1 2 3 0 1 2 3 Measles All2 Yellow fever No vacci- nations Percen- tage with a vaccina- tion card seen Number of chil- dren 12-23 90.0 90.0 85.3 76.9 53.6 92.2 87.2 75.9 68.8 58.0 58.5 6.1 83.0 695 24-35 86.6 87.4 82.0 72.6 46.1 91.1 86.2 71.0 67.8 52.2 51.9 7.6 73.3 649 36-47 86.1 85.2 78.1 69.0 45.8 88.4 80.9 65.6 61.0 46.3 52.1 10.1 64.9 695 48-59 84.4 82.8 76.5 65.3 42.6 87.8 79.7 63.5 59.9 41.7 50.5 9.9 60.2 612 Total 86.9 86.6 80.8 71.3 47.2 90.1 83.8 69.4 64.9 50.0 53.9 8.3 70.6 2,652 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. For chil- dren whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 9.3.2 Acute Respiratory Infections Pneumonia and other respiratory tract infections are leading causes of death among young chil- dren in Ghana. In cases of pneumonia, early diagnosis and treatment with antibiotics can prevent a large proportion of deaths due to acute respiratory infections (ARI). The prevalence of ARI in the 2003 GDHS was estimated by asking mothers whether their children under age five had been ill with a cough accom- panied by short, rapid breathing in the two weeks preceding the survey. These symptoms, though com- patible with pneumonia, are subjective (i.e., mother's perception of illness) and not validated by a medical examination. Table 9.13 shows the percentage of children under five years who had a cough accompanied by short rapid breathing (symptoms of ARI) and the percentage of children with symptoms of ARI taken to a health facility or provider. Mothers reported that 10 percent of children under five had symptoms of ARI in the two weeks prior to the survey. Of these, 44 percent were taken to a health facility or provider. Differentials in the prevalence of ARI by background characteristics are minimal. However, it is worthwhile to note that symptoms of ARI are particularly high among children age 6-23 months and among children living in the Volta region. Treatment patterns vary by background characteristics. Children age 12-35 months, urban chil- dren, and children of mothers with middle/JSS level of education are more likely than other children to be taken to a health provider for treatment. Differentials by region are hard to interpret due to the small number of cases. 156 | Maternal and Child Health Table 9.13 Prevalence and treatment of symptoms of ARI Percentage of children under five years who had a cough accompanied by short, rapid breathing (symp- toms of acute respiratory infection (ARI)), and among children who had symptoms of ARI, the percentage for whom treatment was sought from a health facility or provider, by background characteristics, Ghana 2003 Background characteristic Percentage of children with symptoms of ARI Number of children Among children with symptoms of ARI, percentage for whom treatment was sought from a health provider1 Number of children Age in months <6 7.5 314 (35.7) 23 6-11 15.8 374 43.4 59 12-23 13.5 695 49.8 94 24-35 8.7 649 52.0 57 36-47 8.6 695 34.8 60 48-59 6.9 612 (38.8) 42 Sex Male 10.9 1,686 43.7 183 Female 9.2 1,654 44.3 152 Residence Urban 8.9 1,114 53.0 99 Rural 10.6 2,225 40.2 236 Region Western 12.5 332 (41.4) 41 Central 10.6 280 (22.7) 30 Greater Accra 8.1 366 (57.9) 30 Volta 20.0 269 (29.0) 54 Eastern 10.4 337 (42.7) 35 Ashanti 8.0 622 (57.1) 50 Brong Ahafo 10.1 366 (49.9) 37 Northern 7.0 457 (39.4) 32 Upper East 9.2 206 (64.8) 19 Upper West 7.5 104 (50.8) 8 Education No education 9.7 1,339 35.3 130 Primary 10.7 761 37.7 81 Middle/JSS 10.1 1,055 54.5 107 Secondary+ 9.3 185 * 17 Wealth quintile Lowest 11.4 864 31.1 98 Second 9.9 740 40.0 73 Middle 10.4 656 47.2 68 Fourth 10.3 572 50.8 59 Highest 7.3 507 (68.9) 37 Total 10.0 3,340 44.0 335 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been sup- pressed. Figures in parentheses are based on 25-49 unweighted cases. 1Excludes pharmacy, shop, and traditional practitioner Maternal and Child Health | 157 9.3.3 Diarrhoeal Diseases Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children in Ghana. Exposure to diarrhoeal-causing agents is frequently related to use of contami- nated water and unhygienic practices related to food preparation, hand-washing, and excreta disposal. For health purposes, it is essential that each household have a specific area designated for hand washing where water, soap, ash, or other cleansing agent as well as a basin for containing clean water are present. This is more likely to ensure regular hand-washing. Hand-washing In the GDHS, respondents were asked where they usually washed their hands. Interviewers were then asked to observe for various hand-washing items for those households that mentioned having an area ‘designated,’ or set aside specifically for hand-washing ‘in the dwelling, yard or plot.’ In each household, interviewers were instructed to circle the following items as present or absent: water or a tap in the desig- nated location where members of the household usually washed their hands, cleansing agent such as soap or ash, and a basin to hold clean water. Table 9.14 shows the percentage of households with hand- washing materials in a designated area within the dwelling, yard, or plot by background characteristics. It is surprising to note that 67 percent of households did not have any hand-washing items in the designated place for hand-washing. This may not mean that hand-washing items are uncommon in Ghana, but may in part be a reflection of the absence of a designated place for hand-washing. Moreover, in some parts of the country, many households live in compound houses where washing areas may be shared between several households, and personal use items such as soap, may not be kept at the designated washing bay for oth- ers to use. Twenty-nine percent of households had water or a tap, 14 percent had soap, ash, or other clean- sing agent, and 16 percent had a basin in the designated area for hand-washing. Only 8 percent of house- holds had all three hand-washing materials in the designated area for hand-washing within the dwelling, yard, or plot. Households in urban areas, those in Greater Accra, those with piped water or with a water source within the dwelling, and households in the highest wealth quintile are more likely than other households to have all three hand-washing materials in a place designated for hand-washing. 158 | Maternal and Child Health Table 9.14 Hand-washing materials in household Percentage of households with hand-washing materials in a designated place within dwelling/yard/plot, by back- ground characteristics, Ghana 2003 Background characteristic Water/ tap Soap, ash, or other cleansing agent Basin All three hand- washing materials No hand- washing materials Number of households Residence Urban 27.2 17.2 18.3 12.0 69.6 2,870 Rural 30.2 10.5 13.5 3.7 64.6 3,381 Region Western 61.4 13.6 16.0 7.4 37.3 612 Central 39.4 9.7 16.7 5.5 56.5 587 Greater Accra 22.0 24.2 23.4 19.4 74.0 890 Volta 7.9 8.3 11.1 6.1 87.8 538 Eastern 57.5 34.7 24.1 15.7 41.1 732 Ashanti 20.3 3.9 8.9 2.0 76.6 1,313 Brong Ahafo 4.4 4.0 4.1 1.5 93.0 665 Northern 26.6 9.2 21.3 3.7 62.4 487 Upper East 36.0 25.4 27.3 7.1 51.1 280 Upper West 8.2 0.0 10.5 0.0 81.6 147 Source of drinking water Piped 29.0 17.9 19.0 12.8 68.2 2,445 Protected well 33.0 11.4 15.0 4.2 61.4 1,737 Open well 25.5 10.0 11.0 3.7 70.8 720 Surface 25.3 8.3 11.1 2.7 70.1 1,140 Other 23.5 22.2 24.2 14.2 67.2 205 Time to water source In dwelling 34.7 26.3 26.0 20.1 61.6 1,393 <5 minutes 12.0 4.5 5.7 1.4 86.0 219 5 to 9 minutes 27.5 11.4 15.2 5.2 68.4 1,100 10+ minutes 28.0 9.8 12.4 3.8 67.3 3,535 Wealth quintile Lowest 28.9 9.7 16.3 3.0 62.9 971 Second 30.6 10.3 10.7 2.9 65.4 1,168 Middle 28.0 8.4 10.9 3.0 69.4 1,315 Fourth 21.8 9.2 11.3 4.8 74.7 1,452 Highest 35.8 28.8 28.9 22.3 60.3 1,345 Total 28.9 13.6 15.7 7.6 66.9 6,251 Note: Total includes 7 cases with missing information on source of drinking water and 5 cases with missing infor- mation on time to water source. Disposal of Stool Table 9.15 shows the percent distribution of mothers, whose youngest child under five years is living with her, by the way in which the child’s faecal matter is disposed of, according to background characteristics and type of toilet facilities in the household. Maternal and Child Health | 159 Table 9.15 Disposal of children's stools Percent distribution of mothers whose youngest child under five years is living with her by way in which child's faecal matter is disposed of, ac- cording to background characteristics and type of toilet facilities in household, Ghana 2003 Children’s stools contained Children’s stools uncontained Uses diapers Background characteristic Child always uses toi- let/latrine Thrown into toilet/ latrine Buried in yard Thrown outside dwell- ing Thrown outside yard Rinsed away Not dis- posed of Dispos- able Wash- able Other Missing Total Number of mothers Residence Urban 8.8 57.2 1.6 5.0 8.8 6.9 0.0 1.0 8.7 1.5 0.5 100.0 868 Rural 4.5 39.6 4.1 11.7 26.1 5.8 0.0 0.0 4.9 2.5 0.6 100.0 1,591 Region Western 3.9 61.1 2.7 4.3 5.3 0.6 0.0 0.0 11.5 10.0 0.5 100.0 223 Central 8.0 62.0 1.6 1.9 12.9 8.2 0.0 0.0 2.5 0.6 2.3 100.0 202 Greater Accra 9.7 50.1 2.1 10.4 6.6 12.1 0.0 1.4 4.2 3.1 0.3 100.0 278 Volta 2.9 35.1 9.5 14.7 21.0 15.0 0.0 0.8 0.0 0.7 0.4 100.0 202 Eastern 3.8 73.4 0.5 3.2 5.3 5.6 0.0 0.4 3.7 3.6 0.5 100.0 245 Ashanti 8.0 61.1 1.1 0.9 13.4 2.3 0.0 0.2 12.4 0.3 0.3 100.0 462 Brong Ahafo 6.2 58.8 2.0 6.7 13.6 4.0 0.1 0.0 7.8 0.5 0.2 100.0 280 Northern 6.3 7.3 4.8 17.2 48.9 8.4 0.0 0.0 4.4 2.5 0.2 100.0 327 Upper East 4.3 2.5 9.2 39.8 39.0 1.3 0.0 0.9 2.7 0.0 0.3 100.0 162 Upper West 0.0 0.2 3.6 8.7 73.4 6.4 0.0 0.2 5.7 0.3 1.6 100.0 77 Education No education 5.0 25.4 4.7 15.4 34.6 6.7 0.0 0.1 4.7 2.9 0.5 100.0 970 Primary 6.0 53.2 3.6 7.6 13.2 6.7 0.0 0.1 6.0 2.9 0.7 100.0 541 Middle/JSS 6.4 62.6 1.6 4.2 9.7 5.5 0.0 0.2 8.1 1.3 0.5 100.0 803 Secondary+ 11.0 61.8 1.5 3.7 4.4 4.6 0.0 4.1 8.3 0.0 0.8 100.0 144 Toilet facilities None 2.0 8.6 6.8 21.4 44.3 6.7 0.1 0.1 5.5 4.0 0.5 100.0 709 Pit latrine 6.4 59.8 2.3 4.9 13.0 5.5 0.0 0.1 5.6 1.6 0.8 100.0 1,017 Improved la- trine 8.6 63.9 1.4 4.5 8.2 6.5 0.0 0.4 4.8 1.4 0.3 100.0 518 Flush toilet 13.8 60.0 0.0 2.3 0.9 6.6 0.0 2.9 12.9 0.5 0.0 100.0 179 Other (0.0) (53.2) (0.0) (1.9) (0.0) (10.6) (0.0) (0.0) (32.1) (2.2) (0.0) 100.0 32 Wealth quintile Lowest 3.6 20.0 4.7 18.8 37.8 6.7 0.1 0.0 4.7 3.0 0.6 100.0 618 Second 4.1 47.3 4.1 7.8 25.5 4.3 0.0 0.0 4.7 1.2 1.0 100.0 517 Middle 6.1 52.0 3.9 6.2 15.2 5.8 0.0 0.1 7.1 3.4 0.3 100.0 497 Fourth 7.5 57.2 1.7 6.4 9.0 9.6 0.0 0.3 5.7 1.8 0.8 100.0 437 Highest 10.8 64.4 0.6 3.7 2.8 4.4 0.0 1.9 10.5 0.9 0.0 100.0 389 Total 6.1 45.8 3.2 9.3 20.0 6.2 0.0 0.4 6.3 2.2 0.6 100.0 2,459 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 4 cases with missing information on toilet facilities. More than half of mothers (55 percent) report that their child’s stool is contained in the toilet or latrine or buried in the yard. Thirty-six percent of mothers report that their child’s stool is uncontained, that is, thrown outside the dwelling or yard, rinsed away, or not disposed of. Seven percent of mothers reported using diapers. Children’s stools are more likely to be contained in urban than in rural areas, in the Eastern Region, by highly educated mothers, in households with improved latrines or flush toilets, and among mothers in the highest wealth quintile. Incidence of Diarrhoea In the 2003 GDHS, mothers were asked whether any of their children under five years of age had diarrhoea at any time during the two-week period prior to the survey. If any child had diarrhoea, the 160 | Maternal and Child Health mother was asked about feeding practices during the diarrhoeal episode and about what actions were taken to treat the diarrhoea. Since the prevalence of diarrhoea varies sea- sonally, the results, which only pertain to the period of fieldwork from late July to late October, should be interpreted with caution. Table 9.16 shows that 15 percent of children under five years had diarrhoea in the two weeks preceding the survey. Not surpris- ingly, very young children are least likely to have had diarrhoea, presumably because most of them are exclusively breastfed and hence less exposed to contaminated food. Children residing in the Upper East and Up- per West regions have a much higher preva- lence of diarrhoea than children in the other regions. Prevalence of diarrhoea is lowest among children of highly educated mothers. Not surprisingly, diarrhoea prevalence is lowest among children who live in house- holds that have all three hand-washing mate- rials, households that have piped water, and households that are in the wealthiest quintile. Use of Oral Rehydration Therapy A simple and effective response to dehydration associated with diarrhoea is a prompt increase in the child’s fluid intake through food and oral rehydration therapy (ORT). ORT may include the use of a solu- tion prepared from commercially produced packets of oral rehydration salts (ORS) or a homemade mixture usually prepared from sugar, salt, and water (recommended home fluids, RHF). Table 9.17 shows the percent- age of mothers with births in the five years preceding the survey who know about ORS packets for treatment of diarrhoea, by back- ground characteristics. Ninety percent of mothers with births in the five years preceding the survey know about ORS. Younger mothers are slightly less likely to know about ORS than older mothers. Knowledge among urban women is higher than among rural women. Knowledge of ORS is lowest among young mothers in the Upper West Region, among mothers with no education, and among mothers in the lowest wealth quintile. Table 9.16 Prevalence of diarrhoea Percentage of children under five years with diarrhoea in the two weeks preceding the survey, by background characteristics, Ghana 2003 Background characteristic Diarrhoea in the two weeks pre- ceding the survey Number of children Age in months <6 5.0 314 6-11 21.2 374 12-23 24.2 695 24-35 17.0 649 36-47 11.5 695 48-59 9.1 612 Sex Male 15.9 1,686 Female 14.6 1,654 Residence Urban 13.6 1,114 Rural 16.1 2,225 Region Western 14.4 332 Central 15.9 280 Greater Accra 12.8 366 Volta 13.3 269 Eastern 15.7 337 Ashanti 14.3 622 Brong Ahafo 13.9 366 Northern 15.3 457 Upper East 20.8 206 Upper West 26.9 104 Mother's education No education 15.7 1,339 Primary 16.6 761 Middle/JSS 14.5 1,055 Secondary+ 11.1 185 Hand-washing materials in household Water/tap 13.6 908 Soap/ash/other cleansing agent 10.7 373 Basin 12.4 515 All three hand-washing materials 7.5 196 None 15.9 2,256 Source of drinking water Piped 12.9 986 Protected well 16.6 1,043 Open well 17.9 451 Surface 14.9 790 Other (13.6) 66 Wealth quintile Lowest 19.7 864 Second 14.2 740 Middle 13.9 656 Fourth 15.2 572 Highest 10.9 507 Total 15.2 3,340 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 4 cases with missing information on source of drinking water. Maternal and Child Health | 161 Table 9.17 Knowledge of ORS packets Percentage of mothers with births in the five years preceding the survey who know about ORS packets for treatment of diar- rhoea, by background characteristics, Ghana 2003 Background characteristic Percentage of mothers who know about ORS packets Number of mothers Age 15-19 81.4 118 20-24 89.7 507 25-29 92.4 651 30-34 90.0 575 35-49 90.2 794 Residence Urban 96.3 946 Rural 86.8 1,699 Region Western 94.6 246 Central 92.7 211 Greater Accra 92.9 303 Volta 80.0 220 Eastern 90.8 266 Ashanti 96.7 507 Brong Ahafo 92.0 297 Northern 79.8 346 Upper East 96.9 166 Upper West 70.1 83 Education No education 83.4 1,025 Primary 89.8 589 Middle/JSS 97.3 879 Secondary+ 97.1 153 Wealth quintile Lowest 81.5 648 Second 86.3 557 Middle 93.2 534 Fourth 96.5 474 Highest 97.8 433 Total 90.2 2,645 ORS = Oral rehydration salts Mothers of children who had diarrhoea in the two weeks preceding the survey were asked what was done to manage or treat the illness. Table 9.18 shows the percentage of children under five years who had diarrhoea in the two weeks preceding the survey taken for treatment to a health provider, the percent- age who received ORT, and the percentage given other treatments, according to background characteris- tics. Mothers reported that 26 percent of their children with diarrhoea were taken to a health provider. More than a third of the children (39 percent) were given a solution made from ORS, 11 percent received 162 | Maternal and Child Health Table 9.18 Diarrhoea treatment Percentage of children under five years who had diarrhoea in the two weeks preceding the survey taken for treatment to a health provider, per- centage who received oral rehydration therapy (ORT), and percentage given other treatments, according to background characteristics, Ghana 2003 Oral rehydration therapy (ORT) Other treatments Background characteristic Percentage taken to a health provider1 ORS packets RHF Either ORS or RHF Increased fluids ORS, RHF, or increased fluids Pill/syrup Injection Intra- venous solution Home remedy/ other No treatment Number of chil- dren Age in months <6 * * * * * * * * * * * 16 6-11 31.8 31.9 9.8 41.7 29.8 53.8 37.0 3.3 0.9 10.6 18.9 79 12-23 26.3 44.5 14.0 52.6 38.8 66.9 36.1 1.4 1.0 11.7 12.2 168 24-35 25.5 40.7 13.6 50.9 48.7 72.2 29.9 0.0 0.0 13.5 8.4 110 36-47 22.8 41.6 9.3 46.1 46.8 68.2 30.6 0.0 0.0 10.5 16.1 80 48-59 21.9 31.0 5.4 34.5 31.4 49.0 34.1 0.0 2.0 16.8 17.5 56 Sex Male 27.4 41.4 11.5 48.4 36.5 63.7 34.2 0.7 1.0 10.3 16.7 268 Female 23.4 35.5 11.3 44.3 43.0 62.9 32.8 1.4 0.3 14.8 11.0 241 Residence Urban 35.5 47.1 6.7 50.3 47.6 67.8 34.1 1.6 0.7 12.9 12.3 152 Rural 21.3 35.0 13.4 44.8 36.2 61.4 33.3 0.7 0.7 12.2 14.8 357 Region Western (27.2) (37.0) (11.4) (48.4) (37.5) (63.3) (40.4) (0.0) (0.0) (14.6) (6.3) 48 Central (23.8) (45.2) (8.4) (46.8) (29.5) (62.3) (19.7) (0.0) (0.0) (15.2) (19.0) 45 Greater Accra (15.5) (28.7) (16.1) (40.8) (41.3) (54.6) (30.7) (3.1) (0.0) (23.5) (15.4) 47 Volta (9.8) (36.5) (25.0) (51.5) (47.5) (70.9) (12.9) (0.0) (7.0) (15.3) (21.7) 36 Eastern (17.0) (32.6) (4.5) (37.0) (33.1) (56.7) (38.8) (0.0) (0.0) (3.6) (23.3) 53 Ashanti 26.7 41.3 6.2 46.4 40.1 64.2 42.1 0.0 0.0 10.0 12.9 89 Brong Ahafo 28.5 43.5 9.4 46.8 45.8 65.3 35.4 1.9 2.1 4.9 9.4 51 Northern 29.0 32.4 17.8 45.8 37.8 59.4 41.2 2.3 0.0 16.0 11.5 70 Upper East 43.0 58.4 12.4 64.8 52.7 82.7 21.3 2.3 0.0 13.3 7.6 43 Upper West 32.8 29.7 7.0 35.8 30.2 55.7 33.5 0.0 0.0 9.5 18.2 28 Mother's educa- tion No education 26.8 37.2 12.4 45.6 38.2 62.7 33.9 1.3 0.0 12.7 12.0 210 Primary 26.3 34.3 11.0 44.0 27.3 57.4 22.0 0.8 0.9 13.5 21.7 126 Middle/JSS 22.8 43.9 11.9 50.4 50.2 69.1 41.2 0.9 0.5 10.6 11.1 153 Secondary+ * * * * * * * * * * * 21 Wealth quintile Lowest 21.0 32.6 14.6 42.5 36.3 59.6 34.7 1.5 0.4 14.2 14.9 170 Second 23.8 34.2 12.7 44.8 35.2 61.3 28.6 0.0 1.0 11.3 17.2 105 Middle 24.3 43.5 12.6 50.0 40.0 66.6 29.7 0.0 0.7 13.1 9.0 91 Fourth 27.3 38.7 6.3 44.0 42.6 60.1 30.1 2.7 0.0 12.9 19.4 87 Highest 41.6 57.4 5.2 59.3 52.7 78.3 50.8 0.0 1.9 7.1 5.1 55 Total 25.5 38.6 11.4 46.4 39.6 63.3 33.5 1.0 0.7 12.4 14.0 509 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. ORT includes solution prepared from oral rehydration salt (ORS) packets, recommended home fluids (RHF), or in- creased fluids. 1 Excludes pharmacy, shop and traditional practitioner Maternal and Child Health | 163 recommended home fluids (RHF), and 40 percent were given increased fluids. Overall, 63 percent re- ceived ORS, RHF, or increased fluids. One-third of children with diarrhoea were given pills or syrup, 1 percent received injections, less than 1 percent received intravenous medication, and 12 percent were given home remedies. One in seven children with diarrhoea were given no treatment at all. Children age 6-11 months are slightly more likely to be taken to a health facility for treatment (32 percent) than those over one year (22-26 percent). Male children (27 percent) are slightly more likely than female children (23 percent) to be taken to a provider for treatment of diarrhoea. Children of women in the highest wealth index were also more likely (42 percent) to be taken to a health provider than chil- dren from poorer households. Very young children (6-11 months) and older children (48-59 months) are less likely than other children to receive ORT. Rural children and children in the lowest wealth quintile are also less likely to receive ORT. Feeding Practices Mothers are encouraged to continue feeding their children normally when they suffer from diarrhoea and to increase the amount of fluids given. These practices help to reduce the likelihood of dehydration and also minimise the adverse consequences of diarrhoea on the child’s nutritional status. Table 9.19 presents data on the percent distribution of children under five years who had diarrhoea in the two weeks preceding the survey by the amount of liquids and food offered compared with normal practice. Most children are given either the same amount of fluids (32 percent) or more fluids than usual (40 percent) when they have diar- rhoea. Fourteen percent of children are given somewhat less fluids than usual, while 12 percent are given much less. One percent of children receive no fluids. Twenty-seven percent of children are offered the same amount of food and 6 percent are offered more food than usual. Thirty percent receive somewhat less food and 26 percent receive much less food than usual, while 7 per- cent receive no food at all. Men are beginning to play a more important role in child caring. In order to ascertain men’s knowledge about feeding practices, the 2003 GDHS asked all men about what they should do when a child had diarrhoea. Forty per- cent of men mentioned that they would give a child with diarrhoea more fluids to drink, while 13 percent mentioned that they would give the same amount of fluid to drink (data not shown). More than a third of men (35 percent) stated that they would give a child less than usual to drink in the event of diarrhoea. 9.4 CHILD HEALTH CARE AND WOMEN’S STATUS A woman’s status could have an impact on the level of health care her child receives. Table 9.20 shows the percentage of children age 12-23 months who were fully vaccinated and the percentage of chil- dren under five years who were ill with a fever and/or who had symptoms of ARI and/or diarrhoea in the two weeks preceding the survey who were taken to a health provider for treatment, by women’s status indicators. Table 9.19 Feeding practices during diarrhoea Percent distribution of children under five years who had diarrhoea in the two weeks preceding the survey by amount of liquids and food offered, compared with normal practice, Ghana 2003 Liquid/food offered Percent Amount of liquids offered Same as usual 32.3 More 39.6 Somewhat less 13.9 Much less 12.3 None 1.0 Don't know 0.9 Total 100.0 Amount of food offered Same as usual 26.7 More 6.0 Somewhat less 29.6 Much less 25.6 None 6.8 Never gave food 5.4 Total 100.0 Number of children 509 164 | Maternal and Child Health Table 9.20 Children’s health care by women's status Percentage of children age 12-23 months who were fully vaccinated, and percentage of children under five years who were ill with a fever, symptoms of ARI and/or diarrhoea, in the two weeks preceding the survey taken to a health pro- vider for treatment, by women's status indicators, Ghana 2003 Women's status indicator Percentage of children 12-23 months fully vaccinated1 Number of children Percentage of children with fever and/or symptoms of ARI taken to health provider2 Number of children Percentage of children with diarrhoea taken to a health provider2 Number of children Number of decisions in which woman has final say3 0 58.5 136 47.6 175 32.0 114 1-2 68.9 157 44.8 187 24.7 125 3-4 75.8 132 44.2 149 17.7 96 5 72.0 270 43.2 328 26.2 175 Number of reasons to refuse sex with husband 0 65.3 54 48.5 55 28.3 35 1-2 67.0 95 37.0 129 26.2 74 3-4 70.2 547 45.8 655 25.1 400 Number of reasons wife- beating is justified 0 73.9 323 48.9 385 23.0 211 1-2 79.3 166 41.0 196 24.1 119 3-4 55.9 138 41.0 200 25.9 116 5 51.5 68 41.1 57 35.9 62 Total 69.4 695 44.6 839 25.5 509 1 Those who have received BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 2 Excludes pharmacy, shop, and traditional practitioner 3 Either by herself or jointly with others The relationship between child health care and women’s status is mixed. The data show that the percentage of children 12-23 months fully vaccinated is higher among children of mothers who have a higher status as measured by all three measures of women’s status. For example, a higher percentage of children of mothers who have a greater say in household decisionmaking (3-5 decisions) are fully immunised than children of mothers who have little or no say (72-75 and 59 percent, respectively). Children of mothers who believe that wife-beating is not justified for any reason at all are also more likely than their counterparts to be taken to a health care provider for treatment of fever and/or ARI. However, there is no clear relationship between the other two women’s status indicators and the care children receive for childhood illnesses. 9.5 WOMEN’S PERCEPTIONS OF PROBLEMS IN OBTAINING HEALTH CARE The 2003 GDHS included a series of questions aimed at obtaining information on the problems women perceive as barriers to accessing health care for themselves. This information is particularly im- portant in understanding and addressing the barriers women may face in seeking care in general. To ob- Maternal and Child Health | 165 tain this information, all GDHS respondents were asked whether each of the following factors would pose a big problem in obtaining medical advice or treatment when they are sick: knowing where to go; getting permission to go; getting money for treatment; distance to the health facility; having to take transport; not wanting to go alone; and concern that there may not be a female provider. Table 9.21 shows the percent- age of women who reported that they have big problems in accessing health care for themselves when they are sick, by type of problem and background characteristics. Clearly, women have problems in accessing health care services, with 68 percent of all women citing at least one of the specified problems. The majority of women said that difficulty in getting money for treatment was a big problem (55 percent), followed by problems with transport and distance to a health facility (33 percent each). Sixteen percent of women were concerned that there may not be a fe- male health provider. Few women (about one in ten) cited knowing where to go for treatment or getting permission to go as big problems in accessing health care for themselves. Women who have five or more children, divorced, separated or widowed women, rural women, women residing in the Upper East Region, women with no education, women who work but not for cash, and women who fall in the lowest wealth quintile are more likely to mention a problem in accessing health care than other women. 9.6 USE OF SMOKING TOBACCO Smoking has a negative effect on the health of a person. Women and men interviewed in the 2003 GDHS were asked about their smoking habits. The data show that very few women in Ghana (less than 1 percent) smoke (data not shown). Table 9.22 indicates the percentage of men who smoke cigarettes or tobacco and the percent dis- tribution of cigarette smokers by number of cigarettes smoked in the preceding 24 hours, according to background characteristics. Smoking is not common in Ghana. Only 9 percent of men smoke cigarettes, a negligible percent smoke a pipe, and 2 percent use other tobacco products. Cigarette smoking is more common among older men (16 percent), men in rural areas (11 percent), men living in the Northern Region (18 percent), men with no education (20 percent), and men in the lowest wealth quintile (15 percent). The majority (78 per- cent) of men smoke 1-5 cigarettes a day. Heavy smoking (six or more cigarettes a day) is concentrated in Greater Accra, Ashanti, and Northern regions, and among wealthier men (fourth and highest wealth quin- tiles). 166 | Maternal and Child Health Table 9.21 Problems in accessing health care Percentage of women who reported they have big problems in accessing health care for themselves when they are sick, by type of problem and background characteristics, Ghana 2003 Problems in accessing health care Background Characteristic Knowing where to go for treatment Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern there may not be a female provider Any of the specified problems Number of women Age 15-19 14.4 12.1 49.6 31.2 30.3 28.1 22.3 67.7 1,148 20-29 11.5 9.0 52.8 31.9 32.6 20.0 16.2 67.1 1,963 30-39 9.5 7.7 56.9 32.7 34.2 17.3 13.2 68.0 1,524 40-49 10.2 7.3 60.9 36.0 35.6 19.7 12.8 71.4 1,056 Number of living chil- dren 0 12.7 10.4 47.0 26.0 25.9 24.3 19.6 64.3 1,872 1-2 11.6 9.7 54.8 34.7 34.1 19.3 14.9 67.7 1,602 3-4 9.7 6.9 59.1 34.8 36.5 17.5 12.3 69.4 1,227 5+ 10.1 7.6 63.9 39.8 41.2 21.0 15.6 75.0 990 Marital status Never married 12.5 11.0 46.1 25.4 24.9 24.5 19.0 63.6 1,616 Married or living to- gether 10.7 8.1 57.0 36.8 37.3 19.4 15.1 69.4 3,549 Divorced, separated, widowed 11.6 8.6 66.2 27.8 30.6 19.8 12.9 74.8 526 Residence Urban 8.9 7.5 43.6 16.8 16.1 16.4 12.9 56.1 2,755 Rural 13.6 10.3 65.2 47.7 49.2 25.0 18.9 79.6 2,936 Region Western 13.1 8.2 52.3 32.8 36.8 23.8 23.9 72.4 553 Central 13.4 7.3 66.8 44.4 44.6 20.9 17.0 80.4 431 Greater Accra 6.2 4.9 31.8 12.4 10.7 12.0 8.2 45.9 942 Volta 9.5 12.3 58.0 32.4 36.0 23.5 16.0 73.7 492 Eastern 19.3 18.1 57.2 30.4 26.6 25.0 22.9 69.6 601 Ashanti 9.6 9.4 50.2 23.2 24.6 21.0 14.6 59.9 1,142 Brong Ahafo 15.0 9.2 65.5 39.4 38.3 20.7 15.3 77.2 569 Northern 11.9 7.7 70.9 55.0 58.7 24.2 15.3 82.2 499 Upper East 9.0 4.6 65.6 63.8 62.5 29.6 18.5 88.2 310 Upper West 5.9 3.7 70.6 46.9 44.6 10.8 15.0 77.5 153 Education No education 12.3 9.8 70.5 50.7 51.3 24.1 17.8 82.9 1,608 Primary 13.5 9.6 57.8 32.3 34.1 24.0 19.0 71.8 1,135 Middle/JSS 11.3 9.6 49.5 25.0 25.0 18.3 15.1 62.6 2,279 Secondary+ 5.1 3.7 29.5 16.9 15.6 16.1 9.6 46.1 669 Employment Not employed 12.5 10.9 48.8 28.2 27.6 24.9 18.8 66.0 1,265 Working for cash 10.8 8.3 55.7 32.8 33.5 18.5 14.4 67.8 3,821 Not working for cash 12.3 9.2 61.0 42.1 42.4 27.3 20.3 75.9 604 Wealth quintile Lowest 14.1 11.0 73.7 60.1 63.3 30.7 22.6 88.0 970 Second 15.0 11.7 67.5 51.7 53.7 26.1 21.0 82.0 949 Middle 13.0 9.1 60.1 31.7 31.5 19.4 13.4 72.9 1,071 Fourth 10.1 8.1 50.8 20.3 19.1 15.5 13.1 63.4 1,245 Highest 6.9 6.5 33.2 13.6 12.9 16.4 12.7 46.8 1,457 Total 11.3 9.0 54.7 32.7 33.1 20.8 16.0 68.2 5,691 Note: Total includes 1 case with missing information on employment. Maternal and Child Health | 167 Table 9.22 Use of smoking tobacco Percentage of men who smoke cigarettes or tobacco and percent distribution of cigarette smokers by number of cigarettes smoked in pre- ceding 24 hours, according to background characteristics, Ghana 2003 Uses tobacco Number of cigarettes Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of men 0 1-2 3-5 6-9 10+ Don't know/ missing Total Number of ciga- rette smokers Age 15-19 0.7 0.0 0.0 99.3 1,107 * * * * * * * 8 20-34 7.0 0.0 0.9 92.2 2,071 8.3 40.9 41.0 6.1 3.7 0.0 100.0 146 35+ 16.4 0.2 3.2 80.5 1,837 3.3 33.5 42.9 10.4 9.7 0.2 100.0 300 Residence Urban 6.8 0.1 0.2 93.0 2,250 6.5 27.2 41.7 11.2 13.0 0.4 100.0 154 Rural 10.8 0.1 2.7 86.7 2,765 4.9 40.4 42.2 7.7 4.8 0.0 100.0 300 Region Western 6.3 0.0 0.3 93.5 476 (13.4) (37.3) (38.9) (3.3) (7.0) (0.0) (100.0) 30 Central 5.6 0.3 0.3 93.9 370 * * * * * * * 21 Greater Accra 6.8 0.1 0.0 93.1 733 (16.4) (18.0) (42.0) (13.6) (10.0) (0.0) (100.0) 50 Volta 7.5 0.1 0.1 92.2 440 (0.0) (29.9) (59.9) (1.7) (8.4) (0.0) (100.0) 33 Eastern 7.4 0.0 0.2 92.4 539 (0.0) (45.1) (50.4) (1.4) (3.2) (0.0) (100.0) 40 Ashanti 8.1 0.0 0.1 91.8 956 1.3 50.1 28.0 12.3 8.4 0.0 100.0 77 Brong Ahafo 10.2 0.2 0.6 89.0 528 6.6 34.3 48.0 7.4 3.7 0.0 100.0 54 Northern 17.7 0.1 6.2 76.5 527 4.1 33.6 37.5 14.7 10.1 0.0 100.0 93 Upper East 11.4 0.3 11.1 79.2 317 6.0 30.3 49.0 6.2 8.7 0.0 100.0 36 Upper West 15.3 0.1 1.8 83.2 130 5.9 38.8 52.2 0.0 3.1 0.0 100.0 20 Education No education 20.3 0.3 6.4 73.7 881 4.7 37.4 41.2 7.8 8.9 0.0 100.0 178 Primary 9.2 0.0 1.8 89.2 803 1.1 42.5 35.7 12.3 8.4 0.0 100.0 74 Middle/JSS 6.6 0.1 0.2 93.1 2,165 4.7 37.0 42.3 8.9 6.6 0.4 100.0 143 Secondary+ 5.0 0.0 0.2 94.9 1,165 14.9 20.4 52.1 7.5 5.1 0.0 100.0 58 Wealth quintile Lowest 15.2 0.1 7.1 78.4 872 5.4 39.2 42.2 6.4 6.8 0.0 100.0 133 Second 11.7 0.3 1.0 87.0 903 7.1 36.8 42.7 10.2 3.2 0.0 100.0 106 Middle 8.2 0.0 0.5 91.5 975 0.0 30.7 50.1 11.4 7.0 0.8 100.0 80 Fourth 6.5 0.1 0.1 93.4 1,060 1.4 44.6 33.2 10.4 10.3 0.0 100.0 68 Highest 5.6 0.0 0.1 94.3 1,204 13.3 25.6 40.1 6.9 14.1 0.0 100.0 67 Total 9.0 0.1 1.6 89.5 5,015 5.4 35.9 42.0 8.9 7.6 0.1 100.0 454 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Nutrition │ 169 NUTRITION 10 Malnutrition plays an important role in the health and welfare of children and women in Ghana. Poor nutrition results in morbidity, mortality, poor education, and fewer opportunities for economic development. Poor education, low socio-economic status, and high fertility are factors that may influence the nutritional status of an individual. In Ghana, children under five years and women of reproductive age are the most vulnerable. Economic evidence also suggests that life expectancy is directly related to poverty and nutrition (Sachs, 1999). Adequate food and sound nutrition are essential to good health. They are crucial not only for human survival, but also for prevention of and recovery from illness. The 2003 GDHS collected data from respondents in order to evaluate the nutritional status of women and young children. For infants and young children, this included information on breastfeeding and complementary feeding. For micronutrients like iron, vitamin A, and iodine, information was collected on intake levels from supplementation and food. Anthropometric measurements (height and weight) were taken for women 15-49 years and children under age five to determine their nutritional status. 10.1 BREASTFEEDING Appropriate feeding practices are of fundamental importance for the survival, growth, development, health, and nutrition of infants and children and for the well being of mothers. Feeding practices are one of the underlying determinants of children’s nutritional status, which in turn influence the risk of illness and ultimately death. Breastfeeding benefits depend on the length of time a child is breastfed, and the frequency and intensity of breastfeeding. Breastfeeding also affects the mother in other ways. The physiological suppression of fertility as a result of intensive breastfeeding influences the length of the interval between pregnancies. 10.1.1 Initiation of Breastfeeding Breastfeeding is sufficient and beneficial for infant nutrition in the first six months of life. Early initiation of breastfeeding (breastfeeding within one hour) facilitates the newborn’s innate sucking reflex, which helps to stimulate breast milk production and provides all of the nutritional requirements of a young infant (Righard and Alade, 1990). The high concentration of antibodies in colostrum, the first yellowish, highly nutritious milk that is present right after delivery, protects the child from infection before the child’s immune system has matured. Early initiation also encourages the bond between mother and baby and helps to maintain the baby’s body temperature. Breastfeeding also helps the uterus to retract, hence reducing postpartum blood loss of the mother. Prelacteal feeding (giving something other than breast milk in the first three days of life) is generally discouraged since it may inhibit breastfeeding and expose the newborn infant to illness. The Baby Friendly Hospital Initiative (BFHI) started in health facilities in Ghana in 1993. This may have had an impact on breastfeeding initiation and the giving of prelacteal feeds among children of mothers assisted at delivery by medically trained health professionals and those delivered in a health facility. Table 10.1 shows the percentage of children born in the five years preceding the survey who were ever breastfed and among children ever breastfed, the proportion who started breastfeeding within one 170 │ Nutrition Table 10.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and among children ever breastfed, percentage who started breastfeeding within one hour and within one day of birth and percentage who re- ceived a prelacteal feed, by background characteristics, Ghana 2003 All children Children ever breastfed Background characteristic Percentage ever breastfed Number of children Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Number of children ever breastfed Sex Male 96.9 1,841 46.8 76.0 18.6 1,784 Female 97.2 1,798 45.8 74.4 20.6 1,748 Residence Urban 97.8 1,204 47.2 76.7 14.3 1,178 Rural 96.7 2,435 45.9 74.5 22.2 2,354 Region Western 96.9 367 35.7 66.9 29.2 356 Central 97.9 304 14.2 82.6 11.1 298 Greater Accra 96.7 390 45.7 68.1 12.8 377 Volta 97.9 298 47.1 79.3 12.3 292 Eastern 97.0 362 39.9 76.2 26.2 351 Ashanti 95.6 685 51.8 74.6 20.4 655 Brong Ahafo 96.9 401 54.3 79.3 24.5 388 Northern 97.9 500 54.1 70.5 24.8 489 Upper East 98.4 215 86.3 92.9 8.6 212 Upper West 97.1 118 17.9 69.7 8.6 114 Mother's education No education 97.7 1,466 48.3 72.7 21.0 1,433 Primary 95.2 843 44.2 74.3 20.3 803 Middle/JSS 97.3 1,139 45.3 78.6 16.9 1,108 Secondary+ 98.2 191 46.4 79.0 21.4 187 Assistance at delivery Health professional3 96.5 1,713 51.4 80.4 14.1 1,652 Traditional birth atten- dant 97.4 1,127 38.7 71.1 24.5 1,097 Other 97.7 696 50.0 73.2 25.0 680 No one 98.6 78 26.5 63.6 26.4 77 Place of delivery Health facility 96.5 1,661 51.6 80.4 13.8 1,602 At home 97.5 1,942 42.5 71.8 24.6 1,894 Wealth quintile Lowest 97.6 941 46.6 71.7 24.0 919 Second 97.0 809 47.1 78.0 23.8 785 Middle 95.7 721 44.1 72.3 18.5 690 Fourth 97.9 617 46.0 76.9 16.7 604 Highest 96.9 551 48.1 79.3 10.4 534 Total 97.0 3,639 46.3 75.2 19.6 3,532 Note: Table is based on all births whether the children are living or dead at the time of interview. Total includes 27 chil- dren with missing information on assistance at delivery, 24 persons with missing information on place of delivery, and 14 persons with ‘other’ place of delivery, who are not shown separately. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life before the mother started breastfeed- ing regularly 3 Doctor, nurse/midwife, or auxiliary midwife Nutrition │ 171 hour and within one day of birth, and those who received a prelacteal feed. The data indicate that almost all (97 percent) Ghanaian children are breastfed for some period of time. Forty-six percent of infants were put to the breast within one hour of birth, and 75 percent started breastfeeding within the first day. The data from 2003 can be compared with similar data collected five years ago. The data show that over the past five years, there was little difference in the percentage of children ever breastfed. However, the percentage breastfed within one hour of birth and one day of birth for children born in the five years preceding the survey (46 and 75 percent, respectively) is noticeably higher than the 1998 levels (25 and 54 percent, respectively) (GSS and MI, 1999). There are no marked differences in the proportion of children ever breastfed by background characteristics. Children of mothers assisted at delivery by medically trained health professionals (doctors, nurse/midwives, or auxiliary nurses) and children delivered in a health facility are more likely to be breastfed immediately after birth or within one day of birth. Initiation of breastfeeding varies among regions. The proportion of infants that are breastfed within one hour of birth ranges from 14 percent in the Central Region to 86 percent in the Upper East Region. The Western Region has the lowest percentage of children who started breastfeeding within one day of birth (67 percent), while the Upper East Region has the highest (93 percent). Prelacteal feeding, something other than breast milk given to newborns prior to the regular flow of breastmilk, is not widely practised in Ghana. Only 20 percent of children born in the five years preceding the survey received a prelacteal feed. Prelacteal feeding is more widely practiced in rural areas (22 percent) than urban areas (14 percent). The Western Region (29 percent) has the highest reported percentage of prelacteal feeding. Children of mothers assisted at delivery by medically trained health professionals have a lower reported rate of receiving prelacteal feeds (14 percent). Women who delivered at home have higher reported rates of prelacteal feeding (25 percent) than those who delivered in a health facility (14 percent). The practice decreases from 24 percent among children of women in the lowest wealth quintile to 10 percent among children of women in the highest wealth quintile. 10.1.2 Age Pattern of Breastfeeding Breast milk is safe, convenient, uncontaminated, and contains all the nutrients needed by the baby in the first six months of life. In Ghana, all women are encouraged to breastfeed their infants exclusively for the first six months and then complement the breastfeeding with nutritious foods for at least two years. Breast milk provides protection against infection through the mother’s antibodies. Supplementing breast milk before 6 months is unnecessary and is strongly discouraged because of the likelihood of contamination, the unaffordability of breast milk substitutes, and the resulting increased risk of diarrhoeal disease. The early introduction of liquids and solids reduces breast milk output because the production and release of milk is influenced by the frequency and intensity of suckling. Breastfeeding remains the best nutrition even for infants of HIV-positive mothers and mothers whose HIV status is unknown, as it provides resistance to opportunistic diseases. Table 10.2 shows the percent distribution of youngest children under three years living with the mother by breastfeeding status and percentage of children under three years using a bottle with a nipple, according to age in months. Based on information about feeding practices in the 24 hours preceding the survey, almost all children are breastfed for at least one year, with only 4 percent of children aged 12-15 months who are not breastfed. By age 16-19 months, 14 percent of children are no longer breastfeeding. Breastfeeding decreases rapidly late in the second year of life, and by 32-35 months of age, virtually all children (94 percent) are weaned. 172 │ Nutrition Table 10.2 Breastfeeding status by age Percent distribution of youngest children under three years living with the mother by breastfeeding status and percentage of chil- dren under three years using a bottle with a nipple, according to age in months, Ghana 2003 Breastfeeding and consuming: Age in months Not breast- feeding Exclusively breastfed Plain water only Water- based liquids/ juice Other milk Comple- mentary foods Total Number of children Percentage using a bottle with a nipple1 Number of children <2 1.3 62.4 31.1 1.5 1.4 2.3 100.0 92 9.4 94 2-3 0.0 64.9 22.4 0.0 7.0 5.7 100.0 88 9.7 90 4-5 0.0 38.9 19.9 1.8 7.3 32.0 100.0 127 15.1 129 6-7 0.8 14.3 27.1 2.7 3.1 52.1 100.0 137 12.9 139 8-9 0.0 3.2 17.0 1.9 2.1 75.8 100.0 102 11.1 102 10-11 1.3 3.4 8.4 0.7 0.0 86.2 100.0 131 7.5 134 12-15 4.2 0.7 7.3 0.0 1.0 86.8 100.0 258 8.9 270 16-19 14.2 0.5 5.5 0.6 0.0 79.2 100.0 224 9.1 230 20-23 33.3 0.0 2.9 0.0 0.7 63.1 100.0 181 5.4 195 24-27 70.1 0.2 0.4 1.0 0.0 28.4 100.0 202 5.3 227 28-31 82.2 0.4 0.5 0.0 0.0 16.9 100.0 158 6.4 212 32-35 93.8 0.0 0.0 0.0 0.0 6.2 100.0 146 6.0 210 <6 0.4 53.4 24.0 1.2 5.5 15.6 100.0 308 11.8 314 6-9 0.4 9.6 22.8 2.4 2.7 62.2 100.0 239 12.2 241 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children classified as breastfeeding and consuming plain water only consume no supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, water-based liq- uids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and water-based liquids and who do not receive complementary foods are classified in the water- based liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years Despite the high breastfeeding prevalence (97 percent) in Ghana, the majority of infants are not fed in compliance with the WHO/UNICEF recommendations (World Health Assembly, 2001). These recommendations call for a period of exclusive breastfeeding for 6 months and the introduction of complementary foods after the age of 6 months. Fifty-three percent of children under 6 months of age are exclusively breastfed in Ghana. This is a slight increase over the proportion reported in the 1998 GDHS (GSS and MI, 1999). Exclusive breastfeeding drops sharply from 65 percent at age 2-3 months to 39 percent at age 4-5 months (Figure 10.1). Six percent of children age 2-3 months and 32 percent of children age 4-5 months are receiving complementary foods in addition to breast milk. This indicates that there are many infants who are at risk of being exposed to bacterial contamination and poor quality foods, even if they started out well with early initiation of breastfeeding. The duration of paid maternity leave in Ghana is 12 weeks; hence, a majority of women return to work when their children are three months old. This may account for the sharp decline in exclusive breastfeeding rates between 2-3 months and 4-5 months. Nutrition │ 173 Figure 10.1 Breastfeeding Practices by Age, Ghana 2003 <2 2-3 4-5 6-7 8-9 10-11 Age in Months 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding The use of a feeding bottle with a nipple is discouraged in Ghana. HIV-positive mothers are told not to use feeding bottles even when they choose to use formula as their feeding option. The use of a bottle with a nipple, regardless of the contents (formula or any other liquid), requires hygienic handling. As a result of inadequate and insufficient cleaning and ease of recontamination after cleaning, the nipple may house disease-causing agents transferable to the baby. Table 10.2 indicates that 12 percent of children under six months and the same proportion of children age 6-9 months are given a feeding bottle with a nipple. Bottle-feeding reaches its peak (15 percent) at age 4-5 months. The percentage of children who are bottle-fed declines to 5 percent by the age of two years. It however increases slightly after that to 6 percent by 28 months. It is assumed that by two years most children are eating solid foods, which does not require feeding by bottle. The percentage of young children bottle-fed has declined markedly over the past five years. For example, bottle-feeding at age 4-5 months has declined from 26 percent in 1998 (GSS and MI, 1999) to 15 percent in 2003. Table 10.3 presents information on the median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, the percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and the mean number of feeds (day and night), by background characteristics. The median duration of any breastfeeding in Ghana is 23 months. Regional differences in breastfeeding prevalence are minimal, with the longest duration being 28 months in the Northern Region and the lowest (19 months) in Greater Accra. The median duration of exclusive breastfeeeding is 2 months and the median duration of predominant breastfeeding is 5 months. Children are considered predominantly breastfed when they are either exclusively breastfed or receive breast milk and plain water, water-based liquids, and/or juice only (excluding other milk and solids). Frequent breastfeeding improves the production of breast milk. It is also a benefit for some mothers who breastfeed exclusively as it delays the return of fertility. 