Ghana - Demographic and Health Survey - 2009

Publication date: 2009

Ghana 2008 G hana 2008 D em ographic and H ealth Survey Demographic and Health Survey Ghana Demographic and Health Survey 2008 Ghana Statistical Service Ghana Health Service Accra, Ghana ICF Macro Calverton, Maryland, U.S.A. September 2009 Ghana Statistical Service Ghana Health Service Ghana AIDS Commission This report summarises the findings of the 2008 Ghana Demographic and Health Survey (GDHS) carried out by the Ghana Statistical Service and the Ghana Health Service. ICF Macro provided financial and technical assistance for the survey through the USAID-funded MEASURE DHS programme, which is designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. Local costs for the survey were partially funded by the Ministry of Health (MOH), the Ghana Statistical Service (GSS), the Ghana AIDS Commission (GAC), UNICEF, UNFPA, and DANIDA. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID or donor organisations. Additional information about the 2008 GDHS may be obtained from the Ghana Statistical Service (GSS), P.O. Box 1098, Accra, Ghana (Telephone: 233-21-671-732; Fax: 233-21-671-731). Additional information about the MEASURE DHS programme may be obtained from MEASURE DHS, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A. (Telephone: 1-301-572-0200; Fax: 1-301-572-0999; Email: reports@macrointernational.com). Suggested citation: Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. 2009. Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro. Contents | iii CONTENTS Page TABLES AND FIGURES . ix CONTRIBUTORS TO THE REPORT . xvii FOREWORD . xix SUMMARY OF FINDINGS . xxi MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxvii MAP OF GHANA . xxviii CHAPTER 1 INTRODUCTION 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 Organization of the Survey . 4 1.5 Sample Design . 5 1.6 Questionnaires . 5 1.7 Haemoglobin Testing . 6 1.8 Pre-test, Training, and Fieldwork . 7 1.8.1 Pre-test . 7 1.8.2 Training and Fieldwork . 7 1.9 Data Processing . 8 1.10 Response Rates . 8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age and Sex . 11 2.2 Household Composition . 12 2.2.1 Children’s Living Arrangements and Orphanhood . 13 2.2.2 School Attendance by Survivorship of Parents . 15 2.3 Educational Attainment of Household Members . 15 2.3.1 Grade Repetition and Dropout Rates . 20 2.4 Housing Characteristics . 22 2.5 Household Durable Goods . 26 2.6 Wealth Quintiles . 27 2.7 Birth Registration . 28 iv | Contents CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics of Respondents . 31 3.2 Educational Attainment . 33 3.3 Literacy . 35 3.4 Access to Mass Media . 37 3.5 Employment . 39 3.6 Occupation . 42 3.7 Type of Employer, Form of Earnings, and Continuity of Employment . 45 3.8 Health Insurance Coverage . 48 3.9 Knowledge and Attitude Concerning Tuberculosis . 57 3.10 Smoking . 59 3.11 Alcohol Consumption . 60 CHAPTER 4 FERTILITY 4.1 Fertility Levels and Trends . 67 4.1.1 Fertility Levels . 67 4.1.2 Differentials in Current and Completed Fertility . 69 4.1.3 Trends in Fertility . 71 4.2 Children Ever Born and Living . 72 4.3 Birth Intervals . 73 4.4 Age at First Birth . 74 4.5 Median Age at First Birth by Background Characteristics . 76 4.6 Teenage Fertility . 77 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods . 79 5.2 Ever Use of Contraception . 82 5.3 Current Use of Contraceptive Methods . 85 5.4 Differentials in Contraceptive Use by Background Characteristics . 87 5.5 Trends in the Use of Family Planning . 87 5.6 Number of Children at First Use of Contraception . 89 5.7 Use of Social Marketing Brands . 90 5.8 Knowledge of Fertile Period . 92 5.9 Timing of Sterilisation . 93 5.10 Source of contraception . 94 5.11 Cost of Contraception . 95 5.12 Informed Choice . 96 5.13 Future Use of Contraception . 98 5.14 Reasons for Not Intending to Use Contraception . 98 5.15 Preferred Method of Contraception for Future Use . 100 5.16 Exposure to Family Planning Messages . 100 5.17 Contact of Non-users with Family Planning Providers . 102 5.18 Husband/Partner’s Knowledge about Woman’s Use of Family Planning . 103 5.19 Attitudes towards Family Planning . 105 5.20 Attitudes towards Having too Many Children . 107 Contents | v CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status . 111 6.2 Polygyny . 112 6.3 Age at First Marriage . 115 6.4 Age at First Sexual Intercourse . 118 6.5 Recent Sexual Activity . 121 6.6 Amenorrhoea, Abstinence, and Insusceptibility . 124 6.7 Menopause . 125 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 127 7.2 Need and Demand for Family Planning . 130 7.3 Ideal Family Size . 132 7.4 Fertility Planning . 134 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Definition, Data Quality, and Methodology. 137 8.2 Levels and Trends in Infant and Child Mortality . 138 8.3 Socio-economic Differentials in Mortality . 140 8.4 Demographic Characteristics and Child Mortality . 141 8.5 Perinatal Mortality . 142 8.6 High-Risk Fertility Behaviour . 144 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 147 9.1.1 Antenatal Care Coverage . 147 9.1.2 Number and Timing of Antenatal Care Visits . 149 9.1.3 Components of Antenatal Care. 150 9.1.4 Tetanus Immunisation . 152 9.2 Delivery Care . 154 9.2.1 Place of Delivery . 154 9.2.2 Assistance at Delivery . 155 9.2.3 Complications of Delivery . 157 9.3 Postnatal Care . 158 9.3.1 Timing of First Postnatal Check-up . 158 9.3.2 Type of Provider of First Postnatal Check-up . 159 9.4 Problems in Accessing Health Care . 161 vi | Contents CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth . 163 10.2 Vaccination Coverage . 165 10.3 Trends in Vaccination Coverage . 168 10.4 Acute Respiratory Infection . 168 10.5 Fever. 170 10.6 Diarrhoeal Disease . 170 10.6.1 Incidence and Treatment of Diarrhoea . 172 10.6.2 Feeding Practices . 174 10.7 Knowledge of ORS Packets . 176 10.8 Stool Disposal . 176 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 179 11.1.1 Measurement of Nutritional Status among Young Children . 179 11.1.2 Results of Data Collection . 180 11.1.3 Levels of Malnutrition . 182 11.1.4 Trends in Children’s Nutritional Status . 183 11.2 Initiation of Breastfeeding. 184 11.3 Breastfeeding Status by Age . 186 11.4 Duration and Frequency of Breastfeeding . 188 11.5 Types of Complementary Foods . 188 11.6 Infant and Young Child Feeding (IYCF) Practices . 191 11.7 Anaemia in children . 193 11.8 Micronutrient Intake among Children. 196 11.9 Nutritional Status of Women . 199 11.10 Foods Consumed by Mothers . 200 11.11 Anaemia in Women . 202 11.12 Micronutrient Intake among Mothers . 204 11.13 Regenerative Health . 206 11.13.1 Vigorous Physical Activity . 206 11.13.2 Duration of Rest . 210 11.13.3 Consumption of Water . 211 11.13.4 Consumption of Fruits . 212 11.13.5 Consumption of Vegetables . 215 11.13.6 Types of Cooking Oil Used in Ghana . 219 CHAPTER 12 MALARIA 12.1 Mosquito Nets . 222 12.1.1 Ownership of Mosquito Nets . 222 12.1.2 Use of Mosquito Nets by Children . 223 12.1.3 Use of Mosquito Nets by Women . 225 12.1.4 Trends in Household Ownership and Use of Mosquito Nets . 227 Contents | vii 12.2 Intermittent Preventive Treatment of Malaria in Pregnancy . 229 12.2.1 Malaria Prophylaxis during Pregnancy . 229 12.2.2 Prevalence and Management of Childhood Malaria . 230 12.3 Exposure to Messages on Malaria . 234 12.3.1 Exposure to Specific Messages on Malaria . 235 CHAPTER 13 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 Knowledge of AIDS . 238 13.2 Knowledge of HIV Prevention Methods . 238 13.3 Beliefs about AIDS . 240 13.4 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 243 13.5 Stigma Associated With Aids and Attitudes Related To HIV/AIDS . 245 13.6 Attitudes towards Negotiating Safer Sex . 247 13.7 Attitudes towards Condom Education for Youth . 249 13.8 Higher-Risk Sex . 250 13.8.1 Multiple Partners and Condom Use . 250 13.8.2 Transactional Sex . 253 13.9 Coverage of prior HIV testing . 255 13.9.1 HIV Testing during Antenatal Care . 255 13.10 Male Circumcision . 258 13.11 Self-reporting of Sexually Transmitted Infections. 259 13.12 Prevalence of Medical Injections . 261 13.13 HIV/AIDS-Related Knowledge and Sexual Behaviour among Youth . 263 13.13.1 HIV/AIDS-Related Knowledge among Young Adults . 263 13.13.2 Knowledge of Condom Sources among Young Adults . 265 13.13.3 Trends in Age at First Sex . 265 13.13.4 Condom Use at First Sex . 266 13.13.5 Abstinence and Premarital Sex . 268 13.13.6 Higher-risk Sex and Condom Use among Young Adults . 269 13.13.7 Age Mixing in Sexual Relationships among Women . 272 13.13.8 Drunkenness during Sex among Young Adults . 273 13.13.9 Recent HIV Tests among Youth . 274 CHAPTER 14 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES 14.1 Employment and Forms of Earnings . 277 14.2 Control over Women’s and Men’s Earnings . 277 14.3 Women’s Participation in Household Decision-making . 282 14.4 Attitudes towards Wife Beating . 286 14.5 Attitudes towards Refusing Sex with Husband . 290 14.6 Women’s Employment Indicators . 293 14.7 Current Use of Contraception by Women’s Status . 295 14.8 Ideal Family Size and Unmet Need by Women’s Status. 296 14.9 Reproductive Health Care and Women’s Empowerment Status. 298 viii | Contents CHAPTER 15 DOMESTIC VIOLENCE 15.1 Measurement of Violence . 300 15.1.1 The Use of Valid Measures of Violence . 300 15.1.2 Ethical Considerations . 301 15.1.3 Special Training for Implementing the Domestic Violence Module . 302 15.1.4 Characteristics of the Sub-sample of Respondents for the Domestic Violence Module . 302 15.2 Experience of Domestic Violence by Women and Men . 302 15.3 Perpetrators of Physical Violence against Women and Men . 305 15.4 Women’s Experience of Force at Sexual Initiation . 305 15.5 Experience of Sexual Violence and Perpetrators of Sexual Violence . 307 15.6 Experience of Different Types of Violence . 309 15.7 Violence during Pregnancy . 309 15.8 Marital Control . 310 15.9 Types of Spousal Violence . 314 15.10 Violence by Spousal Characteristics and Women’s Indicators . 320 15.11 Frequency of Spousal Violence by Husbands . 322 15.12 Onset of Spousal Violence . 323 15.13 Types of Injuries to Women Resulting from Spousal Violence . 323 15.14 Physical Violence by Women and Men against Their Spouse . 324 15.15 Help-seeking to Stop Violence . 328 REFERENCES . 331 APPENDIX A SAMPLE DESIGN FOR THE 2008 GDHS . 335 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 341 APPENDIX C DATA QUALITY TABLES . 359 APPENDIX D PERSONS INVOLVED IN THE 2008 GHANA DEMOGRAPHIC AND HEALTH SURVEY . 365 APPENDIX E QUESTIONNAIRES . 369 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 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 Children's living arrangements and orphanhood . 14 Table 2.4.1 Educational attainment of the female household population . 16 Table 2.4.2 Educational attainment of the male household population . 17 Table 2.5 School attendance ratios . 19 Table 2.6 Grade repetition and dropout rates for primary school . 21 Table 2.7 Household drinking water . 23 Table 2.8 Household sanitation facilities . 24 Table 2.9 Household characteristics . 25 Table 2.10 Household durable goods . 27 Table 2.11 Wealth quintiles . 28 Table 2.12 Birth registration of children under age five . 29 Figure 2.1 Population Pyramid . 12 Figure 2.2 Age-Specific School Attendance Rates . 22 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents . 32 Table 3.2.1 Educational attainment: Women . 33 Table 3.2.2 Educational attainment: Men . 34 Table 3.3.1 Literacy: Women . 35 Table 3.3.2 Literacy: Men . 36 Table 3.4.1 Exposure to mass media: Women . 37 Table 3.4.2 Exposure to mass media: Men . 38 Table 3.5.1 Employment status: Women . 40 Table 3.5.2 Employment status: Men. 41 Table 3.6.1 Occupation: Women . 43 Table 3.6.2 Occupation: Men . 44 Table 3.7.1 Type of employment: Women . 46 Table 3.7.2 Type of employment: Men . 47 Table 3.8.1 Health insurance coverage: Women . 48 Table 3.8.2 Health insurance coverage: Men . 49 Table 3.9.1 N/DHIS Membership Payment: Women . 50 Table 3.9.2 N/DHIS Membership Payment: Men . 51 Table 3.10 Possession of valid N/DHIS card . 52 Table 3.11 Out-of-pocket payment for drugs and services by respondents insured with N/DHIS . 53 Table 3.12 Reported need for health services not covered by N/DHIS . 54 x | Tables and Figures Table 3.13 N/DHIS card holders’ perceived quality of services received . 55 Table 3.14 Client satisfaction . 56 Table 3.15.1 Knowledge and attitudes concerning tuberculosis: Women . 57 Table 3.15.2 Knowledge and attitude concerning tuberculosis: Men . 58 Table 3.16.1 Use of tobacco: Women . 59 Table 3.16.2 Use of tobacco: Men . 60 Table 3.17.1 Use of alcohol: Women . 62 Table 3.17.2 Use of alcohol: Men . 63 Table 3.18 Frequency of drunkenness among men . 65 Figure 3.1 Employment Status of Women and Men age 15-49 . 42 Figure 3.2 Occupation of Women and Men Age 15-49 . 45 Figure 3.3 Type of Earnings of Employed Women and Men Age 15-49 . 47 CHAPTER 4 FERTILITY Table 4.1 Current fertility . 68 Table 4.2 Fertility by background characteristics . 70 Table 4.3 Trends in age-specific fertility rates . 71 Table 4.4 Children ever born and living . 73 Table 4.5 Birth intervals . 75 Table 4.6 Age at first birth . 76 Table 4.7 Median age at first birth . 77 Table 4.8 Teenage pregnancy and motherhood . 78 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence . 68 Figure 4.2 Total Fertility Rates, Selected Sub-Saharan Countries . 69 Figure 4.3 Trends in Fertility, 1988-2008 .72 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 80 Table 5.2 Knowledge of contraceptive methods by background characteristics . 81 Table 5.3.1 Ever use of contraception: Women . 83 Table 5.3.2 Ever use of contraception: Men . 84 Table 5.4 Current use of contraception by age . 86 Table 5.5 Current use of contraception by background characteristics . 88 Table 5.6 Number of children at first use of contraception . 90 Table 5.7 Pill brand and cost . 91 Table 5.8 Condom brand and cost . 92 Table 5.9 Knowledge of fertile period . 93 Table 5.10 Source of modern contraception methods . 94 Table 5.11 Cost of modern contraceptive methods . 96 Table 5.12 Informed choice . 97 Table 5.13 Future use of contraception . 98 Table 5.14 Reason for not intending to use contraception in the future . 99 Table 5.15 Preferred method of contraception for future use . 100 Table 5.16 Exposure to family planning messages . 101 Table 5.17 Contact of non-users with family planning providers . 103 Table 5.18 Husband/partner's knowledge of women's use of contraception . 104 Table 5.19.1 Women’s attitudes towards use of contraception by women . 105 Table 5.19.2 Men’s attitudes towards use of contraception by men . 106 Table 5.20.1 Women’s attitudes towards having too many children . 108 Table 5.20.2 Men’s attitudes towards having too many children . 109 Tables and Figures | xi Figure 5.1 Trends in Contraceptive Use among Currently Married Women Age 15-49 . 89 Figure 5.2 Trends in Source of Modern Contraceptive Methods, Ghana 1988-2008 . 95 Figure 5.3 Percentage of Women and Men Exposed to Family Planning Messages in the Media . 102 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 111 Table 6.2.1 Number of women's co-wives . 113 Table 6.2.2 Number of men's wives . 114 Table 6.3 Age at first marriage . 116 Table 6.4.1 Median age at first marriage: Women . 117 Table 6.4.2 Median age at first marriage: Men . 118 Table 6.5 Age at first sexual intercourse . 119 Table 6.6.1 Median age at first sexual intercourse: Women . 120 Table 6.6.2 Median age at first intercourse: Men . 121 Table 6.7.1 Recent sexual activity: Women . 122 Table 6.7.2 Recent sexual activity: Men . 123 Table 6.8 Post-partum amenorrhoea, abstinence and insusceptibility . 124 Table 6.9 Median duration of amenorrhoea, post-partum abstinence and Post-partum insusceptibility . 125 Table 6.10 Menopause . 126 Figure 6.1 Percentage of Married Men Age 15-49 with Two or More Wives, by Region . 115 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 128 Table 7.2.1 Desire to limit childbearing: Women . 129 Table 7.2.2 Desire to limit childbearing: Men . 130 Table 7.3 Need and demand for family planning: Currently married women . 131 Table 7.4 Ideal number of children . 133 Table 7.5 Mean ideal number of children . 134 Table 7.6 Fertility planning status . 135 Table 7.7 Wanted fertility rates . 136 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 139 Table 8.2 Early childhood mortality rates by socio-economic characteristics . 140 Table 8.3 Early childhood mortality rates by demographic characteristics . 142 Table 8.4 Perinatal mortality . 143 Table 8.5 High-risk fertility behaviour . 144 Figure 8.1 Mortality Trends, Ghana 1988-2008 . 139 xii | Tables and Figures CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 148 Table 9.2 Number of antenatal care visits and timing of first visit . 150 Table 9.3 Components of antenatal care . 152 Table 9.4 Tetanus toxoid injections . 153 Table 9.5 Place of delivery . 155 Table 9.6 Assistance during delivery . 156 Table 9.7 Timing of first postnatal check-up . 159 Table 9.8 Type of provider of first postnatal check-up . 160 Table 9.9 Problems in accessing health care . 162 Figure 9.1 Trends in Maternity Care Indicators, Ghana 1988-2008 . 149 Figure 9.2 Trends in Tetanus Toxoid Injections, Ghana 2003 and 2008 . 154 Figure 9.3 Assistance by Skilled Provider during Childbirth . 157 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth . 164 Table 10.2 Vaccinations by source of information . 165 Table 10.3 Vaccinations by background characteristics . 167 Table 10.4 Vaccinations in first year of life . 168 Table 10.5 Prevalence and treatment of symptoms of ARI . 169 Table 10.6 Prevalence and treatment of fever . 171 Table 10.7 Prevalence of diarrhoea . 172 Table 10.8 Diarrhoea treatment . 173 Table 10.9 Feeding practices during diarrhoea . 175 Table 10.10 Knowledge of ORS packets or pre-packaged liquids . 176 Table 10.11 Disposal of children's stools . 177 Figure 10.1 Vaccination Coverage at Any Time Before the Survey Among Children 12-23 Months . 166 Figure 10.2 Trends in Vaccination Coverage, Ghana 1988-2008 . 166 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 181 Table 11.2 Initial breastfeeding . 185 Table 11.3 Breastfeeding status by age . 187 Table 11.4 Median duration and frequency of breastfeeding . 189 Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview . 190 Table 11.6 Infant and young child feeding (IYCF) practices . 192 Table 11.7 Prevalence of anaemia in children . 195 Table 11.8 Micronutrient intake among children . 197 Table 11.9 Nutritional status of women . 200 Table 11.10 Foods consumed by mothers in the day and night preceding the interview . 202 Table 11.11 Micronutrient intake among mothers . 203 Table 11.12 Prevalence of anaemia in women . 205 Table 11.13.1 Frequency of vigorous physical activity: Women . 208 Table 11.13.2 Frequency of vigorous physical activity: Men . 209 Table 11.14.1 Daily duration of rest: Women . 210 Tables and Figures | xiii Table 11.14.2 Daily duration of rest: Men . 211 Table 11.15.1 Weekly consumption of fruits: Women . 212 Table 11.15.2 Weekly consumption of fruits: Men . 213 Table 11.16.1 Number of servings of fruits consumed: Women . 214 Table 11.16.2 Number of servings of fruits consumed: Men . 215 Table 11.17.1 Weekly consumption of vegetables: Women . 216 Table 11.17.2 Weekly consumption of vegetables: Men . 217 Table 11.18.1 Number of servings of vegetables consumed: Women . 218 Table 11.18.2 Number of servings of vegetables consumed: Men . 219 Table 11.19 Types of cooking oil used in Ghana . 220 Figure 11.1 Nutritional Status of Children by Age . 182 Figure 11.2 Trends in Nutritional Status of Children under Five Years . 184 Figure 11.3 Infant Feeding Practices by Age . 187 Figure 11.4 Infant and Young Child Feeding (IYCF) Practices . 193 Figure 11.5 Trends in Anaemia Status among Children under Five Years. 196 Figure 11.6 Trends in Nutritional Status among Women 15-49 Years . 201 Figure 11.7 Trends in Anaemia Status among Women 15-49 Years . 204 CHAPTER 12 MALARIA Table 12.1 Ownership of mosquito nets . 223 Table 12.2 Use of mosquito nets by children . 224 Table 12.3.1 Use of mosquito nets by women . 226 Table 12.3.2 Use of mosquito nets by pregnant women . 227 Table 12.4 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy . 230 Table 12.5 Prevalence and prompt treatment of fever . 231 Table 12.6 Type and timing of anti-malarial drugs . 233 Table 12.7 Sources of messages on malaria . 234 Table 12.8 Exposure to specific messages on malaria . 236 Figure 12.1 Trends in Household Ownership of Mosquito Nets, GDHS 2003 and GDHS 2008 . 228 Figure 12.2 Trends in Use of Mosquito Nets by Children under Five and Pregnant Women (Any Net and ITNs), GDHS 2003 and GDHS 2008 . 228 CHAPTER 13 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS . 238 Table 13.2 Knowledge of HIV prevention methods . 239 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 241 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 242 Table 13.4 Knowledge of prevention of mother to child transmission of HIV . 244 Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women . 246 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men . 247 Table 13.6 Attitudes towards negotiating safer sexual relations with husband . 248 Table 13.7 Adult support of education about condom use to prevent AIDS . 249 Table 13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 251 Table 13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men . 252 xiv | Tables and Figures Table 13.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men . 254 Table 13.10.1 Coverage of prior HIV testing: Women . 255 Table 13.10.2 Coverage of prior HIV testing: Men . 256 Table 13.11 Pregnant women counselled and tested for HIV . 258 Table 13.12 Male circumcision . 259 Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STIs symptoms . 260 Table 13.14 Prevalence of medical injections . 262 Table 13.15 Comprehensive knowledge about AIDS and of a source of condoms among youth . 264 Table 13.16 Age at first sexual intercourse among youth . 266 Table 13.17 Condom use at first sexual intercourse among youth . 267 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 268 Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk sexual intercourse in the past 12 months: Women . 270 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk sexual intercourse in the past 12 months: Men . 271 Table 13.20 Drunkenness during sexual intercourse among youth . 273 Table 13.21 Recent HIV tests among youth . 274 Figure 13.1 Women and Men Seeking Treatment for STIs . 261 Figure 13.2 Abstinence, Being Faithful, and Condom Use (ABC) Among Young Women and Men Age 15-24 . 272 CHAPTER 14 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES Table 14.1 Employment and cash earnings of currently married women and men . 278 Table 14.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings: Women . 279 Table 14.2.2 Control over men’s cash earnings . 280 Table 14.3 Women's control over their own earnings and those of their husbands . 281 Table 14.4.1 Women's participation in decision-making . 282 Table 14.4.2 Women's participation in decision-making according to men . 283 Table 14.5.1 Women's participation in decision-making by background characteristics . 284 Table 14.5.2 Men's attitudes towards wives' participation in decision-making . 285 Table 14.6.1 Attitudes towards wife beating: Women . 287 Table 14.6.2 Attitudes towards wife beating: Men . 289 Table 14.7.1 Attitudes towards refusing sexual intercourse with husband: Women . 291 Table 14.7.2 Attitudes towards refusing sexual intercourse with husband: Men . 292 Table 14.7.3 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse . 294 Table 14.8 Indicators of women's empowerment . 295 Table 14.9 Current use of contraception by women's status . 296 Table 14.10 Women's empowerment and ideal number of children and unmet need for family planning . 297 Table 14.11 Reproductive health care by women's empowerment . 298 Figure 14.1 Number of Decisions in Which Currently Married Women Participate . 286 Tables and Figures | xv CHAPTER 15 DOMESTIC VIOLENCE Table 15.1 Experience of physical violence . 303 Table 15.2 Persons committing physical violence . 305 Table 15.3 Force at sexual initiation . 306 Table 15.4 Experience of sexual violence . 307 Table 15.5 Age at first experience of sexual violence . 308 Table 15.6 Persons committing sexual violence . 308 Table 15.7 Experience of different forms of violence . 309 Table 15.8 Violence during pregnancy . 310 Table 15.9.1 Degree of marital control exercised by husbands, according to wives . 311 Table 15.9.2 Degree of marital control exercised by wives, according to husbands . 313 Table 15.10.1 Forms of spousal violence: Women . 314 Table 15.10.2 Forms of spousal violence: Men . 316 Table 15.11.1 Spousal violence by background characteristics: Women . 318 Table 15.11.2 Spousal violence by background characteristics: Men . 319 Table 15.12 Spousal violence by husband's characteristics and empowerment indicators . 321 Table 15.13 Frequency of spousal violence among women who report violence . 322 Table 15.14 Injuries to women and men as a result of spousal violence . 324 Table 15.15.1 Violence by women against their spouse . 325 Table 15.15.2 Violence by men against their spouse . 327 Table 15.16.1 Help-seeking to stop violence: Women . 328 Table 15.16.2 Help-seeking to stop violence: Men . 329 Table 15.17 Sources where help was sought to stop violence . 330 Figure 15.1 Percentage of Ever-married Women Who Have Experienced Specific Forms of Physical or Sexual Violence Committed by Their Current or Most Recent Husband/Partner during the Past 12 Months . 315 Figure 15.2 Percentage of Ever-married Men Who Have Experienced Specific Forms of Physical Violence Committed by Their Current or Most Recent Wife/Partner during the Past 12 Months . 316 APPENDIX A SAMPLE DESIGN FOR THE 2008 GDHS Table A.1 Proportional distribution of 412 EAs by region . 335 Table A.2 Expected number of selected households by region . 336 Table A.3 Final allocation of households by region, and number of EAs by urban and rural areas . 336 Table A.4 Sample implementation: All households selected for the interview with the Household Questionnaire (the verbal autopsy survey and individual interviews) . 337 Table A.5 Sample implementation: Women . 338 Table A.6 Sample implementation: Men . 339 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Ghana 2008 . 344 Table B.2 Sampling errors for National sample, Ghana 2008 . 345 Table B.3 Sampling errors for Urban sample, Ghana 2008 . 346 Table B.4 Sampling errors for Rural sample, Ghana 2008 . 347 Table B.5 Sampling errors for Western sample, Ghana 2008 . 348 Table B.6 Sampling errors for Central sample, Ghana 2008 . 349 xvi | Tables and Figures Table B.7 Sampling errors for Greater Accra sample, Ghana 2008 . 350 Table B.8 Sampling errors for Volta sample, Ghana 2008 . 351 Table B.9 Sampling errors for Eastern sample, Ghana 2008 . 352 Table B.10 Sampling errors for Ashanti sample, Ghana 2008 . 353 Table B.11 Sampling errors for Brong Ahafo, Ghana 2008 . 354 Table B.12 Sampling errors for Northern sample, Ghana 2008 . 355 Table B.13 Sampling errors for Upper East sample, Ghana 2008 . 356 Table B.14 Sampling errors for Upper West sample, Ghana 2008 . 357 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 359 Table C.2.1 Age distribution of eligible and interviewed women . 360 Table C.2.2 Age distribution of eligible and interviewed men . 360 Table C.3 Completeness of reporting . 361 Table C.4 Births by calendar years . 361 Table C.5 Reporting of age at death in days . 362 Table C.6 Reporting of age at death in months . 362 Table C.7 Nutritional status of children by NCHS/CDC/WHO International Reference Population. 363 Contributors to the Report | xvii CONTRIBUTORS TO THE REPORT This report was authored by the following persons: Mr. Sylvester Gyamfi, Ghana Statistical Service Mr. Peter Takyi Peprah, Ghana Statistical Service Mr. Louis Toboh, Ghana Statistical Service Ms. Joyce Ami Amedoe, National Population Council Dr. Gloria J. Quansah Asare, Ghana Health Service, Ministry of Health Rev. Mrs. Emma Sepah, Ghana Statistical Service Mr. Emmanuel George Ossei, Ghana Statistical Service Mr. Marfo Yentumi Nkansah, Ghana Statistical Service Mrs. Gladys Brew, Ghana Health Service, Ministry of Health Ms. Eunice Sackey, Ghana Health Service, Ministry of Health Mr. James Frimpong, National Malaria Control Programme, Ghana Health Service. Dr. Sylvia Anie-Akwetey, Ghana AIDS Commission Ms. Efua Amponsaa Anyanful, the Ministry for Women and Children's Affairs Ms. Patience Cofie, Ghana Health Service, Ministry of Health Dr. Gulnara Semenov, ICF Macro Mrs. Zhuzhi Moore, ICF Macro Dr. Pav Govindasamy, ICF Macro Foreword | xix FOREWORD The 2008 Ghana Demographic and Health Survey (GDHS) is a national survey covering all ten regions of the country. The survey was designed to collect, analyse, and disseminate information on housing and household characteristics, education, maternal health and child health, nutrition, family planning, gender, and knowledge and behaviour related to HIV/AIDS. It included, for the first time, a module on domestic violence as one of the topics of investigation. The 2008 GDHS is the fifth DHS survey to be undertaken in Ghana since 1988. All five surveys have been implemented by the Statistical Service of Ghana, in close collaboration with other stakeholders in various sectors of government, researchers, civil society organisations, and international organisations. The planning and implementation of the survey was carried out jointly by the Statistical Service and the Ministry of Health/Ghana Health Service management team. The Statistical Service is grateful to the Ministry of Health and the Ghana Health Service for their valuable partnership and especially for providing vehicles for the monitoring exercises during the fieldwork; and the ethical committee for the ethical clearance that allowed us to perform the anaemia testing. The Service is also grateful to USAID, UNFPA, DANIDA, UNICEF, and the Ghana AIDS Commission for co-funding the survey. The Statistical Service further acknowledges the technical assistance provided by ICF Macro during preparation and finalisation of the survey instruments, training of fieldworkers, and monitoring of field data collection. We also extend our appreciation to all who participated directly or indirectly in this study: the authors, who are cited at the beginning of this report, the field staff, and other survey personnel whos names appear in Appendix D. Above all, we appreciate the co-operation of all the survey respondents for making the 2008 GDHS a success. It is our hope that this report will be useful for advocacy, results-oriented decision-making, and inform service delivery. This report provides only a snapshot of the analysis that can be done with the data that have been collected. It is our sincere hope that researchers will deepen our understanding of the topics covered in the survey by undertaking further research with the survey dataset. Dr. Grace Bediako Government Statistician Ghana Statistical Service Summary of Findings | xxi SUMMARY OF FINDINGS The 2008 Ghana Demographic and Health Survey (2008 GDHS) is the fifth in a series of national-level population and health surveys conducted in Ghana as part of the global Demo- graphic and Health Surveys (DHS) programme. The survey is designed to provide information to monitor the population and health situation in Ghana as a follow-on to the 1988, 1993, 1998 and 2003 GDHS surveys. The survey used a two- stage sample based on the 2000 Population and Housing Census to produce separate estimates for key indicators for each of the ten regions in Ghana. The GDHS 2008 household sample of more than 12,000 households was large enough to provide a sampling frame for conducting case- specific child mortality surveillance for children under five years using a Verbal Autopsy Ques- tionnaire. Each household selected for the GDHS was eligible for interview with the Household Questionnaire, and a total of 11,778 households were interviewed. In half of the households se- lected for the survey, all eligible women age 15- 49 and all eligible men age 15-59 were inter- viewed with the Women’s and Men’s Question- naires, respectively. A total of 4,916 women age 15-49 and 4,568 men age 15-59 from 6,141 households were interviewed. Data collection took place over a three-month period, from early September to late November 2008. The survey obtained detailed information on fertility, marriage, sexual activity, fertility pref- erences, awareness and use of family planning methods, breastfeeding practices, nutritional sta- tus of women and young children, childhood mortality, maternal and child health, awareness and behaviour regarding HIV/AIDS, and other sexually transmitted infections (STIs). In addi- tion, the 2008 GDHS collected information on domestic violence, malaria and use of mosquito nets, and carried out anaemia testing and anthro- pometric measurements for women and children. Data on causes of child mortality based on verbal autopsy reports are not included to this report and will be presented as a separate publication. The 2008 GDHS was implemented by the Ghana Statistical Service (GSS) in collaboration with the Ghana Health Service. Technical assis- tance was provided by ICF Macro through the MEASURE DHS programme. Financial support for the survey was provided by the U.S. Agency for International Development (USAID), the Government of Ghana, UNICEF, UNFPA and Danish International Development Agency (DANIDA). FERTILITY Fertility Levels and Trends. Comparison of the results from the 2008 GDHS with the four earlier DHS surveys indicates that the total fertil- ity rate (TFR) has declined dramatically over the past 20 years, from 6.4 children per woman in 1988 to 4.4 children per woman in 1998. It stabi- lised at that level until 2003 and then declined again to 4.0 in 2008. Women in all age groups have shared in the declining fertility rates. The decline in fertility was especially rapid during the period between 1988 and mid-1998. With a TFR of 4.0 in 2008, Ghana is seen as having achieved its fertility target of 4.0 children per woman two years before the target year (2010). This TFR is also considered as one of the lowest in sub- Saharan Africa Fertility Differentials. There are substantial variations in fertility by background character- istics. The TFR for rural areas (4.9 births) is higher than the TFR for urban areas (3.1 births). Over the five-year period preceding the 2008 GDHS there was a decline in fertility among women in rural areas from 5.6 births per woman in 2003 to 4.9 births currently, while the TFR for women in urban areas remained the same. The total fertility rate is highest in the Northern region (6.8 children per woman) and lowest in the Greater Accra region (2.5 children per woman). As expected, women’s education is strongly associated with lower fertility, decreasing from 6.0 children among women with no education to 2.1 children among women with at least secondary education. Similar differentials are seen by wealth quintile, with the TFR decreasing from 6.5 children among women in the lowest wealth quintile to 2.3 children among women in the highest wealth quintile. Unplanned Fertility. Despite a steady rise in the level of contraceptive use over the past xxii | Summary of Findings twenty years, the 2008 GDHS data indicate that unplanned pregnancies are still common in Gha- na. Overall, 14 percent of births in Ghana are un- wanted, while 23 percent are mistimed (wanted later). The proportion of unplanned births de- clined slightly from 42 percent in 1993 to 36 per- cent in 1998, but rose again to 40 percent in 2003 before declining to 37 percent in 2008. The pro- portion of births that are unwanted increased substantially from 9 percent in 1993 to 16 per- cent in 2003, but dropped slightly to 14 percent by 2008. Fertility Preferences. There is considerable desire among currently married Ghanaians to control the timing and number of births. Thirty- six percent of currently married women would like to wait two or more years before the next birth, and 36 percent do not want to have another child, or are sterilised. About one-fifth (19 per- cent) of currently married women would like to have a child soon (within two years). A compari- son of the results over the five DHS surveys show that the desire to space births among cur- rently married women has declined in the past 20 years, from 45 percent in 1988 to 36 percent in 2008. However, the desire to limit births has in- creased from 23 percent in 1988 to 35 percent in 2008. 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 4.6 children in 2008. FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is nearly universal, with 98 percent of all women and 99 percent of all men age 15-49 knowing at least one modern method of family planning. Among all women, the most widely known methods of family planning are the male condom (94 percent), the pill (87 per- cent), injectables (86 percent), the female con- dom (81 percent), and rhythm (70 percent). About six in ten women have heard of female sterilisation, implants, and withdrawal, while 43 percent of all women have heard of the IUD and 35 percent have heard about emergency contra- ception. The lactational amenorrhoea method (LAM) is the least known method of family planning among both women and men There has been an increase in the level of awareness of contraceptive methods over time. The proportion of all women who know any method of contraception has risen from 76 per- cent in 1988 to 98 percent in 2003 and 2008. The proportion of women who know about implants has risen steeply from 4 percent in 1993 to 64 percent in 2008. A similar trend is seen among men. Use of Contraception. At the time of the 2008 GDHS, 24 percent of currently married women were using a method of contraception. The most commonly used modern method of contraception among married women is injecta- bles (6 percent), followed by the pill (5 percent). Male condoms and female sterilisation are used by 2 percent each, while implants are used by 1 percent of married women. The most commonly used traditional method is rhythm, which is used by 5 percent of married women. Trends in Contraceptive Use. Overall con- traceptive use among married women in Ghana has nearly doubled over the past 20 years. The survey results indicate a relatively large increase in the late 1980s and 1990s, from 13 to 22 percent of married women currently using family planning. However, there has been only a small increase in contraceptive use over the past ten years. The contraceptive prevalence rate increased from 22 percent among currently married women in 1998 to 25 percent in 2003 and has remained steady over the past five years (24 percent in 2008). Similarly, the use of modern methods nearly doubled over the past 15 years from 10 percent in 1993 to 19 percent in 2003, before declining slightly to 17 percent in 2008. Overall, there has been only a small decrease in use of traditional methods over the past 20 years. 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 decreased to 9 percent in 1998 and to 7 percent in 2003, and remained at this level in 2008. Differentials in Contraceptive Use. Wom- en in urban areas are more likely to use contra- ceptive methods (27 percent) than their rural counterparts (21 percent). The highest contracep- tive prevalence rate by region is in the Greater Accra region (33 percent), followed by the Brong-Ahafo and Volta regions (29 percent each). The Northern region reports the lowest level of contraceptive use (6 percent). Women with at least some secondary education are more than twice as likely to use contraception as wom- en with no education. Household wealth status is Summary of Findings | xxiii related to the use of contraception; 14 percent of currently married women in the lowest wealth quintile are using a contraceptive method, com- pared with 31 percent of their counterparts in the highest wealth quintile. Source of Modern Methods. In Ghana, both the public and private sectors are important sources of supply for users of modern methods (39 and 51 percent, respectively). Government hospitals or polyclinics are the most common public source (20 percent), followed by govern- ment health centres (14 percent). In addition, 5 percent combined obtain their methods from government health posts or community-based health and planning services (CHPS) com- pounds, and family planning clinics. In the past 20 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 43 percent in 1988 to 51 percent in 2008, although there was a slight decline over the past five years from 54 percent in 2003. The reliance on public sources for all modern methods decreased from 47 percent in 1998 to 39 percent in 2008. Unmet Need for Family Planning. Thirty- five percent of married women have an unmet need for family planning. Unmet need for spac- ing births is higher than unmet need for limiting births (23 and 13 percent, respectively), and is unchanged since 2003. Only 40 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. The survey shows that over nine in ten mothers (95 percent) received antena- tal care from a health professional (doctor, nurse, midwife, or community health officer). The re- sults indicate that there has been a marked im- provement in antenatal care coverage in Ghana over the past 20 years. In 1988, 82 percent of mothers received antenatal care for their most re- cent birth in the five years preceding the survey, compared with 95 percent of mothers in 2008. The proportion of women receiving no antenatal care declined slightly from 6 percent in 2003 to 4 percent in 2008. In the Volta region, however, about one in ten pregnant women did not receive any antenatal care in the five years preceding the survey (the same as in 2003). Neonatal tetanus is a leading cause of neo- natal death in developing countries where a high proportion of deliveries occur at home or in plac- es where hygienic conditions may be poor. Teta- nus toxoid (TT) vaccinations are given to preg- nant women to prevent neonatal tetanus. The survey results show that, for the most recent live birth in the five years preceding the survey, more than half (56 percent) of women in Ghana re- ceived two or more tetanus injections during pregnancy and 72 percent of births are protected against neonatal tetanus. A comparison between the 2003 and 2008 surveys on the percentage of women who had two or more TT injections dur- ing their last pregnancy that ended in a live birth shows that there has been an increase from 50 percent in 2003 to 56 percent in 2008. The larg- est increases were seen in the Upper East region (46 percent in 2003, compared with 62 percent in 2008) and the Greater Accra region (52 percent in 2003, compared with 66 percent in 2008). With regard to anti-malarial indicators, the results show that 32 percent of pregnant women and 26 percent of all women slept under a mos- quito net the night before the survey interview; 28 and 24 percent, respectively, slept under an ever-treated net, and 27 and 24 percent, respec- tively, slept under an insecticide-treated net (ITN). There has been a substantial increase in the use of nets by women and children, con- sistent with the overall increase in the ownership of ITNs. For example, the proportion of pregnant women who slept under an ITN the night before the survey increased from 3 percent in 2003 to 27 percent in 2008. The Ministry of Health and the Ghana Na- tional Malaria Control Programme recommend that pregnant women take at least two doses of SP/Fansidar during pregnancy as intermittent preventive treatment (IPT) against malaria. Over half (56 percent) of women with a birth in the two years preceding the survey who used IPT re- ceived SP/Fansidar during an antenatal visit. On- ly 44 percent of women said they received 2 or more doses, and at least one during an ANC visit. Delivery Care. Nationally, 57 percent of births in the five years preceding the survey oc- curred in health facilities, with 48 percent in pub- lic health facilities and 9 percent in private health facilities. Forty-two percent of births take place xxiv | Summary of Findings at home. The results also show that medically trained providers assisted 59 percent of deliver- ies, TBAs assisted 30 percent of deliveries, and relatives or friends assisted 8 percent of deliver- ies. There has been an increase in access to pro- fessional assistance during delivery over the past five years, from 47 percent in 2003 to 59 percent in 2008; over the same period, there has been a decrease in the use of relatives or no assistance at delivery, from 21 to 11 percent. Despite these improvements, medically assisted deliveries con- tinue to be low in Ghana, with 41 percent not benefiting from professional delivery assistance over the past five years. Postnatal Care. Two in three women who had a live birth in the five years preceding the survey received postnatal care within two days of delivery (67 percent) and one in fourteen re- ceived postnatal care 3-41 days after delivery (7 percent). About one in five women who had a birth in the five years preceding the survey did not receive postnatal care at all (23 percent). CHILD HEALTH Childhood Mortality. Results from the five GDHS surveys show a marked decline in child- hood mortality over the past 20 years. This de- cline appears to have halted briefly during the period 1999-2003, and then continued a further decline between 2003 and 2008. For example, the under-five mortality rate decreased from 111 per 1,000 live births for the period 0-4 years pre- ceding the 2003 GDHS to 80 per 1,000 during the same period prior to the 2008 GDHS. Despite this decline, the results show that one in every thirteen Ghanaian children dies before reaching the age of five. Over two-thirds of these deaths occur in the first year of life―infant mortality is 50 deaths per 1,000 live births and child mortali- ty is 31 deaths per 1,000 children age one. Neo- natal mortality is 30 deaths per 1,000 live births in the most recent five-year period, while post- neonatal mortality is 21 deaths per 1,000 live births. Neonatal deaths account for 60 percent of the deaths in infancy. Childhood Vaccination Coverage. Seven- ty-nine percent of Ghanaian children age 12-23 months are fully immunised at any time before the survey, while only 1 percent received no vac- cinations at all. At least 96 percent of children 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 about 86 to 88 percent of children receiving the recommended three doses of these vaccines. Nine in ten children received the measles vaccine and have also been vaccinated against yellow fe- ver. The percentage of children age 12-23 months who have been fully vaccinated has in- creased over the past twenty years, from 47 per- cent in 1988 to 79 percent in 2008. Child Illness and Treatment. Among chil- dren under five years of age, 6 percent were re- ported to have had symptoms of acute respiratory illness (ARI) in the two weeks preceding the sur- vey. Of these, half were taken to a health facility or provider for treatment. Twenty percent of children under five years had diarrhoea in the two weeks preceding the survey and 41 percent of these children were taken to a health provider. Less than half of children with diarrhoea (45 per- cent) were given a solution made from oral rehy- dration salts (ORS), 13 percent received recom- mended home fluids (RHF), and 38 percent were given increased fluids. Overall, 67 percent re- ceived ORS, RHF, or increased fluids, compared with 63 percent in 2003. One in five children under five years (20 percent) had a fever in the two weeks preceding the survey. Of these, 43 percent of children took an anti-malarial drug. Only 24 percent of chil- dren took the anti-malarial drug on the same or the next day after the onset of the illness. Arte- misinin Combination Therapy (ACT) was the most common anti-malarial drug given for fever in 2008 (22 percent), followed by chloroquine (9 percent), Fansidar (4 percent), and Camoquine (2 percent). Quinine, reserved for treatment of se- vere and complicated malaria cases in health fa- cilities, is taken by less than 2 percent of children with a fever. Four percent of children were given other anti-malarial drugs. NUTRITION Breastfeeding Practices. The results indi- cate that almost all (98 percent) Ghanaian chil- dren are breastfed for some period of time. Over half of infants were put to the breast within one hour of birth, and 82 percent started breastfeed- ing within the first day. Exclusive breastfeeding is recommended by the World Health Organisa- tion through the age of 6 months, but in Ghana only 63 percent of children under 6 months are exclusively breastfed. Overall, the median dura- tion of breastfeeding in Ghana is 20 months and Summary of Findings | xxv the median duration of exclusive breastfeeding is 3 months. The findings show that over the past five years there has been little change in the percent- age of children ever breastfed; however, the per- centage who started breastfeeding within one day of birth increased from 46 percent in 2003 to 52 percent in 2008, and the percentage who started breastfeeding within 1 day of birth increased from 75 to 82 percent over the same five-year pe- riod. The proportion of children who received a prelacteal feed decreased slightly from 20 per- cent in 2003 to 18 percent in 2008. The percentage of young children bottle-fed has not changed over the past five years, in the 2008 GDHS, 11 percent of children under six months were given a feeding bottle with a nipple, compared with 12 percent of children in the 2003 GDHS. Bottle-feeding peaks at age 6-8 months (21 percent). Intake of Vitamin A. Ensuring that chil- dren age 6-59 months receive enough vitamin A may be the single most effective child survival intervention. Deficiencies in this micronutrient can cause blindness and can increase the severity of infections such as measles and diarrhoea. Fif- ty-six percent of children age 6-59 months were reported to have received a vitamin A supple- ment in the 6 months preceding the survey—a considerable decline from 78 percent in 2003. However, in 2008, twice as many children under three who live with their mother consumed fruits and vegetables rich in vitamin A, compared with their counterparts in 2003 (81 and 41 percent, re- spectively). Sixty percent of mothers with a birth in the past five years reported receiving a vitamin A dose postpartum, an increase from 43 percent in 2003. Fourteen percent of interviewed women reported night blindness during pregnancy. How- ever, after adjusting for blindness not attributed to vitamin A deficiency during pregnancy, the results showed that only 2 percent of women ex- perienced night blindness during their last preg- nancy. Prevalence of anaemia. Iron-deficiency anaemia is a major threat to maternal health and child health. Overall, 78 percent of Ghanaian children age 6-59 months have some level of anaemia, including 23 percent of children who are mildly anaemic, 48 percent who are moder- ately anaemic, and 7 percent who are severely anaemic. Children in the Upper East and Upper West regions are the most likely to be anaemic (88-89 percent). The prevalence of anaemia in children has increased slightly over the past five years, from 76 percent in 2003 to 78 percent in 2008. The prevalence of anaemia is less pro- nounced among women than among children. Fifty-nine percent of Ghanaian women age 15-49 are anaemic, with 39 percent mildly anaemic, 18 percent moderately anaemic, and 2 percent se- verely anaemic. Anaemia is lowest among wom- en is in the Upper East region (48 percent) and highest in the Western region (71 percent). The level of anaemia among women age 15-49 in Ghana has increased over the past five years from 45 percent in 2003 to 59 percent in 2008, with the most noticeable increase occurring in the prevalence of moderate anaemia (9 percent in 2003 and 18 percent in 2008). Nutritional Status of Children. According to the 2008 GDHS, 28 percent of children under five are stunted and 10 percent are severely stunted. Nine percent of children under five are wasted and 2 percent are severely wasted. Weight-for-age results show that 14 percent of children under five are underweight, with 3 per- cent severely underweight. Children whose bio- logical mothers were not in the household are more likely to be stunted (33 percent) than chil- dren whose mothers were interviewed (28 per- cent). Data from the 1988, 1993, 1998, 2003, and 2008 GDHS surveys were all re-calculated ac- cording to the new WHO child growth reference standards, but restricted to children living with their mother and the mother was interviewed with the Women’s Questionnaire. Overall, the proportion of children under five who are stunted decreased from 34 percent in 1988, to 31 percent in 1998, and then rose to 35 percent in 2003 be- fore decreasing to 28 percent in 2008. The pro- portion of underweight children decreased from 23 percent in 1988 and 1993 to 14 percent in 2008. The proportion of children who are wasted decreased over the past 15 years from 14 percent in 1993 to 9 percent in 2008, with no marked change over the past five years. Infant and Young Child Feeding (IYCF). Infant and young child feeding (IYCF) practices include timely introduction of solid and semi- xxvi | Summary of Findings solid foods beginning at age six months, and thereafter increasing the amount and variety of foods and the frequency of feeding as the child gets older, while still maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months. Overall, only 36 percent of Ghana- ian children age 6-23 months are fed in accord- ance with IYCF practices. Nutritional Status of Women. Only 1 per- cent of Ghanaian women are below 145 centime- tres in height. The mean BMI for women age 15- 49 in Ghana is 23.6, and falls in the normal range (18.5-24.9) for all categories of background characteristics. Nine percent of women were found to be chronically malnourished (BMI less than 18.5), while 30 percent were overweight or obese. Over the past fifteen years (from 1993 to 2008), there has been little change in the percent- age of mothers whose height is below 145 centi- metres, and little change in the mean BMI. The proportion of women who are obese or over- weight has increased somewhat from 25 percent in 2003 to 30 percent in 2008 HIV/AIDS Awareness of AIDS. Knowledge of AIDS is universal in Ghana: 98 percent of women and 99 percent of men have heard of AIDS. Never- theless, the 2008 GDHS results indicate that only one in four women (25 percent) and one in three men (33 percent) have a comprehensive knowledge of HIV/AIDS prevention and trans- mission, i.e., know that consistent use of con- doms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chances of getting HIV/AIDS, knowing that a healthy-looking person can have HIV (the virus that causes AIDS), and rejecting two of the most common local misconceptions about the trans- mission of AIDS in Ghana—namely, that AIDS can be transmitted through mosquito bites and by supernatural means. General knowledge of HIV transmission during breastfeeding is high: 85 percent among women and 78 percent among men. However, only half of women and 44 percent of men know that the risk of mother-to-child-transmission (MTCT) of HIV can be reduced if a mother takes special drugs during pregnancy. Although low, these levels of knowledge about the special drugs that can prevent transmission of HIV to babies, are a substantial increase from the 16 percent for both sexes in 2003. Attitudes towards People Living with HIV/AIDS. It is encouraging to see that 75 per- cent of women and 79 percent of men age 15-49 are willing to care for a family member with HIV in their own household, and that nearly half of women and 58 percent of men do not want to keep secret that a family member is HIV posi- tive. Approximately two-thirds of women and men also believe that an HIV-positive female teacher should be allowed to continue teaching. However, only one in three women and two in five men say that they would buy fresh vegeta- bles from a vendor with AIDS. HIV-Related Behavioural Indicators. One of the strategies for reducing the risk of contract- ing an STI is for young people to delay the age at which they become sexually active. Eight percent of women and 4 percent of men reported that they had sexual intercourse by age 15. Forty-four percent of women and 28 percent of men said that they first had sexual intercourse by age 18. Sexual intercourse with a non-marital, non- cohabiting partner is associated with an increased risk of contracting sexually transmitted diseases. The GDHS results on higher-risk sexual behav- iour indicate that the proportion of women en- gaging in higher-risk sexual intercourse has in- creased slightly from 21 percent in the 2003 GDHS to 23 percent in the 2008 GDHS. At the same time, the proportion of women who used a condom during their last higher-risk sexual inter- course decreased from 28 percent in the 2003 GDHS to 25 percent in the 2008 GDHS. As with women, the proportion of men who engage in higher-risk sexual intercourse has in- creased slightly from 38 percent in the 2003 GDHS to 42 percent in 2008 GDHS; however, the proportion using condoms during their last higher-risk sexual intercourse has not changed (45 percent in the 2003 GDHS and 2008 GDHS). The mean number of lifetime sexual partners reported in the 2008 GDHS was two for women and five for men. Millennium Development Goal Indicators | xxvii Millennium Development Goal Indicators Goal Indicator Value Male Female Total 1. Eradicate extreme poverty and hunger 4. Prevalence of underweight children under five years1 15.4 12.4 13.9 2. Achieve universal primary education 6. Net attendance ratio in primary education2 73.4 74.2 73.8 7. Percentage of pupils starting grade 1 who reach grade 53 83.5 84.2 83.9 7a. Primary completion rate4 0.9 0.9 0.9 8. Literacy rate for those age 15-24 years5 78.3 68.0 na 3. Promote gender equality and empower women 9. Ratio of girls to boys in primary, secondary, and tertiary education6 na na 93.3 10. Ratio of literate women to men age 15-24 years5 na na 86.9 11. Share of women in wage employment in the non- agricultural sector7 na na 48.7 4. Reduce child mortality 13. Under-five mortality rate8 na na 80.0 14. Infant mortality rate8 na na 50.0 15. Percentage of children age one year immunised against measles9 88.5 91.7 90.2 5. Improve maternal health 16. Maternal mortality ratio na na na 17. Percentage of births attended by skilled health personnel10 na na 58.7 6. Combat HIV/AIDS, malaria and other diseases 19. Percentage of current users of contraception using condoms11 29.6 11.3 na 19A. Condom use at last higher-risk sex12 46.4 28.2 na 19B. Percentage of population age 15-24 years with comprehensive correct knowledge of HIV/AIDS13 34.2 28.3 na 19C. Contraceptive prevalence rate14 na 23.5 na 20. Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years15 0.7 na 0.8 22. Percentage of population in malaria-risk areas using effective malaria prevention and treatment measures16 na na 48.8 22A. Percentage of children under five sleeping under ITN 37.5 40.0 38.7 22B. Percentage of children under five with fever appropriately treated with anti-malarial drugs 43.7 42.1 43.0 Urban Rural Total 7. Ensure environmental sustainability 29. Percentage of population using solid fuels17 74.9 96.8 87.2 30. Percentage of population with sustainable access to an improved water source, urban and rural18 93.0 76.6 83.8 31. Percentage of population with access to improved sanitation, urban and rural19 17.9 8.1 12.4 32. Percentage of households with access to secure tenure na na na na = Not applicable 1 Based on children who slept in the household the night before the interview (de facto). 2 Based on de facto population. Numerator is children age 6-11 currently attending school; denominator is children age 6-11 years. 3 Based on de facto population. This indicator is calculated using rates of promotion, dropout, and repetition for a given school year. The rates are used to project an estimate for the percentage of students attending grade 1 who are expected to reach grade 5, with or without repetition. 4 Ratio of the total number of students completed grade 6 of primary school to the total number of children of official graduation age (11-13 years). 5 Literacy rate for those age 15–24 is the percentage of the population age 15–24 who can read a short simple statement on everyday life and is not equivalent to literacy rate in the DHS report. The ratio of literate women to men age 15–24 is the ratio of the female literacy rate to the male literacy rate for the age group 15–24. 6 Based on de facto population age 6-24 years 7 Numerator is all women working in the non-agricultural sector who received payment in cash, or in cash and in kind; denominator is all women and all men with non-agricultural occupation. 8 Mortality rates refer to a 5-year period before the survey. 9 In Ghana, the measles vaccinations are given at the age of 9 months. The values presented in the table are for children age 12-23 months who have been vaccinated at any time against measles. 10 Skilled health personnel includes: doctor, nurse, midwife, auxiliary midwife, and community health officer. 11 The number of women age 15-49 in marital or consensual unions who report they are using a condom to avoid pregnancy (regardless of whether they are also using additional methods) is divided by the total number of women age 15-49 in union who are practicing, or whose sexual partners are practicing, contraception. The indicator is not equivalent to condom use prevalence as a main method of contraception. 12 Based on de facto population age 15-24. Higher-risk sex is sexual intercourse with a non-marital, non-cohabiting partner. 13 Respondents with “comprehensive correct knowledge” of AIDS are those who say that using a condom every time for sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting the AIDS virus, and furthermore, say that a healthy-looking person can have the AIDS virus, and who reject the common misconception that HIV can be spread by mosquito bites and by sharing food with someone with AIDS. 14 Based on women age 15-49 in marital or consensual unions 15 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent. Note that these indicators do not take into account children who live outside of households, e.g., in institutions or on the street, because the GDHS includes only households in its sample. 16 Based on de facto population with at least one insecticide-treated bednet (ITN) and is not equivalent to the percentage of households with at least one ITN in the DHS report 17 Solid fuel includes: coal, charcoal, wood, straw, crops, animal dung and other. 18 Improved drinking water sources include: water from pipe/tap, public tap, borehole or pump, protected well, protected spring or rainwater. Improved water sources do not include: vendor-provided water, bottled water, tanker trucks or unprotected wells and springs. 