174 │ Nutrition Table 10.3 indicates that almost all breastfed children under 6 months (97 percent) are breastfed six or more times in the past 24 hours, with an average of 7 daytime feeds and 5 nighttime feeds. Table 10.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Ghana 2003 Breastfeeding children under six months2 Median duration (months) of breastfeeding1 Background characteristic Any breast- feeding Exclusive breastfeeding Predominant breastfeeding3 Number of children Percentage breastfed 6+ times in last 24 hours Mean number of day feeds Mean number of night feeds Number of chil- dren Sex Male 22.8 2.8 5.1 1,090 96.0 7.7 4.6 168 Female 22.3 1.2 5.1 1,085 97.9 7.1 4.4 143 Residence Urban 20.4 4.1 5.0 732 99.3 8.1 4.3 97 Rural 23.3 1.4 5.1 1,442 95.8 7.1 4.6 214 Region Western 20.2 0.6 2.4 215 (100.0) (7.8) (4.9) 34 Central 21.3 0.5 6.3 184 * * * 22 Greater Accra 19.3 5.7 6.9 229 (100.0) (7.7) (4.9) 28 Volta 22.9 3.2 4.1 184 * * * 27 Eastern 21.2 2.9 3.4 220 * * * 23 Ashanti 20.6 1.9 3.2 407 (96.3) (7.8) (4.4) 59 Brong Ahafo 22.6 3.5 6.2 240 (100.0) (9.0) (4.3) 39 Northern 28.2 0.7 7.4 297 92.5 6.2 3.5 47 Upper East 26.4 1.4 8.3 129 (97.2) (4.8) (4.7) 20 Upper West 27.4 5.1 7.0 70 (84.3) (10.0) (4.7) 13 Mother's education No education 25.3 2.0 6.4 863 94.5 7.2 4.3 139 Primary 21.6 1.9 4.1 511 98.2 7.4 5.0 66 Middle/JSS 20.8 2.6 4.2 676 99.0 7.6 4.5 96 Secondary + 17.4 2.9 4.1 124 * * * 11 Wealth quintile Lowest 26.8 2.4 6.9 548 96.0 6.9 4.7 76 Second 22.8 0.7 5.2 477 94.4 7.4 4.5 81 Middle 21.6 1.8 4.6 450 97.2 7.9 4.6 78 Fourth 20.6 3.0 3.9 364 (100.0) (7.5) (4.3) 42 Highest 19.2 3.7 4.4 336 (100.0) (7.8) (4.3) 34 Total 22.5 2.3 5.1 2,175 96.9 7.4 4.5 312 Mean for all children 22.2 3.8 6.9 na na na na na Note: Median and mean durations are based on current status. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Percentages in parentheses are based on 25-49 unweighted cases. na = Not applicable 1 It is assumed that non-last-born children or last born child not living with the mother are not currently breastfeeding 2 Excludes children who do not have a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, water-based liquids, and/or juice only (excludes other milk) Nutrition │ 175 Although the median duration of breastfeeding is slightly longer in the rural areas (23 months) than in the urban areas (20 months), exclusive breastfeeding is somewhat shorter in rural areas (1 month) than in urban areas (4 months). Exclusive breastfeeding rates increase with increases in mother’s level of education and wealth quintile. 10.2 COMPLEMENTARY FEEDING 10.2.1 Types of Complementary Foods In line with the WHO/UNICEF global strategy on infant and young child feeding, the Ghana Health Service recommends 6 months as the optimal age to introduce complementary foods. This is because after 6 months of age, breast milk alone is not sufficient to meet all the nutritional requirements of the infant. The period after 6 months of age is a crucial time for children because they are being introduced to the family diet, and a number of issues come into force. These include income, hygiene, general care, and choice of complementary foods. The spread of HIV/AIDS has created another challenge for breastfeeding. Ghana has in place legislation under the Food and Drugs Law to control the marketing of breast milk substitutes by baby food manufacturers. The legislative instrument Breastfeeding Promotions Regulation 2000 (L.I.1667) went into effect in May 2000. The purpose is to prevent the aggressive marketing of breast milk substitutes, hence protecting breastfeeding practices. Table 10.4 shows the percentage of youngest children under three years of age living with the mother who consumed specific foods in the day or night preceding the interview, by breastfeeding status and age. It is important to note that the categories presented in Table 10.4 are not mutually exclusive. The child who consumed milk could also have consumed semi-solid foods. The data show that among breastfeeding infants in Ghana, very few receive infant formula. Forty-seven percent of breastfeeding children age 4-5 months are introduced to solid or semi-solid foods and 30 percent are introduced to foods made from grains. Table 10.4 also shows that at the age of 6-9 months, more than 70 percent of breastfeeding infants received solid foods in the 24 hours before the survey. The majority (53 percent) consumed food made from grains, 29 percent received fruits and vegetables, and 21 percent received animal products (in addition to breast milk). Foods rich in vitamin A were consumed by only 24 percent of breastfeeding infants 6-9 months, and fats by only 8 percent. The findings indicate that, in terms of nutrition, the food mixtures given during this transition period are somewhat limited. By 10-11 months, almost all (91 percent) infants are receiving solids foods. This is a marked improvement over the 1998 GDHS figure of 73 percent for this age group (GSS and MI, 1999). By that same age, 10-11 months, a larger proportion are consuming grains (76 percent), fruits and vegetables (53 percent), and foods rich in vitamin A (46 percent). Although animal products (a major source of iron and vitamin A) are consumed by 46 percent of children in this age group, consumption of animal products is not as prevalent as the other foods. By 20- 23 months, grains (84 percent), fruits and vegetables (62 percent), and foods rich in vitamin A (53 percent) are consumed by the majority of breastfeeding children; consumption of animal products increases slightly to 58 percent. Few children under two years of age are not breastfed. For non-breastfeeding children about two years of age, the rates of consumption of food are about the same as for breastfeeding children; however, these children do not have the added nutritional benefit of breast milk, and very few receive other milk, but these children do consume more meat than breastfed children. 176 │ Nutrition Table 10.4 Foods consumed by children in the day or night preceding the interview Percentage of youngest children under three years of age living with the mother who consumed specific foods in the day or night preced- ing the interview, by breastfeeding status and age, Ghana 2003 Solid/semi-solid foods Age in months Infant formula Other milk/ cheese/ yoghurt Other liquids1 Food made from grains Fruits/ vege- tables2 Food made from roots/ tubers Food made from legumes Meat/ fish/ shellfish/ poultry/ eggs Food made with oil/ fat/ but- ter Fruits and vegeta- bles rich in vita- min A3 Any solid or semi- solid food Number of chil- dren BREASTFEEDING CHILDREN <2 1.4 1.4 2.9 2.3 0.4 0.4 0.0 0.0 0.0 0.4 3.3 91 2-3 1.7 7.8 1.7 5.7 1.1 0.0 0.0 0.0 0.0 1.1 15.6 88 4-5 6.3 9.9 7.1 30.3 3.6 1.7 0.9 0.9 0.0 2.7 46.5 127 6-7 9.9 13.1 15.7 42.9 13.5 6.9 6.7 14.2 6.0 11.6 62.0 136 8-9 12.9 19.4 32.8 66.8 49.5 19.6 14.3 29.9 10.9 39.5 83.2 102 10-11 6.7 13.8 25.2 75.7 53.1 30.4 13.5 46.0 17.1 45.7 90.8 129 12-15 6.3 13.9 26.8 78.9 60.9 33.0 20.3 58.4 19.8 50.2 96.0 247 16-19 4.8 17.0 34.3 79.5 62.2 30.6 22.2 58.1 23.7 48.6 95.7 192 20-23 6.2 14.8 36.9 84.3 61.7 39.6 26.6 58.4 25.3 52.7 99.0 121 24-35 3.1 7.1 34.1 86.5 57.3 39.0 23.9 50.7 23.6 47.5 96.3 98 <6 3.5 6.8 4.3 14.9 1.9 0.9 0.4 0.4 0.0 1.6 24.8 306 6-9 11.2 15.8 23.0 53.1 28.9 12.3 10.0 20.9 8.1 23.5 71.1 238 NON-BREASTFEEDING CHILDREN 16-19 (17.5) (37.2) (39.6) (95.2) (72.5) (53.7) (30.1) (83.0) (42.8) (45.6) (100.0) 32 20-23 7.3 25.9 37.4 93.2 70.3 47.4 31.4 78.6 43.9 60.4 100.0 60 24-35 4.5 19.2 43.0 89.2 73.4 49.5 27.1 71.8 28.7 62.0 99.0 409 Note: Breastfeeding status and food consumed refer to a "24-hour" period (yesterday and last night). Percentages in parentheses are based on 25-49 un- weighted cases. 1 Does not include plain water 2 Includes fruits and vegetables rich in vitamin A 3 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A 10.2.2 Frequency of Foods Consumed by Children Table 10.5 and Figure 10.2 present the mean number of times specific foods were consumed in the day or night preceding the interview by youngest children under three years of age living with the mother, according to breastfeeding status and age. Infants and young children eat small meals and, therefore, frequent meals are necessary to provide them with the required nutrients. It is recommended that children age 6-8 months eat a minimum of 2-3 meals and snacks per day in addition to breast milk. For children over 8 months of age, 3-5 meals should be consumed by breastfed children (WHO, 1998). The number of meals required is based on the energy density of the foods being fed. Consuming an appropriate variety of foods is essential for the child’s nutrition. Table 10.5 shows that on average foods made from grains are given to breastfeeding children only once a day from age 6-9 months, which is the best time for introducing complementary foods. Foods containing grain include flour made from maize, millet, or sorghum, which is used to make a fermented or Nutrition │ 177 unfermented porridge (koko). This food is consumed a little more than once a day through one year of age and twice a day at about two years of age for breastfed children. At two years, non-breastfeeding children are receiving foods made from grain twice a day like breastfeeding children. Fruits and vegetables are consumed about twice a day by both breastfeeding and non-breastfeeding children at about two years. Foods enriched with oil/fat/butter—thereby increasing caloric intake—are consumed less than once a day. Animal products are consumed an average of once a day by both groups of children at two years of age. Table 10.6 presents the mean number of days specific foods were received in the seven days preceding the interview by youngest children under three years of age, living with the mother, by breastfeeding status and age. Plain water is given almost on a daily basis. It also shows that foods most commonly given to children are those made from grains. They are given about four times a week. Animal products and green leafy vegetables are given three times a week. Table 10.5 Frequency of foods consumed by children in the day or night preceding the interview Mean number of times specific foods were consumed in the day or night preceding the interview by youngest children under three years of age living with the mother, according to breastfeeding status and age, Ghana 2003 Solid/semi-solid foods Age in months Infant formula Other milk/ cheese/ yoghurt Other liquids1 Food made from grains Fruits/ vegetables2 Food made from roots/ tubers Food made from leg- umes Meat/ fish/ shell- fish/ poul- try/ eggs Food made with oil/ fat/ butter Fruits and vegetables rich in vitamin A3 Number of chil- dren BREASTFEEDING CHILDREN <2 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 91 2-3 0.1 0.1 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 88 4-5 0.1 0.2 0.1 0.5 0.1 0.0 0.0 0.0 0.0 0.1 127 6-7 0.1 0.1 0.2 0.8 0.3 0.1 0.1 0.2 0.1 0.2 136 8-9 0.3 0.4 0.6 1.2 1.1 0.2 0.2 0.5 0.2 0.7 102 10-11 0.3 0.4 0.5 1.5 1.3 0.5 0.3 0.7 0.3 0.9 129 12-15 0.1 0.2 0.4 1.4 1.3 0.4 0.3 1.0 0.3 0.9 247 16-19 0.1 0.2 0.5 1.4 1.4 0.4 0.3 1.0 0.3 0.9 192 20-23 0.1 0.3 0.7 1.8 1.5 0.5 0.3 0.9 0.3 1.1 121 24-35 0.0 0.1 0.5 1.8 1.4 0.6 0.3 0.9 0.3 1.0 98 <6 0.1 0.1 0.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 306 6-9 0.2 0.2 0.4 1.0 0.6 0.1 0.1 0.3 0.1 0.4 238 NON-BREASTFEEDING CHILDREN 16-19 (0.3) (0.4) (0.6) (2.0) (1.7) (0.6) (0.3) (1.8) (0.5) (1.0) 32 20-23 0.1 0.5 0.6 1.7 2.0 0.7 0.4 1.4 0.5 1.2 60 24-35 0.1 0.3 0.7 1.7 2.0 0.7 0.3 1.4 0.4 1.3 409 Note: Breastfeeding status and food consumed refer to a "24-hour" period (yesterday and last night). Percentages in parentheses are based on 25-49 unweighted cases. 1 Does not include plain water 2 Includes fruits and vegetables rich in vitamin A 3 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables rich in vitamin A 178 │ Nutrition 0.1 0.4 1.0 1.1 1.7 1.9 2.2 2.3 2.6 2.5 3.0 3.3 3.0 3.3 3.1 3.0 <2 2-3 4-5 6-7 8-9 10-11 12-15 16-19 20-23 24-35 Child's age (months) 0.0 1.0 2.0 3.0 4.0 Mean number of meals (solid/semisolid food) Breastfeeding Not breastfeeding Figure 10.2 Frequency of Meals Consumed by Children under 36 Months of Age Living with Their Mother, by Breastfeeding Status, Ghana 2003 Note: Data are not shown for groups with fewer than 25 unweighted cases. GDHS 2003 Table 10.6 Frequency of foods consumed by children in preceding seven days Mean number of days specific foods were received in the seven days preceding the interview by youngest children under three years of age living with the mother, by breastfeeding status and age, Ghana 2003 Liquids Solid/semisolid foods Fruits and vegetables rich in vitamin A Age in months Plain water Infant formula Other milk Fruit juice Other liquids Food made from grains Food made from roots/ tubers Fruits and vegetables not rich in vitamin A Food made from leg- umes Cheese/ yoghurt Meat/ fish/ shellfish/ poultry/ eggs Food made with oil/ fat/ butter Pumpkin/ red or yellow yams/ carrots/ red sweet potatoes Green leafy vegeta- bles Mango/ papaya/ other local fruits rich in vitamin A Num- ber of chil- dren BREASTFEEDING CHILDREN <2 2.2 0.1 0.1 0.0 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 91 2-3 2.0 0.2 0.4 0.1 0.1 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 88 4-5 3.9 0.4 0.7 0.2 0.1 2.0 0.1 0.1 0.1 0.0 0.1 0.0 0.1 0.1 0.0 127 6-7 5.7 0.8 1.0 0.4 0.4 2.9 0.3 0.3 0.4 0.1 0.6 0.2 0.2 0.4 0.2 136 8-9 6.5 0.9 1.0 1.1 0.5 4.3 1.2 1.5 0.9 0.2 1.6 0.6 0.7 1.6 0.5 102 10-11 6.7 0.5 0.6 0.9 0.7 4.7 1.8 1.5 0.9 0.1 2.8 0.8 0.8 2.0 0.6 129 12-15 6.8 0.4 0.9 1.0 0.7 5.0 1.8 1.8 1.2 0.1 3.6 1.0 1.1 2.3 0.5 247 16-19 6.8 0.3 0.8 1.3 1.0 5.1 1.8 2.1 1.4 0.2 3.9 1.3 1.1 2.4 0.8 192 20-23 6.9 0.4 0.7 1.0 1.6 5.5 2.3 1.9 1.3 0.1 3.5 1.3 1.5 2.4 0.7 121 24-35 6.9 0.2 0.3 0.9 1.3 5.9 2.2 1.8 1.4 0.1 3.2 1.5 1.0 2.6 0.7 98 <6 2.9 0.2 0.5 0.1 0.1 0.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 306 6-9 6.1 0.8 1.0 0.7 0.5 3.5 0.6 0.9 0.6 0.1 1.1 0.4 0.4 0.9 0.3 238 Total 5.8 0.4 0.7 0.8 0.7 3.9 1.3 1.3 0.8 0.1 2.2 0.7 0.7 1.6 0.4 1,330 NON-BREASTFEEDING CHILDREN 16-19 (6.9) (1.3) (2.0) (1.4) (0.9) (6.0) (2.9) (3.2) (1.5) (0.2) (5.4) (2.3) (1.1) (2.6) (1.2) 32 20-23 6.9 0.6 1.3 1.8 0.9 5.6 2.9 3.4 1.8 0.6 4.9 2.1 2.0 2.3 0.8 60 24-35 6.8 0.3 1.1 1.8 1.3 5.7 2.7 2.6 1.6 0.3 4.6 1.5 1.6 2.6 1.1 409 Total 6.8 0.4 1.2 1.8 1.2 5.7 2.7 2.7 1.6 0.3 4.6 1.7 1.6 2.5 1.0 516 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Percentages in parentheses are based on 25-49 unweighted cases. Nutrition │ 179 10.3 MICRONUTRIENTS Micronutrients are essential for the metabolic processes in the body and they play a major role in the nutrition and health of an individual. The 2003 GDHS collected various types of data that are useful in assessing the micronutrient status of young children and women. 10.3.1 Iodisation of Household Salt In Ghana, a number of programmes aim at reducing micronutrient deficiencies. These include salt iodisation and vitamin A supplementation for children under five years of age through mass campaigns linked to national immunisation days. Vitamin A supplementation for children under five years of age and postpartum women (not later than 6 weeks after delivery) through routine health services has also begun but on a limited scale. Women are given vitamin A supplements during the postpartum period to assist both the mother and her breastfeeding children. Disorders induced by dietary iodine deficiency constitute a major global nutrition concern. A lack of sufficient iodine can lead to goitre, hypothyroidism, impaired mental functions, retarded mental and physical development, and diminished school performance. Iodine deficiency in the foetus leads to increased rates of abortion, stillbirths, congenital anomalies, cretinism, psychomotor defects, and neonatal mortality. Iodine deficiency can be avoided by using salt that has been fortified with iodine (iodised salt). Table 10.7 presents the percent distribution of households with salt tested for iodine content by level of iodine in salt (parts per million), percentage of households tested, and percentage of households with no salt, according to background characteristics. It shows that 90 percent of the households interviewed in the 2003 GDHS had their salt tested for iodine, while 9 percent had no salt available in the household. Fifty-nine percent of households are consuming salt that is not iodised, 13 percent of households are consuming inadequately iodised salt (<15 ppm), and only 28 percent are consuming adequately iodised salt (15+ ppm). Although Ghana has a salt iodisation law, there is need for more stringent enforcement and monitoring. The proportion of households with adequately iodised salt in rural areas (16 percent) is markedly lower than in the urban areas (44 percent). There are equally marked regional differences in adequacy of iodine levels in salt, ranging from 6 percent of households in the Northern and Upper East regions to 50 percent in the Greater Accra Region. 10.3.2 Micronutrient Intake among Children Vitamin A is an essential micronutrient for the normal functioning of the visual system, growth and develoment, resistance to disease, and for reproduction. Vitamin A is believed to improve immunity and, hence, reduce mortality rates in children and women. Table 10.8 shows the percentage of children under age three who consumed fruits and vegetables rich in vitamin A in the seven days preceding the survey, and the percentage of children age 6-59 months who received vitamin A supplements in the 6 months preceding the survey. It also indicates the percentage of children under five living in households that have adequately iodised salt. Table 10.8 shows that 41 percent of children under three who live with their mothers consume fruits and vegetables rich in vitamin A. The fact that 78 percent of children 6-59 months are reported to have received a vitamin A supplement in the previous 6 months is encouraging. The data indicate that only 23 percent of children under the age of three live in households that use adequately iodised salt. Consumption of vitamin A supplements is highest in the age group 24-35 months. There are no marked differences between the sexes on the consumption of vegetables and fruits rich in vitamin A, vitamin A supplements, or iodised salt. There is also little difference by birth order in the consumption of 180 │ Nutrition vitamin A supplements or foods rich in vitamin A. However, children of birth order greater than three are less likely than children of birth order 1-3, to be living in households that use adequately iodised salt. As expected, non-breastfeeding children consume more micronutrient-rich foods than breastfeeding children. There are minimal differences between urban and rural children in the consumption of fruits and vegetables rich in vitamin A and vitamin A supplementation. Data also indicate that the consumption of foods rich in vitamin A is higher for children of women with a secondary or higher education compared with those with primary or no education. There are marked regional differences in micronutrient intake among children. For example, the level of vitamin A supplementation among children ranges from 67 percent in the Central Region to 86 percent in the Upper East Region. Table 10.7 Iodisation of household salt Percent distribution of households with salt tested for iodine content by level of iodine in salt (parts per million), percentage of households tested, and percentage of households with no salt, according to background characteristics, Ghana 2003 Iodine content among households tested Background characteristic None (0 ppm) Inadequate (<15 ppm) Adequate (15+ ppm) Total Number of households Percentage of households tested Percentage of households with no salt Number of households Residence Urban 43.9 12.4 43.7 100.0 2,460 85.7 12.8 2,870 Rural 69.9 13.9 16.2 100.0 3,159 93.4 5.2 3,381 Region Western 45.5 15.5 39.1 100.0 544 88.9 10.4 612 Central 81.1 3.7 15.1 100.0 541 92.1 7.9 587 Greater Accra 47.0 3.1 49.9 100.0 731 82.2 15.3 890 Volta 78.6 6.7 14.7 100.0 491 91.2 6.3 538 Eastern 73.7 7.7 18.5 100.0 649 88.7 8.0 732 Ashanti 37.0 26.0 36.9 100.0 1,191 90.7 9.0 1,313 Brong Ahafo 43.0 21.9 35.1 100.0 614 92.3 7.2 665 Northern 87.7 6.5 5.8 100.0 462 94.9 4.3 487 Upper East 89.7 4.4 5.9 100.0 259 92.5 5.1 280 Upper West 36.8 35.1 28.1 100.0 137 93.2 1.3 147 Wealth quintile Lowest 80.2 11.0 8.8 100.0 932 96.0 2.7 971 Second 73.2 13.8 13.0 100.0 1,100 94.2 4.7 1,168 Middle 63.4 16.5 20.1 100.0 1,186 90.2 7.9 1,315 Fourth 53.4 15.4 31.2 100.0 1,248 85.9 12.9 1,452 Highest 27.5 8.7 63.8 100.0 1,152 85.7 12.5 1,345 Total 58.5 13.2 28.3 100.0 5,619 89.9 8.7 6,251 ppm=parts per million Nutrition │ 181 Table 10.8 Micronutrient intake among children Percentage of youngest children under age three living with the mother who consumed fruits and vegetables rich in vita- min A in the seven days preceding the survey, percentage of children age 6-59 months who received vitamin A supple- ments in the six months preceding the survey, and percentage of children under five living in households using ade- quately iodised salt, by background characteristics, Ghana 2003 Background characteristic Consumed fruits and vegetables rich in vitamin A1 Number of children un- der age three Consumed vitamin A supplements Number of children age 6-59 months Percentage living in households using ade- quately io- dised salt2 Number of children un- der five Age in months <6 1.5 308 na na 23.7 299 6-9 23.4 239 65.4 241 22.3 230 10-11 46.0 131 74.3 134 16.8 127 12-23 51.4 662 79.1 695 21.5 662 24-35 59.2 507 82.8 649 24.7 620 36-47 na na 80.8 695 20.2 655 48-59 na na 75.9 612 25.3 577 Sex Male 42.1 934 79.8 1,515 22.2 1,591 Female 40.3 912 76.9 1,511 23.0 1,577 Birth order 1 41.4 391 77.0 690 27.8 715 2-3 42.5 693 78.1 1,067 26.4 1,118 4-5 39.3 376 78.1 687 17.3 711 6+ 40.8 385 80.7 581 15.9 624 Breastfeeding status Breastfeeding 33.6 1,330 75.5 1,052 19.9 1,304 Not breastfeeding 60.5 509 79.8 1,930 24.6 1,822 Residence Urban 40.8 629 80.6 1,017 42.5 1,037 Rural 41.5 1,217 77.2 2,009 12.9 2,131 Region Western 40.5 168 80.1 297 31.5 318 Central 49.6 156 66.8 259 5.6 263 Greater Accra 34.5 194 74.3 339 40.9 328 Volta 39.8 151 82.2 242 13.6 252 Eastern 50.5 184 78.4 313 11.8 320 Ashanti 51.3 345 82.0 563 39.0 588 Brong Ahafo 47.7 206 75.1 328 32.8 353 Northern 27.2 263 78.3 409 4.1 445 Upper East 23.9 120 85.5 186 3.3 202 Upper West 34.1 60 84.8 91 26.0 99 Mother's education No education 33.8 744 74.5 1,200 11.8 1,295 Primary 42.5 421 75.0 694 19.0 707 Middle/JSS 47.2 574 84.1 958 31.8 992 Secondary+ 56.5 107 86.2 174 64.8 175 Mother's age at birth <20 41.1 207 73.9 339 21.2 349 20-24 42.5 447 76.0 765 22.5 774 25-29 39.7 464 79.9 756 24.5 807 30-34 39.5 359 79.3 587 21.7 616 35-49 43.3 370 81.2 579 22.1 622 Wealth quintile Lowest 32.7 486 76.3 788 8.2 840 Second 48.0 398 75.6 658 12.7 718 Middle 39.6 369 79.2 576 18.9 603 Fourth 43.8 308 78.2 530 29.6 542 Highest 45.7 284 84.8 474 60.6 466 Total 41.2 1,846 78.4 3,026 22.6 3,169 Note: Information on vitamin A supplements is based on mother's recall. Figures in parentheses are based on 25-49 un- weighted cases. na = Not applicable 1 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mango, papaya, and other fruits and vegetables that are rich in vitamin A 2 Salt containing 15 ppm of iodine or more. Excludes children in households in which salt was not tested. 182 │ Nutrition 10.3.3 Micronutrient Intake Among Mothers It is recommended that mothers in Ghana be given two doses of vitamin A (24 hours apart) within 8 weeks of delivery. Mothers who deliver at health institutions are to receive a dose of vitamin A before they are discharged from the institution and given the second dose to take at home the following day. This is to boost the vitamin A level for their benefit and, through their breast milk, for the benefit of the child. Table 10.9 shows the percentage of women with a birth in the five years preceding the survey who received a vitamin A dose in the first two months after delivery, the percentage who experienced night blindness during pregnancy, the percentage who took iron tablets for a specific number of days, and the percentage who live in households using adequately iodised salt, by background characteristics. The table shows that only 43 percent of mothers with a birth in the last five years reported receiving a vitamin A dose postpartum. Vitamin A supplementation is slightly higher among mothers of first births. Vitamin A supplementation among women is higher in urban areas (50 percent) than in rural areas (39 percent). The Upper East Region, where the programme was started before other regions, has the highest level of postpartum supplementation of vitamin A (73 percent), while the Western Region has the lowest (21 percent). This indicates the need for strengthening routine supplementation by health services immediately after a birth, because it is the best opportunity to capture most of the mothers. Table 10.9 also shows that 8 percent of interviewed women reported night blindness during pregnancy. When the data are adjusted for blindness not attributed to vitamin A deficiency during pregnancy, only 2 percent of women reported night blindness during their last pregnancy. Women age 25- 29 and those who have had six or more births are more likely to report a higher prevalence of night blindness associated with vitamin A deficiency during pregnancy. Night blindness is notably higher in the Upper West, Volta, and Northern regions of the country. Prevalence of night blindness is also higher among women with little or no education and women from the two lowest wealth quintiles. Iron-deficiency anaemia is a major threat to maternal health; it contributes to low birth weight, lowered resistance to infection, poor cognitive development, and decreased work capacity. Furthermore, anaemia increases morbidity from infections because it adversely affects the body’s immune response. According to the government policy, all pregnant mothers attending antenatal clinics are supposed to be given iron tablets during their pregnancy. International recommendations are that iron tablets be taken daily for at least three months during pregnancy. It should be noted that although four in five women reported having taken iron tablets during their pregnancy, only 40 percent took them for 90 or more days (Table 10.9). According to the baseline study on prevalence and etiology of anaemia conducted in 1995 (GHS, 1995), 65 percent of pregnant women, 59 percent of lactating mothers, 71 percent of school-age children and 84 percent of preschool children were found to be anaemic. This situation poses a challenge to the Ghana government if morbidity and mortality due to anaemia and other micronutrient deficiencies is to be reduced. Table 10.9 shows that only 24 percent of women live in households where adequately iodised salt is used. There are no marked differences in the level of micronutrient supplementation by mother’s age at birth or number of children ever born. Nutrition │ 183 Table 10.9 Micronutrient intake among mothers Percentage of women with a birth in the five years preceding the survey who received a vitamin A dose in the first two months after delivery, per- centage who suffered from night blindness during pregnancy, percentage who took iron tablets or syrup for specific number of days, and percentage who live in households using adequately iodised salt, by background characteristics, Ghana 2003 Night blindness dur- ing pregnancy Number of days iron tablets taken during pregnancy Background characteristic Received vitamin A dose post- partum1 Reported Adjusted2 None <60 60-89 90+ Don't know Missing Number of women Percentage living in households using ade- quately iodised salt3 Number of women Age at birth <20 42.0 6.5 1.4 18.7 21.7 9.5 40.2 9.8 0.1 297 21.9 277 20-24 42.6 7.3 1.7 18.0 22.9 8.8 40.7 9.7 0.0 607 24.3 570 25-29 41.0 8.3 2.5 18.0 19.3 9.6 40.3 12.4 0.4 647 25.1 615 30-34 44.2 5.7 1.5 19.7 18.3 8.2 42.6 9.8 1.3 508 24.5 486 35-49 45.3 9.6 2.1 20.2 21.7 9.0 35.3 12.1 1.8 586 23.3 564 Number of children ever born 1 47.1 6.9 1.6 16.8 19.1 11.4 42.4 10.2 0.0 565 28.6 538 2-3 41.5 7.3 1.9 17.4 20.9 6.2 42.2 12.2 1.1 940 28.5 887 4-5 42.7 6.6 1.4 19.7 19.3 8.5 41.2 10.0 1.2 582 18.9 548 6+ 41.9 10.1 2.8 22.7 23.6 11.8 31.1 10.2 0.5 558 17.5 538 Residence Urban 49.7 5.9 2.0 12.6 12.8 6.7 54.9 12.1 0.9 946 43.8 881 Rural 39.3 8.6 1.9 22.4 25.2 10.2 31.2 10.2 0.7 1,699 13.4 1,631 Region Western 20.5 7.0 2.3 21.5 17.0 9.2 39.5 12.9 0.0 246 34.8 233 Central 39.7 4.6 1.3 17.0 12.0 13.4 57.2 0.5 0.0 211 6.9 201 Greater Accra 40.5 7.1 2.0 14.1 10.2 4.3 56.4 14.6 0.3 303 42.7 271 Volta 24.1 12.0 5.0 15.3 50.0 13.8 15.6 5.0 0.3 220 12.7 206 Eastern 34.3 6.5 0.5 21.4 26.8 8.9 35.2 5.0 2.7 266 13.0 251 Ashanti 50.7 4.0 0.8 14.4 14.4 13.9 53.9 2.3 1.0 507 39.5 486 Brong Ahafo 53.2 6.7 0.4 6.8 15.0 10.1 39.2 28.6 0.3 297 35.6 285 Northern 46.8 12.8 3.7 31.8 32.2 2.0 11.9 21.4 0.7 346 4.3 338 Upper East 72.9 9.7 0.6 25.6 7.6 4.5 58.0 3.4 0.9 166 3.8 161 Upper West 47.7 12.0 5.6 39.2 33.0 5.7 7.8 13.1 1.1 83 26.2 79 Education No education 43.4 11.0 2.4 27.5 23.9 8.1 27.9 12.0 0.7 1,025 11.9 989 Primary 39.2 5.5 1.4 15.9 21.7 8.7 43.2 9.9 0.6 589 20.1 552 Middle/JSS 44.3 5.1 1.9 11.7 18.5 10.2 48.2 10.4 1.1 879 34.1 827 Secondary+ 48.0 8.2 0.7 14.5 9.1 8.9 56.7 10.8 0.0 153 65.2 143 Wealth quintile Lowest 40.5 10.1 2.1 29.5 24.9 7.7 25.1 12.1 0.7 648 8.0 629 Second 39.5 10.4 2.7 19.2 26.8 12.3 31.8 9.7 0.3 557 12.6 541 Middle 39.4 5.7 1.5 16.7 25.0 10.8 38.6 8.1 0.8 534 20.2 493 Fourth 48.1 6.8 1.5 14.3 13.0 8.2 49.9 14.0 0.5 474 31.0 451 Highest 50.4 3.9 1.5 10.4 10.0 5.3 61.9 10.6 1.7 433 61.9 398 Total 43.0 7.7 1.9 18.9 20.7 9.0 39.7 10.9 0.8 2,645 24.1 2,512 Note: For women with two or more live births in the five-year period, data refer to the most recent birth. 1 In the first two months after delivery 2 Women who reported night blindness but did not report difficulty with vision during the day 3 Salt containing 15 ppm of iodine or more. Excludes women in households in which salt was not tested. 184 │ Nutrition 10.3.4 Prevalence of Anaemia in Children The most common causes of anaemia in Ghana are inadequate dietary intake of iron, malaria, and intestinal worm infestation (GHS, 2003a). Iron and folic acid supplementation and anti-malarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bed nets by pregnant women and children under five, and six-month de-worming for children age two to five years are some of the measures being pursued by the Ghana Health Service to reduce anaemia prevalence among vulnerable groups. Table 10.10 shows the percentage of children age 6-59 months classified as having anaemia, by background characteristics. Three-quarters of Ghanaian children 6-59 months old have some level of anaemia, including 23 percent of children who are mildly anaemic, 47 percent who are moderately anaemic, and 6 percent who are severely anaemic. Prevalence of anaemia among children is higher in rural areas (80 percent) than in urban areas (68 percent). The Northern Region has the highest prevalence of anaemia (83 percent), while the Greater Accra Region has the lowest (61 percent). Prevalence of anaemia is also higher among children of mothers with little or no education, young mothers (15-19 years), and children in households in the two poorest wealth quintiles. This indicates the widespread nature of the problem and the need to intensify the various components of the anaemia control strategy. 10.3.5 Prevalence of Anaemia in Women Table 10.11 presents information on prevalence of anaemia among women age 15-49. The prevalence of anaemia is less pronounced among women than among children. Forty-five percent of women age 15-49 are anaemic, with 35 percent mildly anaemic, 9 percent moderately anaemic, and less than 1 percent severely anaemic. Differences by urban-rural place of residence are not large. About half of women in seven regions in Ghana (including Greater Accra) suffer from some degree of anaemia. Women residing in Brong Ahafo Region are least likely to be anaemic. Lack of education, being pregnant, and living in poor households are also associated with higher prevalence of anaemia in women of childbearing age. Nutrition │ 185 Table 10.10 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteris- tics, Ghana 2003 Anaemia status Background characteristic Any anaemia Mild anae- mia 10.0- 10.9 g/dl) Moderate anaemia (7.0-9.9 g/dl) Severe anaemia (below 7.0 g/dl) Number of children Age in months 6-9 74.5 19.5 46.6 8.4 227 10-11 85.7 24.0 48.6 13.0 121 12-23 83.5 19.2 54.2 10.1 661 24-35 76.4 21.3 50.2 5.0 635 36-47 73.5 24.4 45.9 3.2 716 48-59 69.5 28.1 38.8 2.5 632 Sex Male 76.2 22.5 47.9 5.8 1,481 Female 75.9 23.5 46.7 5.7 1,511 Birth order1 1 75.4 24.1 46.0 5.2 566 2-3 76.6 23.2 48.5 4.8 935 4-5 76.4 21.0 47.5 7.9 624 6+ 78.1 21.4 50.3 6.4 537 Birth interval in months1 First birth2 75.1 24.0 45.5 5.5 573 <24 81.6 22.0 50.0 9.6 273 24-47 78.9 21.8 51.1 6.0 1,142 48+ 72.0 22.8 44.3 4.9 673 Residence Urban 67.8 26.1 37.8 4.0 984 Rural 80.1 21.5 51.9 6.7 2,008 Region Western 80.4 23.8 47.6 9.0 293 Central 76.8 24.5 46.4 5.9 267 Greater Accra 61.3 24.0 33.2 4.1 324 Volta 72.7 25.3 45.6 1.8 255 Eastern 74.4 24.2 46.5 3.7 292 Ashanti 79.0 23.1 48.5 7.4 553 Brong Ahafo 74.9 22.4 45.9 6.6 333 Northern 82.5 18.7 58.1 5.7 403 Upper East 79.1 22.2 49.4 7.5 186 Upper West 78.3 23.9 52.0 2.5 86 Mother's education3 No education 81.6 20.4 55.2 6.0 1,097 Primary 77.9 23.6 47.3 7.0 625 Middle/JSS 71.8 24.0 41.7 6.0 859 Secondary+ 60.6 27.9 31.8 0.8 154 Mother's age3 15-19 86.5 29.5 47.3 9.7 76 20-24 79.1 17.9 53.0 8.2 490 25-29 77.5 22.8 49.7 5.0 706 30-34 75.1 25.8 44.5 4.9 607 35-49 74.3 22.5 46.0 5.8 857 Mother’s status Mother interviewed 76.6 22.5 48.1 6.0 2,660 Mother not interviewed but in the household 73.5 27.4 41.5 4.6 75 Mother not in the household4 71.2 26.4 40.7 4.1 257 Wealth quintile Lowest 82.2 19.2 55.5 7.5 774 Second 81.7 23.0 51.7 7.1 660 Middle 79.2 23.4 50.0 5.8 597 Fourth 68.8 23.5 40.7 4.7 521 Highest 61.1 28.6 30.4 2.1 441 Total 76.1 23.0 47.3 5.8 2,992 Note: Table is based on children who stayed in the household the night before the interview. g/dl = grams per deciliter 1 Excludes children whose mothers were not interviewed 2 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 3 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the household schedules. 4 Includes children whose mothers are deceased 186 │ Nutrition Table 10.11 Prevalence of anaemia in women Percentage of women age 15-49 with anaemia, by background characteristics, Ghana 2003 Anaemia status Background characteristic Any anaemia Mild anaemia Moderate anaemia Severe anaemia Number of women Age1 15-19 45.8 37.2 7.9 0.7 1,060 20-24 45.0 34.1 10.2 0.7 939 25-29 42.5 34.1 8.1 0.2 893 30-34 43.8 35.9 7.1 0.8 729 35-39 47.5 36.1 9.8 1.6 669 40-44 43.9 32.4 10.9 0.6 529 45-49 44.5 32.4 10.5 1.6 454 Children ever born2 None 43.6 34.1 8.6 0.8 1,635 1 45.3 34.6 9.6 1.1 740 2-3 43.6 34.8 8.4 0.4 1,223 4-5 47.2 37.0 9.7 0.5 851 6+ 45.6 34.7 9.4 1.4 823 Maternity status2 Pregnant 64.9 37.0 26.7 1.2 400 Breastfeeding 47.9 40.1 7.3 0.5 1,262 Neither 41.4 32.9 7.6 0.9 3,610 Using IUD2 Yes 31.6 27.5 4.2 0.0 31 No 44.8 35.0 9.0 0.8 5,242 Residence Urban 41.6 32.4 8.2 1.1 2,524 Rural 47.6 37.2 9.7 0.6 2,748 Region Western 39.1 31.9 6.3 0.8 531 Central 38.0 29.4 7.5 1.1 414 Greater Accra 47.0 37.8 8.5 0.7 861 Volta 48.5 36.0 12.2 0.3 468 Eastern 48.4 37.4 10.0 1.0 524 Ashanti 46.2 34.3 10.5 1.4 1,078 Brong Ahafo 33.5 26.3 6.9 0.2 544 Northern 49.8 42.7 6.4 0.6 445 Upper East 51.0 35.0 15.4 0.6 272 Upper West 49.7 44.9 4.5 0.3 136 Education1 No education 48.7 37.9 10.0 0.8 1,485 Primary 44.5 33.9 10.0 0.7 1,059 Middle/JSS 44.5 35.2 8.4 0.9 2,122 Secondary + 36.1 28.4 6.8 0.8 606 Wealth quintile Lowest 53.7 42.1 11.1 0.5 899 Second 45.6 35.0 10.1 0.6 893 Middle 47.3 36.4 9.7 1.2 1,012 Fourth 40.7 31.7 8.4 0.5 1,153 Highest 39.6 31.5 6.8 1.2 1,316 Total 44.7 34.9 9.0 0.8 5,272 Note: Table is based on women who stayed in the household the night before the interview. Women with <7.0 g/dl of hemoglobin have severe anaemia, women with 7.0-9.9 g/dl have moderate anaemia, and pregnant women with 10.0-10.9 g/dl and nonpregnant women with 10.0-11.9 g/dl have mild anaemia. g/dl = grams per deciliter 1 For women who are not interviewed, information is taken from the Household Questionnaire 2 Excludes women who were not interviewed Nutrition │ 187 10.3.6 Prevalence of Anaemia in Children by Anaemia Status of Mother Table 10.12 shows the percentage of children age 6-59 months classified as anaemic, by the anaemia status of the mother. There is not a strong relationship between the anaemia status of mothers and the anaemia status of children except in the case of mothers with moderate anaemia, whose children are more likely to suffer from severe anaemia (9 percent) than children of mothers with no anaemia (5 percent) or those with mild anaemia (6 percent). Table 10.12 Prevalence of anaemia in children by anaemia status of mother Percentage of children age 6-59 months classified as having anaemia, by anaemia status of mother, Ghana 2003 Anaemia status of child Anaemia status of mother Any anaemia Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (below 7.0 g/dl) Number of children No anaemia 73.3 23.0 45.0 5.3 1,391 Any anaemia 80.6 22.1 51.7 6.7 1,237 Mild anaemia 80.0 21.5 52.3 6.1 988 Moderate anaemia 83.1 24.2 50.0 8.8 239 Severe anaemia * * * * 10 Total 76.7 22.6 48.2 6.0 2,629 Note: Table is based on children who stayed in the household the night before the inter- view. Table includes only cases with anaemia measurements for both mothers and children. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. g/dl = grams per deciliter 10.4 NUTRITIONAL STATUS OF CHILDREN UNDER AGE FIVE The 2003 GDHS included information on the nutritional status of children under five years of age for three indices, namely, weight-for-age, height-for-age, and weight-for-height. 10.4.1 Measures of Nutritional Status in Childhood In addition to questions on feeding practices associated with infant and young children, the 2003 GDHS included anthropometric measurements for all children under five years of age. Each interviewing team was equipped with a lightweight electronic SECA scale, designed and manufactured under the guidance of UNICEF, and a measuring board specifically produced by Shorr Productions for use in survey settings. Children younger than 24 months were measured lying down on the board (recumbent length), while standing height was measured for older children. The scale also allowed for the weighing of very young children, with an automatic mother-child adjustment, which eliminated the mother’s weight while she stood with her baby on the weighing scale. In previous GDHS surveys, anthropometric measurements were restricted to children born to women interviewed with the Women’s Questionnaire. However, these data are not representative of all children, since they exclude children whose mothers were not in the household (either because they did not live there, or because they had died), children whose mothers were not eligible for the individual interview (i.e., under age 15 or age 50 and over), and children whose mothers did not complete an 188 │ Nutrition individual interview. To overcome these biases, the 2003 GDHS included weight and height measurements of all children who were born in the five years preceding the survey and listed in the Household Questionnaire, irrespective of the interview status of their mother. As recommended by the World Health Organisation (WHO), the anthropometric measurements of children in the survey are compared with an international reference population defined by the U.S. National Centre for Health Statistics (NCHS) and accepted by the U.S. Centres for Disease Control and Prevention (CDC). Each of the three nutritional status indicators described below are expressed in standard deviation units (Z-scores) from the median for the reference population. The use of this reference population is based on the finding that well nourished young children of all population groups (for which data exist) follow very similar growth patterns. The reference populations serve as a point of comparison, facilitating the examination of differences in the anthropometric status of subgroups in a population and changes in nutritional status over time. In any large population, there is variation in height and weight; this variation approximates a normal distribution. Each of these indices—height-for-age, weight-for-height, and weight-for-age—gives different information about growth and body composition used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the median of the reference population are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effect of malnutrition in a population and does not vary according to recent dietary intake. The weight-for-height index measures body mass in relation to body length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the median of the reference population are considered thin (wasted) for their height and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard devia- tions from the median of the reference population are classified as underweight. Table 10.13 shows the percentage of children under five years classified as malnourished according to height-for-age, weight-for-height, and weight-for-age, by background characteristics. A total of 3,586 children under five were identified in the households. Eight percent of children had missing information on height or weight, 3 percent had implausibly high or low values for height or weight measures, and less than 1 percent had incomplete age information. The analysis on nutritional status is based on the remaining 89 percent or 3,183 children. According to the 2003 GDHS, 30 percent of children under five are stunted and 11 percent severely stunted. Seven percent of children under five are wasted and 1 percent severely wasted. Weight- for-age results show that 22 percent of children under five are underweight, with 5 percent severely underweight. Table 10.13 and Figure 10.3 indicate that stunting is evident among children as young as 6 months of age (6 percent). Stunting increases with the age of the child. This is evidenced by the marked increase in stunting levels from 14 percent at 6-9 months to 35 percent at age 12-23 months. There are no Nutrition │ 189 marked differences between males (33 percent) and females (27 percent) in the levels of stunting among children under five years. Table 10.13 also shows that the longer the birth interval, the lower the stunting levels. Birth size is an important indicator of a child’s nutritional status at birth and in the future. According to Table 10.13, a larger percentage of children who were reported to have been small or very small at birth were stunted (40 percent) compared with children who were average or larger in size at birth (27 percent). Table 10.13 indicates that wasting is more common in the age group 6-23 months and decreases as the child ages. Weight-for-age is an index of chronic or acute malnutrition. It does not distinguish between a child who is underweight because of stunting or wasting. Underweight is very minimal for children less than 6 months of age but becomes more pronounced at age 6 months and above (during the normal complementary feeding period). This may be because most children are still primarily breastfeeding until 6 months of age. Table 10.13 also shows that rural children are more likely to be stunted and underweight than urban children, while the proportion wasted is almost the same in both rural and urban areas (7 percent). Regional variation in nutritional status of children is substantial. The Central, Northern, Upper East and Upper West regions have stunting levels that are above the national average. Children living in the Upper East, Northern, and Upper West regions also have underweight levels above the national average, in addition to children from the Volta Region. Size at birth is also related to wasting in children; a larger percentage of children reported by mothers as very small at birth are wasted (12 percent), compared with those reported as average or larger (7 percent). Wasting is particularly high in the Volta, Upper East, and Upper West regions. The percentage of malnourished children decreases with increasing level of mother’s education. About a third of children whose mothers have no education are stunted or underweight. The pattern is less clear with levels of wasting. Mother’s age has no marked influence on the nutritional status of the child. There are no strong differences by sex and birth order. Table 10.13 indicates that children whose biological mothers were not in the household are more likely to be malnourished (34 percent stunted and 25 percent underweight) than children whose mothers were interviewed. Poor nutritional status among children is obvious among those who live in poor households. For example, two-fifths of children who live in households in the lowest wealth quintile are stunted compared with one-eighth of children in the highest wealth quintile. A similar pattern is seen among children who are underweight. The relationship between wasting and wealth is not that strong. 