19 Improved sanitary means of excreta disposal includes: facilities that hygienically separate human excreta from human, animal and insect contact. Facilities such as sewers or septic tanks, pour-flush latrines and simple pit or ventilated improved pit (VIP) latrines are assumed to be adequate, provided that they are not public (not shared) xxviii | Map of Ghana GHANA ^ Cote d’Ivoire Burkina Faso Togo Northern Volta Ashanti Brong-Ahafo Western Eastern Upper West Central Upper East Greater Accra � 0 60 12030 Kilometers Gulf of Guinea Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geography The Republic of Ghana is centrally located on the West African coast and has a total land area of 238,537 square kilometres. It is bordered by three French-speaking countries: Togo on the east, Burkina Faso on the north and northwest, and Côte d’Ivoire on the west. The Gulf of Guinea on the south forms a coastline extending 560 kilometres. Ghana is a lowland country except for a range of hills on the eastern border and Mt. Afadjato—the highest point above sea level (884 metres)—which is west of the Volta River. Ghana can be divided into three ecological zones: the sandy coastline backed by a coastal plain, which is crossed by several rivers and streams; the middle belt and western parts of the country, which are heavily forested and have many streams and rivers; and a northern savannah, which is drained by the Black and White Volta rivers. The Volta Lake, created by the hydroelectric dam in the east, is one of the largest artificial lakes in the world. Ghana has a tropical climate with temperatures and rainfall varying according to distance from the coast and elevation. The average annual temperature is about 26ºC (79ºF). 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 independence from British rule on 6 March 1957, and became a republic in the British Commonwealth of Nations on 1 July 1960. Its administrative and political capital is Accra, with a population of 1.7 million (GSS, 2002). Ghana operates a multi-party democratic presidential system of government with 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. There are 10 administrative regions, Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West. The regions are sub-divided into 170 districts to ensure equitable resource allocation and efficient and effective administration at the local levels. The distribution of Ghana’s population by urban-rural residence shows that the proportion of the population living in urban areas has increased substantially since 1960. In that year, only 23 percent of the population lived in the urban areas. This proportion increased to 29 percent in 1970 and then 32 percent in 1984. In 2000, the proportion of the population living in urban areas reached 44 percent. 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) (GSS, 2002). 2 | Introduction 1.1.3 Economy The structure of the economy has seen marginal changes over the past two decades. Agriculture is still the most important area of economic activity, followed by services, and then industry. Agriculture contributes 34 percent of the gross domestic product (GDP) (GSS, 2008) and it employs about 50 percent of the population (GSS, 2002). Within the agriculture sector, crops and livestock are the most important sub-sector, contributing 66 percent to the sector’s growth. Between 2003 and 2008, however, there was a slight decline in the growth rate of the agriculture sector, from 6 to 5 percent. The service sector, with a growth rate of 10 percent, is the fastest growing sector of the economy and it contributes one-third of the country’s GDP. Wholesale and retail trade is the most important sub-sector, accounting for one-quarter of the sector’s growth. The industrial sector contributes a little over one-quarter (26 percent) to the country’s GDP. The construction sub-sector has the greatest impact on the sector’s contribution to the GDP as well as sector growth. The leading export commodities of the country are cocoa, gold, and timber. In recent times, the economy has diversified to include exports of non-traditional commodities such as pineapples, bananas, yams, and cashew nuts. Tourism is fast gaining prominence as a foreign exchange earner. Over the past decade the Government of Ghana has embarked on various economic and poverty-reduction programmes with the aim of improving the living conditions of its citizenry. In 2007, the Livelihood Empowerment Against Poverty Programme (LEAP) was introduced, and in 2008 individuals identified as poor started receiving monthly allowances. There have been many changes in the education sector over the past decade. At the Basic Education Level, pre-school education has officially been incorporated into the education system and all primary schools are required to have nurseries or kindergartens. In the 2005/2006 academic year, the Capitation Grant was introduced countrywide and the government absorbed school fees of all pupils in government basic schools (Darko et al., 2009). As a result, all pupils in government basic schools now have free education. During the same period, the School Feeding Programme was introduced on a pilot basis, and it has since been extended to all basic schools. While the feeding programme aims at improving the nutritional status of school pupils, it has also resulted in increased enrolment in schools. At the secondary level, the three-year Senior Secondary School System was changed to the four-year Senior High School after the 2007/2008 academic year1. The introduction of the Ghana Education Trust Fund (GETFUND) has brought many improvements to the education system. The fund provides educational infrastructure such as buildings to the country’s tertiary institutions and, as a result, has improved teaching and learning in educational institutions. 1.2 DEMOGRAPHIC PROFILE There are a variety of sources that provide demographic information about the Ghanaian population, including censuses, administrative/routine data, and surveys. Population censuses provide more comprehensive demographic information than all the other sources. Ghana has undertaken four censuses since independence in 1957. The first post-independence census was conducted in 1960, reporting a population of 6.7 million. This was followed by the 1970 Census, reporting a population 8.6 million, giving an inter-censual growth rate of 2.4 percent. The 1984 and 2000 censuses recorded populations of 12.3 million and 18.9 million, respectively, with an average growth rate of 2.7 percent between the two census periods. The population density per square kilometre has more than doubled from 36 persons in 1970 to 79 persons in 2000. The sex ratio over the past 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 1 The change in name from Senior Secondary to Senior High School and the change from three years to four years have not affected the results of the 2008 GDHS. Introduction | 3 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. 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. (GSS, 1979; 1985; 2002). Because population censuses are resource intensive, expensive to implement, and generally take place at intervals of ten years, sample surveys are important for informing demographic profiles. During inter-censual periods, sample surveys are conducted to collect a wide range of data to complement the census data. Because sample surveys are cheaper and can be implemented more quickly, they are conducted at regular intervals. The Ghana Demographic and Health Survey (GDHS), which is a household survey, is an example of the collection of sample survey data. One other important but often neglected data source in Ghana is administrative (or routine) data. These data are generated as a by-product of events and processes and they provide relatively up- to-date information to fill the data gaps in both censuses and surveys. Vital registration systems (birth and death registration), health systems (immunisations), and education data (enrolment) are examples of administrative data. 1.3 POPULATION POLICY AND REPRODUCTIVE HEALTH PROGRAMMES The 1969 National Population Policy was revised in 1994 after 25 years of implementation. The revision took into account emerging issues such as HIV/AIDS, population and the environment, concerns about the elderly and children, and the development of new strategies to ensure achievement of the revised policy objectives. The revision of population policy also entailed concerted effort to systematically integrate population variables in all areas of development planning. The major goals of the revised population policy include: • Reducing the total fertility rate from 5.5 in 1993 to 5.0 by the year 2000, 4.0 by 2010, and 3.0 by 2020. Accordingly, the policy aims at achieving a contraceptive prevalence rate (CPR) of 15 percent for use of modern methods by the year 2000, 28 percent by 2010, and 50 percent by the year 2020; • Reducing the population growth rate from about 3 percent per annum to 1.5 percent by the year 2020; and • Increasing life expectancy from the current level of 58 years, to 65 years by 2010, and to 70 years by 2020 (NPC, 1994). The attainment of these population goals is recognised as an integral component of the national strategy to accelerate economic development, eradicate poverty, and enhance the quality of life of all Ghanaians. 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. In collaboration with the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the World Bank, and other development partners, Ghana has implemented several projects aimed at reducing reproductive health problems in the population. Support from these agencies has targeted policy coordination, implementation, and service delivery. The government is committed to improving access and equity of access to essential health care services. The priority areas identified include addressing the problems of HIV/AIDS and other sexually transmitted infections (STIs), malaria, tuberculosis, guinea worm disease, poliomyelitis, 4 | Introduction reproductive health, maternal and child health, accidents and emergencies, non-communicable diseases, oral health and eye care, and specialised services. Emphasis is also being placed on preventive as well as community-based health care services. This has necessitated the introduction of the Community-based Health Planning and Services (CHPS) programme in which trained nurses are stationed in selected communities to provide health care services to the people of the community. The scare associated with the spread of HIV/AIDS attracted considerable attention from the government and its development partners. The government set up the National AIDS Commission to oversee the implementation of HIV/AIDS programmes using a multi-sectoral approach. This was to ensure that HIV/AIDS prevention education, treatment, care and support reached every corner of the country. The Ghana Health Service (GHS) also set up the National AIDS Control Programme (NACP) to offer HIV/AIDS prevention education and services. The combined efforts of all stakeholders ensured the implementation of the Ghana HIV/AIDS Strategic Framework: 2001-2005 (World Bank, 2003). This collaborative effort had a positive impact and in 2003 only 2 percent of Ghanaian adults had contracted HIV (GSS, 2004). This level is expected to decline. Roll back malaria, tuberculosis (TB-DOTS), and Integrated Management of Childhood Illnesses (IMCI) are still priority areas under the country’s health care system. Other health interventions instituted as part of government’s efforts to make health care accessible and affordable to all include the introduction of the National Health Insurance Scheme (NHIS) and the free maternal care programme (United Nations, 2008). 1.4 OBJECTIVES AND ORGANISATION OF THE SURVEY The 2008 GDHS is designed to provide data to monitor the population and health situation in Ghana. This is the fifth round in a series of national level population and health surveys conducted in Ghana under the worldwide Demographic and Health Surveys programme. Specifically, the 2008 GDHS has the primary objective of providing current and reliable information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality, maternal and child health, domestic violence, and awareness and behaviour regarding AIDS and other sexually transmitted infections (STIs). The information collected in the 2008 GDHS will provide updated estimates of basic demographic and health indicators covered in the earlier rounds of 1988, 1993, 1998, and 2003 surveys. The long-term objective of the survey includes strengthening the technical capacity of major government institutions, including the Ghana Statistical Service (GSS). The 2008 GDHS also provides comparable data for long-term trend analysis in Ghana, since the surveys were implemented by the same organisation, using similar data collection procedures. It also adds to the international database on demographic and health–related information for research purposes. The 2008 GDHS was carried out by the Ghana Statistical Service (GSS) and the Ghana Health Service (GHS). ICF Macro, an ICF International Company, provided technical support for the survey through the MEASURE DHS programme. Funding for the survey came from the United States Agency for International Development (USAID), through its office in Ghana, and the Government of Ghana, with support from the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the Ghana AIDS Commission (GAC), and the Danish Development Agency (DANIDA). The survey was conducted from 8 September to 25 November 2008 on a nationally representative sample of 12,323 households.2 Each of these households was visited to obtain information about the household using the Household Questionnaire. The Household Questionnaire 2 The GDHS 2008 sample was designed to be large enough to provide a sampling frame to conduct case-specific child mortality surveillance for children under five years of age using a Verbal Autopsy Questionnaire. Introduction | 5 was also used to identify deaths of children under five years occurring in the household since January 2005. Based on this information, a Verbal Autopsy Questionnaire was administered in each household with identified deaths. Data on causes of childhood mortality based on the verbal autopsy are not included in this report and will be presented later as a separate publication. 1.5 SAMPLE DESIGN The 2008 GDHS was a household-based survey, implemented in a representative probability sample of more than 12,000 households selected nationwide. This sample was selected in such a manner as to allow for separate estimates of key indicators for each of the 10 regions in Ghana, as well as for urban and rural areas separately. The 2008 GDHS utilised a two-stage sample design. The first stage involved selecting sample points or clusters from an updated master sampling frame constructed from the 2000 Ghana Population and Housing Census. A total of 412 clusters were selected from the master sampling frame. The clusters were selected using systematic sampling with probability proportional to size. A complete household listing operation was conducted from June to July 2008 in all the selected clusters to provide a sampling frame for the second stage selection of households. The second stage of selection involved the systematic sampling of 30 of the households listed in each cluster. The primary objectives of the second stage of selection were to ensure adequate numbers of completed individual interviews to provide estimates for key indicators with acceptable precision and to provide a sample large enough to identify adequate numbers of under-five deaths to provide data on causes of death. Data were not collected in one of the selected clusters due to security reasons, resulting in a final sample of 12,323 selected households. Weights were calculated taking into consideration cluster, household, and individual non-responses, so the representations were not distorted. 1.6 QUESTIONNAIRES Each household selected for the GDHS was eligible for interview with the Household Questionnaire. In half of the households selected for the survey, all women age 15-49 and all men age 15-59 were eligible to be interviewed if they were either usual residents of the households or visitors present in the household on the night before the survey. Height and weight measurements of female respondents and children under the age of five years were done only in the households selected for the individual interview. Eligible women and children age 6 to 59 months in the households selected for individual interview were also tested for anaemia. Three questionnaires were used for the 2008 GDHS: the Household Questionnaire, the Women’s Questionnaire and the Men’s Questionnaire. The content of these questionnaires was based on model questionnaires developed by the MEASURE DHS programme and the 2003 GDHS Questionnaires. A questionnaire design workshop organised by GSS was held in Accra to obtain input from the Ministry of Health and other stakeholders on the design of the 2008 GDHS Questionnaires. Based on the questionnaires used for the 2003 GDHS, the workshop and several other informal meetings with various local and international organisations, the DHS model questionnaires were modified to reflect relevant issues in population, family planning, domestic violence, HIV/AIDS, malaria and other health issues in Ghana. These questionnaires were translated from English into three major local languages, namely Akan, Ga, and Ewe. The questionnaires were pre-tested in July 2008. The lessons learnt from the pre-test were used to finalise the survey instruments and logistical arrangements. 6 | Introduction The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor and roof of the house, ownership of various durable goods, and ownership and use of mosquito nets. The Household Questionnaire was also used to record height and weight measurements, consent for, and the results of, haemoglobin measurements for women age 15-49 and children under five years. The haemoglobin testing procedure is described in detail in the next section. The Household Questionnaire was also used to record all deaths of household members that occurred since January 2003. Based on this information, in each household that reported the death of a child under age five years since January 2005,3 field editors administered a Verbal Autopsy Questionnaire. Data on child mortality based on the verbal autopsy will be presented in a separate publication. The Women’s Questionnaire was used to collect information from all women age 15-49 in half of selected households. These women were asked questions about themselves and their children born in the five years since 2003 on the following topics: education, residential history, media exposure, reproductive history, knowledge and use of family planning methods, fertility preferences, antenatal and delivery care, breastfeeding and infant and young child feeding practices, vaccinations and childhood illnesses, marriage and sexual activity, woman’s work and husband’s background characteristics, childhood mortality, awareness and behaviour about AIDS and other sexually transmitted infections (STIs), awareness of TB and other health issues, and domestic violence. The Women’s Questionnaire included a series of questions to obtain information on women’s exposure to malaria during their most recent pregnancy in the five years preceding the survey and the treatment for malaria. In addition, women were asked if any of their children born in the five years preceding the survey had fever, whether these children were treated for malaria and the type of treatment they received. The Men’s Questionnaire was administered to all men age 15-59 living in half of the selected households 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 or nutrition. 1.7 HAEMOGLOBIN TESTING In half of households selected for the 2008 GDHS survey, consenting women age 15-49 and children age 6-59 months were tested for anaemia. The protocol for haemoglobin testing was approved by the ICF Macro Institutional Review Board (IRB) in Calverton, Maryland, USA and the Ghana Health Service Ethical Review Committee in Accra, Ghana. Haemoglobin testing is the primary method of anaemia diagnosis. Testing was done using the HemoCue system. A consent statement was read to the eligible respondent or to the parent or responsible adult for young children and unmarried women age 15-17. This statement explained the purpose of the test, indicated that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. In the case of persons whose haemoglobin level was lower than the cut-off point, a referral form was provided to the respondent to be taken to a doctor or a health facility. 3 Data were collected for all members of the household who had died in the five years preceding the survey (January 2003-November 2008). However, the verbal autopsy questionnaire was only administered for children under age five at the time of death, who died in the three years preceding the survey (between January 2005- November 2008). Introduction | 7 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 the case of adults and children six months of age and older) was pricked with a sterile, non-reusable, self-retractable lancet and a drop of blood collected on a HemoCue microcuvette, which serves as a measuring device, 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 lower than the cut-off point and who agreed to have their condition reported, a referral form was given to be taken to a local health personnel or health facility. 1.8 PRE-TEST, TRAINING, AND FIELDWORK 1.8.1 Pre-test Pre-test training and practice fieldwork were conducted from 23 June to 12 July 2008 for 14 participants: seven women and seven men. Training entailed classroom discussions and practice focusing on the three questionnaires: Household Questionnaire, Women’s Questionnaire, and Men’s questionnaire. Two trainers assigned by the GSS conducted the training with support from ICF Macro. Guest speakers from the MOH were invited to make short presentations on family planning, child health, and nutrition programmes in place in Ghana. The participants, most of whom had been involved in the previous DHS survey, actively discussed the questionnaires and made suggestions for modifications. Based on these suggestions, all versions of the questionnaires (English, Akan, Ewe, and Ga) were updated for the pre-test fieldwork. Pre-test fieldwork was done in several stages. Interviewers were divided into four teams and during the period July 7-11 all teams worked in three urban areas and two rural areas. A total of 68 women’s interviews, 66 men’s interviews, and 79 household interviews were completed. Interviews were conducted in English, Akan, Ewe, and Ga. By the end of the pre-test, a few errors in skip patterns and translation were identified and corrected. 1.8.2 Training and Fieldwork Fieldwork training began on 11 August 2008 at Winneba Sports College, located about 35 miles west of Accra. Three weeks of training on the GDHS were followed by three days of training on the Verbal Autopsy Questionnaire for deaths of children under five years. A total of 160 persons were trained on the GDHS at one training location. The first week of training also included 10 data entry personnel. Most of the trainees had prior experience as interviewers in previous GDHS surveys. The trainees were also recruited on the basis of language skills. Interviewer training was conducted mostly in English by senior staff from GSS, with technical input from ICF Macro. In addition, resource persons from other agencies made presentations on family planning, Ghana’s programme on Integrated Management of Childhood Illnesses (IMCI), nutrition and anthropometric measurements, and malaria. All participants were trained on 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 written tests. All of the participants were trained on how to complete the Household Questionnaire, the Women’s Questionnaire and the Men’s Questionnaire, and how to collect anthropometric measurements. In addition to interviewer training, all female interviewers were trained in anaemia testing and in informed consent procedures. Training included four days of field practice, three days implementing the Household and Individual Questionnaires, and one day implementing the Verbal Autopsy Questionnaires. Trainees also practiced interviewing (mock interviews) in English as well as in the local languages. During training, it was emphasised that only female interviewers interview respondents for the Women’s Questionnaire and only male interviewers interview respondents for the Men’s Questionnaire. Trainees selected as supervisors and field editors were given an additional two days of training on 8 | Introduction how to supervise fieldwork and edit questionnaires, followed by three days of training on the Verbal Autopsy Questionnaire for deaths of children under five years. At the end of the main training 23 teams were designated to carry out the fieldwork. Each team was composed of one supervisor, one editor, two female interviewers, two male interviewers, and a driver. A standby list of 22 people was kept for replacement in cases of interviewer attrition. Interviewers were selected on the basis of in-class participation, field practice, fluency in the Ghanaian languages, and an assessment test. The most experienced trainees, those who had participated in the pre-test and those who did extremely well during the training were selected to be supervisors and editors. Senior staff from GSS coordinated and supervised the fieldwork activities. ICF Macro partici- pated in field supervision of interviews, weight and height measurements, and blood sample col- lection. Data collection took place over a two and half-month period, from early September to late November 2008.4 1.9 DATA PROCESSING The processing of the GDHS results began shortly after the fieldwork commenced. Com- pleted questionnaires were returned periodically from the field to the GSS office in Accra, where they were entered and edited by data processing personnel who were specially trained for this task. Data were entered using CSPro, a programme specially developed for use in DHS surveys. All data were entered twice (100 percent verification). The concurrent processing of the data was a distinct advan- tage for data quality, because GSS had the opportunity to advise field teams of problems detected during data entry. The data entry and editing phase of the survey was completed in February 2009. 1.10 RESPONSE RATES Table 1.1 shows response rates for the 2008 GDHS. A total of 12,323 households were selected in the sample, of which 11,913 were occupied at the time of the fieldwork. This difference between selected and occupied households occurred mainly because some of the selected structures were found to be vacant or destroyed. The number of occupied households successfully interviewed was 11,778, yielding a household response rate of 99 percent. In the households selected for individual interview in the survey (50 percent of the total 2008 GDHS sample), a total of 5,096 eligible women were identified; interviews were completed with 4,916 of these women, yielding a response rate of 97 percent. In the same households, a total of 4,769 eligible men were identified and interviews were completed with 4,568 of these men, yielding a response rate of 96 percent. The response rates are slightly lower 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. 4 Several weeks before the start of training, GSS decided to increase the number of field teams from the originally planned 15 to a total of 23. The increase in field teams was done in order to conclude all data collection prior to national elections held on 7 December 2008. The increase in the number of field teams reduced the period of data collection from 120 to 79 days. Introduction | 9 Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Ghana 2008 Residence Result Urban Rural Total Household interviews Households selected 5,458 6,865 12,323 Households occupied 5,252 6,661 11,913 Households interviewed 5,175 6,603 11,778 Household response rate1 98.5 99.1 98.9 Interviews with women age 15-49 Number of eligible women 2,239 2,857 5,096 Number of eligible women interviewed 2,162 2,754 4,916 Eligible women response rate2 96.6 96.4 96.5 Interviews with men age 15-59 Number of eligible men 2,014 2,755 4,769 Number of eligible men interviewed 1,914 2,654 4,568 Eligible men response rate2 95.0 96.3 95.8 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 Presented in this chapter are descriptive summaries of the social, economic, and demographic characteristics of households sampled for the survey. The basic characteristics of the sampled population, that is, age, sex, education, and place of residence and the socio-economic conditions of the households, form the basis of the background information by which most key demographic and health indices are analysed throughout this report. This information is crucial for the interpretation of key demographic and health indicators from which to draw meaningful policies and programmes for intervention, and for measuring the representativeness of the survey. One focus of this chapter is to describe the environment in which men, women, and children live. This description presents the general characteristics of the population, such as the age-sex structure, literacy and education, household arrangements (headship, size), and housing facilities (sources of water supply, sanitation facilities, dwelling characteristics and household possessions). A distinction is made between urban and rural areas because many of these indicators differ by urban- rural residence. In the 2008 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 arrange- ments, and eat together as a 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 of the household or the de facto household population (including visitors who spent the night preceding the interview in the household and who were present at the time of the interview). 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important variables in analysing demographic trends. Table 2.1 and Figure 2.1 present the distribution of the de facto household population in the 2008 GDHS survey by five- year age groups, according to sex and urban-rural residence. 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. However, while the results of the 2008 GDHS indicate that 41 percent of the population is under 15 years, this is an improvement since the 2003 survey in which 44 percent of the population was under 15 years. Five percent of the population is in the older age groups (65 years and above), and this has not changed much since 2003. 12 | Household Population and Housing Characteristics 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 2008 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 13.0 10.8 11.8 15.2 13.8 14.5 14.3 12.5 13.3 5-9 13.2 11.7 12.4 16.6 15.0 15.7 15.2 13.5 14.3 10-14 12.7 12.3 12.5 14.7 12.4 13.5 13.8 12.4 13.1 15-19 10.7 10.3 10.5 10.8 9.1 9.9 10.7 9.7 10.2 20-24 9.1 9.6 9.4 6.3 7.4 6.8 7.5 8.4 7.9 25-29 7.9 9.3 8.7 5.7 7.5 6.6 6.7 8.3 7.5 30-34 6.4 6.9 6.7 4.9 5.6 5.3 5.5 6.2 5.9 35-39 5.8 6.3 6.0 5.3 5.7 5.5 5.5 6.0 5.7 40-44 4.2 4.7 4.5 3.9 4.5 4.2 4.0 4.6 4.3 45-49 4.1 4.3 4.2 3.9 4.0 3.9 4.0 4.1 4.0 50-54 3.6 4.4 4.1 3.0 4.0 3.5 3.3 4.2 3.7 55-59 2.8 2.6 2.7 2.2 2.7 2.5 2.4 2.7 2.5 60-64 2.3 2.0 2.1 2.3 2.3 2.3 2.3 2.1 2.2 65-69 1.5 1.3 1.4 1.7 1.8 1.8 1.6 1.6 1.6 70-74 1.2 1.6 1.4 1.6 1.8 1.7 1.5 1.7 1.6 75-79 0.7 0.9 0.8 0.9 0.9 0.9 0.8 0.9 0.9 80+ 0.7 1.0 0.8 1.0 1.4 1.2 0.9 1.2 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 8,706 10,144 18,850 11,920 12,510 24,430 20,626 22,654 43,280 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 GDHS 2008 Male Percent Female Age 2.2 HOUSEHOLD COMPOSITION The size and composition of households and the sex of the head of household are important factors affecting the welfare of the household. Table 2.2 shows the information collected in the 2008 GDHS on the sex of the head of household and the mean household size. In Ghana, the mean household size is 3.7 persons, with households in rural areas being larger (4.0 persons) than those in urban areas (3.4 persons). Household Population and Housing Characteristics | 13 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18, according to residence, Ghana 2008 Characteristic Residence Total Urban Rural Household headship Male 63.2 69.2 66.3 Female 36.8 30.8 33.7 Total 100.0 100.0 100.0 Number of usual members 1 24.7 19.3 21.9 2 16.1 13.8 14.9 3 16.1 14.8 15.4 4 14.0 14.0 14.0 5 12.1 12.2 12.1 6 7.4 9.8 8.7 7 4.5 6.4 5.5 8 2.1 4.0 3.1 9+ 2.7 5.6 4.2 Total 100.0 100.0 100.0 Mean size of households 3.4 4.0 3.7 Percentage of households with orphans and foster children under 18 years of age Foster children1 18.0 19.0 18.6 Double orphans 1.0 0.7 0.9 Single orphans 6.5 7.7 7.1 Foster and/or orphan children 20.9 22.5 21.7 Number of households 5,627 6,150 11,777 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under 18 years of age living in households where neither their mother nor their father is a de jure resident. Two-thirds (66 percent) of households are headed by males, while one-third (34 percent) are headed by females. The percentage of female-headed households is higher in urban areas (37 percent) than in rural areas (31 percent). Single-person households are more common in urban areas (25 percent) than rural areas (19 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. 2.2.1 Children’s Living Arrangements and Orphanhood Information on households with foster children and orphans was collected in the 2008 GDHS. Foster children are defined here as children under age 18 living in households with neither their mother nor their father present; orphans are children with one or both parents dead. Foster children and orphans are of concern because they may be at increased risk of neglect or exploitation when their mothers or fathers are not present to assist them. Table 2.3 shows the distribution of foster children and children with one or both parent dead, according to background characteristics. The table is based on de jure household members. Eighteen percent of children under age 18 are foster children and 8 percent are orphan children. The percentage of foster and orphan children is higher in urban areas (20 and 8 percent, respectively) than rural areas (16 and 7 percent, respectively). 14 | Household Population and Housing Characteristics Table 2.3 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents; the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Ghana 2008 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percent- age not living with a biological parent Percent- age with one or both parents dead Number of children Both alive Only father alive Only mother alive Both dead Missing informa- tion on father/ mother1 Father alive Father dead Mother alive Mother dead Age 0-4 65.2 23.9 1.3 2.0 0.2 6.4 0.4 0.2 0.2 0.2 100.0 7.2 2.3 5,832 <2 69.1 27.0 0.7 0.7 0.1 2.0 0.3 0.0 0.2 0.1 100.0 2.4 1.2 2,243 2-4 62.8 21.9 1.6 2.9 0.3 9.1 0.6 0.3 0.3 0.4 100.0 10.2 3.0 3,589 5-9 54.4 18.3 3.3 5.3 0.7 15.1 1.1 1.1 0.4 0.3 100.0 17.6 6.6 6,261 10-14 47.3 16.8 5.0 6.4 1.0 18.9 1.4 2.0 1.0 0.2 100.0 23.4 10.5 5,717 15-17 41.4 16.5 6.4 6.5 1.5 19.8 1.7 3.9 1.6 0.7 100.0 27.0 15.1 2,727 Sex Male 55.5 18.5 3.6 5.6 0.8 12.8 0.9 1.3 0.6 0.4 100.0 15.6 7.2 10,378 Female 52.0 19.9 3.6 4.0 0.7 15.9 1.3 1.6 0.7 0.3 100.0 19.5 8.0 10,159 Residence Urban 48.2 22.0 3.9 4.6 0.7 16.5 1.2 1.6 0.9 0.3 100.0 20.2 8.4 8,224 Rural 57.5 17.3 3.4 5.0 0.8 12.9 1.0 1.3 0.5 0.3 100.0 15.7 7.0 12,313 Region Western 59.7 15.8 2.7 5.2 0.6 12.8 1.0 1.5 0.3 0.2 100.0 15.7 6.2 1,969 Central 43.0 27.8 3.4 4.7 0.7 17.0 1.2 1.4 0.4 0.4 100.0 20.0 7.0 2,047 Greater Accra 52.6 19.4 4.8 4.5 1.1 13.9 1.1 1.4 1.2 0.1 100.0 17.5 9.5 2,483 Volta 48.7 22.6 2.1 3.5 0.5 18.4 1.6 1.7 0.4 0.5 100.0 22.1 6.3 1,830 Eastern 49.7 20.7 2.3 7.3 0.9 16.7 0.9 0.5 0.5 0.4 100.0 18.6 5.1 2,052 Ashanti 43.9 26.3 3.8 5.1 0.4 16.9 1.3 1.8 0.4 0.1 100.0 20.4 7.7 3,673 Brong Ahafo 50.7 21.7 5.0 3.7 0.8 15.1 1.4 0.9 0.5 0.3 100.0 17.8 8.7 2,015 Northern 75.5 5.9 1.7 4.4 0.9 8.1 0.5 0.7 1.7 0.7 100.0 11.0 5.5 2,580 Upper East 63.6 9.7 7.6 5.0 1.2 8.5 0.6 3.4 0.3 0.1 100.0 12.9 13.1 1,289 Upper West 61.7 10.9 4.9 4.4 1.1 12.2 1.6 2.4 0.4 0.3 100.0 16.7 10.5 598 Wealth quintile Lowest 68.6 10.0 3.9 5.1 1.2 8.0 0.6 1.4 0.8 0.2 100.0 10.9 8.0 4,654 Second 51.5 21.9 3.4 4.2 0.5 15.3 1.2 1.1 0.6 0.4 100.0 18.2 6.8 4,405 Middle 41.0 27.9 4.1 5.2 0.6 17.1 1.7 1.3 0.5 0.5 100.0 20.7 8.3 4,161 Fourth 49.9 21.1 4.0 4.6 0.6 16.6 1.0 1.5 0.5 0.3 100.0 19.6 7.6 3,886 Highest 56.5 15.4 2.5 5.1 0.8 15.7 0.8 2.1 1.0 0.1 100.0 19.5 7.2 3,431 Total <15 55.7 19.6 3.2 4.6 0.7 13.5 1.0 1.1 0.5 0.3 100.0 16.1 6.4 17,810 Total <18 53.8 19.2 3.6 4.8 0.8 14.3 1.1 1.5 0.7 0.3 100.0 17.5 7.6 20,537 Note: Table is based on de jure children who usually live in the household. 1 Includes children with father dead, mother dead, both dead and one parent dead but missing information on survival status of the other parent. Detailed information on living arrangements and orphanhood for children under age 18 is presented in Table 2.3. Of the 20,537 children under age 18 reported in the 2008 GDHS, about 54 percent live with both parents, 19 percent live with their mother only, although their father is alive, 5 percent live with their father only, although their mother is alive, and 14 percent live with neither of their natural parents, although both parents are alive. Table 2.3 also provides data on the extent of orphanhood, that is, the proportion of children who have lost one or both parents. Less than one percent of children under age 18 have both parents dead while 8 percent have one or both parents dead. The percentage of children living with both biological parents decreases with increasing age of the child. Children in rural areas are more likely than those in urban areas to live with both parents. The highest proportion of children living with both parents is in the Northern region (76 percent), followed by the Upper East and Upper West regions (64 and 62 percent, respectively). By wealth status, the proportion of children under age 18 living with both parents shows a U-shaped pattern with increasing wealth quintile. The highest proportions are among children in the lowest and highest wealth quintiles (69 and 57 percent, respectively) and the lowest proportion is in the middle wealth quintile (41 percent). Household Population and Housing Characteristics | 15 2.2.2 School Attendance by Survivorship of Parents Children who are orphaned or live in a house with chronically ill adults may be at a greater risk of dropping out of school because of lack of money to pay school fees or the need to stay at home to care for the sick relative. The GDHS included information to monitor such situations and collected information on school attendance of children age 10-14 by parental survival. The proportion of children age 10-14 attending school whose parents are both dead is 67 percent and the proportion whose parents are both living and the child is residing with at least one parent is 88 percent (data not shown separately). The overall ratio of school attendance of children whose parents are dead to those whose parents are living, and the child resides with at least one parent, is 0.76. Further breakdown by background characteristics was not possible due to the low number of orphans (60 unweighted cases). 2.3 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Education is important because it helps individuals make informed decisions that impact their health and well-being. Ghana’s educational system 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 until the introduction of the current system of education, the six years of primary education were 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 many institutions offering vocational, technical, and professional training that may be tertiary or non-tertiary. Over the past decade there have been many changes in the education sector. At the Basic Education Level, pre-school education has officially been incorporated into the education system and all primary schools are required to have nurseries or kindergarten. At the secondary level, since the 2007/2008 academic year, the three-year Senior Secondary School System has been changed to the four-year Senior High School.1 The different systems of formal education have been taken into account in tabulating the educational attainment of women and men interviewed in the 2008 GDHS. Table 2.4.1 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-one percent of women have never been to school, about 31 percent have some primary or have completed primary school, 36 percent have some secondary or have completed secondary school, and about 3 percent have more than secondary school education. The data show 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, which was introduced in 1996. Education varies by place of residence. Urban women are more likely to be educated than rural women. For instance, 21 percent of urban females have no education, compared with 40 percent of rural females. The proportion of urban females with some secondary education or higher (52 percent) is almost twice as high as that of rural females (27 percent). 1 The change in name from Senior Secondary to Senior High School and the change from three years to four years have not affected the results of the GDHS. 16 | Household Population and Housing Characteristics It is notable that females in the northern half of the country (the Northern, Upper East, and Upper West regions) are seriously disadvantaged. More than half to two-thirds of women in these three regions have never been to school, compared with less than one-fifth in the Greater Accra and Ashanti regions. In addition, 21 percent of females in Greater Accra have completed secondary education or higher, compared with 4 percent or less in the Northern, Upper East and Upper West regions. It is worth noting that the proportion of female household members who have never attended school decreases with higher wealth status. Sixty-two percent of women in the lowest wealth quintile have no education, compared with only 10 percent in the highest quintile. Table 2.4.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Ghana 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 48.2 51.3 0.1 0.1 0.0 0.0 0.2 100.0 2,506 0.0 10-14 7.9 67.7 9.7 14.6 0.0 0.0 0.1 100.0 2,806 3.4 15-19 10.1 15.8 9.4 58.7 5.7 0.3 0.0 100.0 2,189 6.9 20-24 16.8 11.3 5.7 41.6 19.8 4.8 0.0 100.0 1,897 8.3 25-29 23.1 12.5 5.3 39.2 12.9 6.9 0.0 100.0 1,876 8.1 30-34 30.0 13.3 5.6 37.6 9.2 4.2 0.2 100.0 1,400 6.2 35-39 33.3 13.6 4.8 39.0 6.3 2.8 0.3 100.0 1,353 5.6 40-44 36.1 12.4 5.1 38.3 5.4 2.6 0.0 100.0 1,046 5.3 45-49 38.9 12.3 3.6 35.0 5.8 4.3 0.0 100.0 928 4.5 50-54 42.1 11.7 4.0 32.7 4.4 4.7 0.4 100.0 945 3.6 55-59 50.5 9.8 2.9 26.1 5.1 5.1 0.4 100.0 603 0.0 60-64 65.0 7.8 0.7 18.7 3.1 4.6 0.0 100.0 482 0.0 65+ 79.9 6.9 1.2 9.4 1.1 1.3 0.1 100.0 1,233 0.0 Residence Urban 20.5 22.2 5.4 36.6 10.4 4.8 0.2 100.0 8,830 6.2 Rural 40.3 28.0 5.0 23.4 2.4 0.8 0.1 100.0 10,453 1.6 Region Western 24.9 28.1 5.5 32.0 5.9 3.5 0.1 100.0 1,738 4.5 Central 30.6 29.6 5.4 29.5 3.5 1.4 0.1 100.0 1,965 3.3 Greater Accra 15.7 19.2 5.6 38.2 14.8 6.6 0.0 100.0 2,904 8.1 Volta 33.3 27.5 7.2 26.1 4.0 1.8 0.2 100.0 1,817 3.0 Eastern 24.8 25.1 7.1 36.4 4.7 1.6 0.3 100.0 1,966 5.0 Ashanti 19.0 28.1 4.0 39.1 6.9 2.7 0.2 100.0 3,629 5.5 Brong Ahafo 33.6 26.6 6.6 28.7 3.6 1.1 0.0 100.0 1,727 3.0 Northern 67.5 17.9 2.7 7.9 2.7 1.0 0.2 100.0 1,886 0.0 Upper East 55.0 27.5 2.9 10.1 2.5 1.9 0.1 100.0 1,136 0.0 Upper West 54.0 27.4 2.9 12.2 2.6 0.8 0.1 100.0 515 0.0 Wealth quintile Lowest 62.1 25.3 3.3 8.5 0.6 0.1 0.1 100.0 3,506 0.0 Second 39.0 30.4 5.5 23.6 1.2 0.1 0.1 100.0 3,816 1.6 Middle 29.9 28.2 6.3 31.9 3.1 0.5 0.2 100.0 4,051 3.6 Fourth 19.2 24.6 5.8 40.4 7.9 2.0 0.1 100.0 3,892 5.9 Highest 10.1 18.5 4.6 40.0 16.6 10.0 0.1 100.0 4,019 8.5 Total 31.3 25.4 5.2 29.4 6.1 2.6 0.1 100.0 19,283 3.7 Note: Total includes females with information missing on age who are not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Household Population and Housing Characteristics | 17 Table 2.4.2 shows that 22 percent of males have never been to school, 30 percent have had some primary or have completed primary education, 42 percent have had some secondary or have completed secondary education, and nearly 6 percent have more than secondary education. Twenty- nine percent of males in rural areas have no education, compared with 13 percent in urban areas. There is a marked urban-rural differential in secondary and higher education: 25 percent of males in urban areas have completed secondary or higher education, compared with only 8 percent in rural areas. Across regions, the pattern for males is similar to the pattern for females. Males in the three northern regions are disadvantaged because 41 to 51 percent have never been to school, compared with less than 20 percent in the other regions, except Brong Ahafo region (26 percent). Variation in education among males according to household wealth status shows a pattern similar to that observed for the female population. Males in households in the upper wealth quintiles are less likely to have no education than those in other quintiles. For example, only 5 percent of males in the highest wealth quintile have no education, compared with 48 percent of those in the lowest quintile. Table 2.4.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Ghana 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 49.9 49.7 0.1 0.2 0.0 0.0 0.1 100.0 2,584 0.0 10-14 8.3 69.6 8.4 13.6 0.0 0.0 0.1 100.0 2,848 3.2 15-19 6.8 17.9 9.5 59.7 5.8 0.4 0.1 100.0 2,215 7.1 20-24 10.0 7.3 3.9 43.4 27.8 7.5 0.1 100.0 1,542 8.7 25-29 13.7 7.2 4.6 40.7 19.5 14.2 0.2 100.0 1,374 8.6 30-34 16.0 6.1 4.8 43.6 18.5 10.9 0.1 100.0 1,143 8.6 35-39 22.5 9.8 3.2 42.2 14.0 8.0 0.3 100.0 1,133 8.9 40-44 24.2 6.8 3.8 44.9 10.8 9.3 0.2 100.0 834 9.2 45-49 25.5 5.6 2.4 43.0 13.2 10.4 0.0 100.0 815 9.3 50-54 20.4 9.1 2.2 42.5 11.3 14.2 0.3 100.0 671 9.4 55-59 21.5 5.0 2.1 44.1 12.8 14.3 0.3 100.0 499 9.4 60-64 37.1 6.6 2.7 34.6 7.9 11.1 0.0 100.0 476 9.0 65+ 53.2 7.0 2.2 26.9 3.9 6.5 0.3 100.0 985 0.0 Residence Urban 13.3 21.2 4.1 36.2 15.4 9.7 0.1 100.0 7,385 8.2 Rural 29.1 28.5 4.9 29.8 4.9 2.7 0.1 100.0 9,743 3.5 Region Western 15.7 22.6 5.4 38.9 9.2 8.2 0.0 100.0 1,712 7.0 Central 18.0 29.1 4.6 37.3 6.6 4.3 0.2 100.0 1,581 5.6 Greater Accra 9.2 18.7 3.7 35.7 20.8 11.8 0.2 100.0 2,476 8.9 Volta 19.6 26.4 6.1 36.4 7.1 4.3 0.1 100.0 1,541 5.6 Eastern 15.0 25.6 5.9 42.8 6.7 3.9 0.1 100.0 1,756 6.6 Ashanti 13.3 25.8 3.7 40.7 10.5 6.0 0.0 100.0 2,991 7.0 Brong Ahafo 26.4 29.0 5.4 28.2 7.2 3.6 0.1 100.0 1,559 3.8 Northern 51.1 23.6 3.0 13.2 5.4 3.3 0.3 100.0 1,956 0.0 Upper East 43.0 31.7 5.0 12.9 4.2 3.2 0.0 100.0 1,080 0.8 Upper West 41.1 31.2 4.1 15.1 5.3 2.9 0.3 100.0 477 1.0 Wealth quintile Lowest 48.2 29.5 4.6 15.4 1.8 0.3 0.1 100.0 3,518 0.1 Second 25.8 30.3 5.4 32.7 4.2 1.4 0.1 100.0 3,353 3.8 Middle 19.7 27.9 5.7 37.5 6.7 2.3 0.1 100.0 3,276 5.4 Fourth 12.1 22.7 4.0 42.9 12.5 5.7 0.1 100.0 3,440 8.1 Highest 5.4 16.7 3.1 34.9 21.3 18.4 0.2 100.0 3,541 9.4 Total 22.3 25.4 4.5 32.6 9.4 5.7 0.1 100.0 17,128 5.4 Note: Total includes males with information missing on age who are not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level 18 | Household Population and Housing Characteristics Males are more likely to be educated than females at all levels of education; thus females continue to lag behind males in education. The median number of years of schooling completed is higher for males (5.4 years) than females (3.7 years). There has been some improvement in the proportion of the population with no education since the last GDHS survey. The proportion of females with no education dropped from 37 percent in 2003 to 31 percent in 2008 and the median number of years of schooling for females nearly doubled from 2.1 to 3.7 years. Similarly, the proportion of males with no education dropped from 26 to 22 percent, with the median years of schooling increasing from 3.9 to 5.4 years. Thus, the male-female gap in educational attainment has narrowed slightly over the period. The 2008 GDHS collected information on school attendance for the population age 3-24 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 (12-17 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 6-25. 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 2.5 presents data on the NAR and GAR for the de facto household population by level of schooling and sex, according to place of residence, region and wealth quintile. Seventy-four 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 108 percent. The distribution shows that both the NAR and GAR are much lower at the secondary school level: 42 percent of students age 12-17 who should be attending secondary school are in school (NAR). The GAR for secondary school is 57 percent. The 2008 GAR was calculated based on the de facto secondary-school-age (12-17) population; however, the 2003 GAR was calculated based on the de jure secondary-school-age (12- 18) population. To enable comparison, the 2008 data were re-calculated using the de jure secondary- school-age (12-18) population. The resulting GAR was 49 percent, which indicates that there has been an increase (improvement) in the proportion of underage or overage youths in secondary school since 2003 (41 percent). The results show slightly higher NARs for females than males at both the primary and secondary school levels, which indicates that that there is not much of a gender gap in school attendance for 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 relatively higher overage or underage attendance among males than females. 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 70 percent compared with 80 percent in urban areas. Similarly, the GAR at the secondary school level is 48 percent in rural areas, compared with 68 percent in urban areas. Regional differences are obvious for the NAR and GAR with attendance ratios notably lower in the Northern and Upper West regions, compared with all other regions, and especially in the case of the GAR at the primary school level for the Northern region (76 percent, compared with the overall GAR of 108 percent). 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 59 percent among students from poorer households (lowest wealth quintile) in primary school to 86 percent among pupils from richer households (highest wealth quintile). Similarly, the GAR rises from 34 percent among secondary school attendees in the lowest wealth quintile to 76 percent among those in the highest wealth quintile. Household Population and Housing Characteristics | 19 Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), by background characteristics, Ghana 2008 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index (GPI)3 Male Female Total Gender Parity Index (GPI)3 PRIMARY SCHOOL Residence Urban 81.0 79.5 80.3 0.98 110.2 108.9 109.5 0.99 Rural 68.8 70.8 69.8 1.03 107.1 105.9 106.6 0.99 Region Western 72.0 71.3 71.6 0.99 105.7 102.7 104.2 0.97 Central 74.3 76.1 75.2 1.02 105.0 114.3 109.6 1.09 Greater Accra 82.7 77.7 80.3 0.94 111.4 106.9 109.2 0.96 Volta 67.9 75.5 71.7 1.11 114.7 120.2 117.4 1.05 Eastern 75.9 74.8 75.4 0.99 116.5 104.3 110.3 0.90 Ashanti 86.8 85.7 86.2 0.99 118.4 113.9 116.1 0.96 Brong Ahafo 73.9 77.4 75.6 1.05 115.4 115.7 115.6 1.00 Northern 55.7 50.4 53.3 0.90 78.4 72.3 75.6 0.92 Upper East 68.5 75.9 71.9 1.11 115.2 120.9 117.8 1.05 Upper West 62.1 67.5 64.7 1.09 105.9 103.8 104.9 0.98 Wealth quintile Lowest 58.2 60.1 59.1 1.03 97.7 93.7 95.8 0.96 Second 72.3 71.6 71.9 0.99 111.5 106.6 109.1 0.96 Middle 74.8 78.1 76.5 1.04 112.0 115.5 113.7 1.03 Fourth 82.1 81.5 81.8 0.99 113.5 113.9 113.7 1.00 Highest 87.6 84.4 85.9 0.96 109.2 108.0 108.6 0.99 Total 73.4 74.2 73.8 1.01 108.3 107.1 107.7 0.99 SECONDARY SCHOOL Residence Urban 53.0 50.9 51.9 0.96 72.8 63.6 67.8 0.87 Rural 34.3 34.9 34.5 1.02 51.1 44.6 48.1 0.87 Region Western 49.1 43.7 46.6 0.89 66.5 58.0 62.6 0.87 Central 43.3 36.5 39.6 0.84 64.5 43.3 53.0 0.67 Greater Accra 52.0 52.2 52.1 1.00 69.5 64.6 66.8 0.93 Volta 37.9 40.6 39.3 1.07 63.6 57.2 60.4 0.90 Eastern 41.1 44.5 42.8 1.08 51.2 56.7 53.8 1.11 Ashanti 52.6 52.8 52.7 1.00 68.8 59.7 64.1 0.87 Brong Ahafo 38.8 38.7 38.8 1.00 58.2 50.9 54.6 0.87 Northern 25.1 26.2 25.6 1.05 46.8 37.0 42.2 0.79 Upper East 28.0 33.3 30.5 1.19 42.4 44.1 43.2 1.04 Upper West 26.6 26.0 26.3 0.98 44.6 44.5 44.6 1.00 Wealth quintile Lowest 24.4 19.3 22.2 0.79 38.5 27.9 33.9 0.72 Second 33.9 36.0 34.9 1.06 52.2 45.7 49.1 0.88 Middle 43.4 39.9 41.7 0.92 60.8 52.6 56.7 0.86 Fourth 50.5 52.0 51.3 1.03 72.1 64.6 68.0 0.90 Highest 62.8 59.1 60.7 0.94 82.7 70.8 76.1 0.86 Total 41.8 42.4 42.1 1.01 59.8 53.6 56.7 0.90 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 (12-17 years) population that is attending 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 primary-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 students 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 NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. 20 | Household Population and Housing Characteristics The Gender Parity Index (GPI) represents the ratio of the NAR (or GAR) for females to the NAR (or GAR) for males. It is presented in Table 2.5 at both the primary and secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI of less than 1 indicates that a smaller proportion of females than males attend school. In Ghana, the GPI is almost 1 (0.99) for primary school attendance and slightly lower than 1 (0.90) for secondary school attendance, indicating that the gender gap is relatively small. There are no differences in the GPI by urban-rural residence. The Eastern and Northern regions showed the widest gap for primary school attendance, and the Central and Northern regions showed the widest gap for secondary school attendance. 2.3.1 Grade Repetition and Dropout Rates Table 2.6 presents school repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year, by school grade and background characteristics. Repetition and drop-out rates describe the flow of pupils through the educational system in Ghana. Repetition rates indicate the percentage of pupils who attended a particular class during the previous school year who are repeating that grade in the current school year, that is, those who were in a particular grade in the 2006/2007 academic year who attended the same grade during the 2007/2008 academic year. Drop-out rates show the percentage of pupils who attended class during the 2006/2007 academic year but did not attend school the following year. Repetition and drop-out rates approach zero when pupils nearly always progress to the next grade at the end of the school year. They often vary across grades, indicating points in the school system where pupils are not regularly promoted to the next grade or they decide to drop out of school. For both sexes the repetition rate declines from grade 1 to grade 4, rises in grade 5 and then declines again in grade 6. The repetition rates are higher for males in grades 1, 2, and 5. In grade 1 the repetition rate is 4 percent for males, compared with 3 percent for females, but in grade 6 the repetition rate for females (2 percent) is higher than that for males (1 percent). There are small variations by urban-rural residence in almost all grades, except for grade 1 where rural residents have a higher repetition rate (4 percent) than their urban counterparts (2 percent). Larger differentials are observed by region, especially in grade 1. While as high as 12 percent and 13 percent of pupils in the Upper West and Northern region, respectively, repeat grade 1, only 1 percent of pupils repeat grade 1 in the Eastern and Central regions. In the Greater Accra region no pupils repeat grades 4 through grade 6. In general, dropout rates are higher than repetition rates in all grades. Dropout rates across grades are similar (4 percent), except for grade 3, which is 5 percent. Males have higher dropout rates than females in almost all grades. From grades 3 through 6, dropout rates are higher for pupils in urban areas than those in rural areas. There are wide regional variations in dropout rates. The regions with worse rates are the Upper West, Northern, and Central regions. Almost one-fifth (17 percent) of grade 6 pupils in the Upper West region drop out of school. Dropout rates are lower for pupils in the Volta, Ashanti, and Upper East regions. Household Population and Housing Characteristics | 21 Table 2.6 Grade repetition and dropout rates for primary school Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year, by school grade and background characteristics, Ghana 2008 Background characteristic School grade 1 2 3 4 5 6 REPETITION RATE1 Sex Male 4.0 2.3 1.4 1.3 1.8 0.8 Female 2.7 1.8 1.8 1.5 1.7 1.5 Residence Urban 1.6 2.5 1.2 0.8 2.5 0.8 Rural 4.3 1.7 1.8 1.9 1.2 1.5 Region Western 2.5 2.5 2.3 4.9 3.5 0.8 Central 1.3 5.2 5.4 0.9 2.4 2.7 Greater Accra 2.2 2.0 1.6 0.0 0.0 0.0 Volta 2.0 0.0 0.4 1.5 1.4 3.1 Eastern 0.8 1.4 1.1 2.6 1.5 0.0 Ashanti 1.7 1.3 1.1 1.1 1.4 1.3 Brong Ahafo 1.5 1.3 0.0 0.0 1.2 1.5 Northern 13.0 3.2 1.1 1.5 3.6 0.0 Upper East 1.6 1.5 0.9 1.5 0.9 0.0 Upper West 12.4 2.0 2.6 0.6 1.8 3.1 Total 3.3 2.0 1.6 1.4 1.7 1.1 DROPOUT RATE2 Sex Male 4.2 4.4 4.1 4.3 3.4 4.9 Female 3.1 3.7 5.9 3.5 3.8 3.5 Residence Urban 3.3 3.9 5.5 4.6 3.8 4.5 Rural 3.9 4.1 4.6 3.4 3.6 3.9 Region Western 5.2 5.0 5.8 5.8 3.5 3.7 Central 7.3 8.2 10.7 8.5 8.6 6.2 Greater Accra 3.1 4.3 5.5 4.6 4.9 5.8 Volta 0.0 0.0 1.4 1.0 3.1 1.6 Eastern 5.0 1.3 4.5 6.7 2.0 3.0 Ashanti 0.0 2.4 2.8 0.6 0.7 0.9 Brong Ahafo 0.8 1.4 2.1 0.7 0.8 5.5 Northern 9.6 10.0 8.7 7.7 8.2 8.4 Upper East 1.6 0.5 0.0 0.0 0.0 0.0 Upper West 11.3 13.5 12.9 9.4 8.8 17.3 Total 3.7 4.0 4.9 3.9 3.7 4.2 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school. Figure 2.2 shows the age-specific attendance rates (ASAR) for the de facto household population age 5-24 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. A little over 66 percent of children age seven are attending school. School attendance rises markedly up to age 11, remains high up to age 13, and then gradually declines. There are no marked differences in the proportion of males and females attending school up to age 16, after which there are substantially higher proportions of males than females attending school. 22 | Household Population and Housing Characteristics Figure 2.2 Age-Specific School 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 Female Male GDHS 2008 2.4 HOUSING CHARACTERISTICS There is a strong correlation between the socio-economic condition of households and the vulnerability of its members, 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 2008 GDHS included questions on the household’s access to electricity, source of drinking water, type of sanitation facilities, flooring materials, and ownership of durable goods. The availability of and accessibility to improved drinking 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, schistosomiasis, trachoma, and dysentery, are common in Ghana. Table 2.7 shows the percent distribution of main sources of drinking water, time to collect drinking water, and person who usually collects drinking water and treatment of water according to residence. Overall, 77 percent of households obtain drinking water from an improved source. Fourteen percent of households have access to piped water in their dwelling, yard, or plot, while 29 percent access drinking water from a public tap. Thirty-three percent of households get their drinking water from a tube well or borehole, or a protected dug well. Thirteen percent of households use non- improved sources of drinking water and about 9 percent use either bottled or sachet water. Surprisingly, there is little difference between urban and rural households in access to improved sources of drinking water (79 and 76 percent, respectively). Household Population and Housing Characteristics | 23 Table 2.7 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and person who usually collects drinking water; and percentage of households and the de jure population that treat water before drinking, according to residence, Ghana 2008 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 78.6 76.2 77.3 81.0 75.4 77.9 Piped water into dwelling/yard/plot 27.0 2.5 14.2 27.0 2.2 13.1 Public tap/standpipe 39.2 19.7 29.0 40.0 17.9 27.6 Tube well or borehole 6.4 47.8 28.0 7.4 49.6 31.2 Protected dug well 5.7 5.1 5.4 6.2 4.9 5.5 Protected spring 0.0 0.1 0.1 0.1 0.1 0.1 Rainwater 0.2 1.0 0.6 0.1 0.7 0.5 Non-improved source 4.6 21.5 13.4 5.4 23.1 15.4 Unprotected dug well 0.9 3.4 2.2 1.2 3.7 2.6 Unprotected spring 0.1 0.9 0.6 0.2 1.1 0.7 Tanker truck/cart with small tank 1.8 0.2 1.0 2.0 0.3 1.0 Surface water 1.7 17.0 9.7 2.0 18.2 11.1 Bottled/sachet water, improved source for cooking/washing1 15.2 1.8 8.2 12.0 1.1 5.9 Bottled/sachet water, non-improved source for cooking/washing1 1.6 0.4 1.0 1.6 0.3 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 93.8 78.0 85.5 93.0 76.6 83.8 Time to obtain drinking water (round trip) Water on premises 41.6 6.1 23.1 40.2 5.5 20.7 Less than 30 minutes 50.5 72.4 61.9 50.5 69.9 61.4 30 minutes or longer 7.2 21.2 14.5 8.7 24.3 17.5 Don’t know/missing 0.7 0.4 0.5 0.7 0.3 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 31.1 56.0 44.1 33.9 60.6 49.0 Adult male 15+ 12.8 15.0 14.0 7.8 8.0 7.9 Female child under age 15 5.3 8.2 6.8 6.5 9.5 8.2 Male child under age 15 3.1 5.1 4.1 4.1 5.6 5.0 Female age 15-17 3.3 5.1 4.2 4.0 5.8 5.0 Male age 15-17 1.7 2.8 2.3 2.0 3.3 2.7 Other 1.1 1.6 1.3 1.4 1.5 1.4 Water on premises 41.6 6.1 23.1 40.2 5.5 20.7 Missing 0.0 0.1 0.1 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 2.6 1.9 2.3 2.6 1.8 2.1 Bleach/chlorine added 1.3 1.4 1.4 1.2 1.4 1.3 Strained through cloth 1.8 5.1 3.5 2.2 6.9 4.8 Ceramic, sand or other filter 1.0 0.8 0.9 1.4 0.8 1.1 Other 2.4 1.4 1.9 2.2 1.2 1.7 No treatment 91.3 90.3 90.8 90.9 88.9 89.8 Percentage using an appropriate treatment method3 6.2 8.6 7.5 6.8 10.2 8.7 Number 5,627 6,150 11,777 19,262 24,818 44,080 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents could report multiple treatment methods so the sum of treatments can exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 24 | Household Population and Housing Characteristics The major source of drinking water for rural households is tube wells or boreholes (48 percent). One-fifth of rural households use a public tap or standpipe as their main source of drinking water. Access to piped drinking water has remained about the same over the past five years (GSS and ORC Macro, 2004). It takes nine in ten urban households and nearly eight in ten rural households less than 30 minutes to obtain water from their nearest source of drinking water. Table 2.7 provides information on persons who usually collect the drinking water. Overall, adult females age 15 and above are more likely to collect drinking water for the household than men and children, and this pattern is more prevalent in the rural areas (56 percent) than in urban areas (31 percent). In about 10 percent of households, it is the responsibility of the child (either male or female) to collect drinking water. Regarding treatment of water, nine in ten households do not treat their water prior to drinking. Of households that do treat their drinking water, the most common treatment methods are straining through cloth (4 percent) and boiling (2 percent). The proportion of the population with access to improved toilet facilities, according to the WHO/UNICEF Joint Monitoring Programme (JMP), which is the UN officially mandated mechanism to monitor global progress in drinking water and sanitation (toilet facility), is the percentage of people using improved and sustainable toilet facilities. An improved toilet facility is considered the most efficient and hygienic method of human waste disposal. Table 2.8 shows the percent distribution of households by type of toilet facility, according to residence. Overall, only 11 percent of households use improved, not shared toilet facilities. There are marked differences by urban-rural residence. Sixteen percent of urban households and 7 percent of rural households use improved toilet facilities that are not shared with other households. However, nearly one in five households (18 percent) has no toilet facilities, a situation that is more common in rural areas (30 percent) than in urban areas (6 percent). Table 2.8 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Ghana 2008 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 15.6 7.3 11.3 17.8 8.2 12.4 Flush/pour flush to piped sewer system 2.2 0.6 1.4 2.6 0.5 1.4 Flush/pour flush to septic tank 8.8 0.9 4.7 9.7 1.0 4.8 Flush/pour flush to pit latrine 2.0 0.2 1.1 2.1 0.2 1.0 Ventilated improved pit (VIP) latrine 1.9 1.9 1.9 2.6 2.2 2.4 Pit latrine with slab 0.7 3.6 2.2 0.8 4.2 2.7 Composting toilet 0.0 0.1 0.0 0.0 0.1 0.1 Non-improved facility 84.3 92.8 88.8 82.1 91.8 87.7 Any facility shared with other households 72.2 48.6 59.9 68.8 42.3 53.9 Flush/pour flush not to sewer/septic tank/ pit latrine 0.1 0.0 0.1 0.1 0.0 0.1 Pit latrine without slab/open pit 4.1 14.0 9.3 4.0 13.6 9.4 Bucket 2.0 0.3 1.1 1.8 0.2 0.9 No facility/bush/field 5.6 29.5 18.1 7.2 35.4 23.1 Missing 0.3 0.4 0.3 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,627 6,150 11,777 19,262 24,818 44,080 Table 2.9 presents the distribution of households by household characteristics, according to residence. Overall, six in ten households (61 percent) in Ghana have electricity; four-fifths (85 percent) of the households in urban areas have electricity, compared with two-fifths (38 percent) of the households in rural areas. The 2008 GDHS findings show an increase in the use of electricity over the past five years, especially among rural households (48 percent in all households and 24 percent in rural households in 2003) (GSS and ORC Macro, 2004). Household Population and Housing Characteristics | 25 Table 2.9 Household characteristics Percent distribution of households and de jure population by housing characteristics; and among households using solid fuel, percent distribution by type of fire/stove, according to residence, Ghana 2008 Housing characteristic Households Population Urban Rural Total Urban Rural Total Electricity Yes 84.8 38.2 60.5 83.8 34.4 56.0 No 15.2 61.7 39.5 16.1 65.5 43.