190 │ Nutrition Table 10.13 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Ghana 2003 Height-for-age Weight-for-height Weight-for-age Background characteristic Percent- age below -3 SD Percent- age below -2 SD1 Mean Z-score SD Percent- age below -3 SD Percent- age below -2 SD1 Mean Z-score SD Percent- age below -3 SD Percent- age below -2 SD1 Mean Z-score SD Number of children Age in months <6 1.0 6.3 0.0 2.0 5.9 0.1 0.0 2.4 0.2 248 6-9 3.0 14.3 (0.3) 3.5 13.5 (0.7) 2.9 13.6 (0.8) 226 10-11 3.6 17.1 (0.9) 3.2 16.3 (0.8) 8.2 35.4 (1.4) 117 12-23 12.3 35.2 (1.6) 1.7 12.6 (0.7) 7.9 30.8 (1.4) 636 24-35 12.8 32.5 (1.5) 1.0 5.5 (0.5) 7.0 26.4 (1.3) 636 36-47 13.3 35.0 (1.5) 0.8 3.8 (0.2) 4.1 21.3 (1.1) 710 48-59 12.5 33.4 (1.5) 0.7 3.4 (0.2) 1.6 18.2 (1.1) 611 Sex Male 12.5 32.8 (1.4) 1.7 7.2 (0.4) 4.9 22.6 (1.1) 1,588 Female 9.2 27.0 (1.2) 1.0 7.1 (0.4) 4.5 21.6 (1.1) 1,595 Birth order2 1 9.4 27.2 (1.2) 1.5 7.3 (0.4) 4.4 21.1 (1.1) 613 2-3 10.2 26.5 (1.2) 1.4 7.0 (0.4) 4.2 21.0 (1.1) 1,019 4-5 11.8 32.3 (1.4) 1.4 7.3 (0.4) 4.8 24.3 (1.1) 660 6+ 10.9 34.1 (1.4) 1.0 6.9 (0.4) 5.0 21.5 (1.1) 590 Birth interval in months2 First birth3 9.4 27.0 (1.2) 1.5 7.4 (0.4) 4.4 21.1 (1.1) 620 <24 16.9 36.8 (1.6) 1.2 5.1 (0.3) 4.7 23.5 (1.2) 291 24-47 12.1 33.1 (1.4) 1.5 7.5 (0.4) 5.3 24.0 (1.2) 1,245 48+ 6.3 22.8 (1.1) 1.1 6.9 (0.3) 3.5 18.2 (0.9) 726 Size at birth2 Very small 13.8 39.8 (1.6) 0.7 12.0 (0.6) 8.9 35.4 (1.5) 179 Small 14.8 39.7 (1.6) 1.4 6.2 (0.6) 6.7 31.5 (1.4) 337 Average or larger 9.8 27.4 (1.2) 1.4 6.8 (0.3) 4.0 19.5 (1.0) 2,348 Residence Urban 6.8 20.5 (0.9) 1.9 6.6 (0.4) 3.2 15.4 (0.9) 1,050 Rural 12.8 34.5 (1.5) 1.1 7.4 (0.4) 5.4 25.4 (1.2) 2,132 Region Western 8.0 28.4 (1.3) 1.1 5.3 (0.3) 2.2 16.5 (1.0) 333 Central 12.5 31.6 (1.4) 0.0 3.0 (0.3) 4.0 22.0 (1.0) 284 Greater Accra 5.5 13.9 (0.6) 2.7 7.2 (0.4) 2.1 11.5 (0.7) 337 Volta 7.8 23.3 (1.1) 3.1 13.9 (0.7) 4.9 25.7 (1.2) 259 Eastern 6.2 27.4 (1.2) 0.7 6.2 (0.3) 3.7 17.3 (1.0) 333 Ashanti 10.2 29.1 (1.3) 0.8 6.7 (0.4) 4.1 20.8 (1.1) 613 Brong Ahafo 10.7 29.4 (1.3) 1.3 5.7 (0.4) 5.5 20.4 (1.1) 356 Northern 21.8 48.8 (1.9) 1.0 6.6 (0.3) 8.7 35.5 (1.5) 415 Upper East 12.1 31.7 (1.3) 2.4 12.9 (0.8) 7.8 32.4 (1.4) 156 Upper West 12.6 34.1 (1.3) 2.6 11.0 (0.3) 6.0 25.9 (1.0) 95 Mother's education4 No education 14.7 38.2 (1.5) 1.4 7.5 (0.4) 6.8 27.5 (1.3) 1,177 Primary 8.2 24.1 (1.1) 1.0 7.8 (0.4) 3.3 18.6 (1.0) 661 Middle/JSS 8.4 25.8 (1.2) 1.5 6.7 (0.4) 3.2 19.7 (1.0) 938 Secondary + 1.8 11.1 (0.5) 1.6 4.6 (0.3) 0.8 7.8 (0.6) 170 Mother's age 15-19 12.4 30.1 (1.2) 1.4 11.3 (0.5) 4.5 26.4 (1.1) 93 20-24 11.4 28.9 (1.3) 2.1 8.0 (0.5) 5.1 23.6 (1.1) 530 25-29 9.4 28.2 (1.2) 1.2 6.7 (0.4) 4.0 20.6 (1.1) 779 30-34 9.9 28.0 (1.2) 1.2 8.2 (0.4) 4.3 22.7 (1.1) 645 35-49 11.1 32.1 (1.3) 1.1 5.9 (0.3) 4.8 20.9 (1.1) 900 Mother’s status Mother interviewed 10.5 29.5 (1.3) 1.4 7.1 (0.4) 4.6 21.9 (1.1) 2,882 Mother not interviewed but in household 7.3 30.0 (1.1) 1.1 9.3 (0.6) 2.1 21.3 (1.1) 65 Mother not in household5 15.0 34.0 (1.5) 1.3 7.0 (0.5) 7.0 25.1 (1.3) 236 Wealth quintile Lowest 16.5 41.8 (1.7) 1.3 8.8 (0.5) 8.7 31.3 (1.4) 799 Second 12.3 31.5 (1.4) 1.1 6.7 (0.4) 4.8 23.9 (1.2) 716 Middle 10.1 30.2 (1.4) 1.3 6.5 (0.4) 2.9 21.5 (1.1) 655 Fourth 6.9 24.2 (1.0) 1.8 6.8 (0.4) 3.6 16.3 (1.0) 541 Highest 4.5 13.2 (0.6) 1.3 6.1 (0.3) 1.5 11.4 (0.7) 471 Total 10.8 29.9 (1.3) 1.3 7.1 (0.4) 4.7 22.1 (1.1) 3,183 Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard devia- tion units (SD) from the median of the NCHS/CDC/WHO International Reference Population. The percentage of children who are more than three or more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown according to background characteristics. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 2 children with missing information on size at birth. 1 Includes children who are below -3 standard deviations (SD) from the International Reference Population median 2 Excludes children whose mothers were not interviewed 3 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 4 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the household schedule. 5 Includes children whose mothers are deceased Nutrition │ 191 Figure 10.3 Stunting, Wasting, and Underweight by Age, Ghana Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five-month moving average. # # ### ## # # # # # ## ######### ############################## ####### ) ) )))) )) ))) ))))))))))))))))))))))))))))))))))))))))))))))))) 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Age (months) 0 10 20 30 40 50 Percent Stunted average Wasted average Underweight average ) # Vulnerable Period GDHS 2003 10.4.2 Trends in Children’s Nutritional Status An analysis of trends in these data shows an increase in the level of stunting but slight decreases in the proportions of children who are wasted or underweight. Caution has to be exercised when compar- ing data from the various DHS surveys conducted in Ghana to assess the trend in the nutritional status. This is because information on children’s nutritional status was gathered for different age groups from one survey to another. In addition, previous DHS surveys collected anthropometric measurements only for children of interviewed women, whereas the 2003 survey collected nutritional status information from all children under age five living in the household at the time of the interview. While it is possible to ad- just for some of these inconsistencies, it is not possible to correct them all. Comparisons are therefore re- stricted to the last five years. The proportion of children under five who are stunted has increased from 26 percent in 1998 to 30 percent in 2003. The proportion underweight decreased from 10 percent in 1998 to 7 percent in 2003. The proportion of children who are wasted also decreased from 25 percent in 1998 to 22 percent in 2003 (GSS and MI, 1999). These trends in nutritional status imply that the problem of malnutrition in Ghana may be due to chronic food shortages. This is evidenced by the fact that the three northern regions, which have annual periods of drought, have consistently recorded the highest levels of stunting. 10.5 NUTRITIONAL STATUS OF WOMEN The 2003 GDHS collected information on the height and weight of women. The data were used to derive two measures of nutritional status, height and body mass index (BMI). A woman’s height may be used to predict the risk of difficulty in delivery (given the relationship between height and the size of the pelvis). The risk of giving birth to a low-birth-weight baby is influenced by the mother’s nutritional status. The cut-off point for height at which mothers can be considered at risk varies between populations but normally falls between 140 centimetres and 150 centimetres; a cutoff point of 145 centimetres is used here. The index used to measure thinness or obesity is known as the body mass index (BMI), or the 192 │ Nutrition Quetelet index. BMI is defined as weight in kilogrammes divided by height squared in metres (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition. A BMI of 25 or above usually indicates overweight or obesity. The 2003 GDHS collected anthropometric information for all women age 15-49, in contrast to earlier surveys, which restricted anthropometric data collection to women who had a live birth in the five years (or three years) preceding the survey. As such, this is a more representative sample because it includes both younger women who may not yet have given birth and older women who would have stopped childbearing. Women for whom there was no information on height and/or weight and for whom a BMI could not be estimated are excluded from this analysis. Table 10.14 shows the nutritional status of women in the reproductive ages 15-49. The mean height of women is 159 centimetres, which is above the critical height of 145 centimetres. Nine percent of women are found to be chronically malnourished (BMI less than 18.5), while 25 percent are overweight. Variations between urban and rural women are marked. More women have a BMI less than 18.5 in rural areas (12 percent) than in urban areas (6 percent). The percentage of overweight or obese women is, however, higher in urban areas (35 percent) than in rural areas (16 percent). The Greater Accra Region has the highest percentage of these women (46 percent) and the Upper West Region has the lowest percentage (7 percent). The percentage of overweight or obese women increases with increasing educational level as well as increasing wealth quintile. Interpretation of trends in women’s nutritional status is complicated by the fact that in the 1993 and the 1998 GDHS only mothers of children under five were measured. In 2003, the data refer to all women age 15-49. A comparison, restricting the data for 2003 to mothers of children under five years, shows that there has been little change in the percentage of mothers whose height is below 145 centimetres and in the mean BMI over the past ten years, from 1993 to 2003. However, there has been a small decline in the percentage of mothers who fall below a BMI of 18.5, from 11 percent in 1993 and 1998 to 9 percent in 2003. Nutrition │ 193 Table 10.14 Nutritional status of women by background characteristics Among women age 15-49, mean height, percentage under 145 cm, mean body mass index (BMI), and percentage with specific BMI levels, by background characteristics, Ghana 2003 Height BMI 1 (kg/m2) Background characteristic Mean height in cm Percent- age below 145 cm Number of women Mean BMI 18.5- 24.9 (normal) <18.5 (thin) 17.0- 18.4 (mildly thin) 16.0- 16.9 (moderat- ely thin) <16.0 (sever- ely thin) ≥25.0 (over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of women Age 15-19 157.7 2.0 1,075 21.1 76.8 15.2 10.9 2.8 1.5 8.0 6.9 1.1 1,002 20-24 158.4 1.5 952 22.4 75.6 7.5 5.3 1.7 0.5 16.9 14.7 2.2 830 25-29 159.2 0.8 909 23.0 66.4 8.3 6.7 1.5 0.1 25.3 18.8 6.4 771 30-34 159.5 1.1 762 24.1 59.5 7.1 6.0 0.7 0.4 33.3 21.7 11.7 668 35-39 159.5 0.7 692 24.4 55.2 7.0 5.8 0.9 0.4 37.8 23.9 13.9 611 40-44 159.1 0.9 545 24.8 53.2 7.1 6.0 0.9 0.3 39.7 23.0 16.7 515 45-49 159.2 0.3 451 24.1 56.3 9.7 6.1 2.4 1.2 34.1 20.0 14.0 439 Residence Urban 159.2 1.1 2,556 24.2 58.4 6.4 5.4 0.7 0.3 35.1 22.4 12.7 2,378 Rural 158.5 1.2 2,831 22.0 72.2 12.0 8.5 2.5 1.0 15.8 12.2 3.6 2,457 Region Western 158.5 1.8 542 22.9 63.0 11.2 9.0 1.5 0.7 25.8 18.8 6.9 498 Central 157.8 2.3 423 23.2 67.1 6.7 4.4 2.0 0.3 26.2 20.5 5.7 380 Greater Accra 159.6 0.7 898 25.3 49.4 4.3 3.9 0.3 0.1 46.3 28.8 17.4 848 Volta 157.6 2.4 475 22.6 71.5 9.7 7.0 2.1 0.6 18.8 12.4 6.4 439 Eastern 158.6 0.7 577 23.3 66.2 8.9 6.6 1.6 0.7 24.8 17.0 7.8 530 Ashanti 158.7 1.3 1,030 23.2 64.3 9.6 7.3 1.6 0.8 26.1 17.3 8.7 917 Brong Ahafo 159.1 0.7 553 22.7 73.0 7.2 4.9 1.4 0.9 19.8 13.7 6.0 485 Northern 159.3 0.5 465 21.1 79.7 12.8 8.9 3.4 0.5 7.5 6.4 1.1 375 Upper East 159.3 0.4 280 20.5 69.5 23.1 17.8 2.6 2.7 7.4 6.9 0.6 239 Upper West 160.2 0.0 142 21.4 82.2 11.3 8.6 1.6 1.1 6.5 5.1 1.4 126 Education No education 158.7 0.8 1,526 22.1 71.5 12.1 8.6 2.2 1.2 16.5 11.8 4.6 1,297 Primary 158.1 2.0 1,096 23.0 65.4 10.3 7.4 2.0 0.8 24.3 17.4 6.9 983 Middle/JSS 158.8 1.1 2,151 23.4 64.5 8.2 6.6 1.2 0.4 27.3 18.1 9.2 1,977 Secondary+ 160.5 0.6 615 24.7 55.2 5.1 3.8 1.1 0.2 39.7 25.9 13.8 578 Wealth quintile Lowest 158.7 1.0 931 21.1 76.7 15.5 11.0 3.1 1.4 7.7 6.4 1.3 794 Second 158.0 1.8 915 21.8 75.5 11.7 8.8 1.9 1.0 12.8 10.8 2.0 805 Middle 158.4 1.0 1,036 22.3 70.4 11.3 8.2 2.3 0.8 18.4 14.2 4.2 906 Fourth 158.7 1.6 1,166 23.6 63.4 6.8 5.5 1.0 0.4 29.8 20.6 9.1 1,062 Highest 159.8 0.6 1,338 25.3 50.2 4.4 3.7 0.5 0.2 45.4 27.3 18.0 1,267 Total 158.8 1.2 5,387 23.1 65.4 9.3 7.0 1.6 0.7 25.3 17.2 8.1 4,835 1 Excludes pregnant women and women with a birth in the preceding 2 months Malaria | 195 MALARIA 11 Malaria is endemic throughout Ghana and continues to be a major public health concern. It is one of the leading causes of morbidity and mortality, especially among pregnant women and children under the age of five. The Ministry of Health (MoH) estimates that over the past ten years, there have been 2-3 million cases of malaria each year, representing 40 percent of outpatient cases, while severe malaria accounts for 33-36 percent of in-patients. Malaria also accounts for 25 percent of the deaths in children under the age of five (GHS, 2001). Since 1999, Ghana has been involved in the international efforts to control malaria under the Roll Back Malaria (RBM) initiative. The objectives of this initiative are to ensure that by the year 2005 at least 60 percent of those at risk of malaria, particularly pregnant women and children under five, have access to the most suitable and affordable combination of personal and community protective measures such as insecticide treated mosquito nets (ITNs) and prompt, effective treatment for malaria. Another objective is to ensure that at least 60 percent of all pregnant women who are at risk of malaria, especially those in their first pregnancies, have access to chemoprophylaxis or intermittent preventive treatment (IPT). 11.1 MOSQUITO NETS 11.1.1 Ownership of Mosquito Nets The ownership and use of mosquito nets, both treated and untreated, is the primary health intervention for reducing malaria transmission and morbidity in a community prone to the vector—the Anopheles mosquito. In Ghana, there are various types of ITNs available on the market. They include the long-lasting ones that require re-treatment after about five years and others that need to be re-treated every six months or after three washes. In an effort to make mosquito nets more affordable, the Government of Ghana has since 2002 waived taxes on the importation of nets into the country. Developmental partners have also contributed by supplying some ITNs for distribution at subsidised costs to pregnant women and children under five in deprived areas of the country. These nets are distributed through routine public health services. Table 11.1 shows the percentage of households with at least one and more than one mosquito net (treated or untreated), and the percentage of households that have at least one and more than one ITN by their background characteristics. The data show that 18 percent of households in Ghana own a mosquito net whether treated or untreated. About 6 percent of households own more than one net. Only 3 percent of households own at least one currently treated net (ITN). Rural households are more likely to own any kind of net (24 percent) compared with urban households (10 percent). Mosquito net ownership is highest in the Volta Region (46 percent) and lowest in the Central Region (9 percent). 196 | Malaria Table 11.1 Ownership of mosquito nets Percentage of households (HH) with at least one and more than one mosquito net (treated or untreated), percentage of households that have at least one and more than one ever-treated net, and the percentage of households that have at least one and more than one insecticide- treated net (ITN), by background characteristics, Ghana 2003 Percentage of house- holds that have: Percentage of house- holds that have: Percentage of house- holds that have: Background characteristic At least one net More than one net Average number of nets per HH At least one ever- treated net More than one ever- treated net Average number of ever- treated nets per HH At least one ITN1 More than one ITN1 Average number of ITNs1 per HH Number of households Residence Urban 9.9 2.0 0.1 3.8 0.7 0.0 2.3 0.5 0.0 2,870 Rural 24.2 8.4 0.4 6.3 1.5 0.1 4.0 1.0 0.1 3,381 Region Western 14.3 3.7 0.2 3.6 0.5 0.0 1.5 0.2 0.0 612 Central 8.7 1.1 0.1 3.2 0.6 0.0 1.8 0.4 0.0 587 Greater Accra 14.2 4.4 0.2 3.8 0.8 0.0 1.9 0.6 0.0 890 Volta 46.1 25.5 0.9 3.8 1.7 0.1 2.5 1.3 0.0 538 Eastern 10.3 2.5 0.1 0.7 0.0 0.0 0.7 0.0 0.0 732 Ashanti 10.1 1.7 0.1 2.7 0.2 0.0 1.6 0.2 0.0 1,313 Brong Ahafo 20.3 4.6 0.3 4.2 1.0 0.1 1.9 0.3 0.0 665 Northern 20.9 5.1 0.3 11.2 2.5 0.1 7.8 1.9 0.1 487 Upper East 35.9 10.6 0.5 32.2 8.8 0.4 25.1 7.0 0.3 280 Upper West 30.2 6.8 0.4 9.8 1.2 0.1 3.3 0.3 0.0 147 Wealth quintile Lowest 27.9 8.7 0.4 10.2 2.0 0.1 7.1 1.3 0.1 971 Second 23.6 9.1 0.4 3.5 1.0 0.0 2.1 0.9 0.0 1,168 Middle 17.1 4.9 0.2 4.0 0.8 0.0 2.0 0.4 0.0 1,315 Fourth 12.1 3.2 0.2 3.1 0.6 0.0 2.2 0.4 0.0 1,452 Highest 11.4 3.0 0.2 6.4 1.5 0.1 3.7 1.1 0.1 1,345 Total 17.6 5.5 0.3 5.2 1.1 0.1 3.2 0.8 0.0 6,251 1 An insecticide treated net (ITN) is a long lasting net that does not require frequent treatment, a pretreated net obtained within the last six months, or a net that has been soaked with insecticide within the past six months With regard to ITNs. Households in the Eastern Region report the lowest ownership of ITNs (1 percent), while those in the Upper East Region (25 percent) have the highest level of ITN ownership, followed by the Northern Region (8 percent). The high level of ownership of ITNs in the Northern and Upper East regions may be attributable to the fact that UNICEF has since 2002 been distributing ITNs at highly subsidised costs to pregnant women and children under five in the Northern and Upper East regions as part of its Child Survival and Reproductive Health programmes. Interestingly, although the Northern Region has benefited from the same programme, ownership of ITNs in the region is not that high, though it is still higher than ownership of ITNs recorded in eight other regions. 11.1.2 Use of Mosquito Nets by Children In the 2003 GDHS, respondents to the Household Questionnaire were asked about the use of mosquito nets by all members of the household the night before the interview. Table 11.2 presents information on the percentage of de facto children under age five years who slept under a mosquito net the night before the survey and the percentage that slept under an ITN by background characteristics. The data show that 15 percent of children under five years slept under a Malaria | 197 mosquito net (treated or untreated) the night before the survey. Five percent of children slept under an ever-treated net while 4 percent are reported as having slept under an ITN the night prior to the survey. Children one year of age and younger are most likely to have slept under any net, an ever-treated net, or an ITN. Children in rural areas are twice as likely to sleep under a mosquito net (18 percent) than their urban counterparts (9 percent). The proportion of children who sleep under any type of mosquito net was highest in the Volta Region (44 percent) and lowest in the Central Region (5 percent) and lowest among children in the highest wealth quintile, presumably because more of these children live in houses that have window netting. Table 11.2 Use of mosquito nets by children Percentage of children under age five who slept under a mosquito net the night before the survey, percentage who slept under an ever-treated net, and percentage who slept under an insecticide-treated net (ITN), by background characteristics, Ghana 2003 Background characteristic Percentage who slept under a net the previous night Percentage who slept under an ever treated net the previous night Percentage who slept under an ITN1 the previous night Number of children Age (in years) < 1 20.1 6.8 5.9 709 1 14.9 5.2 4.3 711 2 14.0 3.9 3.0 698 3 11.8 4.1 2.8 791 4 12.8 2.5 1.7 685 Sex Male 15.3 4.7 3.5 1,811 Female 14.0 4.3 3.5 1,782 Residence Urban 9.0 4.5 3.5 1,202 Rural 17.5 4.5 3.5 2,391 Region Western 9.2 3.3 1.0 346 Central 5.4 1.4 0.7 306 Greater Accra 14.8 4.5 3.1 390 Volta 43.7 2.5 2.2 303 Eastern 8.2 0.3 0.3 372 Ashanti 8.1 1.5 1.2 661 Brong Ahafo 17.5 3.9 2.1 388 Northern 11.7 7.4 7.0 488 Upper East 24.1 22.7 21.0 231 Upper West 21.7 5.6 1.9 108 Wealth quintile Lowest 16.8 7.2 6.2 918 Second 17.1 2.0 1.6 797 Middle 16.0 3.6 1.9 717 Fourth 11.2 3.0 2.6 625 Highest 9.6 6.6 5.0 537 Total 14.7 4.5 3.5 3,593 Note: Based on de facto children in the household. 1 An insecticide treated net (ITN) is a long lasting net that does not require any treatment, a pretreated net obtained within the last six months, or a net that has been soaked with insecticide within the past six months 198 | Malaria ITN use is not affected by residence and shows a U-shaped pattern according to the wealth index. i.e., greatest use of ITNs in households in the lowest and highest wealth quintiles. The percentage of children who sleep under an ever-treated net or ITN is highest in the Upper East Region and lowest in the Eastern Region. 11.1.3 Use of Mosquito Nets by Pregnant Women Malaria is especially dangerous during pregnancy and this has prompted many advocacy cam- paigns to educate not only pregnant women, but also the general public on the importance of preventing malaria during pregnancy. Table 11.3 shows the percentage of all de facto women and de facto pregnant women who slept under a mosquito net whether treated or untreated, and the proportion who slept under an ITN the night prior to the survey, by background characteristics. The data show no difference in the use of nets between pregnant and nonpregnant women. Ten percent of pregnant women slept under a net, 4 percent slept under an ever-treated net, and 3 percent slept under an ITN the night before the interview. Table 11.3 Use of mosquito nets by pregnant women Percentage of all women and pregnant women age 15-49 who slept under a mosquito net (treated or untreated), who slept under an ever- treated net, and who slept under an insecticide-treated net (ITN) the previous night, by background characteristics, Ghana 2003 Percentage of women who: Percentage of pregnant women who: Background characteristic Slept under net the previ- ous night Slept under ever-treated net the previ- ous night Slept under ITN1 the pre- vious night Number of women Slept under net the previ- ous night Slept under ever-treated net the previ- ous night Slept under ITN1 the pre- vious night Number of pregnant women Residence Urban 4.6 1.8 1.4 2,821 5.6 2.9 1.6 137 Rural 15.3 4.0 2.9 3,024 11.5 4.2 3.2 277 Region Western 6.0 2.3 1.1 567 (0.0) (0.0) (0.0 ) 39 Central 4.1 1.9 1.4 445 (3.8) (3.8) (3.8) 36 Greater Accra 6.6 1.3 1.1 966 (12.1) (3.0) (3.0) 35 Volta 34.9 2.6 1.9 513 (14.4) (0.0) (0.0) 33 Eastern 5.6 0.0 0.0 617 (6.3) (0.0) (0.0) 43 Ashanti 5.3 1.5 0.8 1,170 9.4 1.7 0.0 87 Brong Ahafo 12.1 2.8 1.5 583 (16.5) (5.6) (3.9) 40 Northern 9.1 6.0 5.3 510 4.6 4.2 1.7 64 Upper East 18.6 16.5 15.1 318 (28.8) (26.5) (23.8) 24 Upper West 15.3 4.9 1.9 157 (14.7) (4.6) (2.9) 13 Wealth quintile Lowest 16.2 5.8 4.9 996 11.9 6.0 4.7 100 Second 15.9 2.2 1.6 978 8.4 4.7 2.8 76 Middle 11.1 2.6 1.4 1,098 11.7 1.0 1.0 98 Fourth 7.0 2.0 1.4 1,286 8.3 2.8 1.9 84 Highest 4.2 2.6 2.0 1,487 4.9 4.9 3.0 55 Total 10.1 2.9 2.2 5,845 9.5 3.8 2.7 414 Note: Based on de facto women in the household. Figures in parentheses are based on 25-49 unweighted cases. 1 An insecticide treated net (ITN) is a long lasting net that does not require any treatment, a pretreated net obtained within the last six months, or a net that has been soaked with insecticide within the past six months Malaria | 199 Women in rural areas are about three times more likely to sleep under a mosquito net than urban women, while rural pregnant women are about twice as likely to sleep under a net as urban pregnant women. As was seen in the data for children, use of mosquito nets among all women is highest in the Volta Region (35 percent) and lowest in the Central Region (4 percent). In general, the use of mosquito nets (treated and untreated) decreases among women as the level of wealth increases. However, this is not the case among pregnant women. Use of mosquito nets by pregnant women shows a U-shaped pattern by wealth index, although women in the highest wealth quintile are slightly less likely than women in the lowest wealth quintile to sleep under any net, treated or untreated. This could be due in part to the fact that many women from wealthy households and urban dwellers live in houses with mosquito screening on windows and doors, hence the redundancy of mosquito net use. 11.2 EXPOSURE TO MEDIA MESSAGES ON MALARIA The 2003 GDHS included a series of questions at the household level on media exposure to information on malaria. The respondents to the Household Questionnaire were asked if they had seen or heard any messages about malaria on various media sources or any messages telling them to give a child with fever chloroquine tablets for three days, and if they had specifically listened to the radio program He Ha Ho. This information is shown in Table 11.4. Table 11.4. Exposure to messages on malaria Percentage of household respondents who heard or saw a message on malaria through various media sources, percentage who heard or saw a message telling them to give a child with fever chloroquine tablets for three days, and percentage who ever listened to the radio program He Ha Ho, according to background characteristics, Ghana 2003 Media sources Background characteristic TV Radio Newspaper/ magazine Poster Leaflets/ brochures Health worker No media exposure Heard/saw mes- sage to give a child with fever chloroquine tab- lets for three days Ever lis- tened to He Ha Ho Number of household respondents Residence Urban 71.5 88.0 30.1 51.4 18.8 41.2 7.7 87.0 36.1 2,870 Rural 32.2 81.3 11.3 33.1 9.0 41.2 13.0 77.6 46.5 3,381 Region Western 53.4 83.2 20.9 45.6 12.2 42.0 9.3 76.8 45.5 612 Central 38.6 82.9 11.9 26.9 5.9 23.1 14.5 81.3 33.3 587 Greater Accra 77.0 88.5 32.4 46.7 19.3 31.2 7.9 89.8 27.1 890 Volta 32.2 71.6 13.4 38.1 12.6 46.3 16.9 71.8 75.7 538 Eastern 52.7 85.2 21.5 30.4 15.5 40.0 11.4 81.2 28.9 732 Ashanti 58.8 87.5 26.1 51.5 18.3 45.0 9.0 85.2 23.0 1,313 Brong Ahafo 54.8 91.9 17.7 64.7 13.0 46.1 6.2 90.8 47.6 665 Northern 22.2 78.7 8.3 29.3 5.6 43.9 11.9 69.3 70.3 487 Upper East 28.0 85.9 7.5 16.8 7.2 64.6 8.2 80.8 81.7 280 Upper West 13.3 66.4 6.5 11.0 4.9 48.5 22.1 72.0 57.3 147 Wealth quintile Lowest 13.6 73.5 4.3 21.2 3.0 40.1 18.4 68.5 51.4 971 Second 25.3 81.9 8.2 31.1 6.9 37.5 14.1 77.2 46.9 1,168 Middle 43.4 83.1 12.1 36.0 8.8 40.3 12.0 80.1 39.7 1,315 Fourth 65.1 86.9 21.7 47.5 15.1 42.0 8.4 85.6 37.2 1,452 Highest 89.0 92.9 47.3 64.0 29.8 45.2 2.8 93.4 37.2 1,345 Total 50.2 84.4 19.9 41.5 13.5 41.2 10.6 81.9 41.7 6,251 200 | Malaria The majority of household respondents said they had heard about malaria on the radio (84 percent), half have seen a message about malaria on the television, while more than two-fifths of respondents have seen a poster on malaria or heard about malaria from a health worker. One-fifth of respondents have read about malaria in a newspaper or magazine and 14 percent have seen leaflets or brochures on malaria. One in ten respondents have had no exposure to malaria messages. Eighty-two percent of respondents have heard or seen a message telling them to give a child with fever chloroquine tablets for three days, and 42 percent of them have heard the radio programme He Ha Ho. Exposure to media messages on malaria is much higher in urban than rural areas, highest in the Brong Ahafo Region, and among those in the highest wealth quintile. 11.3 MALARIA DIAGNOSIS, CASE MANAGEMENT, AND TREATMENT 11.3.1 Malaria Prophylaxis during Pregnancy One of the strategies the MoH and the Ghana National Malaria Control Programme has adopted for malaria control is the Intermittent Preventive Treatment (IPT) of pregnant women with sulphadoxine- pyrimethamine (SP), also known as Fansidar. According to this policy, from the second trimester of pregnancy (after quickening), pregnant women are expected to receive three doses of SP, at monthly intervals (GHS, 2003b). This replaces the former policy of giving a full dose of chloroquine for treatment at first antenatal visit followed by two tablets weekly till 6 weeks postpartum (GHS, 2003c). This policy decision was finalised at the end of 2003, hence during the period of data collection for the 2003 GDHS the old policy was still in force. The data on anti-malarial drugs from the 2003 GDHS depend on accurate reporting of types of drugs taken. It is likely that some women are not sure of the type of drug they took during pregnancy or gave to their children. Table 11.5 shows the percentage of women with a birth in the five years preceding the survey who took any anti-malarial drug two or more times for prevention of malaria during their pregnancy, those who took chloroquine, and those who took Fansidar (SP) by background characteristics. The data show that 58 percent of mothers reported that they took some anti-malarial drug for the prevention of malaria when pregnant. It also shows that chloroquine is more frequently (12 percent) used than SP (1 percent), presumably because the old programme was still in force during the fielding of the survey. The 1 percent of women who used SP received the drug during an antenatal visit. The data imply that the majority of women either took other drugs apart from chloroquine or SP, or did not know whether the drug contained chloroquine or Fansidar. Chloroquine is sold under many different brand names, and women may not realise that the active ingredient in their drug is still chloroquine. Urban women (67 percent) are more likely to take anti-malarial drugs during pregnancy than rural women (53 percent). The Brong Ahafo Region (72 percent) has the highest percentage of women taking any anti-malarial drug, while Upper West (21 percent) has the lowest. The use of anti-malarial drugs during pregnancy increases with increasing levels of wealth and education. The use of IPT by pregnant women for the last birth in the year preceding the survey can serve as a baseline for the newly instituted IPT programme. As expected, only 1 percent of women with a birth in the 12 months preceding the survey received Fansidar during their ANC visit. Most of them were from the Upper East Region (data not shown). Table 11.6 shows, among mothers who took anti-malarial drugs for prevention during the last pregnancy leading to a live birth in the five years preceding the survey, the percentage who took sulfadoxine-pyrimethamine (SP/Fansidar) by background characteristics. Two percent of mothers took Fansidar during their last pregnancy. Among mothers who took Fansidar, most took it more than three times and four in five received it during an antenatal visit (data not shown). Malaria | 201 Table 11.5 Use of Intermittent Preventive Treatment (IPT) by pregnant women Among women who gave birth in the five years preceding the survey, percentage who took anti-malarial drugs for prevention of malaria during the most recent pregnancy leading to a live birth, and percentage who received intermittent preventive treatment (IPT) with chloro- quine or sulphadoxine pyrimethamine (SP/Fansidar), by background characteristics, Ghana 2003 Use of IPT by pregnant women Background characteristic Percentage of pregnant women who took any anti-malarial drug for prevention during their last pregnancy Percentage who took chloroquine for protection Percentage who received at least 2 doses of SP/Fansidar during ANC visit Number of women Residence Urban 66.7 12.8 0.6 946 Rural 53.4 11.8 0.9 1,699 Region Western 54.7 12.7 0.4 246 Central 67.9 14.8 0.4 211 Greater Accra 65.4 9.7 1.0 303 Volta 66.3 16.6 1.0 220 Eastern 46.9 10.7 0.5 266 Ashanti 64.3 12.0 1.0 507 Brong Ahafo 72.0 15.5 0.7 297 Northern 39.7 7.9 0.0 346 Upper East 58.7 15.7 3.1 166 Upper West 20.5 5.1 0.9 83 Education No Education 47.9 10.3 0.5 1,025 Primary 59.1 13.7 1.0 589 Middle/JSS 68.1 13.3 1.1 879 Secondary+ 68.0 13.0 1.0 122 Wealth quintile Lowest 45.1 11.0 0.7 648 Second 58.7 12.3 0.7 557 Middle 57.1 12.6 1.0 534 Fourth 67.5 16.2 0.6 474 Highest 68.1 8.6 1.1 433 Total 58.1 12.2 0.8 2,645 202 | Malaria Table 11.6 Use of Fansidar for Intermittent Preventive Treatment (IPT) For mothers who took anti-malarial drugs for prevention of malaria during the last pregnancy leading to a live birth in the five years preceding the survey, percentage who took sulfadoxine-pyrimethamine (SP/Fansidar), by background characteristics, Ghana 2003 Background characteristic Percentage who took SP/Fansidar Number of mothers who took anti-malarial drug Residence Urban 1.4 631 Rural 2.1 907 Region Western 0.8 135 Central 0.7 143 Greater Accra 2.8 198 Volta 1.5 146 Eastern 1.0 125 Ashanti 2.6 326 Brong Ahafo 1.3 214 Northern 0.0 137 Upper East 5.3 97 Upper West 4.2 17 Education No education 1.1 491 Primary 2.0 348 Middle/JSS 2.4 598 Secondary+ 1.5 83 Wealth quintile Lowest 2.9 292 Second 1.2 327 Middle 1.8 305 Fourth 1.3 320 Highest 2.0 295 Total 1.8 1,538 11.3.2 Prevalence and Management of Childhood Malaria Since the major manifestation of malaria is fever, in the 2003 GDHS mothers were asked whether their children under age five had a fever in the two weeks preceding the survey. Although fever can occur all year round, malaria is more prevalent during the rainy season, and such temporal factors must be taken into account when interpreting the occurrence of fever as an indicator of malaria prevalence. If a fever was reported, the mother was asked whether treatment was sought at a health facility and whether the child was given any medication and, if so, how soon the medication was taken after the episode of illness started. Table 11.7 shows the percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, the percentage who took anti-malarial drugs and the percentage who took anti-malarial drugs the same or next day, by background characteristics. Twenty-one percent of children under five years had a fever in the two weeks preceding the survey. Of these, 63 Malaria | 203 percent of children took an anti-malarial drug. Forty-four percent of children took the anti-malarial drug on the same or the next day after the onset of the illness. Table 11.7 Prevalence and prompt treatment of fever Percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, percentage who took anti-malarial drugs and percentage who took anti-malarial drugs the same/next day after developing fever, by background characteristics, Ghana 2003 Background characteristic Percentage of children with fever Number of children Percentage who took anti- malarial drug Percentage who took anti- malarial drug same/next day Number of children with fever Age in months < 12 18.1 688 66.4 47.3 124 12-23 28.1 695 59.1 42.5 195 24-35 24.5 649 62.1 42.3 159 36-47 17.4 695 70.8 50.9 121 48-59 17.9 612 57.4 39.1 109 Sex Male 21.7 1,686 62.1 42.8 366 Female 20.8 1,654 63.5 45.7 344 Residence Urban 22.4 1,114 65.2 49.4 250 Rural 20.7 2,225 61.4 41.4 460 Region Western 23.2 332 67.3 54.9 77 Central 24.3 280 44.0 37.2 68 Greater Accra 20.9 366 65.5 42.9 77 Volta 30.5 269 67.1 50.0 82 Eastern 19.8 337 66.8 49.8 67 Ashanti 20.4 622 58.7 42.1 127 Brong Ahafo 18.3 366 67.0 55.0 67 Northern 15.5 457 61.0 35.6 71 Upper East 21.3 206 70.5 31.8 44 Upper West 30.1 104 66.5 31.3 31 Education No education 19.6 1,339 60.3 34.9 262 Primary 22.7 761 69.9 52.5 173 Middle/JSS 21.2 1,055 57.8 43.7 224 Secondary+ 30.9 147 (69.8) (66.3) 45 Wealth quintile Lowest 21.5 864 59.0 37.8 186 Second 19.0 740 55.4 35.6 141 Middle 22.0 656 65.0 46.5 144 Fourth 23.3 572 76.9 55.8 133 Highest 20.9 507 58.3 49.0 106 Total 21.3 3,340 62.8 44.2 710 Note: Figures in parentheses are based on 25-49 unweighted cases. The highest prevalence of fever is reported among children age 12-23 months (28 percent), followed by those age 24-35 months (25 percent). Fever is less common among children age less than 12 204 | Malaria months and those age 48-59 months (18 percent). The proportion of children with fever differs little by gender of the child and urban-rural residence. The Volta and Upper West regions have the highest percentage of children with fever (about 30 percent), while the Northern Region has the lowest (16 percent). There is no clear association between the prevalence of fever and wealth. The prevalence of fever is highest among children of highly educated mothers. It is plausible that highly educated mothers are more likely to recognize and report the prevalence of fever than poorly educated mothers. Children age 36-47 months are most likely to be given anti-malarial drugs for the treatment of fever and are also most likely to receive the drugs the same or the next day. Differences by gender are minimal. Children living in the urban areas are slightly more advantaged than children in the rural areas to be given anti-malarial drugs and within a day or two. Children living in the Upper East Region are most likely to have been given an anti-malarial drug (71 percent), but together with the Upper West Region, the least likely to have taken the drugs the same or the next day. On the whole, children in the Brong Ahafo Region are most likely to receive anti-malarial drugs within a day or two. There is no clear association between the intake of anti-malarial drugs and wealth; nevertheless, children living in households that are relatively wealthy (fourth wealth quintile) are most likely to be given anti-malarial drugs and within the first day or two of fever. Even though education does not exert a strong positive impact in determining if mothers give children anti-malarial drugs, children of highly educated mothers are much more likely than children of other mothers to be given these drugs the same day or the next. Table 11.8 presents information on the type and timing of anti-malarial drugs given to children under age five with fever in the two weeks preceding the survey, the percentage who took specific anti- malarial drugs and the percentage who took each type of drug the same or next day after developing fever, by background characteristics. Chloroquine is by far the most common anti-malarial drug given for fever (59 percent), followed by Amodiaquine and Quinine (2 percent each) and Fansidar (less than 1 percent). It is noteworthy that although the use of quinine to treat malaria is relatively low in the country as a whole, one in ten children residing in the Upper West Region has been treated with quinine. Forty-four percent of children took chloroquine the same or the next day following the onset of fever. Children age 36-47 months are more likely than other children to be treated with chloroquine for malaria. About three in five children in both the urban and rural areas took chloroquine, but urban children are more likely than rural children to have received the drug within a day or two following the onset of fever. About two-thirds of children in the Western, Greater Accra, Volta, Eastern, Brong Ahafo, and Upper East regions received chloroquine and about one in two children residing in the Western, Volta, Eastern, and Brong Ahafo regions took chloroquine the same day or the next. Children in the middle or higher wealth quintiles are more likely than other children to have received chloroquine within a day or two of developing a fever. Children of highly educated mothers also have a slight advantage over other children in receiving some malaria treatment and receiving it promptly. Malaria | 205 Table 11.8 Type and timing of anti-malarial drugs Among children under age five with fever in the two weeks preceding the survey, percentage who took specific anti-malarial drugs and the percent- age who took each type of drug the same/next day after developing fever, by background characteristics, Ghana 2003 Background characteristic Percentage who took chloroquine Percentage who took chloroquine same/next day Percentage who took SP/Fansidar Percentage who took Amodiaquine Percentage who took Amodiaquine same/next day Percentage who took quinine Number of children with fever Age in months < 12 61.8 47.0 0.0 0.3 0.3 4.3 124 12-23 54.5 41.4 0.0 3.8 1.0 1.4 195 24-35 59.6 41.7 0.0 1.6 0.7 0.9 159 36-47 68.1 50.9 0.9 2.2 0.7 0.3 121 48-59 54.4 37.8 0.7 1.3 1.3 2.2 109 Sex Male 58.0 42.2 0.5 2.2 0.8 1.9 366 Female 60.5 44.9 0.0 1.8 0.8 1.6 344 Residence Urban 61.7 49.0 0.8 1.9 0.7 1.7 250 Rural 57.9 40.6 0.0 2.1 0.8 1.7 460 Region Western 64.5 53.1 0.0 2.8 1.9 0.0 77 Central 44.0 37.2 0.0 1.7 0.0 0.0 68 Greater Accra 65.5 42.9 0.0 0.0 0.0 0.0 77 Volta 67.1 50.0 0.0 0.0 0.0 0.0 82 Eastern 66.8 49.8 0.0 0.0 0.0 0.0 67 Ashanti 50.3 41.2 0.9 4.3 0.8 4.3 127 Brong Ahafo 62.6 52.0 0.0 4.4 3.0 0.0 67 Northern 56.7 35.6 1.2 1.2 1.2 3.2 71 Upper East 65.5 31.8 0.0 2.1 0.0 3.0 44 Upper West 53.2 30.2 0.0 2.9 1.2 10.5 31 Education No education 54.3 34.1 0.3 1.6 0.7 4.0 262 Primary 67.5 51.0 0.0 2.3 1.5 0.0 173 Middle/JSS 55.4 43.5 0.5 2.2 0.2 0.2 224 Secondary + (69.5) (66.3) (0.0) (2.2) (1.8) (3.0) 45 Wealth quintile Lowest 55.2 37.3 0.0 0.5 0.5 3.3 186 Second 52.1 34.6 0.0 3.2 1.0 0.1 141 Middle 64.0 46.5 0.0 0.6 0.0 1.3 144 Fourth 69.6 54.7 0.6 5.1 1.7 3.1 133 Highest 56.3 48.1 1.0 1.0 1.0 0.0 106 Total 59.2 43.5 0.3 2.0 0.8 1.7 710 Note: Figures in parentheses are based on 25-49 unweighted cases. SP = sulphadoxine pyrimethamine HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 207 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 12 Acquired immune deficiency syndrome (AIDS) was first recognised internationally in 1981. Today it is a serious problem in much of the world, with countries in sub-Saharan Africa, and especially those located in the east, central, and southern parts of the continent, most affected. The growing AIDS epidemic threatens to halt social and economic gains in many countries, especially in Africa. In Ghana, as in the rest of Africa, sexual (especially heterosexual) contact and mother-to-child transmission (MTCT) are the two most common ways HIV/AIDS infections are spread. HIV was first identified in Ghana in March 1986. Since then the epidemic has spread slowly but steadily. Ghana initially responded to HIV/AIDS as a health rather than a developmental issue and consequently directed the Ministry of Health (MOH) to address the problem. In 1987, the National AIDS Control Programme (NACP) was established under the MOH to implement and coordinate the country’s HIV/AIDS programme. In addition, a National HIV/AIDS and STI Policy was developed to guide the national response. The MOH through the NACP has spearheaded various strategies to contain and limit the spread of HIV infection. These strategies include maintaining a safe blood supply, ensuring safe use of needles, and disseminating information through public campaigns to change social attitudes and behaviour. In 2000, when it became apparent that HIV prevalence rates were steadily increasing, the government established the Ghana AIDS Commission (GAC) for effective resource mobilization, management, and co-ordination of HIV/AIDS activities and targeted prevention measures expected to successfully raise awareness and promote behavioural change among the population. The national HIV/AIDS Strategic Framework developed in 2001 provides goals and objectives for a national response to the disease. Questions in the 2003 GDHS provide a unique opportunity to determine the level of awareness and practice regarding the transmission of the AIDS virus. Both female and male respondents were asked if they have ever heard of AIDS; what a person could do to avoid getting AIDS; if they know a person with AIDS or who died of AIDS; if they are aware of MTCT; and if they ever talked to their spouse about ways of preventing AIDS. Other questions concerned the extent of stigma or discrimination towards people living with HIV/AIDS (PLWHA), attitudes towards teaching children about condom use, testing for HIV/AIDS, knowledge of other sexually transmitted infections (STIs) and infection with STIs. 12.1 HIV/AIDS–RELATED KNOWLEDGE AND ATTITUDES Table 12.1 shows that 98 percent of women and 99 percent of men have heard of AIDS, indicating that awareness of AIDS in Ghana is universal. There is little variation in knowledge among both men and women by background characteristics; however, awareness is somewhat lower among women in the Northern Region (88 percent). Although most respondents have heard about AIDS, personal knowledge about PLWHAs or per- sons who have died of AIDS is low for both men and women. Thirty-seven percent of women and 38 per- cent of men age 15-49 know someone personally who has the virus that causes AIDS or who has died of AIDS. Women in the Ashanti (49 percent) and Brong Ahafo (48 percent) regions are most likely to know someone personally who has the virus or who has died of AIDS. Fifty-eight percent of men in the Upper East Region know someone personally who has the virus or has died of AIDS. Personal knowledge of someone with AIDS increases with the educational level of respondents from 31 percent among women with no education to 41 percent among those with at least secondary education. Comparable percentages for men are 34 and 44 percent, respectively. 