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 3.8 21.5 13.0 4.1 23.6 15.1 Dung 0.1 2.0 1.1 0.1 2.7 1.6 Wood/planks 0.1 0.0 0.1 0.1 0.0 0.1 Palm/bamboo 0.0 0.0 0.0 0.0 0.0 0.0 Parquet or polished wood 0.2 0.0 0.1 0.2 0.0 0.1 Ceramic tiles/terrazzo 5.0 0.7 2.7 5.0 0.7 2.6 Cement 56.0 65.3 60.8 58.0 64.3 61.6 Woolen carpet/synthetic carpet 18.3 3.6 10.6 17.3 2.8 9.1 Linoleum/rubber carpet 16.2 6.8 11.3 14.9 5.7 9.7 Other 0.3 0.0 0.1 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 63.4 56.3 59.7 48.8 39.3 43.5 Two 23.8 26.0 24.9 30.1 30.4 30.3 Three or more 12.0 17.4 14.8 20.2 29.9 25.7 Missing 0.8 0.4 0.6 0.8 0.4 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 46.6 33.5 39.8 49.3 35.3 41.4 In a separate building 11.2 26.5 19.2 11.9 27.6 20.7 Outdoors 37.9 37.5 37.7 37.3 36.3 36.7 Missing 4.3 2.5 3.3 1.5 0.9 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.9 0.2 0.5 1.0 0.1 0.5 LPG/natural gas/biogas 24.0 3.1 13.1 22.1 2.1 10.8 Kerosene 0.8 0.2 0.5 0.6 0.1 0.3 Charcoal 55.9 18.9 36.6 56.6 15.0 33.2 Wood 14.1 74.9 45.8 18.2 81.6 53.9 Straw/shrubs/grass 0.1 0.2 0.2 0.1 0.2 0.2 No food cooked in household 4.3 2.4 3.3 1.5 0.9 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 70.1 94.0 82.6 74.9 96.8 87.2 Number of households/ population 5,627 6,150 11,777 19,262 24,818 44,080 Type of fire/stove among households using solid fuels1 Closed stove/coal pot with chimney 0.1 0.2 0.2 0.1 0.3 0.2 Open fire/coal pot/open stove without chimney or hood 99.8 99.7 99.8 99.8 99.6 99.7 Missing 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 Number of households/ population using solid fuel 3,945 5,783 9,728 14,433 24,024 38,457 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung LPG = Liquid petroleum gas 26 | Household Population and Housing Characteristics The type of flooring material used in dwellings is a proxy indicator of the socio-economic status of the household as well as the likelihood of exposure to disease-causing agents. Most households in Ghana (85 percent) have finished floors (terrazzo, tiles, cement, carpet, and linoleum), with only 14 percent of households having rudimentary or natural flooring material (earth, sand, or mud mixed with dung). However, over the past five years there has been a small decline in the percentage of households with finished floors, 88 percent in 2003, compared with 86 percent in 2008 (GSS and ORC Macro, 2004). Rural households are much more likely to have cement floors (65 percent) than urban households (56 percent). The second most common flooring material in rural areas is earth and sand (22 percent). About 16 percent of urban households have linoleum floors and 18 percent have carpeted floors. The number of rooms used for sleeping provides an indication of the extent of crowding in households. Overcrowding increases the risk of contracting infectious diseases like acute respiratory infections and skin diseases, which particularly affect children. In the 2008 GDHS, only 15 percent of households had three or more rooms for sleeping; most (60 percent) had one room. Households in rural areas are more likely than those in urban areas to have three or more rooms for sleeping (17 and 12 percent, respectively). Four in ten households (40 percent) do their cooking inside their house, 19 percent cook in a separate building, and 38 percent cook outdoors. This pattern was observed in both urban and rural areas. The majority of households use solid fuels (primarily wood and charcoal) for cooking in Ghana (83 percent). While in rural areas three in four households (75 percent) use wood for cooking, only 14 percent of urban households use wood. More than one in two urban households (56 percent) and nearly one-fifth of rural households (19 percent) use charcoal. Liquefied petroleum gas (LPG) or natural gas is used more commonly by urban households (24 percent) than rural households (3 percent). Few households use electricity for cooking (1 percent), even in urban areas, presumably because of the higher cost. The 2008 GDHS results indicate that all (100 percent) households that use solid fuel for cooking do so without a chimney or hood, and there is no marked difference between urban and rural areas. A closed fire or stove with a chimney is used by less than 1 percent of households in Ghana. 2.5 HOUSEHOLD DURABLE GOODS Information was collected in the 2008 GDHS on the availability of household durable goods such as household effects, means of transportation, and ownership of agricultural land and farm animals. Table 2.10 shows that 74 percent of households own a radio, 57 percent own a mobile telephone, 43 percent own a television, and 26 percent own a refrigerator. Urban households are much more likely than rural households to own these goods. For instance, 79 percent of urban households own a radio, compared with 69 percent of rural households. Mobile telephones are available in 78 percent of households in urban areas and 37 percent of rural households. While 67 percent of urban households have a television, only 21 percent of households in rural areas have a television. Twenty-six percent of households have a bicycle; this means of transportation is more common in the rural areas than in urban areas (31 and 20 percent, respectively). Urban households are four times more likely than rural households to own a car or truck (12 and 3 percent, respectively). Household Population and Housing Characteristics | 27 Table 2.10 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals, by residence, Ghana 2008 Possession Households Population Urban Rural Total Urban Rural Total Household effects Radio 79.4 68.6 73.7 80.9 70.3 74.9 Television 67.1 20.7 42.9 69.1 20.0 41.5 Mobile telephone 78.4 37.3 57.0 80.4 37.6 56.3 Non-mobile telephone 6.5 0.6 3.4 7.2 0.7 3.5 Refrigerator 43.6 9.1 25.6 46.5 8.9 25.3 Means of transport Bicycle 19.7 31.2 25.7 25.2 39.7 33.4 Animal drawn cart 0.5 1.3 0.9 0.6 2.0 1.4 Motorcycle/scooter 4.7 4.4 4.5 6.0 6.0 6.0 Car/truck 11.9 2.5 7.0 14.0 2.9 7.7 Boat with a motor 0.2 0.8 0.5 0.3 1.1 0.7 Ownership of agricultural land 23.4 66.7 46.0 28.1 73.1 53.4 Ownership of farm animals1 21.0 57.9 40.3 27.8 68.3 50.6 Number 5,627 6,150 11,777 19,262 24,818 44,080 1 Cattle, milk cows, bulls, horses, donkeys, mules, goats, sheep, pigs, rabbits, grasscutter, chickens, or other poultry Nearly half of households (46 percent) own agricultural land and 40 percent have farm animals. Table 2.10 shows that rural households are almost three times as likely to own agricultural land as urban households (67 and 23 percent, respectively). Similarly, 58 percent of rural households own farm animals, compared with only 21 percent of urban households. 2.6 WEALTH QUINTILES Using the wealth quintile index, the fifth round DHS survey (2008 GDHS) and the 2003 GDHS were able to provide information on the wealth status of Ghanaian households. Wealth quintiles provide a consistent measure of combined indicators of household income and expenditures that was not available during the first three DHS surveys in Ghana. The wealth quintile, as constructed, used information on household ownership 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 flooring material. 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 populations. The 2008 GDHS provides an opportunity to examine the distribution of Ghana’s population by household wealth status. Table 2.11 shows the percent distribution of the de jure population by wealth quintiles, according to residence and region. Seventy-four percent of the urban population is in the two highest wealth quintiles, compared with only 14 percent of the rural population. The rural population predominates in the two lowest quintiles. The regional distribution shows that Greater Accra is the richest region, with 64 percent of the population in the highest quintile, whilst the Upper West region has less than 4 percent of its population in the highest quintile. Residents of the three northern regions are most likely to be in the lowest wealth quintile. 28 | Household Population and Housing Characteristics Table 2.11 Wealth quintiles Percent distribution of the jure population by wealth quintiles, according to residence and region, Ghana 2008 Residence/ region Wealth quintile Total Number of population Lowest Second Middle Fourth Highest Residence Urban 1.9 5.6 19.1 32.3 41.2 100.0 19,262 Rural 34.0 31.2 20.7 10.5 3.6 100.0 24,818 Region Western 9.0 26.9 22.3 21.0 20.8 100.0 4,186 Central 3.2 28.1 31.1 24.3 13.3 100.0 4,234 Greater Accra 0.6 2.5 8.0 25.2 63.7 100.0 6,338 Volta 19.2 27.9 29.3 16.0 7.6 100.0 4,006 Eastern 12.7 26.9 27.2 22.6 10.6 100.0 4,437 Ashanti 6.2 20.1 23.0 27.0 23.7 100.0 8,021 Brong Ahafo 25.2 24.0 22.9 21.3 6.6 100.0 4,100 Northern 58.6 17.1 12.5 7.6 4.2 100.0 4,948 Upper East 71.6 12.5 4.7 5.2 6.0 100.0 2,613 Upper West 52.7 21.8 12.3 9.9 3.4 100.0 1,196 Total 20.0 20.0 20.0 20.0 20.0 100.0 44,080 2.7 BIRTH REGISTRATION The Convention on the Right of the Child (UN General Assembly, 1989) states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Parents are required to give their children a name and to register the child because the child has a right to know who his or her parents are and to have a nationality through registration in accordance with national laws and relevant international instruments. Table 2.12 shows the percentage of children under five whose births were officially registered and the percentage with a birth certificate at the time of the survey. Not all children reported as registered had a birth certificate at the time of the survey because some certificates may have been lost or were never issued. However, all children with a certificate had been registered. The births of 71 percent of children under five in Ghana have been registered; 55 percent have birth certificates and 16 percent do not. There is no substantial variation in birth registration by sex of child. There were, however, marked differences by urban-rural residence. While 82 percent of children under five in urban areas have had their births registered, only 65 percent of their rural counterparts have been registered. The distribution of children whose births are registered varies by region. Children in the Greater Accra region are more likely to be registered (85 percent) than children in all other regions. Central, Eastern, and Brong Ahafo regions each have more than 20 percent of children who have had their births registered but do not have a birth certificate. The Volta region has the lowest level of birth registration (58 percent). Households in the highest wealth quintile (88 percent) are much more likely to have a birth registered than those in the lowest wealth quintile (60 percent). Household Population and Housing Characteristics | 29 Table 2.12 Birth registration of children under age five Percentage of de jure children under five years whose births are registered with the civil authorities, according to background characteristics, Ghana 2008 Background characteristic Percentage of children whose births are registered Number of children Has birth certificate Does not have a birth certificate Total registered Age <2 51.7 18.7 70.4 2,243 2-4 57.5 14.3 71.8 3,589 Sex Male 56.2 16.0 72.2 2,972 Female 54.3 16.0 70.2 2,859 Residence Urban 71.5 10.3 81.8 2,242 Rural 45.1 19.5 64.6 3,590 Region Western 52.9 12.5 65.4 535 Central 44.6 22.0 66.6 576 Greater Accra 76.2 8.8 85.1 684 Volta 51.3 6.7 58.0 478 Eastern 48.0 28.1 76.1 521 Ashanti 57.9 16.9 74.8 1,059 Brong Ahafo 51.1 20.5 71.7 615 Northern 47.8 16.8 64.6 882 Upper East 69.1 8.8 77.9 317 Upper West 59.3 11.2 70.4 166 Wealth quintile Lowest 40.3 19.2 59.5 1,433 Second 45.8 17.7 63.5 1,272 Middle 54.2 18.2 72.4 1,130 Fourth 67.1 13.8 80.9 1,119 Highest 79.7 8.1 87.8 877 Total 55.3 16.0 71.2 5,832 Characteristics of Survey Respondents | 31 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 2008 GDHS. The basic information on women and men in the reproductive age group is crucial for the interpretation of the 2008 GDHS finding within the context of reproduction, health, and women’s status. 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 quintile. This chapter also includes information on literacy, exposure to mass media, employment and earnings, health insurance coverage, knowledge and attitudes concerning tuberculosis, and use of tobacco and alcohol. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 shows the distribution of women age 15-49 and men age 15-49 by selected background characteristics including age, marital status, urban-rural residence, region, education, religion, ethnicity, and wealth status. The age distribution shows that more than half of women (56 percent) and men (55 percent) are under age 30. The proportion of respondents in each age group generally decreases as age increases reflecting the comparatively young age structure of the Ghanaian population. The results of the 2008 GDHS indicate that 59 percent of women are married or in union (living in an informal arrangement with a partner), compared with 48 percent of men. Because men marry later in life than women, almost half of the men interviewed in the survey (48 percent) have never married, compared with about one-third (32 percent) of women. On other hand, women are more likely than men to be widowed, divorced, or separated (9 and 4 percent, respectively) The distribution of respondents by urban-rural residence shows that over half of women (52 percent) and men (54 percent) live in the rural areas. The distribution by region shows that about one in five respondents are from the Ashanti region, one in six are from Greater Accra, and about one in ten are from the Western, Central, Eastern, Northern, Volta, and Brong Ahafo regions. The regions with smallest proportion of respondents are the Upper East and Upper West regions. Men are more likely than women to have received education at every level of schooling. About one in five women and one in six men have only primary education, while 17 percent of women and 29 percent of men have secondary or higher education. Twenty-one percent of women and 13 percent of men have no education. The majority of respondents are Christians: 78 percent of women and 72 percent of men. Fifteen percent of women and 17 percent of men are Muslims. As expected, Akan is the largest ethnic group, with 51 percent of women and 47 percent of men, followed by the Mole-Dagbani, who make up 16 percent of women and 17 percent of men, and the Ewe, with 13 percent of women and 15 percent of men. 32 | Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Ghana 2008 Background characteristic Women Men Weighted percentage Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 20.8 1,025 1,037 22.4 911 942 20-24 17.9 878 869 17.4 704 706 25-29 16.9 832 817 15.4 624 608 30-34 13.1 644 636 13.1 533 524 35-39 13.0 638 637 13.0 528 511 40-44 9.6 470 485 9.7 394 393 45-49 8.7 429 435 9.0 364 366 Marital status Never married 32.4 1,593 1,546 47.7 1,936 1,934 Married 45.4 2,232 2,361 42.5 1,724 1,752 Living together 13.1 644 589 5.6 226 206 Divorced/separated 7.0 345 316 3.9 157 142 Widowed 2.1 101 104 0.4 15 16 Residence Urban 48.5 2,383 2,162 46.0 1,866 1,696 Rural 51.5 2,533 2,754 54.0 2,191 2,354 Region Western 9.1 447 438 9.9 403 382 Central 8.6 424 334 8.0 326 249 Greater Accra 17.3 853 692 16.0 649 531 Volta 8.8 431 433 9.2 373 367 Eastern 9.8 483 479 10.1 411 394 Ashanti 20.6 1,011 815 19.4 785 621 Brong Ahafo 8.7 425 403 8.5 347 324 Northern 9.5 467 497 10.7 435 472 Upper East 5.1 253 373 5.4 219 313 Upper West 2.5 122 452 2.7 108 397 Education No education 21.2 1,042 1,243 13.3 540 662 Primary 20.1 988 999 15.3 619 677 Middle/JSS 41.5 2,039 1,893 42.4 1,721 1,616 Secondary + 17.2 844 777 28.8 1,167 1,085 Missing 0.1 4 4 0.3 11 10 Religion Catholic 12.4 610 733 13.1 530 593 Anglican/Methodist/Presbyterian 16.9 829 723 16.6 672 589 Pentecostal/Charismatic 37.2 1,827 1,696 29.1 1,179 1,082 Other Christian 11.1 544 478 13.5 548 484 Moslem 15.0 738 832 17.0 691 780 Traditional/spiritualist 4.2 205 266 5.3 215 291 No religion 3.1 153 178 5.2 211 216 Other/missing 0.1 9 10 0.3 12 15 Ethnicity Akan 50.7 2,493 2,136 47.2 1,915 1,619 Ga/Dangme 7.0 343 309 6.2 253 225 Ewe 12.9 633 637 14.7 597 580 Guan 2.5 122 117 2.3 94 97 Mole-Dagbani 16.2 795 1,071 16.9 685 982 Grussi 2.4 118 226 2.6 104 133 Gruma 3.7 184 202 5.1 205 223 Mande 0.6 29 28 0.5 20 19 Other 4.0 197 188 4.5 182 168 Missing 0.0 1 2 0.1 3 4 Wealth quintile Lowest 15.9 783 1,089 17.5 708 953 Second 18.3 900 921 18.2 738 777 Middle 19.9 979 897 17.2 699 654 Fourth 22.8 1,119 1,024 24.0 974 867 Highest 23.1 1,135 985 23.1 939 799 Total 15-49 100.0 4,916 4,916 100.0 4,058 4,050 50-59 na na na na 510 518 Total 15-59 na na na na 4,568 4,568 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 | 33 3.2 EDUCATIONAL ATTAINMENT Education provides people with the knowledge and skills that can lead to a better quality of life. Level of education has been found to be closely associated with the health of women and children, as well as reproductive health behaviours of women and men. Tables 3.2.1 and 3.2.2 show 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. Twenty-one percent of women have never been to school, 15 percent have some primary education, 6 percent completed primary education, 45 percent have some secondary education, 10 percent completed secondary school, and 4 percent have attained more than secondary education. Younger persons have generally reached higher levels of schooling than older persons. The median years of schooling for women and men are 7.2 and 8.5 years, respectively. The results show that men have more education than women at all levels. For example, about twice as many men as women have completed secondary education or higher (24 percent, compared with 14 percent). Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median number of years completed, according to background characteristics, Ghana 2008 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Missing Age 15-24 10.6 13.1 6.9 52.6 14.2 2.5 0.1 100.0 7.7 1,902 15-19 7.1 13.4 8.3 62.7 8.3 0.2 0.0 100.0 7.3 1,025 20-24 14.7 12.6 5.3 40.9 21.2 5.1 0.2 100.0 8.2 878 25-29 18.9 14.7 4.7 42.7 10.3 8.7 0.0 100.0 8.2 832 30-34 28.3 15.3 5.2 38.6 8.8 3.7 0.0 100.0 6.0 644 35-39 27.5 19.1 4.7 40.1 5.4 3.1 0.1 100.0 5.6 638 40-44 33.6 14.6 4.6 38.8 5.9 2.5 0.0 100.0 5.3 470 45-49 39.0 12.6 4.0 35.7 4.7 3.7 0.2 100.0 4.6 429 Residence Urban 10.9 10.8 4.8 50.3 16.4 6.7 0.0 100.0 8.5 2,383 Rural 30.8 18.1 6.3 39.4 4.1 1.2 0.1 100.0 5.1 2,533 Region Western 13.9 17.7 6.7 47.7 10.1 3.4 0.4 100.0 7.9 447 Central 16.2 19.0 7.9 47.1 7.4 2.5 0.0 100.0 7.0 424 Greater Accra 7.7 9.3 5.4 46.5 21.8 9.4 0.0 100.0 8.8 853 Volta 22.9 16.8 7.8 40.7 9.4 2.2 0.2 100.0 6.1 431 Eastern 10.7 16.9 7.1 56.5 6.1 2.7 0.0 100.0 7.7 483 Ashanti 9.9 15.7 3.5 58.3 9.4 3.2 0.0 100.0 8.1 1,011 Brong Ahafo 24.9 11.6 8.2 47.2 6.6 1.5 0.0 100.0 6.4 425 Northern 65.7 8.0 2.7 16.3 5.1 2.1 0.0 100.0 0.0 467 Upper East 49.0 20.0 3.7 17.7 4.5 4.8 0.4 100.0 0.2 253 Upper West 48.1 21.2 2.2 22.4 4.7 1.3 0.0 100.0 0.2 122 Wealth quintile Lowest 59.6 16.9 5.2 16.7 1.4 0.1 0.1 100.0 0.0 783 Second 26.2 21.9 7.4 42.8 1.6 0.1 0.0 100.0 5.2 900 Middle 16.7 16.4 6.4 52.7 6.9 0.9 0.1 100.0 7.3 979 Fourth 10.5 13.5 5.4 55.8 11.9 2.7 0.2 100.0 8.1 1,119 Highest 5.1 6.5 3.7 47.6 23.7 13.3 0.0 100.0 9.3 1,135 Total 21.2 14.5 5.6 44.7 10.1 3.9 0.1 100.0 7.2 4,916 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level 34 | Characteristics of Survey Respondents As a result of the government’s intervention, girls who drop out of school because of pregnancy can now return to school after delivery and continue their education. The government’s policy has led to a marked improvement in education among girls age 15-24; whereas 16 percent of girls age 15-24 had no education in 2003 (GSS and ORC Macro, 2004), only 11 percent had no education in 2008. The results of the 2008 GDHS indicate that educational attainment among both women and men has improved substantially over time; this can be seen in the changes between age cohorts. For example, 39 percent of women in the oldest age cohort (45-49) have no education, compared with 7 percent of those age 15-19; the corresponding percentages for men are 23 and 5 percent, respectively. There is also a marked difference in educational attainment by rural-urban residence. Thirty- one percent of women and 20 percent of men in rural areas have no education, compared with 11 percent of women and 6 percent of men in urban areas. Among regions, the Greater Accra region has by far the largest proportion of women and men who have completed secondary school. Educational attainment is lowest for both women and men in the Northern, Upper East, and Upper West regions. As expected, level of education increases with wealth quintile. Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median number of years completed, according to background characteristics, Ghana 2008 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Missing Age 15-24 6.2 12.9 6.5 53.5 16.7 3.9 0.3 100.0 8.1 1,615 15-19 4.8 16.4 8.8 62.3 7.0 0.5 0.1 100.0 7.3 911 20-24 8.0 8.4 3.6 42.2 29.1 8.3 0.5 100.0 8.8 704 25-29 13.2 8.8 4.4 41.0 17.8 14.4 0.3 100.0 8.5 624 30-34 16.2 6.5 5.5 40.0 17.2 14.4 0.2 100.0 8.6 533 35-39 19.7 11.0 3.6 43.3 13.0 9.2 0.3 100.0 8.9 528 40-44 21.0 8.0 4.1 47.6 11.4 7.8 0.0 100.0 9.3 394 45-49 23.2 7.0 2.2 49.1 10.3 7.7 0.6 100.0 9.2 364 Residence Urban 5.6 6.1 3.3 48.7 23.1 12.9 0.4 100.0 9.3 1,866 Rural 19.9 13.7 6.6 46.5 8.8 4.3 0.1 100.0 7.4 2,191 Region Western 6.1 7.1 5.2 59.3 13.8 8.2 0.2 100.0 8.8 403 Central 6.6 11.9 5.8 54.5 11.0 9.9 0.3 100.0 8.5 326 Greater Accra 3.5 5.5 3.5 46.3 24.9 15.8 0.5 100.0 9.7 649 Volta 8.4 12.3 8.0 53.2 12.6 5.6 0.0 100.0 8.3 373 Eastern 2.5 6.6 7.6 65.4 11.2 6.7 0.0 100.0 8.6 411 Ashanti 6.6 9.4 3.2 56.3 19.0 5.4 0.2 100.0 8.7 785 Brong Ahafo 17.1 13.9 6.9 39.7 12.9 8.4 1.0 100.0 7.6 347 Northern 48.4 10.9 2.3 19.6 12.4 6.4 0.1 100.0 0.9 435 Upper East 34.4 21.5 7.8 22.0 7.6 6.4 0.2 100.0 3.9 219 Upper West 30.2 19.4 5.1 28.4 11.5 5.4 0.0 100.0 5.0 108 Wealth quintile Lowest 45.6 19.0 7.4 24.4 3.0 0.5 0.1 100.0 1.4 708 Second 15.1 14.6 7.1 53.3 7.9 1.6 0.3 100.0 7.4 738 Middle 7.6 10.2 6.4 58.9 12.3 4.2 0.3 100.0 8.4 699 Fourth 3.9 6.8 3.7 57.2 19.9 8.2 0.3 100.0 8.9 974 Highest 1.6 3.6 2.1 42.0 28.0 22.5 0.3 100.0 11.0 939 Total 15-49 13.3 10.2 5.1 47.5 15.4 8.3 0.3 100.0 8.5 4,058 50-59 19.4 6.2 2.0 46.8 10.7 14.5 0.3 100.0 9.4 510 Total 15-59 14.0 9.7 4.7 47.5 14.8 9.0 0.3 100.0 8.6 4,568 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level Characteristics of Survey Respondents | 35 3.3 LITERACY The ability to read and write is an important personal asset, allowing individuals increased opportunities in life. Knowing the distribution of the literate population can help programme managers—especially those concerned with health and family planning—know how to reach women and men with their messages. The 2008 GDHS assessed respondents’ ability to read by asking them to read a simple sentence in the local language (or in English). Only women and men who had never attended school and those who had attended only primary school or middle/JSS1 were asked to read the sentence; it was assumed that everyone with secondary or higher education was literate. Literacy was measured by whether the respondent could read none, part, or all, of the sentence. Persons who were blind or visually impaired were excluded. Tables 3.3.1 and 3.3.2 show the percent distribution of women and men age 15-49 respectively, by level of literacy, and percent literate, according to background characteristics. Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Ghana 2008 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 71.2 4.2 6.4 18.1 0.0 0.0 0.1 100.0 81.8 1,025 20-24 67.1 1.4 2.4 28.6 0.0 0.2 0.3 100.0 70.9 878 25-29 61.7 0.5 1.3 36.1 0.1 0.0 0.2 100.0 63.6 832 30-34 51.1 0.4 1.6 46.7 0.2 0.0 0.0 100.0 53.1 644 35-39 48.6 0.3 1.8 49.3 0.0 0.0 0.0 100.0 50.7 638 40-44 47.2 1.0 1.4 50.3 0.0 0.0 0.0 100.0 49.7 470 45-49 44.1 0.9 2.3 52.1 0.0 0.3 0.2 100.0 47.4 429 Residence Urban 73.5 1.2 2.4 22.8 0.1 0.0 0.1 100.0 77.0 2,383 Rural 44.7 1.8 3.1 50.1 0.0 0.1 0.1 100.0 49.6 2,533 Region Western 61.3 1.0 2.8 34.7 0.0 0.0 0.2 100.0 65.1 447 Central 57.0 1.1 3.9 37.8 0.0 0.2 0.0 100.0 62.0 424 Greater Accra 77.6 1.8 2.9 17.5 0.1 0.0 0.0 100.0 82.4 853 Volta 52.2 2.8 3.1 41.3 0.3 0.4 0.0 100.0 58.1 431 Eastern 65.4 1.1 4.4 29.0 0.0 0.0 0.2 100.0 70.8 483 Ashanti 70.9 0.9 1.9 26.0 0.0 0.0 0.3 100.0 73.7 1,011 Brong Ahafo 55.3 2.2 1.3 41.1 0.0 0.0 0.0 100.0 58.9 425 Northern 23.6 0.7 1.4 74.1 0.0 0.0 0.2 100.0 25.7 467 Upper East 27.0 3.6 3.8 65.7 0.0 0.0 0.0 100.0 34.3 253 Upper West 28.4 1.1 4.2 65.6 0.0 0.7 0.0 100.0 33.8 122 Wealth quintile Lowest 18.2 1.7 2.7 77.0 0.0 0.1 0.3 100.0 22.6 783 Second 44.5 1.6 3.6 50.2 0.0 0.2 0.0 100.0 49.6 900 Middle 60.4 1.1 2.6 35.6 0.1 0.0 0.1 100.0 64.2 979 Fourth 70.4 1.8 3.0 24.5 0.1 0.0 0.2 100.0 75.2 1,119 Highest 84.6 1.4 2.0 11.9 0.0 0.1 0.0 100.0 88.0 1,135 Total 58.6 1.5 2.8 36.9 0.0 0.1 0.1 100.0 62.9 4,916 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 1 Middle/JSS (3 years) and Senior Secondary School (3 years) are the education levels used in this report, although, at the secondary level, the 3-year Senior Secondary School was changed to the 4-year Senior High School after the 2007/2008 academic year. This change did not affect the Ghana DHS data 36 | Characteristics of Survey Respondents Sixty-three percent of women and 77 percent of men are literate, while 37 percent of women and 22 percent of men cannot read at all. As in the case of educational attainment, men are more likely to be literate than women. The male-female difference is larger at older than younger ages. There is also a strong urban-rural difference in literacy for both sexes. Fifty percent of rural women are literate, compared with 77 percent of urban women. Similarly, 67 percent of rural men are literate, compared with 89 percent of urban men. Regional differences are marked. The Greater Accra region has the highest proportion of women and men who are literate, while the Northern, Upper East, and Upper West regions have the lowest proportions who are literate. In general, literacy increases with wealth quintile. Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Ghana 2008 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 69.8 6.1 8.0 15.9 0.1 0.0 0.0 100.0 84.0 911 20-24 79.6 1.1 3.6 15.4 0.0 0.0 0.3 100.0 84.3 704 25-29 73.3 1.2 2.1 22.3 0.3 0.1 0.8 100.0 76.6 624 30-34 71.5 0.9 2.6 24.7 0.0 0.0 0.2 100.0 75.1 533 35-39 65.5 0.4 3.2 30.7 0.0 0.0 0.3 100.0 69.0 528 40-44 66.8 0.4 2.6 29.6 0.6 0.0 0.0 100.0 69.8 394 45-49 67.1 1.3 0.9 29.5 0.0 0.7 0.6 100.0 69.3 364 Residence Urban 84.7 1.6 2.5 10.6 0.2 0.0 0.5 100.0 88.8 1,866 Rural 59.7 2.5 5.0 32.5 0.1 0.1 0.1 100.0 67.1 2,191 Region Western 81.4 0.5 1.9 15.8 0.4 0.0 0.0 100.0 83.8 403 Central 75.4 3.0 3.0 16.5 0.0 0.7 1.3 100.0 81.4 326 Greater Accra 87.0 2.1 3.7 6.5 0.0 0.0 0.7 100.0 92.8 649 Volta 71.3 3.2 6.5 18.8 0.0 0.2 0.0 100.0 81.0 373 Eastern 83.3 1.6 3.6 11.3 0.2 0.0 0.0 100.0 88.5 411 Ashanti 80.7 1.6 1.9 15.6 0.2 0.0 0.0 100.0 84.2 785 Brong Ahafo 61.1 2.5 6.1 30.1 0.2 0.0 0.0 100.0 69.6 347 Northern 38.3 1.6 4.4 55.4 0.0 0.0 0.3 100.0 44.3 435 Upper East 36.0 4.2 6.1 53.5 0.0 0.0 0.2 100.0 46.3 219 Upper West 45.2 2.9 6.9 44.5 0.0 0.0 0.3 100.0 55.1 108 Wealth quintile Lowest 27.9 1.7 6.7 63.4 0.1 0.1 0.1 100.0 36.2 708 Second 62.9 3.3 4.0 29.6 0.1 0.0 0.1 100.0 70.2 738 Middle 75.4 2.8 4.5 17.0 0.2 0.0 0.0 100.0 82.8 699 Fourth 85.3 1.5 3.3 9.0 0.2 0.2 0.4 100.0 90.2 974 Highest 92.5 1.4 1.7 3.8 0.0 0.0 0.7 100.0 95.5 939 Total 15-49 71.2 2.1 3.9 22.4 0.1 0.1 0.3 100.0 77.1 4,058 50-59 72.1 0.5 1.5 25.1 0.4 0.0 0.4 100.0 74.1 510 Total 15-59 71.3 1.9 3.6 22.7 0.1 0.1 0.3 100.0 76.8 4,568 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Survey Respondents | 37 3.4 ACCESS TO MASS MEDIA Access to information is essential in increasing people’s knowledge and awareness of what is taking place around them. In the 2008 GDHS, information was collected on respondents’ exposure to print and broadcast media, both of which are effective in reaching the population with important health messages such as those on reproductive health and HIV/AIDS. In the survey, exposure to media was assessed by asking how often a respondent reads a newspaper, watches television, or listens to the radio. Tables 3.4.1 and 3.4.2 show that exposure of women and men to print and broadcast media in Ghana is high, although men are more likely to have access to the media than women. Seventy-six percent of women and 88 percent of men listen to the radio at least once a week, and a high proportion of women and men watch television. For example, 54 percent of women and 61 percent of men watch television at least once a week. Twice as many women (17 percent) as men (8 percent) have no access to the media. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Ghana 2008 Background characteristic At least once a week Not exposed to any media Number of women Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 25.6 62.1 73.9 19.4 15.2 1,025 20-24 18.8 61.1 79.5 14.4 12.7 878 25-29 14.0 57.3 77.9 10.5 15.4 832 30-34 8.7 52.8 76.4 7.6 17.8 644 35-39 8.3 45.0 76.9 7.6 19.4 638 40-44 9.4 42.4 76.7 8.0 19.3 470 45-49 7.5 41.7 72.6 6.0 22.3 429 Residence Urban 23.3 73.9 81.3 19.6 9.2 2,383 Rural 6.9 35.3 71.9 4.3 23.7 2,533 Region Western 23.9 56.9 89.6 18.3 7.0 447 Central 10.6 52.0 70.9 8.6 19.8 424 Greater Accra 27.6 80.8 80.5 23.5 8.0 853 Volta 20.4 41.4 79.3 12.8 15.1 431 Eastern 9.9 57.7 88.1 7.6 8.0 483 Ashanti 11.2 58.5 75.7 9.1 15.8 1,011 Brong Ahafo 5.3 41.9 80.8 3.6 15.5 425 Northern 7.0 33.2 55.9 5.6 38.4 467 Upper East 10.5 30.6 61.0 9.6 36.0 253 Upper West 9.5 27.4 63.9 5.0 29.9 122 Education No education 0.4 24.1 59.7 0.1 34.9 1,042 Primary 2.0 43.7 73.2 1.2 19.8 988 Middle/JSS 13.2 61.3 81.4 9.8 11.9 2,039 Secondary+ 51.9 85.4 88.9 42.9 2.2 844 Wealth quintile Lowest 3.2 12.3 56.0 1.5 41.4 783 Second 4.6 28.4 71.3 2.2 24.5 900 Middle 9.8 49.3 81.7 6.5 12.8 979 Fourth 17.7 71.6 80.9 13.8 9.3 1,119 Highest 32.6 89.8 85.7 28.6 4.0 1,135 Total 14.8 54.0 76.4 11.7 16.7 4,916 Note: Total includes women with information missing on education who are not shown separately. 38 | Characteristics of Survey Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Ghana 2008 Background characteristic At least once a week Not exposed to any media Number of men Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 20.5 62.8 83.7 16.0 10.2 911 20-24 32.1 67.7 87.8 26.2 8.1 704 25-29 27.9 65.8 90.4 23.7 4.4 624 30-34 27.9 63.2 91.3 25.0 6.6 533 35-39 23.8 58.2 89.9 20.3 7.6 528 40-44 27.4 52.5 91.0 24.0 8.2 394 45-49 20.8 48.0 87.2 16.9 9.6 364 Residence Urban 40.8 85.1 91.2 36.2 3.1 1,866 Rural 12.9 40.9 85.8 9.1 12.0 2,191 Region Western 27.7 63.5 94.4 22.3 3.0 403 Central 16.6 71.3 91.7 14.3 5.4 326 Greater Accra 48.9 88.1 90.6 43.2 2.5 649 Volta 26.4 44.9 91.9 19.3 6.1 373 Eastern 25.5 59.0 93.0 20.7 5.2 411 Ashanti 22.1 70.7 91.3 20.2 4.3 785 Brong Ahafo 19.2 52.8 88.7 15.4 8.5 347 Northern 17.2 39.2 75.2 12.8 20.6 435 Upper East 12.9 27.1 67.9 9.5 28.6 219 Upper West 13.6 42.0 81.6 10.2 13.7 108 Education No education 0.6 23.3 74.0 0.6 24.3 540 Primary 4.2 44.7 82.1 2.6 13.5 619 Middle/JSS 17.6 63.8 91.5 14.1 4.8 1,721 Secondary+ 60.9 83.9 93.5 52.5 1.8 1,167 Wealth quintile Lowest 5.1 14.7 75.4 1.6 22.8 708 Second 9.9 34.6 86.4 5.9 10.6 738 Middle 18.1 57.7 90.9 13.4 7.0 699 Fourth 31.8 85.1 93.1 27.4 2.0 974 Highest 53.2 95.1 92.4 48.9 1.3 939 Total 15-49 25.8 61.2 88.3 21.5 7.9 4,058 50-59 36.1 52.9 89.4 28.1 7.8 510 Total 15-59 26.9 60.3 88.4 22.3 7.9 4,568 Note: Total includes men with information missing on education who are not shown separately. Characteristics of Survey Respondents | 39 Media exposure is higher among younger women (15-19) than older women (45-49). However, among men, exposure is lowest among those age 15-19 and highest among those age 20-24. Men and women in urban areas are about four times more likely to be exposed to mass media than those in rural areas. Likewise, residents in the Greater Accra region (24 percent of women and 43 percent of men) are more likely to be exposed to all three media than those in the other nine regions. Exposure to mass media is positively associated with level of education and household wealth status; the proportion exposed to all three media increases with level of education and wealth quintile. Exposure to all three media changed little over the five-year period between 2003 and 2008 for both women and men (GSS and ORC Macro, 2004). 3.5 EMPLOYMENT Male and female respondents age 15 and older were asked whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. The measurement of employment, however, is difficult because some work, especially work on family farms, in family businesses, or in the informal sector, is often not perceived as employment and hence not reported as such. To avoid underestimating respondent’s employment, the DHS questionnaire asks respondents several questions to probe for their employment status and to ensure complete coverage of employment in both the formal and informal sectors. Respondents are asked a number of questions to elicit their current employment status and continuity of employment in the 12 months before the survey. Respondents are considered “employed” if they are currently working (i.e. worked in the past seven days) or if they worked at any time during the 12 months preceding the survey. Tables 3.5.1 and 3.5.2 show the percent distribution of women and men age 15-49 by employment status, according to background characteristics. Overall, 75 percent of women and 78 percent of men age 15-49 are currently employed and 3 percent of women and men were employed during the past year but are not currently employed (Figure 3.1). Current employment increases with age and number of living children for both women and men. The low level of current employment among younger women and men is related to the majority being still in school. Women and men who have never married are less likely to be currently employed than those who are currently married, divorced, separated, or widowed. Women and men in rural areas are more likely to be currently employed than those living in urban areas. 40 | Characteristics of Survey Respondents Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Ghana 2008 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 32.7 3.1 64.2 100.0 1,025 20-24 70.0 4.1 25.9 100.0 878 25-29 85.1 4.4 10.5 100.0 832 30-34 90.3 2.0 7.6 100.0 644 35-39 94.1 2.0 3.9 100.0 638 40-44 93.0 1.9 5.1 100.0 470 45-49 92.8 1.9 5.2 100.0 429 Marital status Never married 45.7 3.9 50.5 100.0 1,593 Married or living together 88.5 2.8 8.8 100.0 2,876 Divorced/separated/widowed 90.4 1.3 8.4 100.0 446 Number of living children 0 47.8 3.9 48.3 100.0 1,691 1-2 84.5 3.3 12.3 100.0 1,447 3-4 92.3 1.9 5.8 100.0 1,050 5+ 92.8 1.9 5.3 100.0 729 Residence Urban 70.5 3.3 26.1 100.0 2,383 Rural 78.8 2.7 18.6 100.0 2,533 Region Western 76.7 1.7 21.6 100.0 447 Central 76.6 1.5 21.9 100.0 424 Greater Accra 66.9 3.9 29.1 100.0 853 Volta 79.7 5.4 14.9 100.0 431 Eastern 75.7 2.1 22.2 100.0 483 Ashanti 75.0 2.7 22.3 100.0 1,011 Brong Ahafo 76.4 1.3 22.3 100.0 425 Northern 78.1 4.7 17.2 100.0 467 Upper East 78.3 4.0 17.7 100.0 253 Upper West 67.5 1.2 31.1 100.0 122 Education No education 88.0 2.6 9.3 100.0 1,042 Primary 79.2 2.2 18.7 100.0 988 Middle/JSS 70.8 2.6 26.6 100.0 2,039 Secondary+ 62.7 5.4 31.9 100.0 844 Wealth quintile Lowest 82.4 2.4 15.2 100.0 783 Second 77.5 2.9 19.6 100.0 900 Middle 75.9 4.3 19.9 100.0 979 Fourth 74.0 1.7 24.3 100.0 1,119 Highest 67.2 3.6 29.2 100.0 1,135 Total 74.8 3.0 22.2 100.0 4,916 Note: Total includes women with information missing on education who are not shown separately. 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Survey Respondents | 41 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Ghana 2008 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 37.3 2.5 60.1 100.0 911 20-24 70.7 4.8 24.4 100.0 704 25-29 91.1 3.2 5.7 100.0 624 30-34 96.1 1.9 2.0 100.0 533 35-39 96.7 2.1 1.3 100.0 528 40-44 97.7 1.1 1.2 100.0 394 45-49 96.5 2.4 1.1 100.0 364 Marital status Never married 57.3 3.9 38.8 100.0 1,936 Married or living together 97.5 1.5 1.0 100.0 1,950 Divorced/separated/widowed 89.7 4.0 6.2 100.0 172 Number of living children 0 60.1 3.8 36.1 100.0 2,086 1-2 95.3 2.4 2.4 100.0 893 3-4 97.5 1.5 1.0 100.0 655 5+ 99.6 0.4 0.1 100.0 424 Residence Urban 74.2 3.7 22.1 100.0 1,866 Rural 81.2 1.9 16.9 100.0 2,191 Region Western 76.9 0.7 22.4 100.0 403 Central 74.2 4.0 21.8 100.0 326 Greater Accra 75.4 4.2 20.4 100.0 649 Volta 83.0 1.9 15.1 100.0 373 Eastern 73.6 1.7 24.7 100.0 411 Ashanti 77.4 3.8 18.8 100.0 785 Brong Ahafo 80.7 1.9 17.4 100.0 347 Northern 83.2 1.6 15.2 100.0 435 Upper East 80.5 3.9 15.6 100.0 219 Upper West 78.2 2.1 19.7 100.0 108 Education No education 96.3 1.2 2.4 100.0 540 Primary 76.5 1.5 21.9 100.0 619 Middle/JSS 76.1 2.3 21.6 100.0 1,721 Secondary+ 73.1 4.7 22.2 100.0 1,167 Wealth quintile Lowest 87.0 1.3 11.6 100.0 708 Second 78.7 1.1 20.2 100.0 738 Middle 74.3 3.4 22.3 100.0 699 Fourth 75.5 2.9 21.5 100.0 974 Highest 76.0 4.4 19.6 100.0 939 Total 15-49 78.0 2.7 19.3 100.0 4,058 50-59 93.1 2.3 4.6 100.0 510 Total 15-59 79.7 2.7 17.6 100.0 4,568 Note: Total includes men with information missing on education who are not shown separately. 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 42 | Characteristics of Survey Respondents Figure 3.1 Employment Status of Women and Men Age 15-49 GDHS 2008 Currently employed 75% Not employed in past 12 months 22% Not currently employed but worked in past 12 months 3% Not currently employed but worked in past 12 months 3%Not employed in past 12 months 19% Currently employed 78% The proportion of women currently employed ranges from 67 percent in the Greater Accra region to 80 percent in the Volta region. There is little variation in the proportion of women currently employed in other regions. Current employment is inversely related to education, falling from 88 percent among women with no education to 63 percent among women with at least secondary education. The corresponding proportions for men are 96 and 73 percent, respectively. A similar pattern is seen by wealth quintile for both women and men. 3.6 OCCUPATION Respondents who are currently employed were asked to state their occupation. Tables 3.6.1 and 3.6.2 show the percent distribution of currently employed women and men by occupation, according to background characteristics. About one-third of working women (30 percent) and two- fifths (41 percent) of men are employed in the agricultural occupations (Figure 3.2). Four times as many women (51 percent) as men (12 percent) work in sales and services. Eleven percent of employed women and 22 percent of employed men are skilled manual workers. Twice as many men (11 percent) as women (5 percent) are working in professional, technical, and managerial positions. Occupation varies by age. Among women, the proportion engaged in agriculture increases with age. For example, 20 percent of working women age 20-24 are engaged in agriculture, compared with 42 percent of women age 45-49. In contrast, the proportion of women engaged in skilled manual work decreases with age. A similar pattern is seen for men. The proportion of men engaged in agriculture increases with age, from 33 percent among men age 20-24 to 59 percent among men in the oldest age group. The proportion of men working in skilled manual work decreases with age. Characteristics of Survey Respondents | 43 A higher proportion of never-married women than ever-married women are engaged in most occupations, with the exception of agriculture. One in three (35 percent) currently married women who are working are engaged in the agricultural sector, compared with about one in four formerly married women (27 percent), and 14 percent of never-married women. Among working men, about two-fifths of those who are currently or formerly married are engaged in the agricultural sector, compared with less than one-third of never-married men. Twenty-four percent each of never-married men and formerly married men are engaged in skilled manual work, compared with 20 percent of married men. Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Ghana 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agri- culture Missing Total Number of women Age 15-19 3.2 0.9 43.7 14.8 0.4 30.3 6.8 100.0 366 20-24 8.4 2.9 51.4 16.1 0.2 19.5 1.5 100.0 651 25-29 5.8 3.5 53.8 13.5 0.0 23.0 0.3 100.0 745 30-34 3.0 1.8 55.0 11.1 0.0 28.4 0.6 100.0 595 35-39 2.8 0.4 50.7 7.4 0.2 37.7 0.8 100.0 613 40-44 2.1 1.0 52.5 5.5 0.7 36.9 1.4 100.0 446 45-49 5.6 0.4 48.3 3.6 0.0 41.7 0.4 100.0 406 Marital status Never married 9.6 4.4 50.5 17.5 0.2 13.5 4.4 100.0 789 Married or living together 3.5 1.2 50.0 9.1 0.2 35.4 0.6 100.0 2,624 Divorced/separated/widowed 2.2 0.6 61.9 8.3 0.0 26.6 0.3 100.0 409 Number of living children 0 11.1 4.9 49.1 17.1 0.3 13.6 3.8 100.0 874 1-2 3.8 1.6 57.3 13.6 0.1 22.7 0.9 100.0 1,269 3-4 2.9 0.4 54.9 6.1 0.0 35.2 0.5 100.0 989 5+ 0.5 0.1 38.2 4.1 0.4 56.3 0.4 100.0 690 Residence Urban 7.7 3.5 68.2 11.6 0.2 7.5 1.3 100.0 1,760 Rural 2.0 0.3 37.0 10.0 0.2 49.0 1.4 100.0 2,062 Region Western 4.7 3.3 49.9 9.7 0.4 31.8 0.2 100.0 351 Central 4.7 0.6 51.9 8.7 0.0 33.1 1.1 100.0 331 Greater Accra 6.7 6.0 70.3 12.5 0.3 3.4 0.8 100.0 605 Volta 4.2 0.5 45.4 7.1 0.5 34.9 7.4 100.0 367 Eastern 3.8 1.4 60.2 11.8 0.0 22.5 0.4 100.0 375 Ashanti 5.1 1.1 57.5 12.0 0.0 24.0 0.3 100.0 785 Brong Ahafo 3.0 0.0 44.7 6.9 0.3 45.0 0.0 100.0 330 Northern 3.0 0.1 30.6 11.4 0.0 52.4 2.5 100.0 387 Upper East 5.7 0.4 28.8 13.1 0.2 51.0 0.9 100.0 208 Upper West 2.1 1.4 26.6 16.2 0.0 52.0 1.5 100.0 84 Education No education 0.0 0.1 33.6 6.7 0.0 58.5 1.0 100.0 945 Primary 0.5 0.0 54.2 11.1 0.2 33.0 0.9 100.0 803 Middle/JSS 1.0 0.3 62.1 14.2 0.1 20.7 1.7 100.0 1,496 Secondary+ 27.4 11.0 48.7 7.8 0.5 2.7 1.8 100.0 575 Wealth quintile Lowest 0.8 0.1 17.7 7.5 0.2 73.0 0.7 100.0 664 Second 0.6 0.1 35.3 8.7 0.1 54.0 1.3 100.0 723 Middle 3.8 0.2 57.5 12.3 0.0 23.7 2.4 100.0 785 Fourth 5.1 2.0 71.4 12.3 0.1 7.4 1.7 100.0 847 Highest 11.7 6.2 66.5 12.1 0.4 2.4 0.7 100.0 804 Total 4.6 1.8 51.4 10.7 0.2 29.9 1.4 100.0 3,822 Note: Total includes women with information missing on education who are not shown separately. 44 | Characteristics of Survey Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Ghana 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agri- culture Missing Total Number of men Age 15-19 2.2 4.6 7.0 23.6 2.3 43.4 16.9 100.0 363 20-24 17.2 10.1 13.7 21.2 0.8 32.5 4.5 100.0 532 25-29 11.8 9.6 15.8 25.9 2.0 32.4 2.4 100.0 588 30-34 14.1 10.8 15.0 22.6 0.4 35.2 1.9 100.0 522 35-39 11.1 8.2 12.2 23.1 0.7 42.8 2.0 100.0 522 40-44 9.2 9.0 9.2 19.3 0.8 48.5 4.0 100.0 389 45-49 10.5 7.9 8.7 11.9 0.2 58.9 1.8 100.0 360 Marital status Never married 14.0 7.1 13.0 24.0 1.9 31.2 8.8 100.0 1,185 Married or living together 10.0 9.5 12.0 20.0 0.6 46.2 1.8 100.0 1,930 Divorced/separated/widowed 9.7 14.0 9.0 23.4 0.0 41.5 2.4 100.0 161 Number of living children 0 14.2 8.4 13.7 23.4 1.8 30.9 7.6 100.0 1,333 1-2 13.2 11.0 14.3 23.7 0.7 34.9 2.1 100.0 872 3-4 8.5 8.5 10.3 20.6 0.4 49.4 2.3 100.0 648 5+ 3.6 6.3 6.0 13.1 0.2 69.0 1.7 100.0 424 Residence Urban 17.9 11.7 20.9 30.4 2.0 13.2 3.9 100.0 1,454 Rural 6.3 6.6 5.3 14.5 0.3 62.4 4.7 100.0 1,822 Region Western 14.6 8.8 11.6 25.4 0.0 37.2 2.4 100.0 313 Central 15.3 8.7 10.0 26.4 0.8 35.7 3.1 100.0 255 Greater Accra 19.8 11.7 24.9 31.7 3.1 4.3 4.5 100.0 517 Volta 10.7 6.5 7.6 15.1 0.6 44.1 15.5 100.0 316 Eastern 9.3 12.0 10.0 18.8 1.1 45.0 3.8 100.0 309 Ashanti 8.5 13.0 13.8 30.0 1.5 31.5 1.7 100.0 638 Brong Ahafo 10.9 5.9 11.2 14.6 0.0 55.9 1.5 100.0 286 Northern 6.7 3.6 5.1 9.4 0.0 72.7 2.5 100.0 369 Upper East 5.0 3.9 5.8 7.5 0.0 69.5 8.4 100.0 185 Upper West 6.3 2.1 6.3 9.8 0.7 71.2 3.6 100.0 87 Education No education 0.5 2.1 3.7 8.4 0.0 84.1 1.2 100.0 527 Primary 1.7 6.7 8.5 20.4 0.3 58.5 4.0 100.0 483 Middle/JSS 3.1 13.1 10.8 30.1 1.2 35.9 5.9 100.0 1,349 Secondary+ 35.1 7.6 21.3 17.4 1.8 12.7 4.1 100.0 908 Wealth quintile Lowest 1.2 0.9 0.8 4.9 0.0 88.5 3.7 100.0 626 Second 3.7 5.5 3.1 14.8 0.1 68.6 4.4 100.0 588 Middle 7.3 10.8 9.7 25.3 0.5 40.4 6.0 100.0 543 Fourth 14.6 13.4 20.5 28.9 1.9 15.4 5.3 100.0 764 Highest 25.7 12.0 22.3 30.7 2.1 4.6 2.6 100.0 755 Total 15-49 11.4 8.8 12.2 21.6 1.0 40.6 4.3 100.0 3,276 50-59 17.1 5.7 13.7 13.0 0.2 49.0 1.4 100.0 487 Total 15-59 12.2 8.4 12.4 20.5 0.9 41.6 4.0 100.0 3,763 Note: Total includes men with information missing on education who are not shown separately. Characteristics of Survey Respondents | 45 Figure 3.2 Occupation of Women and Men Age 15-49 GDHS 2008 Agriculture 30% Unskilled manual 1% Unskilled manual <1% Skilled manual 11% Agriculture 41% Professional/ technical/ managerial 5% Professional/ technical/ managerial 11% Sales and services 51% Clerical 9% Clerical 2% Skilled manual 22% Sales and services 12% Half of never-married women and currently married women, and two-thirds of divorced, separated, or widowed women (62 percent) are employed in sales and services, but less than 1 percent of each group of women is engaged in unskilled manual work. For both women and men, there is a direct relationship between the number of living children and agriculture as an occupation. 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 services and skilled manual work. Agricultural work is the predominant occupation among both women and men in the Northern, Upper West, Upper East, and Brong Ahafo regions. In contrast, the majority of working women in the Greater Accra, Eastern, and Ashanti regions are in sales and services. Among working men, the highest proportions engaged in the professional, technical and managerial work, sales and services, and skilled manual work, are in the Greater Accra and Ashanti regions. Respondents’ occupation is related to level of education. Among women and men with no education, 59 percent of women and 84 percent of men work in agriculture. In contrast, the majority of women and men with secondary or higher education are employed in non-agricultural occupations. Likewise, women and men in the lowest wealth quintile are predominantly engaged in agriculture, while those in the highest wealth quintile are mostly in sales and services or professional, technical and managerial work. 3.7 TYPE OF EMPLOYER, FORM OF EARNINGS, AND CONTINUITY OF EMPLOYMENT Tables 3.7.1 and 3.7.2 show the percent distribution of women and men age 15-49 employed in the 12 months preceding the survey by the type of earnings and employer, and continuity of employment, according to type of employment (agricultural or non-agricultural). Nearly two-thirds of respondents who work receive cash earnings while about one in five receives earnings in cash and in- kind. Fourteen percent of women and 15 percent of men are not paid at all (Figure 3.3). 46 | Characteristics of Survey Respondents Table 3.7.1 Type of employment: Women Percent distribution of women age 15-49 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 2008 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 39.4 75.1 63.8 Cash and in-kind 34.6 11.5 18.3 In-kind only 7.3 2.6 4.0 Not paid 18.5 10.7 13.7 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Type of employer Employed by family member 18.5 5.0 9.0 Employed by non-family member 10.5 23.7 19.7 Self-employed 70.9 71.3 71.2 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Continuity of employment All year 63.4 87.0 79.9 Seasonal 33.5 9.3 16.5 Occasional 2.8 3.5 3.4 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 1,144 2,626 3,822 Note: Total includes women with information missing on type of employment who are not shown separately. The majority of women (71 percent) are self-employed, compared with 52 percent of men. Another 9 percent of women and 11 percent of men are employed by a family member, and 20 percent of women and 37 percent of men are employed by a non-family member. Most working women (80 percent) and the majority of working men (71 percent) are employed throughout the year, and 17 and 25 percent of women and men, respectively, have seasonal jobs. Women and men are more likely to do seasonal work if they are employed in agriculture than if they are in non-agricultural occupations. Continuity of employment is more assured for women and men who are engaged in non-agricultural work. Characteristics of Survey Respondents | 47 Table 3.7.2 Type of employment: Men Percent distribution of men age 15-49 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 2008 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 35.7 83.1 62.3 Cash and in-kind 33.7 8.7 18.7 In-kind only 6.4 1.8 3.7 Not paid 24.2 6.4 15.2 Missing 0.0 0.0 0.1 Total 100.0 100.0 100.0 Type of employer Employed by family member 19.4 5.1 11.2 Employed by non-family member 11.3 54.9 36.8 Self-employed 69.2 39.9 51.9 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Continuity of employment All year 53.8 83.1 70.5 Seasonal 43.1 11.9 25.0 Occasional 2.6 4.7 4.1 Missing 0.5 0.2 0.3 Total 100.0 100.0 100.0 Number of men employed during the last 12 months 1,329 1,806 3,276 Note: Total includes men with information missing on type of employment who are not shown separately. Figure 3.3 Type of Earnings of Employed Women and Men Age 15-49 Women Men Cash only 64% Not paid 14% Cash and in-kind 18% Not paid 15% Cash only 62% In-kind only 4% Cash and in-kind 19% In-kind only 4% Note: Total may not add to 100 due to rounding. GDHS 2008 48 | Characteristics of Survey Respondents 3.8 HEALTH INSURANCE COVERAGE The national health insurance scheme (Act 650) was passed in 2003 with the aim of making health care accessible to all. Tables 3.8.1 and 3.8.2 show the percent distribution of women and men by membership in the national or district health insurance scheme (N/DHIS) or mutual health organisation or community-based insurance scheme, according to background characteristics. Thirty- nine percent of women and 29 percent of men are covered by the N/DHIS, compared with 1 percent of women and men who are covered by the community-based and mutual health organisation insurance schemes. Health insurance through an employer is almost non-existent, with less than 1 percent of respondents covered by insurance through their employer or by privately purchased commercial insurance. A high proportion of women (60 percent) and men (70 percent) say that they are not covered by any type of the health insurance scheme. Table 3.8.1 Health insurance coverage: Women Percent distribution of women age 15-49 by type of health insurance coverage, according to background characteristics, Ghana 2008 Background characteristic National/ District Health Insurance Scheme (N/DHIS) Health insurance through employer Mutual health organisation/ community- based insurance Privately purchased commercial insurance No health insurance Total Number of women Age 15-19 37.0 0.2 1.3 0.2 61.7 100.0 1,025 20-24 33.8 0.0 0.8 0.0 65.4 100.0 878 25-29 40.3 0.0 1.1 0.0 58.6 100.0 832 30-34 41.8 0.0 0.9 0.2 57.0 100.0 644 35-39 42.1 0.0 0.6 0.0 57.8 100.0 638 40-44 42.9 0.5 1.4 0.0 55.2 100.0 470 45-49 36.8 0.0 1.7 0.0 61.2 100.0 429 Residence Urban 41.8 0.2 1.3 0.0 56.8 100.0 2,383 Rural 36.0 0.0 0.9 0.1 63.2 100.0 2,533 Region Western 42.6 0.0 0.0 0.0 57.4 100.0 447 Central 23.2 0.0 1.2 0.0 75.6 100.0 424 Greater Accra 24.6 0.1 0.1 0.0 75.1 100.0 853 Volta 30.2 0.0 0.3 0.0 69.3 100.0 431 Eastern 49.6 0.0 2.0 0.0 48.7 100.0 483 Ashanti 40.7 0.3 2.8 0.3 56.0 100.0 1,011 Brong Ahafo 58.9 0.0 0.7 0.0 40.4 100.0 425 Northern 38.8 0.0 0.7 0.0 61.2 100.0 467 Upper East 54.8 0.0 0.2 0.0 44.9 100.0 253 Upper West 47.0 0.0 0.9 0.0 51.6 100.0 122 Education No education 32.2 0.0 0.6 0.0 67.4 100.0 1,042 Primary 30.0 0.0 1.0 0.1 68.8 100.0 988 Middle/JSS 42.3 0.1 1.1 0.1 56.5 100.0 2,039 Secondary+ 48.6 0.3 1.8 0.0 49.4 100.0 844 Wealth quintile Lowest 29.3 0.0 0.9 0.0 70.2 100.0 783 Second 31.7 0.0 0.7 0.0 67.6 100.0 900 Middle 37.8 0.0 0.5 0.0 61.7 100.0 979 Fourth 43.8 0.0 1.3 0.3 54.5 100.0 1,119 Highest 47.0 0.4 1.7 0.0 51.1 100.0 1,135 Total 38.8 0.1 1.1 0.1 60.1 100.0 4,916 Note: Total includes women with information missing on education who are not shown separately. Characteristics of Survey Respondents | 49 Table 3.8.2 Health insurance coverage: Men Percent distribution of men age 15-49 by type of health insurance coverage, according to background characteristics, Ghana 2008 Background characteristic National/ District Health Insurance Scheme (N/DHIS) Health insurance through employer Mutual health organisation/ community- based insurance Privately purchased commercial insurance No health insurance Total Number of men Age 15-19 33.8 0.0 0.7 0.0 65.5 100.0 911 20-24 22.5 0.2 0.7 0.0 76.6 100.0 704 25-29 20.5 0.0 0.3 0.0 79.2 100.0 624 30-34 33.9 0.2 2.4 0.0 64.0 100.0 533 35-39 30.8 0.2 1.8 0.0 67.6 100.0 528 40-44 30.7 0.0 1.0 0.0 68.3 100.0 394 45-49 28.1 0.6 1.3 0.0 70.0 100.0 364 Residence Urban 33.0 0.3 1.6 0.0 65.1 100.0 1,866 Rural 24.9 0.0 0.6 0.0 74.7 100.0 2,191 Region Western 27.6 0.3 1.8 0.0 70.3 100.0 403 Central 23.3 0.0 0.0 0.0 76.7 100.0 326 Greater Accra 19.9 0.2 0.4 0.0 79.5 100.0 649 Volta 24.0 0.0 0.0 0.0 76.0 100.0 373 Eastern 33.9 0.0 0.0 0.0 66.1 100.0 411 Ashanti 28.0 0.3 3.4 0.0 68.7 100.0 785 Brong Ahafo 44.1 0.2 2.2 0.0 54.1 100.0 347 Northern 31.6 0.0 0.0 0.0 68.4 100.0 435 Upper East 27.9 0.0 0.0 0.0 72.1 100.0 219 Upper West 40.9 0.0 0.0 0.0 59.1 100.0 108 Education No education 17.5 0.0 0.1 0.0 82.4 100.0 540 Primary 21.0 0.0 0.6 0.0 78.7 100.0 619 Middle/JSS 26.0 0.1 1.1 0.0 72.9 100.0 1,721 Secondary+ 41.9 0.3 1.7 0.0 56.2 100.0 1,167 Wealth quintile Lowest 16.6 0.0 0.0 0.0 83.4 100.0 708 Second 22.5 0.0 0.4 0.0 77.4 100.0 738 Middle 25.9 0.0 1.0 0.0 73.2 100.0 699 Fourth 35.2 0.3 1.4 0.0 63.2 100.0 974 Highest 37.7 0.3 2.2 0.0 59.9 100.0 939 Total 15-49 28.6 0.1 1.1 0.0 70.3 100.0 4,058 50-59 37.9 0.6 2.3 0.3 59.0 100.0 510 Total 15-59 29.7 0.2 1.2 0.0 69.0 100.0 4,568 Note: Total includes men with information missing on education who are not shown separately. Women age 20-24 (34 percent) and men age 25-29 (21 percent) are least likely to be covered by the N/DHIS. Urban residents are more likely than rural residents to be covered by the N/DHIS. Regional differentials show that at least half of women in the Eastern, Brong Ahafo, and Upper East regions are covered by the national or district health insurance scheme. The Brong Ahafo region has the highest coverage (59 percent of women and 44 percent of men), compared with other regions. Women and men who have secondary or higher education are more likely to be covered by the national or district health insurance scheme than women and men with no education. Likewise, respondents in the highest wealth quintile are more likely to be covered by the health insurance scheme than those in lower wealth quintiles. 50 | Characteristics of Survey Respondents Respondents covered by the N/DHIS were further asked whether they paid their N/DHIS membership themselves. Tables 3.9.1 and 3.9.2 show the percent distribution of women and men, respectively, by the person who paid for the insurance. Table 3.9.1 N/DHIS Membership Payment: Women Percent distribution of women age 15-49 covered under the National/District Health Insurance Scheme (N/DHIS) by person who paid for membership, according to background characteristics, Ghana 2008 Background characteristic Membership payment made by: No payment, woman exempt as pensioner, elderly, or poor Other Missing Total Percentage with member- ship paid Number of women with N/DHIS Woman, for self Relative or friend Employer Age 15-19 5.7 91.2 1.2 0.5 1.0 0.4 100.0 98.1 379 20-24 26.3 67.1 2.1 0.0 3.6 0.8 100.0 95.6 297 25-29 43.5 49.4 6.0 0.0 1.0 0.0 100.0 99.0 335 30-34 36.9 56.3 2.8 0.0 3.7 0.4 100.0 96.0 269 35-39 45.8 50.0 3.1 0.0 1.1 0.0 100.0 98.9 268 40-44 55.4 39.1 3.2 0.0 2.1 0.3 100.0 97.7 202 45-49 49.6 45.4 3.7 0.1 1.2 0.0 100.0 98.7 158 Employment (past 12 months) Not employed 11.1 86.5 1.3 0.2 1.0 0.0 100.0 98.8 424 Employed for cash 43.8 49.9 4.0 0.0 2.0 0.3 100.0 97.7 1,252 Employed not for cash 25.9 67.8 1.5 0.5 3.6 0.7 100.0 95.2 229 Marital status Never married 20.8 75.1 3.0 0.3 0.8 0.0 100.0 98.9 571 Married or living together 36.0 57.7 3.4 0.0 2.5 0.3 100.0 97.1 1,190 Divorced/separated/ widowed 75.6 20.6 1.5 0.0 1.4 0.9 100.0 97.7 147 Residence Urban 36.7 58.0 3.9 0.1 1.1 0.1 100.0 98.7 996 Rural 32.0 62.3 2.3 0.1 2.8 0.4 100.0 96.6 912 Region Western 25.9 64.4 7.0 0.0 2.4 0.3 100.0 97.3 191 Central 29.0 56.9 7.5 1.2 5.4 0.0 100.0 93.4 98 Greater Accra 40.5 57.1 1.8 0.0 0.7 0.0 100.0 99.3 210 Volta 52.5 34.6 10.7 0.0 2.1 0.0 100.0 97.9 130 Eastern 39.6 57.3 1.7 0.0 0.9 0.4 100.0 98.7 239 Ashanti 38.9 58.0 1.6 0.0 1.0 0.6 100.0 98.4 412 Brong Ahafo 22.0 73.0 1.0 0.0 4.0 0.0 100.0 96.0 251 Northern 30.8 64.1 1.7 0.3 2.3 0.8 100.0 96.6 181 Upper East 35.2 60.5 2.9 0.0 1.3 0.0 100.0 98.7 139 Upper West 20.7 76.2 1.5 0.2 1.3 0.0 100.0 98.5 58 Wealth quintile Lowest 32.7 63.4 0.0 0.1 3.8 0.0 100.0 96.1 229 Second 30.1 63.7 0.9 0.0 4.4 0.8 100.0 94.7 285 Middle 36.3 58.0 2.3 0.5 2.6 0.2 100.0 96.6 370 Fourth 34.6 62.0 2.7 0.0 0.5 0.1 100.0 99.3 490 Highest 36.1 56.4 6.6 0.0 0.6 0.3 100.0 99.1 533 Total 15-49 34.5 60.1 3.1 0.1 1.9 0.3 100.0 97.7 1,908 Note: Total includes respondents with information missing on employment who are not shown separately Overall, 98 percent of women and 99 percent of men covered by the N/DHIS have their membership paid. Approximately one-third of women and half of men paid for the insurance themselves. Older respondents, those employed for cash, and those who are currently or formerly married are more likely to pay for insurance themselves than other respondents. Only 3 percent of women and 13 percent of men age 15-49 said that their insurance was paid by the employer. Compared with the national average, women age 25-29, those in the Volta, Central, and Western regions, and those in the highest wealth quintile are at least twice as likely to report that their insurance is paid by their employer. Among men, those in their late 30s and early 40s (23 and 24 Characteristics of Survey Respondents | 51 percent), those employed for cash (20 percent), men who are currently married (19 percent), those in the Western region (26 percent), in the Volta and Upper East regions (17 percent each), and those in the highest wealth quintile (23 percent), are most likely to report that their insurance is paid by their employer. Table 3.9.2 N/DHIS Membership Payment: Men Percent distribution of men age 15-49 covered under the National/District Health Insurance Scheme (N/DHIS) by person who paid for membership, according to background characteristics, Ghana 2008 Background characteristic Membership payment made by: No payment, man exempt as pensioner, elderly, or poor Other Missing Total Percentage with member- ship paid Number of men with N/DHIS Man, for self Relative or friend Employer Age 15-19 6.7 90.3 0.4 0.5 2.2 0.0 100.0 97.3 308 20-24 32.8 57.1 9.5 0.0 0.7 0.0 100.0 99.3 159 25-29 71.2 10.6 15.4 0.0 2.5 0.3 100.0 97.2 128 30-34 79.7 3.2 17.1 0.0 0.0 0.0 100.0 100.0 181 35-39 76.4 0.9 22.5 0.0 0.2 0.0 100.0 99.8 163 40-44 75.2 1.3 23.5 0.0 0.0 0.0 100.0 100.0 121 45-49 78.1 0.7 19.7 0.0 1.4 0.0 100.0 98.6 102 Employment (past 12 months) Not employed 12.1 84.8 1.1 0.5 1.5 0.0 100.0 98.0 271 Employed for cash 66.3 12.5 20.4 0.0 0.7 0.1 100.0 99.2 730 Employed not for cash 53.1 44.8 0.0 0.0 2.1 0.0 100.0 97.9 160 Marital status Never married 23.2 67.7 7.0 0.3 1.9 0.0 100.0 97.8 554 Married or living together 78.6 2.2 18.7 0.0 0.4 0.1 100.0 99.5 577 Divorced/separated/ widowed (67.7) (13.2) (19.1) (0.0) (0.0) (0.0) 100.0 (100.0) 30 Residence Urban 49.9 34.2 15.3 0.0 0.7 0.0 100.0 99.3 616 Rural 54.2 33.3 10.6 0.3 1.5 0.1 100.0 98.1 545 Region Western 44.0 29.4 25.8 0.0 0.8 0.0 100.0 99.2 111 Central 60.6 25.6 13.8 0.0 0.0 0.0 100.0 100.0 76 Greater Accra 58.3 26.7 12.6 0.0 2.4 0.0 100.0 97.6 129 Volta 40.2 36.7 17.1 0.0 6.0 0.0 100.0 94.0 90 Eastern 54.3 36.9 8.8 0.0 0.0 0.0 100.0 100.0 139 Ashanti 48.7 39.8 11.0 0.0 0.6 0.0 100.0 99.4 220 Brong Ahafo 54.6 35.8 9.7 0.0 0.0 0.0 100.0 100.0 153 Northern 51.3 35.7 12.2 0.0 0.8 0.0 100.0 99.2 137 Upper East 54.7 25.1 16.5 2.3 0.7 0.7 100.0 96.3 61 Upper West 58.8 33.0 6.9 0.0 1.4 0.0 100.0 98.6 44 Wealth quintile Lowest 62.2 32.0 1.8 0.8 2.8 0.3 100.0 96.1 118 Second 60.9 31.8 5.4 0.3 1.6 0.0 100.0 98.0 166 Middle 48.2 41.4 8.3 0.0 2.0 0.0 100.0 98.0 181 Fourth 52.0 35.0 13.0 0.0 0.0 0.0 100.0 100.0 343 Highest 46.0 30.1 23.0 0.0 0.9 0.0 100.0 99.1 354 Total 15-49 51.9 33.8 13.1 0.1 1.1 0.0 100.0 98.7 1,161 50-59 60.6 2.7 35.1 1.1 0.6 0.0 100.0 98.4 194 Total 15-59 53.1 29.3 16.2 0.3 1.0 0.0 100.0 98.7 1,355 Note: Figures in parentheses are based on 25-49 unweighted cases Differences in the source of the insurance payment by urban-rural residence are small but regional differences are large. For example, women in the Volta region are most likely to pay for the insurance themselves (53 percent), or their employer pays for it (11 percent), and least likely to have the insurance paid for by a relative or friend (35 percent). On the other hand, women in the Upper West and Brong Ahafo regions are the least likely to pay for the insurance themselves (21-22 52 | Characteristics of Survey Respondents percent), or have the employer pay for it (2 percent or less), and most likely to be helped by relatives or friends (at least 73 percent). Among men, those living in the Volta and Western regions are the least likely to pay for the insurance themselves (40 and 44 percent, respectively), and most likely to have their employer pay for the insurance (17 and 26 percent, respectively), compared with men in other regions. Men in the two lowest wealth quintiles (who are most in need of financial assistance) are more likely to pay for the insurance themselves, while men in the two highest wealth quintiles are more likely to have their insurance paid by their employer. Table 3.10 shows that about nine in ten respondents insured with the N/DHIS have a valid card (seen or unseen by the interviewer). One in four women and one in three men were not able to show the N/DHIS card at the time of the interview. One in ten insured respondents does not have a valid membership card. The proportion of those who do not have a card is especially high among women in the Ashanti and Brong Ahafo regions (21 and 25 percent, respectively) and among men in the Upper West and Greater Accra regions (19 and 16 percent, respectively). The median duration of waiting time to receive the insurance card is 8 weeks for women and 7 weeks for men. The waiting time is longer for women in their late 30s, women in the Central, Greater Accra, Volta, and Ashanti regions, men living in the Upper West region, and women in the fourth wealth quintile (11 weeks each). Table 3.10 Possession of valid N/DHIS card Percent distribution of N/DHIS insured women and men age 15-49 by possession of a valid N/DHIS card and whether or not card was seen by interviewer, and among respondents with a valid N/DHIS card, median number of weeks respondent waited to receive card, according to background characteristics, Ghana 2008 Background characteristic Women Men Has valid N/DHIS card Does not have valid card Missing Total Median number of weeks waited for card Number of women Has valid N/DHIS card Does not have valid card Missing Total Median number of weeks waited for card Number of men Card seen Card not seen Card seen Card not seen Age 15-19 58.9 27.4 13.3 0.4 100.0 7.0 379 56.6 35.1 8.3 0.0 100.0 4.7 308 20-24 57.0 27.0 15.2 0.8 100.0 7.6 297 54.8 31.0 14.2 0.0 100.0 6.8 159 25-29 60.0 30.0 9.7 0.4 100.0 8.7 335 55.1 38.0 6.9 0.0 100.0 7.3 128 30-34 66.7 21.4 11.5 0.4 100.0 7.6 269 61.2 30.5 8.3 0.0 100.0 7.4 181 35-39 67.5 22.2 9.7 0.6 100.0 11.1 268 57.8 34.5 7.7 0.0 100.0 7.3 163 40-44 64.5 24.4 11.0 0.0 100.0 7.6 202 57.6 34.8 7.6 0.0 100.0 7.2 121 45-49 61.0 28.7 10.3 0.0 100.0 7.7 158 56.2 28.0 14.7 1.0 100.0 8.5 102 Residence Urban 61.5 25.8 12.3 0.4 100.0 8.8 996 56.5 34.4 8.8 0.2 100.0 7.0 616 Rural 62.3 26.2 11.1 0.4 100.0 7.3 912 57.8 32.2 9.9 0.0 100.0 7.2 545 Region Western 73.2 13.2 13.6 0.0 100.0 3.9 191 53.1 43.1 3.8 0.0 100.0 3.8 111 Central 54.4 38.8 5.2 1.7 100.0 11.3 98 46.8 39.2 12.6 1.4 100.0 9.8 76 Greater Accra 59.6 36.3 4.1 0.0 100.0 11.1 210 44.7 39.6 15.7 0.0 100.0 7.0 129 Volta 77.7 18.9 3.4 0.0 100.0 11.2 130 58.0 36.4 5.6 0.0 100.0 3.7 90 Eastern 66.6 28.7 4.3 0.4 100.0 7.3 239 72.0 26.2 1.9 0.0 100.0 5.3 139 Ashanti 56.4 22.0 20.6 0.9 100.0 11.2 412 54.1 32.4 13.5 0.0 100.0 8.0 220 Brong Ahafo 56.7 18.8 24.5 0.0 100.0 3.6 251 59.8 29.6 10.6 0.0 100.0 4.7 153 Northern 75.6 14.0 9.6 0.8 100.0 7.7 181 61.5 29.9 8.6 0.0 100.0 9.0 137 Upper East 35.0 63.5 1.5 0.0 100.0 7.5 139 66.4 32.2 1.4 0.0 100.0 5.2 61 Upper West 73.7 20.5 5.8 0.0 100.0 9.2 58 52.9 28.5 18.6 0.0 100.0 11.2 44 Wealth quintile Lowest 58.1 37.2 4.7 0.0 100.0 7.4 229 62.0 28.2 9.9 0.0 100.0 7.0 118 Second 64.4 23.4 11.4 0.8 100.0 7.3 285 61.2 28.0 10.8 0.0 100.0 7.9 166 Middle 60.0 24.8 14.9 0.2 100.0 7.3 370 58.5 29.8 11.7 0.0 100.0 6.0 181 Fourth 63.5 23.2 13.3 0.0 100.0 11.0 490 57.3 36.6 5.9 0.3 100.0 5.7 343 Highest 62.0 26.0 11.2 0.8 100.0 7.7 533 52.8 36.5 10.7 0.0 100.0 7.2 354 Total 15-49 61.9 26.0 11.7 0.4 100.0 7.7 1,908 57.1 33.4 9.4 0.1 100.0 7.1 1,161 50-59 na na na na na na na 56.1 33.9 10.0 0.0 100.0 5.3 194 Total 15-59 na na na na na na na 57.0 33.5 9.5 0.1 100.0 7.1 1,355 na = Not applicable Characteristics of Survey Respondents | 53 Table 3.11 shows that the vast majority of the respondents insured with the N/DHIS did have to pay out of pocket for drugs and services at some time before the survey. Only 6 percent of respondents said they did not pay out of pocket. Differences across subgroups by background characteristics are small. Women in the Eastern region, men in the Western region, and those in the highest wealth quintiles are the least likely to pay out of pocket. Table 3.11 Out-of-pocket payment for drugs and services by respondents insured with N/DHIS Percent distribution of N/DHIS insured women and men age 15-49 by whether they made out-of-pocket payments for drugs and services, according to background characteristics, Ghana 2008 Background characteristic Women Men Out-of-pocket payments Out-of-pocket payments Yes No Some- times Missing Total Number of women Yes No Some- times Total Number of men Age 15-19 4.2 5.1 90.5 0.2 100.0 379 9.1 3.7 87.3 100.0 308 20-24 13.1 5.5 81.4 0.0 100.0 297 18.1 3.1 78.8 100.0 159 25-29 17.0 5.3 77.2 0.5 100.0 335 13.7 4.4 81.9 100.0 128 30-34 9.4 7.1 82.9 0.6 100.0 269 19.9 9.3 70.8 100.0 181 35-39 12.3 7.1 80.7 0.0 100.0 268 20.9 11.9 67.2 100.0 163 40-44 14.7 6.5 78.8 0.0 100.0 202 15.4 10.3 74.3 100.0 121 45-49 13.8 4.7 80.8 0.7 100.0 158 20.7 3.3 76.0 100.0 102 Employment (past 12 months) Not employed 7.4 4.7 87.5 0.5 100.0 424 10.1 4.0 85.9 100.0 271 Employed for cash 12.7 6.7 80.4 0.3 100.0 1,252 18.0 8.4 73.6 100.0 730 Employed not for cash 13.8 3.8 82.4 0.0 100.0 229 15.7 1.0 83.3 100.0 160 Marital status Never married 9.5 5.9 84.6 0.0 100.0 571 11.5 4.0 84.6 100.0 554 Married or living together 12.6 5.9 81.1 0.3 100.0 1,190 20.3 8.6 71.1 100.0 577 Divorced/separated/ widowed 11.7 5.6 82.0 0.8 100.0 147 (11.1) (6.3) (82.6) 100.0 30 Residence Urban 12.6 6.5 80.4 0.4 100.0 996 17.7 6.5 75.9 100.0 616 Rural 10.5 5.1 84.2 0.1 100.0 912 13.8 6.2 80.0 100.0 545 Region Western 13.7 0.5 85.8 0.0 100.0 191 10.5 18.9 70.6 100.0 111 Central 8.1 3.4 87.4 1.1 100.0 98 7.8 3.4 88.8 100.0 76 Greater Accra 17.7 7.5 74.0 0.8 100.0 210 28.9 10.3 60.8 100.0 129 Volta 39.1 0.7 59.5 0.7 100.0 130 35.5 8.3 56.1 100.0 90 Eastern 9.2 14.6 76.2 0.0 100.0 239 10.6 4.1 85.3 100.0 139 Ashanti 9.5 8.0 82.2 0.3 100.0 412 13.1 3.9 82.9 100.0 220 Brong Ahafo 6.7 8.1 85.2 0.0 100.0 251 4.7 5.4 89.9 100.0 153 Northern 6.6 1.0 92.4 0.0 100.0 181 24.0 3.8 72.2 100.0 137 Upper East 3.4 0.4 95.9 0.3 100.0 139 12.8 1.9 85.3 100.0 61 Upper West 9.2 0.7 90.1 0.0 100.0 58 12.3 0.8 87.0 100.0 44 Wealth quintile Lowest 6.4 1.5 92.1 0.0 100.0 229 13.9 5.0 81.2 100.0 118 Second 10.3 7.5 81.8 0.3 100.0 285 10.6 4.7 84.8 100.0 166 Middle 10.1 4.5 85.5 0.0 100.0 370 14.9 4.3 80.9 100.0 181 Fourth 11.4 6.9 81.3 0.3 100.0 490 15.0 6.0 78.9 100.0 343 Highest 15.8 6.9 76.8 0.5 100.0 533 20.2 8.9 70.8 100.0 354 Total 15-49 11.6 5.9 82.2 0.3 100.0 1,908 15.8 6.3 77.8 100.0 1,161 50-59 na na na na na na 16.3 7.9 75.8 100.0 194 Total 15-59 na na na na na na 15.9 6.6 77.5 100.0 1,355 Note: Total includes respondents with information missing on employment who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 54 | Characteristics of Survey Respondents Women and men insured with the N/DHIS were also asked whether there were any services they needed from a health provider that were not covered by the N/DHIS. Table 3.12 shows that more men than women reported that they needed additional services that were not covered by the N/DHIS (26 and 17 percent, respectively). A similar proportion of women (27 percent) and men (28 percent) expressed a need for laboratory services. Surprisingly, more men (32 percent) than women (6 percent) reported needing coverage for postnatal care (data not shown separately). Women in their 20s, those living in urban areas, women in the Ashanti and Volta regions, and those in the two highest wealth quintiles are more likely than other women to report the need for services not covered by the N/DHIS insurance. The proportion of men who reported the need for additional coverage is high among men employed for cash and currently married men, and generally increases with age and wealth status. Reported need for additional insurance coverage is especially high among men in the Volta and Ashanti regions (40 and 37 percent, respectively). Table 3.12 Reported need for health services not covered by N/DHIS Percent distribution of women and men age 15-49 by reported need for health services that are not covered by N/DHIS, according to background characteristics, Ghana 2008 Background characteristic Women Men Need health services not covered by N/DHIS: Need health services not covered by N/DHIS: Yes No Missing Total Number of women Yes No Missing Total Number of men Age 15-19 11.2 88.5 0.2 100.0 379 21.9 78.1 0.0 100.0 308 20-24 19.5 80.5 0.0 100.0 297 19.9 80.1 0.0 100.0 159 25-29 22.9 76.6 0.5 100.0 335 28.2 70.9 0.9 100.0 128 30-34 18.8 81.2 0.0 100.0 269 29.3 70.7 0.0 100.0 181 35-39 18.6 81.4 0.0 100.0 268 29.9 70.1 0.0 100.0 163 40-44 15.4 84.6 0.0 100.0 202 33.6 66.4 0.0 100.0 121 45-49 15.0 84.4 0.6 100.0 158 28.5 71.5 0.0 100.0 102 Employment (past 12 months) Not employed 16.2 83.5 0.2 100.0 424 17.5 82.0 0.4 100.0 271 Employed for cash 18.1 81.7 0.2 100.0 1,252 30.0 70.0 0.0 100.0 730 Employed not for cash 16.1 83.9 0.0 100.0 229 25.1 74.9 0.0 100.0 160 Marital status Never married 16.4 83.6 0.0 100.0 571 21.7 78.1 0.2 100.0 554 Married or living together 18.2 81.5 0.2 100.0 1,190 31.3 68.7 0.0 100.0 577 Divorced/separated/ widowed 14.9 84.5 0.6 100.0 147 (19.4) (80.6) (0.0 ) 100.0 30 Residence Urban 21.4 78.3 0.4 100.0 996 26.7 73.1 0.2 100.0 616 Rural 13.1 86.9 0.0 100.0 912 26.0 74.0 0.0 100.0 545 Region Western 15.0 85.0 0.0 100.0 191 21.1 78.9 0.0 100.0 111 Central 17.6 81.4 1.0 100.0 98 25.7 74.3 0.0 100.0 76 Greater Accra 21.3 77.8 0.8 100.0 210 21.4 78.6 0.0 100.0 129 Volta 22.8 77.2 0.0 100.0 130 40.4 59.6 0.0 100.0 90 Eastern 18.4 81.2 0.4 100.0 239 29.3 70.7 0.0 100.0 139 Ashanti 26.7 73.3 0.0 100.0 412 36.5 63.0 0.5 100.0 220 Brong Ahafo 2.4 97.6 0.0 100.0 251 17.0 83.0 0.0 100.0 153 Northern 19.5 80.5 0.0 100.0 181 19.7 80.3 0.0 100.0 137 Upper East 6.4 93.6 0.0 100.0 139 26.6 73.4 0.0 100.0 61 Upper West 13.7 86.3 0.0 100.0 58 20.0 80.0 0.0 100.0 44 Wealth quintile Lowest 7.2 92.8 0.0 100.0 229 23.8 76.2 0.0 100.0 118 Second 11.6 88.4 0.0 100.0 285 21.8 78.2 0.0 100.0 166 Middle 14.9 84.8 0.2 100.0 370 24.4 75.6 0.0 100.0 181 Fourth 20.1 79.9 0.0 100.0 490 25.2 74.8 0.0 100.0 343 Highest 24.2 75.3 0.5 100.0 533 31.6 68.1 0.3 100.0 354 Total 15-49 17.4 82.4 0.2 100.0 1,908 26.4 73.5 0.1 100.0 1,161 50-59 na na na na na 34.0 66.0 0.0 100.0 194 Total 15-59 na na na na na 27.5 72.4 0.1 100.0 1,355 Note: Total includes respondents with information missing on employment who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases na = Not applicable Characteristics of Survey Respondents | 55 Table 3.13 presents data on client satisfaction among respondents insured with the N/DHIS. Half of men and women insured with the N/DHIS think that the N/DHIS card holders get better service than other clients. About one in ten insured respondents think that the N/DHIS card holders get worse service than other clients. Respondents in the wealthiest households, who generally have higher expectation of quality services, have the highest proportion of client dissatisfaction. For example, 15 percent of men in the highest wealth quintile, compared with 8 percent of men in the lowest wealth quintile think that the N/DHIS card holders get worse service than other clients. A similar pattern is seen for women. Client dissatisfaction is especially high among respondents age 25- 29 and among those in the Central and Greater Accra regions (25 and 17 percent, respectively for men and 18 percent each for women). Table 3.13 N/DHIS card holders’ perceived quality of services received Percent distribution of N/DHIS insured women and men age 15-49 by perceived quality of services received compared with other clients, according to background characteristics, Ghana 2008 Background characteristic Women Men Compared with other clients, N/DHIS card holders receive services that are: Compared with other clients, N/DHIS card holders receive services that are: Better Same Worse Don’t know/ not sure Missing Total Number of women Better Same Worse Don’t know/ not sure Missing Total Number of men Age 15-19 46.4 40.2 7.8 5.6 0.0 100.0 379 53.0 32.7 8.7 5.2 0.5 100.0 308 20-24 43.7 43.4 9.8 3.0 0.0 100.0 297 52.4 30.2 13.6 3.9 0.0 100.0 159 25-29 44.3 39.6 14.1 1.2 0.8 100.0 335 49.7 25.7 21.6 3.0 0.0 100.0 128 30-34 47.8 41.6 8.2 2.3 0.0 100.0 269 48.1 42.3 9.2 0.4 0.0 100.0 181 35-39 52.4 38.3 7.6 1.7 0.0 100.0 268 52.8 35.9 10.6 0.8 0.0 100.0 163 40-44 42.9 40.2 12.2 4.1 0.6 100.0 202 54.1 35.6 7.6 2.7 0.0 100.0 121 45-49 48.2 36.4 8.7 6.7 0.0 100.0 158 55.0 30.6 8.4 5.8 0.2 100.0 102 Employment (past 12 months) Not employed 50.8 35.7 9.1 4.4 0.0 100.0 424 57.4 28.6 10.5 2.9 0.5 100.0 271 Employed for cash 43.2 43.6 10.2 2.8 0.3 100.0 1,252 47.0 37.5 12.3 3.2 0.0 100.0 730 Employed not for cash 55.4 30.8 9.2 4.6 0.0 100.0 229 65.7 24.7 5.7 3.8 0.1 100.0 160 Marital status Never married 43.2 43.3 8.9 4.6 0.0 100.0 571 52.5 31.5 11.3 4.5 0.3 100.0 554 Married or living together 48.3 38.3 10.1 2.9 0.3 100.0 1,190 52.2 35.2 10.6 1.9 0.0 100.0 577 Divorced/separated/ widowed 43.5 43.7 10.8 1.9 0.0 100.0 147 (42.1) (41.7) (12.1) (4.1) (0.0) 100.0 30 Residence Urban 44.6 41.9 11.0 2.3 0.2 100.0 996 49.5 33.8 12.5 4.0 0.2 100.0 616 Rural 48.4 38.4 8.5 4.5 0.2 100.0 912 54.9 33.4 9.3 2.3 0.0 100.0 545 Region Western 58.4 33.7 5.6 2.3 0.0 100.0 191 65.4 21.5 12.3 0.8 0.0 100.0 111 Central 31.4 42.3 18.1 8.2 0.0 100.0 98 30.8 39.3 24.8 5.1 0.0 100.0 76 Greater Accra 27.9 52.3 17.5 1.5 0.8 100.0 210 38.8 39.0 17.4 4.8 0.0 100.0 129 Volta 44.9 43.4 6.5 5.2 0.0 100.0 130 43.1 52.1 2.4 2.4 0.0 100.0 90 Eastern 23.9 68.0 6.6 1.2 0.4 100.0 239 54.9 35.8 7.6 1.6 0.0 100.0 139 Ashanti 65.7 26.6 5.2 2.5 0.0 100.0 412 42.7 46.6 10.0 0.0 0.6 100.0 220 Brong Ahafo 37.7 48.6 12.2 1.0 0.5 100.0 251 62.8 24.0 8.2 4.9 0.0 100.0 153 Northern 54.8 21.5 16.8 7.0 0.0 100.0 181 64.8 12.2 13.3 9.7 0.0 100.0 137 Upper East 52.3 35.7 5.4 6.6 0.0 100.0 139 52.3 43.2 4.5 0.0 0.0 100.0 61 Upper West 56.4 23.2 12.6 7.7 0.0 100.0 58 72.0 16.6 9.0 1.9 0.5 100.0 44 Wealth quintile Lowest 52.2 34.0 7.6 6.2 0.0 100.0 229 62.1 24.6 7.9 5.4 0.0 100.0 118 Second 51.6 35.0 9.2 3.8 0.5 100.0 285 59.2 32.3 5.4 2.9 0.1 100.0 166 Middle 43.8 44.0 8.7 3.3 0.3 100.0 370 52.1 33.6 10.4 3.9 0.0 100.0 181 Fourth 43.9 42.3 11.2 2.6 0.0 100.0 490 51.2 34.3 10.6 3.4 0.4 100.0 343 Highest 45.3 41.2 10.5 2.6 0.3 100.0 533 46.1 36.6 15.2 2.0 0.0 100.0 354 Total 15-49 46.4 40.2 9.8 3.4 0.2 100.0 1,908 52.0 33.6 11.0 3.2 0.1 100.0 1,161 50-59 na na na na na na na 58.7 28.6 10.8 1.9 0.0 100.0 194 Total 15-59 na na na na na na na 53.0 32.9 11.0 3.0 0.1 100.0 1,355 Note: Total includes respondents with information missing on employment who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 56 | Characteristics of Survey Respondents Table 3.14 presents respondents’ opinions on the quality of services received the last time the insured respondent was treated at a health facility. Overall, 82 percent of women and 77 percent of men with N/DHIS coverage said that the services were good the last time they were treated at a health facility. Women in the Greater Accra region and men in the Northern region were less likely to say that the services received the last time they were treated at a clinic or hospital were good (67 percent each), compared with over 90 percent of insured respondents in the Western region. Only 9 percent of women and 12 percent of men complained that the waiting period was too long, and an even smaller proportion (4 percent) said that they did not receive enough information about their illness and treatment from the health provider. Women in the highest wealth quintile were less likely than other women to say that the services were good, and more likely to say that the waiting period was too long. Table 3.14 Client satisfaction Percent distribution of N/DHIS insured women and men age 15-49 by client satisfaction with most recent visit to a clinic or hospital for treatment, and problem (if any) that occurred during visit, according to background characteristics, Ghana 2008 Background characteristic Women Men Client satisfaction and problem during visit Client satisfaction and problem during visit Satisfied Not satisfied Other Missing Total Number of women Satisfied Not satisfied Other Missing Total Number of men Good service Waiting time too long Staff not polite Did not receive enough infor- mation Good service Waiting time too long Staff not polite Did not receive enough infor- mation Age 15-19 79.8 6.2 1.8 3.4 8.3 0.4 100.0 379 80.3 11.8 0.7 1.7 5.0 0.5 100.0 308 20-24 81.7 10.6 0.1 3.8 2.4 1.3 100.0 297 70.7 12.6 3.4 5.1 8.3 0.0 100.0 159 25-29 80.2 9.4 1.8 5.6 1.6 1.3 100.0 335 70.3 12.6 4.0 5.5 7.6 0.0 100.0 128 30-34 83.5 11.9 1.2 1.0 2.0 0.4 100.0 269 78.2 10.7 3.3 4.6 3.3 0.0 100.0 181 35-39 85.5 7.0 0.7 4.0 1.6 1.1 100.0 268 80.3 10.8 0.5 5.5 2.9 0.0 100.0 163 40-44 83.1 7.3 2.0 2.4 2.5 2.7 100.0 202 73.6 14.5 1.6 3.7 6.6 0.0 100.0 121 45-49 82.1 6.8 1.5 3.4 4.5 1.8 100.0 158 78.5 11.4 2.3 2.7 5.2 0.0 100.0 102 Employment (past 12 months) Not employed 82.8 5.7 1.2 3.9 5.5 1.0 100.0 424 78.5 10.3 1.7 2.2 6.7 0.5 100.0 271 Employed for cash 82.6 9.5 1.4 3.3 2.1 1.1 100.0 1,252 75.7 12.5 2.3 4.9 4.5 0.0 100.0 730 Employed not for cash 78.1 8.1 1.1 3.8 7.3 1.5 100.0 229 78.2 11.9 1.2 1.8 6.8 0.0 100.0 160 Marital status Never married 81.1 6.2 1.7 4.2 5.8 1.0 100.0 571 76.8 12.0 2.2 2.9 5.8 0.3 100.0 554 Married or living together 81.8 9.9 1.1 3.5 2.5 1.2 100.0 1,190 76.4 12.1 1.8 4.9 4.7 0.0 100.0 577 Divorced/separated/ widowed 87.9 6.8 1.2 0.6 1.8 1.7 100.0 147 (79.7) (6.8) (2.4) (2.6) (8.6) (0.0) 100.0 30 Residence Urban 80.9 9.7 1.3 3.6 3.7 0.8 100.0 996 75.0 11.7 2.5 4.6 5.9 0.2 100.0 616 Rural 83.3 7.2 1.3 3.4 3.2 1.6 100.0 912 78.6 12.2 1.5 3.0 4.7 0.0 100.0 545 Region Western 95.5 0.8 0.0 3.0 0.3 0.4 100.0 191 91.4 3.4 1.6 0.8 2.8 0.0 100.0 111 Central 76.7 10.0 0.0 3.1 10.2 0.0 100.0 98 75.0 9.5 1.9 3.7 10.0 0.0 100.0 76 Greater Accra 67.3 16.3 4.0 7.2 3.8 1.4 100.0 210 72.9 10.8 5.5 3.3 7.4 0.0 100.0 129 Volta 79.1 8.2 0.8 5.4 6.5 0.0 100.0 130 73.7 13.4 0.0 8.6 4.3 0.0 100.0 90 Eastern 81.9 10.8 0.8 2.5 2.6 1.4 100.0 239 78.0 16.1 4.3 0.5 1.1 0.0 100.0 139 Ashanti 83.5 8.6 1.4 2.4 2.2 1.8 100.0 412 70.4 19.2 1.7 5.9 2.1 0.6 100.0 220 Brong Ahafo 90.0 3.3 1.4 2.8 1.5 1.1 100.0 251 84.7 8.0 0.0 3.8 3.6 0.0 100.0 153 Northern 76.1 7.8 1.9 3.5 8.7 2.0 100.0 181 67.3 10.3 1.4 5.5 15.5 0.0 100.0 137 Upper East 83.0 12.4 0.0 2.4 1.7 0.5 100.0 139 79.9 12.0 2.2 1.6 4.3 0.0 100.0 61 Upper West 79.1 10.7 1.1 5.1 3.4 0.5 100.0 58 84.1 7.1 1.0 2.1 5.8 0.0 100.0 44 Wealth quintile Lowest 80.1 8.0 0.9 3.9 5.6 1.6 100.0 229 74.1 16.4 0.2 3.1 6.2 0.0 100.0 118 Second 85.8 6.0 1.7 2.9 2.5 1.2 100.0 285 82.5 6.4 2.2 1.7 7.2 0.0 100.0 166 Middle 84.4 6.4 1.0 3.3 3.7 1.2 100.0 370 78.6 11.4 0.3 5.8 4.0 0.0 100.0 181 Fourth 84.7 8.7 0.3 3.7 1.9 0.6 100.0 490 73.7 12.1 2.3 5.7 5.8 0.4 100.0 343 Highest 76.9 11.5 2.4 3.6 4.3 1.4 100.0 533 76.8 13.2 3.2 2.3 4.5 0.0 100.0 354 Total 15-49 82.1 8.5 1.3 3.5 3.5 1.2 100.0 1,908 76.7 11.9 2.0 3.8 5.4 0.1 100.0 1,161 50-59 na na na na na na na na 76.8 9.9 4.6 3.7 4.4 0.4 100.0 194 Total 15-59 na na na na na na na na 76.7 11.6 2.4 3.8 5.2 0.2 100.0 1,355 Note: Total includes respondents with information missing on employment who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable Characteristics of Survey Respondents | 57 3.9 KNOWLEDGE AND ATTITUDE CONCERNING TUBERCULOSIS Tuberculosis is primarily caused by a bacteria called Mycobacterium tuberculosis.2 The disease usually affects the lungs, although other organs are involved in up to one-third of cases. If properly treated, tuberculosis caused by drug-susceptible strains is curable in virtually all cases. If untreated, more than half the cases may be fatal within five years. Transmission is usually airborne through the spread of droplets produced when patients with infectious pulmonary tuberculosis cough. Tuberculosis is a major global health problem and is currently responsible for the deaths of about two million people each year. Tuberculosis is a significant public health problem in Ghana. The 2008 GDHS collected information on respondent’s knowledge and attitudes concerning tuberculosis (TB). Tables 3.15.1 and 3.15.2 show the percentage of women and men who have heard of TB, and among those who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want a family member’s TB to be kept secret. Table 3.15.1 Knowledge and attitudes concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Ghana 2008 Background characteristic All women Women who have heard of TB: Percentage who have heard of TB Number of women Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of women Age 15-19 81.9 1,025 73.0 82.6 42.1 840 20-24 87.6 878 74.8 83.9 34.8 769 25-29 90.2 832 72.9 86.1 28.6 751 30-34 87.9 644 70.0 83.6 30.0 566 35-39 89.6 638 70.3 84.2 28.0 572 40-44 90.9 470 68.8 85.6 26.5 427 45-49 88.6 429 70.9 84.6 21.5 380 Residence Urban 93.9 2,383 79.8 88.5 32.6 2,239 Rural 81.6 2,533 63.4 79.6 30.6 2,066 Region Western 86.1 447 72.0 86.0 42.2 385 Central 86.6 424 49.9 86.8 41.2 367 Greater Accra 93.1 853 85.5 90.3 22.8 794 Volta 95.5 431 77.3 74.3 10.9 412 Eastern 91.9 483 75.5 78.5 34.2 444 Ashanti 93.7 1,011 72.9 86.6 32.5 947 Brong Ahafo 87.2 425 59.6 85.3 53.7 371 Northern 64.9 467 56.4 77.8 21.3 303 Upper East 75.5 253 83.9 85.2 28.7 191 Upper West 75.3 122 68.0 77.7 47.1 92 Education No education 69.9 1,042 59.3 77.2 25.5 729 Primary 81.3 988 62.0 77.0 32.4 802 Middle/JSS 94.7 2,039 72.8 85.0 34.3 1,930 Secondary+ 99.5 844 90.5 95.4 30.2 840 Wealth quintile Lowest 68.0 783 60.7 73.9 27.1 532 Second 82.5 900 58.2 78.0 30.8 743 Middle 90.5 979 67.5 85.8 32.7 886 Fourth 93.1 1,119 77.2 84.5 35.0 1,042 Highest 97.1 1,135 85.4 92.0 30.2 1,102 Total 87.6 4,916 72.0 84.2 31.6 4,305 Note: Total includes women with information missing on education who are not shown separately. 2 Bovine tuberculosis was eliminated by the introduction of pasteurization. In Ghana, any commercially available animal milk is pasteurized, and milk products available for human consumption are made from pasteurized milk. 58 | Characteristics of Survey Respondents Nearly nine in ten women and men in Ghana have heard of TB. The youngest respondents and those in rural areas are less likely than others to have heard of TB. Similarly, respondents with less education and those in households in the lowest wealth quintile are less likely to know about TB. Among women and men who have heard of TB, a high proportion of the respondents know that TB is spread through the air by coughing (72 percent of women and 79 percent of men). At least 84 percent of respondents know that TB can be cured. The knowledge that TB can be cured is generally lower among the youngest respondents, those with less education, and those in the lower wealth quintiles. Some amount of stigma is attached to TB. For example, almost one-third of women and one- fifth of men said that if a family member had TB, they would want it to remain a secret. Table 3.15.2 Knowledge and attitude concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Ghana 2008 Background characteristic All men Men who have heard of TB: Percentage who have heard of TB Number of men Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of men Age 15-19 84.5 911 77.5 87.5 26.9 770 20-24 91.2 704 82.8 91.9 23.8 642 25-29 92.7 624 80.8 88.8 20.9 578 30-34 93.4 533 76.4 90.8 21.6 498 35-39 94.1 528 77.6 90.2 15.1 497 40-44 94.8 394 77.5 92.1 13.3 373 45-49 95.6 364 75.9 88.2 17.5 348 Residence Urban 95.6 1,866 85.1 91.8 23.6 1,783 Rural 87.7 2,191 72.7 88.0 18.4 1,923 Region Western 93.4 403 65.1 88.3 30.0 377 Central 95.4 326 73.0 90.1 24.8 311 Greater Accra 95.9 649 87.7 91.0 15.1 622 Volta 94.2 373 81.7 89.6 6.0 351 Eastern 89.3 411 84.8 83.1 22.7 367 Ashanti 96.5 785 78.0 94.6 28.9 758 Brong Ahafo 90.9 347 76.8 88.5 22.0 315 Northern 72.3 435 75.8 86.8 16.8 315 Upper East 89.0 219 81.6 93.6 6.7 195 Upper West 87.7 108 71.8 82.1 32.1 95 Education No education 75.8 540 66.6 87.4 13.2 410 Primary 81.9 619 66.3 80.9 23.1 507 Middle/JSS 94.4 1,721 76.6 89.1 23.1 1,624 Secondary+ 99.0 1,167 91.2 95.5 19.5 1,156 Wealth quintile Lowest 77.6 708 67.8 85.7 16.2 550 Second 87.2 738 69.8 87.7 20.9 643 Middle 93.5 699 75.0 85.6 21.8 654 Fourth 96.3 974 83.9 92.5 23.3 938 Highest 98.1 939 88.6 94.0 20.5 921 Total 15-49 91.3 4,058 78.7 89.8 20.9 3,706 50-59 95.8 510 77.4 90.9 12.4 489 Total 15-59 91.8 4,568 78.5 89.9 19.9 4,195 Note: Total includes men with information missing on education who are not shown separately. Characteristics of Survey Respondents | 59 3.10 SMOKING Smoking is a known risk factor for cardiovascular disease. It also causes lung and other forms of cancer, and contributes to the severity of pneumonia, emphysema, and chronic bronchitis. Smoking may also have an impact on individuals who are exposed to the smoke second-hand. For example, inhaling second-hand smoke may adversely affect children’s growth and cause childhood illness, especially respiratory diseases. Because smoking is an acquired behaviour that is chosen by individuals, all morbidity and mortality caused by smoking is preventable. To measure the extent of smoking among Ghanaian adults, women and men who were interviewed in the 2008 GDHS were asked if they currently smoke cigarettes or use other forms of tobacco. Tables 3.16.1 and 3.16.2 show the dis- tribution of women and men who smoke cigarettes, or a pipe, or use tobacco. Smoking in Ghana is higher among men than women. Almost all women and 93 percent of men say they do not use tobacco at all and only 6 percent of men age 15-49 said they currently smoke cigarettes. Young men are less likely to smoke than men in their 30s and 40s. Men in urban areas are less likely to smoke cigarettes than men in rural areas. Among men who smoke cigarettes, 37 percent say they smoke 3-5 cigarettes per day, and 6 percent say they smoke 10 or more cigarettes per day (data not shown). Among men, the highest proportions of current smokers are in the Northern, Upper East, and Upper West regions (12-13 percent). Only 1 percent of men in the Central region are current smokers. Men with the least education and those in the poorest households are more likely to smoke cigarettes than other men (18 and 14 percent, respectively). The proportion of current cigarette smokers among men age 15-59 has declined slightly over the past five years, from 9 percent in 2003 to 7 percent in 2007. Table 3.16.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or use other tobacco products, by background characteristics and maternity status, Ghana 2008 Background characteristic Uses tobacco Does not use tobacco Number of women Cigarettes Other tobacco Age 15-19 0.1 0.0 99.8 1,025 20-24 0.1 0.0 99.9 878 25-29 0.2 0.0 99.8 832 30-34 0.0 0.0 99.7 644 35-39 0.3 0.5 99.1 638 40-44 0.2 0.7 99.3 470 45-49 0.5 0.7 98.8 429 Maternity status Pregnant 0.3 0.2 99.5 360 Breastfeeding (not pregnant) 0.2 0.0 99.8 1,038 Neither 0.2 0.2 99.5 3,517 Residence Urban 0.2 0.0 99.8 2,383 Rural 0.1 0.4 99.4 2,533 Region Western 0.0 0.3 99.7 447 Central 0.3 0.0 99.3 424 Greater Accra 0.0 0.0 100.0 853 Volta 0.0 0.0 100.0 431 Eastern 0.5 0.1 99.4 483 Ashanti 0.2 0.2 99.6 1,011 Brong Ahafo 0.2 0.0 99.8 425 Northern 0.4 0.9 98.9 467 Upper East 0.2 0.3 99.4 253 Upper West 0.0 1.1 98.9 122 Education No education 0.1 0.8 99.0 1,042 Primary 0.3 0.0 99.7 988 Middle/JSS 0.2 0.1 99.7 2,039 Secondary+ 0.0 0.0 100.0 844 Wealth quintile Lowest 0.2 0.9 99.0 783 Second 0.0 0.3 99.6 900 Middle 0.3 0.0 99.7 979 Fourth 0.2 0.0 99.7 1,119 Highest 0.1 0.0 99.9 1,135 Total 0.2 0.2 99.6 4,916 Note: Total includes women with information missing on education who are not shown separately. 60 | Characteristics of Survey Respondents Table 3.16.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products, by background characteristics, Ghana 2008 Background characteristic Uses tobacco Does not use tobacco Number of men Cigarettes Pipe Other tobacco Age 15-19 0.4 0.0 0.1 99.3 911 20-24 2.8 0.0 0.3 97.0 704 25-29 5.8 0.2 1.2 93.9 624 30-34 8.5 0.4 2.3 90.8 533 35-39 11.0 0.2 3.3 87.9 528 40-44 12.1 0.0 4.4 86.6 394 45-49 11.4 0.5 3.0 87.2 364 Residence Urban 4.5 0.0 1.1 95.2 1,866 Rural 7.7 0.3 2.2 91.4 2,191 Region Western 2.8 0.0 0.9 97.2 403 Central 0.8 0.0 0.3 98.9 326 Greater Accra 5.3 0.0 1.2 94.1 649 Volta 6.8 0.0 1.4 92.3 373 Eastern 3.5 0.0 0.5 96.2 411 Ashanti 5.3 0.1 1.3 94.6 785 Brong Ahafo 8.9 0.2 1.9 90.8 347 Northern 11.9 0.6 5.4 85.8 435 Upper East 11.6 0.8 3.9 86.0 219 Upper West 12.9 0.0 0.7 87.1 108 Education No education 17.7 0.6 6.8 79.6 540 Primary 8.2 0.3 1.7 90.9 619 Middle/JSS 4.0 0.1 0.7 95.8 1,721 Secondary + 3.2 0.0 0.8 96.6 1,167 Wealth quintile Lowest 14.4 0.7 4.9 83.1 708 Second 5.9 0.0 1.1 93.9 738 Middle 5.3 0.0 1.0 94.3 699 Fourth 4.7 0.1 1.4 95.1 974 Highest 2.5 0.0 0.5 97.3 939 Total 15-49 6.2 0.2 1.7 93.1 4,058 50-59 16.0 0.6 6.5 81.0 510 Total 15-59 7.3 0.2 2.2 91.8 4,568 Note: Total includes men with information missing on education who are not shown separately. 3.11 ALCOHOL CONSUMPTION Alcohol abuse is a serious problem in many countries and is of increasing concern in Ghana. Alcohol consumption is considered one of the highest risk factor for death and disability. Potential consequences of alcohol abuse include increased risk of accidents, cirrhosis, hypertension, psychological illnesses, and congenital malformations. Moreover, alcohol consumption aggravates the risk of family problems as well as other social and employment issues such as alcohol addiction, accidents, criminal behaviour, inadvertent injuries, violence, homicide and suicide, road traffic problems. Because there is lack of consistent information available in the country on alcohol consumption and alcohol abuse, a series of questions related to alcohol consumption were included in the 2008 GDHS. All respondents were asked whether they drink alcoholic beverages, and if yes, how frequently they had consumed alcohol during the past seven days: once, 2-3 times, 4 times or more, or not at all. Characteristics of Survey Respondents | 61 Table 3.17.1 shows that 18 percent of women in Ghana drink alcoholic beverages. Alcohol consumption varies by age, employment status, marital status and region. Consumption increases from 7 percent in the age group 15-19 to 26 percent in the age group 45-49. Employed women are twice as likely to drink alcohol (20 percent) as women who are not employed (10 percent). Similarly, formerly married women (26 percent) and currently married women (20 percent) are more likely to drink alcohol than never-married women (11 percent). Urban-rural differences in alcohol consumption are minimal. The highest consumption is found in the Upper West region (37 percent); the lowest consumption of alcoholic beverages is in the Brong Ahafo region (9 percent). By level of education, women with Middle/JSS level of education are least likely to drink alcohol (15 percent) while women with no education (21 percent) and women with the highest education (20 percent) are most likely to drink alcohol. Similarly, women in the lowest and highest wealth quintiles (23 and 21 percent, respectively) are more likely to drink alcohol, compared with women in the second to fourth wealth quintiles (14-16 percent). In general, women who do drink alcohol do not drink frequently; one-third of women did not drink any alcoholic beverages in the week preceding the survey, 37 percent of women drank alcohol once during the past 7 days, 23 percent drank alcohol 2-3 times in the past week, and 7 percent drank alcohol 4 or more times in the week preceding the survey. Women in their late 30s and late 40s and those in the Eastern (37 percent), Upper West (36 percent), Upper East (34 percent) and Northern (28 percent) regions were the most likely to report consumption of alcohol 2-3 times in the week preceding the survey. Nearly one in five (18 percent) women in the Upper West region drank alcoholic beverages 4 or more times in the week before the survey, compared with about 2 percent of women in the Brong Ahafo region. Less educated women and those in the lowest wealth quintiles were also more likely to drink 2-3 times in the week before the survey than more educated women and women in the higher wealth quintiles. Table 3.17.2 shows that the proportion of men in Ghana who drink alcoholic beverages (35 percent) is higher than the proportion of women, and men who drink alcohol also tend to drink more frequently than women. Consumption of alcoholic beverages by men increases rapidly from 8 percent in age group 15-19, to 27 percent in age group 20-24, to 44 percent in age group 25-29; then it stabilises with little variation (44-47 percent) through age 39. By their early 40s, over half of men in Ghana drink alcoholic beverages (52 percent). Among men who drink there is little difference in alcohol consumption by background characteristics such as level of education, wealth quintile, and urban-rural residence; however, the lowest consumption of alcohol is in the Northern region (14 percent). As with women, men who are employed (41 percent) are more likely to drink alcohol than men who are not employed (9 percent), but the difference is considerably larger for men. Similarly, formerly married men (53 percent) and currently married men (47 percent) are more than twice as likely to drink alcohol, compared with never-married men (21 percent). 62 | Characteristics of Survey Respondents Table 3.17.1 Use of alcohol: Women Percentage of women age 15-49 who drink alcoholic beverages and among women who drink alcohol, the number of times they drank alcohol in the 7 days preceding the survey, by background characteristics, Ghana 2008 Background characteristic Percentage of women who drink alcoholic beverages Number of women Among women who drink alcohol, the number of times alcohol was drunk in the past 7 days Once 2-3 times 4 times or more None Missing Number of women Age 15-19 6.6 1,025 38.1 12.8 1.1 47.3 0.7 68 20-24 16.7 878 40.6 13.7 3.5 42.0 0.3 146 25-29 16.4 832 39.6 24.9 6.8 28.8 0.0 137 30-34 20.7 644 33.5 20.6 11.2 34.6 0.0 133 35-39 25.3 638 29.2 29.9 11.5 28.6 0.9 162 40-44 22.2 470 40.7 24.1 6.1 28.2 0.8 104 45-49 26.0 429 39.2 28.4 8.2 24.2 0.0 111 Employment (past 12 months) Not employed 10.0 1,094 39.8 14.6 3.8 40.1 1.7 110 Employed 19.7 3,822 36.4 23.9 8.0 31.6 0.2 751 Marital status Never married 11.0 1,593 38.0 11.3 3.5 46.8 0.3 175 Married or living together 19.8 2,876 36.1 26.4 8.2 28.8 0.5 569 Divorced/separated/widowed 26.3 446 38.6 21.7 9.5 30.1 0.0 117 Residence Urban 17.0 2,383 36.4 15.0 4.5 44.2 0.0 404 Rural 18.0 2,533 37.3 29.5 10.1 22.5 0.7 457 Region Western 10.6 447 (51.4) (17.0) (4.1) (27.5) (0.0) 48 Central 16.4 424 21.9 13.5 9.3 55.3 0.0 70 Greater Accra 26.2 853 34.7 14.1 7.2 44.1 0.0 223 Volta 24.3 431 54.8 27.7 6.1 11.3 0.0 105 Eastern 14.2 483 22.8 36.6 10.9 29.8 0.0 69 Ashanti 12.9 1,011 33.0 20.3 3.2 42.5 1.1 131 Brong Ahafo 8.6 425 27.4 21.2 2.4 49.0 0.0 37 Northern 15.2 467 35.1 28.3 11.4 25.2 0.0 71 Upper East 25.0 253 53.9 33.9 6.9 2.5 2.8 63 Upper West 37.3 122 32.7 35.9 18.0 13.5 0.0 46 Education No education 21.3 1,042 38.8 31.9 9.5 19.3 0.6 222 Primary 18.0 988 35.4 25.4 14.1 24.8 0.3 178 Middle/JSS 14.5 2,039 39.7 19.0 4.4 36.4 0.5 296 Secondary+ 19.5 844 30.6 13.9 2.9 52.6 0.0 165 Wealth quintile Lowest 23.3 783 42.2 33.9 7.0 16.1 0.7 183 Second 15.6 900 32.4 30.8 18.0 18.6 0.3 141 Middle 13.5 979 30.3 18.8 8.7 42.2 0.0 133 Fourth 14.7 1,119 40.0 16.4 5.1 38.5 0.0 165 Highest 21.2 1,135 36.8 15.9 2.5 44.2 0.6 241 Total 17.5 4,916 36.8 22.7 7.4 32.7 0.4 861 Note: Total includes women with information missing on employment and education who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. Characteristics of Survey Respondents | 63 Table 3.17.2 Use of alcohol: Men Percentage of men age 15-49 who drink alcoholic beverages and among men who drink alcohol, the number of times they drank alcohol in the 7 days preceding the survey, by background characteristics, Ghana 2008 Background characteristic Percentage of men who drink alcoholic beverages Number of men Among men who drink alcohol, the number of times alcohol was drunk in the past 7 days Once 2-3 times 4 times or more None Missing Number of men Age 15-19 7.5 911 42.6 25.7 4.6 27.2 0.0 69 20-24 26.5 704 33.0 32.5 9.3 25.0 0.2 187 25-29 43.6 624 32.9 35.8 12.4 18.9 0.0 272 30-34 44.2 533 32.0 36.2 15.7 16.1 0.0 235 35-39 47.1 528 25.2 39.7 21.1 14.1 0.0 249 40-44 51.7 394 20.8 45.8 21.0 12.4 0.0 204 45-49 50.8 364 21.5 43.4 25.3 9.8 0.0 185 Employment (past 12 months) Not employed 8.7 781 43.3 26.8 6.8 23.2 0.0 68 Employed 40.7 3,276 27.9 38.7 17.1 16.3 0.0 1,332 Marital status Never married 20.5 1,936 34.0 32.8 8.3 24.8 0.1 396 Married or living together 46.8 1,950 27.1 39.9 19.6 13.4 0.0 913 Divorced/separated/widowed 53.1 172 20.7 42.5 23.8 13.0 0.0 91 Residence Urban 33.4 1,866 33.4 30.4 13.3 22.9 0.0 624 Rural 35.4 2,191 24.8 44.3 19.3 11.6 0.1 777 Region Western 32.1 403 21.0 35.2 25.7 18.2 0.0 129 Central 37.0 326 33.7 20.1 18.1 28.2 0.0 121 Greater Accra 40.7 649 33.8 31.7 8.2 26.3 0.0 265 Volta 42.5 373 23.5 42.3 23.4 10.7 0.0 158 Eastern 39.6 411 19.3 53.7 18.3 8.7 0.0 163 Ashanti 33.0 785 26.4 40.9 20.7 11.9 0.0 259 Brong Ahafo 34.4 347 42.4 36.9 9.6 11.2 0.0 119 Northern 14.0 435 43.5 27.7 6.3 22.5 0.0 61 Upper East 39.5 219 22.6 50.0 13.3 14.1 0.0 87 Upper West 35.2 108 25.3 39.0 23.2 11.4 1.1 38 Education No education 34.9 540 28.0 40.5 22.1 9.4 0.0 189 Primary 32.3 619 29.1 39.5 20.0 11.2 0.2 200 Middle/JSS 35.3 1,721 26.7 43.1 16.8 13.5 0.0 608 Secondary + 34.1 1,167 31.8 29.1 11.7 27.5 0.0 397 Wealth quintile Lowest 35.5 708 26.3 44.0 17.6 12.0 0.0 251 Second 31.9 738 23.2 43.2 24.6 8.9 0.2 235 Middle 33.2 699 21.7 46.2 19.1 13.1 0.0 232 Fourth 32.4 974 32.8 34.8 16.0 16.4 0.0 315 Highest 39.0 939 34.4 28.4 10.0 27.2 0.0 366 Total 15-49 34.5 4,058 28.6 38.1 16.6 16.6 0.0 1,400 50-59 54.4 510 28.1 33.2 27.3 11.3 0.0 278 Total men 15-59 36.7 4,568 28.5 37.3 18.4 15.8 0.0 1,678 Note: Total includes men with information missing on education who are not shown separately. 64 | Characteristics of Survey Respondents Men drink alcoholic beverages more often than women. In the week preceding the survey only 17 percent of men did not drink any alcoholic beverages; 29 percent of men drank alcohol once, 38 percent of men drank alcohol 2-3 times, and 17 percent of men drank alcohol 4 or more times. The proportion of men who drank alcohol 2-3 times in the week preceding the survey increases rapidly with age, from 26 percent in age group 15-19, to 33 percent in age group 20-24, then levels off at about 36-40 percent among men in their 30s, and peaks at 46 percent among men in their early 40s. The proportion of men who drank alcohol 2-3 times in the past week was higher in rural areas (44 percent) than in urban areas (30 percent). It was substantially higher in the Eastern and Upper East regions (54 and 50 percent, respectively). Men in the Central and Northern regions were the least likely to drink alcohol 2-3 times in the past week (20 and 28 percent, respectively). Men with more education and those in the wealthiest households (about 28 percent each) were less likely to drink 2-3 times in the week preceding the survey than less educated men and men in the poorest households (about 40 percent each). Alcohol consumption 4 or more times in the week preceding the survey was highest among men in the oldest age group (25 percent), men in the Western (26 percent) and Volta (23 percent) regions, men with no education (22 percent), and those in the second wealth quintile (25 percent). Table 3.18 shows that among men age 15-49 who drink alcohol, 30 percent never get drunk, about two-thirds (65 percent) get drunk sometimes, and 5 percent get drunk often. Men age 45-49 (8 percent), divorced, separated, or widowed men (10 percent), men with no education and men in the middle wealth quintile (7 percent each) are more likely to get drunk often than other men. The highest proportion of men who get drunk often (15 percent) is in the Central region, followed by the Eastern region (10 percent). The national average is 5 percent. The findings from the 2008 GDHS confirm that drinking alcoholic beverages is higher among men than women and varies substantially across the regions and subgroups. Characteristics of Survey Respondents | 65 Table 3.18 Frequency of drunkenness among men Percentage of men age 15-49 who drink alcoholic beverages and among men who drink alcohol, the frequency with which they get drunk (often, sometimes, or never), by background characteristics, Ghana 2008 Background characteristic Percentage of men who drink alcoholic beverages Number of men Frequency of drunkenness among men who drink alcohol Often Sometimes Never Missing Number of men Age 15-19 7.5 911 1.9 63.5 33.0 1.6 69 20-24 26.5 704 3.0 67.3 29.5 0.2 187 25-29 43.6 624 1.2 64.1 34.3 0.3 272 30-34 44.2 533 6.4 68.3 25.3 0.0 235 35-39 47.1 528 7.4 57.1 35.4 0.0 249 40-44 51.7 394 6.1 68.1 25.8 0.0 204 45-49 50.8 364 8.0 66.8 25.2 0.0 185 Employment (past 12 months) Not employed 8.7 781 5.5 66.2 28.3 0.0 68 Employed 40.7 3,276 5.1 64.8 29.9 0.2 1,332 Marital status Never married 20.5 1,936 3.2 64.7 31.5 0.6 396 Married or living together 46.8 1,950 5.4 64.7 29.9 0.0 913 Divorced/separated/widowed 53.1 172 9.8 67.6 22.7 0.0 91 Residence Urban 33.4 1,866 3.5 66.4 29.9 0.2 624 Rural 35.4 2,191 6.3 63.8 29.8 0.2 777 Region Western 32.1 403 3.7 50.7 45.6 0.0 129 Central 37.0 326 14.6 59.1 26.3 0.0 121 Greater Accra 40.7 649 2.9 65.8 31.3 0.0 265 Volta 42.5 373 2.6 69.7 27.7 0.0 158 Eastern 39.6 411 10.4 70.2 19.4 0.0 163 Ashanti 33.0 785 2.9 82.6 14.2 0.4 259 Brong Ahafo 34.4 347 3.4 62.5 34.1 0.0 119 Northern 14.0 435 7.1 49.7 43.2 0.0 61 Upper East 39.5 219 1.1 49.7 48.3 0.8 87 Upper West 35.2 108 8.0 29.4 60.5 2.0 38 Education No education 34.9 540 7.1 58.3 34.6 0.0 189 Primary 32.3 619 5.3 63.3 30.6 0.7 200 Middle/JSS 35.3 1,721 5.4 68.1 26.4 0.2 608 Secondary+ 34.1 1,167 3.6 63.8 32.5 0.0 397 Wealth quintile Lowest 35.5 708 3.6 57.9 38.0 0.4 251 Second 31.9 738 6.5 67.0 26.3 0.2 235 Middle 33.2 699 7.4 65.7 26.8 0.0 232 Fourth 32.4 974 5.8 68.5 25.4 0.3 315 Highest 39.0 939 3.0 64.8 32.2 0.0 366 Total 15-49 34.5 4,058 5.1 64.9 29.8 0.2 1,400 50-59 54.4 510 12.2 59.5 27.2 1.1 278 Total men 15-59 36.7 4,568 6.2 64.0 29.4 0.3 1,678 Note: Total includes men with information missing on education who are not shown separately. Fertility | 67 FERTILITY 4 The Government of Ghana initiated its first National Population Policy in 1969 to manage population resources in a manner consistent with the government’s ultimate objective to accelerate the rate of economic development and improve the quality of life of the people. After 25 years, population growth still remained unacceptably high and so the Population Policy was revised in 1994 to include a systematic integration of population in development planning with renewed emphasis on fertility reduction to accelerate economic modernisation, sustainable development, and poverty eradication (NPC, 1994). Since then, Ghana has made substantial progress in reducing fertility. One of the major indicators provided by the DHS surveys in Ghana has been the current fertility rate, which is important for development of population policies and programmes. This chapter looks at a number of fertility indicators including current fertility levels, trends, and differentials; age at first birth, and teenage pregnancy and motherhood. 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. Then for each live birth, information was collected on the age, sex, and survival status of the child. For dead children, age at death was recorded. 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 a specified age group and represent a valuable measure for assessing the current age pattern of childbearing. They are calculated by dividing the number of live births to women in a specific age group by the number of woman-years lived in that age group. • 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 age-specific fertility rates. 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. • 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 2006-2008. A three-year period was chosen because it reflects the current fertility situation, and also provides a sufficient number of cases for statistical precision. 4.1 FERTILITY LEVELS AND TRENDS 4.1.1 Fertility Levels Table 4.1 shows the age-specific fertility rates, total fertility rates, general fertility rates, and crude birth rates for Ghana as a whole and for urban and rural areas. The 2008 GDHS findings indicate that the main childbearing years for Ghanaian women are during their 20s and early 30s. Urban-rural differences in childbearing rates are evident for all age groups, but are especially large in the early 20s. Figure 4.1 shows that fertility among rural women is highest in the age group 20-24 (243 births per 1,000), while among urban women, fertility peaks later in the age group 25-29 (173 births per 1,000). 68 | Fertility Table 4.1 Current fertility Age-specific and total fertility rate, the general fertility rate and the crude birth rate for the three years preceding the survey, by residence, Ghana 2008 Age group Residence Total Urban Rural 15-19 49 82 66 20-24 114 243 176 25-29 173 236 206 30-34 157 189 173 35-39 89 140 118 40-44 37 77 59 45-49 3 13 8 TFR (15-49) 3.1 4.9 4.0 GFR 105 165 136 CBR 27.1 33.6 30.8 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population + + + + + + + # # # # # # # ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 250 300 Births per 1,000 women Urban Rural Total) # + GDHS 2008 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence The total fertility rate (TFR), which is calculated for women age 15-49, is a useful measure for examining the overall level of fertility. The 2008 findings presented in Table 4.1 indicate that a Ghanaian woman who is at the beginning of her childbearing years will, on average, give birth to 4.0 children by the end of her reproductive period (if fertility levels remain constant at the levels observed in the three-year period preceding the 2008 GDHS). The TFR for rural areas (4.9 births) is higher than the rate for urban areas (3.1 births); however, over the past five years the TFR in rural areas declined from 5.6 to 4.9, while the rate in urban areas remained the same. Fertility | 69 The general fertility rate (GFR) for Ghana is 136. This means that for every 1,000 women in the population, there are 136 births. Table 4.1 shows a crude birth rate (CBR) for Ghana of 30.8 per 1,000 population for the period under review. Both measures are based on the birth history for the three-year period preceding the survey. One of the main targets of the 1994 revised National Population Policy was to reduce the total fertility rate from 5.5 to 5.0 by the year 2000, to 4.0 by 2010, and to 3.0 by 2020 (NPC, 1994). With a TFR of 4.0 in 2008, Ghana has achieved its fertility target two years before the target year (2010). The TFR in Ghana is one of the lowest in sub-Saharan Africa (Figure 4.2). 7.1 6.7 6.6 6.3 6.2 5.7 5.7 5.5 5.4 5.3 5.2 5.1 4 3.9 3.8 3.6 Ni ge r 2 00 6 Ug an da 20 06 Ma li 2 00 6 Co ng o D .R. 20 07 Za mb ia 20 07 Gu ine a 2 00 5 Be nin 20 06 Rw an da 20 07 Eth iop ia 20 05 Se ne ga l 2 00 5 Lib eri a 2 00 7 Sie rra Le on e 2 00 8 Gh an a 2 00 8 Sw az ila nd 20 06 -07 Zim ba bw e 2 00 5- 06 Na mi bia 20 06 -0 7 0 2 4 6 8 10 Births per woman Figure 4.2 Total Fertility Rates, Selected Sub-Saharan Countries Note: Rates refer to the three-year period preceding the survey, except for Niger where rate refers to the five-year period preceding the survey 4.0 4.1.2 Differentials in Current and Completed Fertility Table 4.2 presents differentials in the total fertility rate and the percentage of women who are currently pregnant by background characteristics. The percentage currently pregnant provides a useful measure of current fertility. However, it may not capture all pregnant women because 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 total fertility rate and the mean number of children ever born can be compared to assess the extent of fertility change over the past two decades in Ghana. There is substantial variation in fertility by region, ranging from a TFR of 2.5 births in Greater Accra to 6.8 births in the Northern region. This means that women in the Northern region have more than twice as many children as women in the Greater Accra region. The TFR is inversely related to women’s level of education. The higher the level of education, the fewer the number of children a woman has. For example, the TFR for women with no education is 6.0 births compared with 2.1 births for women with secondary or higher education. A similar inverse relationship is seen by wealth quintile. Fertility declines as household wealth status increases, from 6.5 births among women in the lowest wealth quintile to 2.3 among women in the highest wealth quintile. 70 | Fertility Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Ghana 2008 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 3.1 6.3 4.3 Rural 4.9 8.3 5.9 Region Western 4.2 7.5 5.0 Central 5.4 7.8 5.5 Greater Accra 2.5 7.0 3.9 Volta 3.8 6.7 5.0 Eastern 3.6 5.3 4.7 Ashanti 3.6 7.6 5.1 Brong Ahafo 4.1 4.8 5.6 Northern 6.8 12.2 6.9 Upper East 4.1 6.9 5.6 Upper West 5.0 7.1 6.4 Education No education 6.0 9.0 6.2 Primary 4.9 7.4 5.6 Middle/JSS 3.5 7.4 4.5 Secondary+ 2.1 4.9 3.0 Wealth quintile Lowest 6.5 8.6 6.4 Second 4.9 9.1 5.9 Middle 4.0 7.1 5.4 Fourth 3.4 5.9 4.4 Highest 2.3 6.6 3.8 Total 4.0 7.3 5.2 Note: Total fertility rates are for the period 1-36 months preceding the interview. At the time of the survey, about 7 percent of the women interviewed were pregnant. Rural women were more likely to be pregnant (8 percent) than urban women (6 percent). The highest proportion of current pregnancy was seen in the Northern region (12 percent) while the lowest proportion was in the Brong Ahafo region (5 percent). The percentage of women currently pregnant decreases with increasing level of education, from 9 percent among women with no education, to 7 percent among those with primary or middle/JSS, to 5 percent among women with at least secondary education. Likewise, there are more currently pregnant women in the two lowest wealth quintiles (9 percent each) than in the two highest wealth quintiles (6 and 7 percent, respectively). Women age 40-49 have given birth to an average of 5.2 children. Comparing this cumulative fertility rate with the TFR indicates that there has been a decline in fertility over time among women in all groups, except the Central and Northern regions, where it has remained the same. Fertility | 71 4.1.3 Trends in Fertility Besides the comparison of current and completed fertility, fertility trends in Ghana can be assessed in several 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 2008 GDHS can also be compared with estimates obtained in earlier surveys or censuses. Table 4.3 uses information from the retrospective birth histories obtained from GDHS respondents to examine the trends in age-specific fertility rates for successive five-year periods preceding the survey. To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of birth. The age-specific rates are progressively truncated with increasing time before the survey. Because women 50 years and over were not interviewed in the 2008 GDHS, 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 earlier prior to the survey, because women in that age group would have been 50 years or older at the time of the survey. Partially truncated rates are enclosed in brackets in the table. Table 4.3 indicates that fertility has fallen substantially in all age groups over time. This de- cline is most apparent between the periods 15-19 and 10-14 years preceding the survey. A comparison of the Age-Specific Fertility Rates (ASFR) obtained from the four previous GDHS surveys (1988, 1993, 1998, and 2003) with the ASFR obtained from the 2008 GDHS is shown in Figure 4.3. This offers an opportunity to assess fertility trends by tracking the pattern of recent fertility estimates from the surveys. Direct estimates of fertility for the three years preceding the survey have been used in this comparison 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 were based on the five years preceding the survey. Fertility trends have to be interpreted in 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. Therefore, the fertility trends shown in Figure 4.3 should be interpreted with caution. The TFR declined markedly from 6.4 children per woman in 1988 to 4.4 children per woman in 1998, stabilised at that level until 2003, and then declined to 4.0 in 2008 (data not shown separately). The decline in fertility was especially rapid during the period between 1988 and 1998. The downward trend in the TFR continued during the last decade, although at a slower pace. The figure shows that all age groups have contributed to the decline in fertility rates (Figure 4.3). 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 2008 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 70 84 94 110 20-24 171 187 194 216 25-29 207 220 232 237 30-34 178 202 194 [235] 35-39 122 140 [171] - 40-44 67 [95] - 45-49 [13] - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 72 | Fertility , , , , , , , + + + + + + + % % % % % % % ( ( ( ( ( ( ( ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 250 300 Births per 1,000 women GHDS 1988 GDHS 1993 GDHS 1998 GDHS 2003 GDHS 2008) ( % + , Figure 4.3 Trends in Fertility, 1988-2008 Note: Rates are for the three-year period preceding the interview. 4.2 CHILDREN EVER BORN AND LIVING Table 4.4 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, according to five-year age groups. Lifetime fertility reflects the accumulation of births over the past 30 years so 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. This proportion declines to 22 percent for women age 25-29, and to 8 percent or less among women age 30 and older. Ghanaian women attain a parity of 5.6 children by the end of their reproductive period, which is 1.6 children more than the total fertility rate. Eight percent of Ghanaian women have 10 or more children by the end of their reproductive period. Although the pattern for currently married women is similar to that for all women, just over one-third (36 percent) of currently married women age 15-19 have not borne a child, while nearly half (48 percent) have borne at least one child. 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 3.4 children, compared with 2.3 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 Fertility | 73 Table 4.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born and mean number of living children, according to age group, Ghana 2008 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 90.1 8.3 1.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,025 0.11 0.11 20-24 50.7 27.7 14.0 5.7 1.3 0.4 0.3 0.0 0.0 0.0 0.0 100.0 878 0.81 0.74 25-29 21.6 23.2 23.7 18.8 8.8 3.0 0.8 0.1 0.0 0.0 0.0 100.0 832 1.83 1.69 30-34 8.1 11.6 23.1 19.4 19.5 9.2 5.3 2.0 1.1 0.8 0.0 100.0 644 3.01 2.76 35-39 5.6 6.8 13.5 15.6 21.6 15.9 9.8 6.6 2.5 1.5 0.4 100.0 638 3.90 3.49 40-44 2.6 6.3 9.9 12.9 14.4 16.8 14.4 9.0 6.8 3.1 3.9 100.0 470 4.79 4.16 45-49 1.5 1.5 7.6 12.0 15.3 12.7 12.7 13.7 10.8 4.6 7.5 100.0 429 5.59 4.73 Total 33.7 13.7 13.2 11.0 9.8 6.5 4.6 3.2 2.1 1.0 1.1 100.0 4,916 2.33 2.07 CURRENTLY MARRIED WOMEN 15-19 36.4 48.4 15.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 85 0.79 0.77 20-24 19.1 41.5 24.1 11.2 2.8 0.7 0.6 0.0 0.0 0.0 0.0 100.0 414 1.42 1.28 25-29 9.0 21.6 29.5 23.9 10.8 3.9 1.1 0.1 0.0 0.0 0.0 100.0 612 2.23 2.06 30-34 4.3 9.7 22.7 22.0 21.1 10.5 5.8 2.1 0.9 1.0 0.0 100.0 539 3.23 2.96 35-39 3.4 3.8 12.6 15.4 23.7 17.4 10.8 7.8 3.0 1.6 0.5 100.0 527 4.19 3.78 40-44 2.5 4.1 8.2 14.0 13.6 17.5 15.5 9.6 7.5 3.3 4.0 100.0 380 4.97 4.34 45-49 1.3 1.6 4.5 10.9 14.3 12.7 13.9 14.8 11.5 5.2 9.4 100.0 319 5.91 5.03 Total 7.7 15.2 18.4 16.7 14.4 9.8 7.0 4.7 3.0 1.5 1.7 100.0 2,876 3.39 3.02 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. 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 1 percent. 4.3 BIRTH INTERVALS A birth interval is defined as the length of time between two live births. The study of birth intervals is important in understanding the health status of young children. Research has shown that short birth intervals are closely associated with poor health of children, especially during infancy. Children born too close to a previous birth, especially if the interval between the births is less than two years, are at increased risk of health problems and dying at an early age. Longer birth intervals, on the other hand, contribute to the improved health status of both mother and child. 74 | Fertility The study of birth intervals is done using two measures: median birth interval and proportion of non-first births that occur 24 months or more after the previous birth. Table 4.5 presents the distribution of second and higher-order births in the five years preceding the survey by the number of months since the previous birth, according to background characteristics. First births are omitted from the table because there is no prior birth with which to measure an interval. The table also shows the median number of months since the preceding birth. Fourteen percent of all non-first births occur less than 24 months after an earlier birth. The median birth interval is 40 months, that is, more than half of non-first births to women in Ghana occur more than three years after a previous birth. There has been little change in the length of birth intervals over the past five years. The median birth interval increases with age from 35 months for births to women age 20-29 to 47 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 substantial differences in the median birth interval by birth order or 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 occurred after an interval 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 postpartum amenorrhoea. The median interval between births is six months longer among women in urban areas (44 months) than among those in rural areas (38 months). By region, the median birth interval ranges from a low of 37 months in the Northern region to 48 months in the Upper East region. Education is not strongly related to median birth interval but there is a correlation between women’s household wealth status and the length of the birth interval. The median birth interval increases steadily from 36 months among women in the lowest (poorest) wealth quintile to 46 months among those in the highest (richest) wealth quintile. 4.4 AGE AT FIRST BIRTH The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. One of the factors that determine the level of fertility in a population is 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. In many countries, postponement of first births, reflecting a rise in age at marriage, has made a large Fertility | 75 Table 4.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Ghana 2008 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 20-29 5.2 12.7 35.0 24.7 10.3 12.1 100.0 862 34.6 30-39 3.1 8.1 23.0 25.2 16.5 24.1 100.0 1,020 42.8 40-49 1.8 9.2 20.0 20.1 16.8 32.0 100.0 319 46.6 Sex of preceding birth Male 3.6 10.6 28.1 23.5 14.0 20.3 100.0 1,134 39.4 Female 4.1 9.8 26.7 24.8 14.1 20.5 100.0 1,083 40.1 Survival of preceding birth Living 2.8 9.2 27.6 24.5 14.5 21.4 100.0 2,020 40.6 Dead 14.0 20.4 25.6 20.2 9.4 10.5 100.0 197 29.5 Birth order 2-3 4.0 10.3 26.8 23.9 13.8 21.3 100.0 1,103 40.3 4-6 3.8 9.0 26.5 24.4 14.9 21.5 100.0 839 40.5 7+ 3.4 13.3 32.8 24.3 12.8 13.4 100.0 275 36.3 Residence Urban 2.9 9.4 22.4 22.9 15.2 27.2 100.0 769 44.2 Rural 4.3 10.6 30.1 24.8 13.5 16.8 100.0 1,448 38.0 Region Western 3.1 11.2 29.3 28.4 10.8 17.2 100.0 211 37.5 Central 8.0 13.1 25.9 19.0 17.1 16.8 100.0 218 37.9 Greater Accra 3.6 10.3 25.0 19.4 14.1 27.5 100.0 233 44.9 Volta 1.4 8.3 28.9 22.2 15.9 23.3 100.0 191 41.2 Eastern 3.1 11.4 26.5 22.0 15.5 21.6 100.0 188 39.8 Ashanti 5.6 10.6 27.8 22.6 13.2 20.2 100.0 407 38.1 Brong Ahafo 1.3 4.6 26.7 24.7 15.1 27.5 100.0 196 43.9 Northern 4.4 12.7 30.7 29.5 11.5 11.3 100.0 382 36.8 Upper East 0.3 4.8 19.1 27.0 18.7 30.1 100.0 126 47.7 Upper West 1.8 8.1 29.5 26.8 13.9 20.0 100.0 65 40.7 Education No education 3.6 10.1 28.8 26.1 14.7 16.6 100.0 841 39.4 Primary 4.6 11.4 28.8 23.8 12.8 18.6 100.0 559 38.0 Middle/JSS 2.6 9.5 26.0 22.4 13.9 25.5 100.0 674 41.2 Secondary+ 8.2 8.8 19.8 22.0 16.3 25.0 100.0 141 42.8 Wealth quintile Lowest 3.9 13.3 33.4 25.7 10.8 13.0 100.0 642 35.8 Second 3.0 10.0 31.1 26.1 13.4 16.3 100.0 494 38.7 Middle 5.6 7.9 23.1 23.9 16.8 22.7 100.0 411 41.5 Fourth 2.6 8.8 23.9 20.6 15.7 28.5 100.0 389 44.0 Highest 4.4 8.6 18.4 22.2 16.4 29.9 100.0 281 45.7 Total 3.8 10.2 27.4 24.1 14.1 20.4 100.0 2,217 39.7 Note: First-order births are excluded from this table. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Total includes cases with information missing on education and 17 weighted cases of non-first births to women age 15-19, and are not shown separately. 76 | Fertility contribution to overall fertility decline. Table 4.6 shows the percentage of women age 15-49 who gave birth by specific exact ages, the percentage who have never given birth, and the median age at first birth, according to current age. The median age at first birth for the youngest cohort for whom a median could be calculated (women age 25-29) is 21.8 years, which is followed by 21.1 years for women age 30-34. 