208 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS and who know someone personally who has the virus that causes AIDS or has died of AIDS, by background characteristics, Ghana 2003 Women Men Background characteristic Has heard of AIDS Percentage who know someone personally who has the virus that causes AIDS or has died of AIDS Number of respondents Has heard of AIDS Percentage who know someone personally who has the virus that causes AIDS or has died of AIDS Number of respondents Age 15-19 98.2 30.3 1,148 98.1 28.3 1,107 20-24 98.6 38.1 1,012 99.6 36.5 684 25-29 98.4 38.1 951 99.8 40.7 754 30-39 98.0 38.4 1,524 99.5 43.6 1,131 40-49 98.7 40.1 1,056 99.8 44.1 853 15-24 98.4 34.0 2,160 98.7 31.5 1,791 Marital status Never married 98.9 33.2 1,616 98.9 31.9 2,040 Ever had sex 99.6 38.3 733 99.5 36.9 889 Never had sex 98.4 29.0 883 98.3 28.0 1,151 Married/Living together 97.9 39.2 3,549 99.6 43.9 2,228 Divorced/Separated/Widowed 99.3 33.8 526 100.0 42.5 261 Residence Urban 99.7 38.1 2,755 99.7 37.0 2,049 Rural 97.1 36.0 2,936 98.9 39.6 2,480 Region Western 99.7 29.1 553 99.5 26.9 435 Central 100.0 33.4 431 99.4 32.6 327 Greater Accra 99.4 31.1 942 100.0 36.5 664 Volta 99.9 31.2 492 100.0 39.9 389 Eastern 99.1 38.9 601 99.3 43.5 484 Ashanti 99.7 48.6 1,142 100.0 42.3 858 Brong Ahafo 99.5 48.1 569 100.0 39.1 483 Northern 87.7 20.2 499 96.3 28.8 489 Upper East 97.8 41.1 310 98.4 58.2 284 Upper West 96.0 42.8 153 97.8 43.5 116 Education No education 95.1 30.7 1,608 98.0 33.9 742 Primary 99.0 35.5 1,135 98.5 36.3 750 Middle/JSS 99.8 40.9 2,279 99.7 38.1 1,972 Secondary+ 100.0 41.4 669 100.0 43.7 1,065 Wealth quintile Lowest 93.8 31.8 970 97.4 36.6 777 Second 97.7 35.8 949 99.8 43.6 802 Middle 99.4 37.8 1,071 99.2 38.0 879 Fourth 99.9 40.4 1,245 99.6 34.1 971 Highest 99.8 37.8 1,457 100.0 40.1 1,100 Total 98.4 37.0 5,691 99.3 38.4 4,529 Total men 15-59 na na na 99.2 39.1 5,015 na = Not applicable 12.2 KNOWLEDGE OF PREVENTION METHODS Controlling the spread of HIV is one of the major objectives in the fight against HIV infection. The challenge is to substantially reduce new HIV infections among the sexually active population and other vulnerable groups. This is done through the promotion of safer sexual behaviour including HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 209 abstinence, condom use, and promoting sex with a single partner who is not infected and who has no other partners. Table 12.2 shows the percentage of women and men age 15-49 who, in response to a prompted Table 12.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to a prompted question, say that people can reduce the risk of getting the AIDS virus by using condoms and by having sex with just one partner who is not infected and who has no other partners, by background characteristics, Gha- na 2003 Women Men Risk of getting AIDS virus can be reduced by: Risk of getting AIDS virus can be reduced by: Background characteristic Using con- doms Limiting sex to one un- infected partner Using condoms and limiting sex to one unin- fected partner Abstain- ing from sex Number of women Using condoms Limiting sex to one un- infected partner Using condoms and limiting sex to one unin- fected partner Abstain- ing from sex Number of men Age 15-19 76.4 85.6 71.5 80.2 1,148 77.6 84.8 70.9 80.7 1,107 20-24 76.9 87.4 73.0 78.0 1,012 85.4 91.8 81.8 84.0 684 25-29 73.0 85.8 69.3 78.6 951 83.9 90.3 79.7 82.2 754 30-39 70.0 84.5 65.5 77.2 1,524 83.2 92.4 79.7 84.6 1,131 40-49 69.4 87.9 66.7 80.4 1,056 82.4 91.5 78.7 81.5 853 15-24 76.6 86.4 72.2 79.2 2,160 80.6 87.5 75.1 81.9 1,791 Marital status Never married 77.3 87.7 72.6 81.5 1,616 81.5 88.6 76.3 83.3 2,040 Ever had sex 81.8 89.1 76.3 81.3 733 89.4 93.2 85.3 86.5 889 Never had sex 73.5 86.5 69.6 81.7 883 75.4 85.0 69.5 80.9 1,151 Married/living together 70.6 84.6 66.8 76.5 3,549 82.9 91.2 79.1 82.7 2,228 Divorced/separated/ widowed 74.9 91.2 71.7 85.8 526 80.7 89.7 76.2 75.7 261 Residence Urban 77.2 89.3 73.2 82.4 2,755 84.0 92.6 80.1 85.0 2,049 Rural 68.9 83.1 64.9 75.4 2,936 80.6 87.7 75.6 80.5 2,480 Region Western 77.2 91.7 72.8 86.0 553 83.1 93.9 79.9 83.6 435 Central 79.2 94.5 76.6 87.8 431 79.9 88.1 73.0 80.7 327 Greater Accra 73.4 81.6 67.7 76.7 942 84.5 92.4 80.3 85.1 664 Volta 70.2 82.9 65.0 72.4 492 89.3 93.6 86.2 89.8 389 Eastern 78.1 92.6 75.1 85.5 601 91.9 95.7 89.3 88.8 484 Ashanti 76.4 92.8 73.6 84.4 1,142 81.4 91.8 76.5 83.2 858 Brong Ahafo 75.4 87.0 69.4 79.3 569 89.2 95.2 85.7 88.2 483 Northern 46.4 58.0 42.6 49.0 499 60.9 72.6 55.9 63.2 489 Upper East 80.4 89.7 78.9 84.7 310 85.1 83.7 77.4 82.9 284 Upper West 60.6 85.3 57.7 75.2 153 65.2 82.4 58.3 71.4 116 Education No education 62.6 76.0 58.0 69.9 1,608 69.1 77.2 62.2 70.5 742 Primary 72.5 87.5 68.8 80.1 1,135 78.8 85.5 72.5 80.6 750 Middle/JSS 78.7 90.9 75.1 82.4 2,279 85.1 93.6 81.5 85.9 1,972 Secondary+ 78.8 91.4 74.4 85.7 669 88.1 95.1 84.9 86.2 1,065 Wealth quintile Lowest 63.6 77.7 59.7 68.8 970 74.3 81.1 67.5 74.8 777 Second 69.2 82.4 65.3 74.7 949 82.7 88.6 76.8 81.1 802 Middle 74.2 90.1 71.1 81.1 1,071 82.2 91.0 78.7 85.5 879 Fourth 76.0 87.7 71.1 83.5 1,245 84.4 91.3 80.0 83.3 971 Highest 77.9 89.8 73.9 82.3 1,457 85.2 95.1 82.7 86.1 1,100 Total 72.9 86.1 68.9 78.8 5,691 82.1 89.9 77.7 82.6 4,529 Total men 15-59 na na na na na 82.1 90.3 78.0 82.8 5,015 na = Not applicable 210 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior question, say that people can reduce the risk of getting the AIDS virus by using condoms, by having sex with just one uninfected partner who has no other partners, and by abstaining from sex, by background characteristics. Knowledge of HIV prevention methods is quite high. Seventy-three percent of women and 82 percent of men know that condom use is a major prevention method. Eighty-six percent and 90 percent of women and men, respectively, know that limiting sex to only one uninfected partner is vital to the prevention of HIV. Sixty-nine percent of women and 78 percent of men know that these two preventive measures in combination can reduce the risk of HIV infection. In addition, 79 percent of women and 83 percent of men know that abstinence can prevent HIV infection. Female respondents who are either married or living together and male respondents who have never had sex are slightly less knowledgeable about the principal ways to prevent HIV transmission than their counterparts. Knowledge of HIV prevention is higher among urban than rural dwellers. Regional variations range from a low of 43 percent in the Northern Region to a high of 79 percent in the Upper East among women, and from a low of 56 percent in the Northern Region to a high of 89 percent in the Eastern Region among men. Knowledge of HIV prevention rises with education levels and wealth. There is no clear pattern between knowledge of HIV prevention and age. 12.3 BELIEFS ABOUT AIDS Misconception about AIDS and HIV transmission is one of the factors that influences discrimina- tion and stigmatisation. The 2003 GDHS inquired about common misconceptions in Ghana. Respondents were asked whether they think it is possible for a healthy-looking person to have the AIDS virus; whether AIDS can be transmitted by mosquito bites; whether AIDS can be transmitted by supernatural means; and whether a person can be infected through sharing food with a person who has AIDS. The results are pre- sented in Tables 12.3.1 for women and 12.3.2 for men, by background characteristics. About four in five women and men correctly know that a healthy looking person can have the AIDS virus. Fifty-five percent of women and 60 percent of men know that AIDS cannot be transmitted through mosquito bites. Less than half of women and three-fifths of men know that AIDS cannot be transmitted by supernatural means. More than 70 percent of women and men know that a person cannot become infected with HIV/AIDS by sharing food with someone who has AIDS. Only 28 percent of women and 39 percent of men believe that a healthy looking person can have the AIDS virus and also reject the two most common misconceptions about AIDS in Ghana (i.e., AIDS can be transmitted by mosquito bites and by supernatural means). It is evident from the survey data that misconceptions about AIDS transmission are high in Ghana. Beliefs on HIV/AIDS transmission vary by residence. Urban residents are much less likely to have misconceptions about HIV/AIDS transmission than rural residents. For example, 50 percent of urban men age 15-49 compared with 29 percent of men residing in rural areas, believe that a healthy looking person can have the AIDS virus, and that a person cannot become infected with AIDS through mosquito bites and supernatural means. Regional variations are marked, with correct beliefs ranging from a low of 20 percent in the Central and Northern regions to a high of 52 percent in the Upper East Region among women, and from a low of 28 percent in the Northern Region to a high of 53 percent in Greater Accra among men. Education and wealth are positively correlated with correct beliefs. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 211 Table 12.3.1 Beliefs about AIDS: women Percentage of women age 15-49 who know that a healthy-looking person can have the AIDS virus and who in response to a prompted question, correctly reject local misconceptions about AIDS transmission or prevention, by background characteristics, Ghana 2003 Percentage of respondents who know that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by witchcraft or other supernatu- ral means A person cannot become infected by sharing food with someone who has AIDS Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common miscon- ceptions Number of women Age 15-19 75.4 65.5 53.9 78.1 32.9 1,148 20-24 81.7 58.3 48.1 78.0 29.8 1,012 25-29 83.3 53.7 45.4 72.3 27.1 951 30-39 79.3 49.3 42.5 66.9 26.0 1,524 40-49 81.0 51.1 43.2 65.6 26.6 1,056 15-24 78.3 62.1 51.2 78.1 31.5 2,160 Marital status Never married 81.4 67.6 54.3 81.8 35.1 1,616 Ever had sex 84.7 60.9 46.5 82.2 27.4 733 Never had sex 78.6 73.3 60.7 81.4 41.4 883 Married/living together 78.7 50.7 44.3 67.6 26.2 3,549 Divorced/separated/ widowed 83.8 47.7 36.6 69.8 22.5 526 Residence Urban 87.0 65.0 50.8 81.9 34.9 2,755 Rural 73.3 46.1 42.3 62.3 22.3 2,936 Region Western 79.3 51.2 39.1 71.6 23.7 553 Central 88.3 44.4 35.3 67.0 20.0 431 Greater Accra 84.4 62.9 49.0 82.1 32.4 942 Volta 79.5 42.1 45.8 58.9 22.3 492 Eastern 83.3 50.8 42.8 72.1 25.8 601 Ashanti 85.7 63.1 44.1 77.2 29.4 1,142 Brong Ahafo 89.1 59.1 46.1 79.6 34.2 569 Northern 44.3 45.0 48.7 45.0 20.1 499 Upper East 75.0 71.7 80.2 85.2 51.8 310 Upper West 68.1 40.2 46.8 53.9 23.6 153 Education No education 65.6 43.1 41.7 55.3 21.0 1,608 Primary 77.9 44.7 35.5 64.5 17.1 1,135 Middle/JSS 86.6 60.0 47.9 81.0 29.5 2,279 Secondary+ 95.1 85.9 71.1 92.4 61.3 669 Wealth quintile Lowest 63.1 43.3 44.9 53.9 22.6 970 Second 73.2 43.8 37.1 61.5 19.4 949 Middle 81.9 50.0 43.3 67.4 23.8 1,071 Fourth 86.2 58.1 45.8 79.0 27.8 1,245 Highest 88.7 72.1 56.3 87.6 42.0 1,457 Total 79.9 55.2 46.4 71.8 28.4 5,691 Note: The two most common local misconceptions involve transmission by mosquito bites and by supernatural means. 212 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.3.2 Beliefs about AIDS: men Percentage of men age 15-49 who know that a healthy-looking person can have the AIDS virus and who in response to a prompted question, correctly reject local misconceptions about AIDS transmission or prevention, by background characteristics, Ghana 2003 Percentage of respondents who know that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by witchcraft or other supernatu- ral means A person cannot become infected by sharing food with someone who has AIDS Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common miscon- ceptions Number of men Age 15-19 79.9 64.3 55.5 75.4 37.1 1,107 20-24 89.3 66.6 62.6 81.3 44.5 684 25-29 87.0 62.8 58.6 77.0 38.9 754 30-39 89.1 54.7 57.6 73.7 37.4 1,131 40-49 87.9 55.0 63.6 72.1 38.1 853 15-24 83.5 65.1 58.2 77.6 39.9 1,791 Marital status Never married 84.9 65.6 60.1 79.0 41.6 2,040 Ever had sex 89.1 66.3 61.8 82.5 43.4 889 Never had sex 81.7 65.0 58.8 76.2 40.2 1,151 Married/living together 87.3 55.6 58.9 72.2 36.6 2,228 Divorced/separated/ widowed 88.5 58.4 53.2 76.8 35.1 261 Residence Urban 89.8 70.9 67.1 85.1 50.3 2,049 Rural 83.4 51.4 52.6 67.6 29.3 2,480 Region Western 87.4 60.2 49.8 78.6 35.6 435 Central 94.2 50.2 45.1 74.3 30.2 327 Greater Accra 91.9 73.2 68.1 86.3 53.1 664 Volta 88.0 55.3 65.1 76.8 40.9 389 Eastern 92.7 55.6 57.1 70.4 39.1 484 Ashanti 85.1 65.2 59.3 81.0 40.1 858 Brong Ahafo 93.2 68.5 53.7 74.9 40.4 483 Northern 69.1 47.3 62.0 56.4 28.0 489 Upper East 79.3 54.5 70.6 76.8 34.3 284 Upper West 66.4 47.8 51.8 61.9 25.0 116 Education No education 72.5 39.8 49.4 53.4 19.8 742 Primary 80.9 44.4 44.6 61.2 21.1 750 Middle/JSS 88.7 61.0 57.5 80.5 37.3 1,972 Secondary+ 95.4 84.4 79.2 91.7 67.1 1,065 Wealth quintile Lowest 75.0 43.0 49.7 59.8 22.0 777 Second 84.2 48.6 47.5 64.0 26.0 802 Middle 87.8 56.9 57.6 75.7 35.5 879 Fourth 89.0 66.1 61.3 80.1 43.4 971 Highest 92.3 78.3 73.5 90.7 58.6 1,100 Total 86.3 60.2 59.1 75.5 38.8 4,529 Total men 15-59 86.1 59.8 59.2 75.2 38.5 5,015 Note: The two most common local misconceptions involve transmission by mosquito bites and by supernatural means. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 213 12.4 STIGMA AND DISCRIMINATION ASSOCIATED WITH HIV/AIDS The survey indicates that knowledge and beliefs about HIV and AIDS influence how PLWHAs and those affected by HIV/AIDS are treated. The extent of stigma and discrimination associated with HIV/AIDS can be ascertained from four questions included in the GDHS: whether respondents are willing to care for a family member with HIV at home; whether respondents would buy fresh vegetables from a vendor who has the AIDS virus; whether respondents believe that a female teacher who had the AIDS virus should be allowed to continue teaching; and whether respondents would want to keep the HIV positive status of a family member a secret. The results are shown in Tables 12.4.1 and 12.4.2. It is encouraging to see that more than two-thirds of women and men age 15-49 are willing to care for a family member with HIV in their own household, and that three-fifths of women and two-thirds of men do not believe that the HIV-positive status of a family member should be kept a secret. Two-fifths of women and half of men also believe that an HIV-positive female teacher should be allowed to continue teaching. However, only one in four women and one in three men say that they would buy fresh vegeta- bles from a vendor with AIDS. The four measures can be combined to provide a single measure of the percentage of women and men who exhibit accepting attitudes towards persons who have AIDS. It is dis- appointing to note that fewer than 10 percent of women and 14 percent of men express accepting attitudes on all four measures. Urban dwellers, those residing in Greater Accra, those with secondary education or higher, and those in the highest wealth quintile are much more likely to express accepting attitudes to- wards people with AIDS than others. 214 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.4.1 Accepting attitudes towards those living with HIV: women Percentage of women age 15-49 who have heard about AIDS expressing accepting attitudes towards people with HIV, by back- ground characteristics, Ghana 2003 Percentage of respondents who: Background characteristic Are willing to care for a family member with HIV at home Would buy fresh vegeta- bles from a vendor with AIDS Believe HIV- positive female teacher should be allowed to con- tinue teaching Believe HIV- positive status of a family member does not need to remain a secret Percentage expressing accepting attitudes on all four measures Number of wo- men who have heard of HIV/AIDS Age 15-19 71.4 29.2 43.8 51.6 8.9 1,127 20-24 71.1 30.9 44.4 57.4 10.3 998 25-29 65.0 23.6 38.0 59.4 7.9 936 30-39 67.9 22.2 33.3 62.1 7.9 1,494 40-49 66.3 23.0 32.3 61.4 7.6 1,042 15-24 71.3 30.0 44.0 54.3 9.6 2,125 Marital status Never married 72.9 34.7 49.3 53.3 11.4 1,599 Ever had sex 71.3 37.2 48.4 55.2 10.9 730 Never had sex 74.3 32.6 50.1 51.8 11.8 869 Married/living together 66.7 21.2 33.5 60.2 6.9 3,476 Divorced/separated/ widowed 65.9 26.8 33.3 63.7 10.0 522 Residence Urban 75.1 33.6 50.0 57.6 12.2 2,748 Rural 62.0 17.8 26.4 59.5 4.9 2,849 Residence Western 54.7 30.5 33.2 63.9 9.3 552 Central 50.6 20.2 32.2 44.5 2.8 431 Greater Accra 73.2 37.2 55.4 60.5 16.0 937 Volta 46.2 31.9 28.1 73.8 7.9 491 Eastern 64.0 25.8 37.6 63.6 8.0 595 Ashanti 75.4 27.8 39.6 61.0 9.4 1,139 Brong Ahafo 84.7 20.1 32.0 52.4 7.4 566 Northern 65.1 7.4 32.1 63.1 2.1 437 Upper East 86.6 11.7 32.4 28.3 3.7 303 Upper West 89.6 12.5 37.2 49.2 4.1 146 Education No education 66.1 12.3 25.1 56.9 3.3 1,529 Primary 59.2 19.9 29.3 58.1 5.2 1,124 Middle/JSS 70.6 30.2 41.2 60.5 9.8 2,275 Secondary+ 81.6 49.9 71.1 56.5 21.2 669 Wealth quintile Lowest 61.4 12.6 25.2 54.1 3.0 909 Second 60.0 14.5 20.9 62.5 4.0 927 Middle 64.9 19.4 29.6 58.6 5.4 1,064 Fourth 69.8 29.7 40.2 57.2 7.5 1,244 Highest 79.5 41.7 61.1 59.9 17.9 1,453 Total 68.4 25.6 38.0 58.5 8.5 5,597 HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 215 Table 12.4.2 Accepting attitudes towards those living with HIV: men Percentage of men age 15-49 who have heard about AIDS expressing accepting attitudes towards people with HIV, by background characteristics, Ghana 2003 Percentage of respondents who: Background characteristic Are willing to care for a family member with HIV at home Would buy fresh vegeta- bles from a vendor with AIDS Believe HIV- positive female teacher should be allowed to con- tinue teaching Believe HIV- positive status of a family member does not need to remain a secret Percentage expressing accepting attitudes on all four measures Number of men who have heard of HIV/AIDS Age 15-19 69.2 35.1 48.4 59.0 11.7 1,087 20-24 76.3 40.3 51.2 62.9 16.7 681 25-29 72.7 34.5 51.1 65.9 14.4 753 30-39 69.9 35.6 46.7 69.8 15.0 1,126 40-49 74.1 35.1 48.8 69.6 15.0 851 15-24 71.9 37.1 49.5 60.5 13.6 1,767 Marital status Never married 73.8 38.8 52.3 60.7 15.3 2,016 Ever had sex 77.4 43.2 55.2 63.7 17.6 884 Never had sex 71.0 35.4 50.0 58.4 13.5 1,132 Married/living together 70.4 32.9 45.4 69.2 13.1 2,219 Divorced/separated/ widowed 71.1 39.6 54.0 70.6 17.7 261 Residence Urban 76.7 45.3 60.6 60.1 19.3 2,044 Rural 68.0 28.1 39.3 70.0 10.2 2,453 Region Western 63.1 32.3 41.7 61.6 9.4 433 Central 72.3 29.2 46.9 66.4 14.9 325 Greater Accra 83.1 49.2 69.4 61.0 24.7 664 Volta 72.5 48.0 44.1 80.4 22.7 389 Eastern 78.0 34.2 44.7 76.7 14.2 480 Ashanti 62.4 38.8 47.9 60.3 10.5 858 Brong Ahafo 63.9 35.2 49.1 55.9 11.9 483 Northern 74.1 20.3 42.1 72.3 8.5 471 Upper East 80.7 28.5 44.8 66.6 14.1 280 Upper West 88.3 21.5 43.7 53.7 7.7 114 Education No education 67.9 14.4 32.6 71.1 4.4 727 Primary 61.9 27.0 34.9 65.5 10.1 739 Middle/JSS 72.0 37.8 48.1 63.8 13.0 1,965 Secondary+ 81.6 53.3 71.5 64.7 26.6 1,065 Wealth quintile Lowest 71.1 21.1 37.6 70.2 8.1 757 Second 63.4 27.7 33.7 68.7 8.6 801 Middle 66.7 31.5 38.0 65.7 9.9 872 Fourth 72.7 38.6 53.4 64.0 14.4 968 Highest 82.3 53.3 72.7 61.0 26.3 1,100 Total 72.0 35.9 49.0 65.5 14.4 4,497 Total men 15-59 71.8 36.3 49.1 66.0 14.8 4,977 216 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior 12.5 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION More than 80 percent of the transmission of HIV is through sexual intercourse. According to the Ghana HIV/AIDS strategic framework, mother to child transmission (MTCT) is estimated to account for about 15 percent of all HIV transmissions in Ghana. One of the key intervention areas of the HIV/AIDS strategic framework for Ghana is the prevention of new infections. The challenge is to make MTCT prevention services available and utilized. It is therefore important to ascertain the knowledge of respondents on how transmission of HIV from mother to child during pregnancy, delivery, and during breastfeeding can be prevented, and to ascertain whether women and men know that the risk of mother to child transmission of HIV can be reduced by the mother taking special drugs during pregnancy. Tables 12.5.1 and 12.5.2 show that general knowledge about HIV transmission during pregnancy, delivery, and breastfeeding is relatively high and ranges between 69 and 75 percent among women and 74 to 82 percent among men. However, few women and men (16 percent each) know that the risk of MTCT can be reduced if a mother takes special drugs during her pregnancy. As seen before, urbanization, education, and wealth, have a positive impact on respondent’s knowledge of MTCT. Women in the Upper West Region and men in the Northern Region are least likely to know both that HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by mothers taking special drugs during pregnancy (a UNAIDS measure). HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 217 Table 12.5.1 Knowledge of prevention of mother to child transmission of HIV: women Percentage of women age 15-49 who know that HIV can be transmitted from mother to child during delivery, during pregnancy and by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Ghana 2003 Percentage who know that: Background characteristic HIV can be transmitted during pregnancy HIV can be transmitted during delivery HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking drugs during pregnancy Number of women Age 15-19 71.9 65.5 68.0 12.6 11.5 1,148 20-24 76.5 70.0 75.1 19.0 18.0 1,012 25-29 79.8 74.0 76.1 16.8 15.9 951 30-39 73.4 67.6 71.0 16.7 16.2 1,524 40-49 76.7 70.3 74.2 14.6 14.1 1,056 15-24 74.1 67.6 71.3 15.6 14.6 2,160 Marital status Never married 78.0 70.7 73.6 15.8 14.6 1,616 Ever had sex 84.6 75.5 79.0 18.0 16.8 733 Never had sex 72.4 66.7 69.2 14.0 12.8 883 Married/living together 73.9 68.0 71.5 16.3 15.7 3,549 Divorced/separated/ widowed 77.2 72.7 76.5 13.7 13.2 526 Residence Urban 82.3 76.4 78.9 18.9 17.9 2,755 Rural 68.8 62.3 66.6 13.2 12.5 2,936 Region Western 65.4 59.5 65.2 16.6 15.3 553 Central 72.2 65.3 74.4 13.0 13.0 431 Greater Accra 84.4 79.2 81.1 14.4 13.6 942 Volta 78.5 69.4 76.2 9.2 8.7 492 Eastern 88.2 82.9 88.1 13.8 13.1 601 Ashanti 85.4 76.2 78.4 26.5 25.3 1,142 Brong Ahafo 72.9 69.3 70.1 21.5 20.0 569 Northern 46.6 40.7 44.4 6.4 6.0 499 Upper East 55.0 53.5 52.0 10.2 9.8 310 Upper West 72.0 69.7 67.8 4.5 4.5 153 Education No education 57.8 53.1 56.1 9.2 9.0 1,608 Primary 73.1 66.9 72.7 13.2 12.7 1,135 Middle/JSS 83.6 76.7 79.8 18.2 17.0 2,279 Secondary+ 93.2 86.2 87.1 29.2 27.5 669 Wealth quintile Lowest 56.1 52.0 54.1 10.0 9.5 970 Second 69.9 62.6 66.8 12.4 12.1 949 Middle 75.2 70.4 75.5 13.8 13.1 1,071 Fourth 82.3 73.4 78.9 15.9 15.4 1,245 Highest 85.8 80.3 81.0 23.8 22.1 1,457 Total 75.3 69.2 72.6 15.9 15.1 5,691 218 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.5.2 Knowledge of prevention of mother to child transmission of HIV: men Percentage of men age 15-49 who know that HIV can be transmitted from mother to child during delivery, during pregnancy, and by breast- feeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by mother taking special drugs during pregnancy, by background characteristics, Ghana 2003 Percentage who know that: Background characteristic HIV can be transmitted during pregnancy HIV can be transmitted during delivery HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking drugs during pregnancy Number of men Age 15-19 74.6 65.3 66.5 12.9 11.4 1,107 20-24 84.2 75.7 76.3 14.5 12.1 684 25-29 85.3 75.9 78.2 19.1 16.5 754 30-39 83.6 76.1 77.4 17.3 15.6 1,131 40-49 83.9 76.9 77.9 16.2 14.3 853 15-24 78.2 69.3 70.2 13.5 11.7 1,791 Marital status Never married 79.3 70.3 71.4 15.5 13.5 2,040 Ever had sex 85.7 76.0 78.6 18.4 15.8 889 Never had sex 74.3 65.8 65.9 13.3 11.6 1,151 Married/living together 84.2 76.5 78.0 16.5 14.6 2,228 Divorced/separated/ widowed 81.3 73.3 73.7 14.1 12.8 261 Residence Urban 86.2 78.5 77.1 20.4 17.3 2,049 Rural 78.2 69.3 72.9 12.2 11.2 2,480 Region Western 79.1 68.7 73.5 18.4 16.9 435 Central 78.2 64.5 74.0 7.2 6.8 327 Greater Accra 89.7 83.1 84.0 18.5 16.5 664 Volta 87.3 82.4 85.4 10.8 10.8 389 Eastern 88.9 82.5 83.1 20.9 17.8 484 Ashanti 84.4 76.4 74.8 23.2 19.9 858 Brong Ahafo 86.4 68.7 69.8 15.6 12.8 483 Northern 61.5 56.7 57.9 7.3 6.0 489 Upper East 73.8 70.6 68.5 10.7 9.8 284 Upper West 76.3 71.0 65.6 8.8 8.0 116 Education No education 66.1 62.2 61.4 5.8 5.1 742 Primary 73.2 68.6 70.8 11.2 10.5 750 Middle/JSS 85.3 74.8 77.9 16.3 14.5 1,972 Secondary+ 92.3 82.5 81.0 25.3 21.6 1,065 Wealth quintile Lowest 69.3 63.5 65.1 8.5 7.5 777 Second 78.1 70.6 72.9 10.2 9.3 802 Middle 84.7 73.3 79.3 15.6 14.0 879 Fourth 83.5 73.3 73.3 16.7 14.4 971 Highest 89.6 83.0 80.7 24.8 21.5 1,100 Total 81.8 73.5 74.8 15.9 14.0 4,529 Total men 15-59 81.8 73.9 74.8 16.0 14.2 5,015 HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 219 12.6 HIV TESTING Voluntary counselling and testing (VCT) is vital in the fight against HIV/AIDS. The 2003 GDHS asked all respondents who had heard of AIDS whether they had ever been tested for the virus, when they were last tested, whether the test was voluntary or mandatory, whether they received the test results, where they went for the test, and if they have not been tested, whether they would like to be tested, and whether they know where to go for the test. Table 12.6, which presents results among all respondents, shows that only about one in ten women and men age 15-49 reported that they had ever been tested for AIDS. The majority of women and men who were tested know their HIV status. Two percent of women and 3 percent of men in Ghana have been tested and received their test results within the last 12 months. 0 220 | H IV/AID S-Related Know ledge, Attitudes, and Behavior Table 12.6 Women and men who had an HIV test and received test results Percent distribution of women and men age 15-49 by status of HIV testing, and percentage of women and men who were tested for HIV and received test results in the past 12 months, according to background characteristics, Ghana 2003 Women Men Ever tested Ever tested Background characteristic Received results No results Never tested Don’t Know/ missing Total Percentage tested and re- ceived results in past 12 months Number of women Received results No results Never tested Don’t Know/ missing Total Percentage tested and re- ceived results in past 12 months Number of men Age 15-19 2.7 1.2 94.3 1.8 100.0 1.0 1,148 2.1 0.7 95.3 1.9 100.0 1.1 1,107 20-24 7.6 2.4 88.4 1.6 100.0 2.6 1,012 4.5 1.1 94.0 0.4 100.0 2.4 684 25-29 11.0 2.9 84.3 1.9 100.0 3.2 951 11.1 1.9 86.7 0.2 100.0 4.9 754 30-39 8.7 3.8 85.4 2.1 100.0 2.9 1,524 10.8 1.9 86.8 0.5 100.0 4.2 1,131 40-49 7.0 2.3 89.5 1.3 100.0 1.8 1,056 9.1 2.8 87.8 0.2 100.0 3.6 853 15-24 5.0 1.8 91.5 1.7 100.0 1.7 2,160 3.0 0.9 94.8 1.3 100.0 1.6 1,791 Marital status Never married 4.9 1.2 92.8 1.1 100.0 1.9 1,616 4.5 0.7 93.7 1.1 100.0 2.0 2,040 Ever had sex 8.0 1.7 89.9 0.4 100.0 2.8 733 7.2 0.7 91.6 0.5 100.0 2.7 889 Never had sex 2.4 0.7 95.3 1.6 100.0 1.1 883 2.4 0.7 95.2 1.7 100.0 1.5 1,151 Married/living to- gether 8.4 3.2 86.2 2.3 100.0 2.5 3,549 10.1 2.6 86.9 0.4 100.0 4.0 2,228 Divorced/separated/ widowed 8.0 2.7 88.5 0.7 100.0 2.3 526 8.3 1.4 90.3 0.0 100.0 5.0 261 Residence Urban 9.3 3.2 87.1 0.4 100.0 3.1 2,755 10.9 1.4 87.5 0.3 100.0 4.7 2,049 Rural 5.5 2.0 89.4 3.1 100.0 1.5 2,936 4.7 1.9 92.3 1.1 100.0 1.9 2,480 Region Western 10.2 1.1 88.4 0.3 100.0 3.5 553 10.9 2.8 85.7 0.5 100.0 4.2 435 Central 2.5 1.1 96.5 0.0 100.0 0.6 431 2.4 0.9 96.0 0.6 100.0 0.8 327 Greater Accra 8.5 2.2 88.7 0.6 100.0 3.2 942 10.9 0.9 88.2 0.0 100.0 5.6 664 Volta 5.1 2.2 92.6 0.1 100.0 2.2 492 4.0 1.6 94.4 0.0 100.0 1.0 389 Eastern 9.3 3.1 86.7 0.9 100.0 2.4 601 6.0 1.9 91.3 0.7 100.0 3.3 484 Ashanti 9.2 1.6 88.6 0.6 100.0 2.2 1,142 10.3 2.3 87.4 0.0 100.0 4.1 858 Brong Ahafo 11.2 8.9 79.1 0.8 100.0 3.6 569 6.4 1.8 91.8 0.0 100.0 2.7 483 Northern 2.7 1.2 83.8 12.3 100.0 1.0 499 4.9 1.0 90.5 3.7 100.0 1.9 489 Upper East 1.8 2.3 93.3 2.7 100.0 0.6 310 5.9 1.3 91.2 1.6 100.0 2.3 284 Upper West 2.0 2.7 91.0 4.3 100.0 1.1 153 5.1 2.1 90.7 2.2 100.0 1.4 116 Education No education 2.8 2.2 90.0 5.0 100.0 1.1 1,608 3.0 1.7 93.4 2.0 100.0 1.7 742 Primary 5.5 2.9 90.4 1.3 100.0 1.4 1,135 5.1 1.3 92.1 1.5 100.0 2.3 750 Middle/JSS 9.7 2.7 87.3 0.3 100.0 3.1 2,279 6.4 1.6 91.7 0.3 100.0 2.5 1,972 Secondary+ 13.6 2.5 83.9 0.0 100.0 4.0 669 14.3 2.1 83.6 0.0 100.0 5.9 1,065 Wealth quintile Lowest 2.9 1.8 88.9 6.4 100.0 0.9 970 2.7 1.3 93.4 2.6 100.0 1.0 777 Second 5.3 2.0 90.3 2.4 100.0 1.5 949 2.7 1.7 95.4 0.2 100.0 1.4 802 Middle 6.0 3.3 89.8 0.8 100.0 2.1 1,071 6.2 1.5 91.5 0.8 100.0 2.5 879 Fourth 8.9 3.0 87.7 0.4 100.0 3.4 1,245 8.6 1.9 89.2 0.4 100.0 3.1 971 Highest 11.3 2.5 85.9 0.2 100.0 2.9 1,457 14.4 1.9 83.7 0.0 100.0 6.6 1,100 Total 7.4 2.6 88.3 1.8 100.0 2.3 5,691 7.5 1.7 90.1 0.7 100.0 3.2 4,529 Total men 15-59 na na na na na na na 7.5 1.6 90.2 0.8 100.0 3.2 5,015 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 221 12.7 COUNSELLING AND TESTING PREGNANT WOMEN The need for voluntary counselling before testing for HIV cannot be over-emphasized. An oppor- tunity for counselling pregnant women on HIV/AIDS arises during antenatal visits. The 2003 GDHS asked women who gave birth in the two years preceding the survey whether they were given any informa- tion or counselled about HIV/AIDS. The results in Table 12.7 show that 1,421 women age 15-49 had a birth in the two years preced- ing the survey. Forty-three percent of these women were counselled during their antenatal visits. Eight percent of these women were voluntarily tested for AIDS, half of whom received their results while half Table 12.7 Pregnant women counselled and tested for HIV Among women who gave birth in the two years preceding the survey, percentage who were counselled and offered HIV testing during antenatal care for their most recent birth, percentage who accepted an offer of testing, and percentage who received their test results, by background characteristics, Ghana 2003 Voluntarily tested for HIV during antenatal care visits Background characteristic Counselled during antenatal visit Received results No results Counselled, tested for HIV and know results Number of women who gave birth in the past 2 years Age 15-19 21.5 5.3 3.6 4.0 96 20-24 44.6 6.3 3.4 5.4 308 25-29 45.9 2.3 3.7 1.5 384 30-39 44.6 4.4 4.0 3.3 522 40-49 43.1 3.7 3.7 2.9 112 15-24 39.1 6.1 3.4 5.1 404 Marital status Never married 27.3 12.1 1.2 6.5 52 Married/living together 44.3 4.1 3.9 3.3 1,289 Divorced/separated/ widowed 37.4 1.0 2.8 1.0 80 Residence Urban 53.9 6.9 6.3 5.1 477 Rural 37.9 2.9 2.4 2.4 944 Region Western 48.6 5.9 0.0 3.8 128 Central 42.0 0.0 0.0 0.0 120 Greater Accra 38.8 3.7 2.4 1.1 150 Volta 50.0 0.8 2.5 0.8 134 Eastern 33.5 5.8 4.4 3.6 142 Ashanti 45.5 6.1 2.3 4.8 245 Brong Ahafo 62.6 10.3 16.3 9.8 158 Northern 26.6 2.0 0.7 2.0 208 Upper East 49.8 1.4 5.4 1.4 86 Upper West 41.8 2.5 3.9 2.5 49 Education No education 31.5 2.4 3.0 1.5 572 Primary 46.0 3.4 2.8 2.6 322 Middle/JSS 52.9 6.5 4.7 5.4 449 Secondary+ 62.8 8.5 6.8 6.6 77 Wealth quintile Lowest 37.6 2.8 2.2 2.7 373 Second 37.1 3.1 3.0 2.5 319 Middle 39.8 4.6 4.5 2.7 284 Fourth 46.3 6.1 4.2 4.8 235 Highest 64.1 5.8 5.9 4.6 210 Total 43.3 4.2 3.7 3.3 1,421 222 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior did not. Three percent of women who had a birth in the past two years were counselled, tested, and given the results of their test. VCT is more common among urban than rural women, and is highest in the Brong Ahafo Region. The percentage of women receiving VCT is positively related to both education and wealth status. Among those who were tested for HIV, 32 percent of women and 48 percent of men asked for the test, while 41 percent of women and 26 percent of men were offered the test and accepted (Figure 12.1). About one-fourth of those tested (26 percent of women and 24 percent of men) indicated that the HIV test was required. 32 41 26 48 26 24 Asked for test Test offered and accepted Test required 0 10 20 30 40 50 60 Percent Women Men Figure 12.1 Reason for Getting HIV Test among Women and Men Age 15-49 Who Have Ever Been Tested GDHS 2003 12.8 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Respondents in the GDHS were asked about their attitude towards negotiating safer sex. Women and men were asked if a wife is justified in refusing to have sexual intercourse with her husband if she knows that he has an STI. The majority of women (86 percent) and men (91 percent) agreed that a wife is justified in refusing to have sexual intercourse with her husband if he has an STI (Table 12.8). Men were also asked if a wife is justified in asking a man to use a condom if he has an STI. Again, most men (92 percent) agreed with this statement. A similar question was not posed to women. There is little variation by background characteristics. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 223 Table 12.8 Attitudes towards negotiating safer sex with husband Percentage of women and men age 15-49 who believe that, if a husband has an STI, his wife can refuse to have sex with him and percentage of men who believe that, if a husband has an STI, his wife can either refuse to have sex with him or propose condom use, by background characteristics, Ghana 2003 Women Men Background characteristic Refuse sex Number of women Refuse sex Propose condom use Refuse sex or propose condom use1 Number of men Age 15-19 84.7 1,148 85.8 87.9 94.4 1,107 20-24 86.5 1,012 91.6 94.1 98.3 684 25-29 86.4 951 91.9 93.8 97.9 754 30-39 85.7 1,524 93.3 91.3 97.3 1,131 40-49 88.1 1,056 91.6 92.6 96.8 853 15-24 85.6 2,160 88.0 90.3 95.9 1,791 Marital status Never married 86.0 1,616 88.5 90.7 96.1 2,040 Ever had sex 87.6 733 92.0 94.5 98.7 889 Never had sex 84.7 883 85.8 87.7 94.1 1,151 Married/living together 85.8 3,549 92.6 92.1 97.3 2,228 Divorced/separated/ widowed 89.6 526 91.0 93.9 96.8 261 Residence Urban 88.1 2,755 92.2 93.5 97.9 2,049 Rural 84.4 2,936 89.4 89.9 95.8 2,480 Region Western 92.3 553 88.7 90.8 95.4 435 Central 87.4 431 94.9 94.5 98.3 327 Greater Accra 87.7 942 92.7 93.7 97.4 664 Volta 82.9 492 91.7 91.2 94.4 389 Eastern 80.3 601 89.6 91.8 96.7 484 Ashanti 85.9 1,142 90.7 93.8 98.5 858 Brong Ahafo 84.4 569 88.9 91.1 97.1 483 Northern 83.3 499 89.6 86.9 95.3 489 Upper East 95.5 310 88.9 88.4 96.1 284 Upper West 83.7 153 89.9 85.7 95.1 116 Education No education 84.5 1,608 88.3 85.8 94.2 742 Primary 83.3 1,135 88.2 87.3 94.6 750 Middle/JSS 88.0 2,279 90.5 92.7 97.3 1,972 Secondary+ 88.8 669 94.3 96.4 99.1 1,065 Wealth quintile Lowest 86.2 970 86.3 86.1 94.0 777 Second 83.7 949 90.6 90.0 96.4 802 Middle 83.5 1,071 91.0 91.0 96.4 879 Fourth 86.2 1,245 90.0 93.0 97.4 971 Highest 89.7 1,457 94.0 95.7 98.6 1,100 Total 86.2 5,691 90.6 91.5 96.8 4,529 Total men 15-59 na na 90.6 91.2 96.7 5,015 na = Not applicable 224 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior 12.9 HIGHER-RISK SEX AND CONDOM USE Sexual intercourse with a non-marital or non-cohabiting partner is associated with an increase in the risk of contracting STIs. Higher-risk sexual behaviour can therefore be defined as having sexual intercourse with any persons other than a spouse or a regular partner. The use of condoms by both men and women during sexual intercourse reduces the risk of contracting HIV. Table 12.9 shows the percentage of women and men age 15-49 who had sexual intercourse with a non-marital, non-cohabiting partner within the 12 months preceding the survey. The table shows that one in five women and two in five men reported engaging in higher-risk sexual behaviour. Higher-risk sexual behaviour is most common among the youngest cohort of women and men. In fact, it is disturbing to note that half of women age 15-24 and more than four-fifths of men in the same age cohort engage in risky sexual behaviour. Among those who did engage in higher-risk sex, 28 percent of women and 45 percent of men age 15-49 used a condom during their higher-risk sex. Higher-risk sex is especially common among women and men who have never married or who are currently divorced, separated, or widowed. For example, nearly all sexually active women who have never married engage in higher-risk sex, while only one-third of them used a condom during their last higher-risk sex. Residents of urban areas are also more likely than their rural counterparts to engage in higher-risk sexual behaviour. The percentage engaging in higher-risk sexual behaviour rises with the level of education. Nevertheless, as education level rises, there is a greater likelihood of respondents reporting using a condom during last higher-risk sex. Higher-risk sexual behaviour increases with increasing wealth quintile. Condom use at last higher-risk sex also increases with the level of household wealth. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 225 Table 12.9 Higher-risk sex and condom use at last higher-risk sex among women and men age 15-49 Among women and men age 15-49 reporting sexual activity in the past 12 months, percentage who had sex with a non- marital, non-cohabiting partner (higher-risk sex) in the past 12 months, and among these women and men, percentage who say they used a condom the last time they had sex with a non-marital, non-cohabiting partner, by background characteristics, Ghana 2003 Women Men Background characteristic Percentage of women engaging in higher-risk sex in the past 12 months Number of women sexually active in the past 12 months Percentage of women who used condom at last higher- risk sex Number of women who had higher-risk sex in past 12 months Percentage of men engaging in higher-risk sex in the past 12 months Number of men sexually active in the past 12 mon- ths Percentage of men who used condom at last higher- risk sex Number of men who had higher-risk sex in past 12 mon- ths Age 15-19 72.1 363 33.5 262 97.9 163 46.2 159 20-24 38.0 685 32.0 261 77.3 387 54.7 299 25-29 16.6 770 27.4 128 50.2 595 43.3 299 30-39 7.4 1,241 13.1 92 25.8 993 37.1 256 40-49 7.7 803 11.2 62 13.2 769 37.5 102 15-24 49.8 1,048 32.7 522 83.4 549 51.7 458 Marital status Never married 98.5 526 34.1 518 99.9 632 49.3 631 Married/living together 3.7 3,116 15.4 116 15.7 2,109 39.0 332 Divorced/separated/ widowed 76.9 221 17.7 170 91.5 166 39.0 152 Residence Urban 27.8 1,730 32.5 481 45.9 1,257 50.3 577 Rural 15.2 2,132 21.2 323 32.6 1,649 38.9 537 Region Western 20.3 380 29.0 77 38.0 294 45.1 112 Central 15.2 291 25.1 (44) 37.2 208 40.1 77 Greater Accra 27.3 577 37.6 158 46.7 431 52.6 201 Volta 23.4 343 35.6 80 45.7 260 57.0 119 Eastern 24.4 439 25.7 107 35.5 348 48.3 123 Ashanti 24.9 780 25.0 194 39.9 558 38.4 223 Brong Ahafo 20.1 433 18.1 87 36.5 307 41.7 112 Northern 8.0 339 19.9 (27) 30.6 297 27.6 91 Upper East 11.4 190 20.4 (22) 31.5 142 50.9 45 Upper West 8.4 91 * 8 19.5 63 39.2 (12) Education No education 7.1 1,187 11.1 84 20.7 506 22.8 105 Primary 19.2 776 20.9 149 41.1 420 23.9 173 Middle/JSS 28.0 1,515 26.9 424 40.1 1,252 46.5 502 Secondary+ 38.3 384 47.8 147 46.0 728 60.0 335 Wealth quintile Lowest 10.4 654 16.0 68 29.8 475 26.1 141 Second 15.8 726 17.2 115 30.6 528 32.6 161 Middle 20.1 775 16.7 156 37.9 576 40.6 218 Fourth 28.3 850 31.0 240 44.0 609 49.2 268 Highest 26.3 858 41.7 225 45.3 719 58.2 326 Total 20.8 3,863 28.0 804 38.4 2,906 44.8 1,115 Total men 15-59 na na na na 35.0 3,339 43.8 1,168 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. na = Not applicable 226 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Sexual intercourse with more than one partner is also associated with a high risk of exposure to STIs. Table 12.10 shows the percentage of women and men age 15-49 who had sexual intercourse with more than one partner in the 12 months preceding the survey. One percent of women and 10 percent of men report having had sexual intercourse with more than one partner in the 12 months preceding the survey. Sexual intercourse with more than one partner is more common among women age 15-24 and Table 12.10 Multiple sex partners among women and men Percentage of women and men age 15-49 who have had sex with more than one partner in the past 12 months, by background characteristics, Ghana 2003 Women Men Background characteristic Percentage who had 2+ partners in the past 12 months Number of women Percentage who had 2+ partners in the past 12 months Number of men Age 15-19 1.5 1,148 2.4 1,107 20-24 1.9 1,012 10.4 684 25-29 0.4 951 13.8 754 30-39 1.0 1,524 13.5 1,131 40-49 0.4 1,056 11.1 853 15-24 1.7 2,160 5.5 1,791 Marital status Never married 2.3 1,616 6.1 2,040 Ever married 0.6 4,075 13.0 2,489 Residence Urban 1.3 2,755 11.1 2,049 Rural 0.8 2,936 8.9 2,480 Region Western 0.9 553 7.3 435 Central 1.5 431 10.7 327 Greater Accra 2.1 942 13.5 664 Volta 0.2 492 12.3 389 Eastern 1.4 601 10.3 484 Ashanti 0.8 1,142 8.7 858 Brong Ahafo 1.2 569 11.4 483 Northern 0.3 499 9.7 489 Upper East 0.6 310 4.7 284 Upper West 0.5 153 4.1 116 Education No education 0.6 1,608 9.1 742 Primary 0.9 1,135 7.7 750 Middle/JSS 1.2 2,279 9.5 1,972 Secondary+ 1.8 669 12.8 1,065 Wealth quintile Lowest 0.2 970 8.4 777 Second 1.4 949 7.4 802 Middle 1.0 1,071 10.3 879 Fourth 0.9 1,245 10.0 971 Highest 1.6 1,457 12.5 1,100 Total 1.1 5,691 9.9 4,529 Total men 15-59 na na 10.1 5,015 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 227 men age 25-39, never-married women and ever-married men, urban women and men, women and men residing in Greater Accra, highly educated women and men, and wealthier women and men. Some of the major strategies for reducing HIV infection among young men and women is to delay the age of first sex, limit the number of sexual partners to one, and encourage and promote consistent and correct use of condoms. Young men and women are the target of most HIV/AIDS interventions aimed at sexual behavioural change. Some of these strategies and interventions seem to have some impact. 12.10 PAID SEX Sex with commercial sex workers is associ- ated with higher-risk sexual behaviour. According to a second-generation surveillance survey con- ducted in 2002 in Kumasi and Accra by The West African Project to combat AIDS and STI, HIV/AIDS prevalence among sex workers is 54 percent in Kumasi and 23 percent in Accra. Table 12.11 shows the percentage of men age 15-49 reporting having had sex with a prostitute in the 12 months preceding the survey. About 2 percent of men reported sex with a prostitute in the last 12 months. Less than half of these men reported using a condom at last sex with a prostitute (data not shown). 