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 28 percent among the oldest cohort (women age 45-49) to 16 percent among the youngest cohort for whom complete information is available (women 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, 2003, and 2008 GDHS surveys for the same age groups reinforces the conclusion that there has been a trend towards a rising age at first birth. Table 4.6 Age at first birth Percentage of women age 15-49 who gave birth by specific exact ages, percentage who have never given birth, and median age at first birth, according to current age, Ghana 2008 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 0.5 na na na na 90.1 1,025 a 20-24 2.2 15.8 32.2 na na 50.7 878 a 25-29 2.3 17.5 36.7 51.8 69.4 21.6 832 21.8 30-34 4.9 24.7 40.5 59.0 77.1 8.1 644 21.1 35-39 2.9 23.8 45.7 61.3 75.6 5.6 638 20.5 40-44 4.8 26.4 45.5 67.1 81.5 2.6 470 20.3 45-49 3.0 27.6 50.5 69.9 85.3 1.5 429 20.0 20-49 3.2 21.5 40.4 na na 18.8 3,891 a 25-49 3.5 23.2 42.8 60.3 76.5 9.5 3,014 20.7 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 4.5 MEDIAN AGE AT FIRST BIRTH BY BACKGROUND CHARACTERISTICS Age at first birth varies by demographic and socio-economic characteristics of women. Table 4.7 shows the median age at first birth for women age 25-49 by current age and background characteristics. Overall, the median age at first birth for women age 25-49 in Ghana is 20.7 years. Women in urban areas (22.1 years) have their first birth two years later than their rural counterparts (20.0 years). Across regions, the median age at first birth ranges from 19.5 years in the Upper East and Upper West regions to 23.2 years in Greater Accra. Age at first birth does not vary substantially by level of education, although the median age at first birth (20.9 years) for women with the highest level of education (Middle/JSS) for which a median could be estimated is at least one year higher than the medians for women with less education—19.9 years for women with no education and 19.3 years for women with primary education. The results on age at first birth by wealth status show that the median age at first birth for women in all five wealth quintiles is the same (20 years). Fertility | 77 Table 4.7 Median age at first birth Median age at first birth among women age 25-49, by current age and background characteristics, Ghana 2008 Background characteristic Current age Women age 25-49 25-29 30-34 35-39 40-44 45-49 Residence Urban 23.8 22.6 21.5 20.9 19.9 22.1 Rural 20.0 19.9 19.9 20.0 20.0 20.0 Region Western 20.9 21.8 20.5 20.9 20.5 21.0 Central 20.5 20.2 20.0 20.2 20.3 20.2 Greater Accra a 23.6 22.1 21.2 19.6 23.2 Volta 19.6 21.1 22.1 19.9 20.1 20.4 Eastern 21.5 19.9 19.6 20.3 19.9 20.2 Ashanti 22.2 20.4 20.4 20.1 20.1 20.8 Brong Ahafo 20.5 20.7 20.7 18.8 18.6 20.2 Northern 21.3 20.9 19.9 21.0 20.4 20.7 Upper East 19.0 19.7 19.2 20.2 19.9 19.5 Upper West 20.4 20.3 19.5 18.5 17.6 19.5 Education No education 19.3 19.9 20.0 20.2 20.0 19.9 Primary 19.5 19.1 19.2 19.0 19.3 19.3 Middle/JSS 21.9 21.6 21.0 20.3 19.8 20.9 Secondary+ a 26.3 28.1 23.8 22.0 a Wealth quintile Lowest 19.4 19.5 20.0 19.9 20.5 19.9 Second a 20.3 19.3 19.3 19.8 20.1 Middle a 20.7 20.2 19.9 19.2 20.1 Fourth a 22.6 21.3 20.8 20.4 19.7 Highest a a 24.2 23.7 22.4 20.0 Total 21.8 21.1 20.5 20.3 20.0 20.7 Note: Total includes cases with information missing on education that are not shown separately. a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 4.6 TEENAGE FERTILITY Adolescent childbearing has potentially negative demographic and social consequences. Births to teenage mothers (age 15-19) have been found to have the highest infant and child mortality in Ghana (GSS and MI, 1994 and 1999). This may be due to these young mothers being more likely to experience complications during pregnancy and delivery 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 4.8 shows the percentage of teenage women 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 3 percent are pregnant with their first child. The percentage of adolescent women who have began childbearing increases with age from less than 1 percent among those who are age 15, to 29 percent among teenagers who are age 19. Urban teenagers differ from their rural counterparts; 11 percent of adolescents in urban areas have begun childbearing, compared with 16 percent of those in rural areas. By region, the percentage of women age 15-19 who have begun childbearing ranges from 7 percent each in the Western and Greater Accra regions to 23 percent in the Central and Northern regions. It is also clear that childbearing decreases substantially as education increases; 31 percent of adolescents with no education have begun childbearing, compared with just 1 percent of teenagers with secondary or higher education. By wealth status, adolescent childbearing decreases from 21 percent in the second wealth quintile to 4 percent in the highest wealth quintile. This finding suggests that poverty is an 78 | Fertility important consideration in understanding adolescent childbearing in Ghana (Nabila and Fayorsey, 1996). Over the past five years there has been no substantial change in the overall percentage of teenage women who have begun childbearing (13 percent in 2008, compared with 14 percent in 2003). However, the urban-rural gap in teenage childbearing has been reduced, from 7 percent in urban areas and 22 percent in rural areas in 2003, to 11 percent in urban areas and 16 percent in rural areas in 2008. Table 4.8 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Ghana 2008 Background characteristic Percentage who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 0.5 0.3 0.7 213 16 1.1 3.4 4.5 187 17 8.3 2.8 11.1 205 18 17.2 4.1 21.4 239 19 22.1 6.8 28.9 181 Residence Urban 8.8 1.9 10.7 493 Rural 10.9 4.8 15.7 532 Region Western 5.9 0.6 6.5 94 Central 18.4 4.8 23.2 101 Greater Accra 5.9 0.8 6.6 162 Volta 9.2 6.6 15.9 91 Eastern 8.0 0.0 8.0 106 Ashanti 5.0 6.1 11.0 202 Brong Ahafo 18.2 4.0 22.2 80 Northern 17.4 5.2 22.6 102 Upper East 9.8 0.8 10.6 56 Upper West 9.4 3.1 12.5 30 Education No education 23.4 7.4 30.9 72 Primary 18.8 7.0 25.9 222 Middle/JSS 7.0 2.4 9.5 571 Secondary+ 1.3 0.0 1.3 159 Wealth quintile Lowest 14.5 3.4 17.9 153 Second 13.2 8.1 21.3 200 Middle 11.2 3.1 14.2 221 Fourth 9.7 1.5 11.2 230 Highest 2.5 1.4 3.9 221 Total 9.9 3.4 13.3 1,025 Family Planning | 79 FAMILY PLANNING 5 This chapter presents the 2008 GDHS findings on contraceptive knowledge and use, attitudes, and sources, as well as exposure to media messages about family planning. The information is par- ticularly 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 because men play an important role in realising women’s reproductive goals. Comparisons are also made, where feasible, with findings from previous surveys to evaluate trends over the past twenty years in Ghana. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge about contraceptive methods is an important step towards gaining access to family planning services and then adopting a suitable contraceptive method. 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 par- ticular 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 con- traception. 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 shows the percentage of all women and men, currently married women and men, and sexually active unmarried women and men age 15-49 who have heard of specific contraceptive methods. 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 remain more widely known than traditional methods. Ninety-eight percent of all women know of a modern method, compared with 77 percent who know of a traditional method. Among women, the male condom is the most commonly known method (94 percent), followed by the pill (87 percent), injectables (86 percent), and the female condom (81 percent). Emergency contraception is known by 35 percent of all women. Lactational amenorrhoea method (LAM) is the least known (9 percent). Among the traditional methods, rhythm is the most commonly known (70 percent), followed closely by withdrawal (61 percent); a small proportion (2 percent) mentioned folk methods. Knowledge of contraceptive methods among currently married women is similar to that among all women, especially regarding 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 (93 percent), followed by injectables (91 percent), the pill (90 percent), and the female condom (81 percent). Emergency contraception is known by 34 percent of married women. LAM is the least known modern method (11 percent). 80 | Family Planning Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who know any contraceptive method, by specific method, Ghana 2008 Method Women Men All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 97.8 97.9 99.9 98.9 99.5 99.6 Any modern method 97.7 97.8 99.9 98.8 99.5 99.6 Female sterilisation 62.6 65.4 63.1 64.3 72.3 67.9 Male sterilisation 36.6 38.8 33.8 47.0 51.2 52.1 Pill 86.6 90.1 90.0 81.8 88.1 88.6 IUD 42.5 48.4 36.3 31.0 37.7 26.8 Injectables 85.6 91.1 87.2 78.4 87.5 84.0 Implants 63.8 73.8 61.2 36.7 47.7 33.5 Male condom 93.9 93.1 99.3 98.3 99.1 99.4 Female condom 81.3 80.7 90.1 86.4 89.2 92.2 Diaphragm 26.1 29.4 21.6 22.5 26.1 24.5 Foam/jelly 25.5 28.4 28.3 31.2 36.5 35.8 Lactational amenorrhoea (LAM) 8.7 10.6 6.5 6.9 9.6 6.0 Emergency contraception 35.4 33.9 48.5 37.1 40.7 49.0 Any traditional method 76.6 78.0 85.8 78.7 87.9 89.8 Rhythm 69.5 69.7 80.8 69.4 79.2 81.2 Withdrawal 61.3 65.6 72.3 69.4 78.1 82.4 Folk method 1.9 2.3 1.6 1.1 0.9 0.9 Mean number of methods known by respondents 15-49 7.8 8.2 8.2 7.6 8.4 8.2 Number of respondents 4,916 2,876 284 4,058 1,950 376 Mean number of methods known by respondents 15-59 na na na 7.7 8.5 8.2 Number of respondents na na na 4,568 2,404 383 na = Not applicable 1 Sexual intercourse in the past 30 days Contraceptive knowledge is highest among sexually active unmarried women (100 percent). Unmarried women reported the male condom to be the most commonly known method (99 percent) followed by the female condom and the pill (90 percent each). Sexually active unmarried women are also more likely to report knowledge of emergency contraception (49 percent), rhythm, and withdrawal methods, while knowledge of male sterilisation, the IUD, injectables, implants, and LAM is higher among married women. Knowledge of contraception is slightly higher among men than women―99 percent of men know of at least one method of contraception (Table 5.1). Like women, a larger proportion of men (99 percent) know a modern method than a traditional method (79 percent). As with women, sexually active unmarried men are more likely to report knowledge of emergency contraception, rhythm, and withdrawal methods, while knowledge of female sterilisation, the IUD, injectables, implants, and LAM is higher among married men. The most commonly known modern method is the male condom reported by 98 percent of all men and 99 percent of married men and sexually active unmarried men. Emergency contraception is known by 37 percent of all men, 41 percent of currently married men, and 49 percent of sexually active unmarried men. The rhythm method is known by 69 percent of all men, 79 percent of currently married men, and 81 percent of sexually active unmarried men. It is worth noting that knowledge of the pill, implants, injectables, and the IUD is lower among men than women. Knowledge of male sterilisation is slightly higher among men than women. On average, women and men in Ghana have heard of at least eight contraceptive methods. Family Planning | 81 Table 5.2 shows differentials in knowledge of any contraceptive method and any modern contraceptive method among currently married women and men age 15-49 by background characteristics. Knowledge of at least one method is high in almost all categories. Nevertheless, it is lower among women in rural areas than in urban areas, and lower among women age 15-19 and those living in the Northern region. Knowledge of at least one method increases with level of education and wealth quintile, but the differences are small. For example, 93 percent of women in the lowest wealth quintile have heard of at least one method of family planning, compared with 100 percent of those in the highest wealth quintile. Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method, by background characteristics, Ghana 2008 Background characteristic Currently married women Currently married men Heard of any method Heard of any modern method1 Number of women Heard of any method Heard of any modern method1 Number of men Age 15-19 93.4 92.5 85 * * 7 20-24 97.1 97.1 414 99.8 99.8 106 25-29 98.0 98.0 612 99.4 99.4 296 30-34 99.1 99.1 539 99.5 99.5 412 35-39 97.6 97.4 527 99.9 99.9 445 40-44 98.2 97.9 380 99.7 99.4 353 45-49 98.0 98.0 319 99.4 99.4 331 Residence Urban 99.2 99.2 1,216 99.9 99.9 832 Rural 96.9 96.8 1,660 99.3 99.2 1,118 Region Western 97.6 97.6 261 100.0 100.0 205 Central 98.6 98.6 254 100.0 100.0 148 Greater Accra 99.6 99.6 422 100.0 100.0 302 Volta 99.7 99.4 290 100.0 99.4 166 Eastern 99.7 99.7 252 99.5 99.5 189 Ashanti 99.5 99.2 542 99.6 99.6 374 Brong Ahafo 98.0 98.0 267 100.0 100.0 172 Northern 91.1 91.1 338 98.0 98.0 237 Upper East 96.9 96.4 168 98.6 98.6 109 Upper West 95.6 95.6 82 99.2 99.2 47 Education No education 94.0 93.7 853 97.9 97.9 398 Primary 99.5 99.5 638 99.8 99.4 251 Middle/JSS 99.5 99.4 1,058 100.0 100.0 812 Secondary+ 100.0 100.0 325 100.0 100.0 485 Wealth quintile Lowest 92.9 92.6 573 97.7 97.7 380 Second 98.7 98.7 577 99.9 99.7 368 Middle 98.6 98.4 525 100.0 100.0 310 Fourth 99.6 99.6 600 100.0 100.0 434 Highest 99.6 99.6 601 100.0 100.0 458 Total 15-49 97.9 97.8 2,876 99.5 99.5 1,950 50-59 na na na 98.5 98.2 454 Total 15-59 na na na 99.3 99.2 2,404 Note: Total includes cases with information missing on education that are not shown separately. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam, or jelly, Lactational Amenorrhoea Method (LAM), and emergency contraception 82 | Family Planning Knowledge of contraceptive methods among women age 15-49 in Ghana has increased substantially over the past two decades, although there has been little or no increase over the past five years. The proportion of all women age 15-49 who have heard of at least one method of family planning increased from 76 percent in 1988 to 98 percent in 2003 and 2008. Knowledge of specific methods has shown even more dramatic increases over the 20-year period. For example, the proportion of women age 15-49 who have heard of injectables increased from 43 to 86 percent, the proportion who have heard of the pill increased from 60 to 87 percent, and the proportion who have heard of the male condom increased from 49 to 94 percent. Knowledge of implants among women age 15-49 increased from 4 percent in 1993 to 64 percent in 2008. The mean number of methods known among all women, however, decreased slightly from 8.6 in 2003 to 7.8 in 2008. There was a similar trend among men age 15-59, the mean number of methods known decreased from 8.8 in 2003 to 7.7 in 2008. 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, and withdrawal. Table 5.3.1 shows the percentage of all women, currently married women, and sexually active unmarried women who have ever used specific methods of family planning, by age, and Table 5.3.2 shows comparable information for men. Fifty percent of all women reported having used a method of contraception at some time; 42 percent have used a modern method and 25 percent have used a traditional method. Among modern methods, the male condom (20 percent) is the most commonly used method, followed by the pill (17 percent) and injectables (14 percent). Male sterilisation, the diaphragm, LAM, and female condoms are the least used methods (less than 1 percent each). Among traditional methods, rhythm (17 percent) is the most commonly used method, followed by withdrawal (14 percent). Emergency contraception has been used by 3 percent of women—an increase of two percentage points since 2003 (1 percent). The use of any contraceptive method increases with age, peaking among women in their late 20s through 30s, and then declining among women in their 40s. Sixty percent of currently married women have used a method of contraception at some time; 50 percent have used a modern method and 29 percent have used a traditional method. The pill is the most commonly used method among currently married women (23 percent) followed by injectables and the male condom (19 percent each). Ever use of contraception is highest among sexually active unmarried women. Seventy-five percent of sexually active unmarried women have used a method of contraception at some time. Sexually active unmarried women tend to use temporary methods of contraception rather than long- term or permanent methods. Forty-four percent of these women have used a male condom, compared with 19 percent of married women. Ever use of emergency contraception is higher among sexually active unmarried women than other women, and they are more likely to have used traditional methods like rhythm and withdrawal. Ever use of family planning has increased over time. The proportion of all women who have ever used any method of contraception increased from 34 percent in 1988 to 50 percent in 2008. Similarly, the proportion of women who have ever used a modern method increased steadily from 21 percent in 1988 to 42 percent in 2008. T ab le 5 .3 .1 E ve r u se o f c on tra ce pt io n: W om en P er ce nt ag e of a ll w om en , cu rr en tly m ar rie d w om en a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 w ho h av e ev er u se d an y co nt ra ce pt iv e m et ho d by m et ho d, a cc or di ng t o ag e, G ha na 2 00 8 A ge A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tra di - tio na l m et ho d Tr ad iti on al m et ho d N um be r of w om en Fe m al e st er ili - sa tio n M al e st er ili - sa tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om D ia - ph ra gm Fo am / je lly LA M Em er - ge nc y co nt ra - ce pt io n Rh yt hm W ith - dr aw al Fo lk m et ho d A LL W O M EN 1 5- 19 19 .5 15 .2 0. 0 0. 1 3. 7 0. 0 1. 2 0. 1 12 .2 0. 4 0. 0 0. 2 0. 0 1. 0 9. 8 6. 2 6. 3 0. 0 1, 02 5 2 0- 24 58 .0 48 .2 0. 0 0. 2 16 .2 0. 2 9. 9 0. 8 32 .3 0. 1 0. 0 1. 1 0. 0 4. 8 30 .6 19 .7 18 .8 0. 4 87 8 2 5- 29 61 .4 51 .9 0. 4 0. 0 20 .9 0. 3 15 .9 2. 2 27 .9 0. 7 0. 2 2. 0 0. 3 4. 9 34 .1 24 .1 19 .6 0. 6 83 2 3 0- 34 60 .6 51 .7 1. 1 0. 2 24 .3 2. 1 22 .5 2. 0 19 .3 0. 4 0. 4 1. 6 0. 0 1. 4 28 .7 19 .7 16 .6 0. 7 64 4 3 5- 39 61 .1 51 .7 0. 8 0. 2 22 .9 1. 9 24 .1 3. 4 17 .5 1. 5 0. 9 1. 5 1. 1 2. 4 26 .2 16 .9 15 .0 1. 1 63 8 4 0- 44 57 .5 49 .4 3. 9 0. 2 25 .2 2. 9 17 .4 3. 3 14 .4 1. 7 1. 0 3. 8 0. 7 2. 6 27 .1 19 .1 14 .3 0. 9 47 0 4 5- 49 48 .3 40 .3 4. 3 0. 2 17 .7 4. 3 13 .7 1. 7 11 .5 1. 0 0. 4 2. 9 1. 6 3. 1 23 .1 16 .2 10 .0 1. 4 42 9 T ot al 50 .4 42 .3 1. 0 0. 1 17 .3 1. 3 13 .7 1. 7 20 .2 0. 7 0. 3 1. 6 0. 4 2. 9 25 .0 16 .9 14 .3 0. 6 4, 91 6 C U RR EN TL Y M AR RI ED W O M EN 1 5- 19 55 .2 41 .0 0. 0 1. 5 15 .8 0. 0 4. 3 0. 9 27 .0 1. 6 0. 0 1. 8 0. 0 2. 3 31 .0 15 .8 24 .3 0. 0 85 2 0- 24 61 .3 50 .7 0. 0 0. 0 22 .7 0. 4 16 .5 1. 5 26 .9 0. 1 0. 0 1. 1 0. 0 3. 2 31 .3 19 .5 19 .4 0. 2 41 4 2 5- 29 62 .6 52 .3 0. 2 0. 0 22 .3 0. 4 17 .5 1. 8 25 .9 1. 0 0. 3 2. 5 0. 4 4. 5 35 .3 24 .4 20 .2 0. 7 61 2 3 0- 34 61 .1 51 .7 1. 3 0. 2 25 .2 2. 1 23 .6 2. 4 16 .8 0. 5 0. 4 1. 4 0. 0 1. 4 26 .4 18 .3 14 .8 0. 8 53 9 3 5- 39 61 .6 52 .4 0. 8 0. 2 24 .2 2. 4 25 .6 3. 7 15 .8 0. 9 0. 8 1. 6 0. 9 2. 3 25 .2 17 .1 14 .1 0. 7 52 7 4 0- 44 58 .8 50 .2 4. 8 0. 3 26 .3 2. 3 17 .7 3. 5 14 .3 2. 1 1. 3 4. 4 0. 8 2. 1 28 .3 21 .3 14 .0 1. 1 38 0 4 5- 49 49 .5 42 .4 5. 4 0. 2 18 .7 5. 4 15 .2 2. 3 11 .8 1. 0 0. 5 2. 5 1. 7 3. 3 22 .6 16 .1 10 .4 1. 1 31 9 T ot al 59 .8 50 .3 1. 6 0. 2 23 .2 1. 9 19 .4 2. 5 19 .4 0. 9 0. 5 2. 1 0. 5 2. 8 28 .8 19 .6 16 .2 0. 7 2, 87 6 SE XU AL LY A C TI VE U N M AR RI ED W O M EN 1 1 5- 19 66 .6 51 .4 0. 0 0. 0 13 .8 0. 0 2. 6 0. 0 43 .8 1. 5 0. 0 0. 0 0. 0 4. 7 40 .5 27 .0 25 .4 0. 0 87 2 0- 24 74 .0 62 .0 0. 0 0. 0 13 .0 0. 0 7. 2 0. 0 48 .4 0. 8 0. 0 3. 4 0. 0 12 .0 36 .7 26 .0 20 .5 0. 0 88 2 5+ 82 .1 71 .4 1. 5 0. 0 31 .2 2. 4 18 .8 6. 6 39 .4 1. 4 0. 0 0. 0 0. 0 3. 9 40 .7 26 .4 25 .3 0. 0 10 9 T ot al 74 .8 62 .3 0. 6 0. 0 20 .2 0. 9 10 .2 2. 5 43 .5 1. 2 0. 0 1. 1 0. 0 6. 7 39 .4 26 .4 23 .9 0. 0 28 4 L AM = L ac ta tio na l a m en or rh oe a m et ho d 1 W om en w ho h ad s ex ua l i nt er co ur se w ith in th e pa st 3 0 da ys | 83Family Planning 84 | Family Planning Table 5.3.2 shows the percentage of all men, currently married men and sexually active un- married men age 15-49 who reported having ever used one of four male methods of contra- ception―male sterilisation, male condom, rhythm, and withdrawal. Ever use is lowest among teenagers and highest among sexually active, unmarried men, 86 percent of whom have used a method. More than half of all men age 15-49 have used a male-oriented method of contraception at some time. The most popular male method, the condom, has been used by 46 percent of all men, 56 percent of currently married men, and 78 percent of sexually active unmarried men. Male sterilisation is practically non-existent in Ghana; less than 1 percent of men reported ever use of male sterilisation. Ever use of contraception is generally higher among men than women, however considerably higher proportions of men than women reported having used rhythm and withdrawal. Of the two traditional methods, rhythm is reported as used more often than withdrawal by all men (29 and 27 percent, respectively) and currently married men (42 and 35 percent, respectively). However, it is less popular than withdrawal among sexually active unmarried men (39 and 45 percent, respectively). Table 5.3.2 Ever use of contraception: Men Percentage of all men, currently married men, and sexually active unmarried men age 15-49 who have ever used any contraceptive method by method, according to age, Ghana 2008 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Number of men Male sterili- sation Male condom Rhythm With- drawal Folk method ALL MEN 15-19 14.7 11.9 0.4 11.7 8.5 4.9 6.3 0.0 911 20-24 57.6 51.3 0.4 51.3 33.2 19.7 25.0 0.3 704 25-29 72.5 63.0 0.5 63.0 52.7 38.5 35.5 0.4 624 30-34 77.3 63.4 0.4 63.2 57.7 40.8 39.1 0.1 533 35-39 72.9 59.0 0.6 59.0 58.7 42.3 39.5 0.5 528 40-44 69.2 52.5 1.0 52.0 51.3 40.4 30.5 0.0 394 45-49 62.6 41.9 0.0 41.9 50.5 40.3 28.8 0.0 364 Total 15-49 56.4 46.1 0.5 46.0 40.5 28.8 27.1 0.2 4,058 50-59 60.9 42.2 0.5 41.8 47.0 36.5 25.6 0.0 510 Total 15-59 56.9 45.7 0.5 45.5 41.2 29.7 26.9 0.2 4,568 CURRENTLY MARRIED MEN 15-19 * * * * * * * * 7 20-24 73.2 60.9 1.4 60.9 51.2 36.0 35.8 0.0 106 25-29 72.9 59.9 0.4 59.9 55.4 43.6 34.0 0.8 296 30-34 78.5 63.5 0.3 63.2 59.7 43.3 38.7 0.2 412 35-39 72.6 57.3 0.3 57.3 58.8 43.1 39.0 0.6 445 40-44 70.4 52.9 1.1 52.4 52.4 41.0 31.7 0.0 353 45-49 62.6 42.4 0.0 42.4 50.6 40.2 29.5 0.0 331 Total 15-49 71.7 55.7 0.5 55.6 55.4 41.9 35.0 0.3 1,950 50-59 63.0 43.7 0.5 43.1 48.7 37.8 26.6 0.0 454 Total 15-59 70.0 53.4 0.5 53.2 54.1 41.1 33.4 0.2 2,404 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 72.4 62.0 0.0 62.0 43.1 23.1 33.4 0.0 61 20-24 86.7 78.9 0.0 78.9 53.7 37.1 38.0 0.9 121 25+ 89.1 82.6 1.1 82.6 69.2 45.4 53.8 0.0 195 Total 15-49 85.6 78.1 0.6 78.1 60.0 39.2 45.4 0.3 376 50-59 * * * * * * * * 7 Total 15-59 85.4 77.7 0.6 77.7 59.8 38.8 45.5 0.3 383 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who had sexual intercourse within the past 30 days Family Planning | 85 5.3 CURRENT USE OF CONTRACEPTIVE METHODS This section presents information on the prevalence of contraceptive use among all women, currently married women, and sexually active unmarried women age 15-49. The level of current use is the most widely used and valuable measure of the success of a family planning programme. Furthermore, it can be used to estimate the reduction in fertility attributable to contraception. The contraceptive prevalence rate (CPR) is usually defined as the percentage of currently married women who are currently using a method of contraception. Table 5.4 shows that about one in four currently married women (24 percent) are currently using some method of contraception. Modern methods of contraception account for almost all the use, with 17 percent of married women reporting use of a modern method, compared with 7 percent using a traditional method. Injectables (6 percent), pills, and rhythm (5 percent each) are the most widely used methods among married women, followed by male condoms, and female sterilisation (2 percent each). Among currently married women, the proportion currently using any modern method of contraception rises with age from 8 percent of those age 15-19 to 19 percent among those age 35-39 and 40-44, after which it declines. Female sterilisation is mostly used by currently married women in their 40s (5 percent); among younger women, 1 percent or less use sterilisation. Except for women age 45-49, injectables and rhythm are the two most commonly used methods among currently married women in every age group. Injectables are most commonly used by married women age 20-24 and those in their 30s, whereas rhythm is mostly used by teenagers and women in their early 40s. Except for women in their late 40s, pills are the third most commonly used method (after injectables and rhythm) in every age group. Among sexually active unmarried women—most of whom are young—the male condom is by far the most commonly used method. This group is seven times as likely to use male condoms as currently married women. After the male condom (18 percent), the most commonly used modern method among sexually active unmarried women is the pill (10 percent), while rhythm (12 percent) is the most widely used traditional method. Table 5.4 also shows that current use is slightly higher among those who are currently married than among all women. However, use is far higher among unmarried women who are sexually active (50 percent) than among married women (24 percent) or all women (19 percent). T ab le 5 .4 C ur re nt u se o f c on tr ac ep tio n by a ge P er ce nt d ist rib ut io n of a ll w om en , c ur re nt ly m ar rie d w om en , a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to a ge , G ha na 2 00 8 A ge A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tra di - tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en Fe m al e st er ili - sa tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om D ia - ph ra gm Fo am / je lly Rh yt hm W ith - dr aw al Fo lk m et ho d A LL W O M EN 1 5- 19 8. 1 5. 2 0. 0 1. 3 0. 0 0. 2 0. 0 3. 6 0. 0 0. 0 0. 2 2. 9 2. 1 0. 6 0. 2 91 .9 10 0. 0 1, 02 5 2 0- 24 21 .3 14 .8 0. 0 4. 0 0. 0 4. 8 0. 1 5. 6 0. 0 0. 0 0. 3 6. 5 4. 3 1. 9 0. 3 78 .7 10 0. 0 87 8 2 5- 29 23 .8 16 .2 0. 4 4. 8 0. 0 4. 8 0. 9 5. 2 0. 0 0. 0 0. 2 7. 6 4. 7 1. 4 1. 4 76 .2 10 0. 0 83 2 3 0- 34 23 .1 16 .4 1. 1 3. 8 0. 4 6. 9 0. 7 3. 1 0. 0 0. 2 0. 2 6. 7 4. 8 1. 4 0. 6 76 .9 10 0. 0 64 4 3 5- 39 23 .9 17 .4 0. 8 5. 2 0. 3 7. 1 1. 2 2. 5 0. 3 0. 0 0. 0 6. 5 4. 0 1. 8 0. 7 76 .1 10 0. 0 63 8 4 0- 44 24 .1 16 .7 3. 9 4. 3 0. 4 4. 9 1. 4 1. 6 0. 0 0. 0 0. 2 7. 4 5. 9 0. 5 1. 0 75 .9 10 0. 0 47 0 4 5- 49 16 .1 11 .6 4. 3 2. 7 0. 5 2. 2 1. 2 0. 7 0. 0 0. 0 0. 0 4. 5 3. 5 1. 0 0. 0 83 .9 10 0. 0 42 9 T ot al 19 .3 13 .5 1. 0 3. 6 0. 2 4. 2 0. 7 3. 6 0. 0 0. 0 0. 2 5. 9 4. 0 1. 3 0. 6 80 .7 10 0. 0 4, 91 6 C U RR EN TL Y M AR RI ED W O M EN 1 5- 19 13 .6 7. 6 0. 0 2. 4 0. 0 2. 1 0. 0 1. 3 0. 0 0. 0 1. 8 6. 0 4. 4 1. 6 0. 0 86 .4 10 0. 0 85 2 0- 24 22 .4 17 .3 0. 0 5. 7 0. 0 7. 9 0. 3 3. 0 0. 0 0. 0 0. 4 5. 1 3. 1 1. 7 0. 3 77 .6 10 0. 0 41 4 2 5- 29 23 .0 14 .2 0. 2 4. 5 0. 0 5. 3 0. 5 3. 4 0. 0 0. 0 0. 2 8. 8 5. 6 1. 5 1. 7 77 .0 10 0. 0 61 2 3 0- 34 23 .3 17 .3 1. 3 4. 1 0. 3 7. 1 0. 9 3. 2 0. 0 0. 3 0. 2 6. 0 4. 1 1. 3 0. 7 76 .7 10 0. 0 53 9 3 5- 39 25 .9 18 .8 0. 8 5. 9 0. 3 8. 2 1. 5 1. 8 0. 3 0. 0 0. 0 7. 1 4. 2 2. 0 0. 9 74 .1 10 0. 0 52 7 4 0- 44 27 .6 19 .0 4. 8 5. 3 0. 3 5. 7 1. 2 1. 5 0. 0 0. 0 0. 3 8. 6 7. 0 0. 6 0. 9 72 .4 10 0. 0 38 0 4 5- 49 20 .2 14 .8 5. 4 3. 3 0. 6 2. 9 1. 6 0. 9 0. 0 0. 0 0. 0 5. 4 4. 1 1. 4 0. 0 79 .8 10 0. 0 31 9 T ot al 23 .5 16 .6 1. 6 4. 7 0. 2 6. 2 0. 9 2. 4 0. 1 0. 1 0. 2 6. 9 4. 7 1. 4 0. 8 76 .5 10 0. 0 2, 87 6 SE XU AL LY A C TI VE U N M AR RI ED W O M EN 1 1 5- 19 52 .6 32 .8 0. 0 9. 5 0. 0 0. 0 0. 0 23 .3 0. 0 0. 0 0. 0 19 .8 13 .7 4. 3 1. 8 47 .4 10 0. 0 87 2 0- 24 43 .7 27 .2 0. 0 3. 8 0. 0 7. 2 0. 0 14 .9 0. 0 0. 0 1. 3 16 .4 13 .7 2. 8 0. 0 56 .3 10 0. 0 88 2 5+ 54 .0 39 .8 1. 5 14 .1 1. 7 5. 2 2. 1 15 .2 0. 0 0. 0 0. 0 14 .2 8. 5 4. 8 0. 9 46 .0 10 0. 0 10 9 T ot al 50 .4 33 .8 0. 6 9. 5 0. 6 4. 2 0. 8 17 .6 0. 0 0. 0 0. 4 16 .6 11 .7 4. 0 0. 9 49 .6 10 0. 0 28 4 N ot e: If m or e th an o ne m et ho d is us ed , o nl y th e m os t e ffe ct iv e m et ho d is co ns id er ed in th is ta bu la tio n. 1 W om en w ho h ad s ex ua l i nt er co ur se w ith in th e pa st 3 0 da ys 86 | Family Planning Family Planning | 87 5.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS Table 5.5 shows the percent distribution of currently married women by current use of family planning methods, according to background characteristics. Current use of contraception varies with number of living children, urban-rural residence, region, education, and wealth. The proportion currently using contraception generally increases with increasing number of children. Seventeen 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 highest among women who have three or four children (27 percent). Women in urban areas are more likely to use contraceptive methods (27 percent) than their rural counterparts (21 percent). The Greater Accra region has the highest contraceptive prevalence rate (33 percent), followed by the Brong Ahafo and Volta regions (29 percent each). The Northern region reports the lowest level of contraceptive use (6 percent). Women with at least some secondary education are more than twice as likely to use contraception as women with no education (30 and 14 percent, respectively). Use of any method and use of any modern method increase with level of education. Use of contraception is also positively related to wealth status, increasing from 14 percent among currently married women in the lowest wealth quintile to 31 percent in the highest wealth quintile. The pattern of current use of modern and traditional methods of contraception is similar across subgroups. Use of both modern and traditional methods is more common in urban areas than rural areas, and increases with level of education and wealth quintile. 5.5 TRENDS IN THE USE OF FAMILY PLANNING Figure 5.1 shows trends in contraceptive use among currently married women based on the results from the 2008 GDHS and four previous DHS surveys. Overall, contraceptive use among married women in Ghana has nearly doubled in the past 20 years. The survey results indicate there was a large increase in contraceptive use in the late 1980s and 1990s, from 13 to 22 percent among married women. However, over the past ten years, increases have been small. The contraceptive prevalence rate increased from 22 percent among currently married women in 1998 to 25 percent in 2003, and has declined in the past five years—24 percent in 2008—a reversal in the trend. Similarly, use of modern methods nearly doubled over the past 15 years from 10 percent in 1993 to 19 percent in 2003, before declining slightly to 17 percent in 2008. Over the past 20 years, there has been a slight decrease in the use of traditional methods. While initially there was a small increase in the use of traditional methods from 8 to 10 percent between 1988 and 1993, use of these methods decreased to 9 percent in 1998 and to 7 percent in 2003 and 2008. T ab le 5 .5 C ur re nt u se o f c on tr ac ep tio n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d ist rib ut io n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, G ha na 2 00 8 B ac kg ro un d ch ar ac te ris tic A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tra di - tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en Fe m al e st er ili - sa tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om D ia - ph ra gm Fo am / je lly Rh yt hm W ith - dr aw al Fo lk m et ho d N um be r of li vi ng ch ild re n 0 17 .1 11 .1 0. 0 4. 0 0. 0 0. 6 0. 0 5. 9 0. 0 0. 0 0. 7 6. 0 5. 4 0. 6 0. 0 82 .9 10 0. 0 24 0 1- 2 20 .3 13 .5 0. 2 3. 4 0. 0 6. 7 0. 2 2. 7 0. 0 0. 0 0. 3 6. 8 4. 5 1. 3 1. 0 79 .7 10 0. 0 1, 07 9 3- 4 27 .3 20 .1 2. 1 6. 4 0. 4 7. 2 1. 3 2. 3 0. 2 0. 0 0. 3 7. 2 5. 2 1. 3 0. 7 72 .7 10 0. 0 91 5 5+ 25 .9 18 .8 3. 9 4. 9 0. 4 6. 4 2. 0 0. 9 0. 0 0. 2 0. 0 7. 2 3. 9 2. 3 1. 0 74 .1 10 0. 0 64 1 R es id en ce U rb an 27 .1 18 .6 1. 7 4. 8 0. 4 6. 2 0. 6 4. 1 0. 1 0. 1 0. 4 8. 5 6. 5 1. 1 1. 0 72 .9 10 0. 0 1, 21 6 Ru ra l 20 .9 15 .1 1. 6 4. 7 0. 1 6. 3 1. 2 1. 2 0. 0 0. 0 0. 1 5. 8 3. 4 1. 7 0. 7 79 .1 10 0. 0 1, 66 0 R eg io n W es te rn 19 .1 13 .2 1. 1 6. 5 0. 0 3. 6 0. 6 1. 3 0. 0 0. 0 0. 0 5. 9 4. 7 1. 2 0. 0 80 .9 10 0. 0 26 1 C en tra l 22 .9 17 .0 3. 0 3. 6 0. 0 7. 7 1. 8 0. 8 0. 0 0. 0 0. 0 5. 9 3. 3 2. 6 0. 0 77 .1 10 0. 0 25 4 G re at er A cc ra 32 .6 22 .2 1. 1 6. 0 0. 9 6. 0 0. 7 6. 1 0. 4 0. 0 1. 1 10 .4 9. 3 1. 1 0. 0 67 .4 10 0. 0 42 2 Vo lta 28 .6 20 .5 2. 9 6. 1 0. 3 7. 1 0. 9 3. 3 0. 0 0. 0 0. 0 8. 1 5. 3 1. 4 1. 5 71 .4 10 0. 0 29 0 Ea st er n 24 .2 17 .0 2. 6 3. 7 0. 4 5. 8 0. 7 3. 8 0. 0 0. 0 0. 0 7. 2 4. 4 2. 5 0. 3 75 .8 10 0. 0 25 2 As ha nt i 27 .0 15 .7 3. 0 4. 9 0. 0 5. 9 1. 0 0. 7 0. 0 0. 0 0. 2 11 .3 5. 4 2. 6 3. 4 73 .0 10 0. 0 54 2 Br on g Ah af o 29 .0 21 .6 0. 0 7. 1 0. 0 6. 9 1. 5 5. 1 0. 0 0. 6 0. 5 7. 4 6. 5 0. 9 0. 0 71 .0 10 0. 0 26 7 N or th er n 5. 9 5. 7 0. 0 1. 8 0. 0 2. 9 0. 4 0. 5 0. 0 0. 0 0. 0 0. 2 0. 2 0. 0 0. 0 94 .1 10 0. 0 33 8 U pp er E as t 14 .7 14 .3 0. 4 2. 5 0. 0 10 .4 1. 0 0. 0 0. 0 0. 0 0. 0 0. 4 0. 0 0. 4 0. 0 85 .3 10 0. 0 16 8 U pp er W es t 21 .7 20 .5 0. 3 2. 7 0. 4 15 .3 1. 1 0. 7 0. 0 0. 0 0. 0 1. 2 0. 8 0. 0 0. 4 78 .3 10 0. 0 82 E du ca tio n N o ed uc at io n 13 .6 10 .8 1. 0 2. 6 0. 1 5. 4 1. 4 0. 3 0. 0 0. 0 0. 0 2. 7 1. 4 0. 9 0. 5 86 .4 10 0. 0 85 3 Pr im ar y 26 .6 18 .0 1. 1 5. 3 0. 4 7. 3 0. 9 2. 2 0. 3 0. 0 0. 5 8. 7 4. 5 3. 0 1. 1 73 .4 10 0. 0 63 8 M id dl e/ JS S 27 .4 19 .6 2. 7 5. 9 0. 1 7. 0 0. 7 3. 1 0. 0 0. 0 0. 2 7. 8 5. 8 1. 0 1. 0 72 .6 10 0. 0 1, 05 8 Se co nd ar y+ 30 .4 18 .5 1. 1 5. 2 0. 4 4. 1 0. 6 6. 2 0. 0 0. 5 0. 4 11 .8 9. 9 1. 3 0. 7 69 .6 10 0. 0 32 5 W ea lth q ui nt ile Lo w es t 14 .2 11 .6 1. 4 4. 0 0. 0 5. 3 0. 8 0. 1 0. 0 0. 0 0. 0 2. 6 1. 5 1. 0 0. 1 85 .8 10 0. 0 57 3 Se co nd 20 .3 14 .4 0. 7 4. 9 0. 1 6. 2 1. 2 1. 3 0. 0 0. 0 0. 0 6. 0 3. 6 1. 9 0. 4 79 .7 10 0. 0 57 7 M id dl e 21 .8 15 .8 1. 2 4. 7 0. 2 5. 9 1. 0 2. 9 0. 0 0. 0 0. 0 6. 0 3. 1 1. 3 1. 6 78 .2 10 0. 0 52 5 Fo ur th 29 .0 20 .0 2. 4 4. 0 0. 3 8. 7 0. 7 3. 1 0. 3 0. 2 0. 2 9. 0 5. 8 1. 9 1. 3 71 .0 10 0. 0 60 0 H ig he st 31 .4 20 .6 2. 5 6. 1 0. 5 5. 1 0. 8 4. 7 0. 0 0. 0 0. 9 10 .8 8. 9 1. 1 0. 8 68 .6 10 0. 0 60 1 T ot al 23 .5 16 .6 1. 6 4. 7 0. 2 6. 2 0. 9 2. 4 0. 1 0. 1 0. 2 6. 9 4. 7 1. 4 0. 8 76 .5 10 0. 0 2, 87 6 N ot e: If m or e th an o ne m et ho d is us ed , o nl y th e m os t e ffe ct iv e m et ho d is co ns id er ed in th is ta bu la tio n. T ot al in cl ud es c as es w ith in fo rm at io n m iss in g on e du ca tio n an d ar e no t s ho w n se pa ra te ly . 88 | Family Planning Family Planning | 89 GDHS 2008 Figure 5.1 Trends in Current Use of Contraceptive Methods Ghana 1988-2008 13 5 8 20 10 10 22 13 9 25 19 7 24 17 7 Any method Any modern method Any traditional method 0 5 10 15 20 25 30 Percentage currently married women 1988 1993 1998 2003 2008 5.6 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION Couples use family planning methods to either limit family size or delay the next birth. The decision to initiate family planning use differs according to the circumstances of couples and individuals concerned. Couples using family planning to control family size (i.e., to stop having children) adopt contraception when they have had the number of children they want. When contraception is used to space births, couples may start to use family planning earlier, with the intention of delaying a possible pregnancy. Using contraception for birth spacing may also be done before a couple has had their desired number of children. In the 2008 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 both a measure of the willingness to postpone the first birth (i.e., women who have no children), and of the desire of women with children to space subsequent births. Thus, differences in fertility-control behaviour among cohorts of women can be observed by examining the parity and number of living children at first use of contraception. Table 5.6 shows the percent distribution of women by number of living children at the time of first use of contraception, according to current age. The results indicate that more Ghanaian women are adopting family planning methods at lower parities (i.e., when they have fewer children) than previously. This change in behaviour can be seen by comparing women’s parity at first use of contraception among younger and older women. Among women age 15-19, 18 percent began using contraception before having any children, compared with 5 percent of women age 40-44. Older women are more likely to have waited until they had children to start using contraception, with the largest proportion starting after they had four or more children. The survey findings suggest a move towards earlier use of contraception by Ghanaian women to delay childbearing. In a culture where smaller family size is becoming a norm, young women adopt family planning at an earlier age than their older counterparts. On the other hand, older women initiate contraceptive use at a later age primarily to limit births rather than to space births. 90 | Family Planning Table 5.6 Number of children at first use of contraception Percent distribution of women age 15-49 by number of living children at the time of first use of contraception, according to current age, Ghana 2008 Current age Never used contra- ception Number of living children at time of first use of contraception Total Number of women 0 1 2 3 4+ Missing 15-19 80.5 17.5 1.6 0.2 0.0 0.0 0.2 100.0 1,025 20-24 42.0 42.6 11.2 2.7 0.8 0.0 0.7 100.0 878 25-29 38.6 27.0 19.9 9.1 4.1 1.1 0.1 100.0 832 30-34 39.4 14.5 16.7 13.6 8.1 7.5 0.2 100.0 644 35-39 38.9 10.8 12.0 12.4 11.4 14.4 0.2 100.0 638 40-44 42.5 5.0 10.8 8.0 11.3 22.3 0.0 100.0 470 45-49 51.7 6.8 7.3 8.1 5.0 21.1 0.0 100.0 429 Total 49.6 20.2 11.1 6.9 4.9 7.0 0.2 100.0 4,916 5.7 USE OF SOCIAL MARKETING BRANDS The proportion of clients using socially marketed brands of contraceptives and private commercial sector contraceptives provides information on market segmentation and guidance on preferred brands and sources of contraceptives. This is critical to ensuring sustainable supplies of contraceptives for clients, according to their preferences. Information on the use of social marketing brands is also important for tracking the success of social marketing programmes and the private commercial sector. Social marketing is an important strategy in Ghana, and the Ghana Social Marketing Foundation (GSMF) is the largest body marketing pills and condoms. New programmes and partners are continually being engaged. The pill and condom are the most commonly used methods of contraception available through social marketing programmes. To assess the use of social marketing brands, pill and condom users in Ghana were asked for the brand name and the cost of their method. The results for pill users are presented in Table 5.7. Secure (a branded form of duofem) is the oral contraceptive pill initially introduced and marketed by the Ghana Social Marketing Foundation, but currently being marketed by other social marketing groups. In 2007, GSMF introduced My Pearl, another brand of combined oral contraceptive. Blue is a newly introduced pill brand for both social marketing programmes and the private commercial sector. Ovrette, Microgynon, Micronor, and Lo- femenal are brands provided by the public sector and through clinics of the Planned Parenthood Association of Ghana (PPAG). The other brands are mainly sold in the private commercial sector. Table 5.7 presents information on both commonly used pill brands and those that are less known. Secure remains the most popular brand in Ghana. It is used by almost half of pill users (47 percent)—among those who mentioned a brand name—and is marketed by Social Marketing Programmes. Three in ten (34 percent) respondents did not know their pill brand, or information is missing on the brand of pills they use. A pill mentioned as N/M tablets is reported by 8 percent of users. The public sector brands Lo-femenal and Microgynon were mentioned by 2 percent and 3 percent, respectively of pill users. This represents a decline of six percentage points in the use of Lo- femenal (8 percent in 2003) and an increase of two percentage points in the use of Microgynon (1 per- cent in 2003). Duofem, which is marketed by the private sector, is used by 2 percent of pill users. Other brands not known by the programme are Skill, Hot, OC, and Nofian, which together constitute about 5 percent of pill use. Family Planning | 91 The table 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 0.31 Ghana cedis.1 Cost varies markedly by brand type, ranging from a high of 0.50 Ghana cedis for Skill to a low of 0.01 Ghana cedis for Oral. Among those who do not know the brand names, the average price of a packet of pills is 0.22 Ghana cedis. The prices of Secure and Migrogynon have increased over the past five years, while Lo-femenal and Duofem are about the same price as in 2003. Table 5.7 Pill brand and cost Percent distribution of current users of pills age 15-49 and average cost per cycle of pills among users who paid for pills, by brand of pills, Ghana 2008 Brand name Percentage of current users of pills Cost per cycle (in pesewas)1 N/M Tablets 7.5 30.9 Skill 1.2 50.0 Secure 46.5 38.5 Hot 1.7 13.4 Lo-femenal 1.9 15.2 OC 1.1 33.6 Blue2 0.3 na Microgynon 3.1 42.6 Oral 0.5 1.4 Duofem 2.0 4.8 Nofian 0.8 0.3 Don’t know/missing 33.5 22.0 Average cost per cycle na 30.9 Total 100.0 na Number 178 165 Note: One US dollar is equivalent to 1.176 new Ghana Cedis at the time of survey; 100 pesewa = 1 Ghana Cedi na = Not applicable 1 Includes only users who paid for pills. 2 This brand has no users who paid for pills Table 5.8 presents information on condom brands and costs of male condoms. The majority (67 percent) of respondents do not know the brand of condom they use, or have information missing on the condom brand; however, they report an average cost of 0.22 Ghana Cedis per condom. The average cost per condom for all brands of condoms reported is also 0.22 Ghana Cedis. 1 One US dollar is equivalent to 1.176 New Ghana cedis (at the time of the survey). 92 | Family Planning Table 5.8 Condom brand and cost Percent distribution of current users of condoms age 15- 49 and average cost per condom among users who paid for condoms, by brand of condom, Ghana 2008 Brand name Percentage of current users of male condoms Cost per condom (in pesewas)1 GSMF Bazuka/Bazooka 1.8 5.0 Champion 17.8 12.8 Panther 2.8 27.8 Private commercial Gold Circle 5.8 25.0 Alatech 0.5 26.7 Night Rider 0.5 50.0 Rough Rider 0.5 50.0 Durex 0.4 100.0 USA 0.6 100.0 Tiger 0.9 5.0 Migrant 0.3 12.5 Unidus2 1.2 na Don’t know/missing 67.0 21.7 Average cost per condom na 22.3 Total 100.0 na Number 175 46 Note: One US dollar is equivalent to 1.176 new Ghana Cedis at the time of survey; 100 pesewa = 1 Ghana Cedi na = Not applicable 1 Includes only users who paid for condoms 2 This brand has no users who paid for condoms Eighteen percent of women who reported using condoms mentioned Champion, 2 percent mentioned Bazuka, and 3 percent cited Panther, all brands marketed by the Ghana Social Marketing Foundation. Gold Circle (6 percent) is a social marketing brand marketed by private commercial outlets. Night Rider, Rough Rider, and Durex, which cost 0.5 to 1 Ghana Cedis each, are sold by the private commercial market. The most popular condoms, Champion and Bazuka, are also among the cheapest. Condoms marketed by the private sector are much more expensive than those marketed by GSMF or the public sector. It is unclear what brand the public sector condoms are, or how much they cost because during the year, different types of no-logo (plain silver or white foiled) male condoms were available at public sector facilities. 5.8 KNOWLEDGE OF FERTILE PERIOD A basic knowledge of reproductive physiology is important for the successful practice of coitus-related methods such as withdrawal, condoms, vaginal methods, and fertility-awareness methods that are collectively referred to as periodic abstinence, rhythm, or the calendar method. Knowledge of the fertile period in a woman’s menstrual cycle is particularly critical in the case of the rhythm method, and the successful practice of natural family planning depends on an understanding of when during the menstrual cycle a woman is most likely to conceive. The 2008 GDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during the menstrual cycle. Both women and men were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual intercourse?” If the answer was “yes,” they were further asked whether that time was just before her period begins, during her period, right after her period ended, or halfway between two periods. Table 5.9 shows the results for all women and men age 15-49 and for those who reported they are currently using the rhythm method. Family Planning | 93 Among all women, about four in ten (39 percent) understand that a woman is most likely to conceive halfway between her menstrual periods. One-quarter of women wrongly believe that the fertile period is right after a woman’s period has ended, while 15 percent of women say they do not know when the fertile period falls, and 12 percent believe that there is no specific fertile time. Knowledge of a woman’s ovulatory cycle is much more limited among men than women. Only 29 percent of men know that a woman is most likely to conceive halfway between her menstrual periods and 21 percent say there is no specific time when a woman is most fertile. Like women, one- quarter of men wrongly believe that the fertile period is right after a woman’s period has ended. As expected, women who use the rhythm method are more likely than non-users to know that the fertile time in a woman’s menstrual cycle is halfway between periods (70 percent, compared with 38 percent). The same pattern is seen for men; 53 percent of men who rely on the rhythm method for contraception know that a woman is most likely to conceive halfway between her menstrual periods, compared with 28 percent of men who are non-users of the rhythm method. There has been consistent improvement in knowledge of the fertile period over the previous GDHS surveys. In 2008, 39 percent of all women and 70 percent of users of the rhythm method correctly reported when a woman is most fertile, compared with 29 percent of all women and 62 percent of users of periodic abstinence in the 2003 survey. Conversely, 25 percent of all women in the 2008 GDHS, compared with 35 percent in the 2003 GDHS wrongly reported that the fertile period is right after the woman’s menstrual period has ended. Table 5.9 Knowledge of fertile period Percent distribution of women and men age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Ghana 2008 Perceived fertile period Women Men Users of rhythm method Non-users of rhythm method All women Users of rhythm method Non-users of rhythm method All men Just before her menstrual period begins 4.7 7.2 7.1 7.0 10.0 9.9 During her menstrual period 3.1 2.8 2.8 5.6 5.3 5.3 Right after her menstrual period has ended 19.1 24.8 24.6 31.4 25.7 25.9 Halfway between two menstrual periods 69.6 37.6 38.9 52.7 28.3 29.2 Other 0.0 0.0 0.0 0.0 0.0 0.0 No specific time 1.3 11.9 11.5 0.0 9.3 8.9 Don’t know 2.1 15.5 14.9 3.3 21.2 20.5 Missing 0.0 0.3 0.2 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 197 4,719 4,916 150 3,908 4,058 5.9 TIMING OF STERILISATION The 2008 GDHS collected information on the timing of female sterilisation among those using the method. However, the number of cases (46 unweighted cases) was too small for meaningful analysis by background characteristics. The median age at sterilisation is 33.6 years. About one-third of sterilised women underwent the procedure at age 30-34, and 31 percent at age 35-39. Nineteen percent of sterilised women underwent the procedure at age 40-44, and 13 percent at age 25-29. The smallest proportion of sterilised women underwent the procedure before age 25 (data not shown). 94 | Family Planning 5.10 SOURCE OF CONTRACEPTION Information on sources of modern contraceptive methods 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 vibrant social marketing programmes that network with pharmacies and chemical sellers, private clinics, and maternity homes as well as major NGOs, such as the PPAG and Marie Stopes International, 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. In the 2008 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 and coded this information to improve the accuracy of the information. Table 5.10 shows that 39 percent of users obtain their contraceptive methods from the public sector. Government hospitals or polyclinics are the most common public source (20 percent), followed by government health centres (14 percent). In addition, 5 percent obtain their methods from government health posts or community-based health and planning services (CHPS) compounds, and family planning clinics. Table 5.10 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Ghana 2008 Source Pill Inject- ables Implants Male condom Total Public sector 12.7 86.9 (79.2) 2.7 39.4 Government hospital/ polyclinic 3.7 45.2 (41.7) 1.7 19.5 Government health centre 6.5 29.6 (33.6) 0.0 14.4 Government health post/ CHPS 1.2 5.8 (0.0) 0.0 2.3 Family planning clinic 0.5 5.0 (3.8) 0.0 2.3 Mobile clinic 0.4 0.0 (0.0) 0.0 0.1 Fieldworker/outreach/ peer educator 0.5 1.3 (0.0) 1.0 0.9 Private medical sector 84.3 11.0 (17.8) 70.9 51.1 Private hospital/clinic 1.2 7.1 (11.6) 0.0 3.5 Pharmacy 8.4 0.0 (0.0) 16.6 7.6 Chemical/drug store 74.7 0.2 (0.0) 54.0 37.9 FP/PPAG clinic 0.0 0.4 (6.2) 0.0 0.9 Maternity home 0.0 3.3 (0.0) 0.3 1.2 Other source 1.4 2.0 (0.0) 6.5 3.0 Shop/market 0.6 0.0 (0.0) 1.1 0.5 Church 0.0 0.6 (0.0) 0.0 0.2 Community volunteer 0.0 0.6 (0.0) 0.0 0.2 Friend/relative 0.8 0.8 (0.0) 5.4 2.0 Other 0.0 0.0 (0.0) 3.6 1.0 Don’t know 0.7 0.0 (0.0) 16.3 5.1 Missing 0.9 0.1 (3.0) 0.0 0.4 Total 100.0 100.0 (100.0) 100.0 100.0 Number of women 178 207 33 175 612 Note: Total includes other modern methods but excludes lactational amenorrhoea method (LAM). Figures in parentheses are based on 25-49 unweighted cases. Total includes 8 users of IUD, 6 users of foam/jelly, and 1 user each of female condom and diaphragm. Family Planning | 95 Over half of women (51 percent) use the private medical sector to obtain their contraceptive methods. Chemical or drug stores (38 percent) and pharmacies (8 percent) account for the largest providers in the medical private sector. Only 4 percent of women obtain their methods from private hospitals and clinics and 2 percent obtain their methods from private maternity homes or PPAG clinics. Three percent of women who are using a modern method of contraception get their method from other sources, mostly from friends or relatives. The type of source differs by method. Whereas the majority of users of injectables and implants obtain their methods from a government source (87 and 79 percent, respectively), pill and condom users are almost as likely to use private medical sector sources (84 and 71 percent, respectively). Three-fourths of pill users and half of condom users get their method from chemical/drug stores, but a sizeable minority of pills users (13 percent) depend on the public medical sector. In the past 20 years, there has been a shift in the sources of modern contraceptive methods from the public to the private sector (Figure 5.2). 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, increased to 54 percent in 2003, and declined to 51 percent in 2008. Reliance on public sources for all modern methods increased from 35 percent in 1988 to 47 percent in 1998, and then declined to 41 percent in 2003. In the five years preceding the 2008 survey, it declined further to 39 percent. Figure 5.2 Trends in Source of Modern Contraceptive Methods, Ghana 1988-2008 35 43 47 41 39 43 52 45 54 51 GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 GDHS 2008 0 10 20 30 40 50 60 Percentage of women Public Private 5.11 COST OF CONTRACEPTION Information on the cost of obtaining contraceptive methods is useful to family planning programmes. It is important to know how much clients are paying for contraceptive methods. This information provides guidance on price differentials among the sectors and pricing of commodities. It also gives an indication of adherence to stipulated prices by the various sectors. In the GDHS, women who were using modern methods of contraception were asked how much they paid in total the last time they obtained their method, including the cost of the method and any consultation they may have had. Table 5.11 shows the percentage of women who obtained the method free and, for those who paid, the median cost, by method and public-private source. 96 | Family Planning In Ghana contraceptives are generally not provided free of charge. Commodities are sold at highly subsidised prices and public sector prices are expected to be lower than those in the private sector. Few respondents were able to provide cost information, which may affect the inferences drawn; nevertheless, the information is useful. The median cost of pills is 0.50 Ghana cedis per pack (0.50 in public sector and 0.60 in private outlets). Male condoms sell at a median price of 0.50 Ghana cedis in the private sector. Injectables cost about twice as much in the private sector, compared with the public sector (1 Ghana cedi and 0.50 Ghana cedis, respectively). Implants are the most expensive method obtained in the public sector and cost 3 Ghana cedis per piece. The public sector prices reported are higher than the stipulated prices. Table 5.11 Cost of modern contraceptive methods Percentage of current users of modern contraceptive methods age 15-49 who received their method free, percentage who do not know the cost of their method, and median cost (in pesewa) of the method, by current method and source of method (public or private), Ghana 2008 Source of method/cost Pill Inject- ables Implants Male condom Total Public sector Received method free (1.2) 0.9 (2.4) * 2.0 Does not know cost (0.0) 1.1 (5.5) * 1.5 Median cost (in pesewa)1 (49.3) 49.7 (299.8) * 49.9 Number of women 23 180 26 5 241 Private medical sector/other Received method free 0.9 (4.9) * 7.7 4.3 Does not know cost 3.1 (9.5) * 64.5 32.0 Median cost (in pesewa)1 59.4 (99.2) * 49.3 59.9 Number of women 155 27 7 170 371 Total Received method free 1.0 1.4 (1.9) 8.3 3.4 Does not know cost 2.7 2.2 (4.4) 62.9 20.0 Median cost (in pesewa)1 49.9 49.8 (299.9) 49.3 50.0 Number of women 178 207 33 175 612 Note: Table excludes lactational amenorrhoea method (LAM). Costs are based on the last time current users obtained method. Costs include consultation costs, if any. For condom, costs are per package; for pills, costs are per cycle. 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. Total includes 8 users of IUD, 6 users of foam/jelly, and 1 user each of female condom and diaphragm. 1 Median cost is based on women who reported a cost; 100 pesewa = 1 Ghana cedi. 5.12 INFORMED CHOICE Informed choice is an important aspect of the delivery of family planning services. Family planning clients have a right to information about their contraceptive method. Providers are required to inform all users of contraceptive methods about 1) the potential side effects of their method, 2) what they should do if they encounter side effects or signs of a problem, and 3) alternate methods of family planning they can use. Current users of modern methods who are well informed about the side effects and problems associated with methods and know of a range of method options are better placed to make an informed choice about the method they would like to use. This information improves the quality of care and compliance by assisting users to cope with side effects, thereby decreasing unnecessary discontinuation of temporary methods. Current users of selected modern contraceptive methods were asked whether, at the time they adopted the particular method, they were informed about the possible side effects or problems that Family Planning | 97 might be encountered with the method. Table 5.12 shows the percentage of current users of modern methods who were either informed about possible side effects or problems with the method used or informed of other methods they could use; these are broken down by method type and source of the method. About half of current users of modern methods received the relevant information to make informed choices. Health providers were somewhat more likely to inform users of modern methods about the side effects or problems of methods used (54 percent) and about other methods that could be used (53 percent), than about what to do if they experienced side effects (51 percent). Information varies by type of method, but is least likely to be provided to pill users. There has been little or no improvement in the provision of information about modern methods (to support informed choice) over the past five years. Public sector clients received more information than private sector clients (seven in ten and three in ten, respectively). The private sector is made up of private hospitals or clinics, pharmacies, and chemical and drug stores. Information on some categories cannot be presented because the percentages are based on small numbers of users. Table 5.12 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, percentage who were informed about possible side effects or problems with the method, percentage who were informed about what to do if they experienced side effects, and percentage who were informed about other methods that could used, by method and source, Ghana 2008 Method/source Among women who started the last episode of use of modern contraceptive method within the past five years, percentage who were: Number of women Informed about side effects or problems with method used Informed about what to do if side effects experienced Informed by a health or family planning worker of other methods that could be used Method Pill 35.8 31.7 34.3 160 Injectables 70.8 67.7 68.7 184 Implants (59.8) (59.8) (72.7) 31 Other1 (48.0) (47.2) (41.3) 39 Initial source of method2 Public sector 67.9 64.7 70.9 223 Government hospital/polyclinic 69.7 65.9 73.6 108 Government health centre 68.2 67.5 65.0 80 Government health post/CHPS * * * 14 Family planning clinic * * * 17 Mobile clinic/fieldworker/outreach/peer educator * * * 6 Private medical sector 36.1 33.7 33.1 148 Private hospital/clinic * * * 24 Pharmacy * * * 13 Chemical/drug store 25.4 25.6 27.4 102 FP/PPAG clinic/maternity home * * * 9 Other source * * * 5 Don’t know * * * 5 Missing3 (50.9) (45.1) (28.4) 32 Total 54.4 51.3 53.2 414 Note: Table excludes users who obtained their method from friends/relatives. Table excludes current users who use either male sterilisation or condoms. 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 1 ‘Other’ methods are IUD, diaphragm, female sterilisation, female condom, and foam/jelly. 2 Source at start of current episode of use 3 Source of method not collected for female or male sterilisation in GDHS 2008, thus source for these methods is set to ‘missing’ 98 | Family Planning 5.13 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. Table 5.13 shows the percent distribution of currently married women who are not using a contraceptive method by intention to use in the future and according to number of living children. Forty-eight percent of currently married non-users say they intend to use family planning in the future, while 46 percent do not intend to use, and 6 percent are unsure. The proportion of those intending to use varies slightly with the number of living children, increasing from 48 percent for those with no children to a peak of 53 percent for those with three children. The proportions who do not intend to use contraception in the future are highest among those with no child (48 percent) and those with 4 or more children (49 percent). These findings indicate there is a need to increase the level of family planning messages and services to target groups, particularly women with four or more children. Over the past 20 years, 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 the timing—from 37 percent in 1988 to 54 percent in 2008. However, over the past five years there has been a slight decline in the proportion of currently married non-users who intend to use family planning in the future, from 54 percent in 2003 to 48 percent in 2008. Table 5.13 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Ghana 2008 Intention to use in the future Number of living children1 Total 0 1 2 3 4+ Intends to use 47.5 49.3 47.9 53.0 43.7 47.5 Unsure 4.9 7.8 5.4 5.0 6.8 6.2 Does not intend to use 47.6 42.5 46.2 41.6 48.6 45.7 Missing 0.0 0.3 0.5 0.4 0.9 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 126 386 478 387 823 2,200 1 Includes current pregnancy 5.14 REASONS FOR NOT INTENDING TO USE CONTRACEPTION An understanding of the reasons non-users of contraception have for intending not to use a contraceptive method in the future, is crucial to identifying strategies to improve the access, accepta- bility, and quality of care of family planning services. Table 5.14 presents the main reasons for not intending to use contraception reported by currently married women who are not using a contraceptive method and who do not intend to use contraception in the future. The most commonly cited reason for not intending to use contraception is fear of side effects, which was mentioned by 26 percent of this subgroup of women. Sixteen percent of non-users said they do not intend to use in the future because they themselves are opposed to using family planning, and an additional 3 percent said that their husband or partner was opposed to family planning. Other reasons given for not intending to use include infecundity/subfecundity (10 percent), menopause/hysterectomy (7 percent), desire for more children and health concerns (8 percent each). Only small proportions of women cited lack of knowledge of methods, lack of access, or cost as the main reason they do not intend to use family planning. Family Planning | 99 Fertility-related reasons for future non-use such as menopause or infertility are more likely to be cited by older women, while younger women are more likely to cite method-related reasons or say that they are opposed to family planning. For example, 22 percent of women age 15-29 are opposed to using family planning, compared with 14 percent of women age 30-49. Similarly, fear of side effects is cited by a larger proportion of younger women than older women (34 and 23 percent, respectively). Younger women are more likely to say that lack of knowledge of methods or sources of methods are the main reasons for future non-use. These results indicate a need for increased pro- vision of information and counselling on the side effects of contraceptive methods by the family planning programme in Ghana, and intensified action targeting younger women. In 2008, the main reasons for not intending to use contraception in the future among currently married women were method-related reasons (41 percent combined), followed by fertility-related reasons (30 percent combined), and opposition to use (23 percent). This pattern is different from the pattern seen in the 2003 survey, where fertility-related issues were cited more frequently (41 percent) than method-related reasons (37 percent). For example, the proportion of women who cited being subfecund/infecund has declined from 15 percent in 2003 to 10 percent in 2008. This decline is most pronounced among women age 30-39 (20 percent in 2003, compared with 13 percent in 2008). The desire to have as many children as possible—as a reason for non-use of contraception in the future—declined among married women, from 14 percent in 2003 to 8 percent in 2008. The decline of this reason is most evident among younger women (17 percent in 2003, compared with 7 percent in 2008). Fear of side effects remains the most cited method-related reason for non-use of contraception among currently married women (26 percent). It increased in importance as a reason for non-use from 18 percent in 1998 to 26 percent in 2003 and 2008. Compared with the 2003 results, lack of knowledge and cost were cited less often as reasons for non-use in the 2008 survey, while inconvenient to use and interferes with body’s normal process were cited more often in the 2008 survey. Table 5.14 Reason for not intending to use contraception in the future Percent distribution of currently married women who are not using a contraceptive method and who do not intend to use a method in the future by main reason for not intending to use contraception, according to age, Ghana 2008 Reason Age Total 15-29 30-49 Fertility-related reasons 11.1 37.4 30.1 Infrequent sex/no sex 2.5 5.3 4.5 Menopausal/had hysterectomy 0.0 10.1 7.3 Subfecund/infecund 1.8 13.3 10.1 Wants as many children as possible 6.8 8.7 8.2 Opposition to use 30.8 19.2 22.5 Respondent opposed 22.1 14.2 16.4 Husband/partner opposed 4.1 2.0 2.6 Others opposed 1.2 0.5 0.7 Religious prohibition 3.4 2.5 2.8 Lack of knowledge 6.4 2.3 3.5 Knows no method 3.7 1.3 2.0 Knows no source 2.7 1.0 1.5 Method-related reasons 48.8 38.5 41.2 Health concerns 8.1 8.2 8.1 Fear of side effects 34.1 22.9 26.0 Lack of access/too far 0.4 0.3 0.3 Cost too much 0.0 1.0 0.7 Inconvenient to use 3.6 2.0 2.4 Interfere with body’s normal process 2.6 4.1 3.7 Other 0.5 1.1 0.9 Don’t know 2.3 1.5 1.7 Total 100.0 100.0 100.0 Number of women 282 724 1,006 100 | Family Planning 5.15 PREFERRED METHOD OF CONTRACEPTION FOR FUTURE USE Of particular interest to programme managers is the preferred methods of non-users who reported that they intend to use a family planning method in the future. This information is useful in assessing the potential demand for specific methods of family planning. Table 5.15 shows that among currently married women, the contraceptive method most preferred for future use is injectables (39 percent), followed by the pill (21 percent), and implants (10 percent). There has been a slight change in the order of preferred methods since the 1998 GDHS. The proportion of non-users who prefer injectables for future use increased from 36 percent in 1998 to 43 percent in 2003, and then declined to 39 percent in 2008. The proportion of non-users who prefer the pill decreased from 21 percent in 1998 to 15 percent in 2003, and then increased to 21 percent in 2008. Preference for implants increased from 4 percent in 1998 to 11 percent in 2003, with little change over the past five years (10 percent in 2008). Intention to use the IUD also increased from 2 percent in 1998 to 4 percent in 2003, and then declined to 1 percent in 2008. In 1998, 4 percent of non-users said that they preferred to use female sterilisation in the future with little change in 2003, compared with just 2 percent in 2008. The proportion preferring the rhythm method (or periodic abstinence) declined markedly from 8 percent in 1998 to 4 percent in 2003 and doubled over the past five years back to 8 percent in 2008. 