12.11 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS AND SYMPTOMS There is a strong link between other sexu- ally transmitted infections (STI) and HIV infection. It is believed that people having any other STI apart from HIV infection have a very high likelihood of being infected with HIV. STIs are therefore identi- fied as co-factors in HIV transmission. One of the key interventions of the National Response on HIV/AIDS is to minimise STI transmission by im- proving the management of STI through strengthen- ing symptomatic management of STIs in both gov- ernment and private health institutions. Table 12.12 shows the percentage of women and men who self-reported an STI and/or symptoms of an STI in the 12 months preceding the survey, among those who have ever had sex. Two percent of women and men report having had an STI in the 12 months preceding the survey. A higher percentage of women than men report ab- normal genital discharge (7 and versus 3 percent, respectively). Three percent of women and 2 per- cent of men reported having a genital sore or ulcer. Table 12.11 Paid sex in past year Percentage of men age 15-49 reporting sex with a pros- titute in the past 12 months, by background characteris- tics, Ghana 2003 Background characteristic Percentage reporting sex with prostitute in the past 12 months Number of men Age 15-19 0.6 1,107 20-24 2.0 684 25-29 2.3 754 30-39 1.8 1,131 40-49 1.4 853 15-24 1.1 1,791 Marital status Never married 1.0 2,040 Married/living together 1.3 2,228 Divorced/separated/ widowed 7.6 261 Residence Urban 1.2 2,049 Rural 1.8 2,480 Region Western 3.6 435 Central 1.3 327 Greater Accra 1.2 664 Volta 1.8 389 Eastern 2.0 484 Ashanti 1.4 858 Brong Ahafo 0.9 483 Northern 1.9 489 Upper East 0.2 284 Upper West 0.0 116 Education No education 1.4 742 Primary 1.1 750 Middle/JSS 2.1 1,972 Secondary+ 1.0 1,065 Wealth index Lowest 1.6 777 Second 2.0 802 Middle 2.0 879 Fourth 1.7 971 Highest 0.8 1,100 Total 1.6 4,529 Total men 15-59 1.5 5,015 228 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Eight percent of women and 4 percent of men reported they had an STI, abnormal genital discharge, or genital sores or ulcers. Younger women and men (15-24), those who have never married, urban women and rural men, women from the Volta Region and men from the Northern Region, highly educated women, and the wealthiest respondents are more likely than others to self-report symptoms of an STI, genital discharge, and sore or ulcer. Table 12.12 Self-reportiing of sexually transmitted infection (STI) and STI symptoms Among women and men who ever had sex, percentage self-reporting an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Ghana 2003 Women Men Background characteristic Percentage with STI Percentage with abnormal genital discharge Percentage with genital sore/ulcer Percentage with STI/discharge/ genital sore/ulcer Number of women who ever had sex Percentage with STI Percentage with abnormal genital discharge Percentage with genital sore/ulcer Percentage with STI/discharge/ genital sore/ulcer Number of men who ever had sex Age 15-19 2.2 10.5 5.6 13.6 448 2.2 6.4 3.0 8.3 221 20-24 1.9 10.2 3.0 12.0 853 3.3 4.7 2.7 7.0 484 25-29 2.1 7.6 2.8 9.6 931 2.2 3.5 2.4 4.7 699 30-39 1.1 4.9 2.1 6.4 1,519 1.3 2.6 1.6 3.6 1,119 40-49 1.5 3.5 1.0 4.8 1,056 0.7 1.0 1.2 2.2 853 Marital status Never married 1.9 12.4 5.0 15.4 733 2.4 4.2 1.9 5.7 889 Married/living to- gether 1.6 5.6 2.1 7.2 3,548 1.3 2.4 1.6 3.6 2,226 Divorced/separated/ widowed 1.2 5.1 1.5 5.8 526 2.5 3.1 4.2 5.8 261 Residence Urban 2.2 7.3 3.1 9.6 2,179 2.0 2.6 1.8 4.0 1,503 Rural 1.2 6.0 2.0 7.3 2,628 1.4 3.2 2.0 4.5 1,873 Region Western 0.2 4.0 1.7 5.0 459 1.6 2.5 1.7 4.4 332 Central 0.3 3.3 0.7 3.3 369 2.5 2.5 1.0 2.5 232 Greater Accra 3.2 7.8 3.8 10.4 738 1.9 1.9 2.0 3.6 519 Volta 1.3 12.4 3.3 14.7 425 0.5 0.5 1.4 1.8 284 Eastern 2.0 4.5 3.2 6.5 526 2.8 2.7 2.3 3.7 378 Ashanti 1.6 6.5 2.5 8.9 948 1.9 3.7 1.7 4.6 646 Brong Ahafo 3.2 9.1 2.7 10.8 496 1.0 2.3 2.7 4.8 344 Northern 0.4 4.0 1.8 5.1 459 1.9 6.0 2.0 7.1 375 Upper East 0.9 4.9 0.8 5.4 259 0.0 3.8 2.2 4.5 189 Upper West 0.7 10.9 1.8 11.9 129 1.2 4.2 1.9 6.1 78 Education No education 1.2 5.3 2.1 6.3 1,522 0.9 3.3 1.5 4.1 625 Primary 1.2 6.2 2.9 7.9 961 0.9 3.1 3.1 5.4 473 Middle/JSS 2.1 7.3 2.3 9.3 1,839 2.4 3.0 2.0 4.5 1,429 Secondary+ 2.1 8.7 3.5 11.7 485 1.6 2.6 1.5 3.5 849 Wealth index Lowest 1.1 5.6 1.7 6.7 875 1.5 3.7 2.0 4.8 562 Second 1.3 6.4 2.2 7.7 858 1.6 3.8 1.6 5.1 594 Middle 1.5 5.8 1.9 7.4 943 1.3 2.2 1.5 3.6 652 Fourth 1.8 6.1 3.2 8.4 1,030 2.9 3.7 3.5 5.4 725 Highest 2.3 8.7 3.2 10.8 1,100 1.1 1.8 1.0 3.0 843 Total 1.6 6.6 2.5 8.3 4,807 1.7 3.0 1.9 4.3 3,376 Total men 15-59 na na na na na 1.6 2.7 1.9 4.0 3,861 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 229 12.12 STI TREATMENT-SEEKING BEHAVIOUR Stigma and discrimination can discourage in- fected persons from seeking professional health care and lead some to resort to self-medication. Table 12.13 shows treatment-seeking behaviour among those who reported an STI or symptoms of an STI, by source of advice or treatment. Just over one-third of women and men sought care. About half (49 percent) of the men who reported an STI or symptoms of an STI sought advice or obtained medicine from a shop or pharmacy. Nearly one-third of men (31 percent) and half of women (44 percent) did not seek any advice or treat- ment. 12.13 SEXUAL BEHAVIOUR AMONG YOUNG WOMEN AND MEN Promoting change in sexual behaviour is an important component of many HIV/AIDS prevention programmes. Those who are not yet sexually active or those who have recently made their sexual debut are thought to be more accepting of programmes focusing on behavioural changes. Subsequent tables in this chap- ter focus on young women and men age 15-24 and the sexual behaviours that affect their risk of exposure to HIV. One of the strategies for reducing the risk of contracting an STI is for young persons to delay the age at which they become sexually active. Table 12.14 shows the percentage of young people who have had sex by exact age 15 and 18, by background characteristics. More women than men have had first sex by age 15 and 18. Seven percent of women and 4 percent of men had sex by exact age 15. Forty-six percent of women and 27 percent of men first had sex by exact age 18. Women and men residing in rural areas have sex earlier than urban settlers. Variations by background characteristics are all greater among women than men. Young women in the Northern Region are most likely to initiate sex at an early age. In contrast, young women in Greater Accra are least likely to initiate sex at an early age. Age at first sex increases with educational attainment. Respondents in the two poorest wealth quintiles have first sex earlier than those in higher quintiles. Table 12.13 Women and men seeking treatment for STIs Percentage of women and men age 15-49 reporting a sexually transmitted infection (STI) or symptoms of an STI in the past 12 months who sought care, by source of treatment, Ghana 2003 Source of advice or treatment Women Men Clinic/hospital/health profes- sional1 36.5 34.9 Traditional healer 14.1 18.4 Advice or medicine from shop/pharmacy 25.9 49.3 Advice from friends/relatives 14.1 21.9 Advice or treatment from any source 56.2 69.3 No advice or treatment 43.8 30.7 Number with STI and/or symp- toms of STI 400 145 Note: Symptoms of an STI are an abnormal genital discharge, a genital sore, or a gential ulcer. 230 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.14 Age at first sex among young women and men Percentage of young women and men age 15-24 and 18-24 who have had sex by exact age 15 and 18, by background characteristics, Ghana 2003 Women Men Background characteristic Percent- age who had sex by exact age 15 Number of wo- men age15-24 Percent- age who had sex by exact age 18 Number of wo- men age18-24 Percent- age who had sex by exact age 15 Number of men age 15-24 Percent- age who had sex by exact age 18 Number of men age 18-24 Age 15-17 8.1 710 na na 3.3 681 na na 18-19 6.3 438 51.9 438 4.8 427 27.8 427 15-19 7.4 1,148 51.9 438 3.9 1,107 27.8 427 20-22 8.1 645 44.7 645 3.8 441 25.9 441 23-24 6.5 367 40.3 367 4.0 243 25.3 243 20-24 7.5 1,012 43.1 1,012 3.9 684 25.7 684 Marital status Never married 4.5 1,417 28.8 755 3.6 1,615 23.5 934 Ever married 13.0 743 64.2 696 6.6 176 42.2 176 Residence Urban 5.4 1,160 36.6 772 3.8 859 24.9 571 Rural 9.8 1,000 56.2 679 4.0 932 28.1 539 Region Western 9.3 214 43.9 141 5.1 172 34.5 100 Central 6.7 177 57.3 115 2.7 140 27.9 86 Greater Accra 4.9 382 30.9 269 5.9 229 24.7 172 Volta 9.7 180 57.0 117 3.4 173 24.7 115 Eastern 7.0 218 48.7 146 4.9 179 28.9 114 Ashanti 6.4 455 43.1 304 3.6 346 27.7 188 Brong Ahafo 10.0 225 53.9 145 3.7 210 26.7 126 Northern 11.8 150 59.4 109 2.0 159 23.8 99 Upper East 5.3 107 40.1 69 1.9 133 19.4 81 Upper West 3.7 51 38.3 35 5.2 50 23.2 30 Education No education 8.8 339 61.2 260 0.8 164 30.7 114 Primary 11.8 473 57.4 276 4.5 401 32.1 184 Middle/JSS 6.7 1,013 43.4 637 5.0 849 27.3 499 Secondary+ 2.2 335 25.2 277 2.0 377 20.4 314 Wealth quintile Lowest 10.7 303 59.9 201 3.7 302 22.8 175 Second 10.4 330 59.0 231 4.5 313 31.6 167 Middle 8.6 409 56.0 258 3.5 371 31.3 223 Fourth 7.7 516 46.1 348 4.5 408 24.4 271 Highest 3.1 603 24.8 412 3.3 397 23.8 274 Total 7.4 2,160 45.8 1,450 3.9 1,791 26.5 1,110 na = Not applicable Promoting the use of condoms is an important strategy in the fight against HIV/AIDS transmission. Knowing where to get a condom is therefore essential. Table 12.15 shows the percentage of young people age 15-24 who know at least one source for condoms. Young women and men are more likely to know a source of a male rather than a female condom. Two-thirds of women and four-fifths of men age 15-24 know a source for a male condom, while less than half of youths know a source for female HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 231 condom. Knowledge of a source is higher among youth age 20-24 than among those age 15-19. Knowledge of a condom source is also higher among sexually active never-married women and men. Urban women and men are more knowledgeable about a source of condoms. There are also regional variations in the knowledge of a source of condoms, with residents in the three northern regions less knowledgeable of a source than youths in the other regions. Knowledge of a source rises steadily and dramatically with level of education and wealth quintile. Table 12.15 Knowledge of a source for condoms among young women and men Percentage of young people age 15-24 who know at least one source of condoms, by background characteristics, Ghana 2003 Women Men Background characteristic Know a source for male condom Know a source for female condom Number of women age 15-24 Know a source for male condom Know a source for female condom Number of men age 15-24 Age 15-19 59.0 41.1 1,148 75.5 43.1 1,107 20-24 70.2 52.2 1,012 88.4 58.0 684 Marital status Never married 66.9 47.9 1,417 79.5 48.5 1,615 Ever had sex 78.6 53.9 559 92.5 60.6 530 Never had sex 59.3 44.0 858 73.1 42.6 1,085 Ever married 59.2 43.3 743 89.2 51.3 176 Residence Urban 76.7 56.5 1,160 90.4 61.2 859 Rural 49.8 34.5 1,000 71.3 37.3 932 Region Western 61.6 40.9 214 89.8 59.7 172 Central 72.7 59.8 177 77.0 32.2 140 Greater Accra 73.3 54.1 382 91.0 70.4 229 Volta 57.5 36.9 180 80.5 46.8 173 Eastern 77.5 59.2 218 85.5 53.3 179 Ashanti 74.8 48.8 455 87.6 51.0 346 Brong Ahafo 64.0 47.3 225 91.4 60.8 210 Northern 22.0 16.2 150 47.8 24.7 159 Upper East 28.6 28.3 107 58.1 22.4 133 Upper West 51.8 42.3 51 59.1 30.5 50 Education No education 28.3 17.8 339 43.6 14.9 164 Primary 51.2 33.6 473 66.1 30.5 401 Middle/JSS 73.5 52.1 1,013 86.7 50.6 849 Secondary+ 91.0 75.7 335 97.6 79.0 377 Wealth quintile Lowest 33.4 25.1 303 54.8 23.6 302 Second 48.3 31.7 330 68.4 36.3 313 Middle 60.9 42.2 409 84.7 43.8 371 Fourth 75.4 51.6 516 89.9 55.0 408 Highest 81.2 63.2 603 95.8 76.1 397 Total 64.3 46.3 2,160 80.5 48.8 1,791 Note: The following sources are not considered sources for condoms in this table: church, friends, family members and home Table 12.16 shows the percentage of young women and men who used a condom the first time they had sex. Twenty-two percent of young women and 37 percent of young men reported condom use at 232 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior first sex. Condom use at first sex is more common among women age 15-19 than among those age 20-24. Men age 20-24 are slightly more likely than men age 15-19 to use a condom at first sex. Condom use at first sex is more common among young women and men who have never married, those residing in the urban areas, and young women and men living in Greater Accra and the Volta Region. Condom use rises steadily and dramatically with increasing education and wealth quintile among both women and men. Table 12.16 Condom use at first sex among young women and men Among women and men age 15-24 who have ever had sex, percentage who used a condom the first time they had sex, by background characteristics, Ghana 2003 Women Men Background characteristic Used a condom at first sex Number of women 15-24 who have ever had sex Used a condom at first sex Number of men 15-24 who have ever had sex Age 15-19 27.9 448 34.3 221 20-24 19.0 853 38.5 484 Marital status Never married 33.8 559 40.1 530 Ever married 13.2 742 28.5 175 Residence Urban 27.8 600 42.0 354 Rural 17.1 701 32.4 351 Region Western 16.2 127 41.1 70 Central 18.7 115 (32.8) 52 Greater Accra 36.1 183 45.8 105 Volta 35.8 117 40.2 76 Eastern 27.6 146 41.2 74 Ashanti 22.6 265 38.7 147 Brong Ahafo 11.9 153 36.7 75 Northern 5.4 110 12.6 53 Upper East 12.6 58 (35.0) 39 Upper West 18.9 28 (19.9) 15 Education No education 8.2 256 15.7 60 Primary 14.3 301 24.1 132 Middle/JSS 27.4 584 37.9 329 Secondary+ 39.1 161 52.4 184 Wealth quintile Lowest 12.0 213 16.6 99 Second 15.8 239 27.7 112 Middle 16.6 281 34.3 151 Fourth 22.8 310 42.9 175 Highest 41.1 258 52.4 168 Total 22.1 1,301 37.2 705 Note: Figures in parentheses are based on 25-49 unweighted cases. Table 12.17 shows the percentage of never-married women and men age 15-24, who have had sex in the last 12 months and among those who had premarital sex in the last 12 months, the percentage who used a condom at last sex. Three out of ten women and two out of ten men age 15-24 who have never married have had sex in the last 12 months. Of these, 35 percent of the women and 52 percent of HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 233 the men used a condom the last time they had sex. Condom use increases steadily as level of education and wealth quintile increases. Table 12.17 Premarital sex and use of condom among young women and men Among never-married women and men age 15-24, percentage who have had sex in the past 12 months, and among those who had premarital sex in the past 12 months, percentage who used a condom at last sex, by background charac- teristics, Ghana 2003 Women Men Background characteristic Had sex in past 12 months Number of never- married women age 15-24 Used condom at last sex Number of women age 15-24 sexually active in past 12 months Had sex in past 12 months Number of never married men age 15-24 Used condom at last sex Number of men 15-24 sexually active in past 12 months Age 15-19 23.5 991 35.0 232 13.9 1,097 47.0 152 20-24 45.1 426 34.7 192 45.2 518 54.4 234 Residence Urban 27.6 890 39.5 246 24.8 789 58.5 195 Rural 33.9 527 28.6 179 23.1 826 44.4 191 Region Western 29.8 145 (40.2) 43 21.9 151 (58.0) 33 Central 20.6 93 * 19 23.0 130 * 30 Greater Accra 28.1 315 40.2 89 28.9 222 61.0 64 Volta 34.8 123 (45.3) 43 31.0 161 (67.8) 50 Eastern 40.8 148 31.5 60 27.9 159 (54.9) 44 Ashanti 31.9 330 29.3 105 21.8 296 (38.7) 65 Brong Ahafo 35.2 122 (27.2) 43 24.9 195 47.8 49 Northern 22.5 55 * 12 18.7 135 (33.8) 25 Upper East 8.5 57 * 5 16.5 120 (53.5) 20 Upper West 18.5 29 * 5 15.1 45 * 7 Education No education 27.5 125 (14.9) 34 16.6 134 (42.7) 22 Primary 28.0 281 25.1 79 20.1 363 27.1 73 Middle/JSS 30.7 720 33.0 221 22.8 759 49.3 173 Secondary+ 31.2 291 55.4 91 32.8 359 71.5 118 Wealth quintile Lowest 24.9 136 (18.2) 34 17.9 265 25.1 47 Second 38.0 172 25.8 66 20.7 280 38.5 58 Middle 36.4 238 19.7 86 26.5 328 45.5 87 Fourth 33.5 352 44.1 118 25.8 370 63.2 95 Highest 23.3 519 46.4 121 26.5 372 65.8 98 Total 30.0 1,417 34.9 425 23.9 1,615 51.5 386 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Table 12.18 shows the percentage of young women and men who had sexual relations with a non- marital, non-cohabiting partner, among those who were sexually active in the last 12 months, and the percentage who say they used a condom the last time they had sex with a non-marital, non-cohabiting partner. One in two young women (50 percent) and more than four in five young men (83 percent) age 15-24 who were sexually active engaged in higher-risk sexual behaviour, that is, they were sexually 234 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior active with a non-marital, non-cohabiting partner. Only 33 percent of women and 52 percent of men used a condom during their last higher-risk sexual intercourse. Table 12.18 Higher-risk sex and condom use at last higher-risk sex Among sexually active young women and men age 15-24, percentage who had sexual relations with a non-marital, non- cohabiting partner in the past 12 months, and among these women and men, percentage who say they used a condom the last time they had sex with a non-marital, non-cohabiting partner, by background characteristics, Ghana 2003 Women Men Background characteristic Percentage engaging in higher- risk sex in the past 12 months Number of women sexually active in the past 12 months Percentage who used a condom at last higher-risk sex Number of women age 15-24 who had higher- risk sex the last 12 month Percentage engaging in higher- risk sex in the past 12 months Number of men sexu- ally active in the past 12 months Percentage used con- dom at last higher-risk sex Number of men age 15-24 who had higher- risk sex in the last 12 months Age 15-19 72.1 363 33.5 262 97.9 163 46.2 159 20-24 38.0 685 32.0 261 77.3 387 54.7 299 Marital status Never married 99.5 425 34.9 423 100.0 386 51.5 386 Ever married 16.0 623 23.7 99 44.0 163 52.8 72 Residence Urban 61.5 488 36.9 300 88.3 261 57.5 231 Rural 39.6 560 27.1 222 78.9 288 45.8 227 Region Western 47.7 100 (36.5) 48 81.6 53 (58.9) 44 Central 29.5 91 * 23 (84.4) 40 (45.4) 34 Greater Accra 66.8 148 38.1 98 91.6 72 59.4 66 Volta 50.9 86 (44.2) 44 91.1 62 (65.7) 56 Eastern 59.2 122 33.3 72 80.6 64 (57.7) 52 Ashanti 63.1 209 30.3 132 82.6 111 42.7 91 Brong Ahafo 46.4 134 24.5 62 91.3 62 46.6 56 Northern 22.4 91 * 23 66.0 45 (32.6) 30 Upper East 28.2 45 * 14 (73.2) 31 (53.8) 22 Upper West 26.7 21 * 16 (70.9) 10 * 7 Education No education 20.3 209 (14.4) 43 61.6 48 (39.5) 29 Primary 42.0 239 24.2 100 75.6 109 29.9 83 Middle/JSS 58.1 470 31.0 273 85.8 257 51.6 220 Secondary+ 82.3 129 52.7 106 92.9 135 69.1 126 Wealth quintile Lowest 28.4 168 20.4 48 71.9 80 32.1 57 Second 42.3 192 22.2 81 77.9 90 39.5 70 Middle 46.5 227 20.4 105 82.1 128 47.7 105 Fourth 53.1 264 38.2 140 88.5 129 60.0 115 Highest 74.9 197 46.2 147 91.0 121 65.0 110 Total 49.8 1,048 32.7 522 83.4 549 51.7 458 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Figure 12.2 summarises data on the proportion of young women and men age 15-24 who fall into various risk categories for HIV. For example, 40 percent of young women and 61 percent of young men have never had sex, while 12 percent and 9 percent, respectively, have had sex but not in the 12 months HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 235 preceding the survey. Nine percent of women and 11 percent of men have had sex with only one partner in the 12 months preceding the survey and used a condom during the most recent sexual encounter. Thirty-eight percent of women and 14 percent of men had sex with only one partner but did not use condoms during the most recent sexual encounter. Less than 1 percent of women and about 3 percent of men had sex with more than one partner in the 12 months preceding the survey and used a condom at last sex. Perhaps the highest risk group is the 1 percent of women and 3 percent of men who had sex with more than one partner in the previous 12 months and did not use a condom during their most recent sex. Figure 12.2 Abstinence, Being Faithful, and Using Condoms Among Women and Men Age 15-24 15-19 20-24 15-24 15-19 20-24 15-24 0 20 40 60 80 100 Never had sex Had sex, but not in past 12 months Only one partner, used condom last time Only one partner, did not use condom last time More than one partner, used condom last time More than one partner, did not use condom last time GDHS 2003 WOMEN MEN Note: Refers to partners in the 12 months prior to the survey and condom use at most recent sexual encounter. A practice that can contribute to the spread of HIV is sexual relations between young women and older men. To obtain information on age-discontinuities in sexual relationships, the 2003 GDHS asked sexually active women age 15-19 who had sex with a non-marital partner in the 12 months preceding the survey, whether the man was younger, about the same age, or older than them. If older, they were also asked if they thought he was less than 10 years older or 10 or more years older. Table 12.19 shows that only 5 percent of women age 15-19 who had non-marital sex in the 12 months before the survey had sexual intercourse with a man 10 or more years older than them. There is little variation by background characteristics of respondents. 12.14 ORPHANHOOD AND CHILDREN’S LIVING ARRANGEMENTS To ascertain if there has been an upsurge in the number of orphans due to death of parents from HIV, the 2003 GDHS sought information on orphanhood and fostering. Table 12.20 shows the percent distribution of children under age 18 by children’s living arrangements and survival status of parents, according to background characteristics. Eighty-two percent of children under age 18 are living with one or both parents, 52 percent of children are living with both parents, 25 percent are living with their mother, and 5 percent are living with their father. Eighteen percent of children do not live with either parent, that is, they are fostered. Younger children, children living in rural areas, those residing in the three northern regions, and those from the lowest wealth quintile are more likely than other children to be living with both parents. 236 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.19 Age discontinuity in sexual relationships Among women age 15-19 who had nonmarital sex in the past 12 months, percentage who have had nonmarital sex with a man 10 or more years older than themselves, by background characteristics, Ghana 2003 Background characteristic Percentage who had nonmarital sex with a man 10+ years older Number of women age 15-19 who had non- marital sex in past 12 mon- ths Age 15-17 1.7 114 18-19 7.9 147 Marital status Never married 4.6 231 Ever married 9.9 30 Residence Urban 6.3 137 Rural 4.0 125 Region Western (4.4) 28 Central * 12 Greater Accra (5.8) 37 Volta * 21 Eastern (7.6) 36 Ashanti 3.5 69 Brong Ahafo (0.0) 33 Northern * 14 Upper East * 7 Upper West * 3 Education No education (4.3) 27 Primary 6.9 54 Middle/JSS 4.7 141 Secondary+ (5.1) 40 Wealth quintile Lowest (2.3) 34 Second (10.1) 43 Middle 4.1 63 Fourth 5.3 67 Highest (4.3) 54 Total 5.2 262 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in pa- rentheses are based on 25-49 unweighted cases. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 237 Table 12.20 also shows that 5 percent of children under 18 years are orphaned, that is, they have lost one or both of their parents, with 4 percent having lost their father, 1 percent having lost their mother, and half a percent having lost both parents. Orphanhood rises with child’s age, from less than 1 percent among children under age 2 to 10 percent among those age 15-17. Children living in the Upper West Region are most likely to be orphaned (8 percent). Table 12.20 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by children's living arrangements and survival status of parents, according to background characteristics, Ghana 2003 Not living with either parent Living with mother but not mother Living with father but not mother Background characteristic Living with both parents Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing information on father/ mother Total Number of children Age <2 67.6 29.6 0.7 0.5 0.1 0.7 0.1 0.1 0.0 0.4 100.0 1,448 2-4 61.1 24.1 2.2 2.5 0.2 8.1 0.5 0.4 0.1 0.8 100.0 2,212 5-9 54.0 20.2 2.8 4.0 0.7 14.7 0.9 1.4 0.4 0.7 100.0 3,664 10-14 42.3 19.9 4.9 6.1 1.4 19.5 1.4 2.4 1.0 1.1 100.0 3,654 15-17 38.3 18.2 7.0 6.3 2.1 19.7 1.0 4.3 1.2 1.7 100.0 1,503 Sex Male 53.6 21.1 3.8 5.0 1.0 11.5 0.9 1.6 0.6 0.9 100.0 6,390 Female 49.4 22.3 3.3 3.5 0.8 16.4 1.0 1.8 0.5 0.9 100.0 6,092 Residence Urban 41.0 27.5 3.6 3.8 1.0 18.2 1.1 2.3 0.6 0.9 100.0 4,747 Rural 58.0 18.1 3.5 4.5 0.9 11.3 0.8 1.4 0.6 0.9 100.0 7,735 Region Western 47.3 21.7 4.6 4.3 1.2 14.5 1.3 4.1 0.4 0.5 100.0 1,149 Central 43.9 32.0 4.3 3.3 0.1 13.3 0.5 1.2 0.5 0.7 100.0 1,047 Greater Accra 40.1 27.0 3.3 4.7 1.0 18.9 1.4 1.9 1.1 0.8 100.0 1,371 Volta 41.5 23.6 2.5 6.4 0.9 19.2 1.1 2.6 0.5 1.6 100.0 1,130 Eastern 50.2 24.9 2.5 3.3 0.9 12.6 1.2 1.2 0.7 2.5 100.0 1,323 Ashanti 44.7 27.4 4.3 4.1 0.9 16.1 0.5 0.7 0.7 0.6 100.0 2,443 Brong Ahafo 50.3 22.8 3.4 4.3 0.4 13.8 1.2 2.8 0.3 0.8 100.0 1,350 Northern 74.7 6.1 1.7 5.2 1.1 8.9 0.7 0.9 0.2 0.5 100.0 1,448 Upper East 75.8 4.7 4.9 2.5 1.8 7.2 0.6 1.3 0.6 0.6 100.0 831 Upper West 68.1 13.5 5.5 2.8 1.6 4.9 0.9 1.4 0.6 0.7 100.0 390 Wealth quintile Lowest 65.2 14.4 3.9 4.1 1.0 8.1 0.8 1.3 0.5 0.7 100.0 2,748 Second 54.3 20.0 4.1 3.6 1.1 13.0 0.9 1.3 0.5 1.2 100.0 2,715 Middle 47.2 25.0 3.4 4.9 0.5 14.4 0.8 2.3 0.4 1.1 100.0 2,624 Fourth 41.3 28.3 3.6 4.7 1.2 16.1 1.1 1.9 1.1 0.8 100.0 2,295 Highest 46.8 22.1 2.5 3.8 0.9 19.7 1.0 1.9 0.4 0.9 100.0 2,099 Total 51.5 21.7 3.6 4.2 0.9 13.9 0.9 1.7 0.6 0.9 100.0 12,481 Total age < 15 53.4 22.2 3.1 3.9 0.8 13.1 0.9 1.4 0.5 0.8 100.0 10,978 There has been little change in the percentage of young children fostered or orphaned over the last five years. For example, the percentage of children under 15 years who are fostered has remained unchanged at 13 percent between 1998 and 2003 (GSS and Macro, 1999). It is generally believed that orphans are more likely to be disadvantaged than children whose par- ents are both living. To ascertain if this is the case, data from the 2003 GDHS was used to compare school attendance among children whose parents were both alive, children living or not living with at least one 238 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior parent, and children who had lost one or both parents. The results indicate that 81 percent of children age 10-14, whose parents are both alive and who are living with one or both parents are in school, compared with 65 percent of children who have lost both parents, with the ratio of school attendance among or- phaned to non-orphaned children age 10-14, being 0.8 (data not shown). HIV Prevalence and Associated Factors | 239 HIV PREVALENCE AND ASSOCIATED FACTORS 13 This chapter presents information on the coverage of HIV testing, the prevalence of HIV, and the factors associated with HIV infection among eligible women and men. The 2003 GDHS is the sixth survey (the others being Dominican Republic, Mali, Zambia, Kenya and Burkina Faso) in the international DHS programme to include HIV testing, and the third only (after Kenya and Burkina Faso) to anonymously link the HIV results with key behavioural, social, and demographic factors. The HIV prevalence data provide important information to plan the national response, to evaluate programme impact, and to measure progress on the Ghana HIV/AIDS Strategic Framework: 2001-2005. The understanding of the prevalence of HIV in the population and the analysis of social, biological, and behavioural factors associated with HIV infection provide new insights into the HIV epidemic in Ghana that may enable more precisely targeted messages and interventions. In Ghana, as in most of sub-Saharan Africa, national HIV prevalence estimates have been derived primarily from HIV sentinel surveillance (HSS) in pregnant women attending antenatal clinics. Currently, the national sentinel surveillance system consists of 30 sites of which 23 are urban and 7 are rural sites strategically located in 28 of the 110 districts, and covering all 10 regions of the country. Since 1992, for 12 weeks each year, pregnant women seeking antenatal care (ANC) for the first time and patients newly diagnosed with sexually transmitted infections (STIs) attending STI clinics in the sentinel sites were tested for HIV using an anonymously unlinked method and the results entered into a database, analysed, and reported by the National AIDS Control Programme (NACP) (Ghana Health Service, 2003d). The latest round of sentinel surveillance was conducted between September and November 2003, and overlapped two of the three months of the GDHS fieldwork. The rate of HIV infection in pregnant women has been shown to be a reasonable proxy for the prevalance level in the combined male and female adult population (WHO and UNAIDS, 2000). However, there are a number of challenges in using sentinel surveillance estimates derived exclusively from pregnant women attending select antenatal clinics for estimating the HIV rate in the general adult population. The ANC data do not capture information on HIV prevalence in non-pregnant women, nor in women who either do not attend a clinic for pregnancy care or receive ANC at facilities not represented in the surveillance system. Pregnant women are also at a higher risk for HIV infection than women who may be avoiding both HIV and pregnancy through the use of condoms or women who are not sexually active and are therefore less likely to become pregnant or expose themselves to HIV. The rates among pregnant women have also been found to be much higher than male HIV prevalence rates. For example, a World Health Organisation study of four cities in sub-Saharan Africa shows higher risk overall in women compared with men (Buve et al., 2001). Although the information from the ANC surveillance system has been very useful for monitoring trends in HIV levels, the inclusion of HIV testing in the GDHS offers the opportunity to better understand the magnitude and patterns of infection levels in the general reproductive-age population. The GDHS results are in turn expected to improve the calibration of annual sentinel surveillance data, so that trends in HIV infection can be more accurately measured in the intervals between general population surveys. In addition, the DHS data have the added advantage of providing behavioural data linked to HIV prevalence, which can be used to guide HIV prevention programmes. 240 | HIV Prevalence and Associated Factors 13.1 COVERAGE OF HIV TESTING Table 13.1 shows the percent distribution of women and men eligible for HIV testing by testing status, according to urban-rural residence and region. HIV tests were conducted for 89 percent of the 5,949 eligible women and 80 percent of the 5,345 eligible men. For both sexes combined, coverage was 85 percent, with rural residents more likely to be tested than their urban counterparts (87 and 81 percent, respectively). There were marked differences in HIV testing coverage by region. Coverage was highest in the Central Region where 93 percent of women and men were tested, and lowest in Greater Accra, where 76 percent of eligible women and men were tested. Coverage was higher among women than among men in every region, with the difference between women and men tested being widest in Greater Accra (84 and 65 percent, respectively) and narrowest in the Northern Region (86 and 85 percent, respectively). Table 13.1 Coverage of HIV testing Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to residence and region (unweighted), Ghana 2003 Residence Region Testing status Urban Rural Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Total WOMEN Tested 87.6 90.5 94.4 94.2 84.4 91.0 85.1 93.4 93.1 85.7 87.6 84.8 89.3 Refused 6.8 4.9 3.0 2.5 7.1 4.3 10.9 4.0 4.2 5.6 5.3 10.1 5.7 Absent for testing 3.8 3.0 2.0 2.5 5.7 3.2 1.9 2.0 1.7 5.0 6.0 3.1 3.3 Interviewed in survey 1.3 0.8 0.0 0.8 0.9 0.9 0.2 1.0 1.1 3.0 2.2 0.2 1.0 Not interviewed 2.6 2.1 2.0 1.7 4.8 2.4 1.7 1.1 0.6 2.0 3.8 2.9 2.3 Other/missing 1.8 1.6 0.6 0.8 2.7 1.5 2.1 0.5 1.1 3.6 1.2 2.1 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,500 3,449 540 361 913 468 530 946 649 638 418 486 5,949 MEN Tested 73.7 83.9 82.4 91.1 65.3 82.2 71.5 85.7 85.0 84.7 80.4 74.9 80.0 Refused 15.1 7.9 12.0 2.5 16.6 7.1 19.2 9.6 7.8 5.2 7.6 17.0 10.7 Absent for testing 8.8 6.2 4.6 5.4 14.1 8.3 7.3 4.4 5.1 6.3 11.1 4.5 7.2 Interviewed in survey 4.2 2.6 1.3 1.3 6.0 3.6 4.0 1.1 4.1 3.1 5.9 0.7 3.2 Not interviewed 4.7 3.7 3.4 4.1 8.2 4.6 3.3 3.3 1.0 3.2 5.2 3.8 4.0 Other/missing 2.4 2.0 1.1 1.0 3.9 2.4 1.9 0.2 2.1 3.8 0.9 3.6 2.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,063 3,282 476 315 721 411 478 819 606 678 423 418 5,345 TOTAL Tested 81.3 87.3 88.8 92.8 76.0 86.9 78.7 89.9 89.2 85.2 83.9 80.2 84.9 Refused 10.6 6.3 7.2 2.5 11.3 5.6 14.9 6.6 5.9 5.4 6.4 13.3 8.1 Absent for testing 6.1 4.6 3.2 3.8 9.4 5.6 4.5 3.1 3.3 5.7 8.6 3.8 5.2 Interviewed in survey 2.6 1.7 0.6 1.0 3.1 2.2 2.0 1.0 2.5 3.0 4.0 0.4 2.0 Not interviewed 3.5 2.9 2.7 2.8 6.3 3.4 2.5 2.1 0.8 2.7 4.5 3.3 3.1 Other/missing 2.0 1.8 0.8 0.9 3.2 1.9 2.0 0.4 1.6 3.7 1.1 2.8 1.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,563 6,731 1,016 676 1,634 879 1,008 1,765 1,255 1,316 841 904 11,294 Individuals who were not tested can be categorized into four groups based on the reason for nonresponse. Eight percent of eligible women and men refused testing when asked for informed consent by the health worker (Table 13.1). Five percent were absent for testing: 2 percent were interviewed in the survey, but were not at home when the health worker arrived for testing and were not found on callbacks; 3 percent were not at home for both the interview and testing. Two percent were missing test results for HIV Prevalence and Associated Factors | 241 some other reason, such as they were incapable of giving consent for testing, there was a mismatch between the questionnaire and the blood sample, or there was a technical problem in taking blood. Refusal is the most important reason for non-response on the HIV testing component, with men nearly twice as likely to refuse testing as women (11 and 6 percent, respectively). Seven percent of men were absent for testing compared with 3 percent of women, with both women and men more likely to be absent for testing and never interviewed, than to have been interviewed but not tested. The proportions falling into the four non-response categories vary by urban-rural residence, with urban coverage below rural coverage among both women and men in every category. The urban-rural differentials in coverage are most marked for refusal rates, which are 7 percent and 15 percent among urban women and men, respectively, and 5 percent and 8 percent for rural women and men, respectively. Regionally, refusal is highest in the Eastern Region among both women (11 percent) and men (19 percent). Variation in refusal rates again accounts for much of the regional disparities. Refusal is also higher among both women and men in the Upper West Region (10 and 17 percent, respectively) and in Greater Accra (7 and 17 percent, respectively). For both women and men, absence is relatively high in Greater Accra and the Upper East. Table 13.2 shows coverage rates for HIV testing by background characteristics. If knowledge of HIV status influenced participation in the testing, coverage would be expected to rise with age because HIV levels increase sharply with age before leveling off or declining at the older ages. In fact, the coverage rate for testing among women is consistent across all age groups (88 to 91 percent). Response rates are somewhat more variable by age among men (77 to 83 percent), but again they do not rise with age as would be expected if they were influenced by HIV status. To further explore whether non-response might have had an impact on the HIV seroprevalence results, additional analysis was undertaken on the relationships between participation in the HIV testing and a number of other characteristics related to HIV risk. The descriptive tables examined in this analysis are included in Appendix A. The variation in response rates with these measures indicate that coverage rates are not uniformly lower among those groups considered to be at higher risk for HIV (Tables A.3-A.6). However, there is some indication that some higher-risk groups may have lower response rates. Where response rates are lower for higher-risk groups, the pattern is more obvious for men than women. For example, response rates are slightly lower among divorced or separated men than among those currently in union, and among those who have ever had sex than among those who have never had sex. Similarly, men who sleep away from home—a characteristic assumed to be related to higher HIV risk—is not strongly related to lower coverage, with the exception of men who slept away more than five times in the past year, who have a slightly lower coverage. The initial descriptive examination of HIV testing coverage levels provided little evidence of a consistent relationship between non-response rate and variables associated with higher HIV risk. Although further analysis is required, this analysis supports the conclusion that the GDHS prevalence rates are a reasonable measure of the actual levels of HIV prevalence in the population. 242 | HIV Prevalence and Associated Factors Table 13.2 Coverage of HIV testing, by background characteristics Percent distribution of women age 15-49 and men age 15-59 eligible for testing by testing status, according to background characteristics (unweighted), Ghana 2003 Testing status Tested Refused Absent Other/missing Background characteristic Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Total Number WOMEN Age 15-19 88.6 0.3 3.9 0.8 1.6 2.4 0.8 1.7 100.0 1,173 20-24 89.8 0.4 3.4 1.1 1.1 2.4 1.1 0.8 100.0 1,045 25-29 89.8 0.2 4.7 1.3 0.9 2.2 0.8 0.2 100.0 1,005 30-34 89.0 0.2 6.4 0.6 0.8 1.5 0.7 0.7 100.0 844 35-39 87.5 0.1 5.6 1.3 0.5 3.0 0.7 1.3 100.0 768 40-44 87.5 0.2 7.3 0.5 1.4 2.5 0.5 0.2 100.0 592 45-49 91.4 0.2 2.9 1.0 0.6 2.3 1.1 0.6 100.0 522 Education No education 87.4 0.5 5.1 0.9 1.2 2.7 1.1 1.0 100.0 2,022 Primary 91.6 0.1 3.8 0.7 0.8 1.7 0.7 0.7 100.0 1,148 Middle/JSS 90.9 0.0 4.3 1.0 0.9 1.7 0.6 0.6 100.0 2,115 Secondary+ 83.9 0.2 7.1 1.2 1.1 4.4 1.1 1.2 100.0 664 Wealth quintile Lowest 88.3 0.4 5.0 0.4 1.0 2.5 1.4 0.9 100.0 1,398 Second 91.0 0.1 3.7 0.9 0.9 1.9 0.6 1.1 100.0 1,040 Middle 92.2 0.0 3.4 0.7 0.8 1.8 0.4 0.8 100.0 1,023 Fourth 88.9 0.5 5.1 1.1 1.0 2.2 0.5 0.7 100.0 1,131 Highest 86.1 0.1 6.1 1.6 1.4 2.9 1.0 0.7 100.0 1,357 Total 89.0 0.2 4.8 0.9 1.0 2.3 0.8 0.8 100.0 5,949 MEN Age 15-19 83.3 0.3 6.0 0.9 3.5 4.5 0.3 1.0 100.0 1,175 20-24 78.4 0.1 10.7 1.3 2.7 4.5 0.5 1.7 100.0 750 25-29 78.7 0.1 9.4 0.6 3.8 5.0 1.3 1.0 100.0 780 30-34 80.0 0.0 11.0 0.6 2.9 3.0 1.8 0.6 100.0 661 35-39 77.7 0.0 12.3 1.5 2.9 3.3 1.1 1.3 100.0 551 40-44 78.5 0.2 12.7 1.4 2.5 2.8 1.2 0.7 100.0 433 45-49 81.9 0.0 8.2 0.2 3.7 4.7 1.1 0.2 100.0 465 50-54 76.6 0.0 11.9 0.9 3.1 4.1 2.2 1.3 100.0 320 55-59 77.6 0.0 11.0 1.4 2.9 2.4 2.9 1.9 100.0 210 Education No education 79.2 0.2 8.5 0.7 3.4 4.1 1.6 2.3 100.0 1,207 Primary 82.4 0.2 7.9 0.9 3.1 2.6 1.8 1.1 100.0 900 Middle/JSS 81.3 0.0 9.2 0.8 2.9 4.6 0.7 0.5 100.0 2,092 Secondary+ 76.2 0.1 13.5 1.5 3.6 3.6 0.8 0.7 100.0 1,140 Wealth quintile Lowest 84.6 0.1 6.2 0.4 2.8 3.0 1.6 1.5 100.0 1,284 Second 84.8 0.2 6.7 0.5 2.5 3.5 0.9 1.0 100.0 1,005 Middle 81.9 0.1 9.3 0.6 3.0 3.3 0.9 0.9 100.0 929 Fourth 77.1 0.3 11.6 0.7 3.1 5.3 0.9 1.0 100.0 978 Highest 70.8 0.0 15.1 2.4 4.4 5.2 1.1 0.8 100.0 1,149 Total 79.8 0.1 9.7 1.0 3.2 4.0 1.1 1.0 100.0 5,345 HIV Prevalence and Associated Factors | 243 13.2 HIV PREVALENCE 13.2.1 HIV Prevalence by Socioeconomic Characteristics Results from the 2003 GDHS indicate that 2 percent of Ghanaian adults are infected with HIV (Table 13.3).1 HIV prevalence in women age 15-49 is nearly 3 percent, while for men 15-59, it is under 2 percent. This female-to-male ratio of 1.8 to 1 is higher than that found in most population-based studies in Africa. The high female-to-male ratio implies that young women are particularly vulnerable to HIV infection compared with young men. Prevalence among females is consistently higher than among males at all age groups except at age 40-44, where male prevalence is higher (Figure 13.1). The female-male gap is particularly large among women and men age 25-29, where women are nearly three and a half times as likely to be HIV positive as men. The peak prevalence among women is at age 35-39 (5 percent), while prevalence rises gradually with age among men to peak at age 40-44 (4 percent). These results compare favourably with the HSS and AIDS data available for Ghana. Table 13.3 HIV prevalence by age Percentage HIV positive among women 15-49 and men 15-59 who were tested, by age, Ghana 2003 Women Men Total Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 0.5 1,035 0.2 1,035 0.3 2,070 20-24 1.9 912 0.0 616 1.2 1,528 25-29 3.4 855 1.0 663 2.3 1,518 30-34 4.2 706 2.8 548 3.6 1,253 35-39 4.7 648 3.1 433 4.0 1,082 40-44 3.0 504 4.1 351 3.5 855 45-49 2.5 437 1.9 401 2.2 838 50-54 na na 3.6 254 na na 55-59 na na 2.8 167 na na Total age 15-49 2.7 5,097 1.5 4,047 2.2 9,144 Total age 15-59 na na 1.6 4,469 na na na = Not applicable Few HIV-infected children survive into their teenage years. As such, infected youth represent more recent cases of HIV infection and serve as an indicator of trends in both prevalence and incidence. The majority of HIV positive persons in the age group 15-24 are women, with less than half a percent among HIV positive men in the same age group. The overall prevalence in youth is under 2 percent. These prevalence levels will provide a baseline for measuring progress toward the goals underlined in the Ghana HIV/AIDS Strategic Framework in future surveys. 1 The prevalence of HIV 2 was found to be 0.4 percent among women age 15-49 and 0.1 percent among men age 15-59, with an overall prevalence of 0.3. Prevalence in this chapter refers to the overall prevalence of HIV 1, HIV 2, and HIV 1/2. 244 | HIV Prevalence and Associated Factors � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 1 2 3 4 5 Pe rc en t Women Men� Figure 13.1 HIV Prevalence by Age Group and Sex GDHS 2003 Women Men As Table 13.4 shows, urban residents are only slightly more likely to be HIV positive than rural residents with the urban-rural difference among women slightly greater than among men. The HIV epidemic shows regional variations. Prevalence is highest in the Eastern Region (4 percent), followed by the Western and Brong Ahafo regions (3 percent each). Prevalence is lowest in the Northern, Central, and Volta regions (1 percent each). Gender differences are apparent in all the regions. Those who have completed primary and middle/JSS education have higher infection levels than those with either no education or at least secondary education. Work status is related to the HIV rate among both women and men, with prevalence twice as high among those currently working than those not currently working. Prevalence is highest among both women and men in the middle wealth quintile. HIV Prevalence and Associated Factors | 245 Table 13.4 HIV prevalence by background characteristics Percentage HIV positive among women and men age 15-49 who were tested for HIV, by background characteristics, Ghana 2003 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Residence Urban 2.9 2,466 1.5 1,826 2.3 4,292 Rural 2.5 2,630 1.4 2,222 2.0 4,852 Region Western 3.9 497 1.8 382 3.0 879 Central 1.7 386 0.3 294 1.1 680 Greater Accra 2.6 842 1.6 585 2.2 1,427 Volta 1.7 440 0.3 346 1.1 786 Eastern 4.4 535 2.9 437 3.7 972 Ashanti 3.0 1,023 1.3 762 2.3 1,784 Brong Ahafo 3.8 512 1.3 440 2.7 952 Northern 0.9 449 1.0 435 1.0 884 Upper East 0.8 277 2.2 259 1.5 535 Upper West 2.0 136 1.6 108 1.8 245 Education No education 2.2 1,438 1.2 653 1.9 2,090 Primary 3.3 1,029 1.5 660 2.6 1,689 Middle/JSS 3.1 2,046 1.9 1,794 2.5 3,839 Secondary+ 1.6 585 0.7 941 1.0 1,525 Employment Currently working 3.0 3,826 1.8 2,920 2.5 6,746 Not currently working 1.8 1,270 0.5 1,127 1.2 2,398 Wealth quintile Lowest 1.4 867 1.4 700 1.4 1,567 Second 2.7 853 1.5 729 2.2 1,582 Middle 4.0 977 2.0 786 3.1 1,764 Fourth 2.9 1,117 1.3 884 2.2 2,001 Highest 2.4 1,283 1.1 947 1.9 2,230 Ethnicity Akan 2.9 2,592 1.0 1,882 2.1 4,473 Ga/Dangme 6.5 401 4.2 303 5.5 705 Ewe 1.3 665 1.4 539 1.3 1,204 Guan 0.0 133 0.8 146 0.4 279 Mole-Dagbani 1.8 648 1.3 714 1.5 1,362 Grussi 2.6 118 3.8 100 3.2 218 Gruma 0.8 127 0.0 125 0.4 251 Hausa 4.6 71 4.9 (39) 4.7 109 Other 2.4 334 1.7 198 2.2 532 Religion Roman Catholic 3.1 701 1.2 571 2.3 1,271 Anglican 1.8 69 0.0 49 1.1 118 Methodist 3.4 382 1.5 255 2.6 637 Presbyterian 3.5 452 3.5 315 3.5 767 Other Christian 2.6 2,322 1.1 1,669 2.0 3,991 Moslem 2.4 816 1.3 772 1.9 1,588 Traditional/spiritualist 1.1 130 2.0 171 1.6 301 No religion 1.7 224 2.4 245 2.0 469 Total 2.7 5,097 1.5 4,047 2.2 9,144 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 6 women and 2 men for whom infor- mation on ethnicity is missing and 1 woman and 2 men for whom information on religion is missing. 246 | HIV Prevalence and Associated Factors 13.2.2 HIV Prevalence by Other Socio-demographic Characteristics Marital status is related to HIV prevalence (Table 13.5). Prevalence is higher among widowed women (7 percent), followed closely by divorced or separated women (6 percent). Among men, prevalence is higher among divorced or separated men (6 percent). Women who report they have had sex but have never been in a union have a higher risk than men in the same category (3 percent and less than 1 percent, respectively). HIV infection among women and men who have never been in a union and have never had sex is almost non-existent, suggesting that non-sexual transmission of HIV is negligible. Table 13.5 HIV prevalence by selected socio-demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested for HIV, by socio-demographic characteristics (marital status, pregnancy status for women, and mobility status for men), Ghana 2003 Women Men Total Socio-demographic characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Currently in union 2.9 3,192 2.3 1,981 2.7 5,173 Widowed 6.7 95 na 14 6.8 109 Divorced/separated 6.2 368 3.3 96 5.2 564 Never in union 1.1 1,442 0.3 1,856 0.6 3,298 Ever had sex 2.5 651 0.3 787 1.3 1,439 Never had sex 0.0 791 0.2 1,068 0.1 1,859 Type of union In polygynous union 3.3 724 1.6 222 2.9 946 Not in polygynous union 2.8 2,468 2.4 1,759 2.6 4,227 Not currently in union 2.4 1,905 0.6 2,066 1.4 3,971 Currently pregnant Pregnant 3.6 385 na na na na Not pregnant/not sure 2.6 4,712 na na na na Numbers of times slept away None na na 1.4 1,662 na na 1-2 na na 1.3 911 na na 3-5 na na 1.2 847 na na 5+ na na 2.2 612 na na Whether away for more than 1 month in the past 12 months Away for more than 1 month na na 1.3 813 na na Away always less than 1 month na na 1.5 1,544 na na Never away na na 1.4 1,662 na na Total 2.7 5,097 1.5 4,047 2.2 9,144 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total in- cludes cases missing data on number of times slept away and whether away for more than one month. na = Not applicable HIV Prevalence and Associated Factors | 247 Prevalence is slightly higher among women in a polygynous union than among women not in a polygynous union or not currently in union. Among men, prevalence is higher among those not in a polygynous union. HIV prevalence among women who are pregnant is 4 percent, providing a useful benchmark to compare with rates for pregnant women tested during sentinel surveillance. The survey results show that men who have slept away from home more than five times in the 12 months prior to the survey have higher HIV prevalence than men who have not slept away from home or have slept away from home less often. There is little difference in prevalence among men by length of time away from home. 13.2.3 HIV Prevalence by Sexual Risk Behaviour Table 13.6 examines the prevalence of HIV infection by sexual behaviour indicators among respondents who have ever had sexual intercourse. In reviewing these results, it is important to remember that responses regarding sexual behaviour may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. There is no clear relationship between age at sexual debut and HIV prevalence. Prevalence is highest among women who first had sexual intercourse before age 16 (5 percent). Prevalence is also relatively high among women whose age at sexual debut is 18-19 (4 percent). Among men, prevalence is highest among those whose age at sexual debut is 18-19 (3 percent). There is no clear relationship between HIV prevalence and higher-risk sex, that is, sex with a non-marital or non-cohabiting partner. Women who have had higher-risk sex in the past 12 months are only slightly more likely to be HIV positive than women who have had no sex in the past 12 months. Men who have had sex but not higher-risk sex in the past 12 months are slightly more likely to be HIV positive than men who were not sexually active during the period. Women who report having had sex with two partners and those who have had two higher-risk partners in the past 12 months are three times as likely to be HIV positive as women who have had only one partner or one higher-risk partner. Among men, no significant difference in prevalence can be detected by number of partners in the past 12 months, but those with one higher-risk partner are somewhat more likely to be HIV positive than men with two higher-risk partners. HIV prevalence is substantially higher among men who paid for sex in the 12 months preceding the survey (7 percent) than among men who paid for sex prior to the past 12 months (3 percent) or who never paid for sex (2 percent). There is little difference in HIV prevalence among those who used a condom at any time and those who used a condom at last sexual contact, in the 12 months preceding to the survey. However, women who did not use condom at last higher-risk sex in the 12 months preceding the survey are twice as likely to be HIV as women who used a condom. On the other hand, among men, prevalence is slightly lower among the former category of condom users than the latter category. Among men, those who used a condom at last paid sex are more likely to be HIV positive (5 percent) than those who did not use a condom at last paid sex (3 percent). The discussion above suggests that there is no consistent relationship between HIV prevalence and sexual behavioural risk, particularly among men. However, more sophisticated analysis that is outside the scope of this report will be necessary to fully understand these relationships because they may be complicated by other factors such as age, residence, and educational status that are associated both with behavioural measures and HIV prevalence. 248 | HIV Prevalence and Associated Factors Table 13.6 HIV prevalence by sexual behaviour characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behaviour char- acteristics, Ghana 2003 Women Men Total Sexual behaviour characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sex <16 4.5 1,103 1.6 431 3.7 1,534 16-17 2.3 1,234 0.6 510 1.8 1,743 18-19 3.6 1,105 2.6 775 3.2 1,880 20+ 2.2 859 2.1 1,257 2.1 2,116 Higher-risk sex in past 12 months Had higher risk sex 3.8 707 1.2 960 2.3 1,667 Had sex, not higher risk 3.0 2,759 2.4 1,604 2.7 4,363 No sex in past 12 months 3.5 839 1.8 414 2.9 1,253 Number of partners in past 12 months 1 3.1 3,412 2.0 2,177 2.6 5,589 2 9.4 50 2.0 321 3.0 371 3+ * 5 0.0 66 0.0 70 Number of higher-risk partners in past 12 months 1 3.4 659 1.4 798 2.3 1,457 2 10.6 44 0.0 122 2.8 167 3+ * 4 (0.0) 40 (0.0) 43 Paid for sex In past 12 months na na 6.9 62 na na Prior to past 12 months na na 2.6 181 na na Never na na 1.7 2,733 na na Any condom use Used condom at any time 3.5 981 1.9 1,616 2.5 2,596 Never used condom 3.1 3,325 2.0 1,361 2.8 4,686 Condom use at last sex in past 12 months Used condom last sex 3.4 285 2.0 526 2.5 811 No condom last sex 3.1 3,181 1.9 2,038 2.6 5,219 Condom use at last higher-risk sex in past 12 months Used condom last higher-risk en- counter 2.2 190 1.4 444 1.6 634 No condom last higher-risk en- counter 4.4 517 1.0 515 2.7 1,032 Condom use first sex1 Used at first sexual encounter 2.1 235 0.0 202 1.1 437 Did not use at first encounter 1.7 803 0.0 339 1.2 1,142 Condom use at last paid sex Used na na 4.5 108 na na Did not use na na 3.0 136 na na Total 3.2 4,306 1.9 2,977 2.7 7,283 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in paren- theses are based on 25-49 unweighted cases. 1Refers to those age 15-24 only na = Not available HIV Prevalence and Associated Factors | 249 13.2.4 HIV Prevalence by Other Characteristics Related to HIV Risk Table 13.7 shows the variation in HIV prevalence by various characteristics related to HIV risk among men and women who have ever had sex. As expected, women and men with history of a sexually transmitted infection (STI) or STI symptoms have higher rates of HIV infection than those with none. Table 13.7 HIV prevalence by other indicators Percentage HIV positive among women and men age 15-49 who ever had sex, by whether they had a sexually transmitted infection (STI), whether they had an HIV test, and reason for HIV test, Ghana 2003 Women Men Total Characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection Had STI or STI symptoms 4.9 360 2.2 137 4.2 496 No STI, no symptoms 3.0 3,946 1.9 2,840 2.6 6,786 HIV testing status Ever tested 4.6 487 1.4 337 3.3 824 Never tested 3.1 3,746 2.0 2,626 2.6 6,372 Reason for HIV testing Asked for test 6.4 150 2.0 149 4.2 299 Offered and accepted 5.2 201 0.0 96 3.5 297 Test required 3.7 68 0.0 87 1.6 155 Total 3.2 4,306 1.9 2,977 2.7 7,283 Note: Total includes 106 women and 17 men with missing information on HIV testing status, and 66 women and 4 men missing information on reason for HIV testing. Women who have been tested for HIV in the past are more likely to be HIV positive than those who have never been tested. Among women who have ever had sex, the level of HIV infection is 5 percent among those who have ever been tested for HIV in the past and who know their status, compared with 3 percent among those who have never been tested. There is little difference in HIV prevalence and testing status among men. HIV prevalence varies by reason for HIV testing, increasing from less than 2 percent among those who stated that the test was required, to more than 4 percent among those who asked for the test. The difference is more obvious among women than men, increasing from 4 percent among women for whom the test was required, to 5 percent among women who were offered the test and accepted, to more than 6 percent among women who asked for the test. Although the individual’s HIV status is associated with prior HIV testing, the above results indicate that many individuals who are HIV positive have not been tested. Nine out of ten of those infected with HIV (88 percent of infected women and 92 percent of infected men) do not know their HIV status, either because they were never tested or because they were tested and did not receive their results (Table 13.8). For women, 12 percent of those who are HIV positive have been tested and know the results for their last test, compared with 7 percent of those who are HIV negative. For men, 8 percent of those who are HIV positive know the results for their last test, compared with 7 percent of those who are HIV negative. It should be noted that testing for HIV may depend on a number of factors including access to testing facilities. Since HIV testing is not available universally in the country, where a person lives may influence the likelihood of being tested for HIV. 250 | HIV Prevalence and Associated Factors Table 13.8 HIV prevalence by prior HIV testing Percent distribution of women and men age 15-49 by HIV testing status prior to the survey, according to whether positive or negative for HIV, Ghana 2003 Women Men HIV testing status HIV positive HIV negative HIV positive HIV negative Ever tested and know results of last test 12.4 7.3 8.2 7.2 Ever tested, does not know results 3.9 2.5 0.0 1.8 Never tested 83.7 90.2 91.8 90.9 Total 100.0 100.0 100.0 100.0 Number 138 4,959 59 3,989 13.2.5 HIV Prevalence and Male Circumcision Lack of circumcision is considered a risk factor for HIV infection, in part because of physiological differences that increase the susceptibility to HIV infection among uncircumcised men. The 2003 GDHS obtained information on male circumcision status, and these results can be used to examine the relationship between HIV prevalence and male circumcision. As Table 13.9 shows, the vast majority of Ghanaian men (95 percent) are circumcised. However, the proportions circumcised vary by region, being markedly lower among men in the three northern regions and especially low in the Upper West Region (68 percent). The percent circumcised is also relatively lower among men who have no education (84 percent), among men in the lowest wealth quintile (82 percent), and among men who adhere to traditional or spiritualist religion (68 percent). The number of men who are not circumcised in the population is rather small and therefore it is difficult to interpret the difference in prevalence between circumcised and uncircumcised men by background characteristics. Caution needs to be exercised when interpreting this table because both the numerators and the denominators on which these percentages are based are quite small. There is little difference in the HIV prevalence by circumcision status; however, some differences by background characteristics are noted. HIV Prevalence and Associated Factors | 251 Table 13.9 HIV prevalence among men by circumcision status Among men age 15-59 who were tested for HIV, percentage who are circumcised and percentage HIV positive among circumcised and uncircumcised men, according to background characteristics, Ghana 2003 All men tested for HIV Circumcised men Uncircumcised men Background characteristic Percentage circumcised Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 95.1 1,035 0.2 985 0.0 50 20-24 96.7 616 0.0 596 (0.0) 20 25-29 97.4 663 0.9 645 (3.1) 17 30-34 95.9 548 2.8 525 (1.8) 23 35-39 93.8 433 3.2 407 1.1 27 40-44 93.7 351 4.4 329 (0.0) 22 45-49 94.5 401 1.5 379 (8.1) 22 50-54 93.9 254 3.9 239 (0.0) 16 55-59 92.0 167 3.0 154 (0.0) 13 Residence Urban 98.6 2,006 1.6 1,978 (0.0) 28 Rural 92.6 2,463 1.7 2,280 1.6 183 Region Western 99.3 421 1.6 419 * 3 Central 99.2 333 1.5 330 * 3 Greater Accra 99.2 645 1.7 640 * 5 Volta 98.3 390 0.9 384 * 7 Eastern 97.5 476 3.1 464 * 12 Ashanti 98.6 855 1.4 843 * 12 Brong Ahafo 96.3 474 1.8 456 * 17 Northern 85.4 470 1.0 401 0.0 69 Upper East 84.1 285 1.4 240 4.9 45 Upper West 68.2 119 1.5 81 2.1 38 Education No education 84.1 774 1.2 651 1.5 123 Primary 94.8 709 1.8 672 3.2 37 Middle/JSS 98.1 1,965 2.1 1,928 0.0 36 Secondary+ 98.6 1,022 0.9 1,008 * 14 Wealth quintile Lowest 81.7 780 1.2 637 1.6 143 Second 96.4 821 1.9 792 0.0 29 Middle 98.8 872 2.1 861 * 11 Fourth 98.4 966 1.5 951 * 16 Highest 98.9 1,030 1.5 1,018 * 12 Religion Roman Catholic 93.9 646 1.2 607 0.0 39 Anglican 92.4 59 2.4 54 0.0 4 Methodist 99.6 292 2.1 291 0.0 1 Presbyterian 97.1 345 3.3 335 0.0 10 Other Christian 97.5 1,800 1.4 1,755 0.9 44 Moslem 98.0 836 1.3 819 * 17 Traditional/spiritualist 67.7 206 2.0 140 3.9 67 No religion 90.3 282 2.3 255 0.0 27 Total 95.3 4,469 1.6 4,258 1.4 210 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Fig- ures in parentheses are based on 25-49 unweighted cases. Total includes 3 men for whom information on ethnicity is missing and 5 men with other religion or missing information on religion. 13.2.6 Prevalence among Couples About 1,800 cohabiting couples were tested for HIV in the 2003 GDHS. Results shown in Table 13.10 indicate that, for the vast majority (96 percent) of cohabiting couples, both partners are HIV negative, while in only 1 percent of couples are both partners HIV positive. There is discordance in the 252 | HIV Prevalence and Associated Factors Table 13.10 HIV prevalence among couples Among cohabiting couples both of whom were tested, percent distribution by HIV results, according to back- ground characteristics, Ghana 2003 Background characteristic Both partners HIV positive Male partner positive, fe- male partner negative Female part- ner positive, male partner negative Both partners HIV negative Total Number Age of woman 15-19 1.7 0.0 0.0 98.3 100.0 57 20-29 0.5 1.7 1.8 96.1 100.0 666 30-39 1.3 2.4 1.8 94.5 100.0 686 40-49 1.1 0.6 0.9 97.5 100.0 383 Age of man 15-19 * * * * 100.0 3 20-29 0.0 0.4 1.6 98.0 100.0 304 30-39 0.8 2.4 1.9 95.0 100.0 653 40-59 1.5 1.5 1.3 95.7 100.0 832 Marital status Married 1.0 1.6 1.5 95.8 100.0 1,792 Living together 1.5 3.0 4.1 91.4 100.0 103 Type of union Monogamous 0.8 1.7 1.5 96.0 100.0 1,483 Polygynous 1.9 1.2 1.8 95.1 100.0 309 Residence Urban 1.1 1.7 2.3 94.9 100.0 626 Rural 0.9 1.6 1.2 96.3 100.0 1,166 Region Western 1.5 1.1 2.8 94.7 100.0 171 Central 1.4 2.6 0.6 95.4 100.0 124 Greater Accra 2.3 2.2 2.3 93.2 100.0 214 Volta 0.0 0.0 3.5 96.5 100.0 137 Eastern 1.4 3.3 1.2 94.1 100.0 191 Ashanti 1.4 0.7 1.7 96.3 100.0 299 Brong Ahafo 0.3 2.0 1.4 96.3 100.0 196 Northern 0.4 1.3 0.9 97.4 100.0 258 Upper East 0.0 1.9 0.0 98.1 100.0 144 Upper West 0.0 2.5 0.0 97.5 100.0 58 Woman’s education No education 0.9 1.5 1.2 96.4 100.0 760 Primary 1.6 1.7 1.6 95.0 100.0 360 Middle/JSS 0.9 1.5 2.0 95.6 100.0 558 Secondary+ 0.0 3.2 1.2 95.6 100.0 115 Man’s education No education 0.2 0.9 0.6 98.3 100.0 523 Primary 1.9 2.2 3.0 92.9 100.0 215 Middle/JSS 1.5 1.8 2.0 94.7 100.0 696 Secondary+ 0.5 2.1 1.2 96.2 100.0 357 Wealth quintile Lowest 0.2 1.7 0.9 97.2 100.0 424 Second 1.2 1.3 0.9 96.6 100.0 374 Middle 1.8 1.4 2.2 94.6 100.0 353 Fourth 0.5 1.6 2.5 95.4 100.0 316 Highest 1.4 2.3 1.5 94.9 100.0 325 Total 1.0 1.6 1.5 95.8 100.0 1,792 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. HIV Prevalence and Associated Factors | 253 HIV positive status in under 2 percent of couples, where one partner is infected and the other is not. Couples where the woman is in the youngest age group (15-19), couples where the man is in the oldest age group (15-49), couples in a polygynous union, urban couples, couples living in Greater Accra, couples with primary education, and couples in the middle wealth quintile have slightly higher HIV prevalence than their counterparts in the other categories. Discordance whereby the man is positive and the woman is not is more common than situations in which the woman is positive and the man is not. The fact that there are more couples that are discordant for HIV than couples that are both infected points to an unmet need for HIV prevention because the majority of these couples do not mutually know their HIV status. Couple-oriented voluntary counselling and testing (VCT) services, where partners (including those in polygynous marriages) go together and receive results together should be advocated for all VCT centers in Ghana. 13.3 DISTRIBUTION OF THE HIV BURDEN IN GHANA An accurate estimation of HIV prevalence is necessary to assess the scope of the AIDS epidemic in Ghana and to track trends over time. Sentinel surveillance data from ANC clinics and from individuals seeking medical treatment for STIs have been the principal source of information on HIV prevalence in Ghana. With the inclusion of HIV testing in the 2003 GDHS, Ghana has joined the first few countries in sub-Saharan Africa to expand the tools employed in monitoring the scope of the AIDS epidemic to include a nationally representative population-based survey. Ideally, the seroprevalence data from the GDHS survey will be examined and used to create a more accurate set of assumptions to use in estimating prevalence rates from future sentinel surveillance data. Indeed, UNAIDS and WHO suggest that population-based surveys “should definitely be used to calibrate the results of routine surveillance systems” (WHO and UNAIDS, 2000). The availability of population-based seroprevalence data from the 2003 GDHS clearly enhances the body of information available on the HIV/AIDS epidemic in Ghana. References | 255 REFERENCES Boerma, J. T. 1988. Monitoring and evaluation of health interventions: Age- and cause-specific mortality and morbidity in childhood. In Research and intervention issues concerning infant and child morbidity and health, 195-218. Proceedings of the East Africa Workshop, International Development Research Center, Manuscript Report 200e. Ottawa, Canada. Buve, A., M. Carael, R.J. Hayes, B. Auvert, B. Ferry, B.N.J. Robinson, S. 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Legon, Ghana: University of Ghana. Republic of Ghana. 1969. Population planning for national progress and prosperity: Ghana population policy. Accra, Ghana. Righard, L., and M.O. Alade. 1990. Effect of delivery room routines on success of the first breast-feed. Lancet 336 (8723):115-1107. Sachs, J. 1999. Helping the poorest. The Economist August 14-20:27-30. Sedgwick, R., 2000. Education in Ghana. World Education News and Review (WENR).13(2) ed. World Bank. 2003. Ghana Poverty Reduction Strategy 2003-2005: An agenda for growth and prosperity. Vol. 1: Analysis and Policy Statement. February 19, 2003. Washington D.C.: The World Bank. World Health Assembly. 2001. Global strategy on infant and young child feeding. Provisional agenda item 13.1. Geneva: World Health Organisation. World Health Organisation (WHO). 1998. Complementary feeding of young children in developing coun- tries: A review of current scientific knowledge. Geneva: World Health Organisation. 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Appendix A | 257 SAMPLE IMPLEMENTATION APPENDIX A Table A.1 Sample implementation: women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall response rates, according to urban-rural residence and region, Ghana 2003 Residence Region Result Urban Rural Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Total Selected households Completed (C) 92.5 95.5 94.3 94.3 90.5 93.3 95.3 93.8 96.3 97.2 95.3 95.0 94.3 Household present but no competent respondent at home (HP) 1.3 0.6 0.2 0.6 3.0 0.2 0.9 0.6 0.4 0.0 1.0 1.3 0.9 Refused (R) 0.3 0.0 0.2 0.0 0.5 0.0 0.3 0.1 0.0 0.0 0.0 0.0 0.1 Dwelling not found (DNF) 0.4 0.1 0.2 0.2 0.4 0.0 0.0 0.6 0.0 0.0 0.3 0.0 0.2 Household absent (HA) 3.6 2.6 3.6 3.1 2.8 3.8 2.4 3.9 2.9 1.6 2.3 3.1 3.0 Dwelling vacant/address not a dwelling (DV) 1.2 0.8 0.8 1.4 1.8 2.3 0.5 0.7 0.4 0.5 1.0 0.6 1.0 Dwelling destroy (DD) 0.1 0.1 0.2 0.0 0.1 0.2 0.3 0.1 0.0 0.0 0.0 0.0 0.1 Other (O) 0.6 0.2 0.7 0.4 0.8 0.2 0.3 0.3 0.0 0.7 0.3 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 2,720 3,908 615 510 930 525 660 1,140 760 608 400 480 6,628 Household response rate (HRR)1 97.9 99.3 99.5 99.2 95.8 99.8 98.7 98.6 99.6 100.0 98.7 98.7 98.7 Eligible women Completed (EWC) 95.0 96.2 97.0 97.5 91.5 94.4 95.5 98.0 98.3 95.6 94.5 95.1 95.7 Not at home (EWNH) 3.2 2.3 1.9 1.7 6.1 3.0 2.6 0.8 0.8 2.4 4.1 2.7 2.7 Postponed (EWP) 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.1 Refused (EWR) 0.8 0.3 0.4 0.3 1.3 0.9 0.2 0.2 0.3 0.5 0.7 0.2 0.5 Partly completed (EWPC) 0.3 0.3 0.4 0.3 0.3 0.2 0.2 0.2 0.0 0.8 0.0 0.4 0.3 Incapacitated (EWI) 0.4 0.7 0.2 0.3 0.5 1.3 0.9 0.3 0.5 0.2 0.7 1.2 0.6 Other (EWO) 0.3 0.2 0.2 0.0 0.1 0.2 0.6 0.4 0.2 0.6 0.0 0.0 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,500 3,449 540 361 913 468 530 946 649 638 418 486 5,949 Eligible woman response rate (EWRR)2 95.0 96.2 97.0 97.5 91.5 94.4 95.5 98.0 98.3 95.6 94.5 95.1 95.7 Overall response rate (ORR)3 93.0 95.5 96.5 96.7 87.6 94.3 94.3 96.6 97.9 95.6 93.3 93.8 94.4 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C ——————————— C + HP + P + R + DNF 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC ————————————————————————— EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 258 | Appendix A Table A.2 Sample implementation: men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall response rates, according to urban-rural residence and region, Ghana 2003 Residence Region Result Urban Rural Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Total Selected households Completed (C) 92.5 95.5 94.3 94.3 90.5 93.3 95.3 93.8 96.3 97.2 95.3 95.0 94.3 Household present but no competent respondent at home (HP) 1.3 0.6 0.2 0.6 3.0 0.2 0.9 0.6 0.4 0.0 1.0 1.3 0.9 Refused (R) 0.3 0.0 0.2 0.0 0.5 0.0 0.3 0.1 0.0 0.0 0.0 0.0 0.1 Dwelling not found (DNF) 0.4 0.1 0.2 0.2 0.4 0.0 0.0 0.6 0.0 0.0 0.3 0.0 0.2 Household absent (HA) 3.6 2.6 3.6 3.1 2.8 3.8 2.4 3.9 2.9 1.6 2.3 3.1 3.0 Dwelling vacant/address not a dwelling (DV) 1.2 0.8 0.8 1.4 1.8 2.3 0.5 0.7 0.4 0.5 1.0 0.6 1.0 Dwelling destroy (DD) 0.1 0.1 0.2 0.0 0.1 0.2 0.3 0.1 0.0 0.0 0.0 0.0 0.1 Other (O) 0.6 0.2 0.7 0.4 0.8 0.2 0.3 0.3 0.0 0.7 0.3 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled house- holds 2,720 3,908 615 510 930 525 660 1,140 760 608 400 480 6,628 Household response rate (HRR)1 97.9 99.3 99.5 99.2 95.8 99.8 98.7 98.6 99.6 100.0 98.7 98.7 98.7 Eligible men Completed (EMC) 92.2 94.8 96.0 95.2 86.1 93.9 94.8 95.8 97.9 94.1 93.4 92.6 93.8 Not at home (EMNH) 5.2 3.8 3.2 4.1 10.0 4.6 3.8 2.6 1.7 2.8 5.7 5.3 4.4 Postponed (EMP) 0.0 0.1 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.2 0.1 Refused (EMR) 1.3 0.2 0.2 0.0 2.8 0.5 0.2 0.4 0.2 0.6 0.2 0.0 0.6 Partly completed (EMPC) 0.1 0.2 0.0 0.0 0.3 0.0 0.2 0.1 0.0 0.4 0.0 0.2 0.1 Incapacitated (EMI) 0.4 0.8 0.6 0.6 0.3 0.5 0.6 0.4 0.2 1.0 0.7 1.7 0.6 Other (EMO) 0.7 0.2 0.0 0.0 0.6 0.0 0.4 0.7 0.2 1.0 0.0 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 2,063 3,282 476 315 721 411 478 819 606 678 423 418 5,345 Eligible man response rate (EMRR)2 92.2 94.8 96.0 95.2 86.1 93.9 94.8 95.8 97.9 94.1 93.4 92.6 93.8 Overall response rate (ORR)3 90.3 94.1 95.5 94.5 82.5 93.7 93.6 94.5 97.5 94.1 92.2 91.4 92.6 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C ——————————— C + HP + P + R + DNF 2 Using the number of eligible men falling into specific response categories, the eligible man response rate (EMRR) is calculated as: 100 * EMC ————————————————————————— EMC + EMNH + EMP + EMR + EMPC + EMI + EMO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 Appendix A | 259 Table A.3 Coverage of HIV testing among interviewed women by socio-demographic charac- teristics Percent distribution of women age 15-49 by HIV-testing status, according to socio-demographic characteristics (unweighted), Ghana 2003 HIV-testing status Socio-demographic characteristic Tested Refused Absent Other/ missing Total Number Marital status Currently in union 93.4 4.9 0.8 0.8 100.0 3,694 Widowed 90.0 8.3 0.8 0.8 100.0 120 Divorced/separated 92.9 6.0 0.5 0.5 100.0 368 Never in union 92.6 4.6 1.8 1.0 100.0 1,509 Ever had sex 92.5 4.9 1.7 0.9 100.0 655 Never had sex 92.6 4.4 1.9 1.1 100.0 854 Type of union Polygynous union 92.4 5.6 1.2 0.9 100.0 934 Not in polygynous union 93.7 4.7 0.7 0.8 100.0 2,760 Not currently in union 92.5 5.1 1.5 0.9 100.0 1,997 Ever had sexual intercourse Yes 93.2 5.1 0.9 0.8 100.0 4,836 No 92.6 4.4 1.9 1.1 100.0 855 Currently pregnant Pregnant 95.2 2.8 1.1 0.9 100.0 435 Not pregnant/not sure 92.9 5.2 1.1 0.9 100.0 5,256 Ethnicity Akan 94.7 4.0 0.8 0.5 100.0 2,481 Ga/Dangme 88.1 9.2 0.9 1.8 100.0 437 Ewe 94.1 4.4 1.0 0.4 100.0 698 Guan 94.3 3.8 0.6 1.3 100.0 159 Mole-Dagbani 89.7 7.5 1.7 1.1 100.0 1,119 Grussi 92.4 7.0 0.6 0.0 100.0 171 Gruma 91.0 1.7 1.7 5.6 100.0 178 Hausa 98.4 1.6 0.0 0.0 100.0 62 Other 96.1 2.1 1.3 0.5 100.0 380 Religion Roman Catholic 93.3 5.6 0.7 0.4 100.0 905 Anglican 92.8 4.3 1.4 1.4 100.0 69 Methodist 93.8 4.3 1.3 0.5 100.0 373 Presbyterian 92.5 5.8 1.1 0.6 100.0 465 Other Christian 93.4 5.0 0.8 0.9 100.0 2,352 Moslem 93.3 3.9 2.3 0.5 100.0 1,013 Traditional/spiritualist 88.6 6.7 1.4 3.3 100.0 210 No religion 92.4 5.3 0.0 2.3 100.0 302 Total 93.1 5.0 1.1 0.9 100.0 5,691 Note: Total includes 6 women for whom information on ethnicity is missing, 1 woman with other religion, and 1 woman with information on religion missing. 260 | Appendix A Table A.4 Coverage of HIV testing among interviewed men by socio-demographic characteristics Percent distribution of interviewed men age 15-59 by HIV-testing status, according to socio- demographic characteristics (unweighted), Ghana 2003 HIV-testing status Socio-demographic characteristic Tested Refused Absent Other/ missing Total Number Marital status Currently in union 85.0 10.3 3.2 1.5 100.0 2,726 Widowed (70.0) (26.7) (0.0) (3.3) 100.0 30 Divorced/separated 78.5 15.6 3.7 2.2 100.0 135 Never in union 85.8 9.9 3.6 0.7 100.0 2,124 Ever had sex 82.8 12.8 3.3 1.0 100.0 956 Never had sex 88.2 7.5 3.9 0.4 100.0 1,168 Type of union In polygynous union 83.5 10.4 3.6 2.4 100.0 412 Not in polygynous union 85.3 10.2 3.2 1.3 100.0 2,314 Not currently in union 85.1 10.4 3.6 0.8 100.0 2,289 Ever had sexual intercourse Yes 84.1 11.2 3.3 1.4 100.0 3,844 No 88.2 7.5 3.8 0.4 100.0 1,171 Circumcision status Circumcised 85.0 10.5 3.4 1.1 100.0 4,648 Not circumcised 86.6 8.2 2.7 2.5 100.0 367 Times slept away in the past 12 months None 85.2 10.1 3.5 1.2 100.0 2,161 1-2 86.3 9.8 3.1 0.8 100.0 1,121 3-5 85.8 9.9 2.7 1.5 100.0 987 5+ 82.0 12.0 4.6 1.4 100.0 724 Whether away for more than 1 month in the past 12 months Away for more than 1 month 85.9 9.8 3.2 1.2 100.0 1,004 Away always less than 1 month 84.6 10.8 3.5 1.2 100.0 1,815 Never away 85.2 10.1 3.5 1.2 100.0 2,161 Ethnicity Akan 84.8 11.4 3.2 0.7 100.0 2,025 Ga/Dangme 80.2 15.7 3.8 0.3 100.0 338 Ewe 86.6 9.1 2.8 1.5 100.0 614 Guan 85.9 7.3 4.7 2.1 100.0 191 Mole-Dagbani 85.3 9.5 4.0 1.3 100.0 1,235 Grussi 87.3 9.6 2.5 0.6 100.0 157 Gruma 89.9 2.1 2.7 5.3 100.0 188 Hausa 66.0 20.0 12.0 2.0 100.0 50 Other 87.9 9.3 1.4 1.4 100.0 214 Religion Roman Catholic 86.1 10.2 2.9 0.8 100.0 794 Anglican 70.2 19.1 6.4 (4.3) 100.0 47 Methodist 84.1 12.0 3.3 0.7 100.0 301 Presbyterian 82.5 14.4 2.2 0.8 100.0 361 Other Christian 86.2 9.6 3.8 0.4 100.0 1,785 Moslem 84.0 10.3 3.9 1.8 100.0 1,050 Traditional/spiritualist 85.5 8.2 3.8 2.5 100.0 317 No religion 85.6 9.6 1.7 3.1 100.0 355 Total 85.1 10.3 3.4 1.2 100.0 5,015 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 22 men with missing information on number of times slept away, 35 men with missing information on whether away for more than 1 month, 3 men with missing information on ethnicity, 3 men of other religion, and 2 men with missing information on religion. Appendix A | 261 Table A.5 Coverage of HIV testing by sexual behaviour characteristics: women Percent distribution of women who ever had sex by HIV-testing status, according to sexual behaviour characteris- tics, Ghana 2003 HIV-testing status Sexual behaviour characteristic Tested Refused Absent Other/ missing Total Number of women Age at first sex <16 93.4 4.8 0.6 1.2 100.0 1,209 16-17 93.0 5.0 1.2 0.8 100.0 1,320 18-19 94.3 4.6 0.7 0.4 100.0 1,117 20+ 92.5 5.6 1.2 0.7 100.0 854 Higher-risk sex in past 12 months Had higher-risk sex 91.9 5.9 1.9 0.3 100.0 724 Had sex, not higher-risk sex 93.8 4.7 0.6 0.9 100.0 3,128 No sex in past 12 months 92.2 5.7 1.1 1.0 100.0 984 Number of partners in past 12 months 1 93.4 4.9 0.9 0.8 100.0 3,791 2 91.4 6.9 1.7 0.0 100.0 58 3+ * * * * 100.0 3 Number of higher-risk partners in past 12 months 1 91.8 6.0 1.9 0.3 100.0 670 2 92.3 5.8 1.9 0.0 100.0 52 3+ * * * * 100.0 2 Any condom use Used condom at any time 92.6 5.7 1.1 0.7 100.0 1,021 Never used condom 93.3 4.9 0.9 0.9 100.0 3,815 Condom use at last sex in past 12 months Used condom last sex 90.8 7.2 1.6 0.3 100.0 305 No condom last sex 93.6 4.7 0.8 0.8 100.0 3,547 Condom use at last higher-risk sex in past 12 months Used condom last higher-risk sex 90.1 7.9 2.0 0.0 100.0 203 No condom last higher-risk sex 92.5 5.2 1.9 0.4 100.0 521 Condom use first sex1 Used at first sexual encounter 94.6 4.6 0.4 0.4 100.0 241 Did not use at first encounter 94.3 3.3 1.4 1.0 100.0 880 HIV-testing status Ever tested and know results of last test 94.9 4.3 0.3 0.5 100.0 371 Ever tested, does not know results 92.5 6.1 0.0 1.4 100.0 147 Never tested 93.0 5.1 1.0 0.8 100.0 4,212 Total 93.2 5.1 0.9 0.8 100.0 4,836 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 336 women for whom information on age at first sex is inconsistent or missing and 106 women with missing information on HIV testing status. 1Refers to those age 15-24 only 262 | Appendix A Table A.6 Coverage of HIV testing by sexual behaviour characteristics: men Percent distribution of men who ever had sex by testing status, according to sexual behaviour characteristics, Ghana 2003 HIV test status Sexual behaviour characteristic Tested Refused Absent Other/ missing Total Number of men Age at first sex <16 81.8 11.2 5.5 1.6 100.0 511 16-17 86.3 11.2 2.0 0.5 100.0 599 18-19 85.2 10.3 3.2 1.4 100.0 916 20+ 83.6 11.7 3.0 1.7 100.0 1,811 Higher-risk sex in past 12 months Had higher risk sex 82.8 12.0 3.8 1.4 100.0 1,077 Had sex, not higher risk 85.1 10.1 3.2 1.6 100.0 2,227 No sex in last 12 months 82.6 14.4 2.2 0.7 100.0 540 Number of partners in past 12 months 1 84.8 10.3 3.4 1.6 100.0 2,824 2 82.0 13.8 3.2 1.0 100.0 406 3+ 81.1 9.5 6.8 2.7 100.0 74 Number of higher-risk partners in past 12 months 1 84.0 11.2 3.5 1.3 100.0 905 2 75.8 18.2 5.3 0.8 100.0 132 3+ (80.0) (10.0) (5.0) (5.0) 100.0 40 Paid for sex In past 12 months 81.7 11.3 5.6 1.4 100.0 71 Prior to past 12 months 84.6 10.0 4.6 0.8 100.0 241 Never 84.2 11.3 3.1 1.4 100.0 3,529 Any condom use Used condom at any time 83.1 12.1 3.9 0.8 100.0 1,827 Never used condom 85.0 10.4 2.6 1.9 100.0 2,017 Condom use at last sex in past 12 months Used condom last sex 82.5 13.5 3.1 0.9 100.0 578 No condom last sex 84.8 10.1 3.5 1.7 100.0 2,726 Condom use at last higher-risk sex in past 12 months Used condom last higher risk en- counter 82.7 13.2 3.3 0.8 100.0 479 No condom last higher risk encoun- ter 82.9 11.0 4.2 1.8 100.0 598 Condom use first sex1 Used at first sexual encounter 84.7 12.4 2.5 0.5 100.0 202 Did not use at first encounter 88.1 8.8 2.9 0.3 100.0 377 Condom use at last paid sex Used 85.1 12.4 2.5 0.0 100.0 121 Did not use 83.2 8.9 6.3 1.6 100.0 191 HIV-testing status Ever tested and know results of last test 80.4 16.5 2.8 0.3 100.0 327 Ever tested, does not know results 92.0 6.7 0.0 1.3 100.0 75 Never tested 84.3 10.8 3.4 1.5 100.0 3,416 Total 84.1 11.2 3.3 1.4 100.0 3,844 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 7 men for whom information on age at first sex is inconsistent or missing, 3 men with missing information on paid for sex and 26 men with missing informa- tion on HIV testing status. 1Refers to those age 15-24 only Appendix B | 263 ESTIMATES OF SAMPLING ERRORS APPENDIX B The estimates from a sample survey are affected by two types of errors: (1) non-sampling errors, and (2) sampling errors. Non-sampling errors are the results of mistakes made in implementing data col- lection and data processing, such as failure to locate and interview the correct household, misunderstand- ing of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2003 Ghana Demographic and Health Sur- vey (GDHS) to minimize this type of error, non-sampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents se- lected in the 2003 GDHS is only one of many samples that could have been selected from the same popu- lation, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to cal- culate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possi- ble samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2003 GDHS sam- ple is the result of a multi-stage stratified design, and, consequently, it was necessary to use more com- plex formulae. The computer software used to calculate sampling errors for the 2003 GDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = =− ⎥⎥⎦ ⎤ ⎢⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ − − == H h h h m i hi h h m z z m m x frvarrSE h 1 2 1 2 1 2 2 1)()( in which hihihi rxyz −= , and hhh rxyz −= 264 | Appendix B where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of sev- eral replications of the parent sample, and calculates standard errors for these estimates using simple for- mulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo- independent replications are thus created. In the 2003 GDHS, there were 412 non-empty clusters. Hence, 412 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − = ∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 412 clusters, r(i) is the estimate computed from the reduced sample of 411 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, ISSA computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the in- crease in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the 2003 GDHS are calculated for selected variables considered to be of pri- mary interest for woman’s survey and for man’s surveys, respectively. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the 10 regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.14 present the value of the statistic (R), its standard error (SE), the number of unweighted (N-UNWE) and weighted (N-WEIG) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known un- weighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 5.493 and its standard error is 0.086. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 5.493±2×0.086. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 5.321 and 5.664. Sampling errors are analyzed for the national woman sample and for two separate groups of esti- mates: (1) means and proportions, and (2) complex demographic rates. The relative standard errors (SE/R) for the means and proportions range between 0.2 percent and 19.3 percent, with an average of 4.2 Appendix B | 265 percent; the highest relative standard errors are for estimates of very low values (e.g., currently using withdrawal). If estimates of very low values (less than 10 percent) were removed, then the average drops to 2.5 percent. So in general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. The relative standard error for the total fertility rate is small, 2.9 percent. However, for the mortality rates, the average relative standard error for the seven 5- year period mortality rates is much higher, 8.1 percent. There are differentials in the relative standard error for the estimates of sub-populations. For ex- ample, for the variable want no more children, the relative standard errors as a percent of the estimated mean for the whole country, and for the urban areas are 2.5 percent and 4.1 percent, respectively. For the total sample, the value of the design effect (DEFT) averaged over all variables is 1.20, which means that due to multi-stage clustering of the sample the average standard error is increased by a factor of 1.20 over that in an equivalent simple random sample. 266 | Appendix B Table B.1 List of selected variables for sampling errors, Ghana 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimate Base population –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All women 15-49 No education Proportion All women 15-49 With secondary education or higher Proportion All women 15-49 Never married (in union) Proportion All women 15-49 Currently married (in union) Proportion All women 15-49 Had first sex before 18 Proportion All women 20-49 Children ever born Mean All women 15-49 Children ever born to women 40-49 Mean All women 40-49 Children surviving Mean All women 15-49 Knowing any contraceptive method Proportion Currently married women 15-49 Knowing any modern contraceptive method Proportion Currently married women 15-49 Ever used any contraceptive method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently female sterilisation Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using IUD Proportion Currently married women 15-49 Currently using condom Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using periodic abstinence Proportion Currently married women 15-49 Currently using withdrawal Proportion Currently married women 15-49 Using public sector source Proportion Currently married women 15-49 Want no more children Proportion Currently married women 15-49 Want to delay at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women 15-49 Mother received tetanus injection Proportion Births in last 5 years Mother received medical care at birth Proportion Births in last 5 years Child has diarrhoea in the last 2 weeks Proportion Children under 5 Child treated with ORS packets Proportion Children under 5 with diarrhoea in last 2 weeks Consulted medical personnel Proportion Children 12-23 months Child having health card, seen Proportion Children 12-23 months Child received BCG vaccination Proportion Children 12-23 months Child received DPT vaccination (3 doses) Proportion Children 12-23 months Child received polio vaccination (3 doses) Proportion Children 12-23 months Child received measles vaccination Proportion Children 12-23 months Child fully immunised Proportion Children 12-23 months Weight-for-height (-2 SD) Proportion Children under 5 who were measured Height-for-age (-2 SD) Proportion Children under 5 who were measured Weight-for-age (-2 SD) Proportion Children under 5 who were measured Has heard of HIV/AIDS Proportion All women 15-49 Knows condoms reduce HIV/AIDS Proportion All women 15-49 Knows limiting partners reduce HIV/AIDS Proportion All women 15-49 Total fertility rate (last 3 years) Rate All women 15-49 Neonatal mortality rate (last 10 years)1 Rate Number of births in last 5 (10 years) Postneonatal mortality rate (last 10 years) 1 Rate Number of births in last 5 (10 years) Infant mortality rate (last 10 years) 1 Rate Number of births in last 5 (10 years) Child mortality rate (last 10 years) 1 Rate Number of births in last 5 (10 years) Under-five mortality rate (last 10 years) 1 Rate Number of births in last 5 (10 years) HIV prevalence Proportion All women 15-49 tested for HIV –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All men 15-59 No education Proportion All men 15-59 With secondary education or higher Proportion All men 15-59 Never married (in union) Proportion All men 15-59 Currently married (in union) Proportion All men 15-59 Had first sex before 18 Proportion All men 20-59 Knowing any contraceptive method Proportion Currently married men 15-59 Knowing any modern contraceptive method Proportion Currently married men 15-59 Want no more children Proportion Currently married men 15-59 Want to delay at least 2 years Proportion Currently married men 15-59 Ideal number of children Mean All men 15-59 Has heard of HIV/AIDS Proportion All men 15-49 Knows condoms reduce HIV/AIDS Proportion All men 15-49 Knows limiting partners reduce HIV/AIDS Proportion All men 15-49 HIV prevalence (15-49) Proportion All men 15-49 tested for HIV HIV prevalence (15-59) Proportion All men 15-59 tested for HIV –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 5 years for national sample and 10 years for regional sample. Appendix B | 267 Table B.2 Sampling errors for total sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.484 0.012 5691 5691 1.809 0.025 0.460 0.508 No education 0.282 0.010 5691 5691 1.670 0.035 0.263 0.302 With secondary education or higher 0.518 0.012 5691 5691 1.744 0.022 0.495 0.541 Never married (in union) 0.284 0.008 5691 5691 1.414 0.030 0.267 0.301 Currently married (in union) 0.624 0.009 5691 5691 1.340 0.014 0.606 0.641 Had first sex before age 18 0.467 0.010 4578 4543 1.318 0.021 0.447 0.486 Currently pregnant 0.074 0.003 5691 5691 1.007 0.047 0.067 0.081 Children ever born 2.532 0.042 5691 5691 1.229 0.017 2.448 2.617 Children surviving 2.215 0.037 5691 5691 1.247 0.017 2.141 2.289 Children ever born to women 40-49 5.493 0.086 1073 1056 1.103 0.016 5.321 5.664 Knowing any contraceptive method 0.980 0.002 3694 3549 1.036 0.002 0.975 0.985 Knowing any modern contraceptive method 0.978 0.003 3694 3549 1.045 0.003 0.973 0.983 Ever used any contraceptive method 0.553 0.013 3694 3549 1.541 0.023 0.527 0.578 Currently using any contraceptive method 0.252 0.009 3694 3549 1.315 0.037 0.233 0.271 Currently using a modern method 0.187 0.008 3694 3549 1.273 0.044 0.170 0.203 Currently using pill 0.055 0.005 3694 3549 1.284 0.087 0.046 0.065 Currently using IUD 0.009 0.002 3694 3549 1.093 0.189 0.006 0.012 Currently using condom 0.031 0.004 3694 3549 1.275 0.117 0.024 0.038 Currently using injectables 0.054 0.004 3694 3549 1.119 0.077 0.046 0.063 Currently using periodic abstinence 0.051 0.005 3694 3549 1.267 0.090 0.042 0.060 Currently using withdrawal 0.008 0.002 3694 3549 1.065 0.193 0.005 0.011 Obtained method from public sector source 0.410 0.022 829 858 1.278 0.053 0.367 0.454 Want no more children 0.360 0.009 3694 3549 1.154 0.025 0.341 0.378 Want to delay birth at least 2 years 0.375 0.009 3694 3549 1.164 0.025 0.356 0.393 Ideal number of children 4.425 0.038 5573 5579 1.380 0.009 4.349 4.501 Mothers received tetanus injection for last birth 0.834 0.009 2777 2645 1.289 0.011 0.816 0.853 Mothers received medical care at delivery 0.471 0.013 3844 3639 1.343 0.028 0.445 0.497 Child had diarrhoea in the last 2 weeks 0.152 0.007 3530 3340 1.074 0.046 0.138 0.166 Treated with ORS packets 0.386 0.021 582 509 0.941 0.055 0.343 0.429 Consulted medical personnel 0.253 0.025 582 509 1.209 0.098 0.203 0.302 Child having health card, seen 0.830 0.014 735 695 0.997 0.017 0.801 0.858 Child received BCG vaccination 0.911 0.012 735 695 1.077 0.013 0.887 0.935 Child received DPT vaccination (3 doses) 0.795 0.016 735 695 1.035 0.020 0.763 0.827 Child received polio vaccination (3 doses) 0.792 0.016 735 695 1.009 0.020 0.760 0.823 Child received measles vaccination 0.832 0.016 735 695 1.131 0.019 0.800 0.864 Child fully immunised 0.694 0.019 735 695 1.067 0.027 0.656 0.732 Height-for-age (-2 SD) 0.299 0.008 3396 3183 0.973 0.028 0.282 0.316 Weight-for-height (-2 SD) 0.071 0.005 3396 3183 1.047 0.069 0.061 0.081 Weight-for-age (-2 SD) 0.221 0.009 3396 3183 1.114 0.039 0.204 0.239 Has heard of HIV/AIDS 0.984 0.002 5691 5691 1.033 0.002 0.980 0.987 Knows condoms reduce HIV/AIDS 0.729 0.008 5691 5691 1.372 0.011 0.713 0.745 Knows limiting partners reduce HIV/AIDS 0.861 0.007 5691 5691 1.484 0.008 0.847 0.875 Total fertility rate (last 3 years) 4.448 0.131 na 15948 1.472 0.029 4.187 4.709 Neonatal mortality (last 5 years) 43.081 4.018 3876 3658 1.098 0.093 35.046 51.116 Post-neonatal mortality (last 5 years) 21.201 2.534 3881 3662 1.081 0.120 16.133 26.270 Infant mortality (last 0-4 years) 64.282 4.421 3881 3662 1.045 0.069 55.441 73.124 Infant mortality (last 5-9 years) 64.984 4.717 3576 3379 1.043 0.073 55.551 74.418 Infant mortality (last 10-14 years) 63.835 4.840 3189 3042 1.002 0.076 54.156 73.514 Child mortality (last 5 years) 50.120 4.197 3963 3732 1.046 0.084 41.727 58.514 Under-five mortality (last 5 years) 111.181 5.926 3968 3736 1.062 0.053 99.330 123.032 HIV prevalence 0.027 0.002 5297 5097 0.987 0.081 0.023 0.031 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.449 0.011 5015 5015 1.541 0.024 0.427 0.470 No education 0.176 0.009 5015 5015 1.630 0.050 0.158 0.193 With secondary education or higher 0.664 0.012 5015 5015 1.768 0.018 0.641 0.688 Never married (in union) 0.407 0.008 5015 5015 1.170 0.020 0.391 0.423 Currently married (in union) 0.533 0.008 5015 5015 1.119 0.015 0.517 0.548 Had first sex before age 18 0.247 0.008 3920 3908 1.227 0.034 0.230 0.264 Knowing any contraceptive method 0.996 0.001 2726 2671 0.944 0.001 0.994 0.999 Knowing any modern contraceptive method 0.996 0.001 2726 2671 0.936 0.001 0.994 0.999 Want no more children 0.338 0.010 2726 2671 1.115 0.030 0.317 0.358 Want to delay birth at least 2 years 0.385 0.010 2726 2671 1.095 0.027 0.365 0.406 Ideal number of children 4.836 0.058 4883 4906 1.199 0.012 4.719 4.953 Has heard of HIV/AIDS 0.993 0.002 4517 4529 1.238 0.002 0.990 0.996 Knows condoms reduce HIV/AIDS 0.821 0.007 4517 4529 1.293 0.009 0.807 0.836 Knows limiting partners reduce HIV/AIDS 0.899 0.007 4517 4529 1.479 0.007 0.886 0.913 HIV prevalence (15-49) 0.015 0.002 3859 4047 1.150 0.152 0.010 0.019 HIV prevalence (15-59) 0.016 0.002 4267 4469 1.144 0.136 0.012 0.021 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 268 | Appendix B Table B.3 Sampling errors for urban sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 2374 2755 na 0.000 1.000 1.000 No education 0.163 0.014 2374 2755 1.802 0.084 0.136 0.190 With secondary education or higher 0.677 0.017 2374 2755 1.764 0.025 0.643 0.711 Never married (in union) 0.382 0.014 2374 2755 1.356 0.035 0.355 0.409 Currently married (in union) 0.521 0.013 2374 2755 1.315 0.026 0.494 0.548 Had first sex before age 18 0.393 0.015 1833 2126 1.272 0.037 0.364 0.422 Currently pregnant 0.051 0.005 2374 2755 1.132 0.101 0.041 0.061 Children ever born 1.891 0.053 2374 2755 1.134 0.028 1.785 1.996 Children surviving 1.674 0.048 2374 2755 1.177 0.029 1.578 1.770 Children ever born to women 40-49 4.756 0.138 399 458 1.110 0.029 4.480 5.032 Knowing any contraceptive method 0.996 0.002 1246 1436 1.091 0.002 0.992 1.000 Knowing any modern contraceptive method 0.996 0.002 1246 1436 