5.16 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 in the few months preceding the survey. Exposure to family planning messages among women and men age 15-49 is shown in Table 5.16. Radio is the most common source of family planning messages for both women (60 percent) and men (69 percent). Approximately half of respondents (45 percent of women and 51 percent of men) saw a family planning message on the television. Newspapers and magazines are the least common source of family planning messages for both women (11 percent) and men (20 percent). Roughly one in three women (32 percent) and one in four men (24 percent) were not exposed to any family planning messages in the three media. These figures represent a considerable decline in exposure to messages on family planning in radio, television, newspapers and magazines over the past five years. In 2003, only about one in five women (20 percent) and one in eight men age 15-59 (12 percent) were not exposed to any family planning messages through radio, television, or newspaper/magazines in the few months preceding the survey (Figure 5.3). Exposure to family planning messages is more common among men than women, more common in urban areas than rural areas, and increases with level of education and wealth quintile. Among the regions, respondents in the Greater Accra, Western, and Ashanti regions and men in the Brong Ahafo region, have the greatest exposure to family planning messages through any media, while respondents in the Upper West, Upper East, Volta and Northern regions have the lowest exposure to family planning messages through the media. Individuals age 15-19 of both sexes report the lowest exposure to family planning messages in the media. Non-exposure to all three media sources among young people age 15-19 is 39 percent for males and 44 percent for females. These results indicate a need for programmes that target youth (with family planning messages) in their preferred media channels and sources of information. Table 5.15 Preferred method of contraception for future use Percent distribution of currently married women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, Ghana 2008 Preferred method Percent distribution currently married women Female sterilisation 2.8 Pill 20.9 IUD 1.4 Injectables 39.1 Implants 9.8 Condom 4.3 Female condom 0.2 Diaphragm 0.2 Foam/jelly 0.4 Rhythm 8.3 Withdrawal 0.6 Other 2.4 Unsure 9.4 Total 100.0 Number of women 1,044 Family Planning | 101 Table 5.16 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on radio or television, or in a newspaper or magazine, in the past few months, according to background characteristics, Ghana 2008 Background characteristic Women Men Radio Television News- paper/ magazine None of specified media sources Number of women Radio Television News- paper/ magazine None of specified media sources Number of men Age 15-19 43.0 39.6 11.8 44.4 1,025 53.6 41.6 12.0 38.5 911 20-24 60.2 49.9 12.2 28.5 878 67.7 53.7 22.1 24.3 704 25-29 65.5 50.1 13.1 26.5 832 73.5 58.5 22.3 20.5 624 30-34 64.0 49.0 9.9 28.0 644 77.4 59.0 24.2 16.7 533 35-39 69.6 46.4 9.7 28.2 638 72.3 51.4 19.4 19.9 528 40-44 67.0 41.6 9.2 28.8 470 77.2 51.4 23.5 19.9 394 45-49 62.2 36.8 6.2 33.9 429 80.2 45.3 20.6 16.8 364 Residence Urban 65.8 65.0 16.2 21.7 2,383 73.1 69.9 29.3 16.3 1,866 Rural 54.6 26.7 5.7 41.4 2,533 66.1 35.2 11.7 31.0 2,191 Region Western 75.6 42.4 12.8 20.8 447 80.7 58.0 20.8 12.0 403 Central 58.5 43.9 11.5 36.4 424 74.7 67.4 19.3 21.9 326 Greater Accra 72.0 77.6 20.1 14.9 853 70.7 69.5 31.5 17.0 649 Volta 49.2 24.4 11.0 44.1 431 61.7 25.4 13.1 34.3 373 Eastern 64.5 42.4 5.1 29.8 483 70.5 53.3 25.8 25.7 411 Ashanti 63.8 58.5 8.9 22.7 1,011 70.7 58.6 17.9 21.3 785 Brong Ahafo 51.5 30.5 9.1 42.0 425 76.3 55.6 15.9 18.1 347 Northern 41.2 20.7 6.3 55.2 467 60.3 31.4 15.1 36.3 435 Upper East 49.5 16.9 7.4 47.7 253 52.8 15.6 10.4 44.1 219 Upper West 38.0 14.3 4.9 58.6 122 62.8 29.3 12.7 32.0 108 Education No education 47.8 18.9 2.4 49.2 1,042 61.0 20.8 1.7 37.5 540 Primary 54.0 32.9 3.2 40.8 988 59.8 32.6 2.8 36.6 619 Middle/JSS 64.2 51.1 8.4 26.9 2,039 70.7 53.3 15.4 23.3 1,721 Secondary+ 72.1 78.3 36.1 12.3 844 76.1 71.6 43.7 13.1 1,167 Wealth quintile Lowest 42.8 7.9 2.6 56.4 783 56.3 11.2 4.2 42.8 708 Second 54.5 20.9 3.4 43.2 900 69.7 32.7 9.6 28.7 738 Middle 56.6 36.2 7.3 35.6 979 68.7 49.7 16.4 27.2 699 Fourth 66.8 63.1 13.0 21.7 1,119 74.9 70.3 25.7 16.4 974 Highest 72.6 80.7 23.2 12.8 1,135 73.7 76.9 36.0 12.6 939 Total 15-49 60.0 45.3 10.8 31.9 4,916 69.3 51.1 19.8 24.2 4,058 50-59 na na na na na 76.4 49.6 31.5 20.1 510 Total 15-59 na na na na na 70.1 51.0 21.1 23.8 4,568 Note: Total includes cases with information missing on education that are not shown separately. na = Not applicable 102 | Family Planning Figure 5.3 Percentage of Women 15-49 and Men 15-59 Exposed to Family Planning Messages in the Media 77 52 20 20 86 58 33 12 60 45 11 32 70 51 21 24 Radio Television Newspaper/ magazine No media sources Radio Television Newspaper/ magazine No media sources 0 20 40 60 80 100 Percentage of women/men 2003 2008 GDHS 2008 Note: No media sources refers to nonexposure to radio, television and newspaper/magazine. WOMEN MEN 5.17 CONTACT OF NON-USERS WITH FAMILY PLANNING PROVIDERS To determine whether non-users of family planning in Ghana have had an opportunity to receive information about family planning from providers, women who were not using contraception were asked whether they had attended a health facility in the past year for any reason and, if so, whether a staff person at that facility spoke to them about family planning methods. They were also asked whether they had been visited by a fieldworker who discussed family planning. The results are shown in Table 5.17. Table 5.17 shows that in the 12 months preceding the survey 13 percent of non-users reported that they had visited a health facility and discussed family planning and 10 percent of women were visited by a fieldworker who discussed family planning. About one in three women (34 percent) visited a health facility but did not discuss family planning. The majority of the women (80 percent) did not discuss family planning with a fieldworker or staff at a health facility. Women age 30-34 are more likely to have discussed family planning with a service provider than younger women or older women. Women in rural areas are more likely to have discussed family planning with health professionals than women in urban areas; likewise, women with no education or primary education are more likely to have discussed family planning with a fieldworker or staff at a health facility than women with higher levels of education. The same pattern is seen by wealth status, women in the lowest wealth quintile are more likely to have discussed family planning with health professionals than women in the highest wealth quintile. These results may indicate that some groups of women are already using contraceptive methods, or that they already have information about family planning and, therefore, do not feel the need to discuss family planning with providers, or they may be less likely to have visited a facility. Discussion of family planning with staff at health facilities is highest in the Upper East, Volta, and Upper West regions (25, 24 and 23 percent, respectively) and lowest in the Central region (9 percent). Discussion of family planning during a visit by a fieldworker is highest in the Northern and Volta regions (19 and 15 percent, respectively) and lowest in the Greater Accra region (8 percent).Women not currently using family planning in the Western, Greater Accra, and Eastern regions are the least likely to discuss family planning with a fieldworker or staff at a health facility. Family Planning | 103 The overall proportion of women not currently using family planning who did not discuss family planning with a fieldworker or staff at a health facility has not changed over the past five years (79 percent in 2003, compared with 80 percent in 2008), however, the proportion of women who visited a health facility but did not discuss family planning has increased slightly from 27 percent in 2003 to 34 percent in 2008. Table 5.17 Contact of non-users with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility and did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor with staff at a health facility, by background characteristics, Ghana 2008 Background characteristic Percentage of women visited by fieldworker who discussed family planning Among women who visited a health facility in the past 12 months, percentage who: Percentage of women who neither discussed family planning with fieldworker nor with staff at health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 5.9 4.0 23.1 91.7 942 20-24 9.7 12.6 37.9 81.3 691 25-29 11.3 20.3 37.7 73.1 635 30-34 13.4 22.2 40.7 69.5 495 35-39 14.6 16.1 34.5 74.1 486 40-44 13.7 11.7 35.6 77.8 357 45-49 9.1 4.4 35.2 88.0 360 Residence Urban 9.3 11.1 39.1 82.6 1,893 Rural 11.4 14.0 29.0 78.3 2,072 Region Western 4.3 10.3 32.1 86.6 380 Central 10.0 9.2 34.5 82.8 342 Greater Accra 7.5 9.8 40.2 85.3 637 Volta 14.8 23.7 22.5 71.1 334 Eastern 8.9 10.0 28.5 83.6 378 Ashanti 10.5 10.1 36.5 82.1 794 Brong Ahafo 9.1 13.7 40.1 80.3 335 Northern 19.1 10.1 38.2 73.9 441 Upper East 10.2 25.2 20.0 71.9 224 Upper West 11.9 22.8 25.7 69.8 99 Education No education 12.9 15.0 31.1 75.5 919 Primary 12.1 12.2 32.5 79.2 785 Middle/JSS 8.7 11.3 33.5 83.3 1,623 Secondary+ 9.3 12.8 40.3 81.4 636 Wealth quintile Lowest 14.5 15.4 24.2 74.6 694 Second 9.7 13.1 29.1 80.1 737 Middle 10.7 13.1 35.2 79.9 794 Fourth 10.5 12.1 36.2 80.7 867 Highest 7.5 10.0 41.9 85.3 873 Total 10.4 12.6 33.8 80.4 3,965 Note: Total includes cases with information missing on education that are not shown separately. 5.18 HUSBAND/PARTNER’S KNOWLEDGE ABOUT WOMAN’S USE OF FAMILY PLANNING The husband or partner’s knowledge about a woman’s use of family planning is an indication of their prior discussion of, interest in, and continued practice of family planning. Inter-spousal/ partner communication is an important intermediate step along the path to adopting a contraceptive method, as well as continuing to use that or other contraceptive methods in the future. Lack of 104 | Family Planning knowledge or discussion of family planning may be related to a number of factors including lack of interest in family planning, hostility to the subject of family planning, or customary reticence to talk about sex-related matters. To assess the extent to which women use contraception without informing their husband/partners, the 2008 GDHS asked married women whether their husband/partners know they are using a method of family planning. Table 5.18 shows that the majority of married women (86 percent) who are using contra- ception say that their husband or partner knows about their use of family planning; only 11 percent said that their husband/partner does not know about their use of contraception, and 3 percent were unsure. Table 5.18 Husband/partner’s knowledge of women’s use of contraception Percent distribution of currently married women age 15-49 who are using a method of contraception, by whether their husband/partner knows about their use of contraception, according to background characteristics, Ghana 2008 Background characteristic Husband/partner’s knowledge of woman’s use of contraception Total Number of women Knows1 Does not know Unsure whether knows/ missing Age 15-19 * * * * 12 20-24 91.5 6.3 2.2 100.0 93 25-29 82.6 14.5 2.9 100.0 141 30-34 88.9 7.0 4.1 100.0 126 35-39 84.2 12.6 3.1 100.0 136 40-44 84.1 12.9 3.0 100.0 105 45-49 88.0 8.7 3.3 100.0 64 Residence Urban 85.9 11.8 2.3 100.0 330 Rural 86.8 9.4 3.8 100.0 347 Region Western (90.1) (9.4) (0.5) (100.0) 50 Central 87.3 10.7 2.1 100.0 58 Greater Accra 86.2 12.6 1.3 100.0 138 Volta 82.9 13.5 3.6 100.0 83 Eastern 82.5 15.8 1.8 100.0 61 Ashanti 84.5 7.7 7.8 100.0 147 Brong Ahafo 94.4 4.0 1.6 100.0 77 Northern (76.2) (19.0) (4.7) (100.0) 20 Upper East (86.8) (13.2) (0.0) (100.0) 25 Upper West 93.9 6.1 0.0 100.0 18 Education No education 89.7 9.1 1.2 100.0 116 Primary 83.2 12.5 4.3 100.0 170 Middle/JSS 86.9 9.3 3.8 100.0 290 Secondary+ 86.0 12.8 1.3 100.0 99 Wealth quintile Lowest 86.8 8.9 4.4 100.0 81 Second 86.2 8.8 5.0 100.0 117 Middle 81.5 13.4 5.2 100.0 115 Fourth 85.3 13.5 1.3 100.0 174 Highest 90.2 8.1 1.8 100.0 189 Total 86.3 10.6 3.1 100.0 676 Note: Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes women who reported use of male sterilisation, male condoms, or withdrawal Family Planning | 105 In Ghana, communication between couples about the use of family planning is high for almost all background characteristics and shows little variation by age, urban-rural residence, level of education, or wealth quintile. A larger proportion of women in the Brong Ahafo and Upper West regions say that their husband or partner is aware of their contraceptive use (94 percent each) than women in the Northern region (76 percent). About one in five current users in the Northern region (19 percent) report that their husband or partners does not know that they are using a method. Interestingly, women with less education and those in the lowest and highest wealth quintiles are more likely than other women to say that their husband or partner knows that they are using family planning. 5.19 ATTITUDES TOWARDS FAMILY PLANNING The 2008 GDHS assessed respondent’s attitudes towards contraception by asking currently married respondents whether they agreed or disagreed with two statements about family planning use: 1) contraception is women’s business and a man should not have to worry about it; and 2) women who use contraception may become promiscuous. The results are shown in Table 5.19.1 for women and in Table 15.19.2 for men. Table 5.19.1 Women’s attitudes towards use of contraception by women Percent distribution of currently married women age 15-49 by two common attitudes regarding women’s use of contraception: “Contraception is a woman’s business,” and “Women who use contraception may become promiscuous” and by whether the woman agrees with these attitudes, according to background characteristics, Ghana 2008 Background characteristic Contraception is a woman’s business Women who use contraception may become promiscuous Number of women Disagree Agree Don’t know Missing Total Disagree Agree Don’t know Missing Total Age 15-19 56.3 36.0 7.4 0.3 100.0 47.4 38.3 13.9 0.3 100.0 85 20-24 61.8 34.5 3.4 0.3 100.0 57.8 34.8 7.2 0.3 100.0 414 25-29 62.5 33.5 4.0 0.0 100.0 60.6 29.7 9.7 0.0 100.0 612 30-34 65.0 31.3 3.7 0.0 100.0 65.2 27.2 7.6 0.0 100.0 539 35-39 61.2 36.1 2.7 0.1 100.0 63.9 30.6 5.4 0.1 100.0 527 40-44 63.3 31.2 5.3 0.2 100.0 60.5 31.5 8.1 0.0 100.0 380 45-49 65.6 28.1 6.3 0.0 100.0 60.2 31.3 8.5 0.0 100.0 319 Residence Urban 67.2 30.8 1.9 0.1 100.0 65.1 28.9 6.0 0.1 100.0 1,216 Rural 59.7 34.4 5.8 0.1 100.0 58.4 32.2 9.4 0.0 100.0 1,660 Region Western 39.6 58.9 1.3 0.2 100.0 56.2 41.9 1.7 0.2 100.0 261 Central 60.3 37.6 1.7 0.4 100.0 64.1 28.2 7.3 0.4 100.0 254 Greater Accra 73.3 25.9 0.8 0.0 100.0 72.0 22.3 5.8 0.0 100.0 422 Volta 82.1 13.9 3.6 0.3 100.0 50.8 41.1 8.1 0.0 100.0 290 Eastern 71.6 28.0 0.4 0.0 100.0 73.6 26.1 0.3 0.0 100.0 252 Ashanti 64.3 35.3 0.4 0.0 100.0 58.5 35.7 5.8 0.0 100.0 542 Brong Ahafo 61.8 35.7 2.5 0.0 100.0 58.5 38.8 2.7 0.0 100.0 267 Northern 50.0 35.1 14.8 0.0 100.0 60.2 22.7 17.0 0.0 100.0 338 Upper East 56.1 26.9 17.0 0.0 100.0 51.3 23.1 25.6 0.0 100.0 168 Upper West 57.0 31.4 11.3 0.3 100.0 62.5 16.3 20.9 0.3 100.0 82 Education No education 55.1 33.6 11.2 0.2 100.0 56.9 27.5 15.5 0.1 100.0 853 Primary 60.5 37.2 2.3 0.0 100.0 57.4 37.5 5.1 0.0 100.0 638 Middle/JSS 66.0 33.3 0.7 0.0 100.0 62.3 32.7 5.1 0.0 100.0 1,058 Secondary+ 77.7 21.6 0.3 0.3 100.0 76.3 20.4 3.0 0.3 100.0 325 Wealth quintile Lowest 52.7 33.9 13.3 0.0 100.0 54.3 29.3 16.4 0.0 100.0 573 Second 58.9 38.2 2.8 0.1 100.0 59.9 33.3 6.8 0.1 100.0 577 Middle 63.7 33.1 3.0 0.2 100.0 61.6 32.7 5.7 0.0 100.0 525 Fourth 66.6 32.1 1.1 0.2 100.0 60.6 33.0 6.3 0.2 100.0 600 Highest 72.0 27.4 0.7 0.0 100.0 69.3 26.0 4.6 0.0 100.0 601 Total 62.9 32.9 4.1 0.1 100.0 61.2 30.8 7.9 0.1 100.0 2,876 Note: Total includes cases with information missing on education that are not shown separately. 106 | Family Planning The results on attitudes towards family planning show that the majority of currently married Ghanaian respondents age 15-49 think that men should take some responsibility towards family planning, with 63 percent of women and 78 percent of men rejecting the statement that contraception is a woman’s business and men should not have to worry about it. However, 33 percent of women and 19 percent of men agree with the statement, and 4 and 2 percent, respectively say they don’t know. Older women and respondents with at least some secondary education are more likely than other respondents to disagree with the statement that contraception is a woman’s business and men should not be involved. Similarly, urban respondents, those in the Volta region, and men in the Greater Accra region are more likely to disagree with the statement. The proportion of women and men who do not think that women alone should deal with family planning increases with increasing wealth quintile. On the other hand, the proportion of respondents who agree that men should not have to worry about contraception is particularly high in the Western region among women (59 percent) and in the Brong Ahafo region among men (31 percent). Table 5.19.2 Men’s attitudes towards use of contraception by women Percent distribution of currently married men age 15-49 by two common attitudes regarding women’s use of contraception: “Contraception is a woman’s business,” and “Women who use contraception may become promiscuous” and by whether the man agrees with these attitudes, according to background characteristics, Ghana 2008 Background characteristic Contraception is a woman’s business Women who use contraception may become promiscuous Number of men Disagree Agree Don’t know Missing Total Disagree Agree Don’t know Missing Total Age 15-19 * * * * 100.0 * * * * 100.0 7 20-24 82.1 11.2 5.9 0.9 100.0 40.1 48.7 10.4 0.9 100.0 106 25-29 73.6 24.0 2.4 0.0 100.0 44.5 50.2 5.3 0.0 100.0 296 30-34 82.5 15.9 1.6 0.0 100.0 48.6 45.9 5.4 0.0 100.0 412 35-39 73.9 22.9 3.0 0.3 100.0 43.9 48.2 7.9 0.0 100.0 445 40-44 82.6 16.1 1.3 0.0 100.0 49.7 41.6 8.8 0.0 100.0 353 45-49 76.4 20.0 2.9 0.7 100.0 48.0 45.0 6.6 0.4 100.0 331 Residence Urban 83.0 14.8 1.7 0.5 100.0 50.1 44.1 5.5 0.3 100.0 832 Rural 74.4 22.6 3.0 0.0 100.0 43.8 48.0 8.3 0.0 100.0 1,118 Region Western 83.8 14.8 1.4 0.0 100.0 49.4 45.7 4.9 0.0 100.0 205 Central 73.8 24.9 0.6 0.7 100.0 47.6 50.0 2.4 0.0 100.0 148 Greater Accra 87.3 9.8 2.2 0.7 100.0 50.0 42.5 7.2 0.3 100.0 302 Volta 87.1 12.9 0.0 0.0 100.0 48.0 51.6 0.5 0.0 100.0 166 Eastern 73.7 23.0 2.5 0.8 100.0 37.1 45.7 16.5 0.8 100.0 189 Ashanti 78.2 21.1 0.7 0.0 100.0 40.6 55.7 3.6 0.0 100.0 374 Brong Ahafo 68.3 31.3 0.4 0.0 100.0 50.0 46.6 3.5 0.0 100.0 172 Northern 66.5 23.1 10.4 0.0 100.0 50.3 35.2 14.5 0.0 100.0 237 Upper East 83.0 14.3 2.7 0.0 100.0 54.7 30.9 14.4 0.0 100.0 109 Upper West 73.9 22.9 3.1 0.0 100.0 36.0 61.0 3.0 0.0 100.0 47 Education No education 68.5 24.9 6.6 0.0 100.0 43.7 43.5 12.8 0.0 100.0 398 Primary 70.7 27.1 2.2 0.0 100.0 44.4 48.4 7.2 0.0 100.0 251 Middle/JSS 80.6 17.6 1.2 0.6 100.0 43.4 51.3 5.0 0.3 100.0 812 Secondary+ 85.2 13.5 1.3 0.0 100.0 54.7 39.4 5.9 0.0 100.0 485 Wealth quintile Lowest 67.7 26.1 6.3 0.0 100.0 41.9 45.1 13.0 0.0 100.0 380 Second 74.0 24.3 1.7 0.0 100.0 43.0 49.1 7.9 0.0 100.0 368 Middle 76.7 21.9 1.0 0.5 100.0 45.6 49.0 5.0 0.5 100.0 310 Fourth 82.4 15.7 1.4 0.4 100.0 48.5 47.9 3.4 0.2 100.0 434 Highest 86.7 11.3 1.7 0.2 100.0 51.8 41.8 6.5 0.0 100.0 458 Total 78.1 19.3 2.4 0.2 100.0 46.5 46.3 7.1 0.1 100.0 1,950 Note: Total includes cases with information missing on education that are not shown separately. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Family Planning | 107 Regarding the statement that women who use contraception may become promiscuous, 31 percent of women agree with the statement and 61 percent disagree, while men are fairly evenly divided between those who agree and those who disagree with the statement (46 and 47 percent, respectively). Eight percent of women and 7 percent of men said they don’t know. Women in the Western, Volta, Brong Ahafo, and Ashanti regions are more likely to agree with the statement than women in other regions. At least half of men in the Ashanti, Volta, and Central regions and 61 percent in the Northern region agree with the statement. Among those who disagree with the statement that women who use contraception may become promiscuous, differentials by age, urban-rural residence, level of education, and wealth status are similar to those for respondents who disagree with the statement on contraception being women’s business. In the 2003 GDHS, the table on men’s attitudes towards contraception was based on all men age 15-59 who know a method of family planning, while in the 2008 GDHS the table was based on currently married men age 15-49 regardless of knowledge of a family planning method. To compare the two surveys, the 2008 GDHS table on men’s attitudes towards contraception was re-calculated to be similar to the table in the 2003 GDHS report. The results indicate that over the past five years there has been a substantial decline in the proportion of men age 15-59 who know a method of family planning and agree with the statement that contraception is women’s business (35 percent in 2003, compared with 20 percent in 2008). There has been a smaller decrease in the proportion of men who agree with the statement that women who use contraception may become promiscuous (53 percent in 2003, compared with 47 percent in 2008 [data not shown]). This indication of improved male attitudes towards contraception may be the result of the targeting of men by Information Education and Communication (IEC) programmes and male involvement/partnership programmes in reproductive health and family planning. 5.20 ATTITUDES TOWARDS HAVING TOO MANY CHILDREN Attitudes of men and women about the consequences of having too many children, and the benefits of smaller families, give an indication of the level of knowledge of the benefits of having smaller families and the motivation to practice family planning. When individuals and couples have a positive attitude towards family planning, they are more likely to adopt a family planning method. In the 2008 GDHS, currently married women and men were asked whether they agreed or disagreed with specific statements about the consequences of having too many children, their opinion on having more children than they can afford, and the likelihood that children in smaller families will succeed. This information is important because it indicates the extent to which further education and publicity are needed to increase acceptance of family planning. Tables 5.20.1 and 5.20.2 show the percent distribution of currently married women and men age 15-49 who agree or disagree with three statements about having many children: “Having too many children may be dangerous for a woman”; “It is better not to have more children than we can afford” and “Children in smaller families are more likely to succeed”. The majority of married women and men age 15-49 agree with the three statements supportive of smaller families. The highest proportions are in agreement with the statement that it is better not to have more children than the parents can afford (92 percent of women and 91 percent of men). More women (17 percent) than men (12 percent) disagree that having too many children may be dangerous for the woman. Agreement on the three statements is higher among women in urban areas than women in rural areas, and increases with level of education and wealth quintile for both sexes. There is little variation in responses by age of respondent. Men in the Eastern region and women in the Northern region are more likely to disagree with all three statements than respondents in the other regions. 108 | Family Planning Table 5.20.1 Women’s attitudes towards having too many children Percent distribution of currently married women age 15-49 by three common attitudes regarding having too many children, according to background characteristics, Ghana 2008 Background characteristic Having too many children may be dangerous for a woman It is better not to have more children than we can afford Children from smaller families are more likely to succeed Number of women Disagree Agree Don’t know Missing Total Disagree Agree Don’t know Missing Total Disagree Agree Don’t know Missing Total Age 15-19 16.8 79.5 3.4 0.3 100.0 9.5 89.2 1.0 0.3 100.0 15.4 79.4 5.0 0.3 100.0 85 20-24 16.6 81.1 1.3 1.0 100.0 7.9 91.1 0.8 0.3 100.0 12.1 85.5 2.1 0.3 100.0 414 25-29 15.8 81.8 2.4 0.0 100.0 5.9 92.5 1.5 0.0 100.0 16.2 81.8 2.0 0.0 100.0 612 30-34 18.6 79.4 1.7 0.2 100.0 7.2 92.1 0.7 0.0 100.0 15.5 83.1 1.4 0.0 100.0 539 35-39 17.4 81.0 1.5 0.1 100.0 8.2 91.5 0.2 0.1 100.0 16.4 82.6 0.9 0.1 100.0 527 40-44 14.9 83.1 1.7 0.3 100.0 7.3 91.7 0.9 0.0 100.0 13.4 85.0 1.6 0.0 100.0 380 45-49 18.4 80.3 0.9 0.4 100.0 6.7 92.4 0.5 0.3 100.0 22.1 77.2 0.7 0.0 100.0 319 Residence Urban 14.8 83.6 1.2 0.4 100.0 5.9 93.6 0.4 0.2 100.0 14.3 84.5 1.1 0.1 100.0 1,216 Rural 18.5 79.2 2.1 0.2 100.0 8.3 90.5 1.1 0.0 100.0 16.9 81.1 1.9 0.0 100.0 1,660 Region Western 8.8 90.4 0.6 0.2 100.0 4.0 95.8 0.0 0.2 100.0 7.4 92.2 0.2 0.2 100.0 261 Central 18.7 79.7 1.2 0.4 100.0 1.4 98.1 0.0 0.4 100.0 5.9 93.2 0.5 0.4 100.0 254 Greater Accra 9.1 89.1 1.1 0.7 100.0 4.7 95.3 0.0 0.0 100.0 15.0 83.9 1.2 0.0 100.0 422 Volta 16.7 83.0 0.0 0.3 100.0 1.7 97.9 0.5 0.0 100.0 7.4 92.1 0.5 0.0 100.0 290 Eastern 18.9 80.4 0.7 0.0 100.0 8.3 91.7 0.0 0.0 100.0 18.5 81.2 0.3 0.0 100.0 252 Ashanti 14.5 84.6 0.5 0.4 100.0 4.9 94.9 0.0 0.2 100.0 15.8 83.0 1.2 0.0 100.0 542 Brong Ahafo 9.5 89.4 1.1 0.0 100.0 7.8 90.9 1.3 0.0 100.0 9.7 89.3 1.1 0.0 100.0 267 Northern 41.5 53.6 5.0 0.0 100.0 25.8 70.7 3.5 0.0 100.0 39.0 55.6 5.3 0.0 100.0 338 Upper East 9.9 85.4 4.7 0.0 100.0 5.2 92.9 1.9 0.0 100.0 21.8 74.6 3.6 0.0 100.0 168 Upper West 27.0 61.9 10.4 0.8 100.0 7.9 87.7 4.1 0.3 100.0 9.7 85.6 4.4 0.3 100.0 82 Education No education 24.4 71.8 3.6 0.2 100.0 12.6 84.9 2.4 0.1 100.0 23.6 72.8 3.5 0.1 100.0 853 Primary 14.8 83.5 1.5 0.3 100.0 6.0 93.7 0.3 0.0 100.0 12.8 86.0 1.2 0.0 100.0 638 Middle/JSS 13.4 85.5 0.9 0.2 100.0 4.5 95.3 0.1 0.1 100.0 11.0 88.4 0.6 0.0 100.0 1,058 Secondary+ 12.7 86.5 0.1 0.7 100.0 4.5 95.2 0.0 0.3 100.0 16.7 82.6 0.4 0.3 100.0 325 Wealth quintile Lowest 25.9 69.8 4.3 0.0 100.0 14.8 82.2 3.0 0.0 100.0 23.8 71.9 4.2 0.0 100.0 573 Second 16.8 81.3 1.4 0.5 100.0 6.4 93.0 0.5 0.1 100.0 14.5 84.7 0.7 0.1 100.0 577 Middle 17.4 80.9 1.1 0.5 100.0 6.7 92.6 0.7 0.0 100.0 14.6 84.2 1.2 0.0 100.0 525 Fourth 12.7 86.0 1.1 0.2 100.0 4.4 95.2 0.0 0.4 100.0 11.8 86.9 1.1 0.2 100.0 600 Highest 12.5 86.6 0.8 0.2 100.0 4.2 95.8 0.0 0.0 100.0 14.3 84.8 0.8 0.0 100.0 601 Total 16.9 81.0 1.7 0.3 100.0 7.3 91.8 0.8 0.1 100.0 15.8 82.6 1.6 0.1 100.0 2,876 Note: Total includes cases with information missing on education that are not shown separately. Family Planning | 109 Table 5.20.2 Men’s attitudes towards having too many children Percent distribution of currently married men age 15-49 by three common attitudes regarding having too many children, according to background characteristics, Ghana 2008 Background characteristic Having too many children may be dangerous for a woman It is better not to have more children than we can afford Children from smaller families are more likely to succeed Number of men Disagree Agree Don’t know Missing Total Disagree Agree Don’t know Missing Total Disagree Agree Don’t know Missing Total Age 15-19 * * * * 100.0 * * * * 100.0 * * * * 100.0 7 20-24 10.4 88.1 0.7 0.9 100.0 7.1 92.0 0.0 0.9 100.0 9.3 88.6 1.3 0.9 100.0 106 25-29 10.9 88.3 0.8 0.0 100.0 7.7 92.3 0.0 0.0 100.0 9.6 90.0 0.4 0.0 100.0 296 30-34 12.8 86.5 0.4 0.3 100.0 7.4 92.4 0.3 0.0 100.0 11.5 87.6 0.9 0.0 100.0 412 35-39 12.9 85.1 1.4 0.5 100.0 9.8 89.4 0.8 0.0 100.0 13.5 85.0 1.5 0.0 100.0 445 40-44 9.1 89.7 1.2 0.0 100.0 8.8 90.4 0.7 0.0 100.0 12.7 84.3 2.6 0.4 100.0 353 45-49 10.9 87.1 1.2 0.8 100.0 6.8 92.2 0.6 0.4 100.0 15.1 83.8 0.7 0.4 100.0 331 Residence Urban 11.2 87.3 0.8 0.7 100.0 6.1 93.1 0.5 0.3 100.0 10.8 87.5 1.3 0.4 100.0 832 Rural 11.7 87.0 1.2 0.1 100.0 9.9 89.6 0.4 0.0 100.0 13.5 85.2 1.3 0.0 100.0 1,118 Region Western 4.6 95.4 0.0 0.0 100.0 3.4 96.6 0.0 0.0 100.0 11.9 88.1 0.0 0.0 100.0 205 Central 6.7 92.5 0.0 0.8 100.0 3.1 96.9 0.0 0.0 100.0 9.5 90.5 0.0 0.0 100.0 148 Greater Accra 13.1 86.2 0.4 0.3 100.0 4.2 95.5 0.0 0.3 100.0 10.0 88.5 0.7 0.7 100.0 302 Volta 10.0 90.0 0.0 0.0 100.0 4.6 95.4 0.0 0.0 100.0 15.7 83.0 1.3 0.0 100.0 166 Eastern 21.9 76.2 1.2 0.8 100.0 24.9 74.3 0.0 0.8 100.0 26.5 70.8 1.9 0.8 100.0 189 Ashanti 10.1 89.6 0.3 0.0 100.0 0.9 99.1 0.0 0.0 100.0 13.2 86.1 0.7 0.0 100.0 374 Brong Ahafo 9.7 90.3 0.0 0.0 100.0 3.8 96.2 0.0 0.0 100.0 6.6 92.6 0.7 0.0 100.0 172 Northern 17.1 75.9 5.4 1.5 100.0 14.0 82.0 3.9 0.0 100.0 13.4 80.9 5.7 0.0 100.0 237 Upper East 9.7 88.4 2.0 0.0 100.0 34.0 66.0 0.0 0.0 100.0 1.9 98.1 0.0 0.0 100.0 109 Upper West 4.1 95.9 0.0 0.0 100.0 3.8 96.2 0.0 0.0 100.0 2.1 97.9 0.0 0.0 100.0 47 Education No education 13.8 82.5 2.8 0.9 100.0 13.5 84.7 1.8 0.0 100.0 12.0 85.1 2.9 0.0 100.0 398 Primary 12.4 87.4 0.2 0.0 100.0 8.8 91.2 0.0 0.0 100.0 12.8 87.2 0.0 0.0 100.0 251 Middle/JSS 11.0 88.0 0.7 0.3 100.0 6.9 92.7 0.1 0.3 100.0 12.7 86.0 0.9 0.4 100.0 812 Secondary+ 10.1 89.2 0.5 0.2 100.0 5.9 93.9 0.2 0.0 100.0 11.9 86.7 1.4 0.0 100.0 485 Wealth quintile Lowest 14.6 82.8 2.0 0.6 100.0 15.8 83.3 0.9 0.0 100.0 12.1 85.1 2.8 0.0 100.0 380 Second 12.0 86.9 0.9 0.3 100.0 9.5 89.8 0.7 0.0 100.0 15.6 84.0 0.4 0.0 100.0 368 Middle 9.4 89.1 1.0 0.5 100.0 6.7 92.1 0.7 0.5 100.0 12.3 86.1 1.1 0.5 100.0 310 Fourth 11.5 87.3 1.0 0.2 100.0 5.7 93.9 0.3 0.2 100.0 10.6 87.9 1.0 0.5 100.0 434 Highest 10.1 89.4 0.2 0.3 100.0 4.6 95.4 0.0 0.0 100.0 11.5 87.3 1.2 0.0 100.0 458 Total 11.5 87.1 1.0 0.4 100.0 8.3 91.1 0.5 0.1 100.0 12.3 86.2 1.3 0.2 100.0 1,950 Note: Total includes cases with missing information on education which are not shown separately. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Other Proximate Determinants of Fertility | 111 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter addresses the principal factors, other than contraception, that affect a woman’s risk of becoming pregnant. These factors include marriage, polygyny, sexual intercourse, post-partum 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 Marriage is a primary indication of the regular exposure of women to the risk of pregnancy and therefore is important for the understanding of fertility. Populations in which age at first marriage is low tend to have early childbearing and high fertility. In Ghana, however, a union is not a prerequisite to childbearing because some childbearing occurs outside of union. There are various types of marriage in Ghana, ranging from customary, civil, and religious marriage to a variety of informal unions. In this report, the term ‘married’ refers to legal or formal marriage, and ‘living together’ refers to an informal union in which a man and a woman live together, even if a formal civil or religious ceremony has not occurred. In later tables that do not list ‘living together’ as a separate category, these women and men are included in the ‘currently married’ group. Respondents who are currently married, widowed, divorced, or separated are referred to as ‘ever-married.’ Table 6.1 shows the percent distribution of women and men interviewed in the 2008 GDHS by current marital status, according to age. Table 6.1 shows that 32 percent of women age 15-49 have never married, 45 percent are formally married, 13 percent are living together, and 9 percent are divorced, separated, or widowed. Marriage occurs relatively early in Ghana, and one in four women age 20-24 are currently married. Table 6.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Ghana 2008 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 90.6 3.7 4.6 0.1 1.0 0.0 100.0 8.3 1,025 20-24 48.6 25.7 21.5 0.6 3.3 0.3 100.0 47.2 878 25-29 20.4 53.5 20.1 1.2 3.9 0.9 100.0 73.6 832 30-34 5.7 70.2 13.5 4.6 4.9 1.0 100.0 83.7 644 35-39 3.4 71.5 11.1 5.0 5.9 3.3 100.0 82.5 638 40-44 1.6 70.6 10.2 6.5 4.9 6.3 100.0 80.8 470 45-49 0.5 66.2 8.2 11.0 6.2 7.9 100.0 74.4 429 Total 32.4 45.4 13.1 3.2 3.9 2.1 100.0 58.5 4,916 MEN 15-19 99.1 0.4 0.3 0.0 0.2 0.0 100.0 0.8 911 20-24 83.2 8.8 6.2 0.2 1.6 0.0 100.0 15.0 704 25-29 49.0 36.9 10.6 1.5 2.1 0.0 100.0 47.4 624 30-34 15.3 67.8 9.5 3.2 3.7 0.4 100.0 77.4 533 35-39 8.6 78.6 5.6 3.4 3.2 0.6 100.0 84.3 528 40-44 3.0 85.6 4.1 4.0 2.8 0.5 100.0 89.7 394 45-49 0.9 86.3 4.7 3.5 2.5 2.1 100.0 91.0 364 Total 15-49 47.7 42.5 5.6 1.8 2.0 0.4 100.0 48.1 4,058 50-59 1.3 86.2 2.9 4.8 2.7 2.2 100.0 89.0 510 Total 15-59 42.5 47.4 5.3 2.2 2.1 0.6 100.0 52.6 4,568 112 | Other Proximate Determinants of Fertility A greater proportion of men (48 percent) than women (32 percent) have never married. Less than half of men (43 percent) are married, 6 percent are living together, and another 4 percent are divorced, separated, or widowed. Men tend to marry at older ages than women. While one in two women age 25-29 is married (54 percent), the proportion of men married in the same age group is one in three (37 percent). Similarly, in the same age cohort 25-29, the proportion of men in an informal union is about half that of women in the same cohort (11 and 20 percent, respectively). Data from earlier GDHS show that there has been a marked increase in the proportion of never-married women, particularly in the younger age cohorts. Among women age 15-49, 20 percent were never married in 1993 (GSS and MI, 1994), 24 percent in 1998 (GSS and MI, 1999), 28 percent in 2003, and 32 percent in 2008. At the same time, the proportion of married women has declined sharply from 54 percent in 2003 to 45 percent in 2008. The decline is most noticeable among women in their 20s; for example, 40 percent of women age 20-24 were married in 2003, compared with 26 percent in 2008. The proportion of women living together with a man increased over the five-year period from 8 to 13 percent, while the proportion of women who are divorced (3 percent), separated (4 percent), and widowed (2 percent) has remained largely the same. The proportion of never-married men age 15-59 increased slightly from 41 percent in 2003 to 43 percent in 2008. 6.2 POLYGYNY Polygyny, which is the practice of having more than one wife, is common in Ghana and has implications for the frequency of sexual activity and fertility levels. In the GDHS, the prevalence of polygyny was measured by asking all currently married women whether their husband or partner had other wives, and if so, how many. Married men were asked whether they had one or more wives or partners. Table 6.2.1 shows the percent distribution of currently married women age 15-49 by number of co-wives, according to background characteristics: 18 percent of currently married women are in polygynous unions. Fifteen percent reported having one co-wife, and 3 percent said they had two or more co-wives. Older women are more likely than younger women to be in polygynous unions. The percentage of women in polygynous unions increases with age, from 7 percent among women age 15-19, to 30 percent among those age 45-49. Rural women are more likely to be in polygynous unions than their urban counterparts and polygyny is more common among women with no education and those in the lowest wealth quintile. Regional variation in the prevalence of polygyny ranges from 6 percent in Greater Accra to 37-38 percent in the Northern and Upper West regions, and 31-32 percent in the Volta and Upper East regions. Overall, the level of polygyny among women decreased from 23 percent in 1998 and 2003 (GSS and MI, 1999; GSS and ORC Macro, 2004) to 18 percent in 2008. At the same time, the proportion of women who reported having two or more co-wives increased from 5 percent in 1998 to 13 percent in 2003, but declined sharply to 3 percent in 2008. Other Proximate Determinants of Fertility | 113 Table 6.2.1 Number of women’s co-wives Percent distribution of currently married women age 15-49 by number of co- wives, according to background characteristics, Ghana 2008 Background characteristic Number of co-wives Total Number of women 0 1 2+ Missing Age 15-19 93.2 6.3 0.5 0.0 100.0 85 20-24 90.7 8.1 0.5 0.7 100.0 414 25-29 84.0 13.4 1.1 1.6 100.0 612 30-34 81.9 14.4 3.0 0.6 100.0 539 35-39 75.9 18.3 4.5 1.3 100.0 527 40-44 76.7 17.1 5.0 1.2 100.0 380 45-49 69.6 24.2 5.7 0.4 100.0 319 Residence Urban 87.1 8.9 3.0 1.0 100.0 1,216 Rural 76.2 19.8 3.0 1.0 100.0 1,660 Region Western 85.7 10.8 0.2 3.2 100.0 261 Central 81.0 14.5 2.2 2.3 100.0 254 Greater Accra 93.1 5.0 1.3 0.5 100.0 422 Volta 68.3 26.5 4.7 0.6 100.0 290 Eastern 90.0 9.2 0.8 0.0 100.0 252 Ashanti 86.0 11.5 1.4 1.1 100.0 542 Brong Ahafo 88.5 9.1 1.3 1.0 100.0 267 Northern 61.3 31.3 6.9 0.4 100.0 338 Upper East 68.4 24.2 7.4 0.0 100.0 168 Upper West 62.3 22.1 14.9 0.7 100.0 82 Education No education 67.6 25.5 5.6 1.3 100.0 853 Primary 79.8 15.0 4.1 1.1 100.0 638 Middle/JSS 87.6 10.8 0.9 0.8 100.0 1,058 Secondary+ 95.0 2.9 1.2 0.9 100.0 325 Wealth quintile Lowest 65.7 28.4 5.2 0.6 100.0 573 Second 76.8 19.7 2.4 1.2 100.0 577 Middle 79.9 13.6 5.2 1.4 100.0 525 Fourth 86.7 10.4 1.6 1.3 100.0 600 Highest 93.9 4.5 1.0 0.6 100.0 601 Total 80.8 15.2 3.0 1.0 100.0 2,876 Note: Total includes cases with information missing on education that are not shown separately. Table 6.2.2 shows the percent distribution of currently married men age 15-49 by number of wives, according to background characteristics: 9 percent of currently married men are in polygynous unions. The discrepancy between the number of wives reported by men and the number of co-wives reported by women may in part be due to differences in definition or conceptual views about who a wife is. At the same time however, the difference is expected because for every polygynous household only one husband is reporting multiple wives while at least two women are reporting co-wives. Conceptual differences may arise from the tendency for some women to describe their husband’s mistresses or girlfriends as wives, whereas men are less likely to classify such persons as wives. The proportion of married men who reported having two or more wives is higher among older men, men in rural areas, those who reside in the Volta, Northern, Upper East, and Upper West regions, those with no education, and those in the lowest wealth quintile (Figure 6.1). 114 | Other Proximate Determinants of Fertility Table 6.2.2 Number of men’s wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Ghana 2008 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 * * 100.0 7 20-24 99.6 0.4 100.0 106 25-29 95.4 4.6 100.0 296 30-34 95.2 4.8 100.0 412 35-39 91.1 8.9 100.0 445 40-44 88.8 11.2 100.0 353 45-49 82.5 17.5 100.0 331 Residence Urban 95.9 4.1 100.0 832 Rural 87.8 12.2 100.0 1,118 Region Western 95.9 4.1 100.0 205 Central 97.1 2.9 100.0 148 Greater Accra 99.6 0.4 100.0 302 Volta 81.8 18.2 100.0 166 Eastern 94.8 5.2 100.0 189 Ashanti 91.4 8.6 100.0 374 Brong Ahafo 96.1 3.9 100.0 172 Northern 76.7 23.3 100.0 237 Upper East 86.6 13.4 100.0 109 Upper West 82.5 17.5 100.0 47 Education No education 81.3 18.7 100.0 398 Primary 88.7 11.3 100.0 251 Middle/JSS 93.9 6.1 100.0 812 Secondary+ 96.1 3.9 100.0 485 Wealth quintile Lowest 79.6 20.4 100.0 380 Second 89.4 10.6 100.0 368 Middle 91.2 8.8 100.0 310 Fourth 96.1 3.9 100.0 434 Highest 97.9 2.1 100.0 458 Total 15-49 91.2 8.8 100.0 1,950 50-59 85.9 14.1 100.0 454 Total 15-59 90.2 9.8 100.0 2,404 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes cases with information missing on education and are not shown separately. Other Proximate Determinants of Fertility | 115 9 4 12 4 3 0 18 5 9 4 23 13 18 GHANA RESIDENCE Urban Rural REGION Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West 0 5 10 15 20 25 30 Percent Figure 6.1 Percentage of Married Men Age 15-49 with Two or More Wives, by Region GDHS 2008 <1 6.3 AGE AT FIRST MARRIAGE Marriage marks the point in a woman’s life when childbearing becomes socially acceptable in Ghana. Marriage is closely associated with fertility because women who marry early will, on average, have more births than women who marry later. Early age at first marriage is an important fertility indicator not only because it increases the length of time a woman is exposed to the risk of pregnancy, but it also tends to lead to early childbearing and 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 husband/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 the percentage of women and men who were first married by specific exact ages, and the median age at first marriage, according to current age. The median age at first marriage for women age 25-49 is 19.8 years, which represents a slight increase over the median reported from the 2003 GDHS (19.4 years). There is a general trend towards later marriage. Thirty-four percent and 52 percent of women age 25-49 were married by exact age 18 and 20, respectively, compared with 35 percent and 56 percent of women in the same age group in the 2003 survey (GSS and ORC Macro, 2004). By age 22, about two-thirds (67 percent) of women age 25-49 were married and by age 25, the proportion married in that age group was 80 percent. The increase in the median age at first marriage is seen most sharply when older and younger age cohorts are compared. There is an almost two-year difference in age at first marriage between women age 45-49 (19.1 years) and women age 25-29 (21.0 years). Men generally marry later in life. Among men age 25-49, no man was married until age 18, and then it was only one in twenty men (5 percent) who were married. By age 20, only 13 percent of men were married and less than half (44 percent) were married by age 25. Across all age groups, the proportions of women married are larger than the proportions of men married. The median age at first marriage for men age 30-34 is 25.7 years, compared with 20.0 years for women in this age group. 116 | Other Proximate Determinants of Fertility Table 6.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Ghana 2008 Current age Percentage first married by exact age Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 2.6 na na na na 90.6 1,025 a 20-24 4.9 24.6 38.6 na na 48.6 878 a 25-29 4.6 27.0 42.3 57.4 72.5 20.4 832 21.0 30-34 9.2 32.2 50.4 65.6 79.8 5.7 644 20.0 35-39 7.8 35.8 54.9 68.9 80.4 3.4 638 19.4 40-44 8.0 37.6 59.4 75.4 86.3 1.6 470 19.1 45-49 8.2 39.9 61.6 75.2 87.4 0.5 429 19.1 20-49 6.8 31.5 49.1 na na 17.1 3,891 a 25-49 7.3 33.5 52.1 66.9 80.0 7.9 3,014 19.8 MEN 15-19 0.0 na na na na 99.1 911 a 20-24 0.0 24.6 38.6 na na 83.2 704 a 25-29 0.0 4.7 13.8 23.6 40.3 49.0 624 a 30-34 0.0 4.1 11.7 22.9 44.8 15.3 533 25.7 35-39 0.0 7.4 12.2 23.3 42.2 8.6 528 26.3 40-44 0.0 5.7 15.3 24.4 45.6 3.0 394 25.8 45-49 0.0 5.0 13.0 24.9 47.6 0.9 364 25.3 20-49 0.0 5.0 12.0 na na 32.8 3,147 a 25-49 0.0 5.4 13.1 23.7 43.6 18.3 2,443 a 20-59 0.0 4.8 11.4 na na 28.4 3,657 a 25-59 0.0 5.1 12.2 22.4 43.0 15.4 2,953 a Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the women/men were married for the first time before reaching the beginning of the age group Table 6.4.1 shows the median age at first marriage among women age 25-49 by current age and background characteristics. The median age at first marriage is consistently lower among women in rural areas than those in urban areas. Regional differentials show that the Greater Accra region has the highest median age at first marriage (22.9 years) among women age 25-49, while the Upper East region has the lowest median age at first marriage (17.8 years). Women with little or no education are more likely to marry at a younger age than those with a higher level of education. Similarly, women in households in the lower wealth quintiles are likely to marry earlier than women in the higher wealth quintiles. Other Proximate Determinants of Fertility | 117 Table 6.4.1 Median age at first marriage: Women Median age at first marriage among women age 25-49 by five-year age groups, according to background characteristics, Ghana 2008 Background characteristic Current age Women age 25-49 25-29 30-34 35-39 40-44 45-49 Residence Urban 23.5 21.9 20.5 20.0 19.3 21.3 Rural 18.9 18.5 18.7 18.5 19.0 18.7 Region Western 19.9 20.6 20.4 (19.7) (20.3) 20.3 Central (20.3) (18.8) 20.3 (19.4) (20.1) 19.7 Greater Accra a 23.2 21.0 21.2 (19.0) 22.9 Volta 18.9 18.3 20.1 (19.2) 18.9 19.2 Eastern 22.1 20.2 18.3 (18.7) (20.2) 19.9 Ashanti 20.9 19.2 19.3 18.6 18.8 19.5 Brong Ahafo 19.1 19.4 (18.4) (16.9) (17.8) 18.4 Northern 19.9 19.4 18.7 (19.2) (18.9) 19.3 Upper East 17.9 (17.6) (17.3) 17.8 (18.4) 17.8 Upper West 19.1 18.9 17.8 (17.3) (16.7) 18.1 Education No education 18.6 18.4 18.6 18.6 18.8 18.6 Primary 18.9 18.3 18.4 17.8 17.8 18.3 Middle/JSS 20.8 20.6 19.8 19.4 19.4 20.1 Secondary+ a 25.8 25.8 (22.2) (21.5) a Wealth quintile Lowest 18.5 18.5 18.5 18.8 18.7 18.6 Second 18.6 18.2 18.0 18.3 19.1 18.4 Middle 20.1 19.1 19.3 17.9 19.4 19.2 Fourth 22.0 20.2 20.2 19.8 18.6 20.3 Highest a 23.4 22.8 21.3 19.4 23.4 Total 21.0 20.0 19.4 19.1 19.1 19.8 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/partner. Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. a = Omitted because less than 50 percent of the women were married for the first time before reaching the beginning of the age group na = Not applicable Table 6.4.2 shows the median age at first marriage for men age 30-59 by current age and background characteristics. The median age at first marriage is consistently lower among men in rural areas (24.9 years) than those in urban areas (27.2 years). Regional differentials show that the highest median age at first marriage among men age 30-59 is in the Greater Accra region (27.9 years), where men marry three years later than those in the Central, Ashanti, and the Upper East regions (24.5-24.8 years). The Ashanti region has the lowest (24.5 years) median age at first marriage for men. Men with primary education are more likely to marry at an earlier age (24.4 years) than those with no education, middle or JSS education, and secondary or higher education. Likewise, men in the three lowest wealth quintiles were married at a younger age than those in the two highest wealth quintiles. Comparing the results from the 2003 GDHS and the 2008 GDHS surveys indicates that, in general, women and men are marrying at a later age than five years ago; the difference for women is 0.4 years while for men the difference is 1.2 years (GSS and ORC Macro, 2004). 118 | Other Proximate Determinants of Fertility Table 6.4.2 Median age at first marriage: Men Median age at first marriage among men age 30-59 by five-year age groups, according to background characteristics, Ghana 2008 Background characteristic Current age Men age 30-59 30-34 35-39 40-44 45-49 50-59 Residence Urban 27.3 28.1 28.2 26.1 26.1 27.2 Rural 23.9 24.9 24.0 25.0 26.1 24.9 Region Western (28.4) 26.7 (25.3) (24.1) 26.0 26.0 Central (24.0) (24.6) * * (24.7) 24.7 Greater Accra 27.7 29.4 28.3 (27.1) 27.1 27.9 Volta (25.0) (25.7) (25.1) (26.0) (25.4) 25.5 Eastern (26.2) (24.7) (26.5) (24.1) 26.6 25.6 Ashanti 24.0 26.2 (24.7) 23.6 24.2 24.5 Brong Ahafo 25.5 (26.5) (25.3) * (27.4) 26.0 Northern 25.6 25.8 (26.0) 26.9 27.2 26.1 Upper East (23.5) (25.2) (23.6) * (27.8) 24.8 Upper West (25.8) (25.2) (26.7) (24.7) (26.7) 25.8 Education No education 25.2 24.0 25.2 26.3 27.2 25.7 Primary 23.9 24.7 (23.8) 24.1 (25.2) 24.4 Middle/JSS 24.9 25.6 26.1 25.0 25.1 25.3 Secondary+ 27.6 29.8 27.0 25.5 26.7 27.6 Wealth quintile Lowest 23.8 24.2 24.8 26.5 27.4 25.5 Second 23.8 24.0 22.8 23.9 26.6 24.0 Middle 24.1 24.8 24.2 25.0 25.2 24.7 Fourth 27.2 27.2 28.4 26.0 25.2 26.5 Highest 27.6 29.7 27.3 26.8 26.8 27.7 Total 25.7 26.3 25.8 25.3 26.1 25.9 Note: The age at first marriage is defined as the age at which the respondent began living with his first spouse/partner. Total includes cases with information missing on education that are not shown separately. 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. 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. Because women and men may engage in sexual relations prior to marriage, age at first sexual intercourse is a more reliable indicator of a woman’s exposure to the risk of pregnancy than age at first marriage. In the 2008 GDHS, women and men were asked how old they were when they first had sexual intercourse. Table 6.5 shows the median age at first sexual intercourse by specific exact ages. Women are likely to experience first sexual intercourse at an earlier age than men. The median age at first sexual intercourse for women age 25-49 is 18.4 years, compared with 20.0 years for men. Eight percent of women and 5 percent of men reported having sexual intercourse by age 15. By age 18, more than two-fifths of women (44 percent) and 26 percent of men have had sexual intercourse. Sixty-three percent of women and 78 percent of men age 15-19 have never had sex. Other Proximate Determinants of Fertility | 119 Table 6.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Ghana 2008 Current age Percentage who had first sexual intercourse by exact age Percentage who never had intercourse Number of respondents Median age at first intercourse 15 18 20 22 25 WOMEN 15-19 8.2 na na na na 62.7 1,025 a 20-24 7.2 41.2 71.4 na na 11.5 878 18.5 25-29 6.6 39.7 64.6 79.3 90.8 3.4 832 18.6 30-34 9.3 43.7 66.1 80.5 87.0 0.2 644 18.4 35-39 7.6 45.7 67.4 80.7 87.5 0.2 638 18.3 40-44 8.3 45.2 67.9 82.2 89.7 0.0 470 18.3 45-49 8.8 51.4 72.9 85.7 90.6 0.0 429 17.9 20-49 7.8 43.7 68.2 na na 3.4 3,891 18.4 25-49 8.0 44.4 67.2 81.2 89.1 1.0 3,014 18.4 15-24 7.8 na na na na 39.1 1,902 a MEN 15-19 3.6 na na na na 78.1 911 a 20-24 5.2 26.8 54.9 na na 26.2 704 19.6 25-29 4.7 25.2 51.6 72.5 87.7 6.9 624 19.9 30-34 4.9 25.2 51.2 73.5 86.4 1.4 533 19.9 35-39 6.3 28.2 47.9 71.8 84.6 1.0 528 20.1 40-44 2.8 27.4 51.5 70.2 83.2 0.0 394 19.9 45-49 3.1 22.8 46.0 70.7 82.9 0.3 364 20.2 20-49 4.7 26.1 51.0 na na 7.7 3,147 19.9 25-49 4.5 25.8 49.9 71.9 85.3 2.3 2,443 20.0 15-24 4.3 na na na na 55.4 1,615 a 20-59 4.6 25.2 49.9 na na 6.7 3,657 a 25-59 4.4 24.8 48.7 71.1 84.5 2.1 2,953 20.1 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Nearly all women and men are sexually active by age 25. Younger women are likely to experience first sexual intercourse at a later age than older women, suggesting that age at first sexual intercourse is rising among women. For example, the proportion of women age 20-24 who were sexually active by age 18 is 41 percent, compared with 51 percent among women age 45-49. In contrast, the trend among men is towards younger age at first sexual intercourse. Among men age 20-24, 27 percent were sexually active by age 18 compared with 23 percent among men age 45-49. Table 6.6.1 shows the median age at first sexual intercourse for women age 20-49 and age 25-49 by current age and background characteristics. Women in urban areas experience first sexual intercourse at slightly later ages than those in rural areas, except for women age 45-49. Women in the Greater Accra and Northern regions are more likely to experience first sexual intercourse about two years later their counterparts in the Upper West region. Women with secondary or higher education begin sexual relations at least three years later than women with primary education. Similarly, women in the highest wealth quintile experience first sexual intercourse at least a year later than women in the lower wealth quintiles. 120 | Other Proximate Determinants of Fertility Table 6.6.1 Median age at first sexual intercourse: Women Median age at first sexual intercourse among women age 20-49 and age 25-49 by five-year age groups, according to background characteristics, Ghana 2008 Background characteristic Current age Women age 20-49 Women age 25-49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban 18.9 19.4 19.0 18.7 18.6 17.8 18.9 18.8 Rural 18.0 18.0 17.8 17.8 18.0 18.0 17.9 17.9 Region Western 18.8 18.8 18.4 18.6 (19.3) (18.1) 18.6 18.6 Central 18.5 (18.3) (17.5) 17.7 (17.7) (18.1) 18.0 17.8 Greater Accra 19.0 20.0 19.1 19.1 18.6 (18.2) 19.0 19.0 Volta 18.4 17.4 17.5 19.1 (18.4) 18.0 18.1 18.0 Eastern 18.0 18.2 17.9 17.7 (17.4) (17.5) 17.9 17.9 Ashanti 18.4 18.7 18.1 18.1 18.2 17.4 18.3 18.2 Brong Ahafo 18.1 18.5 19.0 (18.3) (18.2) (17.7) 18.3 18.4 Northern 18.4 19.0 19.8 19.0 (20.1) (19.3) 19.2 19.4 Upper East 18.0 17.9 (17.7) (18.1) 17.7 (17.9) 17.9 17.9 Upper West 18.0 16.8 17.8 17.6 (17.0) (16.6) 17.5 17.2 Education No education 17.6 17.6 18.2 17.9 18.4 18.1 18.0 18.1 Primary 17.5 17.7 17.3 17.6 17.2 17.0 17.5 17.5 Middle/JSS 18.2 18.7 18.4 18.4 18.3 17.8 18.4 18.4 Secondary+ 19.9 21.2 20.5 20.6 (19.4) (18.9) a 20.5 Wealth quintile Lowest 17.5 17.9 18.1 17.7 19.1 18.3 18.0 18.1 Second 18.3 17.8 17.6 17.6 17.6 17.5 17.8 17.7 Middle 18.2 18.3 17.6 17.9 17.8 18.2 18.1 18.0 Fourth 18.4 18.9 18.5 18.2 18.4 17.7 18.4 18.4 Highest 19.3 20.0 19.6 19.3 18.8 17.8 19.3 19.3 Total 18.5 18.6 18.4 18.3 18.3 17.9 18.4 18.4 Note: Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group Table 6.6.2 shows that the median age at first sexual intercourse for men age 25-59 is 20.1 years. Men in urban and rural areas experience first sexual intercourse at about the same age (20.3 and 19.9 years, respectively). Men in the Northern region have first sexual relations at least two years later than their counterparts in the Eastern, Ashanti, and Central regions. Differentials by education are small, ranging from 19.7 years among men with primary education to 20.5 years among men with no education. Differentials by household wealth status are also small, with median age at first sexual intercourse being almost the same for men in the lowest wealth quintile (20.4 years) as for those in the highest wealth quintile (20.3 years). Other Proximate Determinants of Fertility | 121 Table 6.6.2 Median age at first intercourse: Men Median age at first sexual intercourse among men age 25-59 by five-year age groups, according to background characteristics, Ghana 2008 Background characteristic Current age Men age 25-59 25-29 30-34 35-39 40-44 45-49 50-59 Residence Urban 20.2 20.1 20.3 20.2 20.4 20.3 20.3 Rural 19.6 19.5 19.9 19.6 20.1 20.5 19.9 Region Western (18.8) (20.6) 19.5 (20.1) (20.2) 20.3 20.0 Central (19.8) (18.7) (20.1) * * (20.0) 19.5 Greater Accra 19.8 19.6 20.1 21.0 (20.8) 19.8 20.1 Volta 20.2 (18.6) (19.4) (19.7) (20.6) (20.2) 20.0 Eastern 18.9 (19.2) (19.4) (18.5) (19.0) 19.5 19.0 Ashanti 19.6 19.0 19.7 (18.4) 19.4 20.1 19.4 Brong Ahafo 19.9 20.8 (20.4) (18.9) * (21.3) 20.4 Northern 20.8 20.9 21.7 (20.9) 21.7 25.0 21.6 Upper East (19.7) (20.3) (20.7) (20.3) * (23.3) 20.6 Upper West 20.6 (20.3) (20.0) (20.2) (23.5) (23.2) 20.8 Education No education 20.0 20.5 20.3 20.4 20.6 21.5 20.5 Primary 19.6 18.7 19.9 (19.2) (19.1) (20.5) 19.7 Middle/JSS 19.5 19.8 19.8 19.5 20.0 20.1 19.8 Secondary+ 20.2 19.8 20.4 20.3 20.4 20.3 20.2 Wealth quintile Lowest 19.7 20.3 20.4 20.5 20.3 22.1 20.4 Second 19.7 19.7 19.5 18.7 20.1 20.2 19.7 Middle 19.2 19.0 19.7 19.4 19.5 20.1 19.5 Fourth 20.0 19.8 20.2 19.8 20.3 20.6 20.1 Highest 20.4 20.0 20.3 20.8 20.7 19.8 20.3 Total 19.9 19.9 20.1 19.9 20.2 20.4 20.1 Note: Total includes cases with information missing on education that are not shown separately. 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. 6.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the risk of pregnancy is related to the frequency of intercourse. 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 intercourse in the past four weeks. The results are shown in Tables 6.7.1 and 6.7.2 for women and men, respectively. Table 6.7.1 shows that in the four weeks preceding the survey, 40 percent of women age 15-49 were sexually active, 28 percent were sexually active in the past 12 months but not in the past four weeks, and 16 percent had not had sex for more than one year. Another 16 percent of women had never had sexual intercourse. The proportion of women who were sexually active in the four weeks preceding the survey increases with age, but declines at age 45-49. Teenagers and women who are not currently in a marital union, as well as women who used to be married, were less likely to be sexually active in the four weeks preceding the survey than older women and women who are currently married or living with a man. Among currently married women, the proportion that had recent sexual intercourse increases slightly with marital duration up to a peak of 63 percent among those married for 20-24 years. Women in urban areas were less likely to be sexually active over the past four weeks (37 percent) than their rural counterparts (43 percent). Among the regions, the Brong Ahafo region has the highest proportion of women who were sexually active in the four weeks before the survey (46 percent) and the Northern region has the lowest proportion (30 percent). Women with at least some secondary education are less likely to be sexually active than less educated women. Differences by wealth status are not large and show no clear pattern. 122 | Other Proximate Determinants of Fertility Table 6.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Ghana 2008 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 12.6 16.3 8.3 0.0 62.7 100.0 1,025 20-24 35.4 38.5 14.1 0.4 11.5 100.0 878 25-29 49.2 31.9 14.9 0.5 3.4 100.0 832 30-34 51.3 32.1 15.9 0.6 0.2 100.0 644 35-39 52.5 29.4 17.5 0.4 0.2 100.0 638 40-44 53.2 25.3 20.9 0.5 0.0 100.0 470 45-49 46.0 23.3 30.0 0.7 0.0 100.0 429 Marital status Never married 14.4 23.2 13.7 0.2 48.6 100.0 1,593 Married or living together 58.4 30.6 10.6 0.4 0.0 100.0 2,876 Divorced/separated/ widowed 12.4 30.3 56.4 0.9 0.0 100.0 446 Marital duration2 Married only once 0-4 years 54.6 37.5 7.0 0.9 0.0 100.0 509 5-9 years 57.8 31.0 11.0 0.2 0.0 100.0 486 10-14 years 59.3 28.1 12.4 0.2 0.0 100.0 387 15-19 years 60.2 26.3 13.4 0.1 0.0 100.0 317 20-24 years 62.5 27.2 9.4 0.8 0.0 100.0 259 25+ years 53.7 29.3 16.4 0.7 0.0 100.0 210 Married more than once 60.0 30.3 9.4 0.3 0.0 100.0 708 Residence Urban 36.8 27.8 17.1 0.3 18.0 100.0 2,383 Rural 42.9 28.5 14.5 0.5 13.6 100.0 2,533 Region Western 42.8 24.5 16.4 0.0 16.3 100.0 447 Central 37.0 36.0 12.9 0.8 13.3 100.0 424 Greater Accra 37.6 27.9 14.9 0.1 19.5 100.0 853 Volta 41.6 29.7 12.1 0.2 16.5 100.0 431 Eastern 41.2 28.7 15.6 0.2 14.2 100.0 483 Ashanti 44.2 26.9 14.0 0.1 14.8 100.0 1,011 Brong Ahafo 46.4 27.4 14.6 0.0 11.6 100.0 425 Northern 29.9 28.2 23.6 1.9 16.4 100.0 467 Upper East 36.7 25.3 19.2 0.8 18.0 100.0 253 Upper West 32.2 27.6 23.8 1.4 14.9 100.0 122 Education No education 43.7 28.8 22.3 0.7 4.5 100.0 1,042 Primary 42.0 30.5 13.9 0.2 13.4 100.0 988 Middle/JSS 40.5 26.2 13.4 0.4 19.5 100.0 2,039 Secondary+ 31.6 29.1 15.6 0.3 23.4 100.0 844 Wealth quintile Lowest 38.5 27.3 20.5 0.7 12.9 100.0 783 Second 42.5 29.7 14.8 0.4 12.6 100.0 900 Middle 38.3 31.1 15.6 0.6 14.5 100.0 979 Fourth 38.0 29.5 16.8 0.1 15.6 100.0 1,119 Highest 42.2 23.7 12.4 0.2 21.5 100.0 1,135 Total 39.9 28.2 15.8 0.4 15.7 100.0 4,916 Note: Total includes cases with information missing on education that are not shown separately. 1 Excludes women who had sexual intercourse within the past 4 weeks 2 Excludes women who are not currently married Table 6.7.2 shows that about two in five men age 15-49 (40 percent) were sexually active in the four weeks preceding the survey, while 27 percent reported having sexual intercourse in the past year (but not within the past 4 weeks). Nine percent had not been sexually active in the past year, and 24 percent had never had sex. As with women, sexual activity increases with age among men, with the highest level among men age 40 and above. Men in union were much more likely to be sexually active than those who were not. There was no difference in recent sexual activity between men in urban and rural areas (about 39 percent); however, there was substantial variation by region, from 27 percent in the Northern and Upper West regions to 46 percent in the Brong Ahafo region. Recent Other Proximate Determinants of Fertility | 123 sexual activity is lower among men with primary education (32 percent) than other men, and it generally increases with wealth status: men in the lowest wealth quintile (34 percent) were least likely to be sexually active in the past four weeks while men in the highest wealth quintile (45 percent) were most likely to be sexually active. Table 6.