1.091 0.002 0.992 1.000 Ever used any contraceptive method 0.666 0.021 1246 1436 1.563 0.031 0.624 0.708 Currently using any contraceptive method 0.314 0.016 1246 1436 1.205 0.050 0.282 0.346 Currently using a modern method 0.242 0.014 1246 1436 1.115 0.056 0.215 0.269 Currently using pill 0.065 0.008 1246 1436 1.127 0.121 0.050 0.081 Currently using IUD 0.015 0.003 1246 1436 0.942 0.216 0.009 0.022 Currently using condom 0.052 0.008 1246 1436 1.228 0.148 0.037 0.068 Currently using injectables 0.060 0.007 1246 1436 1.048 0.118 0.045 0.074 Currently using periodic abstinence 0.061 0.008 1246 1436 1.136 0.126 0.046 0.076 Currently using withdrawal 0.009 0.003 1246 1436 1.096 0.317 0.003 0.015 Obtained method from public sector source 0.384 0.032 407 476 1.338 0.084 0.319 0.448 Want no more children 0.364 0.015 1246 1436 1.082 0.041 0.335 0.394 Want to delay birth at least 2 years 0.331 0.013 1246 1436 0.973 0.039 0.305 0.357 Ideal number of children 3.884 0.042 2348 2723 1.212 0.011 3.801 3.968 Mothers received tetanus injection for last birth 0.906 0.012 817 946 1.199 0.014 0.882 0.931 Mothers received medical care at delivery 0.797 0.017 1043 1204 1.246 0.022 0.762 0.832 Child had diarrhoea in the last 2 weeks 0.136 0.012 969 1114 1.052 0.090 0.112 0.160 Treated with ORS packets 0.471 0.043 139 152 0.944 0.090 0.386 0.556 Consulted medical personnel 0.355 0.050 139 152 1.136 0.141 0.255 0.455 Child having health card, seen 0.846 0.026 219 248 1.064 0.031 0.794 0.899 Child received BCG vaccination 0.959 0.016 219 248 1.200 0.017 0.927 0.992 Child received DPT vaccination (3 doses) 0.862 0.027 219 248 1.148 0.031 0.808 0.916 Child received polio vaccination (3 doses) 0.828 0.027 219 248 1.042 0.033 0.775 0.882 Child received measles vaccination 0.858 0.026 219 248 1.073 0.030 0.807 0.909 Child fully immunised 0.755 0.032 219 248 1.084 0.042 0.691 0.819 Height-for-age (-2 SD) 0.205 0.015 932 1050 1.062 0.072 0.175 0.235 Weight-for-height (-2 SD) 0.066 0.009 932 1050 1.044 0.133 0.048 0.083 Weight-for-age (-2 SD) 0.154 0.013 932 1050 1.086 0.086 0.128 0.181 Has heard of HIV/AIDS 0.997 0.001 2374 2755 1.127 0.001 0.995 1.000 Knows condoms reduce HIV/AIDS 0.772 0.011 2374 2755 1.238 0.014 0.750 0.793 Knows limiting partners reduce HIV/AIDS 0.893 0.008 2374 2755 1.267 0.009 0.877 0.909 Total fertility rate (last 3 years) 3.120 0.144 na 7674 1.163 0.046 2.833 3.407 Neonatal mortality (last 10 years) 38.116 5.035 2035 2344 1.140 0.132 28.045 48.186 Post-neonatal mortality (last 10 years) 16.506 3.214 2036 2345 1.089 0.195 10.078 22.935 Infant mortality (last 10 years) 54.622 5.621 2036 2345 1.092 0.103 43.380 65.864 Child mortality (last 10 years) 40.275 4.940 2051 2360 1.069 0.123 30.394 50.155 Under-five mortality (last 10 years) 92.697 7.691 2052 2361 1.111 0.083 77.315 108.079 HIV prevalence 0.029 0.003 2183 2466 0.970 0.120 0.022 0.036 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 1903 2250 na 0.000 1.000 1.000 No education 0.080 0.014 1903 2250 2.244 0.175 0.052 0.108 With secondary education or higher 0.807 0.019 1903 2250 2.059 0.023 0.770 0.845 Never married (in union) 0.470 0.014 1903 2250 1.246 0.030 0.441 0.498 Currently married (in union) 0.463 0.013 1903 2250 1.112 0.027 0.438 0.489 Had first sex before age 18 0.240 0.014 1482 1746 1.251 0.058 0.212 0.267 Knowing any contraceptive method 0.999 0.001 894 1042 0.854 0.001 0.998 1.000 Knowing any modern contraceptive method 0.999 0.001 894 1042 0.854 0.001 0.998 1.000 Want no more children 0.363 0.016 894 1042 0.965 0.043 0.332 0.394 Want to delay birth at least 2 years 0.341 0.016 894 1042 0.978 0.046 0.310 0.372 Ideal number of children 4.087 0.084 1880 2225 1.493 0.020 3.920 4.254 Has heard of HIV/AIDS 0.997 0.002 1725 2049 1.232 0.002 0.994 1.000 Knows condoms reduce HIV/AIDS 0.840 0.010 1725 2049 1.190 0.012 0.819 0.861 Knows limiting partners reduce HIV/AIDS 0.926 0.011 1725 2049 1.787 0.012 0.904 0.949 HIV prevalence (15-49) 0.015 0.004 1375 1826 1.104 0.242 0.008 0.022 HIV prevalence (15-59) 0.016 0.004 1516 2006 1.102 0.224 0.009 0.023 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 269 Table B.4 Sampling errors for rural sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 3317 2936 na na 0.000 0.000 No education 0.395 0.014 3317 2936 1.604 0.034 0.367 0.422 With secondary education or higher 0.369 0.013 3317 2936 1.556 0.035 0.343 0.395 Never married (in union) 0.192 0.009 3317 2936 1.259 0.045 0.175 0.209 Currently married (in union) 0.720 0.009 3317 2936 1.184 0.013 0.701 0.738 Had first sex before age 18 0.531 0.012 2745 2417 1.303 0.023 0.506 0.556 Currently pregnant 0.095 0.005 3317 2936 0.900 0.048 0.086 0.104 Children ever born 3.135 0.055 3317 2936 1.155 0.017 3.025 3.244 Children surviving 2.723 0.048 3317 2936 1.169 0.018 2.628 2.819 Children ever born to women 40-49 6.058 0.105 674 598 1.110 0.017 5.849 6.267 Knowing any contraceptive method 0.970 0.004 2448 2113 1.086 0.004 0.962 0.977 Knowing any modern contraceptive method 0.966 0.004 2448 2113 1.100 0.004 0.958 0.974 Ever used any contraceptive method 0.476 0.015 2448 2113 1.508 0.032 0.445 0.506 Currently using any contraceptive method 0.209 0.011 2448 2113 1.384 0.054 0.187 0.232 Currently using a modern method 0.149 0.010 2448 2113 1.343 0.065 0.130 0.168 Currently using pill 0.049 0.006 2448 2113 1.391 0.124 0.037 0.061 Currently using IUD 0.005 0.002 2448 2113 1.285 0.372 0.001 0.008 Currently using condom 0.017 0.003 2448 2113 1.091 0.170 0.011 0.022 Currently using injectables 0.051 0.005 2448 2113 1.158 0.101 0.040 0.061 Currently using periodic abstinence 0.044 0.006 2448 2113 1.379 0.130 0.032 0.055 Currently using withdrawal 0.007 0.002 2448 2113 0.984 0.233 0.004 0.011 Obtained method from public sector source 0.444 0.027 422 382 1.128 0.062 0.389 0.498 Want no more children 0.356 0.012 2448 2113 1.197 0.033 0.333 0.380 Want to delay birth at least 2 years 0.405 0.013 2448 2113 1.272 0.031 0.380 0.430 Ideal number of children 4.941 0.058 3225 2856 1.452 0.012 4.825 5.056 Mothers received tetanus injection for last birth 0.794 0.013 1960 1699 1.373 0.016 0.769 0.820 Mothers received medical care at delivery 0.309 0.015 2801 2435 1.466 0.048 0.280 0.339 Child had diarrhoea in the last 2 weeks 0.161 0.009 2561 2225 1.111 0.053 0.144 0.178 Treated with ORS packets 0.350 0.025 443 357 0.987 0.071 0.300 0.400 Consulted medical personnel 0.209 0.028 443 357 1.278 0.133 0.153 0.265 Child having health card, seen 0.820 0.017 516 447 0.976 0.020 0.787 0.854 Child received BCG vaccination 0.885 0.016 516 447 1.103 0.018 0.852 0.918 Child received DPT vaccination (3 doses) 0.758 0.020 516 447 1.045 0.027 0.717 0.798 Child received polio vaccination (3 doses) 0.771 0.019 516 447 1.030 0.025 0.733 0.810 Child received measles vaccination 0.818 0.021 516 447 1.198 0.025 0.776 0.859 Child fully immunised 0.660 0.024 516 447 1.109 0.036 0.612 0.708 Height-for-age (-2 SD) 0.345 0.010 2464 2132 0.954 0.029 0.325 0.365 Weight-for-height (-2 SD) 0.074 0.006 2464 2132 1.065 0.080 0.062 0.086 Weight-for-age (-2 SD) 0.254 0.011 2464 2132 1.145 0.043 0.232 0.276 Has heard of HIV/AIDS 0.971 0.003 3317 2936 1.071 0.003 0.964 0.977 Knows condoms reduce HIV/AIDS 0.689 0.011 3317 2936 1.415 0.017 0.666 0.712 Knows limiting partners reduce HIV/AIDS 0.831 0.010 3317 2936 1.594 0.012 0.810 0.852 Total fertility rate (last 3 years) 5.646 0.161 na 8274 1.393 0.029 5.324 5.969 Neonatal mortality (last 10 years) 42.501 3.399 5404 4683 1.082 0.080 35.702 49.300 Post-neonatal mortality (last 10 years) 27.198 2.517 5416 4692 1.073 0.093 22.164 32.231 Infant mortality (last 10 years) 69.698 4.170 5416 4692 1.087 0.060 61.359 78.038 Child mortality (last 10 years) 52.222 4.439 5459 4721 1.197 0.085 43.344 61.101 Under-five mortality (last 10 years) 118.281 5.817 5471 4730 1.151 0.049 106.647 129.915 HIV prevalence 0.025 0.003 3114 2630 0.980 0.109 0.020 0.031 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 3112 2765 na na 0.000 0.000 No education 0.254 0.012 3112 2765 1.531 0.047 0.230 0.278 With secondary education or higher 0.548 0.015 3112 2765 1.724 0.028 0.517 0.578 Never married (in union) 0.356 0.009 3112 2765 1.041 0.025 0.338 0.374 Currently married (in union) 0.589 0.009 3112 2765 1.071 0.016 0.570 0.608 Had first sex before age 18 0.253 0.010 2438 2162 1.171 0.041 0.233 0.274 Knowing any contraceptive method 0.995 0.002 1832 1629 0.991 0.002 0.991 0.998 Knowing any modern contraceptive method 0.995 0.002 1832 1629 0.981 0.002 0.991 0.998 Want no more children 0.321 0.013 1832 1629 1.206 0.041 0.295 0.348 Want to delay birth at least 2 years 0.414 0.013 1832 1629 1.169 0.033 0.387 0.441 Ideal number of children 5.458 0.084 3003 2681 1.170 0.015 5.290 5.626 Has heard of HIV/AIDS 0.989 0.003 2792 2480 1.293 0.003 0.984 0.994 Knows condoms reduce HIV/AIDS 0.806 0.010 2792 2480 1.380 0.013 0.785 0.826 Knows limiting partners reduce HIV/AIDS 0.877 0.008 2792 2480 1.309 0.009 0.861 0.893 HIV prevalence (15-49) 0.014 0.003 2484 2222 1.152 0.192 0.009 0.020 HIV prevalence (15-59) 0.017 0.003 2751 2463 1.151 0.169 0.011 0.022 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 270 | Appendix B Table B.5 Sampling errors for Western sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.398 0.031 524 553 1.447 0.078 0.336 0.460 No education 0.223 0.025 524 553 1.374 0.112 0.173 0.273 With secondary education or higher 0.532 0.040 524 553 1.836 0.075 0.452 0.612 Never married (in union) 0.298 0.024 524 553 1.209 0.081 0.250 0.346 Currently married (in union) 0.576 0.027 524 553 1.239 0.047 0.522 0.629 Had first sex before age 18 0.509 0.043 412 431 1.732 0.084 0.424 0.594 Currently pregnant 0.071 0.012 524 553 1.082 0.171 0.047 0.095 Children ever born 2.596 0.149 524 553 1.286 0.058 2.297 2.895 Children surviving 2.257 0.146 524 553 1.461 0.065 1.966 2.548 Children ever born to women 40-49 5.510 0.213 96 102 0.841 0.039 5.084 5.936 Knowing any contraceptive method 0.995 0.005 308 319 1.195 0.005 0.986 1.000 Knowing any modern contraceptive method 0.995 0.005 308 319 1.195 0.005 0.986 1.000 Ever used any contraceptive method 0.619 0.029 308 319 1.048 0.047 0.561 0.677 Currently using any contraceptive method 0.282 0.026 308 319 0.996 0.091 0.231 0.334 Currently using a modern method 0.177 0.016 308 319 0.713 0.088 0.146 0.208 Currently using pill 0.043 0.012 308 319 1.021 0.275 0.019 0.066 Currently using IUD 0.010 0.006 308 319 1.066 0.611 0.000 0.022 Currently using condom 0.031 0.011 308 319 1.066 0.340 0.010 0.052 Currently using injectables 0.037 0.013 308 319 1.225 0.355 0.011 0.064 Currently using periodic abstinence 0.073 0.017 308 319 1.123 0.228 0.040 0.107 Currently using withdrawal 0.023 0.008 308 319 0.928 0.343 0.007 0.039 Obtained method from public sector source 0.295 0.057 76 78 1.080 0.193 0.181 0.409 Want no more children 0.376 0.032 308 319 1.146 0.084 0.312 0.439 Want to delay birth at least 2 years 0.341 0.037 308 319 1.386 0.110 0.266 0.416 Ideal number of children 4.239 0.105 517 547 1.542 0.025 4.029 4.449 Mothers received tetanus injection for last birth 0.884 0.027 237 246 1.277 0.030 0.830 0.938 Mothers received medical care at delivery 0.386 0.037 352 367 1.233 0.096 0.312 0.460 Child had diarrhoea in the last 2 weeks 0.144 0.013 319 332 0.676 0.093 0.117 0.171 Treated with ORS packets 0.370 0.064 46 48 0.919 0.174 0.242 0.499 Consulted medical personnel 0.272 0.060 46 48 0.902 0.221 0.152 0.393 Child having health card, seen 0.874 0.036 60 59 0.804 0.041 0.801 0.946 Child received BCG vaccination 0.925 0.037 60 59 1.054 0.040 0.851 1.000 Child received DPT vaccination (3 doses) 0.789 0.064 60 59 1.161 0.082 0.660 0.917 Child received polio vaccination (3 doses) 0.837 0.057 60 59 1.134 0.068 0.723 0.950 Child received measles vaccination 0.764 0.050 60 59 0.869 0.066 0.664 0.864 Child fully immunised 0.604 0.070 60 59 1.036 0.116 0.464 0.744 Height-for-age (-2 SD) 0.284 0.020 323 333 0.749 0.071 0.244 0.324 Weight-for-height (-2 SD) 0.053 0.013 323 333 0.896 0.237 0.028 0.078 Weight-for-age (-2 SD) 0.165 0.026 323 333 1.162 0.160 0.112 0.218 Has heard of HIV/AIDS 0.997 0.002 524 553 0.977 0.002 0.992 1.000 Knows condoms reduce HIV/AIDS 0.772 0.023 524 553 1.244 0.030 0.726 0.817 Knows limiting partners reduce HIV/AIDS 0.917 0.014 524 553 1.164 0.015 0.889 0.945 Total fertility rate (last 3 years) 4.478 0.487 na 1545 1.511 0.109 3.504 5.453 Neonatal mortality (last 10 years) 36.712 8.774 654 680 1.054 0.239 19.164 54.261 Post-neonatal mortality (last 10 years) 29.750 7.538 655 681 1.036 0.253 14.674 44.826 Infant mortality (last 10 years) 66.462 11.217 655 681 1.063 0.169 44.028 88.896 Child mortality (last 10 years) 46.025 7.883 657 683 0.919 0.171 30.259 61.791 Under-five mortality (last 10 years) 109.428 15.169 658 684 1.124 0.139 79.091 139.766 HIV prevalence 0.039 0.007 509 497 0.866 0.192 0.024 0.053 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.381 0.025 457 476 1.087 0.065 0.331 0.430 No education 0.073 0.020 457 476 1.640 0.273 0.033 0.114 With secondary education or higher 0.724 0.036 457 476 1.732 0.050 0.652 0.797 Never married (in union) 0.385 0.026 457 476 1.140 0.067 0.333 0.437 Currently married (in union) 0.537 0.025 457 476 1.077 0.047 0.487 0.587 Had first sex before age 18 0.304 0.030 359 368 1.215 0.097 0.245 0.363 Knowing any contraceptive method 0.996 0.004 248 255 1.025 0.004 0.987 1.000 Knowing any modern contraceptive method 0.996 0.004 248 255 1.025 0.004 0.987 1.000 Want no more children 0.424 0.036 248 255 1.139 0.084 0.352 0.495 Want to delay birth at least 2 years 0.350 0.043 248 255 1.430 0.124 0.264 0.437 Ideal number of children 4.280 0.124 455 474 1.166 0.029 4.032 4.529 Has heard of HIV/AIDS 0.995 0.004 419 435 1.076 0.004 0.987 1.000 Knows condoms reduce HIV/AIDS 0.831 0.025 419 435 1.372 0.030 0.781 0.881 Knows limiting partners reduce HIV/AIDS 0.939 0.015 419 435 1.304 0.016 0.908 0.969 HIV prevalence (15-49) 0.018 0.008 357 382 1.126 0.443 0.002 0.034 HIV prevalence (15-59) 0.016 0.007 392 421 1.119 0.442 0.002 0.030 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 271 Table B.6 Sampling errors for Central sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.384 0.048 352 431 1.850 0.125 0.288 0.480 No education 0.252 0.037 352 431 1.602 0.147 0.178 0.326 With secondary education or higher 0.467 0.037 352 431 1.374 0.078 0.394 0.541 Never married (in union) 0.248 0.034 352 431 1.467 0.136 0.180 0.315 Currently married (in union) 0.637 0.031 352 431 1.192 0.048 0.575 0.698 Had first sex before age 18 0.571 0.029 277 338 0.963 0.050 0.514 0.628 Currently pregnant 0.083 0.017 352 431 1.132 0.200 0.050 0.117 Children ever born 2.718 0.210 352 431 1.432 0.077 2.299 3.138 Children surviving 2.393 0.164 352 431 1.299 0.068 2.065 2.720 Children ever born to women 40-49 6.484 0.337 68 76 1.123 0.052 5.811 7.157 Knowing any contraceptive method 1.000 0.000 220 274 na 0.000 1.000 1.000 Knowing any modern contraceptive method 1.000 0.000 220 274 na 0.000 1.000 1.000 Ever used any contraceptive method 0.442 0.037 220 274 1.108 0.084 0.368 0.516 Currently using any contraceptive method 0.152 0.026 220 274 1.070 0.171 0.100 0.203 Currently using a modern method 0.132 0.026 220 274 1.155 0.200 0.079 0.185 Currently using pill 0.023 0.010 220 274 0.949 0.420 0.004 0.042 Currently using IUD 0.000 0.000 220 274 na na 0.000 0.000 Currently using condom 0.030 0.011 220 274 0.970 0.373 0.008 0.052 Currently using injectables 0.058 0.014 220 274 0.890 0.243 0.030 0.086 Currently using periodic abstinence 0.009 0.007 220 274 1.020 0.710 0.000 0.023 Currently using withdrawal 0.010 0.007 220 274 1.038 0.691 0.000 0.024 Obtained method from public sector source 0.477 0.090 50 55 1.258 0.188 0.298 0.657 Want no more children 0.437 0.045 220 274 1.341 0.103 0.347 0.527 Want to delay birth at least 2 years 0.389 0.045 220 274 1.370 0.116 0.299 0.479 Ideal number of children 3.882 0.079 350 428 1.255 0.020 3.723 4.040 Mothers received tetanus injection for last birth 0.876 0.037 168 211 1.476 0.042 0.802 0.950 Mothers received medical care at delivery 0.384 0.057 241 304 1.468 0.148 0.271 0.497 Child had diarrhoea in the last 2 weeks 0.159 0.017 221 280 0.724 0.108 0.125 0.193 Treated with ORS packets 0.452 0.068 36 45 0.823 0.150 0.317 0.588 Consulted medical personnel 0.238 0.067 36 45 0.950 0.282 0.104 0.373 Child having health card, seen 0.840 0.042 52 68 0.851 0.050 0.755 0.924 Child received BCG vaccination 0.952 0.028 52 68 0.967 0.029 0.896 1.000 Child received DPT vaccination (3 doses) 0.879 0.032 52 68 0.739 0.037 0.815 0.944 Child received polio vaccination (3 doses) 0.890 0.032 52 68 0.758 0.036 0.826 0.954 Child received measles vaccination 0.865 0.048 52 68 1.046 0.056 0.768 0.961 Child fully immunised 0.821 0.045 52 68 0.874 0.055 0.730 0.911 Height-for-age (-2 SD) 0.316 0.024 223 284 0.782 0.077 0.267 0.364 Weight-for-height (-2 SD) 0.030 0.010 223 284 0.864 0.323 0.011 0.049 Weight-for-age (-2 SD) 0.220 0.031 223 284 1.075 0.141 0.158 0.282 Has heard of HIV/AIDS 1.000 0.000 352 431 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.792 0.029 352 431 1.321 0.036 0.735 0.849 Knows limiting partners reduce HIV/AIDS 0.945 0.010 352 431 0.836 0.011 0.925 0.966 Total fertility rate (last 3 years) 4.966 0.514 na 1180 1.417 0.103 3.939 5.994 Neonatal mortality (last 10 years) 36.828 9.258 465 584 1.040 0.251 18.313 55.344 Post-neonatal mortality (last 10 years) 13.439 4.961 465 584 0.956 0.369 3.518 23.361 Infant mortality (last 10 years) 50.268 11.146 465 584 1.068 0.222 27.976 72.559 Child mortality (last 10 years) 41.469 11.127 469 587 1.188 0.268 19.215 63.723 Under-five mortality (last 10 years) 89.652 14.607 469 587 1.149 0.163 60.438 118.866 HIV prevalence 0.017 0.006 340 386 0.807 0.332 0.006 0.028 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.283 0.036 300 370 1.363 0.125 0.212 0.354 No education 0.093 0.020 300 370 1.212 0.218 0.053 0.134 With secondary education or higher 0.701 0.035 300 370 1.310 0.049 0.631 0.770 Never married (in union) 0.432 0.033 300 370 1.161 0.077 0.365 0.498 Currently married (in union) 0.527 0.033 300 370 1.156 0.063 0.461 0.594 Had first sex before age 18 0.327 0.027 221 271 0.863 0.083 0.273 0.382 Knowing any contraceptive method 1.000 0.000 157 195 na 0.000 1.000 1.000 Knowing any modern contraceptive method 1.000 0.000 157 195 na 0.000 1.000 1.000 Want no more children 0.456 0.041 157 195 1.026 0.090 0.374 0.538 Want to delay birth at least 2 years 0.277 0.040 157 195 1.107 0.143 0.197 0.356 Ideal number of children 4.132 0.090 288 355 0.890 0.022 3.951 4.312 Has heard of HIV/AIDS 0.994 0.006 263 327 1.186 0.006 0.983 1.000 Knows condoms reduce HIV/AIDS 0.799 0.031 263 327 1.250 0.039 0.737 0.861 Knows limiting partners reduce HIV/AIDS 0.881 0.022 263 327 1.094 0.025 0.838 0.925 HIV prevalence (15-49) 0.003 0.003 252 294 0.929 1.009 0.000 0.010 HIV prevalence (15-59) 0.015 0.007 287 333 0.982 0.470 0.001 0.029 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 272 | Appendix B Table B.7 Sampling errors for Greater Accra sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.897 0.014 835 942 1.293 0.015 0.869 0.924 No education 0.124 0.015 835 942 1.317 0.121 0.094 0.154 With secondary education or higher 0.712 0.025 835 942 1.574 0.035 0.663 0.761 Never married (in union) 0.400 0.023 835 942 1.340 0.057 0.355 0.445 Currently married (in union) 0.505 0.022 835 942 1.273 0.044 0.461 0.549 Had first sex before age 18 0.358 0.022 657 739 1.199 0.063 0.313 0.403 Currently pregnant 0.040 0.006 835 942 0.899 0.153 0.028 0.052 Children ever born 1.713 0.081 835 942 1.128 0.047 1.551 1.874 Children surviving 1.506 0.075 835 942 1.206 0.050 1.356 1.656 Children ever born to women 40-49 3.921 0.226 151 171 1.152 0.058 3.468 4.374 Knowing any contraceptive method 0.994 0.005 415 476 1.191 0.005 0.985 1.000 Knowing any modern contraceptive method 0.994 0.005 415 476 1.191 0.005 0.985 1.000 Ever used any contraceptive method 0.709 0.034 415 476 1.524 0.048 0.641 0.777 Currently using any contraceptive method 0.340 0.029 415 476 1.253 0.086 0.281 0.398 Currently using a modern method 0.260 0.025 415 476 1.164 0.097 0.210 0.310 Currently using pill 0.052 0.015 415 476 1.344 0.282 0.023 0.082 Currently using IUD 0.013 0.006 415 476 1.033 0.448 0.001 0.024 Currently using condom 0.064 0.015 415 476 1.284 0.240 0.033 0.095 Currently using injectables 0.068 0.011 415 476 0.872 0.159 0.046 0.089 Currently using periodic abstinence 0.060 0.014 415 476 1.184 0.230 0.033 0.088 Currently using withdrawal 0.016 0.007 415 476 1.107 0.429 0.002 0.029 Obtained method from public sector source 0.321 0.050 138 167 1.260 0.156 0.221 0.422 Want no more children 0.457 0.025 415 476 1.001 0.054 0.408 0.506 Want to delay birth at least 2 years 0.242 0.024 415 476 1.148 0.100 0.193 0.290 Ideal number of children 3.519 0.050 822 927 1.031 0.014 3.418 3.620 Mothers received tetanus injection for last birth 0.851 0.023 264 303 1.044 0.027 0.805 0.896 Mothers received medical care at delivery 0.814 0.030 339 390 1.180 0.037 0.754 0.873 Child had diarrhoea in the last 2 weeks 0.128 0.022 317 366 1.084 0.169 0.085 0.172 Treated with ORS packets 0.287 0.066 40 47 0.930 0.230 0.155 0.419 Consulted medical personnel 0.155 0.072 40 47 1.107 0.466 0.011 0.300 Child having health card, seen 0.826 0.050 67 75 1.081 0.061 0.725 0.927 Child received BCG vaccination 0.910 0.045 67 75 1.112 0.049 0.821 1.000 Child received DPT vaccination (3 doses) 0.787 0.067 67 75 1.321 0.085 0.654 0.920 Child received polio vaccination (3 doses) 0.774 0.061 67 75 1.192 0.079 0.652 0.897 Child received measles vaccination 0.878 0.047 67 75 1.159 0.053 0.785 0.971 Child fully immunised 0.691 0.076 67 75 1.300 0.110 0.538 0.843 Height-for-age (-2 SD) 0.139 0.017 308 337 0.850 0.119 0.106 0.173 Weight-for-height (-2 SD) 0.072 0.014 308 337 0.926 0.198 0.044 0.101 Weight-for-age (-2 SD) 0.115 0.020 308 337 1.106 0.176 0.075 0.156 Has heard of HIV/AIDS 0.994 0.003 835 942 1.172 0.003 0.988 1.000 Knows condoms reduce HIV/AIDS 0.734 0.016 835 942 1.040 0.022 0.702 0.766 Knows limiting partners reduce HIV/AIDS 0.816 0.017 835 942 1.292 0.021 0.782 0.851 Total fertility rate (last 3 years) 2.907 0.237 na 2658 1.161 0.082 2.433 3.382 Neonatal mortality (last 10 years) 28.957 7.403 644 726 1.094 0.256 14.150 43.764 Post-neonatal mortality (last 10 years) 15.949 5.725 646 728 1.093 0.359 4.499 27.399 Infant mortality (last 10 years) 44.906 9.769 646 728 1.161 0.218 25.369 64.443 Child mortality (last 10 years) 31.203 8.518 645 727 1.176 0.273 14.166 48.239 Under-five mortality (last 10 years) 74.707 13.228 647 729 1.222 0.177 48.252 101.163 HIV prevalence 0.026 0.007 768 842 1.203 0.265 0.012 0.040 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.895 0.017 621 733 1.367 0.019 0.861 0.929 No education 0.058 0.013 621 733 1.335 0.215 0.033 0.084 With secondary education or higher 0.863 0.022 621 733 1.602 0.026 0.819 0.907 Never married (in union) 0.461 0.021 621 733 1.034 0.045 0.419 0.502 Currently married (in union) 0.471 0.020 621 733 1.001 0.043 0.430 0.511 Had first sex before age 18 0.301 0.023 526 623 1.142 0.076 0.255 0.347 Knowing any contraceptive method 1.000 0.000 286 345 na 0.000 1.000 1.000 Knowing any modern contraceptive method 1.000 0.000 286 345 na 0.000 1.000 1.000 Want no more children 0.461 0.028 286 345 0.938 0.060 0.405 0.516 Want to delay birth at least 2 years 0.227 0.024 286 345 0.965 0.106 0.179 0.275 Ideal number of children 3.431 0.057 618 728 1.006 0.017 3.317 3.545 Has heard of HIV/AIDS 1.000 0.000 560 664 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.845 0.019 560 664 1.234 0.022 0.807 0.882 Knows limiting partners reduce HIV/AIDS 0.924 0.017 560 664 1.527 0.019 0.890 0.958 HIV prevalence (15-49) 0.016 0.007 425 585 1.222 0.464 0.001 0.031 HIV prevalence (15-59) 0.017 0.007 470 645 1.192 0.419 0.003 0.031 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 273 Table B.8 Sampling errors for Volta sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.294 0.035 442 492 1.628 0.120 0.224 0.365 No education 0.207 0.031 442 492 1.630 0.152 0.144 0.270 With secondary education or higher 0.520 0.029 442 492 1.234 0.056 0.462 0.579 Never married (in union) 0.295 0.028 442 492 1.280 0.094 0.240 0.351 Currently married (in union) 0.617 0.032 442 492 1.378 0.052 0.553 0.681 Had first sex before age 18 0.538 0.029 362 404 1.102 0.054 0.481 0.596 Currently pregnant 0.069 0.009 442 492 0.728 0.128 0.051 0.086 Children ever born 2.562 0.131 442 492 1.073 0.051 2.299 2.825 Children surviving 2.211 0.109 442 492 1.020 0.049 1.994 2.428 Children ever born to women 40-49 5.279 0.220 98 108 0.872 0.042 4.839 5.719 Knowing any contraceptive method 0.989 0.006 278 304 1.035 0.006 0.977 1.000 Knowing any modern contraceptive method 0.989 0.006 278 304 1.035 0.006 0.977 1.000 Ever used any contraceptive method 0.647 0.048 278 304 1.657 0.073 0.552 0.743 Currently using any contraceptive method 0.236 0.026 278 304 1.010 0.109 0.184 0.287 Currently using a modern method 0.193 0.029 278 304 1.244 0.153 0.134 0.252 Currently using pill 0.036 0.011 278 304 0.987 0.305 0.014 0.059 Currently using IUD 0.002 0.002 278 304 0.714 1.011 0.000 0.005 Currently using condom 0.037 0.013 278 304 1.109 0.338 0.012 0.063 Currently using injectables 0.099 0.022 278 304 1.223 0.222 0.055 0.143 Currently using periodic abstinence 0.041 0.014 278 304 1.198 0.350 0.012 0.069 Currently using withdrawal 0.000 0.000 278 304 na na 0.000 0.000 Obtained method from public sector source 0.534 0.065 73 80 1.111 0.122 0.404 0.665 Want no more children 0.456 0.032 278 304 1.073 0.070 0.392 0.520 Want to delay birth at least 2 years 0.290 0.026 278 304 0.968 0.091 0.237 0.343 Ideal number of children 3.756 0.068 433 483 0.888 0.018 3.620 3.892 Mothers received tetanus injection for last birth 0.816 0.031 202 220 1.125 0.038 0.754 0.878 Mothers received medical care at delivery 0.450 0.049 274 298 1.421 0.109 0.352 0.549 Child had diarrhoea in the last 2 weeks 0.133 0.018 248 269 0.844 0.137 0.096 0.170 Treated with ORS packets 0.365 0.100 36 36 1.179 0.275 0.164 0.565 Consulted medical personnel 0.098 0.066 36 36 1.260 0.674 0.000 0.230 Child having health card, seen 0.855 0.054 64 66 1.192 0.064 0.747 0.964 Child received BCG vaccination 0.912 0.044 64 66 1.197 0.048 0.824 1.000 Child received DPT vaccination (3 doses) 0.893 0.042 64 66 1.046 0.047 0.809 0.977 Child received polio vaccination (3 doses) 0.903 0.040 64 66 1.048 0.045 0.822 0.983 Child received measles vaccination 0.894 0.046 64 66 1.154 0.052 0.802 0.986 Child fully immunised 0.823 0.050 64 66 1.005 0.061 0.723 0.922 Height-for-age (-2 SD) 0.233 0.020 244 259 0.637 0.084 0.193 0.272 Weight-for-height (-2 SD) 0.139 0.032 244 259 1.336 0.228 0.075 0.202 Weight-for-age (-2 SD) 0.257 0.030 244 259 1.017 0.118 0.196 0.317 Has heard of HIV/AIDS 0.999 0.001 442 492 0.798 0.001 0.996 1.000 Knows condoms reduce HIV/AIDS 0.702 0.038 442 492 1.735 0.054 0.626 0.777 Knows limiting partners reduce HIV/AIDS 0.829 0.035 442 492 1.957 0.042 0.759 0.899 Total fertility rate (last 3 years) 4.429 0.413 na 1369 1.308 0.093 3.603 5.255 Neonatal mortality (last 10 years) 44.111 10.384 519 573 1.132 0.235 23.343 64.880 Post-neonatal mortality (last 10 years) 31.368 8.282 519 573 1.040 0.264 14.804 47.932 Infant mortality (last 10 years) 75.479 11.969 519 573 0.996 0.159 51.542 99.417 Child mortality (last 10 years) 40.899 9.082 522 576 0.977 0.222 22.736 59.062 Under-five mortality (last 10 years) 113.291 12.642 522 576 0.901 0.112 88.008 138.575 HIV prevalence 0.017 0.006 425 440 0.919 0.337 0.006 0.029 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.280 0.045 386 440 1.982 0.162 0.189 0.370 No education 0.079 0.020 386 440 1.457 0.254 0.039 0.119 With secondary education or higher 0.725 0.035 386 440 1.516 0.048 0.655 0.794 Never married (in union) 0.447 0.032 386 440 1.262 0.072 0.383 0.511 Currently married (in union) 0.515 0.030 386 440 1.158 0.057 0.456 0.574 Had first sex before age 18 0.277 0.022 301 339 0.832 0.078 0.234 0.320 Knowing any contraceptive method 1.000 0.000 205 227 na 0.000 1.000 1.000 Knowing any modern contraceptive method 1.000 0.000 205 227 na 0.000 1.000 1.000 Want no more children 0.388 0.043 205 227 1.258 0.111 0.302 0.474 Want to delay birth at least 2 years 0.365 0.036 205 227 1.070 0.099 0.293 0.438 Ideal number of children 4.387 0.172 382 435 1.430 0.039 4.043 4.731 Has heard of HIV/AIDS 1.000 0.000 339 389 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.893 0.030 339 389 1.783 0.034 0.833 0.953 Knows limiting partners reduce HIV/AIDS 0.936 0.019 339 389 1.463 0.021 0.897 0.975 HIV prevalence (15-49) 0.003 0.003 299 346 0.976 0.979 0.000 0.010 HIV prevalence (15-59) 0.008 0.006 338 390 1.189 0.701 0.000 0.020 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 274 | Appendix B Table B.9 Sampling errors for Eastern sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.401 0.031 506 601 1.444 0.079 0.338 0.464 No education 0.159 0.023 506 601 1.392 0.142 0.114 0.205 With secondary education or higher 0.606 0.026 506 601 1.195 0.043 0.554 0.658 Never married (in union) 0.282 0.027 506 601 1.339 0.095 0.228 0.335 Currently married (in union) 0.590 0.021 506 601 0.959 0.036 0.548 0.632 Had first sex before age 18 0.435 0.028 414 493 1.129 0.063 0.380 0.490 Currently pregnant 0.073 0.011 506 601 0.989 0.157 0.050 0.096 Children ever born 2.629 0.125 506 601 1.054 0.048 2.378 2.880 Children surviving 2.378 0.119 506 601 1.112 0.050 2.140 2.616 Children ever born to women 40-49 5.799 0.286 98 116 1.167 0.049 5.227 6.372 Knowing any contraceptive method 0.990 0.006 302 354 1.037 0.006 0.977 1.000 Knowing any modern contraceptive method 0.990 0.006 302 354 1.037 0.006 0.977 1.000 Ever used any contraceptive method 0.578 0.031 302 354 1.091 0.054 0.516 0.640 Currently using any contraceptive method 0.271 0.030 302 354 1.166 0.110 0.211 0.330 Currently using a modern method 0.215 0.027 302 354 1.157 0.127 0.160 0.270 Currently using pill 0.077 0.017 302 354 1.092 0.219 0.043 0.110 Currently using IUD 0.007 0.005 302 354 1.018 0.717 0.000 0.016 Currently using condom 0.035 0.010 302 354 0.940 0.284 0.015 0.055 Currently using injectables 0.042 0.011 302 354 0.917 0.254 0.020 0.063 Currently using periodic abstinence 0.046 0.014 302 354 1.135 0.299 0.018 0.073 Currently using withdrawal 0.010 0.006 302 354 1.008 0.570 0.000 0.022 Obtained method from public sector source 0.352 0.035 82 99 0.651 0.098 0.283 0.421 Want no more children 0.467 0.033 302 354 1.131 0.070 0.401 0.532 Want to delay birth at least 2 years 0.303 0.025 302 354 0.946 0.083 0.253 0.353 Ideal number of children 3.969 0.071 500 593 1.108 0.018 3.827 4.111 Mothers received tetanus injection for last birth 0.783 0.035 228 266 1.272 0.045 0.713 0.853 Mothers received medical care at delivery 0.465 0.037 316 362 1.129 0.080 0.391 0.540 Child had diarrhoea in the last 2 weeks 0.157 0.026 294 337 1.125 0.167 0.105 0.210 Treated with ORS packets 0.326 0.061 47 53 0.760 0.189 0.203 0.449 Consulted medical personnel 0.170 0.091 47 53 1.501 0.532 0.000 0.351 Child having health card, seen 0.848 0.046 65 77 1.029 0.054 0.756 0.940 Child received BCG vaccination 0.888 0.040 65 77 1.024 0.045 0.807 0.968 Child received DPT vaccination (3 doses) 0.770 0.054 65 77 1.027 0.071 0.661 0.878 Child received polio vaccination (3 doses) 0.731 0.049 65 77 0.875 0.067 0.633 0.829 Child received measles vaccination 0.791 0.060 65 77 1.184 0.076 0.671 0.912 Child fully immunised 0.656 0.067 65 77 1.121 0.103 0.521 0.790 Height-for-age (-2 SD) 0.274 0.026 300 333 0.964 0.097 0.221 0.327 Weight-for-height (-2 SD) 0.062 0.012 300 333 0.883 0.196 0.038 0.086 Weight-for-age (-2 SD) 0.173 0.026 300 333 1.115 0.150 0.121 0.225 Has heard of HIV/AIDS 0.991 0.006 506 601 1.330 0.006 0.980 1.000 Knows condoms reduce HIV/AIDS 0.781 0.020 506 601 1.071 0.025 0.742 0.821 Knows limiting partners reduce HIV/AIDS 0.926 0.011 506 601 0.962 0.012 0.904 0.949 Total fertility rate (last 3 years) 4.250 0.359 na 1700 1.306 0.084 3.533 4.968 Neonatal mortality (last 10 years) 41.509 7.989 646 744 0.886 0.192 25.532 57.486 Post-neonatal mortality (last 10 years) 22.472 5.844 646 744 0.963 0.260 10.784 34.159 Infant mortality (last 10 years) 63.980 10.390 646 744 0.985 0.162 43.201 84.759 Child mortality (last 10 years) 32.894 8.153 651 751 1.029 0.248 16.588 49.201 Under-five mortality (last 10 years) 94.770 12.973 651 751 1.085 0.137 68.824 120.717 HIV prevalence 0.044 0.009 448 535 0.886 0.196 0.027 0.061 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.379 0.021 453 539 0.919 0.055 0.337 0.421 No education 0.079 0.012 453 539 0.984 0.158 0.054 0.104 With secondary education or higher 0.748 0.028 453 539 1.358 0.037 0.692 0.803 Never married (in union) 0.375 0.017 453 539 0.755 0.046 0.341 0.410 Currently married (in union) 0.568 0.021 453 539 0.884 0.036 0.527 0.609 Had first sex before age 18 0.258 0.031 362 428 1.336 0.119 0.196 0.319 Knowing any contraceptive method 0.998 0.002 262 306 0.692 0.002 0.995 1.000 Knowing any modern contraceptive method 0.998 0.002 262 306 0.692 0.002 0.995 1.000 Want no more children 0.426 0.033 262 306 1.069 0.077 0.361 0.492 Want to delay birth at least 2 years 0.298 0.032 262 306 1.136 0.108 0.234 0.362 Ideal number of children 4.327 0.134 446 530 1.290 0.031 4.059 4.596 Has heard of HIV/AIDS 0.993 0.003 406 484 0.726 0.003 0.986 0.999 Knows condoms reduce HIV/AIDS 0.919 0.015 406 484 1.125 0.017 0.888 0.949 Knows limiting partners reduce HIV/AIDS 0.957 0.007 406 484 0.741 0.008 0.943 0.972 HIV prevalence (15-49) 0.029 0.010 313 437 1.021 0.331 0.010 0.049 HIV prevalence (15-59) 0.031 0.010 342 476 1.030 0.314 0.011 0.050 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 275 Table B.10 Sampling errors for Ashanti sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.584 0.033 927 1142 2.065 0.057 0.517 0.651 No education 0.168 0.018 927 1142 1.479 0.108 0.131 0.204 With secondary education or higher 0.642 0.025 927 1142 1.577 0.039 0.593 0.692 Never married (in union) 0.326 0.019 927 1142 1.250 0.059 0.287 0.364 Currently married (in union) 0.563 0.020 927 1142 1.216 0.035 0.523 0.603 Had first sex before age 18 0.455 0.025 729 887 1.335 0.054 0.405 0.504 Currently pregnant 0.076 0.009 927 1142 1.008 0.116 0.058 0.093 Children ever born 2.523 0.093 927 1142 1.065 0.037 2.337 2.708 Children surviving 2.231 0.086 927 1142 1.116 0.038 2.059 2.402 Children ever born to women 40-49 5.685 0.178 171 206 0.925 0.031 5.329 6.041 Knowing any contraceptive method 0.990 0.005 539 643 1.197 0.005 0.979 1.000 Knowing any modern contraceptive method 0.988 0.005 539 643 1.168 0.005 0.978 0.999 Ever used any contraceptive method 0.626 0.032 539 643 1.523 0.051 0.562 0.689 Currently using any contraceptive method 0.297 0.025 539 643 1.282 0.085 0.247 0.348 Currently using a modern method 0.210 0.023 539 643 1.316 0.110 0.163 0.256 Currently using pill 0.087 0.016 539 643 1.303 0.182 0.056 0.119 Currently using IUD 0.016 0.005 539 643 1.015 0.347 0.005 0.026 Currently using condom 0.028 0.009 539 643 1.227 0.313 0.010 0.045 Currently using injectables 0.028 0.007 539 643 0.939 0.238 0.015 0.041 Currently using periodic abstinence 0.080 0.016 539 643 1.386 0.203 0.047 0.112 Currently using withdrawal 0.004 0.003 539 643 1.079 0.740 0.000 0.010 Obtained method from public sector source 0.359 0.053 142 182 1.304 0.147 0.254 0.465 Want no more children 0.371 0.022 539 643 1.036 0.058 0.328 0.414 Want to delay birth at least 2 years 0.357 0.020 539 643 0.973 0.056 0.317 0.397 Ideal number of children 4.510 0.076 918 1131 1.306 0.017 4.357 4.662 Mothers received tetanus injection for last birth 0.878 0.018 423 507 1.113 0.021 0.842 0.914 Mothers received medical care at delivery 0.599 0.027 578 685 1.085 0.045 0.546 0.653 Child had diarrhoea in the last 2 weeks 0.143 0.017 529 622 0.998 0.119 0.109 0.177 Treated with ORS packets 0.413 0.060 78 89 0.931 0.145 0.293 0.532 Consulted medical personnel 0.267 0.070 78 89 1.185 0.262 0.127 0.408 Child having health card, seen 0.765 0.040 110 123 0.947 0.053 0.684 0.846 Child received BCG vaccination 0.928 0.028 110 123 1.082 0.030 0.872 0.984 Child received DPT vaccination (3 doses) 0.824 0.038 110 123 0.990 0.046 0.748 0.900 Child received polio vaccination (3 doses) 0.797 0.041 110 123 1.012 0.051 0.715 0.878 Child received measles vaccination 0.822 0.046 110 123 1.205 0.056 0.729 0.914 Child fully immunised 0.716 0.045 110 123 0.999 0.063 0.625 0.807 Height-for-age (-2 SD) 0.291 0.022 531 613 0.973 0.074 0.248 0.335 Weight-for-height (-2 SD) 0.067 0.011 531 613 0.957 0.158 0.046 0.089 Weight-for-age (-2 SD) 0.208 0.021 531 613 1.046 0.100 0.167 0.250 Has heard of HIV/AIDS 0.997 0.002 927 1142 1.142 0.002 0.993 1.000 Knows condoms reduce HIV/AIDS 0.764 0.017 927 1142 1.230 0.022 0.729 0.798 Knows limiting partners reduce HIV/AIDS 0.928 0.013 927 1142 1.473 0.014 0.903 0.953 Total fertility rate (last 3 years) 4.109 0.322 na 3187 1.415 0.078 3.464 4.754 Neonatal mortality (last 10 years) 57.385 7.447 1141 1361 0.951 0.130 42.492 72.279 Post-neonatal mortality (last 10 years) 22.144 4.978 1143 1364 1.143 0.225 12.188 32.099 Infant mortality (last 10 years) 79.529 8.310 1143 1364 0.945 0.104 62.908 96.149 Child mortality (last 10 years) 40.158 5.987 1148 1369 0.965 0.149 28.183 52.133 Under-five mortality (last 10 years) 116.493 10.652 1150 1372 1.005 0.091 95.190 137.796 HIV prevalence 0.030 0.005 882 1023 0.911 0.176 0.019 0.040 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.555 0.026 785 956 1.463 0.047 0.503 0.607 No education 0.094 0.014 785 956 1.312 0.145 0.067 0.122 With secondary education or higher 0.786 0.019 785 956 1.310 0.024 0.747 0.824 Never married (in union) 0.391 0.024 785 956 1.370 0.061 0.343 0.439 Currently married (in union) 0.523 0.023 785 956 1.287 0.044 0.477 0.569 Had first sex before age 18 0.200 0.020 603 729 1.209 0.099 0.160 0.239 Knowing any contraceptive method 1.000 0.000 419 500 na 0.000 1.000 1.000 Knowing any modern contraceptive method 1.000 0.000 419 500 na 0.000 1.000 1.000 Want no more children 0.323 0.023 419 500 1.024 0.072 0.276 0.370 Want to delay birth at least 2 years 0.388 0.024 419 500 0.988 0.061 0.341 0.435 Ideal number of children 4.582 0.102 777 947 1.229 0.022 4.377 4.787 Has heard of HIV/AIDS 1.000 0.000 703 858 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.814 0.018 703 858 1.195 0.022 0.779 0.849 Knows limiting partners reduce HIV/AIDS 0.918 0.013 703 858 1.251 0.014 0.892 0.944 HIV prevalence (15-49) 0.013 0.004 624 762 0.877 0.304 0.005 0.021 HIV prevalence (15-59) 0.014 0.004 701 855 0.923 0.290 0.006 0.023 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 276 | Appendix B Table B.11 Sampling errors for Brong Ahafo sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.424 0.029 638 569 1.473 0.068 0.366 0.482 No education 0.274 0.030 638 569 1.694 0.109 0.214 0.334 With secondary education or higher 0.497 0.039 638 569 1.992 0.079 0.418 0.576 Never married (in union) 0.231 0.026 638 569 1.536 0.111 0.180 0.283 Currently married (in union) 0.701 0.023 638 569 1.275 0.033 0.654 0.747 Had first sex before age 18 0.482 0.029 510 456 1.320 0.061 0.424 0.541 Currently pregnant 0.070 0.011 638 569 1.133 0.164 0.047 0.093 Children ever born 2.556 0.138 638 569 1.374 0.054 2.280 2.833 Children surviving 2.305 0.126 638 569 1.393 0.055 2.054 2.556 Children ever born to women 40-49 5.587 0.239 121 107 1.114 0.043 5.110 6.064 Knowing any contraceptive method 0.972 0.008 449 398 0.993 0.008 0.956 0.987 Knowing any modern contraceptive method 0.970 0.007 449 398 0.834 0.007 0.956 0.983 Ever used any contraceptive method 0.640 0.036 449 398 1.604 0.057 0.567 0.713 Currently using any contraceptive method 0.330 0.027 449 398 1.225 0.083 0.275 0.384 Currently using a modern method 0.248 0.020 449 398 0.979 0.081 0.208 0.288 Currently using pill 0.100 0.017 449 398 1.191 0.169 0.067 0.134 Currently using IUD 0.018 0.007 449 398 1.132 0.400 0.004 0.032 Currently using condom 0.030 0.011 449 398 1.364 0.369 0.008 0.051 Currently using injectables 0.077 0.015 449 398 1.173 0.191 0.048 0.107 Currently using periodic abstinence 0.072 0.012 449 398 0.980 0.166 0.048 0.096 Currently using withdrawal 0.009 0.003 449 398 0.632 0.322 0.003 0.014 Obtained method from public sector source 0.451 0.064 127 114 1.442 0.142 0.323 0.578 Want no more children 0.335 0.025 449 398 1.098 0.073 0.286 0.384 Want to delay birth at least 2 years 0.401 0.025 449 398 1.092 0.063 0.350 0.451 Ideal number of children 4.396 0.114 637 568 1.607 0.026 4.167 4.624 Mothers received tetanus injection for last birth 0.902 0.019 337 297 1.176 0.021 0.863 0.940 Mothers received medical care at delivery 0.584 0.034 459 401 1.279 0.058 0.516 0.651 Child had diarrhoea in the last 2 weeks 0.139 0.025 424 366 1.472 0.181 0.089 0.190 Treated with ORS packets 0.435 0.071 58 51 1.071 0.164 0.292 0.578 Consulted medical personnel 0.261 0.090 58 51 1.537 0.345 0.081 0.441 Child having health card, seen 0.875 0.034 86 75 0.895 0.039 0.806 0.943 Child received BCG vaccination 0.911 0.042 86 75 1.265 0.046 0.827 0.995 Child received DPT vaccination (3 doses) 0.853 0.040 86 75 0.993 0.047 0.773 0.933 Child received polio vaccination (3 doses) 0.834 0.044 86 75 1.051 0.053 0.745 0.923 Child received measles vaccination 0.871 0.034 86 75 0.886 0.039 0.802 0.939 Child fully immunised 0.790 0.046 86 75 0.996 0.058 0.698 0.881 Height-for-age (-2 SD) 0.294 0.025 412 356 1.079 0.085 0.244 0.344 Weight-for-height (-2 SD) 0.057 0.014 412 356 1.175 0.247 0.029 0.086 Weight-for-age (-2 SD) 0.204 0.023 412 356 1.105 0.112 0.159 0.250 Has heard of HIV/AIDS 0.995 0.002 638 569 0.646 0.002 0.992 0.999 Knows condoms reduce HIV/AIDS 0.754 0.020 638 569 1.164 0.026 0.714 0.794 Knows limiting partners reduce HIV/AIDS 0.870 0.016 638 569 1.217 0.019 0.838 0.902 Total fertility rate (last 3 years) 4.826 0.298 na 1575 1.071 0.062 4.230 5.421 Neonatal mortality (last 10 years) 35.771 11.022 844 723 1.522 0.308 13.727 57.814 Post-neonatal mortality (last 10 years) 22.086 5.642 845 724 0.982 0.255 10.802 33.371 Infant mortality (last 10 years) 57.857 11.182 845 724 1.267 0.193 35.493 80.221 Child mortality (last 10 years) 34.844 6.079 847 725 0.933 0.174 22.686 47.002 Under-five mortality (last 10 years) 90.685 11.208 848 726 1.048 0.124 68.269 113.101 HIV prevalence 0.038 0.005 603 512 0.703 0.144 0.027 0.049 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.386 0.022 593 528 1.121 0.058 0.341 0.431 No education 0.142 0.019 593 528 1.336 0.135 0.103 0.180 With secondary education or higher 0.684 0.031 593 528 1.628 0.045 0.622 0.746 Never married (in union) 0.426 0.018 593 528 0.881 0.042 0.390 0.462 Currently married (in union) 0.513 0.020 593 528 0.994 0.040 0.472 0.554 Had first sex before age 18 0.168 0.018 438 385 1.009 0.107 0.132 0.205 Knowing any contraceptive method 0.995 0.003 310 271 0.896 0.003 0.988 1.000 Knowing any modern contraceptive method 0.995 0.003 310 271 0.896 0.003 0.988 1.000 Want no more children 0.373 0.034 310 271 1.249 0.092 0.305 0.442 Want to delay birth at least 2 years 0.414 0.029 310 271 1.042 0.071 0.356 0.472 Ideal number of children 4.454 0.118 591 526 1.345 0.026 4.219 4.690 Has heard of HIV/AIDS 1.000 0.000 543 483 na 0.000 1.000 1.000 Knows condoms reduce HIV/AIDS 0.892 0.013 543 483 0.978 0.015 0.866 0.918 Knows limiting partners reduce HIV/AIDS 0.952 0.013 543 483 1.457 0.014 0.925 0.979 HIV prevalence (15-49) 0.013 0.006 478 440 1.048 0.411 0.002 0.025 HIV prevalence (15-59) 0.017 0.006 514 474 0.980 0.330 0.006 0.028 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 277 Table B.12 Sampling errors for Northern sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.255 0.020 610 499 1.150 0.080 0.215 0.296 No education 0.788 0.016 610 499 0.988 0.021 0.755 0.820 With secondary education or higher 0.127 0.014 610 499 1.005 0.107 0.100 0.154 Never married (in union) 0.119 0.015 610 499 1.134 0.125 0.089 0.149 Currently married (in union) 0.864 0.015 610 499 1.046 0.017 0.835 0.893 Had first sex before age 18 0.483 0.028 517 423 1.279 0.058 0.427 0.539 Currently pregnant 0.130 0.011 610 499 0.833 0.087 0.107 0.153 Children ever born 3.260 0.103 610 499 0.946 0.031 3.054 3.465 Children surviving 2.673 0.074 610 499 0.847 0.028 2.525 2.821 Children ever born to women 40-49 6.693 0.297 92 71 1.158 0.044 6.100 7.287 Knowing any contraceptive method 0.927 0.012 527 431 1.067 0.013 0.903 0.952 Knowing any modern contraceptive method 0.912 0.015 527 431 1.184 0.016 0.883 0.942 Ever used any contraceptive method 0.256 0.029 527 431 1.507 0.112 0.199 0.313 Currently using any contraceptive method 0.121 0.014 527 431 1.018 0.119 0.092 0.150 Currently using a modern method 0.077 0.011 527 431 0.929 0.140 0.056 0.099 Currently using pill 0.026 0.005 527 431 0.690 0.183 0.017 0.036 Currently using IUD 0.004 0.003 527 431 1.097 0.716 0.000 0.011 Currently using condom 0.008 0.006 527 431 1.424 0.680 0.000 0.020 Currently using injectables 0.025 0.008 527 431 1.213 0.331 0.008 0.041 Currently using periodic abstinence 0.011 0.006 527 431 1.336 0.554 0.000 0.023 Currently using withdrawal 0.003 0.003 527 431 1.145 0.963 0.000 0.008 Obtained method from public sector source 0.559 0.107 39 35 1.322 0.191 0.346 0.772 Want no more children 0.151 0.013 527 431 0.850 0.088 0.125 0.178 Want to delay birth at least 2 years 0.567 0.023 527 431 1.050 0.040 0.522 0.613 Ideal number of children 6.866 0.213 567 461 1.619 0.031 6.440 7.292 Mothers received tetanus injection for last birth 0.720 0.034 429 346 1.556 0.047 0.652 0.788 Mothers received medical care at