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Ghana 2008 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 7.1 8.7 5.9 0.2 78.1 100.0 911 20-24 25.6 32.9 15.0 0.3 26.2 100.0 704 25-29 47.5 34.3 10.7 0.6 6.9 100.0 624 30-34 54.5 33.4 10.0 0.7 1.4 100.0 533 35-39 58.8 31.9 7.9 0.4 1.0 100.0 528 40-44 60.4 31.0 8.1 0.6 0.0 100.0 394 45-49 60.8 29.6 8.0 1.3 0.3 100.0 364 Marital status Never married 16.4 22.0 12.2 0.2 49.2 100.0 1,936 Married or living together 63.0 30.8 5.3 0.9 0.0 100.0 1,950 Divorced/separated/ widowed 32.0 42.8 25.1 0.0 0.1 100.0 172 Marital duration2 Married only once 0-4 years 60.7 31.5 6.7 1.1 0.0 100.0 399 5-9 years 60.3 31.7 6.5 1.5 0.0 100.0 398 10-14 years 66.4 30.0 2.9 0.7 0.0 100.0 284 15-19 years 57.5 35.2 6.6 0.7 0.0 100.0 209 20-24 years 60.8 30.7 7.6 0.9 0.0 100.0 153 25+ years 74.3 18.6 4.5 2.6 0.0 100.0 64 Married more than once 67.1 29.8 3.0 0.2 0.0 100.0 443 Residence Urban 39.5 27.2 10.4 0.4 22.5 100.0 1,866 Rural 39.4 27.1 8.6 0.7 24.3 100.0 2,191 Region Western 41.1 27.4 6.6 0.3 24.5 100.0 403 Central 44.1 23.4 8.2 0.3 24.0 100.0 326 Greater Accra 44.2 26.7 10.1 0.7 18.3 100.0 649 Volta 32.9 28.9 10.0 0.0 28.2 100.0 373 Eastern 41.8 27.8 6.7 0.7 23.0 100.0 411 Ashanti 43.5 26.6 8.2 0.0 21.8 100.0 785 Brong Ahafo 46.1 28.1 10.3 0.0 15.4 100.0 347 Northern 26.9 25.9 15.8 1.8 29.6 100.0 435 Upper East 28.2 32.3 8.8 1.4 29.3 100.0 219 Upper West 27.4 26.5 8.7 0.6 36.7 100.0 108 Education No education 41.3 31.3 14.8 2.0 10.6 100.0 540 Primary 32.2 25.8 6.9 0.5 34.5 100.0 619 Middle/JSS 41.9 24.1 7.3 0.2 26.4 100.0 1,721 Secondary+ 38.7 30.3 11.5 0.1 19.4 100.0 1,167 Wealth quintile Lowest 34.1 27.3 11.0 1.5 26.1 100.0 708 Second 38.1 27.7 8.1 0.6 25.6 100.0 738 Middle 38.1 25.9 10.1 0.0 25.9 100.0 699 Fourth 40.4 28.1 9.5 0.2 21.7 100.0 974 Highest 44.6 26.4 8.6 0.5 19.9 100.0 939 Total 15-49 39.5 27.1 9.4 0.5 23.5 100.0 4,058 50-59 57.0 26.7 14.0 1.5 0.8 100.0 510 Total 15-59 41.4 27.1 9.9 0.6 20.9 100.0 4,568 Note: Total includes cases with information missing on education that are not shown separately. 1 Excludes men who had sexual intercourse within the past 4 weeks 2 Excludes men who are not currently married 124 | Other Proximate Determinants of Fertility Comparing the results of the 2008 GDHS and the 2003 GDHS (GSS and ORC Macro, 2004) shows that there has been a slight decline in the proportion of women age 15-49 who were sexually active in the four weeks preceding the survey, from 42 percent in 2003 to 40 percent in 2008, and among men age 15-59, from 45 to 41 percent during the same period. 6.6 AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Post-partum 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. Post- partum protection from conception can be prolonged by breastfeeding, which can lengthen the duration of amenorrhoea. Delaying the resumption of post-partum sexual relations can also prolong protection. The period of voluntary sexual inactivity after childbirth is referred to as post-partum 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 post-partum sexual abstinence. Table 6.8 shows the percent- age of births in the three years preceding the survey for which mothers were post-partum amenorrhoeic, abstaining, and insusceptible, by number of months since the birth. Mean and median durations are also shown. In Ghana, the median duration of amenorrhoea is 9 months; the median duration of post-partum abstinence is slightly lower at 8 months. Women are insusceptible to pregnancy for about one year after a birth (median of 12 months and a mean of 15 months). Ninety- six percent of women who gave birth in the two months preceding the survey were still abstaining from sex at the time of the survey. The proportion of women abstaining decreases with increasing months since delivery, particularly during the first year after a birth. Almost all women are insusceptible to the risk of pregnancy during the first two months after a birth because of post-partum amenorrhoea and post-partum abstinence. At 8 to 9 months after a birth, about half of women are still amenorrhoeic but only 41 percent are abstaining. By 12 to 13 months, about one-third of women (31 percent) are still amenorrhoeic, two-fifth are still abstaining, but only half are insusceptible—the latter because of loss of the combined effect of amenorrhoea and abstinence. By 34 to 35 months, the effect of post-partum amenorrhoea is almost completely gone (3 percent) and insusceptibility to pregnancy is low (6 percent). A comparison of data from the 1998, 2003, and 2008 GDHS surveys indicates that the median duration of post-partum amenorrhoea, abstinence, and insusceptibility remained unchanged between 1998 (GSS an MI, 1999) and 2003 (GSS and ORC Macro, 2004) but decreased between 2003 and 2008. Table 6.8 Post-partum amenorrhoea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are post-partum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Ghana 2008 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 <2 94.6 96.2 97.6 86 2-3 83.5 82.2 93.8 122 4-5 69.3 71.2 86.3 112 6-7 62.5 58.6 80.9 103 8-9 52.1 40.8 70.6 93 10-11 42.0 30.4 55.8 112 12-13 31.3 39.6 52.4 95 14-15 26.1 25.3 40.1 106 16-17 15.6 24.1 33.3 122 18-19 18.3 22.9 31.8 90 20-21 6.1 17.6 22.9 75 22-23 4.7 15.5 17.9 86 24-25 2.6 14.6 17.3 84 26-27 0.5 12.5 13.0 102 28-29 0.4 13.9 14.3 107 30-31 0.0 8.0 8.0 88 32-33 1.8 4.4 6.2 76 34-35 2.7 2.9 5.6 66 Total 30.6 34.1 44.0 1,724 Median 8.9 7.5 12.4 na Mean 10.6 11.9 15.2 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth Other Proximate Determinants of Fertility | 125 Table 6.9 shows the median duration of amenorrhoea, post-partum abstinence, and post- partum insusceptibility by background characteristics. Differentials are not strong; however, the period of post-partum insusceptibility is shorter among women in urban areas than those in rural areas. There is an inverse relationship between level of education and wealth quintile on the one hand and women’s insusceptibility to pregnancy on the other. However, women with no education and those in the lowest wealth quintile are more likely to experience a longer period of post-partum amenorrhoea and abstinence—and therefore a longer period of post-partum insusceptibility (17 and 19 months, respectively). Table 6.9 Median duration of amenorrhoea, post-partum abstinence and post-partum insusceptibility Median number of months of post-partum amenorrhoea, post- partum abstinence, and post-partum insusceptibility following births in the three years preceding the survey, by background characteristics, Ghana 2008 Background characteristic Post-partum amenorrhoea Post-partum abstinence Post-partum insusceptibility1 Mother’s age 15-29 7.9 6.6 11.8 30-49 10.1 8.5 13.8 Residence Urban 7.9 8.1 10.4 Rural 9.9 7.4 13.9 Education No education 12.6 10.9 16.9 Primary 8.6 8.9 11.9 Middle/JSS 6.8 6.6 9.8 Secondary+ (8.1) (6.9) (9.9) Wealth quintile Lowest 13.3 12.1 18.5 Second 7.8 7.3 12.6 Middle (8.5) (8.3) (10.2) Fourth 7.5 6.1 10.1 Highest (7.5) (5.8) (8.4) Total 8.9 7.5 12.4 Note: Medians are based on the status at the time of the survey (current status). Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth 6.7 MENOPAUSE Menopause marks the onset of infecundity and is another factor influencing the risk of pregnancy. In this report, women are considered menopausal if they are neither pregnant nor post- partum amenorrhoeic, and have not had a menstrual period in the past six months. Table 6.10 shows that overall, 9 percent of women age 30-49 are menopausal. The proportion of women who are menopausal increases with age from 2 percent among women age 30-34 to 45 percent among women age 48-49. Compared with the results from the 2003 GDHS, the proportion of women who are menopausal has declined considerably among women age 46-47, from 33 percent in 2003 to 22 percent in 2008. Less than one in two women age 48-49 are menopausal, which is almost the same as in 2003 (GSS and ORC Macro, 2004). 126 | Other Proximate Determinants of Fertility Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Ghana 2008 Age Percentage menopausal1 Number of women 30-34 2.2 644 35-39 2.7 638 40-41 3.2 214 42-43 8.7 185 44-45 19.7 209 46-47 22.3 145 48-49 45.1 146 Total 8.9 2,181 1 Percentage of all women who are not pregnant and not post-partum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 127 FERTILITY PREFERENCES 7 A principal objective of the 1994 Population Policy was to promote a small family norm through information and education campaigns and to target for a two-year minimum birth interval for all births by 2020. The government has since actively promoted the voluntary acceptance of family planning methods. All couples are being encouraged to decide freely and responsibly on the timing, number, and spacing of their children for a family size that can be managed (NPC, 1994). In the 2008 GDHS, women and men were asked specific questions about their 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 questions were designed to ascertain individual fertility preferences. Although survey information on fertility preferences can be influenced by the respondent’s current family size, it is still useful to family planning programmes for assessing the need for spacing and limiting births and the extent of mistimed and unwanted births. 7.1 DESIRE FOR MORE CHILDREN Table 7.1 shows fertility preferences among currently married women and currently married men by the number of living children at the time of the survey. The findings indicate that there is considerable desire among married Ghanaians to control the timing and number of births. Thirty-six percent of currently married women would like to wait for two or more years for the next birth, and another 36 percent do not want to have another child or are sterilised, totalling about 72 percent who want to delay or limit the next birth. Only about one-fifth (19 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 similar pattern of fertility preferences is seen for currently married men. Table 7.1 also shows that fertility preferences and the number of children a woman has are closely related. About three in four currently married women (74 percent) without a child would like to have one soon, compared with 63 percent in 2003. However, interest in controlling the pace of childbearing once the first child is born is high; almost two-thirds (60 percent) of women with one child want to delay the next birth. Interest in controlling the number of births grows substantially as the number of children increases; the proportion of married women wanting no more children or who are sterilised increases from 2 percent among women with one child to 77 percent among women with six or more children. Men without a child are more likely to want to delay the first birth (i.e., wait at least two years), compared with women (34 and 13 percent, respectively). Conversely, women who have not started childbearing are more likely to want a child within two years than men (74 and 56 percent, respectively). A comparison of the findings from the five GDHS surveys shows that the desire to space births among currently married Ghanaian women has declined while the desire to limit births has risen. Over the past 20 years, the desire to space births has decreased from 45 percent in 1988 (GSS and IRD, 1989) to 36 percent in 2008; however, this change has been minimal in the past ten years. Over the same period, the desire to limit births (excluding sterilised women) has increased from 23 percent in 1988 to 35 percent in 2008. Again this change has been minimal over the past 10 years. 128 | Fertility Preferences Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Ghana 2008 Desire for children Number of living children1 Total 15-49 Total 15-59 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 73.7 30.1 21.7 15.5 8.3 6.4 5.2 19.3 na Have another later3 12.8 59.9 53.6 38.7 26.7 16.1 7.8 35.7 na Have another, undecided when 10.8 4.7 2.5 1.4 0.7 0.3 0.7 2.4 na Undecided 1.8 2.1 2.5 6.6 4.7 6.1 5.9 4.3 na Want no more 0.0 1.7 17.3 34.0 55.6 66.0 73.5 34.8 na Sterilised4 0.0 0.0 0.4 2.2 1.9 4.5 3.2 1.6 na Declared infecund 0.8 1.5 1.8 1.3 1.9 0.2 3.0 1.6 na Missing 0.0 0.0 0.2 0.3 0.0 0.4 0.6 0.2 na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na Number of women 167 476 608 523 438 297 368 2,876 na MEN5 Have another soon2 55.8 35.5 22.3 16.7 12.5 14.1 14.9 22.7 20.8 Have another later3 34.4 57.6 50.4 41.7 29.9 29.1 22.3 40.0 34.0 Have another, undecided when 4.0 1.4 1.6 3.3 1.0 1.7 3.0 2.2 1.9 Undecided 4.1 1.7 3.2 3.9 5.7 7.6 2.7 3.8 3.8 Want no more 0.0 2.8 21.8 32.1 49.9 47.6 56.0 30.3 38.4 Sterilised4 0.0 0.8 0.6 1.6 0.6 0.0 0.7 0.7 0.7 Declared infecund 0.0 0.0 0.0 0.7 0.0 0.0 0.0 0.1 0.2 Missing 1.7 0.3 0.0 0.0 0.3 0.0 0.4 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 141 325 398 340 308 167 272 1,950 2,404 na = Not applicable 1 The number of living children includes current pregnancy for women 2 Wants next birth within 2 years 3 Wants to delay (next) birth for 2 or more years 4 Includes both female and male sterilisation 5 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Table 7.2.1 shows the percentage of currently married women who want no more children or have been sterilised by the number of living children and background characteristics. Women in urban areas are more likely than those in rural areas to want no more children, irrespective of the number of children a woman has, although the overall urban-rural difference is slightly less than one percentage point (37 and 36 percent, respectively). Men show a similar pattern regarding desire to limit births (Table 7.2.2). The desire to limit the number of children is higher among urban than rural men, highest among men with middle/JSS education, and men in the highest wealth quintile. Women in the Eastern region and men in the Western region are most likely than women and men in the other regions to want to limit the number of children they have (47 percent and 41 percent, respectively). The desire to limit childbearing is lowest in the Northern region among both women and men (20 percent and 9 percent, respectively). Fertility Preferences | 129 Table 7.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Ghana 2008 Background characteristic Number of living children1 Total 1 2 3 4 5 6+ Residence Urban 2.3 21.9 51.0 66.4 72.7 79.5 36.8 Rural 1.2 13.4 23.4 51.6 69.4 76.0 36.2 Region Western 3.9 26.4 35.2 63.8 74.7 88.0 44.8 Central 0.0 7.3 26.3 59.0 91.8 91.5 41.3 Greater Accra 1.9 36.6 67.6 87.9 91.6 84.5 45.7 Volta 2.0 22.2 38.9 66.2 73.6 70.6 39.0 Eastern 2.7 14.8 55.6 67.5 79.5 96.5 46.7 Ashanti 2.2 14.1 31.0 58.9 75.3 80.3 34.9 Brong Ahafo 1.2 7.7 32.5 38.4 50.2 78.2 26.1 Northern 0.0 1.7 14.5 15.7 32.2 53.4 20.0 Upper East 1.9 8.6 16.7 51.4 69.2 74.6 34.4 Upper West 1.4 0.4 10.7 37.3 33.0 77.5 23.8 Education No education 1.0 11.3 23.6 34.9 62.8 67.3 36.4 Primary 0.0 17.2 32.0 52.7 63.0 86.5 36.8 Middle/ JSS 2.2 16.5 44.0 76.8 84.6 88.8 38.8 Secondary+ 2.9 32.7 46.1 84.7 90.3 100.0 28.4 Wealth quintile Lowest 0.0 12.5 12.5 37.6 48.9 66.8 32.0 Second 1.9 11.8 23.6 49.7 76.1 81.1 37.7 Middle 3.6 13.8 36.9 53.7 70.4 77.5 37.1 Fourth 0.9 16.7 47.5 72.2 84.0 90.0 37.3 Highest 2.2 29.3 53.1 78.7 82.0 88.8 38.0 Total 1.7 17.7 36.1 57.5 70.5 76.7 36.5 Note: Women who have been sterilised or who have stated their current method is male sterilisation are considered to want no more children. Total includes women with information missing on education who are not shown separately. 1 The number of living children includes current pregnancy. When the number of living children is taken into account, educational differences are more striking. For example, among women with three children, the percentage who want to limit childbearing increases from 24 percent among those with no education to 46 percent among women with secondary or higher education. A similar pattern is seen by wealth quintile. In general, women and men in the lowest wealth quintile are least likely to want to limit the number of children. 130 | Fertility Preferences Table 7.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Ghana 2008 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 0.0 3.8 29.1 44.7 64.9 62.1 57.2 32.1 Rural 0.0 3.3 15.3 25.8 41.9 42.7 56.5 30.1 Region Western 0.0 8.3 21.1 47.7 58.4 55.9 84.7 41.3 Central 0.0 0.0 30.8 20.5 55.1 78.4 66.4 37.9 Greater Accra 0.0 3.1 41.9 57.2 78.8 57.9 83.3 38.1 Volta 0.0 3.9 24.0 25.2 44.7 94.1 49.9 31.2 Eastern 0.0 0.0 28.6 31.7 62.4 39.8 62.7 39.3 Ashanti 0.0 5.5 16.9 42.1 49.9 53.5 73.9 33.4 Brong Ahafo 0.0 4.4 15.4 36.3 32.1 55.8 82.2 29.5 Northern 0.0 2.4 0.0 11.7 15.9 3.7 17.8 8.7 Upper East 0.0 1.9 3.5 6.3 32.6 33.2 38.2 17.5 Upper West 0.0 0.0 2.4 8.4 37.5 23.9 41.4 14.4 Education No education 0.0 0.5 10.0 9.4 31.3 23.2 39.7 20.2 Primary 0.0 0.0 21.6 29.6 43.0 37.7 51.8 29.3 Middle/ JSS 0.0 4.4 24.1 41.4 56.1 52.1 71.8 37.7 Secondary+ 0.0 4.7 26.4 40.8 64.6 88.2 57.2 29.3 Wealth quintile Lowest 0.0 3.2 8.6 15.2 25.2 21.5 33.0 18.9 Second 0.0 0.0 17.9 19.7 40.3 51.3 72.3 34.7 Middle 0.0 3.3 20.1 31.6 53.8 65.4 63.0 36.4 Fourth 0.0 3.7 21.4 41.7 65.9 65.5 66.1 31.6 Highest 0.0 5.5 34.0 52.1 67.5 62.1 66.2 33.8 Total 15-49 0.0 3.6 22.4 33.7 50.5 47.6 56.6 31.0 50-59 14.8 33.2 64.8 68.4 79.8 80.6 75.5 73.8 Total 15-59 0.4 4.4 26.5 37.6 56.4 57.1 64.8 39.1 Note: Men who have been sterilised or who state in response to the question about desire for children that their wife has been sterilised are considered to want no more children. Total includes men with information missing on education who are not shown separately. 1 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 7.2 NEED AND DEMAND FOR FAMILY PLANNING This section discusses the extent of the need for family planning in Ghana and the potential demand for contraception to space or limit childbearing. Currently married women who do not want any more children or who 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 a family planning method are said to have a met need for family planning. The total demand for family planning comprises women with unmet need and met need for family planning. Table 7.3 shows the need for family planning among currently married women by background characteristics. Thirty-five percent of married women have an unmet need for family planning. Unmet need for spacing is higher than unmet need for limiting children (23 and 13 percent, respectively). Overall, about one in four currently married women is using a method of contraception (12 percent for spacing births and 11 percent for limiting births). The total demand for family planning among women is 59 percent (35 percent for spacing births and 24 percent for limiting births). Only 40 percent of the demand for family planning is currently being met, which implies that the contraceptive needs of three-fifths of currently married women are not being met. Fertility Preferences | 131 Table 7.3 Need and demand for family planning: Currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and percentage with demand for contraception satisfied, by background characteristics, Ghana 2008 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 58.8 2.9 61.7 12.9 0.7 13.6 71.7 3.6 75.3 18.1 85 20-24 36.9 5.2 42.2 21.4 1.0 22.4 58.3 6.2 64.5 34.7 414 25-29 34.1 5.9 40.0 18.4 4.7 23.0 52.4 10.6 63.0 36.6 612 30-34 22.1 11.1 33.2 15.1 8.2 23.3 37.2 19.2 56.5 41.3 539 35-39 14.5 20.5 35.0 8.7 17.1 25.9 23.2 37.6 60.9 42.5 527 40-44 7.5 23.4 30.9 2.6 25.0 27.6 10.1 48.4 58.5 47.2 380 45-49 3.5 16.7 20.1 1.1 19.0 20.2 4.6 35.7 40.3 50.1 319 Residence Urban 19.4 12.9 32.3 13.8 13.3 27.1 33.3 26.2 59.4 45.6 1,216 Rural 24.7 12.8 37.6 11.1 9.8 20.9 35.8 22.6 58.4 35.7 1,660 Region Western 22.3 17.0 39.4 8.6 10.5 19.1 31.0 27.5 58.5 32.7 261 Central 33.8 15.9 49.7 10.4 12.5 22.9 44.3 28.4 72.6 31.6 254 Greater Accra 13.0 13.4 26.5 12.7 20.0 32.6 25.7 33.4 59.1 55.2 422 Volta 21.4 12.8 34.2 15.5 13.1 28.6 37.0 25.9 62.9 45.6 290 Eastern 22.5 17.1 39.6 10.0 14.2 24.2 32.6 31.3 63.9 37.9 252 Ashanti 22.7 13.8 36.5 15.8 11.2 27.0 38.5 25.0 63.5 42.6 542 Brong Ahafo 24.8 10.5 35.3 20.0 8.9 29.0 44.9 19.4 64.3 45.0 267 Northern 25.2 6.7 31.9 4.6 1.3 5.9 29.8 8.0 37.8 15.7 338 Upper East 22.7 9.4 32.1 7.2 7.4 14.7 29.9 16.8 46.7 31.4 168 Upper West 19.4 8.6 28.1 15.9 5.8 21.7 35.3 14.4 49.8 43.6 82 Education No education 22.3 12.8 35.1 5.7 7.9 13.6 27.9 20.7 48.6 27.9 853 Primary 25.1 15.9 41.0 16.0 10.6 26.6 41.1 26.5 67.6 39.4 638 Middle/ JSS 21.9 12.5 34.4 13.3 14.2 27.4 35.2 26.7 61.9 44.4 1,058 Secondary+ 20.0 8.3 28.3 18.8 11.6 30.4 38.8 19.9 58.6 51.8 325 Wealth quintile Lowest 25.6 10.6 36.2 7.5 6.7 14.2 33.1 17.4 50.5 28.2 573 Second 26.6 16.2 42.8 12.4 7.9 20.3 39.0 24.1 63.1 32.2 577 Middle 25.3 14.1 39.4 11.7 10.1 21.8 37.0 24.3 61.2 35.6 525 Fourth 20.9 14.0 34.9 15.1 13.9 29.0 36.0 27.9 64.0 45.4 600 Highest 14.6 9.5 24.2 14.4 17.0 31.4 29.0 26.6 55.6 56.5 601 Total 22.5 12.9 35.3 12.3 11.2 23.5 34.8 24.1 58.9 40.0 2,876 Note: Total includes women with information missing on education who are not shown separately. 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose current pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 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. 132 | Fertility Preferences A comparison of the findings from the 2003 and the 2008 GDHS surveys shows that there has been little change in unmet need for family planning among currently married women over the five- year period. Likewise, the total demand for family planning did not show any substantial change. There was, however, a decrease of three percentage points in the level of demand satisfied: from 43 percent in 2003 to 40 percent in 2008. Unmet need generally decreases with age; in Ghana, the sharpest declines are between the two youngest age groups (from 62 to 42 percent) and the two oldest age groups (from 31 to 20 percent). As can be seen in Table 7.3, younger women have a greater unmet need for spacing, while older women have a greater unmet need for limiting. Women in rural areas have a greater unmet need for family planning than their urban counterparts (38 percent, compared with 32 percent). It is also interesting to note that women in rural areas have higher unmet need for spacing than their urban counterparts. Unmet need is highest in the Central region (50 percent) and lowest in the Greater Accra region (27 percent). Not surprisingly, the percentage of demand satisfied is highest in Greater Accra (55 percent) and lowest in the Northern region (16 percent). With the exception of the Greater Accra region—where unmet need and met need for spacing are almost equal (13 percent)—unmet need for spacing is higher than the unmet need for limiting in all regions. Women with secondary or higher education have a lower level of unmet need for family planning (28 percent) than women with primary education (41 percent) or no education (35 percent). Total demand for family planning is highest for women with primary education (68 percent) and lowest for women with no education (49 percent). The percentage of demand satisfied ranges from 28 percent among women with no education to 52 percent among women with secondary or higher level education. Unmet need for family planning is highest among women in the second wealth quintile and lowest among women in the highest wealth quintile (43 and 24 percent, respectively). In all wealth quintiles, unmet need for spacing is higher than unmet need for limiting. Also, the percentage of demand satisfied ranges from 28 percent for women in the lowest wealth quintile to 57 percent for women in the highest wealth quintile. 7.3 IDEAL FAMILY SIZE Respondents were asked to consider a hypothetical situation independent of their current family size and to report the number of children they would choose to have. Information on what women and men believe to be the 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?” Nevertheless, even though these questions are based on hypothetical situations, they give an idea of the total number of children women who have not started childbearing will have in the future, while among older women and high parity women this information provides a measure of the level of unwanted fertility. Table 7.4 shows that 98 percent of women and 99 percent of men gave a numeric response to the questions on ideal number of children. Fertility Preferences | 133 Table 7.4 Ideal number of children Percent distribution of women and men age 15-49 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 2008 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 0.4 0.5 0.1 0.4 0.3 0.9 0.4 0.4 1 0.5 1.0 0.7 0.6 0.6 0.3 0.0 0.6 2 12.9 11.6 9.7 3.9 4.1 3.2 4.1 8.8 3 33.6 34.7 23.1 17.6 8.0 10.0 3.9 23.5 4 36.1 31.1 41.4 43.1 40.6 25.1 23.9 35.7 5 9.1 9.1 9.6 14.0 12.3 21.5 15.3 11.5 6+ 6.4 10.6 14.6 18.3 32.2 36.5 48.0 17.9 Non-numeric responses 1.0 1.4 0.9 2.1 1.9 2.7 4.4 1.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,591 749 728 589 507 341 412 4,916 Mean ideal number children for:2 All women 3.7 3.8 4.2 4.5 5.0 5.2 6.0 4.3 Number 1,576 738 721 577 497 332 394 4,835 Currently married women 3.5 3.9 4.2 4.5 5.0 5.3 6.1 4.6 Number 163 470 603 511 432 288 351 2,818 MEN3 0 0.4 0.0 0.2 0.4 0.6 0.0 0.3 0.3 1 0.7 0.7 1.9 0.3 0.0 0.5 0.6 0.7 2 12.1 16.1 11.3 4.3 4.1 3.0 1.3 10.0 3 29.9 35.0 21.5 19.3 11.6 9.5 6.7 24.7 4 31.9 29.0 36.3 36.2 30.8 14.4 18.7 30.7 5 13.0 9.1 15.9 16.9 15.0 22.3 8.4 13.5 6+ 11.5 9.6 12.2 21.5 36.6 47.4 60.7 19.1 Non-numeric responses 0.6 0.5 0.8 1.1 1.3 3.0 3.2 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,035 449 443 366 320 168 277 4,058 Mean ideal number children for men 15-49:2 All men 4.0 3.8 4.2 4.6 5.4 6.5 7.8 4.5 Number 2,023 446 440 362 316 163 268 4,018 Currently married men 4.1 3.9 4.2 4.6 5.4 6.5 7.9 5.1 Number 138 323 394 336 303 162 264 1,921 Mean ideal number children for men 15-59:2 All men 4.0 3.8 4.2 4.6 5.3 6.3 7.8 4.7 Number 2,027 456 483 404 390 229 467 4,512 Currently married 4.1 3.9 4.1 4.6 5.3 6.3 7.8 5.3 Number 142 333 438 378 377 228 463 2,360 1 The number of living children includes current pregnancy for women 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). The mean ideal number of children for all women age 15-49 is 4.3, while for men age 15-49 it is 4.5, indicating that men’s ideal number of children is slightly higher than women’s ideal number of children. Currently married women and currently married men prefer larger ideal family sizes (4.6 and 5.1, respectively) than all women and all men. There are two likely reasons for this pattern. First, to the extent that women and men are able to implement their fertility preferences, those who want smaller families will tend to achieve smaller families. At the same time, however, some women and men who already have children may find it difficult to say that they would have preferred to have had fewer children than they have. These women and men are likely to report the number of children they 134 | Fertility Preferences have as their preferred number of children. In general, women and men have similar patterns regarding ideal number of children. However, the percentages for women and men diverge after an ideal family size of three: 36 percent of all women consider four children as ideal, compared with 31 percent of all men. On the other hand 12 percent of women consider five children to be ideal, compared with 14 percent of men. The preference for a larger family size is higher for men than women, irrespective of the number of living children. The mean ideal number of children increases with the number of living children. Among all women, the ideal number of children ranges from 3.7 for those with no children to 6.0 for those with six or more children. As with women, the mean ideal number of children among all men increases with the number of children and ranges from 4.0 for those with no children to 7.8 for those with six or more children. The results of the GDHS surveys conducted over the past 20 years show that, although there has been an overall decline in ideal family size among currently married women— from a mean of 5.5 children in 1988 (GSS and MI, 1989) to 4.6 children in 2008—there has been little change in the past 15 years. And, while there appears to have been a slight increase in ideal family size among both women and men over the past ten years (GSS and MI, 1999), a downward trend can be seen in the five years preceding the survey. Table 7.5 shows the mean ideal number of children for all women by background characteristics. Ideal family size increases with age, from 3.8 children among women age 15- 24 to 5.3 children among women age 45-49. This pattern sug- gests a trend towards smaller family size. The ideal family size for women in rural areas is higher, compared to their urban counterparts. Mean ideal number of children is highest in the Northern region (6.6); women residing in the Greater Accra region have the lowest ideal family size (3.4). There are variations in mean ideal number of children by level of education: women with no education have the highest ideal number of children (5.8), while those with secondary or higher education have the lowest ideal number of children (3.4). A similar pattern is seen by wealth quintile, with women in the lowest wealth quintile wanting an ideal number of 5.8 children and those in the highest wealth quintile wanting 3.5 children. 7.4 FERTILITY PLANNING Women were asked a series of questions about all their children born in the five years preceding the survey, as well as any current pregnancy, to determine whether the pregnancy was planned, mistimed, or unwanted. The answers to these questions provide insight into the degree to which couples are able to control their fertility. 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 results show that 62 percent of births in the five years preceding the survey were planned Table 7.5 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Ghana 2008 Background characteristic Mean ideal number of children Number of women1 Age 15-19 3.8 1,014 20-24 3.8 875 25-29 4.0 814 30-34 4.6 634 35-39 4.6 626 40-44 5.0 457 45-49 5.3 416 Residence Urban 3.9 2,351 Rural 4.7 2,484 Region Western 4.2 447 Central 3.8 414 Greater Accra 3.4 843 Volta 4.2 426 Eastern 3.9 479 Ashanti 4.2 995 Brong Ahafo 4.2 424 Northern 6.6 448 Upper East 4.9 235 Upper West 5.7 122 Education No education 5.8 996 Primary 4.3 969 Middle/ JSS 3.9 2,025 Secondary+ 3.4 841 Wealth quintile Lowest 5.8 758 Second 4.6 882 Middle 4.2 969 Fourth 3.9 1,100 Highest 3.5 1,126 Total 4.3 4,835 Note: Total includes women with information missing on education who are not shown separately. 1 Number of women who gave a numeric response Fertility Preferences | 135 (wanted then) while 37 percent were unplanned―23 percent were mistimed (wanted later) and 14 percent were not wanted. The proportion of planned births increases from 57 percent for birth order one to 71 percent for birth order three, then decreases sharply for subsequent births. The proportion of mistimed births decreases with increasing birth order, and the proportion of unwanted births decreases between the first and second birth and then increases for subsequent births. A similar pattern is seen by women’s age, with mistimed births generally decreasing as age increases. The proportion of births that were not wanted declines among women in their 20s and then increases with age. One in four births to women in their 40s was not wanted. Table 7.6 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Ghana 2008 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 57.2 27.7 15.0 0.0 100.0 781 2 68.0 25.9 5.8 0.3 100.0 700 3 70.5 19.4 9.5 0.6 100.0 556 4+ 58.6 20.3 20.5 0.6 100.0 1,232 Mother’s age at birth <20 41.2 38.9 19.9 0.0 100.0 369 20-24 59.4 29.6 10.5 0.5 100.0 846 25-29 69.3 22.6 7.9 0.1 100.0 825 30-34 70.0 14.5 14.6 0.9 100.0 664 35-39 62.2 16.4 21.0 0.4 100.0 371 40-44 58.5 9.0 32.1 0.4 100.0 170 45-49 (65.0) (8.2) (26.9) (0.0) 100.0 24 Total 62.3 23.1 14.2 0.4 100.0 3,269 Note: Figures in parentheses are based on 25-49 unweighted cases. The proportion of unplanned births decreased from 42 percent in 1993 to 36 percent in 1998 but increased to 40 percent in 2003. Unplanned births decreased again to 37 percent in 2008. Although the proportion of unwanted births increased markedly from the 1993 and 1998 level of 9 percent to 16 percent in 2003, it had decreased to 14 percent in 2008. Table 7.7 provides information on total “wanted” fertility rates and total fertility rates for the three years preceding the survey, by 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 comparison of the total wanted fertility and total fertility rate suggests the potential demographic impact of the elimination of unwanted births. The total wanted fertility rate, which was 4.2 in 1993, fell to 3.7 in 1998 and remained at 3.7 in 2003. In the three years preceding the 2008 GDHS, the total wanted fertility rate had declined to 3.5. During the same period, the total fertility rate fell from 5.2 children per woman in 1993 to 4.4 in 1998, remained unchanged at 4.4 in 2003 and decreased to 4.0 in 2008. 136 | Fertility Preferences The wanted fertility rate in rural areas is 1.5 children more than in urban areas (4.2 and 2.7, respectively). The gap between wanted and actual fertility in rural areas is larger than in urban areas, suggesting that urban women may be better able to translate their ideal family size into their actual family size. At the regional level, women in the Greater Accra region want the fewest children (2.2) while women in the Northern region want the most children (6.3). However, the Upper West region has the smallest gap between desired and actual fertility (0.2), while the Central region has the largest gap (about 1.1 children), which suggests that women in the Central region are less able to translate their desired family size into practice. Women’s education has an inverse relationship with fertility, with the largest gap between wanted and actual fertility (0.7 children) observed for those with no education and those with primary education. There is also an inverse relationship between women’s wealth status and fertility, with the largest gap between wanted and actual fertility (0.8 children) observed for those in the lowest quintile and second quintile. Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three-year period preceding the survey, by background characteristics, Ghana 2008 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 2.7 3.1 Rural 4.2 4.9 Region Western 3.4 4.2 Central 4.3 5.4 Greater Accra 2.2 2.5 Volta 3.4 3.8 Eastern 3.0 3.6 Ashanti 3.0 3.6 Brong Ahafo 3.6 4.1 Northern 6.3 6.8 Upper East 3.6 4.1 Upper West 4.8 5.0 Education No education 5.3 6.0 Primary 4.2 4.9 Middle/ JSS 2.9 3.5 Secondary+ 1.8 2.1 Wealth quintile Lowest 5.7 6.5 Second 4.1 4.9 Middle 3.3 4.0 Fourth 3.0 3.4 Highest 2.0 2.3 Total 3.5 4.0 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. Total includes women with information missing on education who are not shown separately. Infant and Child Mortality | 137 INFANT AND CHILD MORTALITY 8 This chapter presents estimates on levels, trends, and differentials in neonatal, post-neonatal, infant, child, and under-five mortality in Ghana. The information used to measure these childhood mortality rates was collected from the birth history section of the Women’s Questionnaire. Women of reproductive age (15-49) were asked a series of questions including, the number of biological sons and daughters living with them, the number living elsewhere, and the number who have died. In addition, for each live birth, women were asked to provide information on the sex, date of birth, whether the birth was single or multiple, and the survival status of the child. Current age was collected for living children, and age at death was collected for dead children. Infant and child mortality rates are basic indicators of a country’s socio-economic situation and quality of life, as well as specific measures of health status. Measures of childhood mortality are also useful in population projections and monitoring and evaluating population and health pro- grammes and policies. Characteristics of childhood mortality such as age patterns and socio-economic and demographic differentials are used to highlight factors that have positive or negative impacts on child survival. Analysis of mortality measures is useful in identifying promising directions for health programmes and improving child survival efforts in Ghana. 8.1 DEFINITION, DATA QUALITY, AND METHODOLOGY Childhood mortality estimates in DHS surveys measure the risk of dying from birth through 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 Post-neonatal 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 age 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 age 12 months. The reliability of mortality estimates depends on the sampling variability of the estimates and on non-sampling errors. Sampling errors for the 2008 GDHS are presented in Appendix B. Non- sampling 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 2008 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 post-neonatal period, as well 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 or one year. This ‘heaping’ took place despite the care taken in the GDHS to minimise errors of this type by requiring that age at death be recorded in days if the death took place within one month of birth, in months if the child died within 24 months of birth, and in 138 | Infant and Child Mortality years if the child died between age 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 2008 GDHS, the cut-off date for asking health questions was 2003, that is, for births since January 2003. An examination of Table C.4 suggests that there is evidence of misreporting of dates of birth for both living and dead children. The calendar year ratios for living and dead children are 74 and 76 percent, respectively, for 2003, compared with 128 and 135 percent, respectively, in 2002. The deficit in calendar year 2003 is believed to be the result of some interviewers increasing children’s ages to avoid having to collect their health information. This transference of children (especially dead 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 2004 for births of children who have died that is more severe than the heaping in 2002. 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. 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 children who died immediately after birth than among those who lived longer, and that omission will be more serious for events that took place in the distant past than for those in the recent past. Table C.5 shows that the percentage of early neonatal deaths ranges from 81 percent for the period 10-14 years preceding the survey to 85 percent for the period 0-4 years before the survey. These results are similar to the results from the 1988 GDHS (GSS and MI, 1998) and the 2003 GDHS (GSS and ORC Macro, 2004). Similarly, Table C.6 shows that neonatal deaths comprise 59 to 64 percent of all infant deaths. These figures are considered plausible.1 Over time, the figures vary within a narrow range for the 20 years preceding 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 periods 0-4, 5-9, and 10- 14 years before the survey. In fact, except for the first period (0-4 years), the others are slightly biased estimates because they are based on the child mortality experiences of women age 15-44 and 15-39, respectively, instead of women age 15-49 as in the period 0-4 years preceding the survey. Therefore, estimating mortality for periods more than 10-15 years before the survey is not advisable. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 presents mortality rates for cohorts of children born in three five-year periods preceding the survey. Under-five mortality in Ghana is 80 deaths per 1,000 live births in the most recent five-year period. This means one in every thirteen Ghanaian children dies before the fifth birthday. Infant mortality is 50 deaths per 1,000 live births and child mortality is 31 deaths per 1,000 children age one year. Neonatal mortality is 30 deaths per 1,000 live births in the most recent five- year period, while the risk of post-neonatal mortality is 21 deaths per 1,000 live births. Neonatal deaths account for 60 percent of the deaths in infancy. 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 | 139 Table 8.1 Early childhood mortality rates Neonatal, post-neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Ghana 2008 Years preceding the survey Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 30 21 50 31 80 5-9 35 22 57 35 90 10-14 35 27 61 46 105 1 Computed as the difference between the infant and neonatal mortality rates Trends in mortality 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 because sampling errors associated with mortality estimates are large. Data from the 2008 GDHS show that infant mortality has declined from 61 deaths per 1,000 live births in the period 10-14 years before the survey to 50 deaths per 1,000 live births in the period 0-4 years before the survey. Over the same period, child mortality declined from 46 deaths per 1,000 children to 31 deaths per 1,000 children, and under-five mortality declined from 105 deaths per 1,000 live births to 80 deaths per 1,000 live births. Neonatal mortality declined slightly, from 35 deaths per 1,000 live births in the period 5-14 years preceding the survey to 30 deaths per 1,000 live births in the period 0-4 years before the survey. Post-neonatal mortality also fell slightly from 27 deaths per 1,000 live births in the period 10-14 years preceding the survey to 21 deaths per 1,000 live births in the period 0-4 years before the survey. Results from the five GDHS surveys (conducted in 1988, 1993, 1998, 2003, and 2008) show a marked decline in childhood mortality over the past 20 years (Figure 8.1). This decline appeared to have halted during the period 1999-2003 but then declined further during the past five years from 2003 to 2008. For example the infant mortality rate has declined from 64 per 1,000 for the 0-4 years preceding the 2003 GDHS to 50 per 1,000 during the same period prior to the 2008 GDHS. This is caused principally by a decrease in the neonatal mortality rate from about 43 per 1,000 for the 0-4 years preceding the 2003 GDHS to 30 per 1,000 during the same period prior to the 2008 GDHS. Similarly, under-five mortality rate decreased from 111 per 1,000 for the 0-4 years preceding the 2003 GDHS to 80 per 1,000 during the same period prior to the 2008 GDHS. 77 84 155 41 26 66 57 119 30 27 57 54 108 43 21 64 50 111 30 21 50 31 80 Neonatal Post-neonatal Infant Child Under-five Mortality rate 0 20 40 60 80 100 120 140 160 Deaths per 1,000 live births 1983-1987 1989-1993 1994-1998 1999-2003 2004-2008 Figure 8.1 Mortality Trends, Ghana 1988-2008 140 | Infant and Child Mortality The under-five mortality rate for the period 5-9 years before the 2008 GDHS (90) is slightly lower than rate for the 0-4 years before the 2003 GDHS (111), while the under-five mortality rate for the period 10-14 years before the 2008 GDHS (105) is nearly identical to the rate for 5-9 years before the 2003 GDHS (108). Similarly, infant mortality rate for the period 5-9 years before the 2008 GDHS (57) is slightly lower than rate for the 0-4 years before the 2003 GDHS (64), while the under-five mortality rate for the period 10-14 years before the 2008 GDHS (61) is close to the rate for 5-9 years before the 2003 GDHS (65) (GSS and ORC Macro, 2004). The decline in both infant and under-five mortality in the five years preceding the 2008 GDHS indicates that the targets set by the Ghana Poverty Reduction Strategy—an infant mortality rate of 50 per 1,000 and an under-five mortality rate of 95 per 1,000 by 2005 (World Bank, 2003)— have been achieved and the Millennium Development Goals’ target for childhood mortality is on track. 8.3 SOCIO-ECONOMIC DIFFERENTIALS IN MORTALITY Child survival is closely related to socio-economic and demographic characteristics of mothers and children. Table 8.2 shows differentials in childhood mortality by four socio-economic variables: residence, region, mother’s education, and household wealth status (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 were calculated for a ten-year period. Mortality levels in rural areas are consistently higher than those in urban areas. In the ten-year period before the survey, infant mortality in rural areas was 56 deaths per 1,000 live births, compared with 46 deaths per 1,000 live births in urban areas. The under-five mortality rate during the same period was 90 deaths per 1,000 live births in rural areas and 75 deaths per 1,000 live births in urban areas. Table 8.2 Early childhood mortality rates by socio-economic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Ghana 2008 Background characteristic Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 30 19 49 27 75 Rural 34 23 56 36 90 Region Western 40 11 51 (14) (65) Central (47) (26) (73) (38) (108) Greater Accra 21 (15) (36) (14) (50) Volta 26 (11) (37) (13) (50) Eastern 29 (25) (53) (30) (81) Ashanti 35 19 54 28 80 Brong Ahafo 27 (10) (37) (41) (76) Northern 35 35 70 72 137 Upper East (17) (30) (46) (33) (78) Upper West 45 52 97 (50) (142) Mother’s education No education 38 23 61 44 102 Primary 35 20 55 35 88 Middle/JSS 23 23 46 23 68 Secondary+ (38) (11) (49) (15) (64) Wealth quintile Lowest 31 28 59 47 103 Second 27 18 45 35 79 Middle 44 26 70 34 102 Fourth 31 14 45 25 68 Highest 31 16 46 14 60 Note: Numbers in parentheses are based on 250-499 unweighted exposed persons; an asterisk indicates that a rate is based on fewer than 250 unweighted exposed persons and has been suppressed. 1 Computed as the difference between the infant and neonatal mortality Infant and Child Mortality | 141 Differences in mortality by region are marked. The infant mortality rate varies from 36 deaths per 1,000 live births in Greater Accra to 97 deaths per 1,000 live births in the Upper West region. Differentials in under-five mortality show a similar pattern. For example, under-five mortality ranges from a low of 50 deaths per 1,000 live births in the Greater Accra and Volta regions to a high of 142 and 137 deaths per 1,000 live births in the Upper West and the Northern regions, respectively. These estimates should be interpreted with caution because of the small number of exposed persons they are based on. As expected, mother’s education is inversely related to a child’s risk of dying. Under-five mortality among children of mothers with no education (102 deaths per 1,000 live births) is substantially higher than under-five mortality among children of women with middle/JSS level education (68 deaths per 1,000 live births). The direct association between level of education and under-five mortality is also seen in infant mortality. Children of women with no education (61 deaths per 1,000 live births) are much more likely to die in the first year than children of women with middle/JSS education (46 deaths per 1,000 live births). Children in households in the highest wealth quintile have the lowest mortality rates for both child mortality and under-five mortality. Infant mortality is lowest among children in the second, fourth, and fifth wealth quintiles. 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 child, age of mother at birth, birth order, length of preceding birth interval, and size of child at birth. Table 8.3 shows the relationship between childhood mortality and these demographic variables. Again, for all variables except birth size, mortality estimates are calculated for the ten-year period preceding the survey to reduce sampling variability. Mortality rates by birth size are for the five-year period preceding the survey because information on birth size was collected only for children born in the past five years. Childhood mortality is higher for males than females (Table 8.3). Under-five mortality rates for male and female children are 93 and 76 deaths per 1,000 live births, respectively. The excess mortality among male children is most likely due to their higher biological risk during the first month of life. Findings from the World Fertility Survey and DHS surveys indicate that births to young mothers (under age 20 years) and older mothers (35 years and over) are at an elevated risk of dying. Results from the 2008 GDHS confirm the expected curvilinear relationship between mother’s age at birth and childhood mortality. First births and higher-order births typically have an elevated risk of dying. Results from the 2008 GDHS generally confirm this pattern. With the exception of child mortality, births of order four 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. This is particularly the case when the birth interval is less than two years. The results of the GDHS 2008 indicate that this pattern holds for all levels of childhood mortality except post-neonatal mortality. For example, under-five mortality among children born less than two years after a previous birth is more than twice the mortality among children born after an interval of four years or more. 142 | Infant and Child Mortality A child’s size at birth has often been found to be an important indicator of the chances of survival during infancy. The majority of births in Ghana take place outside of a health facility setting, and these babies are seldom weighed at birth. The mother’s assessment of the size of the baby at birth is used as a proxy for birth weight. The GDHS results indicate that among babies assessed by their mother as ‘small or very small,’ infant mortality is twice the level observed for babies assessed as ‘average or larger’ at birth. The difference in infant mortality between the two groups is largely attributed to neonatal mortality, which is almost twice as high among small or very small babies as among average or larger babies. Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Ghana 2008 Demographic characteristic Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Sex of child Male 36 22 58 38 93 Female 29 20 49 28 76 Mother’s age at birth <20 43 26 69 43 109 20-29 28 19 46 28 73 30-39 35 25 60 37 95 40-49 (40) * * * * Birth order 1 35 18 52 33 84 2-3 24 24 48 29 75 4-6 36 18 54 38 90 7+ 49 31 80 (33) (110) Previous birth interval2 <2 years 60 28 88 47 131 2 years 24 30 53 35 86 3 years 30 26 56 29 83 4+ years 23 11 33 25 58 Birth size3 Small/very small (49) (35) (84) * * Average or larger 25 17 42 * * Note: Numbers in parentheses are based on 250-499 unweighted exposed persons; an asterisk indicates that a rate is based on fewer than 250 unweighted exposed persons and has been suppressed. 1 Computed as the difference between the infant and neonatal mortality 2 Excludes first-order births 3 Rates are for the five-year period preceding the survey 8.5 PERINATAL MORTALITY The perinatal mortality rate serves as a good indicator of the state of health of a population generally, and at delivery in particular. It reflects the level of utilisation of health services and the ability of women to cope with the demands of childbirth, to deliver a healthy baby. Women in the 2008 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 among live births that occurred 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 infant deaths that occurred within the first week of life is highly susceptible to omission and misreporting. However, retrospective surveys such as the 2008 GDHS generally provide more representative and accurate perinatal death rates than the vital registration system. Infant and Child Mortality | 143 Table 8.4 shows that out of the 2,949 reported pregnancies of at least seven months’ gestation, 40 were stillbirths and 75 were early neonatal deaths, yielding an overall perinatal mortality rate of 39 per 1,000 pregnancies of 7 months or more duration. Perinatal mortality is highest among mothers age 30-39 (45 per 1,000 pregnancies) and lowest among mothers age 20-29 (33 per 1,000 pregnancies). Table 8.4 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 2008 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 6 9 (44) 339 20-29 18 33 33 1,511 30-39 15 27 45 933 40-49 1 7 * 166 Previous pregnancy interval in months4 First pregnancy 13 15 43 649 <15 2 7 * 119 15-26 4 19 45 523 27-38 6 12 30 586 39+ 16 22 35 1,072 Residence Urban 12 26 34 1,116 Rural 28 49 42 1,834 Mother’s education No education 10 25 37 962 Primary 13 20 44 735 Middle/JSS 13 25 39 983 Secondary+ 4 5 (36) 267 Wealth quintile Lowest 8 17 33 752 Second 4 13 27 646 Middle 10 24 61 559 Fourth 7 13 36 568 Highest 11 8 (44) 425 Total 40 75 39 2,949 Note: Figures in parentheses are based on 250 to 499 unweighted pregnancies of 7+ months duration. An asterisk indicates that a figure is based on fewer than 250 unweighted pregnancies of 7+ months duration and has been suppressed. Total includes 3 weighted pregnancies with information missing on maternal education. 1 Stillbirths are foetal 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, expressed per 1000. 4 Categories correspond to birth intervals of <24 mos., 24-35 mos., 36-47 mos., and 48+ mos. Perinatal mortality is highest when the previous pregnancy interval is 15 to 26 months (45 per 1,000 pregnancies). Perinatal mortality is also higher among women in rural areas than those in urban areas (42 and 34 per 1,000 pregnancies, respectively). There is no clear relationship between perinatal mortality and women’s level of education or household wealth status. 144 | Infant and Child Mortality 8.6 HIGH-RISK FERTILITY BEHAVIOUR The survival of infants and children depends in part on the demographic and biological characteristics of their mothers. These characteristics are of particular importance because many health problems 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 8.5 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. Table 8.5 shows the percentage of births in the five years preceding the survey that fall into the various risk categories. Exactly half (50 percent) of births in Ghana have elevated mortality risks that are avoidable, and about three in ten (31 percent) are not in any high-risk category. Among those who are at risk, 31 percent of births are in a single high-risk category, while 19 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. Table 8.5 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 2008 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high-risk category 30.8 1.00 20.5a Unavoidable risk category First-order births between ages 18 and 34 19.6 1.22 6.3 Single high-risk category Mother’s age <18 4.2 1.13 0.3 Mother’s age >34 1.8 1.26 6.3 Birth interval <24 months 5.1 0.99 8.9 Birth order >3 19.6 1.03 11.6 Subtotal 30.6 1.05 27.2 Multiple high-risk category Age <18 and birth interval <24 months2 0.2 * 0.1 Age >34 and birth interval <24 months 0.1 * 0.5 Age >34 and birth order >3 13.4 1.67 31.0 Age >34 and birth interval <24 months and birth order >3 1.8 2.45 5.5 Birth interval <24 months and birth order >3 3.5 2.80 9.0 Subtotal 19.0 2.02 46.1 In any avoidable high-risk category 49.7 1.42 73.3 Total 100.0 na 100.0 Number of births/women 2,909 na 2,876 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilised women Infant and Child Mortality | 145 The most vulnerable births are those to women who are age 35 or older, with a birth interval less than 24 months. These children are eight times more likely to die than children not in any high- risk category. Twenty percent of births occur to mothers who have three or more births, and another 13 percent of births occur to mothers who are 35 years or older and have had three or more children. These children whose mothers are 35 years or older and have had three or more children are about two times more likely to die than children with no risk. The final column of Table 8.5 shows the distribution of currently married women who have the potential for having a high-risk birth, by category of risk. Thirty-one percent of these women are (or would be) too old and have (or would have) too many children. The potential for having a birth in a multiple high-risk category is much higher (46 percent) than the potential for having a birth in a single high-risk category (27 percent). Maternal Health | 147 MATERNAL HEALTH 9 The health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. This chapter presents findings on several areas related to maternal health—antenatal, delivery, and postnatal care—as well as problems in accessing care. These findings are important for designing appropriate strategies and interventions to improve maternal and newborn health care services. 9.1 ANTENATAL CARE 9.1.1 Antenatal Care Coverage The major objective of antenatal care is to identify and treat problems during pregnancy such as anaemia and infections. It is during an antenatal care visit that screening for complications and advice on a range of issues including birth preparedness, place of delivery, and referral of mothers with complications occur. Information on antenatal care is of great value in identifying subgroups of women who do not use such services and is useful in planning improvements in the services. The antenatal care findings from the 2008 Ghana Demographic and Health Survey (GDHS) provide information on the type of service provider, the number of antenatal care visits, the stage of pregnancy at the time of the first visit, and the services and information provided during antenatal care, including whether tetanus toxoid was received. Table 9.1 presents the percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by the type of antenatal care provider consulted during the pregnancy for the most recent birth, according to background characteristics. If a woman received antenatal care from more than one provider, the provider with the highest qualifications was recorded. Since the last survey in 2003, the Ghana Health Service has included another category of health care providers (community health officers) within the health care delivery system. Community health officers provide services in the community-based health planning and services (CHPS) compounds. Services received from community health officers are included in the 2008 GDHS. The survey shows that over nine in ten mothers (95 percent) receive antenatal care from a health professional (doctor, nurse, midwife, or community health officer). Almost no mothers receive antenatal care from a traditional midwife, and 4 percent of mothers do not receive any antenatal care. Differences in antenatal care coverage by women’s age at birth are not large; however, there are some differences by birth order. Mothers in Ghana are somewhat more likely to receive antenatal care from a health professional for the first birth (99 percent) than for births of order six or higher (92 percent). There are some differences in the use of antenatal care services between women in urban and rural areas. Health professionals provide antenatal care services for 98 percent of mothers in urban areas, compared with 94 percent of mothers in rural areas. The vast majority of mothers receive antenatal care services from health professionals regardless of region of residence (96-98 percent); however, mothers in the Volta and Central regions are less likely than other women to have access to antenatal care (91 and 92 percent, respectively). 148 | Maternal Health Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth, and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Ghana 2008 Background characteristic Doctor Nurse/ midwife Auxiliary midwife Com- munity health officer Tradi- tional birth attendant (trained) Tradi- tional birth attendant (un- trained) Other No one Missing Total Percentage receiving antenatal care from a skilled provider1 Number of women Mother’s age at birth <20 16.1 67.5 6.6 7.1 0.0 0.0 0.5 2.3 0.0 100.0 97.3 214 20-34 24.6 63.6 2.6 4.6 0.2 0.1 0.7 3.4 0.1 100.0 95.5 1,475 35-49 23.1 59.5 4.4 7.3 0.2 0.0 0.9 4.4 0.2 100.0 94.3 410 Birth order 1 26.6 63.8 4.1 4.0 0.0 0.0 0.0 1.5 0.0 100.0 98.5 467 2-3 26.1 62.3 2.6 4.4 0.3 0.2 0.5 3.5 0.0 100.0 95.5 786 4-5 22.6 63.8 2.4 6.3 0.3 0.1 1.3 3.0 0.3 100.0 95.0 498 6+ 14.5 63.6 5.5 8.2 0.3 0.0 1.3 6.5 0.2 100.0 91.8 348 Residence Urban 33.9 60.1 2.0 1.8 0.3 0.0 0.3 1.4 0.2 100.0 97.8 844 Rural 16.4 65.3 4.3 7.8 0.2 0.1 1.0 4.8 0.1 100.0 93.9 1,255 Region Western 12.4 74.6 5.8 2.9 0.0 0.0 0.0 4.3 0.0 100.0 95.7 189 Central 17.2 74.1 1.1 0.0 0.7 0.0 2.3 3.8 0.8 100.0 92.4 200 Greater Accra 47.6 46.9 1.3 0.0 0.8 0.5 0.7 2.3 0.0 100.0 95.7 262 Volta 17.1 53.9 10.4 9.6 0.0 0.0 0.0 8.9 0.0 100.0 91.1 181 Eastern 41.0 52.1 0.0 2.9 0.5 0.2 0.3 2.9 0.0 100.0 96.0 185 Ashanti 27.0 68.6 1.4 0.3 0.0 0.0 0.6 2.2 0.0 100.0 97.3 396 Brong Ahafo 14.5 75.8 5.8 0.3 0.0 0.0 1.1 2.4 0.0 100.0 96.4 218 Northern 13.5 56.5 4.4 21.2 0.0 0.0 1.1 3.3 0.0 100.0 95.6 291 Upper East 14.3 67.9 0.7 12.9 0.0 0.0 0.0 3.7 0.6 100.0 95.7 119 Upper West 14.0 67.0 6.5 10.1 0.0 0.0 0.0 2.4 0.0 100.0 97.6 58 Mother’s education No education 11.4 66.1 4.4 11.6 0.1 0.1 1.2 5.0 0.1 100.0 93.5 647 Primary 21.3 64.4 3.7 4.1 0.5 0.3 0.7 4.7 0.3 100.0 93.5 511 Middle/JSS 28.2 64.5 2.9 2.0 0.1 0.0 0.5 1.9 0.0 100.0 97.6 738 Secondary+ 50.2 46.2 1.3 1.3 0.0 0.0 0.0 1.1 0.0 100.0 98.9 201 Wealth quintile Lowest 9.5 62.2 6.0 14.8 0.2 0.1 1.3 5.8 0.1 100.0 92.5 480 Second 17.3 65.9 4.4 5.6 0.3 0.3 1.0 5.1 0.0 100.0 93.2 461 Middle 21.0 71.2 1.3 2.6 0.3 0.0 0.5 3.1 0.0 100.0 96.1 400 Fourth 28.2 65.9 2.8 0.8 0.2 0.0 0.4 1.7 0.0 100.0 97.7 436 Highest 49.7 47.3 1.4 0.7 0.0 0.0 0.0 0.4 0.5 100.0 99.1 322 Total 23.5 63.2 3.4 5.4 0.2 0.1 0.7 3.5 0.1 100.0 95.4 2,099 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Total includes cases with information missing on mother’s education 1 Skilled provider includes doctor, nurse, midwife, auxiliary midwife, and community health officer The proportion of women receiving no antenatal care declined slightly from 6 percent in 2003 to 4 percent in 2008. In the Volta region, however, about one in 10 pregnant women did not receive any antenatal care in the five years preceding the survey (as in the previous survey of 2003). The availability of community health officers has substantially increased access to professional care for women during the antenatal period in the three northern regions and, consequently, reduced the proportion of women who receive no antenatal care. For instance, 16 percent of women received no antenatal care in the Northern region in 2003, compared with just 3 percent in 2008. The same trend is seen in the Upper East and Upper West regions, where the percentage of women receiving no antenatal care dropped from 14 and 9 percent, respectively, in 2003 to 4 and 2 percent, respectively, in 2008. According to the survey results, the use of antenatal care services is related to women’s educational level. Almost all mothers with at least some secondary education receive prenatal care services from a health professional, compared with 94 percent of mothers with primary or no Maternal Health | 149 education. There is also a positive relationship between professional antenatal care coverage and wealth quintile, with women in the highest wealth quintile more likely to receive care from a health professional than those in the lowest wealth quintile, although the difference is small (99 and 93 percent, respectively). Midwives and other mid-level providers make up the largest proportion of health professionals providing antenatal care in all regions except in the Greater Accra region, where antenatal care provided by midwives and other mid-level providers is almost equal to that provided by doctors. Although doctors tend to provide antenatal care for wealthier and more educated women, it is gratifying to note that the majority of women have access to professional care during pregnancy. The results indicate that there has been a marked improvement in antenatal care coverage in Ghana over the past 20 years. In 1988, 82 percent of mothers received antenatal care for all births in the five years preceding the survey, compared with 95 percent of mothers in 2008 for their most recent birth (Figure 9.1). Figure 9.1 Trends in Maternity Care Indicators Ghana 1988-2008 82 70 40 86 77 44 89 81 44 92 84 47 95 88 59 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 2008 Note: Data for 1988, 1993, and 1998 are with reference to births, whereas data for antenatal care and tetanus toxoid for 2003 and 2008 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. In the 2008 GDHS, a skilled provider includes a doctor, nurse, midwife, auxiliary midwife, and a community health officer, while in all previous surveys a community health officer was not included. 