delivery 0.183 0.027 623 500 1.532 0.145 0.130 0.237 Child had diarrhoea in the last 2 weeks 0.153 0.021 569 457 1.280 0.134 0.112 0.194 Treated with ORS packets 0.324 0.034 95 70 0.668 0.106 0.255 0.392 Consulted medical personnel 0.290 0.064 95 70 1.237 0.221 0.162 0.419 Child having health card, seen 0.809 0.029 113 92 0.791 0.036 0.750 0.868 Child received BCG vaccination 0.841 0.034 113 92 0.930 0.040 0.774 0.908 Child received DPT vaccination (3 doses) 0.622 0.039 113 92 0.853 0.063 0.543 0.700 Child received polio vaccination (3 doses) 0.625 0.036 113 92 0.772 0.057 0.553 0.696 Child received measles vaccination 0.760 0.046 113 92 1.147 0.061 0.667 0.853 Child fully immunised 0.480 0.044 113 92 0.931 0.092 0.391 0.568 Height-for-age (-2 SD) 0.488 0.027 527 415 1.108 0.055 0.435 0.542 Weight-for-height (-2 SD) 0.066 0.012 527 415 0.999 0.177 0.042 0.089 Weight-for-age (-2 SD) 0.355 0.027 527 415 1.159 0.076 0.301 0.409 Has heard of HIV/AIDS 0.877 0.014 610 499 1.082 0.016 0.848 0.905 Knows condoms reduce HIV/AIDS 0.464 0.039 610 499 1.941 0.085 0.385 0.542 Knows limiting partners reduce HIV/AIDS 0.580 0.031 610 499 1.547 0.053 0.518 0.642 Total fertility rate (last 3 years) 6.970 0.383 na 1434 1.170 0.055 6.203 7.736 Neonatal mortality (last 10 years) 37.745 6.111 1194 958 0.968 0.162 25.523 49.967 Post-neonatal mortality (last 10 years) 31.752 5.390 1196 960 1.014 0.170 20.972 42.533 Infant mortality (last 10 years) 69.498 7.700 1196 960 0.964 0.111 54.098 84.897 Child mortality (last 10 years) 90.456 15.697 1215 974 1.317 0.174 59.062 121.849 Under-five mortality (last 10 years) 153.667 15.553 1217 976 1.112 0.101 122.561 184.772 HIV prevalence 0.009 0.004 546 449 0.886 0.391 0.002 0.017 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.280 0.022 638 527 1.221 0.078 0.236 0.323 No education 0.595 0.024 638 527 1.244 0.041 0.546 0.643 With secondary education or higher 0.249 0.024 638 527 1.373 0.094 0.202 0.296 Never married (in union) 0.334 0.019 638 527 1.013 0.057 0.296 0.372 Currently married (in union) 0.622 0.016 638 527 0.841 0.026 0.590 0.654 Had first sex before age 18 0.210 0.023 511 426 1.286 0.111 0.163 0.256 Knowing any contraceptive method 0.985 0.007 396 328 1.119 0.007 0.971 0.999 Knowing any modern contraceptive method 0.985 0.007 396 328 1.119 0.007 0.971 0.999 Want no more children 0.083 0.010 396 328 0.745 0.125 0.062 0.104 Want to delay birth at least 2 years 0.602 0.025 396 328 1.000 0.041 0.553 0.651 Ideal number of children 8.184 0.287 586 486 1.110 0.035 7.610 8.758 Has heard of HIV/AIDS 0.963 0.011 587 489 1.477 0.012 0.940 0.986 Knows condoms reduce HIV/AIDS 0.609 0.029 587 489 1.414 0.047 0.552 0.666 Knows limiting partners reduce HIV/AIDS 0.726 0.030 587 489 1.616 0.041 0.666 0.785 HIV prevalence (15-49) 0.010 0.006 522 435 1.470 0.651 0.000 0.022 HIV prevalence (15-59) 0.009 0.006 571 470 1.474 0.649 0.000 0.021 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 278 | Appendix B Table B.13 Sampling errors for Upper East sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.218 0.050 395 310 2.415 0.230 0.118 0.319 No education 0.724 0.056 395 310 2.469 0.077 0.613 0.835 With secondary education or higher 0.158 0.043 395 310 2.331 0.271 0.072 0.244 Never married (in union) 0.192 0.028 395 310 1.426 0.148 0.135 0.248 Currently married (in union) 0.763 0.033 395 310 1.564 0.044 0.696 0.830 Had first sex before age 18 0.556 0.038 320 248 1.356 0.068 0.480 0.631 Currently pregnant 0.079 0.013 395 310 0.952 0.164 0.053 0.105 Children ever born 2.877 0.146 395 310 1.154 0.051 2.586 3.169 Children surviving 2.609 0.132 395 310 1.175 0.051 2.345 2.873 Children ever born to women 40-49 5.743 0.243 88 69 1.226 0.042 5.257 6.228 Knowing any contraceptive method 0.972 0.011 302 236 1.105 0.011 0.951 0.993 Knowing any modern contraceptive method 0.972 0.011 302 236 1.105 0.011 0.951 0.993 Ever used any contraceptive method 0.257 0.033 302 236 1.312 0.129 0.191 0.323 Currently using any contraceptive method 0.119 0.038 302 236 2.013 0.316 0.044 0.194 Currently using a modern method 0.097 0.031 302 236 1.803 0.318 0.035 0.158 Currently using pill 0.020 0.010 302 236 1.299 0.527 0.000 0.041 Currently using IUD 0.004 0.004 302 236 1.024 0.965 0.000 0.011 Currently using condom 0.009 0.007 302 236 1.249 0.768 0.000 0.022 Currently using injectables 0.064 0.023 302 236 1.612 0.354 0.019 0.110 Currently using periodic abstinence 0.022 0.009 302 236 1.025 0.392 0.005 0.040 Currently using withdrawal 0.000 0.000 302 236 na na 0.000 0.000 Obtained method from public sector source 0.694 0.087 31 25 1.037 0.126 0.520 0.869 Want no more children 0.219 0.025 302 236 1.061 0.116 0.168 0.269 Want to delay birth at least 2 years 0.482 0.019 302 236 0.658 0.039 0.444 0.519 Ideal number of children 5.781 0.170 377 291 1.330 0.029 5.442 6.121 Mothers received tetanus injection for last birth 0.798 0.039 224 166 1.428 0.049 0.719 0.877 Mothers received medical care at delivery 0.278 0.042 291 215 1.379 0.153 0.193 0.363 Child had diarrhoea in the last 2 weeks 0.208 0.028 279 206 1.046 0.137 0.151 0.265 Treated with ORS packets 0.584 0.066 60 43 0.886 0.113 0.452 0.715 Consulted medical personnel 0.430 0.093 60 43 1.311 0.216 0.244 0.617 Child having health card, seen 0.879 0.046 52 39 0.998 0.053 0.786 0.971 Child received BCG vaccination 0.978 0.017 52 39 0.786 0.017 0.944 1.000 Child received DPT vaccination (3 doses) 0.778 0.053 52 39 0.908 0.069 0.672 0.885 Child received polio vaccination (3 doses) 0.841 0.066 52 39 1.264 0.078 0.710 0.972 Child received measles vaccination 0.912 0.046 52 39 1.139 0.050 0.821 1.000 Child fully immunised 0.770 0.056 52 39 0.942 0.073 0.658 0.883 Height-for-age (-2 SD) 0.317 0.027 221 156 0.857 0.085 0.263 0.371 Weight-for-height (-2 SD) 0.129 0.024 221 156 1.053 0.187 0.081 0.177 Weight-for-age (-2 SD) 0.324 0.031 221 156 0.976 0.095 0.263 0.386 Has heard of HIV/AIDS 0.978 0.005 395 310 0.690 0.005 0.967 0.988 Knows condoms reduce HIV/AIDS 0.804 0.041 395 310 2.058 0.051 0.722 0.887 Knows limiting partners reduce HIV/AIDS 0.897 0.041 395 310 2.671 0.045 0.816 0.979 Total fertility rate (last 3 years) 4.747 0.387 na 863 1.197 0.082 3.972 5.521 Neonatal mortality (last 10 years) 21.753 7.095 576 434 1.164 0.326 7.562 35.944 Post-neonatal mortality (last 10 years) 10.774 5.262 578 435 0.907 0.488 0.250 21.298 Infant mortality (last 10 years) 32.527 8.951 578 435 1.066 0.275 14.625 50.428 Child mortality (last 10 years) 47.806 12.147 578 435 1.061 0.254 23.511 72.101 Under-five mortality (last 10 years) 78.777 16.728 580 436 1.254 0.212 45.320 112.234 HIV prevalence 0.008 0.006 365 277 1.158 0.656 0.000 0.020 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.223 0.084 395 317 3.991 0.375 0.056 0.391 No education 0.489 0.056 395 317 2.227 0.115 0.377 0.601 With secondary education or higher 0.267 0.065 395 317 2.916 0.244 0.137 0.397 Never married (in union) 0.427 0.024 395 317 0.959 0.056 0.379 0.475 Currently married (in union) 0.541 0.025 395 317 0.993 0.046 0.491 0.591 Had first sex before age 18 0.240 0.045 298 238 1.808 0.187 0.150 0.329 Knowing any contraceptive method 0.995 0.004 220 171 0.766 0.004 0.988 1.000 Knowing any modern contraceptive method 0.995 0.004 220 171 0.766 0.004 0.988 1.000 Want no more children 0.152 0.030 220 171 1.215 0.194 0.093 0.211 Want to delay birth at least 2 years 0.547 0.039 220 171 1.174 0.072 0.468 0.626 Ideal number of children 7.015 0.349 367 297 1.268 0.050 6.318 7.712 Has heard of HIV/AIDS 0.984 0.007 351 284 1.073 0.007 0.970 0.999 Knows condoms reduce HIV/AIDS 0.851 0.023 351 284 1.206 0.027 0.805 0.897 Knows limiting partners reduce HIV/AIDS 0.837 0.045 351 284 2.290 0.054 0.747 0.927 HIV prevalence (15-49) 0.022 0.012 303 259 1.386 0.533 0.000 0.045 HIV prevalence (15-59) 0.020 0.010 340 285 1.379 0.526 0.000 0.041 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 279 Table B.14 Sampling errors for Upper West sample, Ghana 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Standard —————————— Design Relative Confidence limits Value error Unweighted Weighted effect error –––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.238 0.055 462 153 2.748 0.229 0.129 0.347 No education 0.633 0.038 462 153 1.687 0.060 0.557 0.708 With secondary education or higher 0.215 0.027 462 153 1.391 0.124 0.162 0.268 Never married (in union) 0.205 0.025 462 153 1.304 0.120 0.156 0.254 Currently married (in union) 0.743 0.030 462 153 1.476 0.040 0.683 0.803 Had first sex before age 18 0.369 0.036 380 124 1.462 0.098 0.296 0.441 Currently pregnant 0.087 0.014 462 153 1.044 0.157 0.060 0.114 Children ever born 3.268 0.201 462 153 1.482 0.062 2.866 3.670 Children surviving 2.564 0.137 462 153 1.303 0.054 2.289 2.838 Children ever born to women 40-49 6.381 0.410 90 30 1.447 0.064 5.562 7.200 Knowing any contraceptive method 0.972 0.014 354 113 1.540 0.014 0.944 0.999 Knowing any modern contraceptive method 0.970 0.012 354 113 1.334 0.013 0.946 0.994 Ever used any contraceptive method 0.662 0.027 354 113 1.078 0.041 0.608 0.716 Currently using any contraceptive method 0.263 0.022 354 113 0.922 0.082 0.220 0.307 Currently using a modern method 0.195 0.020 354 113 0.937 0.101 0.155 0.234 Currently using pill 0.016 0.005 354 113 0.741 0.306 0.006 0.026 Currently using IUD 0.000 0.000 354 113 na na 0.000 0.000 Currently using condom 0.022 0.008 354 113 0.976 0.348 0.007 0.037 Currently using injectables 0.111 0.019 354 113 1.117 0.168 0.074 0.149 Currently using periodic abstinence 0.062 0.015 354 113 1.161 0.240 0.032 0.092 Currently using withdrawal 0.004 0.003 354 113 0.893 0.754 0.000 0.010 Obtained method from public sector source 0.783 0.042 71 23 0.858 0.054 0.699 0.868 Want no more children 0.232 0.023 354 113 1.013 0.098 0.186 0.277 Want to delay birth at least 2 years 0.507 0.033 354 113 1.259 0.066 0.440 0.574 Ideal number of children 5.552 0.171 452 149 1.311 0.031 5.210 5.893 Mothers received tetanus injection for last birth 0.776 0.027 265 83 1.031 0.035 0.722 0.830 Mothers received medical care at delivery 0.333 0.051 371 118 1.762 0.152 0.232 0.435 Child had diarrhoea in the last 2 weeks 0.269 0.033 330 104 1.283 0.125 0.202 0.335 Treated with ORS packets 0.297 0.076 86 28 1.368 0.256 0.145 0.449 Consulted medical personnel 0.328 0.079 86 28 1.434 0.242 0.169 0.487 Child having health card, seen 0.756 0.072 66 21 1.337 0.095 0.613 0.900 Child received BCG vaccination 0.914 0.036 66 21 1.024 0.039 0.842 0.986 Child received DPT vaccination (3 doses) 0.755 0.073 66 21 1.360 0.097 0.609 0.901 Child received polio vaccination (3 doses) 0.741 0.066 66 21 1.209 0.089 0.609 0.873 Child received measles vaccination 0.795 0.069 66 21 1.358 0.086 0.657 0.932 Child fully immunised 0.603 0.079 66 21 1.289 0.131 0.445 0.760 Height-for-age (-2 SD) 0.341 0.037 307 95 1.235 0.109 0.266 0.415 Weight-for-height (-2 SD) 0.110 0.015 307 95 0.834 0.137 0.080 0.140 Weight-for-age (-2 SD) 0.259 0.031 307 95 1.188 0.118 0.198 0.320 Has heard of HIV/AIDS 0.960 0.012 462 153 1.353 0.013 0.935 0.984 Knows condoms reduce HIV/AIDS 0.606 0.021 462 153 0.920 0.035 0.564 0.647 Knows limiting partners reduce HIV/AIDS 0.853 0.019 462 153 1.136 0.022 0.816 0.891 Total fertility rate (last 3 years) 5.462 0.376 na 433 1.349 0.069 4.711 6.213 Neonatal mortality (last 10 years) 61.672 11.218 756 245 1.019 0.182 39.236 84.108 Post-neonatal mortality (last 10 years) 43.408 8.535 759 246 1.234 0.197 26.338 60.479 Infant mortality (last 10 years) 105.080 10.568 759 246 0.826 0.101 83.945 126.215 Child mortality (last 10 years) 114.903 12.051 778 252 1.028 0.105 90.801 139.005 Under-five mortality (last 10 years) 207.909 14.089 781 253 0.854 0.068 179.731 236.087 HIV prevalence 0.020 0.009 411 136 1.250 0.432 0.003 0.037 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.216 0.066 387 130 3.141 0.304 0.085 0.348 No education 0.449 0.058 387 130 2.275 0.128 0.334 0.564 With secondary education or higher 0.345 0.044 387 130 1.809 0.127 0.257 0.432 Never married (in union) 0.400 0.040 387 130 1.593 0.099 0.321 0.480 Currently married (in union) 0.567 0.037 387 130 1.457 0.065 0.494 0.641 Had first sex before age 18 0.167 0.017 301 101 0.812 0.105 0.132 0.202 Knowing any contraceptive method 0.991 0.006 223 74 0.981 0.006 0.978 1.000 Knowing any modern contraceptive method 0.988 0.007 223 74 0.926 0.007 0.974 1.000 Want no more children 0.156 0.019 223 74 0.770 0.120 0.119 0.194 Want to delay birth at least 2 years 0.492 0.030 223 74 0.884 0.060 0.433 0.551 Ideal number of children 6.182 0.415 373 126 1.654 0.067 5.352 7.012 Has heard of HIV/AIDS 0.978 0.010 346 116 1.274 0.010 0.958 0.998 Knows condoms reduce HIV/AIDS 0.652 0.031 346 116 1.190 0.047 0.591 0.713 Knows limiting partners reduce HIV/AIDS 0.824 0.014 346 116 0.692 0.017 0.795 0.852 HIV prevalence (15-49) 0.016 0.007 286 108 0.948 0.442 0.002 0.030 HIV prevalence (15-59) 0.017 0.007 312 119 0.913 0.395 0.004 0.030 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix C | 281 DATA QUALITY TABLES APPENDIX C Table C.1 Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Ghana 2003 Male Female Male Female Age Number Percent- age Number Percent- age Age Number Percent- age Number Percent- age 0 346 3.0 388 3.0 33 117 1.0 135 1.1 1 373 3.2 316 2.5 34 100 0.9 136 1.1 2 351 3.0 353 2.7 35 132 1.2 211 1.6 3 412 3.6 366 2.8 36 98 0.8 163 1.3 4 337 2.9 360 2.8 37 91 0.8 130 1.0 5 305 2.7 297 2.3 38 115 1.0 149 1.2 6 391 3.4 402 3.1 39 86 0.8 102 0.8 7 399 3.5 358 2.8 40 111 1.0 187 1.5 8 377 3.3 376 2.9 41 70 0.6 90 0.7 9 377 3.3 321 2.5 42 109 0.9 124 1.0 10 400 3.5 326 2.5 43 80 0.7 102 0.8 11 340 3.0 296 2.3 44 51 0.4 74 0.6 12 379 3.3 360 2.8 45 134 1.2 151 1.2 13 457 4.0 394 3.1 46 87 0.8 90 0.7 14 331 2.9 310 2.4 47 69 0.6 79 0.6 15 242 2.1 261 2.0 48 96 0.8 91 0.7 16 257 2.2 243 1.9 49 58 0.5 54 0.4 17 220 1.9 232 1.8 50 88 0.8 90 0.7 18 239 2.1 264 2.1 51 47 0.4 101 0.8 19 191 1.7 191 1.5 52 61 0.5 132 1.0 20 181 1.6 269 2.1 53 61 0.5 100 0.8 21 147 1.3 181 1.4 54 45 0.4 70 0.5 22 133 1.2 216 1.7 55 54 0.5 104 0.8 23 118 1.0 216 1.7 56 59 0.5 70 0.5 24 128 1.1 172 1.3 57 28 0.2 48 0.4 25 147 1.3 241 1.9 58 37 0.3 51 0.4 26 157 1.4 205 1.6 59 20 0.2 47 0.4 27 144 1.3 157 1.2 60 35 0.3 110 0.9 28 174 1.5 220 1.7 61 46 0.4 31 0.2 29 136 1.2 158 1.2 67 27 0.2 32 0.2 30 168 1.5 220 1.7 68 36 0.3 43 0.3 31 103 0.9 127 1.0 69 25 0.2 11 0.1 32 146 1.3 203 1.6 70+ 325 2.8 472 3.7 Don't know/missing 14 0.1 15 0.1 Total 11,500 100.0 12,865 100.0 282 | Appendix C Table C.2 Age distribution of eligible and interviewed women and men De facto household population of women age 10-54 and men age 10-64, interviewed women age 15-49 and men age 15-59, and percentage of eli- gible women and men who were interviewed (weighted), by five-year age groups, Ghana 2003 Interviewed women age 15-49 Age group Household population of women age 10-54 Number Percent Percentage of eligible women inter- viewed 10-14 1,685 Na na na 15-19 1,191 1,128 20.2 94.6 20-24 1,053 1,006 18.0 95.5 25-29 981 944 16.9 96.2 30-34 821 797 14.3 97.0 25-39 756 712 12.7 94.2 40-44 577 557 10.0 96.6 45-49 465 445 8.0 95.8 50-54 492 Na na na 15-49 5,845 5,588 100.0 95.6 Interviewed men age 15-59 Age group Household population of men age 10-64 Number Percent Percentage of eligible men interviewed 10-14 1,907 Na na na 15-19 1,148 1,071 22.2 93.2 20-24 707 660 13.7 93.3 25-29 758 706 14.7 93.2 30-34 634 604 12.5 95.2 25-39 522 486 10.1 93.1 40-44 420 398 8.3 94.6 45-49 445 419 8.7 94.1 50-54 301 282 5.9 93.7 55-59 197 189 3.9 95.5 60-64 253 Na na na 15-59 5,134 4,814 100.0 93.8 Note: The de facto population includes all residents and non-residents who stayed in the household the night before the interview. Weights for both household population of women and men and interviewed women and men are household weights. Age is based on the household schedule. na = Not applicable Appendix C | 283 Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Ghana 2003 Subject Reference Group Percentage with missing information Number of cases Birth date Births in the 15 years preceding the survey Month Only 2.09 10,038 Month and Year 0.19 10,038 Age at death Deceased children born in the 15 years pre- ceding the survey 0.58 1,039 Age/date at first union1 Ever-married women age 15-49 0.43 4,075 Respondent's education All women age 15-49 0.00 5,691 Diarrhoea in last 2 weeks Living children age 0-59 months 2.27 3,340 Anthropometry Height Living children age 0-59 months (from the household questionnaire) 5.22 3,597 Weight 5.04 3,597 Height or weight 5.49 3,597 Anaemia Children All de facto living children 0-59 months 8.74 3,275 Women All de facto women age 15-49 11.05 5,845 1 Both year and age missing 284 | Appendix C Table C.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living, dead, and total children (weighted), Ghana 2003 Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Calendar year Living Dead Total Living Dead Total Living Dead Total Living Dead Total 2003 499 43 541 100.0 100.0 100.0 97.8 95.5 97.6 na na na 2002 731 43 773 100.0 100.0 100.0 103.8 107.7 104.1 na na na 2001 631 46 677 100.0 100.0 100.0 95.0 111.2 96.0 87.8 78.7 87.2 2000 706 73 779 99.9 100.0 99.9 113.6 124.8 114.6 110.3 110.8 110.3 1999 649 86 736 100.0 100.0 100.0 102.5 99.7 102.2 103.7 146.3 107.4 1998 546 45 591 99.9 97.5 99.7 92.0 96.6 92.4 82.4 47.9 78.1 1997 675 101 777 99.1 92.4 98.2 102.3 137.8 106.3 115.6 152.6 119.4 1996 622 88 710 96.8 89.9 96.0 110.0 127.8 112.1 98.3 96.0 98.0 1995 591 82 673 96.8 91.6 96.2 95.7 85.3 94.3 100.2 99.0 100.0 1994 558 77 635 97.3 86.1 96.0 143.4 124.4 140.9 92.8 93.1 92.8 1999-2003 3,215 291 3,506 100.0 100.0 100.0 102.9 107.8 103.3 na na na 1994-1998 2,992 393 3,385 98.0 91.0 97.2 107.0 115.3 107.9 na na na 1989-1993 2,697 344 3,040 96.6 90.3 95.9 109.2 103.2 108.5 na na na 1984-1988 1,891 329 2,220 95.9 90.0 95.1 103.8 101.1 103.4 na na na < 1984 1,811 450 2,260 94.3 87.2 92.8 99.5 117.9 102.9 na na na All 12,606 1,806 14,412 97.3 91.2 96.6 104.8 109.6 105.4 na na na na = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x Appendix C | 285 Table C.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Ghana 2003 Number of years preceding the survey Age at death (days) 0-4 5-9 10-14 15-19 Total 0-19 <1 31 22 19 15 87 1 53 49 36 27 165 2 6 9 12 8 35 3 23 15 12 9 58 4 7 4 4 8 24 5 6 3 2 3 14 6 4 7 3 1 16 7 9 9 6 8 32 8 4 0 0 1 5 9 1 0 2 2 5 10 2 1 0 1 4 11 0 0 1 0 1 12 0 2 0 0 2 13 1 1 0 0 1 14 6 4 8 4 22 15 0 0 0 1 1 17 0 0 0 1 1 19 0 1 0 0 1 20 0 1 0 0 1 21 1 2 1 1 5 22 0 0 0 2 2 25 1 0 0 0 2 31+ 1 0 0 0 1 Total 0-30 155 130 107 92 483 Percent early neonatal1 83.1 84.6 82.7 76.7 82.2 1 (0-6 days/0-30 days) × 100 286 | Appendix C Table C.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to occur at age under one month, for five-year peri- ods of birth preceding the survey, Ghana 2003 Number of years preceding the survey Age at death (months) 0-4 5-9 10-14 15-19 Total 0-19 <1a 155 130 107 92 483 1 5 11 11 12 39 2 12 7 13 10 42 3 10 11 10 10 42 4 13 7 4 14 38 5 3 4 2 4 13 6 7 15 14 4 41 7 9 7 10 2 28 8 2 7 8 4 22 9 6 8 3 5 22 10 2 0 3 3 8 11 2 3 2 1 8 12 10 9 5 14 37 13 2 0 0 1 4 14 2 2 1 2 7 15 0 0 2 1 4 16 2 1 1 1 6 17 0 0 2 0 2 18 1 10 7 3 21 20 1 1 0 1 2 22 3 1 0 1 4 23 1 0 0 1 2 1 Year 14 34 20 23 91 Total 0-11 225 211 187 162 786 Percent neonatal1 68.8 61.5 57.0 56.5 61.5 a Includes deaths under one month reported in days 1 Under one month / under one year Appendix D | 287 PERSONS INVOLVED IN THE 2003 GHANA DEMOGRAPHIC AND HEALTH SURVEY APPENDIX D Ghana Statistical Service Project Secretariat Staff Dr. K.A.Twum-Baah, Project Director Mrs. Edith Mote, Survey Manager Mr. Baah Wadieh, Field Coordinator/ Researcher Mr. Henry Nii Odai, Field Coordinator/ Data Processing Supervisor Mr. K. B. Danso-Manu, Field Coordinator/ Researcher Mr. Opoku Manu Asare, Field Coordinator/ Researcher Mr. Stephen Amoah, Field Coordinator/ Researcher Mrs. Faustina Frempong Ainguah, Field Coordinator/ Researcher Mr. Kwaku Peprah, Field Coordinator/ Researcher Mrs. Jacqueline Anum, Data Processing Assistant Mr. Yaw Misefa, Data Processing Assistant Administrative/Logistics Support Staff Mr. William A. Addy, Project Accountant Mr. Kingsley Fobi-Boateng, Assistant Project Accountant Mr. Richard Mensah, Project Internal Auditor Mr. Emmanuel Odei, Project Storekeeper Mr. Edward Arko, Assistant Project Storekeeper Mr. D.Q. Obuobie, Project Transport Officer Ms. Hannah Konadu, Project Secretary Regional Statisticians/Coordinators George Mettle David Kombat Kofi Agyemang- Duah Martin K. Poku Mrs. Bema Wadieh M. E. Duncan Anthony Amuzu Slyvester Gyamfi Jasper Adeku Nkansah Marfo Data Entry Operators Mrs. Angela Dodoo Margaret Tandoh Aurelia Hotor Mary Colley Berty Laryea Patience Odai Christina Wiredu Sophia Nyan Emelia Acquaye Mrs. Victoria Quartey Lucy Mills Mrs. Victoria Sotie 288 | Appendix D Office Editors N.B.Mensah Rebecca Quainoo Eric Nii Amoo Shirley Nartey Dorothy Blankson Kate Bruce Abdul Owusu Ofori Field Supervisors James Asamoah Kwame Djangbah Abeka Ansah Alhaji Enum Charles Klutse Bismark Owusu Adjei Paul Addo Ben Opoku Acheampong W.A. Tarezina Marian Dodoo S.K.Teye Narh Omar Seidu Beatrice Saforo Isaac Addae Adamu Mukaila Field Editors Richard Nguah Augusta Okantey Yaw Adu Twum S.S. Adusu Judith Atipoe E.B. Asare Eric Antwi Chris Parbi Pakindam Kombat Emmanuel Essiaw George Helegbe Samuel Brefo Darwkwah A.O. Nortey Opoku Addo Nyarko Larbi Nurses Diana Tetteh Millicent Adams Matha V.N. Adjovu Hannah Amponsah Audrey Twumasi Ankrah Comfort Kotey Annie Bondzie-Simpson Justina Yeboah Bernice Ossei Hayford Laryea Latifatu Akunnor Matilda Quist Victoria Afutu Rosina Komla Salamatu Ibrahim Naamaawu Alhassan Lucy Bonuedie Eva Aryee Interviewers Irene Kukubor Emmanuel Djan Emmanuel Nana Poku Gloria Akoto-Bamfo Samuel Kobina Fred Takyi Ohene Darkwa Charity Ameyaw Francisca Thompson Rosemond Akrofi Barbara Mallet Priscilla Opoku Doris Bondzie Quaye Festus Manu Godwin Woanya Alice Animdife Louis Okine Joseph Asiedu Tenkorang Peace Sam Henry Doe Silas Okpoti Angela Otchi Stephen Gbesemetey Paschalina Ampofo John Agyaho Delali Schwinneiger Comfort Ashitey Moses Ansah Francisca Drai Stella Adjei Evelyn Amasah Juliet Acquah Benjamin Donkor Bernice Yussif Charles Okyere Larbi Michael Opoku Acheampong Odei Gyebi Esther Commordor Joana Y. Oteng Kofi Agyapong Ernest Twum Rosemond Asase Alex Ntim Rachel Tarezina Patrick Agyekum Darko Seth Oppong Awal Alabira Lawrencia Serwaa Boateng Appendix D | 289 Ellen Aduonum Mustapha Haruna Selina Akolgo Michael Opoku Ayete Jacob Nabin Libabatu Yussif Felix Debrah David Afful Jacob Azuri Adosinaba Philip Bawa Abdul Kadir Vitus Bobruno Dorothy Baako Drivers Stephen Kumordji Emmanuel Chartey Emmanuel Nani George K. Akorful Emmanuel Kofi Oduro Andrews Pepprah Jonas Kwakye Afosah Kwaku Afriyie Emmanuel Addae Dickson Anane Frempong George Karikari Samuel Incoom Victor Okine Samuel K. Dam Simon Kofi Ernest Annan E. A. Anthony Jonathan Lawluvi Gershon Nornyibey Addokwei Saka Godfred Opata Listing Supervisors Emmanuel Nana Poku Johnathan Horgbey Samuel Akrofi Darko Isaac Addae Opoku Yeboah Michael Opoku Acheampong J.B.K.Amankrah Gabriel Opoku Nyarko E.Owusu Sefa Nyarko Larbi Charles Otchere Larbi Samuel Brefo Darkwa Mustapha Haruna Listers Gloria Akoto-Bamfo Delali Schwenninger Stella Adjei Sampson Wadieh Patrick K. Amehoe E.B.Asare Eugene Agbeshie Walanyo Doe Bansah Michael Opoku Ayete Nicholas Ainguah J.B. Acquaye Phyllis Painstil Ohene Darkwa Richard Aduonum Kwadwo Darko Isaac Kwesi Asante Collins Abrokwah Patrich D. Agyekum Joana Y. Oteng Priscilla Opoku Seth Oppong Godwin Woanya Ernest Twum Johnathan Enchil Isaac A. Beresie Francisca Thompson Perigrino Brimah Paul Kwadwo Asare Martin Akotuah Farouk Muntack Eunice Appiah Samuel Fobi-Boateng Godwin Fiatusey Peter Agbeli Judith Kwapong Stephen Tabi Isaac Osei Appah Evelyn Amassah Salas Okopti-Akunnor Noguchi Memorial Institute for Medical Research Professor David Ofori-Adjei, Director Dr. Mubarak Osei-Kwasi, Senior Research Fellow, Virology Unit Dr. William Kwabena Ampofo, Research Fellow, Virology Unit Mr. Jacob Arthur-Quarm, Virology Unit Mr. Kwashie Kudiabor, Senior Research Assistant, Virology Unit Mrs. Evelyn Bonney, Senior Research Assistant, Virology Unit 290 | Appendix D ORC Macro Dr. Pav Govindasamy, Senior Country Coordinator Dr. Alfredo Aliaga, Senior Sampling Expert Mrs. Jeanne Cushing, Senior Data Processing Specialist Mrs. Jasbir Sangha, Biomarker Specialist Dr. Ruilin Ren, Sampling Specialist Mr. Daniel Vadnais, Deputy Advisor for Communications Dr. Sidney Moore, Editor Ms. Phyllis Ruiz, Document Production Ms. Katherine Senzee, Document Production Ms. Justine Faulkenburg, Document Production Ms. Monika Jeziorek, Graphic Design Ms. Hena Khan, Graphic Design Appendix E | 291 QUESTIONNAIRES APPENDIX E July 15, 2003 GHANA DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE GHANA STATISTICAL SERVICE IDENTIFICATION LOCALITY NAME NAME OF HOUSEHOLD HEAD EA NUMBER . HOUSEHOLD NUMBER . REGION . DISTRICT. URBAN/RURAL (URBAN=1, RURAL=2) . CITY/LARGE TOWN/SMALL TOWN/VILLAGE . (CITY=1, LARGE TOWN=2, SMALL TOWN=3, VILLAGE=4) ňņņŎņņŎņņʼn Ň ųŇųųŇ ųŇ ŊņņŐņņŐņņō Ňų Ň ųŇ ŌņņŐņņō ŇųųŇ ųŇ ŌņņŐņņō ŇųųŇ ųŇ ŊņņŐņņō ŇųųŇ Ōņņō Ňų Ň Ŋņņŋ INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE INTERVIEWER’S NAME RESULT* ňņņŎņņʼn DAY ŇųųŇųųŇ ŌņņŐņņō MONTH ŇųųŇųųŇ ňņņŎņņŐņņŐņņō YEAR Ň 2Ň 0Ň00Ň3ųŇ ŊņņŐņņŐņņŐņņō NAME Ň ŇųųŇųųŇ ŊņņŏņņŐņņō RESULT ŇųųŇ Ŋņņŋ NEXT VISIT: DATE TIME TOTAL NO. OF VISITS ňņņʼn ŇųųŇ Ŋņņŋ TOTAL PERSONS IN HOUSEHOLD ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ TOTAL ELIGIBLE WOMEN ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ TOTAL ELIGIBLE MEN ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ *RESULT CODES: 1 COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 4 POSTPONED 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER (SPECIFY) LINE NO. OF RESP. TO HOUSEHOLD QUEST. ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ LANGUAGE LANGUAGE OF QUESTIONNAIRE: ENGLISH LANGUAGE OF INTERVIEW *** NATIVE LANGUAGE OF RESPONDENT*** WAS A TRANSLATOR USED? (YES=1, NO=2). *** LANGUAGE CODES: 1 ENGLISH 2 AKAN 3 GA 4 EWE 5 NZEMA 6 DAGBANI 7 OTHER______________________ (SPECIFY) ňņņʼn Ň1 Ň Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY NAME NAME DATE ňņŎņŎņʼn Ň ŇųŇųŇ Ŋņŏņŏņŋ DATE ňņŎņŎņʼn Ň ŇųŇųŇ Ŋņŏņŏņŋ ňņŎņŎņʼn Ň ŇųŇųŇ Ŋņŏņŏņŋ ňņŎņŎņʼn Ň ŇųŇųŇ Ŋņŏņŏņŋ 293Appendix E | HOUSEHOLD SCHEDULE Now we would like some information about the people who usually live in your household or who are staying with you now. LINE NO. USUAL RESIDENTS AND VISITORS RELATIONSHIP TO HEAD OF HOUSEHOLD SEX RESIDENCE AGE ELIGIBILITY Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household?* Is (NAME) male or female? Does (NAME) usually live here? Did (NAME) stay here last night? How old is (NAME)? CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6 CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 (1) (2) (3) (4) (5) (6) (7) (8) (9) (9A) M F YES NO YES NO IN YEARS 01 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 01 01 01 02 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 02 02 02 03 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 03 03 03 04 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 04 04 04 05 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 05 05 05 06 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 06 06 06 07 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 07 07 07 08 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 08 08 08 09 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 09 09 09 10 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 10 10 10 * CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD: 01 = HEAD 02 = WIFE OR HUSBAND 03 = SON OR DAUGHTER 04 = SON-IN-LAW OR DAUGHTER-IN-LAW 05 = GRANDCHILD 06 = PARENT 07 = PARENT-IN-LAW 08 = BROTHER OR SISTER 09 = CO-WIFE 10 = OTHER RELATIVE 11 = ADOPTED/FOSTER/ STEPCHILD 12 = NOT RELATED 98 = DON’T KNOW 294 | Appendix E LINE NO. PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD** EDUCATION IF ALIVE IF ALIVE IF AGE 5 YEARS OR OLDER IF AGE 5-24 YEARS Is (NAME)’s biological mother alive? Does (NAME)’s biological mother live in this house- hold? IF YES: What is her name? RECORD MOTHER’S LINE NUMBER Is (NAME)’s biological father alive? Does (NAME)’s biological father live in this house- hold? IF YES: What is his name? RECORD FATHER’S LINE NUMBER Has (NAME) ever attended school? What is the highest level of school (NAME) has attended?*** What is the highest grade (NAME) completed at that level?*** Is (NAME) currently attending school? During the current school year, did (NAME) attend school at any time? During the current school year, what level and grade [is/was] (NAME) attending?*** During the previous school year, did (NAME) attend school at any time? During that school year, what level and grade did (NAME) attend?*** (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) YES NO DK YES NO DK YES NO LEVEL GRADE YES NO YES NO LEVEL GRADE YES NO LEVEL GRADE 01 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 02 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 03 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 04 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 05 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 06 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 07 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 08 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 09 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 10 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ** CODES FOR Q.10 THROUGH Q.13 THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD. IN Q.11 AND Q.13, RECORD ‘00’ IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE. ***CODES FOR Qs. 15, 18 AND 20 EDUCATION LEVEL: 1 = PRIMARY 2 = MIDDLE/JSS 3 = SECONDARY/SSS 4 = HIGHER 8 = DON’T KNOW EDUCATION GRADE: 00 = LESS THAN 1 YEAR COMPLETED (FOR Q.15 ONLY. THIS CODE IS NOT ALLOWED FOR Q.18 AND Q.20 98 = DON‘T KNOW 295Appendix E | LINE NO. USUAL RESIDENTS AND VISITORS RELATIONSHIP TO HEAD OF HOUSEHOLD SEX RESIDENCE AGE ELIGIBILITY Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household?* Is (NAME) male or female? Does (NAME) usually live here? Did (NAME) stay here last night? How old is (NAME)? CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6 CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 (1) (2) (3) (4) (5) (6) (7) (8) (9) (9A) M F YES NO YES NO IN YEARS 11 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 11 11 11 12 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 12 12 12 13 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 13 13 13 14 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 14 14 14 15 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 15 15 15 16 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 16 16 16 17 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 17 17 17 18 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 18 18 18 19 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 19 19 19 20 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 1 2 1 2 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 20 20 20 * CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD: 01 = HEAD 02 = WIFE OR HUSBAND 03 = SON OR DAUGHTER 04 = SON-IN-LAW OR DAUGHTER-IN-LAW 05 = GRANDCHILD 06 = PARENT 07 = PARENT-IN-LAW 08 = BROTHER OR SISTER 09 = CO-WIFE 10 = OTHER RELATIVE 11 = ADOPTED/FOSTER/ STEPCHILD 12 = NOT RELATED 98 = DON’T KNOW ** Q.10 THROUGH Q.13 THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD. IN Q.11 AND Q.13, RECORD ‘00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE. ***CODES FOR Qs. 15, 18 AND 20 EDUCATION LEVEL: 1 = PRIMARY 2 = MIDDLE/JSS 3 = SECONDARY/SSS 4 = HIGHER 8 = DON’T KNOW EDUCATION GRADE: 00 = LESS THAN 1 YEAR COMPLETED (FOR Q.15 ONLY. THIS CODE IS NOT ALLOWED FOR Q.18 AND Q.20 98 = DON’T KNOW 296 | Appendix E LINE NO. PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD** EDUCATION IF ALIVE IF ALIVE IF AGE 5 YEARS OR OLDER IF AGE 5-24 YEARS Is (NAME)’s biological mother alive? Does (NAME)’s biological mother live in this house- hold? IF YES: What is her name? RECORD MOTHER’S LINE NUMBER Is (NAME)’s biological father alive? Does (NAME)’s biological father live in this house- hold? IF YES: What is his name? RECORD FATHER’S LINE NUMBER Has (NAME) ever attended school? What is the highest level of school (NAME) has attended?*** What is the highest grade (NAME) completed at that level?*** Is (NAME) currently attending school? During the current school year, did (NAME) attend school at any time? During the current school year, what level and grade [is/was] (NAME) attending?*** During the previous school year, did (NAME) attend school at any time? During that school year, what level and grade did (NAME) attend? (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) YES NO DK YES NO DK YES NO LEVEL GRADE YES NO YES NO LEVEL GRADE YES NO LEVEL GRADE 11 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 12 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 13 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 14 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 15 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 16 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 17 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 18 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 19 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 20 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 8 ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 Ŋ� GO TO 18 1 2 GO TO ŋ 19 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 2 NEXT ŋ LINE ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ TICK HERE IF CONTINUATION SHEET USED ňņņʼn Ŋņņŋ Just to make sure that I have a complete listing: 1) Are there any other persons such as small children or infants that we have not listed? YES ňņņʼn Ŋņņŏņņ� ENTER EACH IN TABLE NO ňņņʼn Ŋņņŋ 2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here? YES ňņņʼn Ŋņņŏņņ� ENTER EACH IN TABLE NO ňņņʼn Ŋņņŋ 3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed? YES ňņņʼn Ŋņņŏņņ� ENTER EACH IN TABLE NO ňņņʼn Ŋņņŋ 297Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 21 What is the main source of drinking water for members of your household? PIPED WATER PIPED INTO DWELLING .11 PIPED INTO YARD/PLOT.12 PUBLIC TAP.13 WATER FROM OPEN WELL OPEN WELL IN DWELLING .21 OPEN WELL IN YARD/PLOT.22 OPEN PUBLIC WELL.23 WATER FROM COVERED WELL OR BOREHOLE PROTECTED WELL IN DWELLING.31 PROTECTED WELL IN YARD/PLOT .32 PROTECTED PUBLIC WELL.33 SURFACE WATER SPRING.41 RIVER/STREAM.42 POND/LAKE.43 DAM.44 RAINWATER .51 TANKER TRUCK.61 BOTTLED WATER .71 SATCHEL WATER .81 OTHER 96 (SPECIFY) ņņ� 22A ņņ� 22A ņņ� 22A ņņ� 22A ņņ� 22A ņņ� 22A ņņ� 22A ņņ� 22A ņņ� 22A 22 How long does it take you to go there, get water, and come back? ňņņŎņņŎņņʼn MINUTES .ŇųųŇųųŇųųŇ Ŋņņŏņņŏņņŋ ON PREMISES.996 22A In the last two weeks, how frequently has water been available from this source? ALL THE TIME .1 SEVERAL HOURS EVERY DAY .2 A FEW TIMES A WEEK .3 LESS FREQUENTLY .4 NOT AT ALL .5 DON’T KNOW .8 22B How does this household primarily dispose of household waste? COLLECTED BY GOVERNMENT .01 COLLECTED BY COMMUNITY ASSOCIATION .02 COLLECTED BY PRIVATE COMPANY .03 DUMPED IN COMPOUND .04 DUMPED IN STREET/EMPTY PLOT .05 BURNED .06 BURIED .07 COMPOSTED .08 RECYCLED .09 FED TO ANIMALS.10 OTHER 96 (SPECIFY) 23 What kind of toilet facilities does your household have? FLUSH TOILET .11 PIT TOILET/LATRINE TRADITIONAL PIT TOILET.21 VENTILATED IMPROVED PIT (VIP) LATRINE .22 BUCKET/PAN.23 NO FACILITY/BUSH/FIELD/BEACH.31 OTHER 96 (SPECIFY) ņņ� 25 24 Do you share these facilities with other households? YES .1 NO .2 ņņ� 25 24A How many households do you share these facilities with? 1-2 .1 3-4 .2 5-9 .3 10+.4 298 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 25 Does your household have: Electricity? A radio? A television? A video deck? A telephone? A refrigerator? YES NO ELECTRICITY .1 2 RADIO .1 2 TELEVISION .1 2 VIDEO DECK .1 2 TELEPHONE.1 2 REFRIGERATOR .1 2 26 What type of fuel does your household mainly use for cooking? ELECTRICITY .01 LPG/NATURAL GAS .02 BIOGAS.03 KEROSENE.04 COAL, LIGNITE.05 CHARCOAL.06 FIREWOOD, STRAW.07 DUNG .08 OTHER 96 (SPECIFY) 26A How likely is it that you could be evicted from this dwelling: Would you say very likely, somewhat likely, not at all likely? VERY LIKELY.1 SOMEWHAT LIKELY .2 NOT AT ALL .3 DON’T KNOW .8 27 MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION. NATURAL FLOOR EARTH/SAND/MUD .11 MUD MIXED WITH DUNG .12 RUDIMENTARY FLOOR WOOD PLANKS.21 PALM/BAMBOO.22 FINISHED FLOOR PARQUET OR POLISHED WOOD.31 LINOLEUM .32 CERAMIC TILES.33 CEMENT .34 CARPET.35 TERRAZZO .36 OTHER 96 (SPECIFY) 28 Does any member of your household own: A bicycle? A motorcycle or motor scooter? A car or truck? A tractor? A horse/cart? YES NO BICYCLE .1 2 MOTORCYCLE/SCOOTER .1 2 CAR/TRUCK.1 2 TRACTOR .1 2 HORSE/CART .1 2 29 Does your household have any mosquito bed nets that can be used while sleeping? YES .1 NO .2 ņņ� 32F 29A How many mosquito bed nets does your household have? ňņņʼn NUMBER.ŇųųŇ Ŋņņŋ 29B When do you use the nets? ALL YEAR ROUND .1 DURING THE RAINY SEASON .2 OTHER 6 (SPECIFY) 299Appendix E | NET # 1 NET # 2 NET #3 30 ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. OBSERVED .1 NOT OBSERVED. 2 OBSERVED . 1 NOT OBSERVED . 2 OBSERVED . 1 NOT OBSERVED . 2 31 How long ago did your household obtain the mosquito bed net? ňņņŎņņʼn MONTHS AGO ŇųųŇųųŇ Ŋņņŏņņŋ MORE THAN 3 YEARS AGO 96 ňņņŎņņʼn MONTHS AGO ŇųųŇųųŇ Ŋņņŏņņŋ MORE THAN 3 YEARS AGO 96 ňņņŎņņʼn MONTHS AGO ŇųųŇųųŇ Ŋņņŏņņŋ MORE THAN 3 YEARS AGO 96 31A How did you obtain the net? BOUGHT IT AT COMMERCIAL PRICE.1 BOUGHT IT WITH VOUCHER OR OTHER SUBSIDY . 2 RECEIVED IT FREE. 3 OTHER 6 (SPECIFY) DON’T KNOW. 8 BOUGHT IT AT COMMERCIAL PRICE.1 BOUGHT IT WITH VOUCHER OR OTHER SUBSIDY . 2 RECEIVED IT FREE. 3 OTHER 6 (SPECIFY) DON’T KNOW. 8 BOUGHT IT AT COMMERCIAL PRICE. 1 BOUGHT IT WITH VOUCHER OR OTHER SUBSIDY . 2 RECEIVED IT FREE. 3 OTHER 6 (SPECIFY) DON’T KNOW. 8 31B When you got the mosquito bed net, was it treated with an insecticide? YES, PRETREATED.1 NO, CAME WITH TREATMENT KIT AND I TREATED IT MYSELF. 2ʼn NO IT WAS NOT Ň TREATED . 3ō OTHER 6ō (SPECIFY) Ň DON’T KNOW.8ō (SKIP TO 32A) ņņņņņņŋ YES, PRETREATED. 1 NO, CAME WITH TREATMENT KIT AND I TREATED IT MYSELF.2ʼn NO IT WAS NOT Ň TREATED .3ō OTHER 6ō (SPECIFY) Ň DON’T KNOW.8ō (SKIP TO 32A) ņņņņņņŋ YES, PRETREATED. 1 NO, CAME WITH TREATMENT KIT AND I TREATED IT MYSELF.2ʼn NO IT WAS NOT Ň TREATED .3ō OTHER 6ō (SPECIFY) Ň DON’T KNOW. 8ō (SKIP TO 32A) ņņņņņņŋ 32 OBSERVE OR ASK THE BRAND OF MOSQUITO BED NET. PERMANET .1 DAWA NET .2 OLYSET.3 LOCALLY MADE .4 OTHER. 6 DON’T KNOW. 8 PERMANET .1 DAWA NET .2 OLYSET.3 LOCALLY MADE .4 OTHER . 6 DON’T KNOW. 8 PERMANET .1 DAWA NET .2 OLYSET.3 LOCALLY MADE .4 OTHER . 6 DON’T KNOW. 8 32A Since you got the mosquito bed net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs? YES. 1 NO. 2 (SKIP TO 32C) ņņņō DON’T KNOW. 8 YES. 1 NO. 2 (SKIP TO 32C) ņņņō DON’T KNOW. 8 YES. 1 NO. 2 (SKIP TO 32C) ņņņō DON’T KNOW. 8 32B How long ago was the net last soaked or dipped? IF LESS THAN 1 MONTH, RECORD >00'. ňņņŎņņʼn MONTHS AGO ŇųųŇųųŇ Ŋņņŏņņŋ MORE THAN 3 YEARS AGO 96 ňņņŎņņʼn MONTHS AGO ŇųųŇųųŇ Ŋņņŏņņŋ MORE THAN 3 YEARS AGO 96 ňņņŎņņʼn MONTHS AGO ŇųųŇųųŇ Ŋņņŏņņŋ MORE THAN 3 YEARS AGO 96 32C Did anyone sleep under this mosquito bed net last night? YES. 1 NO.2 (SKIP TO 32E) ņņņō DON’T KNOW.8 YES. 1 NO. 2 (SKIP TO 32E) ņņņō DON’T KNOW. 8 YES. 1 NO. 2 (SKIP TO 32E) ņņņō DON’T KNOW. 8 300 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 32D Who slept under this mosquito bed net last night? RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ NAME ňņņŎņņʼn LINE NO ŇųųŇųųŇ Ŋņņŏņņŋ 32E GO BACK TO 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 32F. GO BACK TO 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 32F. GO BACK TO 30 IN THE FIRST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE NETS, GO TO 32F 32F In the past year, have you seen or heard messages about malaria: On the television? On the radio? In a newspaper or magazine? From a poster? From leaflets or brochures? From a health worker? YES NO TELEVISION .1 2 RADIO .1 2 NEWSPAPER/MAGAZINE.1 2 POSTER.1 2 LEAFLETS/BROCHURES.1 2 HEALTH WORKER .1 2 32G Have you seen or heard any messages telling you to give a child with fever chloroquine tablets for three days? YES .1 NO .2 DON’T KNOW .8 32H Have you ever listened to the radio program “He Ha Ho?” YES .1 NO .2 DON’T KNOW .8 33 Where do you usually wash your hands? IN DWELLING/YARD/PLOT.1 SOMEWHERE ELSE .2 NOWHERE.3 ņʼn ņŏ� 34A 34 ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT. YES NO WATER/TAP.1 2 SOAP, ASH OR OTHER CLEANSING AGENT .1 2 BASIN.1 2 34A Are you currently a member of a mutual health organization or health insurance scheme? YES .1 NO .2 DON’T KNOW .8 ņʼn ņŏ� 34E 34B What type of scheme are you a member of? PRIVATE HEALTH INSURANCE.1 MHO .2 GOVT.HEALTH COVERAGE.3 OTHER 6 (SPECIFY) 301Appendix E | 34C What benefits does your scheme cover? CONSULTATION . A DRUGS. B LABORATORY COSTS.C X-RAY.D ADMISSION . E SURGERY. F SPECIALIST CARE.G EXTRA OR BETTER FEEDING IN HOSPITAL.H TRANSPORT .I ANTENATAL CARE .J NORMAL DELIVERY CARE . K COMPLICATED DELIVERY CARE.L FAMILY PLANNING .M OTHER N (SPECIFY) 34D Have you or any member of your family ever benefited from the scheme? YES .1 NO .2 DON’T KNOW .8 ʼn Ō�35 ŋ 34E Will you consider joining a scheme in the future? YES .1 NO .2 DON’T KNOW .8 35 ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION). 0 PPM (NO IODINE).1 7 PPM.2 15 PPM.3 ABOVE 30 PPM .4 NO SALT IN HH .5 SALT NOT TESTED ________________ 6 (SPECIFY REASON) 302 | Appendix E HEIGHT, WEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TESTING CHECK COLUMNS (2), (7), (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6. WOMEN 15-49 WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49 LINE NO. FROM COL.(8) NAME FROM COL.(2) AGE FROM COL.(7) What is (NAME)’s date of birth? WEIGHT (KILOGRAMS) HEIGHT (CENTIMETERS) MEASURED LYING DOWN OR STANDING UP RESULT 1 MEASURED 2 NOT PRESENT 3 REFUSED 6 OTHER (36) (37) (38) (39) (40) (41) (42) (43) YEARS ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ CHILDREN UNDER AGE 6 WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1998 OR LATER LINE NO. FROM COL.(9) NAME FROM COL.(2) AGE FROM COL.(7) What is (NAME)’s date of birth?* WEIGHT (KILOGRAMS) HEIGHT (CENTIMETERS) MEASURED LYING DOWN OR STANDING UP RESULT 1 MEASURED 2 NOT PRESENT 3 REFUSED 6 OTHER LYING STAND. ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼnňņņŎņņʼnňņņŎņņŎņņŎņņʼn ŇųųŇųųŇŇųųŇųųŇŇųųŇųųŇųųŇųųŇ ŊņņŏņņŋŊņņŏņņŋŊņņŏņņŏņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn Ňų0ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼnňņņŎņņʼnňņņŎņņŎņņŎņņʼn ŇųųŇųųŇŇųųŇųųŇŇųųŇųųŇųųŇųųŇ ŊņņŏņņŋŊņņŏņņŋŊņņŏņņŏņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn Ňų0ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼnňņņŎņņʼnňņņŎņņŎņņŎņņʼn ŇųųŇųųŇŇųųŇųųŇŇųųŇųųŇųųŇųųŇ ŊņņŏņņŋŊņņŏņņŋŊņņŏņņŏņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn Ňų0ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼnňņņŎņņʼnňņņŎņņŎņņŎņņʼn ŇųųŇųųŇŇųųŇųųŇŇųųŇųųŇųųŇųųŇ ŊņņŏņņŋŊņņŏņņŋŊņņŏņņŏņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn Ňų0ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼnňņņŎņņʼnňņņŎņņŎņņŎņņʼn ŇųųŇųųŇŇųųŇųųŇŇųųŇųųŇųųŇųųŇ ŊņņŏņņŋŊņņŏņņŋŊņņŏņņŏņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn Ňų0ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ ňņņŎņņʼnňņņŎņņʼnňņņŎņņŎņņŎņņʼn ŇųųŇųųŇŇųųŇųųŇŇųųŇųųŇųųŇųųŇ ŊņņŏņņŋŊņņŏņņŋŊņņŏņņŏņņŏņņŋ ňņņŎņņŎņņʼn ňņņʼn Ňų0ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ ňņņŎņņŎņņʼn ňņņʼn ŇųųŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ TICK HERE IF CONTINUATION SHEET USED ňņņʼn Ŋņņŋ * FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM Q215 IN MOTHER’S BIRTH HISTORY AND ASK DAY. 303Appendix E | HEMOGLOBIN MEASUREMENT OF WOMEN 15-49 CHECK COLUMN (38): LINE NO. OF PARENT/ RESPONSIBLE ADULT. RECORD ‘00' IF NOT LISTED IN HOUSEHOLD SCHEDULE READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT* CIRCLE CODE (AND SIGN) HEMOGLOBIN LEVEL (G/DL) CURRENTLY PREGNANT RESULT 1 MEASURED 2 NOT PRESENT 3 REFUSED 6 OTHER (44) (45) (46) (47) (48) (49) AGE 15-17 AGE 18-49 GRANTED REFUSED YES NO/DK 1 2 Ň GO TO 46 ņņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ 1 2 Ň GO TO 46 ņņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ 1 2 Ň GO TO 46 ņņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ 1 2 ňņņʼn ŇųųŇ Ŋņņŋ HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1998 OR LATER LINE NO. OF PARENT/ RESPONSIBLE ADULT. RECORD ‘00' IF NOT LISTED IN HOUSEHOLD SCHEDULE READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT* CIRCLE CODE (AND SIGN) HEMOGLOBIN LEVEL (G/DL) RESULT 1 MEASURED 2 NOT PRESENT 3 REFUSED 6 OTHER GRANTED REFUSED ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ ňņņŎņņʼn ŇųųŇųųŇ Ŋņņŏņņŋ 1 " SIGN 2 Ň NEXT LINE ņņŋ ňņņŎņņʼn ňņņʼn ŇųųŇųųŇ ŇųųŇ Ŋņņŏņņŋ.Ŋņņŋ ňņņʼn ŇųųŇ Ŋņņŋ * CONSENT STATEMENT Hello, my name is (YOUR NAME) and I am from the Ghana Health Services and collaborating with the Ghana Statistical Service that is carrying out this health survey. .As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia. We request that you (and all children born in 1998 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential. May I now ask that you (and NAME OF CHILD[REN]) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done. Note: In countries where some