9.1.2 Number and Timing of Antenatal Care Visits Antenatal care is more beneficial in preventing adverse outcomes when it is sought early in the pregnancy and is continued through to delivery. Under normal circumstances, the World Health Organisation (WHO) recommends that a woman without complications have at least four antenatal care visits, the first of which should take place during the first trimester. Table 9.2 presents information on antenatal care visits including the number of visits and the timing of the first visit. In Ghana, there is an increasing trend among pregnant women to have four or more antenatal care visits. Among women age 15-49 years who had a live birth in the five years preceding the survey, about four in five (78 percent) pregnant women had four or more antenatal care visits for the most recent live birth. This is an increase over the 2003 survey when about seven in ten (69 percent) pregnant women had four or more visits during their pregnancy. Although women in urban areas are more likely than women in rural areas to make four or more antenatal care visits, the increase between 2003 and 2008 was larger for women in rural areas (from 61 to 72 percent) than for women in urban areas (from 84 to 88 percent). 150 | Maternal Health Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Ghana 2008 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 1.4 4.8 3.5 1 1.2 3.8 2.8 2-3 6.8 17.7 13.3 4+ 88.1 71.5 78.2 Don’t know/ missing 2.5 2.2 2.3 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.4 4.8 3.5 <4 61.3 50.8 55.0 4-5 30.0 33.2 31.9 6-7 5.8 9.4 8.0 8+ 0.8 1.2 1.1 Don’t know/missing 0.6 0.5 0.6 Total 100.0 100.0 100.0 Number of women 844 1,255 2,099 Median months pregnant at first visit (for those with ANC) 3.7 3.9 3.8 Number of women with ANC 830 1,194 2,024 There is also an increasing trend for women to have their first antenatal care visit before the fourth month of pregnancy (55 percent in 2008, compared with 46 percent in 2003), and the urban- rural gap is narrowing. Sixty-one percent of women in urban areas and 51 percent of women in rural areas had their first antenatal visit before their fourth month of pregnancy (56 and 41 percent, respectively, in 2003) while 30 percent of women in urban areas and 33 percent of women in rural areas have their first visit between the fourth and fifth month of pregnancy (34 and 35 percent, respectively, in 2003). Among women who received antenatal care, the median number of months pregnant at first visit is 3.7 months for women in urban areas, and 3.9 months for women in rural areas, compared with 3.8 and 4.2 months, respectively, in 2003. 9.1.3 Components of Antenatal Care The quality of antenatal care is measured to a large extent by the essential service package provided to pregnant women. The components of this package include prevention and management of anaemia and malaria, which are achieved through screening and appropriate management. Micronutrient supplementation, tetanus immunisation, and monitoring of certain vital signs to help in the early detection and management of complications that may arise are also included in this important care package. Pregnancy complications are a primary source of maternal and newborn morbidity and mortality. Therefore, ensuring that pregnant women receive information on the signs of complications is an important component of antenatal care. To help assess antenatal care services, respondents were asked whether they had been advised of possible pregnancy complications and whether they had received certain screening tests during at least one of their antenatal care visits. Caution should be used in considering this information on the components of antenatal care because it is dependent on pregnant women’s recall of events during antenatal care that may have taken place a number of years before the interview. Nevertheless, the results are useful in providing insights into the content of antenatal care. Maternal Health | 151 Table 9.3 presents information on the percentage of pregnant women who took iron tablets or syrup, were informed of the signs of pregnancy complications, and received selected services during antenatal care visits for their most recent birth in the past five years. Information on pregnant women who took malaria preventive treatment is covered in Chapter 12. The data show that irrespective of whether women attended an antenatal clinic or not, the vast majority (87 percent) of women with a recent birth took iron supplements during pregnancy, but only 35 percent took de-worming medicine during the pregnancy. Although pregnant women are generally cautioned to take medication only on the advice of a health professional, the taking of supplements appears to be a good practice for women in their childbearing years, in view of the relatively high levels of anaemia in pregnant women. De-worming, which is also one of the anaemia-prevention strategies, is done with caution, especially in pregnant women, because of the possible side effects particularly when taken in early pregnancy. In accordance with policy, health professionals prescribe de-worming tablets for pregnant women either based on laboratory findings or the prevalence of the parasites in a specific locality. Variation in iron supplementation by age of woman at birth is minimal. However, there is a slight decrease in the proportion of women who take iron supplements as birth order increases. Substantial variations in use of iron supplements are noted by urban-rural residence, region, education, and wealth quintile. For example, 90 percent of women in urban areas took iron tablets or syrup during pregnancy, compared with 84 percent of women in rural areas. Women in the Greater Accra, Western and Ashanti regions, those who are better educated, and those living in wealthier households are much more likely than other women to have taken iron supplements during pregnancy. Women in the Northern and Upper West regions are the least likely to have taken iron supplements during pregnancy. Women in the Greater Accra are the least likely to have taken de-worming medicine during pregnancy. The proportion of women who undergo basic tests during pregnancy is nearly universal throughout Ghana: virtually all women who gave birth in the five years preceding the 2008 GDHS reported that, for the most recent birth, they were weighed and had their blood pressure measured; about 90 percent of mothers had a blood sample taken and had their urine tested. On the other hand, just over two-thirds (68 percent) of these women were informed of the signs of pregnancy complications. The likelihood of receiving the information about the signs of pregnancy complications is related to women’s level of education, household wealth status, age, residence (urban-rural), and region. For instance, women with middle/JSS and secondary and higher education, women in the highest wealth quintile, and women living in urban areas are more likely than other women to be informed about pregnancy complications. The proportion of women who reported that they received information about complications increases with age, with women under age 20 being least likely to receive this information. Regional differences in the receipt of information about pregnancy are especially marked. For example, about four in five women (85 percent) in the Volta region were informed about the signs of complications, compared with about two in five women (46 percent) in the Northern region. The findings from the 2008 GDHS indicate that there has been only a slight increase in the quality of antenatal care, compared with the previous survey. One area of antenatal care that needs strengthening is providing information on the signs of pregnancy complications. Another area that needs strengthening is access to basic laboratory services such as urine and blood testing in the Northern and Upper West regions; these two regions are disproportionately affected by limited access to these components of antenatal care. For instance, while at the national level access to urine and blood testing for pregnant women is 90 percent, only six in ten pregnant women in the Northern region have access to these components of care, and in the Upper West region, about two in three pregnant women have access to urine testing and three in four have access to blood testing. 152 | Maternal Health Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Ghana 2008 Background characteristic Among women with a live birth in the past five years, the percentage who during the pregnancy for their last birth: Number of women with a live birth in the past five years Among women who received antenatal care for their most recent birth in the past five years, the percentage who received specific services Number of women with ANC for their most recent birth Took iron tablets or syrup Took intestinal parasite drugs Informed of signs of pregnancy complica- tions Weighed Blood pressure measured Urine sample taken Blood sample taken Mother’s age at birth <20 86.8 33.2 214 57.6 96.9 92.9 89.3 86.2 209 20-34 86.7 35.2 1,475 70.9 96.9 97.5 92.0 91.7 1,424 35-49 85.6 34.6 410 64.8 97.4 97.8 84.9 87.9 391 Birth order 1 88.6 34.5 467 70.4 96.6 95.4 92.5 91.9 460 2-3 86.7 35.7 786 69.7 97.1 97.6 92.2 90.9 758 4-5 86.7 36.8 498 70.6 97.5 97.8 91.4 91.3 482 6+ 82.8 30.9 348 58.9 96.7 97.1 81.5 85.9 324 Residence Urban 89.9 34.4 844 76.6 97.7 98.5 96.3 96.0 830 Rural 84.2 35.2 1,255 62.6 96.6 96.1 86.2 86.5 1,194 Region Western 92.2 39.1 189 69.5 97.2 99.5 97.5 97.3 181 Central 88.8 41.4 200 73.7 96.1 95.4 92.7 91.7 191 Greater Accra 93.9 14.5 262 74.7 96.4 98.7 96.7 96.5 256 Volta 90.4 33.7 181 84.8 99.4 99.8 96.8 94.7 165 Eastern 89.5 38.0 185 75.3 96.0 97.3 96.0 96.2 180 Ashanti 91.5 37.4 396 68.8 97.6 97.4 96.2 94.8 387 Brong Ahafo 84.5 51.0 218 64.5 97.7 95.7 95.1 96.2 213 Northern 69.3 25.7 291 45.5 95.2 93.0 62.3 63.9 282 Upper East 83.8 35.9 119 64.9 98.7 98.8 95.0 96.0 114 Upper West 69.2 51.5 58 79.7 98.8 97.9 66.4 74.9 56 Mother’s education No education 78.6 30.4 647 57.6 96.0 95.5 79.4 81.5 614 Primary 88.0 35.2 511 66.9 97.4 97.3 93.2 92.2 485 Middle/JSS 91.2 39.3 738 75.6 97.3 97.4 95.7 94.6 724 Secondary+ 90.4 32.1 201 78.5 98.2 100.0 97.7 98.2 199 Wealth quintile Lowest 77.4 30.9 480 54.8 95.7 93.8 77.3 79.0 451 Second 85.0 40.9 461 63.3 96.7 97.5 88.3 89.1 437 Middle 87.6 37.2 400 68.8 97.5 97.8 94.5 92.0 388 Fourth 92.1 35.4 436 79.2 97.9 97.6 95.8 96.2 429 Highest 93.0 28.7 322 79.5 97.5 99.5 99.2 98.8 319 Total 86.5 34.9 2,099 68.4 97.0 97.1 90.3 90.4 2,024 Note: Total includes cases with information missing on mother’s education 9.1.4 Tetanus Immunisation Neonatal tetanus is a leading cause of neonatal death in developing countries where a high proportion of deliveries are conducted at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) immunisation is given to pregnant women to prevent neonatal tetanus. If a woman has received no previous TT injections, for full protection a pregnant woman needs two doses of TT during pregnancy. However, if a woman was immunised before she became pregnant, she may require one or no TT injections during pregnancy, depending on the number of injections she has ever received and the timing of the last injection. For a woman to have lifetime protection, a total of five doses is required. The 2008 GDHS collected information on whether women received at least two TT injections and whether the pregnancy for the most recent live birth in the five years preceding the survey was protected against neonatal tetanus. Maternal Health | 153 Table 9.4 shows that more than half of women (56 percent) in Ghana receive two or more tetanus injections during pregnancy and that 72 percent of births are protected against neonatal tetanus. Older women and those with six or more births are the least likely to receive two or more tetanus injections during the pregnancy for their last live birth, possibly because by that time they already have received all five doses required for lifetime protection, compared with younger and lower parity women. There is little variation in tetanus toxoid coverage by age at birth and birth order; however, there are differences by residence. For example, 76 percent of births in urban areas are protected against tetanus, compared with 70 percent of births in rural areas. There are also marked differences by region. In the Volta region, 81 percent of births are protected against neonatal tetanus, compared with 61 percent of births in the Upper West region. Education of the mother is positively related to tetanus toxoid coverage in Ghana; 83 percent of births to women with secondary or higher education are protected against neonatal tetanus, compared with 64 percent of births to women with no education. Similarly, women living in wealthier households are more likely to have received two or more tetanus toxoid injections during their last pregnancy and their births are more likely to be protected against tetanus than women in the lowest wealth quintiles. A comparison between the 2003 and 2008 surveys on the percentage of women who had two or more TT injections during their last pregnancy that ended in a live birth shows that there has been an increase from 50 percent in 2003 to 56 percent in 2008 (Figure 9.2). The most marked increase is seen in the Upper East region (46 percent in 2003, compared with 62 percent in 2008) and the Greater Accra region (52 percent in 2003, compared with 66 percent in 2008). Contrary to the general trend, during the same period the proportion of women who had two or more TT injections during their last pregnancy that ended in a live birth declined in the Central and Upper West regions by about 4 or 5 percentage points. Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Ghana 2008 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last live birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 56.4 68.3 214 20-34 57.7 72.8 1,475 35-49 50.7 70.8 410 Birth order 1 64.3 73.7 467 2-3 56.2 72.2 786 4-5 54.0 72.9 498 6+ 48.3 67.7 348 Residence Urban 61.2 75.5 844 Rural 52.8 69.6 1,255 Region Western 54.1 63.8 189 Central 55.1 70.8 200 Greater Accra 66.4 76.7 262 Volta 50.3 81.4 181 Eastern 49.0 72.9 185 Ashanti 57.2 77.4 396 Brong Ahafo 58.9 73.1 218 Northern 53.5 62.5 291 Upper East 62.3 68.7 119 Upper West 45.2 60.5 58 Mother’s education No education 52.6 64.2 647 Primary 53.7 71.8 511 Middle/JSS 58.3 75.7 738 Secondary+ 65.7 82.9 201 Wealth quintile Lowest 49.8 64.6 480 Second 51.4 67.2 461 Middle 51.4 70.4 400 Fourth 65.7 79.6 436 Highest 65.4 81.3 322 Total 56.2 71.9 2,099 Note: Total includes cases with information missing on mother’s education 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth. 154 | Maternal Health Figure 9.2 Trends in Tetanus Toxoid Injections, Ghana 2003 and 2008 50 57 47 52 59 52 49 43 49 57 48 46 50 56 61 53 54 55 66 50 49 57 59 54 62 45 GHANA RESIDENCE Urban Rural REGION Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West 0 10 20 30 40 50 60 70 80 Percent 2003 2008 9.2 DELIVERY CARE Labour and delivery is the shortest and most critical period of the pregnancy-childbirth continuum because most maternal deaths arise from complications during delivery. Even with the best possible antenatal care, any delivery can become a complicated one and, therefore, skilled assistance is essential to safe delivery care. For numerous reasons many women do not seek skilled care even when they understand the safety reasons for doing so. Some reasons include cost of service, the distance to the health facility, and quality of care. The introduction of free maternity services and locating CHPS compounds closer to where people live are some of the efforts that have been made to remove barriers to accessing skilled maternity care. The CHPS compounds are manned by community health officers, some of whom are midwives or have midwifery skills to attend deliveries and make referrals should complications arise. 9.2.1 Place of Delivery Respondents in the 2008 GDHS were asked to report the place of birth for all their children born in the five years preceding 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. Overall, 57 percent of births were delivered in health facilities, with the public sector accounting for the largest proportion; this is an increase since the 2003 GDHS (46 percent). Low parity women are more likely than high parity women to deliver at a health facility. A child born in an urban area is twice as likely to have been delivered at a health facility as a child living in a rural area. One in four children in the Northern region is delivered at a health facility, compared with four in five children in the Greater Accra region. Use of delivery facilities rises with level of mother’s education from 35 percent of births among women with no education to 91 percent among women with at least a secondary education. The same pattern is seen by wealth status; births in health facilities increase from 24 percent among women in the lowest wealth quintile to 93 percent among those in the highest wealth quintile. Maternal Health | 155 Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Ghana 2008 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mother’s age at birth <20 46.0 4.9 48.8 0.3 0.0 100.0 50.9 333 20-34 49.1 9.9 40.2 0.4 0.5 100.0 58.9 2,079 35-49 47.2 6.6 45.2 0.6 0.4 100.0 53.8 497 Birth order 1 57.6 11.5 30.6 0.3 0.0 100.0 69.1 688 2-3 49.8 9.6 39.5 0.6 0.4 100.0 59.4 1,107 4-5 46.0 5.6 47.6 0.3 0.6 100.0 51.6 659 6+ 34.5 6.9 57.4 0.5 0.7 100.0 41.4 455 Antenatal care visits1 None 13.1 0.0 82.6 4.3 0.0 100.0 13.1 72 1-3 29.0 5.5 64.9 0.6 0.0 100.0 34.4 338 4+ 56.9 10.9 31.9 0.3 0.0 100.0 67.8 1,640 Residence Urban 66.8 15.6 16.8 0.4 0.4 100.0 82.4 1,104 Rural 37.1 4.6 57.5 0.5 0.4 100.0 41.7 1,806 Region Western 43.2 15.1 40.4 0.5 0.9 100.0 58.3 271 Central 46.8 4.8 47.0 0.3 1.1 100.0 51.7 292 Greater Accra 62.2 21.5 15.1 1.2 0.0 100.0 83.7 346 Volta 48.0 5.6 46.3 0.0 0.0 100.0 53.7 244 Eastern 55.3 3.6 39.0 2.1 0.0 100.0 59.0 254 Ashanti 57.2 12.8 29.8 0.0 0.2 100.0 70.0 545 Brong Ahafo 57.3 7.4 35.3 0.0 0.0 100.0 64.7 272 Northern 23.9 2.4 72.8 0.0 0.9 100.0 26.3 456 Upper East 46.1 0.0 52.6 0.9 0.5 100.0 46.1 148 Upper West 44.2 1.1 53.8 0.5 0.4 100.0 45.3 82 Mother’s education No education 30.7 3.8 64.4 0.3 0.8 100.0 34.6 952 Primary 44.7 8.6 45.8 0.5 0.4 100.0 53.3 722 Middle/JSS 61.7 11.1 26.4 0.6 0.1 100.0 72.8 970 Secondary+ 73.2 17.7 8.5 0.5 0.0 100.0 90.9 263 Wealth quintile Lowest 22.1 1.4 75.7 0.2 0.6 100.0 23.5 744 Second 41.7 7.0 50.2 1.0 0.1 100.0 48.7 641 Middle 53.5 8.6 36.5 0.7 0.7 100.0 62.1 549 Fourth 68.8 11.3 19.6 0.0 0.3 100.0 80.1 560 Highest 71.5 21.2 6.6 0.3 0.3 100.0 92.8 415 Total 48.4 8.7 42.0 0.5 0.4 100.0 57.1 2,909 Note: Total includes cases with information missing on mother’s education and number of ANC visits 1 Includes only the most recent birth in the five years preceding the survey 9.2.2 Assistance at Delivery Table 9.6 shows the percent distribution of live births in the five years preceding the survey by person providing assistance, according to background characteristics. The survey results show that 59 percent of births in Ghana are delivered with the assistance of a health professional (i.e., doctor, nurse/midwife, community health officer/nurse), 30 percent are delivered by a traditional birth attendant, and about one in ten births is assisted by a relative, or receives no assistance. 156 | Maternal 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, percentage of births assisted by a skilled provider, and the percentage delivered by caesarean-section, according to background characteristics, Ghana 2008 Background characteristic Person providing assistance during delivery Total Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Doctor Nurse/ midwife Auxiliary midwife Com- munity health officer Tradi- tional birth attendant (trained) Tradi- tional birth attendant (un- trained) Relative/ other No one Don’t know/ missing Mother’s age at birth <20 7.3 40.2 2.8 1.9 22.8 16.5 6.9 1.7 0.0 100.0 52.2 3.3 333 20-34 11.8 45.0 2.2 1.5 15.5 13.3 8.1 2.0 0.5 100.0 60.6 7.4 2,079 35-49 10.3 40.7 3.1 0.9 14.4 15.7 9.1 5.3 0.6 100.0 54.9 7.4 497 Birth order 1 16.3 50.3 2.8 1.3 12.2 10.4 6.2 0.5 0.0 100.0 70.7 10.0 688 2-3 10.7 45.5 2.4 2.0 16.4 13.9 7.5 0.9 0.6 100.0 60.6 6.3 1,107 4-5 8.9 42.3 1.6 1.1 16.4 15.6 8.8 4.9 0.6 100.0 53.8 5.8 659 6+ 7.0 31.7 3.0 1.0 21.2 17.8 11.3 6.2 0.8 100.0 42.6 5.2 455 Place of delivery Health facility 19.3 73.9 3.5 2.1 0.6 0.1 0.4 0.1 0.0 100.0 98.8 12.1 1,662 Elsewhere 0.0 3.6 0.9 0.7 37.3 32.9 18.5 5.9 0.2 100.0 5.2 0.0 1,236 Residence Urban 19.6 61.6 2.6 0.6 8.6 3.5 2.0 1.2 0.4 100.0 84.3 10.6 1,104 Rural 5.8 32.8 2.3 2.0 20.8 20.5 11.9 3.4 0.5 100.0 43.0 4.7 1,806 Region Western 7.6 47.7 4.9 1.5 21.3 4.4 8.2 3.6 0.9 100.0 61.7 5.4 271 Central 12.4 39.1 2.5 0.0 25.7 7.7 9.6 1.5 1.5 100.0 54.0 10.0 292 Greater Accra 29.7 52.3 2.3 0.0 10.0 1.8 2.4 1.5 0.0 100.0 84.3 10.2 346 Volta 6.0 41.9 4.3 1.4 14.9 25.4 4.3 1.7 0.0 100.0 53.7 6.0 244 Eastern 9.4 48.5 0.3 2.5 21.0 11.0 4.1 3.1 0.0 100.0 60.8 7.6 254 Ashanti 16.0 54.6 1.0 1.0 11.7 7.5 6.8 1.2 0.2 100.0 72.6 10.7 545 Brong Ahafo 8.7 53.0 3.9 0.0 9.8 15.5 4.9 4.2 0.0 100.0 65.5 4.9 272 Northern 1.1 22.9 1.2 2.1 20.1 35.5 12.6 3.6 0.9 100.0 27.2 2.5 456 Upper East 1.4 33.7 3.8 7.8 6.5 16.0 27.7 2.2 0.9 100.0 46.7 1.1 148 Upper West 6.8 32.6 4.0 2.8 26.9 11.7 8.6 6.3 0.4 100.0 46.1 3.5 82 Mother’s education No education 4.1 28.5 1.8 2.0 18.9 27.0 12.8 4.0 0.9 100.0 36.3 3.4 952 Primary 7.9 41.4 3.1 2.2 22.3 10.8 9.0 2.9 0.4 100.0 54.6 4.5 722 Middle/JSS 15.7 55.9 2.3 0.5 11.8 7.5 4.6 1.5 0.3 100.0 74.4 9.4 970 Secondary+ 27.9 59.9 3.3 1.2 5.7 0.4 1.5 0.0 0.0 100.0 92.4 16.8 263 Wealth quintile Lowest 2.2 19.4 0.8 1.8 21.4 34.5 15.0 4.2 0.7 100.0 24.2 1.3 744 Second 5.8 37.0 4.2 3.1 20.9 13.3 12.1 3.4 0.4 100.0 50.0 5.0 641 Middle 9.2 52.1 2.6 1.0 17.7 8.6 6.3 2.0 0.7 100.0 64.8 8.4 549 Fourth 17.6 60.8 2.8 0.6 11.8 2.8 1.7 1.6 0.3 100.0 81.7 9.1 560 Highest 28.6 63.8 1.9 0.3 3.2 1.1 0.6 0.3 0.3 100.0 94.6 15.0 415 Total 11.0 43.7 2.4 1.5 16.2 14.1 8.1 2.5 0.5 100.0 58.7 6.9 2,909 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Total includes cases with information missing on place of delivery and mother’s education 1 Skilled provider includes doctor, nurse, midwife, auxiliary midwife, and community health officer. As in the case of antenatal care, the use of community health officers provides women with access to professional assistance during childbirth. Although the overall effect of using community health officers is much lower for delivery than antenatal care, this arrangement is proving the most beneficial for the Upper East region, where community health officers’ contribution to delivery care is eight times higher than that provided by doctors (8 and 1 percent, respectively). Maternal Health | 157 Delivery assistance by a health professional shows little association with women’s age, but it is related to how many children a woman has: the more children a woman has the less likely is she to have a health professional attending her delivery. A woman giving birth in an urban area is twice as likely to be delivered by a health professional as a woman giving birth in a rural area. Professional assistance at birth also tends to increase with mother’s level of education and wealth quintile (Figure 9.3). GDHS 2008 59 84 43 36 55 74 92 24 50 65 82 95 GHANA RESIDENCE Urban Rural MOTHER'S EDUCATION No education Primary Middle/JSS Secondary + WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 100 120 Percent Figure 9.3 Assistance by Skilled Provider during Childbirth There has been a 12 percentage point increase in access to professional assistance at delivery over the past five years, from 47 percent in 2003 to 59 percent in 2008. During the same period, there was a decrease from 21 to 11 percent in the use of relatives or no one for delivery assistance. However, there is still lack of clarity about the midwifery competence of the new category of health professionals, community health officers. If their contribution to skilled attendance at delivery (about 2 percent) in the 2008 GDHS were removed, there would still be a 10 percentage point increase in skilled attendance at delivery, with the Western region having the largest increase (22 percentage points), followed by the Central region (16 percentage points). The smallest increase in skilled attendance at delivery was in the Greater Accra region (3 percentage points) (data not shown separately). 9.2.3 Complications of Delivery Access to caesarean section operations is a measure of access to emergency care for childbirth complications. The global estimate of a 5 to 15 percent access to caesarean sections is considered adequate in any given population. The denominator used in calculating access to caesarean sections in the surveys conducted over the years is based on live births, not on total deliveries. This should be kept in mind when interpreting the results. Table 9.6 presents data on the prevalence of births by caesarean section. Nationally, access to caesarean section has increased from 4 percent in 2003 to 7 percent in 2008. Caesarean sections are more common in urban areas (11 percent) than in rural areas (5 percent), probably because of the greater access to doctors in urban areas. There are regional differences in access to caesarean sections, with the women in the Ashanti region having the greatest access, followed by women in the Greater Accra and Central regions. Women in the Upper East region have the least access to caesarean sections (1 percent), about the same as five years earlier in the 2003 GDHS. The largest increase in 158 | Maternal Health access to caesarean section is in the Central region (from 1 to 10 percent). The Greater Accra region is the only region where there has actually been a decrease in access to caesarean sections (from 12 to 10 percent). As expected, women with higher levels of education and those living in wealthier households tend to have greater access to caesarean section than their less educated and less wealthy counterparts, the main reason for this being that they are more likely to deliver with the assistance of a health professional who is able to perform C-sections. Women in the highest wealth quintile are about fifteen times more likely to have access to caesarean section than women in the lowest wealth quintile (15 and 1 percent, respectively). 9.3 POSTNATAL CARE Skilled care for mothers is critical in the days after they give birth. Up to 45 percent of all maternal deaths occur within one day of delivery, and 65 percent occur within the first week. This period is also critical to newborn survival because 50 to 70 percent of life-threatening newborn illnesses occur within the first week of life (AED, the Manoff Group, and USAID, 2005). A postnatal check-up within the first week of delivery is therefore an important strategy for ensuring optimal maternal and newborn health. In Ghana, the first postnatal check-up is advised within the first three days of delivery and subsequent check-ups are made as appropriate. To assess the extent of postnatal care utilisation, women who were interviewed in the GDHS were asked about their most recent birth in the five years preceding the survey, specifically, whether they received a health check-up after the delivery, the timing of the first postnatal check-up, and the type of health provider performing the postnatal check-up. This information is shown in Tables 9.7 and 9.8 according to background characteristics. 9.3.1 Timing of First Postnatal Check-up The survey results on postnatal care indicate that about three in five women (57 percent) receive a postnatal check-up within 24 hours of delivery, and about seven in ten (68 percent) are checked within the first two days. Seven percent of women receive postnatal care 3 to 41 days after delivery. Having a postnatal check-up within the most crucial period (first two days) is primarily associated with how many children a woman has; women with fewer children are more likely to have an early postnatal check-up than women with more children. Women delivering in a health facility are more than twice as likely to have a postnatal check-up within the first two days, compared with women delivering elsewhere. Women in the highest wealth quintile are about twice as likely to have an early postnatal check-up as women in the lowest wealth quintile, and a similar pattern is seen by level of education. Women in the Northern region (45 percent) are least likely to have access to a postnatal check-up within the first two days, probably because facility-based delivery care is also lowest in this region. Maternal Health | 159 Table 9.7 Timing of first postnatal check-up Among women age 15-49 with a birth in the five years preceding the survey, the percent distribution of mother’s first postnatal check-up for the last live birth by time after delivery, according to background characteristics, Ghana 2008 Background characteristic Time after delivery of mother’s first postnatal check-up No postnatal check-up1 Total Number of women Less than 4 hours 4-23 hours 1-2 days 3-41 days Don’t know/ missing Mother’s age at birth <20 42.1 8.4 10.6 9.8 0.6 28.5 100.0 214 20-34 48.3 11.4 11.4 6.5 1.5 21.0 100.0 1,475 35-49 42.7 10.5 9.4 8.9 1.1 27.4 100.0 410 Birth order 1 54.2 12.2 9.7 6.1 0.6 17.2 100.0 467 2-3 46.1 12.9 11.5 7.4 1.1 21.1 100.0 786 4-5 44.7 10.1 11.6 8.5 1.8 23.4 100.0 498 6+ 40.0 6.0 10.4 7.1 2.0 34.5 100.0 348 Place of delivery Health facility 61.3 15.4 10.9 4.0 1.9 6.6 100.0 1,263 Elsewhere 24.3 4.2 11.1 12.3 0.5 47.6 100.0 835 Residence Urban 56.2 15.7 10.0 4.8 1.6 11.8 100.0 844 Rural 40.1 7.7 11.5 9.0 1.1 30.5 100.0 1,255 Region Western 36.1 18.4 7.7 5.3 1.9 30.6 100.0 189 Central 41.9 13.9 10.8 6.3 0.8 26.2 100.0 200 Greater Accra 57.5 15.3 16.0 0.9 0.8 9.5 100.0 262 Volta 22.6 7.8 18.2 17.2 1.2 33.0 100.0 181 Eastern 53.7 10.8 11.3 7.6 0.0 16.6 100.0 185 Ashanti 61.5 9.3 9.1 4.2 1.7 14.3 100.0 396 Brong Ahafo 56.1 9.5 6.4 3.1 1.9 23.0 100.0 218 Northern 32.3 6.1 6.4 12.7 2.1 40.4 100.0 291 Upper East 34.7 10.5 19.9 16.1 0.8 18.0 100.0 119 Upper West 56.5 9.1 9.4 5.9 0.6 18.4 100.0 58 Education No education 35.8 6.8 8.8 10.6 1.4 36.5 100.0 647 Primary 43.4 10.2 12.0 6.7 0.8 26.9 100.0 511 Middle/JSS 55.5 13.3 10.7 5.6 1.2 13.7 100.0 738 Secondary+ 55.6 17.2 16.1 4.7 2.8 3.7 100.0 201 Wealth quintile Lowest 30.1 4.0 11.1 12.7 1.4 40.7 100.0 480 Second 40.9 8.0 11.0 7.7 0.6 31.9 100.0 461 Middle 52.8 9.7 12.4 5.4 1.2 18.4 100.0 400 Fourth 56.7 17.2 8.0 4.2 1.9 12.0 100.0 436 Highest 57.6 18.6 12.6 5.3 1.6 4.3 100.0 322 Total 46.5 10.9 10.9 7.3 1.3 23.0 100.0 2,099 Note: Total includes cases with information missing on mother’s education and place of delivery 1 Includes women who received a check-up after 41 days 9.3.2 Type of Provider of First Postnatal Check-up Table 9.8 presents information on the types of postnatal care providers used, according to mothers’ background characteristics. In Ghana, 63 percent of mothers obtain postnatal care from a health professional, and 12 percent get postnatal care from traditional birth attendants. About one in four women (23 percent) do not receive any postnatal care within 41 days, which almost marks the end of the postnatal period. 160 | Maternal Health Table 9.8 Type of provider of first postnatal check-up Among women age 15-49 with a birth in the five years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check for the last live birth, according to background characteristics, Ghana 2008 Background characteristic Type of health provider of mother’s first postnatal check-up No postnatal check-up1 Total Number of women Doctor/ nurse/ midwife Auxiliary midwife Com- munity health officer Traditional birth attendant (trained) Traditional birth attendant (untrained) Other Don’t know/ missing Mother’s age at birth <20 52.3 1.7 1.9 8.3 3.8 3.5 0.0 28.5 100.0 214 20-34 59.7 2.6 2.6 7.6 3.8 2.5 0.2 21.0 100.0 1,475 35-49 53.7 2.0 2.5 7.2 5.5 1.8 0.0 27.4 100.0 410 Birth order 1 67.5 2.5 2.3 5.7 3.0 1.8 0.0 17.2 100.0 467 2-3 61.1 3.1 2.1 6.8 3.8 2.0 0.1 21.1 100.0 786 4-5 55.0 1.8 3.2 8.7 4.1 3.5 0.4 23.4 100.0 498 6+ 41.3 1.7 2.7 10.3 6.3 3.2 0.0 34.5 100.0 348 Place of delivery Health facility 87.2 3.5 1.9 0.4 0.0 0.3 0.1 6.6 100.0 1,263 Elsewhere 13.5 0.8 3.4 18.4 10.3 5.9 0.2 47.6 100.0 835 Residence Urban 77.4 2.8 1.2 4.7 1.4 0.5 0.3 11.8 100.0 844 Rural 44.6 2.2 3.4 9.5 6.0 3.9 0.1 30.5 100.0 1,255 Region Western 52.2 3.7 1.4 9.2 0.0 2.8 0.0 30.6 100.0 189 Central 49.2 1.6 0.7 13.4 4.0 4.0 0.8 26.2 100.0 200 Greater Accra 81.8 2.2 0.0 5.7 0.8 0.0 0.0 9.5 100.0 262 Volta 50.6 5.9 3.3 5.4 1.9 0.0 0.0 33.0 100.0 181 Eastern 67.8 0.9 0.8 8.6 3.3 2.1 0.0 16.6 100.0 185 Ashanti 66.6 1.8 1.0 9.4 3.0 3.9 0.0 14.3 100.0 396 Brong Ahafo 64.2 4.1 0.0 3.4 3.1 2.2 0.0 23.0 100.0 218 Northern 32.1 1.1 7.4 4.9 10.4 3.5 0.2 40.4 100.0 291 Upper East 51.0 1.7 10.6 5.9 11.7 1.0 0.0 18.0 100.0 119 Upper West 46.7 1.8 5.4 13.8 6.7 5.9 1.4 18.4 100.0 58 Mother’s education No education 38.2 1.5 5.4 7.3 7.6 3.4 0.1 36.5 100.0 647 Primary 51.6 2.5 1.6 10.6 4.0 2.4 0.3 26.9 100.0 511 Middle/JSS 71.6 2.5 1.2 6.6 2.1 2.3 0.1 13.7 100.0 738 Secondary+ 85.6 4.6 0.5 4.1 0.5 0.9 0.0 3.7 100.0 201 Wealth quintile Lowest 27.4 1.6 6.4 8.9 10.2 4.8 0.1 40.7 100.0 480 Second 46.7 3.7 2.2 8.1 4.0 3.4 0.1 31.9 100.0 461 Middle 61.2 2.4 1.7 10.3 3.1 2.8 0.0 18.4 100.0 400 Fourth 76.1 2.5 0.6 7.1 1.1 0.6 0.0 12.0 100.0 436 Highest 90.1 1.7 0.7 2.1 0.5 0.0 0.7 4.3 100.0 322 Total 57.8 2.4 2.5 7.6 4.1 2.5 0.1 23.0 100.0 2,099 Note: Total includes cases with information missing on mother’s education and place of delivery 1 Includes women who received a check-up after 41 days Maternal Health | 161 Differentials in type of postnatal care provider are similar to those for postnatal care coverage in general. The likelihood of women receiving postnatal care from health professionals decreases with increasing parity. Women in the highest wealth quintile are more than twice as likely to receive postnatal care from a health professional as those in the lowest wealth quintile. Similarly, mothers with secondary and higher education are twice as likely to receive postnatal care from a health professional as those with no education. Finally, women in the Northern region (41 percent) have the least access to a postnatal check-up from a health professional because of the low level of facility- based delivery care in the region. 9.4 PROBLEMS IN ACCESSING HEALTH CARE Where health services are present, there are many factors—social, cultural, and economic— that cause women not to use the services, particularly when the health concern is related to sexual or reproductive matters. Information on such factors is particularly important in understanding and addressing the barriers women face in seeking care during pregnancy and at the time of delivery. In the 2008 GDHS, women were asked whether each of the following factors would be a big problem or not a big problem in seeking health care for themselves: getting permission to go for treatment, getting money for treatment, distance to a health facility, having to take transportation, not wanting to go alone to the health facility, concern that there may not be a health provider, and concern that there may be no drugs available. As shown in Table 9.9, more than seven in ten Ghanaian women reported that they have at least one serious problem when they access health care for themselves. The two major concerns were getting money for treatment and availability of drugs (each 45 percent). The next major concern was the availability of a health care provider (44 percent). Women had about equal concern regarding the distance to the health facility and having to take transport (one in four women). Getting permission to go for treatment was the least of women’s worries (7 percent). About one in five women considered the lack of a female provider and not wanting to go alone a problem. In general, women with at least a secondary education and women in the highest wealth quintile were least likely to report having a serious problem in accessing health facilities. The greatest disparity was seen regarding the problem of having to take transport to health facilities: 50 percent of women in the lowest wealth quintile regarded this as a serious problem, compared with only 13 percent of women in the highest wealth quintile. 162 | Maternal Health Table 9.9 Problems in accessing health care Percentage of women age 15-49 who reported having serious problems accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Ghana 2008 Background characteristic Problems in accessing health care Number of women Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available Concern no drugs available At least one problem accessing health care Age 15-19 9.5 45.8 25.6 24.2 24.5 26.0 44.3 46.8 77.7 1,025 20-34 7.0 43.1 25.3 23.4 15.7 19.8 42.2 43.1 71.9 2,354 35-49 5.5 47.8 26.9 27.9 18.6 21.1 45.1 46.2 73.3 1,537 Number of living children 0 7.9 41.2 22.9 20.8 20.8 23.7 43.0 44.0 72.4 1,691 1-2 6.7 44.7 25.3 24.2 15.4 18.6 40.6 42.9 72.7 1,447 3-4 5.9 47.0 26.6 27.0 15.6 21.9 46.0 46.2 72.3 1,050 5+ 7.4 52.3 33.0 33.3 22.8 21.5 47.1 48.8 79.5 729 Marital status Never married 8.1 44.2 24.0 21.7 21.0 23.1 42.3 43.9 74.3 1,593 Married or living together 6.7 43.8 26.9 26.4 16.9 20.9 43.6 45.0 72.2 2,876 Divorced/separated/ widowed 5.2 57.1 26.1 27.2 19.0 19.4 47.4 47.5 79.7 446 Employed past 12 months Not employed 8.9 44.5 25.9 23.4 22.7 26.4 44.9 46.8 76.8 1,094 Employed for cash 5.7 43.4 25.8 25.3 17.0 20.2 43.6 44.7 71.1 3,140 Employed not for cash 10.0 53.8 26.1 25.8 18.2 19.2 40.8 42.6 79.4 677 Residence Urban 4.8 40.0 16.4 15.2 14.2 17.9 37.4 38.0 66.6 2,383 Rural 9.2 49.9 34.8 34.2 22.4 24.8 49.3 51.3 80.1 2,533 Region Western 8.1 26.6 24.1 22.1 20.4 28.2 79.6 83.0 90.8 447 Central 3.3 40.6 22.2 20.0 19.2 8.8 26.2 28.5 65.6 424 Greater Accra 4.3 41.2 15.7 13.8 12.5 19.3 17.3 18.9 59.0 853 Volta 5.4 64.3 30.6 34.7 28.5 32.4 38.1 35.8 77.8 431 Eastern 3.3 37.7 22.8 26.3 16.9 14.0 44.3 44.0 70.0 483 Ashanti 4.8 45.3 20.3 17.3 16.8 23.5 59.0 59.4 80.4 1,011 Brong Ahafo 3.9 39.5 24.8 28.6 13.7 28.4 51.7 52.7 71.5 425 Northern 12.0 53.8 35.1 28.2 19.4 16.2 22.6 27.5 68.7 467 Upper East 33.9 67.1 69.4 68.7 30.3 23.9 66.5 69.0 84.3 253 Upper West 10.8 56.8 35.5 40.0 21.6 20.5 46.7 47.7 83.9 122 Education No education 11.2 56.8 38.1 37.2 21.9 22.9 42.8 44.6 80.0 1,042 Primary 8.2 52.9 28.9 30.4 23.6 24.0 48.7 49.2 78.5 988 Middle/JSS 5.2 41.2 21.2 19.6 15.6 20.4 44.2 45.7 72.3 2,039 Secondary+ 5.0 30.9 18.3 16.4 14.9 19.2 36.5 37.8 62.4 844 Wealth quintile Lowest 14.6 60.2 50.9 49.7 28.0 28.9 47.1 50.0 82.3 783 Second 8.0 49.8 30.2 32.1 20.2 24.4 51.5 51.8 82.3 900 Middle 5.0 49.1 22.5 21.7 19.5 18.3 45.8 46.8 79.0 979 Fourth 3.8 41.3 18.6 17.3 16.0 18.8 42.1 43.9 69.8 1,119 Highest 6.1 31.3 15.2 12.7 11.9 19.5 34.2 35.0 59.5 1,135 Total 7.0 45.1 25.9 25.0 18.4 21.5 43.5 44.9 73.5 4,916 Note: Total includes cases with information missing on mother’s employment in the past 12 months and mother’s education Child Health | 163 CHILD HEALTH 10 This chapter presents the findings on child health from the 2008 GDHS. It focuses particularly on neonatal conditions (birth weight and size at birth), children’s vaccination status, and treatment practices that are commonly used for children experiencing the three major childhood illnesses: acute respiratory infection (ARI), fever, and diarrhoea. The information on children’s birth weight and size, treatment practices, and contact with health facilities when children are sick paves the way to strategic planning and implementation of programmes to reduce neonatal and infant mortality. 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 assist with planning effective improvements for these services. Information was obtained for all live births that occurred in the five years preceding the survey. Wherever possible, data from the 2008 GDHS are compared with data from the four earlier DHS surveys in Ghana, conducted in 1988, 1993, 1998 and 2003. However, analysis of trends in maternity care indicators is complicated by differences in the questions asked. The first three GDHS surveys asked questions on antenatal care and tetanus injections for all births, whereas the 2003 and 2008 surveys confined these questions to the most recent birth. In addition, the questions on maternity care and children’s health referred to periods of varying lengths (sometimes five years 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. Therefore, caution should be used in interpreting the trend data. 10.1 CHILD’S SIZE AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illnesses and the chances of survival. Children whose birth weight is less than 2.5 kilograms, or children reported to be “very small” or “smaller than average” are considered to have a higher than average risk of early childhood death. For births in the five years preceding the survey, birth weight was recorded in the questionnaire if available from written records or mother’s recall. Because birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth was also obtained. Even though it is subjective, it can be a useful proxy for the weight of the child. Table 10.1 presents information on child’s weight and size at birth according to background characteristics. Birth weights were reported for only 43 percent of births in the five years preceding the survey. It is unlikely that these births are representative of all births because births in urban areas and births to mothers in higher wealth quintiles are over-represented, and the pattern of birth weights by background characteristics is likely to be biased. The results on size of the baby at birth show only small differences by background characteristics. The proportion of babies reported to be of ‘average or larger’ size at birth increases with mother’s age at birth and with level of education and wealth quintile, although the differences are not large. The Upper East region has the smallest proportion of babies reported as average or larger in size at birth, and the Western region has the largest proportion. 164 | Child Health Table 10.1 Child’s weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percentage of all births with a reported birth weight; and percent distribution of all live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, according to background characteristics, Ghana 2008 Background characteristic Percent distribution of births with a reported birth weight1 Percentage of all births with a reported birth weight Percent distribution of all live births by size of child at birth Less than 2.5 kg 2.5 kg or more Total Number of births Very small Smaller than average Average or larger Don’t know/ missing Total Number of births Mother’s age at birth <20 8.1 91.9 100.0 115 34.5 5.3 13.0 80.3 1.4 100.0 333 20-34 9.8 90.2 100.0 947 45.6 3.8 9.3 85.3 1.6 100.0 2,079 35-49 12.4 87.6 100.0 184 37.0 4.9 7.2 87.0 0.9 100.0 497 Birth order 1 8.3 91.7 100.0 368 53.4 5.1 10.1 83.5 1.3 100.0 688 2-3 10.2 89.8 100.0 514 46.5 3.6 8.9 86.1 1.4 100.0 1,107 4-5 12.5 87.5 100.0 241 36.6 3.7 8.5 86.1 1.8 100.0 659 6+ 9.6 90.4 100.0 123 27.0 4.6 10.6 83.3 1.4 100.0 455 Residence Urban 9.3 90.7 100.0 742 67.3 3.4 8.2 86.7 1.7 100.0 1,104 Rural 11.2 88.8 100.0 503 27.9 4.6 10.1 84.1 1.3 100.0 1,806 Region Western 16.8 83.2 100.0 113 41.9 2.4 3.7 91.8 2.0 100.0 271 Central 8.3 91.7 100.0 70 24.1 0.3 6.9 90.8 1.9 100.0 292 Greater Accra 5.3 94.7 100.0 268 77.6 2.7 9.1 87.2 1.0 100.0 346 Volta 11.1 88.9 100.0 68 28.0 1.1 15.2 83.7 0.0 100.0 244 Eastern 11.4 88.6 100.0 131 51.3 5.8 6.4 87.8 0.0 100.0 254 Ashanti 11.6 88.4 100.0 343 63.0 7.3 7.1 85.2 0.4 100.0 545 Brong Ahafo 9.1 90.9 100.0 97 35.6 3.4 12.5 83.6 0.5 100.0 272 Northern 10.5 89.5 100.0 100 22.0 5.9 10.9 79.3 3.9 100.0 456 Upper East 5.5 94.5 100.0 39 26.2 6.0 14.4 75.6 3.9 100.0 148 Upper West 14.1 85.9 100.0 16 19.4 1.4 16.4 81.4 0.7 100.0 82 Mother’s education No education 11.4 88.6 100.0 219 23.0 4.4 10.7 82.0 2.8 100.0 952 Primary 12.9 87.1 100.0 255 35.3 4.8 9.4 85.1 0.8 100.0 722 Middle/JSS 9.0 91.0 100.0 557 57.4 2.9 8.7 87.7 0.7 100.0 970 Secondary+ 7.8 92.2 100.0 212 80.7 5.6 7.0 86.4 1.1 100.0 263 Wealth quintile Lowest 4.3 95.7 100.0 115 15.5 4.9 13.2 79.5 2.3 100.0 744 Second 11.9 88.1 100.0 204 31.9 4.4 7.8 87.1 0.6 100.0 641 Middle 13.7 86.3 100.0 233 42.4 3.6 7.6 86.7 2.1 100.0 549 Fourth 9.2 90.8 100.0 349 62.4 3.3 8.0 87.7 0.9 100.0 560 Highest 9.3 90.7 100.0 344 82.9 3.9 9.1 85.8 1.2 100.0 415 Total 10.0 90.0 100.0 1,246 42.8 4.1 9.4 85.0 1.5 100.0 2,909 Note: Total includes cases with information missing on education that are not shown separately. 1 Based on either a written record or the mother’s recall Child Health | 165 10.2 VACCINATION COVERAGE The 2008 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 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 require three vaccinations at approximately 6, 10, and 14 weeks of age. The measles and yellow fever vaccines should be given at nine months of age. Currently, the pentavalent vaccine “DPT/HepB/HiB,” introduced 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 of each vaccination 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, 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 10.2 shows the percentage of children age 12-23 months who received specific vaccines at any time before the survey by source of information. Seventy-nine percent of Ghanaian children age 12-23 months are fully immunised; only 1 percent of children received no vaccinations (Figure 10.1). Seventy percent of children age 12-23 months were fully vaccinated by 12 months of age. Table 10.2 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 2008 Source of information BCG DPT Polio1 Measles Yellow fever All basic vacci- nations2 No vacci- nations Number of children 1 2 3 0 1 2 3 Vaccinated at any time before survey Vaccination card 83.0 85.1 84.5 82.0 60.0 85.1 84.5 81.4 79.3 78.9 75.9 0.2 474 Mother’s report 12.8 13.0 11.1 6.8 8.3 12.2 9.8 5.1 10.9 10.2 3.1 0.8 78 Either source 95.8 98.0 95.5 88.8 68.2 97.2 94.3 86.4 90.2 89.1 79.0 1.0 552 Vaccinated by 12 months of age3 95.6 97.6 95.2 87.7 68.2 96.8 93.7 84.7 79.9 77.8 69.8 1.6 552 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) 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. 166 | Child Health 96 98 96 89 68 97 94 86 90 89 79 1 BCG 1 2 3 0 1 2 3 Measles Yellow fever All None 0 20 40 60 80 100 Percent Figure 10.1 Vaccination Coverage at Any Time Before the Survey among Children 12-23 Months DPT Polio GDHS 2008 Looking at coverage for specific vaccines, 96 percent of children have received the BCG vaccination, 98 percent received the first DPT dose, and 97 percent received the first polio dose (Polio 1). Coverage for all three vaccinations declines with subsequent doses; only 89 percent of children received the recommended three doses of DPT and 86 percent received three doses of polio. These figures reflect dropout rates of 9 percent for DPT and 11 percent for polio; the dropout rate represents the proportion of children who received the first dose of a vaccine, but did not get the third dose. This is an improvement from 2003 when drop-out rates for DPT and polio were 12 and 15 percent, respectively, and especially from 1998 when drop-out rates for DPT and polio were 19 and 22 percent, respectively (GSS, NMIMR, and ORC Macro, 2004, GSS and MI, 1999). Ninety percent of children received the measles vaccine and 89 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 is minimal. The percentage of children age 12-23 months who have been fully vaccinated has increased over the past twenty years, from 47 percent in 1988 (GSS and IRD, 1989) to 79 percent in 2008 (Figure 10.2). Figure 10.2 Trends in Vaccination Coverage, Ghana 1988-2008 47 55 62 69 79 GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 GDHS 2008 0 20 40 60 80 100 Pe rc en t a ge o f c h i 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). Child Health | 167 Table 10.3 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. There is little difference in the proportion of children fully vaccinated by sex of the child or by urban-rural residence. Boys (80 percent) and children in rural areas (79 percent) are slightly more likely to be fully vaccinated than girls and children in urban areas (78 percent each). The proportion of children fully immunised increases somewhat as birth order increases, from 73 percent among first births to 82 percent among births of order four or five. Coverage falls to below 60 percent for children in the Northern region. Vaccination coverage varies in other regions, from 73 percent of children in the Central region fully immunised to 94 percent in the Brong Ahafo region. Children whose mothers attended only primary or middle/JSS school are more likely to be fully vaccinated than children whose mothers have no education. Surprisingly, children of mothers who attended secondary school or higher are among the least likely to be fully vaccinated, along with children of mothers with no education (74 and 73 percent, respectively). The proportion of children fully immunised increases with wealth quintile, from 75 percent in the lowest wealth quintile to 86 percent in the fourth quintile and 84 percent in the highest quintile. Table 10.3 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 seen by interviewer, by background characteristics, Ghana 2008 BCG DPT Polio1 Measles Yellow fever All basic vacci- nations2 No vacci- nations Percentage with a vacci- nation card seen Number of children1 2 3 0 1 2 3 Sex Male 96.7 97.9 95.9 88.8 65.3 95.9 94.1 86.1 88.5 87.3 79.7 0.9 85.8 264 Female 95.0 98.2 95.2 88.8 71.0 98.4 94.5 86.7 91.7 90.7 78.4 1.0 85.9 287 Birth order 1 93.1 97.6 94.1 85.1 72.2 94.0 90.7 81.1 86.7 86.5 73.2 2.0 81.0 129 2-3 96.8 97.8 95.7 90.5 73.6 97.4 95.3 86.9 91.6 90.4 80.4 0.9 85.9 222 4-5 96.5 99.5 96.4 88.9 67.6 100.0 95.0 88.1 92.6 91.0 81.9 0.0 91.0 123 6+ 96.1 96.9 96.1 90.0 47.5 97.7 96.1 91.2 88.1 86.4 80.1 1.2 86.1 78 Residence Urban 97.3 97.5 93.8 87.2 82.2 95.5 91.0 83.9 93.4 92.6 78.3 0.7 81.0 214 Rural 94.8 98.3 96.6 89.8 59.4 98.3 96.4 88.0 88.1 86.8 79.4 1.1 89.0 338 Region Western 98.9 97.1 97.1 96.0 65.0 99.2 99.2 89.9 89.7 87.2 82.1 0.0 88.0 50 Central (100.0) (100.0) (96.4) (81.0) (50.6) (95.6) (90.8) (84.5) (87.3) (84.3) (73.2) (0.0) (83.5) 56 Greater Accra (100.0) (98.3) (98.3) (88.6) (87.7) (97.5) (97.5) (83.1) (92.4) (92.4) (79.9) (0.0) (77.7) 61 Volta (96.5) (100.0) (95.0) (89.5) (61.8) (100.0) (95.0) (81.4) (92.0) (92.0) (79.3) (0.0) (81.7) 44 Eastern 98.5 97.7 96.3 91.5 68.9 95.8 95.8 87.4 86.8 88.7 76.3 0.0 85.2 55 Ashanti 95.4 97.2 95.7 91.4 77.8 97.2 92.9 90.9 93.0 90.7 84.6 2.8 86.3 114 Brong Ahafo (98.2) (98.3) (97.0) (95.7) (79.7) (98.3) (98.3) (95.7) (95.7) (95.7) (93.9) (0.0) (96.3) 49 Northern 84.3 96.7 88.3 75.1 48.1 94.4 86.8 73.4 80.5 78.2 58.5 2.5 82.1 76 Upper East (97.0) (100.0) (100.0) (95.8) (72.2) (100.0) (100.0) (92.6) (96.5) (96.6) (87.8) (0.0) (98.6) 28 Upper West 92.1 96.7 96.7 94.8 66.0 98.1 94.8 94.8 96.7 96.7 88.8 1.9 93.1 18 Mother’s education No education 91.0 97.2 93.8 84.5 51.9 97.0 92.3 83.3 86.2 84.4 73.0 2.3 86.7 170 Primary 98.2 97.3 95.8 90.1 72.5 96.7 94.2 88.0 89.5 88.7 82.0 0.0 90.9 140 Middle/JSS 98.3 98.7 97.1 91.8 74.1 99.0 97.2 89.0 93.2 92.3 83.5 0.8 84.6 194 Secondary+ 95.7 100.0 94.6 88.1 89.9 92.3 90.2 82.0 93.9 93.6 73.5 0.0 73.5 48 Wealth quintile Lowest 89.4 98.4 95.1 88.0 48.6 99.1 95.1 86.3 87.5 85.1 74.5 0.9 90.5 129 Second 95.6 95.1 92.2 86.5 55.5 94.9 93.7 84.9 86.0 84.9 77.4 2.1 86.0 124 Middle 97.3 98.5 96.6 82.1 72.6 95.7 89.5 82.1 89.6 89.0 75.0 1.5 81.7 110 Fourth 100.0 100.0 97.5 95.8 86.5 99.5 97.0 90.2 95.5 95.5 86.2 0.0 86.1 110 Highest 98.7 98.7 97.3 93.3 88.9 96.7 96.7 89.8 94.7 93.2 84.3 0.0 83.7 78 Total 95.8 98.0 95.5 88.8 68.2 97.2 94.3 86.4 90.2 89.1 79.0 1.0 85.9 552 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) 168 | Child Health 10.3 TRENDS IN VACCINATION COVERAGE Table 10.4 shows 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. Sixty percent of children received all their vaccinations by 12 months of age. Children in the oldest cohort (48-59 months) were less likely to have received all their vaccinations (53 percent) than children age 12-23 months (70 percent). This pattern is seen with each vaccine but is more marked when all the vaccines are considered together. The findings support a trend towards increased vaccination coverage in 2008, compared with previous surveys. Vaccination cards were shown to interviewers for 86 percent of children age 12-23 months, compared with 60 percent of children age 48-59 months. The difference may be partly a result of the cards for older children having been lost or misplaced over the longer period of time. The results of the 2008 GDHS indicate that there has been a substantial increase in vaccination coverage over the past five years, from 69 percent fully immunised in 2003 to 79 percent in 2008. The coverage levels for various vaccines have also improved, and the proportion of children who received no vaccinations has declined from 5 to 1 percent. The greatest improvements in vaccination coverage are in the Upper West region (from 60 percent fully immunised in 2003 to 89 percent in 2008), the Western region (from 60 percent in 2003 to 82 percent in 2008), and among children in the poorest households (from 54 percent in 2003 to 75 percent in 2008). Immunisation coverage has also improved among children of mothers with no education (27 percent increase) and children of mothers with primary education (23 percent increase). The regional differences in vaccination coverage should be interpreted with caution because of the small number of cases. Table 10.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card by interviewer, by current age of child, Ghana 2008 Age in months BCG DPT Polio1 Measles Yellow fever All basic vacci- nations2 No vacci- nations Percentage with a vaccination card seen Number of children1 2 3 0 1 2 3 12-23 95.6 97.6 95.2 87.7 68.2 96.8 93.7 84.7 79.9 77.8 69.8 1.6 85.9 552 24-35 94.3 94.7 91.7 84.2 65.3 95.6 91.0 79.3 77.6 74.0 63.2 3.8 79.3 496 36-47 90.2 91.3 85.8 75.0 68.5 91.7 84.0 69.4 73.3 71.0 53.5 5.1 65.5 506 48-59 91.6 90.7 83.7 72.6 64.5 91.4 85.3 68.4 74.1 71.7 52.5 5.1 59.7 559 Total 93.0 93.6 89.2 79.9 66.6 93.9 88.6 75.5 76.5 73.9 59.9 3.9 72.5 2,112 Note: Information was obtained from a vaccination card or the mother’s report. 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 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) 10.4 ACUTE RESPIRATORY INFECTION Pneumonia and other respiratory tract infections are leading causes of death among young children in Ghana. In the case 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 2008 GDHS was estimated by asking mothers whether their children under age five had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms, though compatible with pneumonia, are subjective (i.e., mother’s perception of illness) and not validated by a medical examination. Table 10.5 shows the percentage of children under five years who had a cough accompanied by short rapid breathing (symptoms of ARI). From mothers’ reports, it was estimated that 6 percent of children under five had symptoms of ARI in the two weeks before the survey. Half of these children (51 percent) were taken to a health facility or provider (data not shown separately). Differentials in the prevalence of ARI by background characteristics are minimal; however, it is worth noting that the prevalence of ARI symptoms is slightly higher among children age 12-23 months and among children in the Northern and Upper West regions. Child Health | 169 Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, by background characteristics, Ghana 2008 Background characteristic Among children under age five: Percentage with symptoms of ARI1 Number of children Age in months <6 3.1 317 6-11 5.0 302 12-23 7.4 552 24-35 5.9 496 36-47 6.0 506 48-59 4.4 559 Sex Male 5.2 1,412 Female 5.8 1,320 Cooking fuel Electricity or gas 3.2 232 Kerosene * 8 Charcoal 5.3 832 Wood/straw2 5.9 1,660 Residence Urban 5.1 1,039 Rural 5.7 1,692 Region Western 3.8 260 Central 3.5 268 Greater Accra 6.3 329 Volta 3.4 237 Eastern 4.1 240 Ashanti 5.8 510 Brong Ahafo 5.7 260 Northern 9.3 413 Upper East 3.1 142 Upper West 7.7 72 Mother’s education No education 4.7 888 Primary 6.5 668 Middle/JSS 5.7 920 Secondary+ 5.0 252 Wealth quintile Lowest 6.2 693 Second 5.5 610 Middle 4.6 507 Fourth 7.4 528 Highest 2.9 393 Total 5.5 2,731 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes cases with information missing on education that are not shown separately. na = Not applicable 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related) are considered a proxy for pneumonia. 2 Includes grass, shrubs, crop residues 170 | Child Health Treatment with antibiotics can often ameliorate the symptoms of ARI, thereby saving lives. In the 2008 GDHS, nearly one-fourth of children (24 percent) under five who had symptoms of ARI in the two weeks before the survey received antibiotics for their illness (data not shown). 10.5 FEVER Fever is a symptom of malaria and other acute infections in children. Malaria and other illnesses that cause fever contribute to high levels of malnutrition and mortality. While fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Because malaria is a major contributory cause of death in infancy and childhood in many developing countries, the so-called presumptive treatment of fever with anti-malarial medication is advocated in many countries where malaria is endemic. Malaria in Ghana is discussed in greater detail in Chapter 12. Table 10.6 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage receiving various treatments, by selected background characteristics. One-fifth (20 percent) of all children under five years of age were reported to have had fever in the past two weeks. Fever is most common among children age 12-47 months (23-26 percent) and then decreases with age. The prevalence of fever is similar for both sexes and for children in both urban and rural areas. Regional differentials show that the proportion of children with fever is highest in the Brong Ahafo region (27 percent) and lowest in the Western region (10 percent). Fever prevalence decreases slightly as wealth quintile increases but shows no clear relationship by education of the mother. About half of children with a fever (51 percent) were taken to a health facility or provider for treatment. Of these, 43 percent were given anti-malarial drugs and one-fourth (25 percent) received antibiotics. The proportion of children who receive these treatments is higher in urban areas than rural areas, and among children whose mothers are better educated and live in wealthier households. 10.6 DIARRHOEAL DISEASE Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children in Ghana, although the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. In the 2008 GDHS, mothers were asked whether any of their children under five years of age had diarrhoea during the two weeks preceding the survey. If a child had diarrhoea, the mother was asked about feeding practices during the diarrhoeal episode and about what actions were taken to treat the diarrhoea. Because the prevalence of diarrhoea varies seasonally, the results of the 2008 GDHS—which pertain to the fieldwork period from September to late November—should be interpreted with caution. Child Health | 171 Table 10.6 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage of children for whom treatment was sought from a health facility or provider, the percentage who took anti-malarial drugs and the percentage who took antibiotic drugs, by background characteristics, Ghana 2008 Background characteristic Among children under age five: Among children under age five with fever: Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took anti-malarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 5.4 317 46.8 * * 17 6-11 18.7 302 48.2 35.2 32.5 57 12-23 26.1 552 56.2 45.9 28.8 144 24-35 24.3 496 50.7 38.5 18.4 120 36-47 23.3 506 45.3 48.2 27.2 118 48-59 15.7 559 51.3 47.0 22.1 88 Sex Male 20.9 1,412 48.8 43.7 23.5 294 Female 18.9 1,320 52.9 42.1 27.2 249 Residence Urban 19.0 1,039 59.6 52.6 31.2 197 Rural 20.5 1,692 45.7 37.5 21.8 347 Region Western 10.3 260 54.8 (34.7) (20.1) 27 Central 23.3 268 31.5 35.3 25.2 62 Greater Accra 12.5 329 53.8 (43.6) (22.3) 41 Volta 18.5 237 34.2 (48.9) (1.7) 44 Eastern 15.7 240 55.2 (32.0) (26.5) 38 Ashanti 25.0 510 54.0 46.0 32.7 128 Brong Ahafo 27.2 260 50.3 49.5 38.4 71 Northern 21.3 413 55.7 36.9 23.1 88 Upper East 21.8 142 75.7 (60.4) (11.5) 31 Upper West 20.3 72 44.3 41.1 22.3 15 Mother’s education No education 19.4 888 45.8 31.7 21.4 173 Primary 22.8 668 44.9 41.9 18.0 152 Middle/JSS 18.4 920 55.4 49.9 36.5 169 Secondary+ 19.9 252 69.6 61.5 22.1 50 Wealth quintile Lowest 19.7 693 40.6 27.9 14.8 136 Second 22.3 610 45.2 38.9 20.2 136 Middle 22.0 507 45.7 47.5 31.6 111 Fourth 19.6 528 60.8 63.5 34.6 104 Highest 14.3 393 79.9 42.4 32.6 56 Total 19.9 2,731 50.7 43.0 25.2 544 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. Total includes cases with information missing on mother’s education that are not shown separately. 1 Excludes pharmacy, shop, and traditional practitioner 172 | Child Health 10.6.1 Incidence and Treatment of Diarrhoea Table 10.7 shows the percentage of children under five with diarrhoea in the two weeks preceding the survey by selected background characte� ustics. One in five children had diarrhoea during this period; 3 percent had diarrhoea with blood, a symptom of dysentery. Not surprisingly, 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. Diarrhoea prevalence increases with age and peaks at 12-23 months (33 percent), then declines at older ages. Age 12-23 months is when children start to walk and are at increased risk of contamination from the environment. The introduction of other liquids and foods at the time of weaning can also facilitate the spread of disease- causing microbes. Differences in diarrhoea prevalence by gender and by urban-rural residence are small. Children in the Northern and Brong Ahafo regions have a higher prevalence of diarrhoea than children in the other regions. Prevalence of diarrhoea is lowest among children in the Volta region (5 percent) and among children of mothers with secondary or higher education (9 percent). Not surprisingly, diarrhoea prevalence is lowest among children who live in households with improved, not shared toilet facilities, and households that are in the highest wealth quintile. Not surprisingly, diarrhoea prevalence is highest among children residing in households without improved source of drinking water. Mothers of children with diarrhoea in the two weeks preceding the survey were asked what was done to manage or treat the illness. Table 10.8 shows the percentage of children with diarrhoea who were taken to a health provider for treat- ment, the percentage who received ORT, and the percentage given other treatments, by background characteristics. Table 10.7 Prevalence of diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Ghana 2008 Background characteristic Diarrhoea in the two weeks preceding the survey Number of children All diarrhoea Diarrhoea with blood Age in months <6 9.9 0.1 317 6-11 27.2 4.1 302 12-23 32.6 3.8 552 24-35 22.1 5.0 496 36-47 14.6 3.5 506 48-59 11.6 1.6 559 Sex Male 19.4 3.7 1,412 Female 20.3 2.5 1,320 Source of drinking water1 Improved 19.8 2.8 2,102 Not improved 23.8 5.5 455 Other/missing 10.2 0.0 174 Toilet facility2 Improved, not shared 12.8 2.3 205 Non-improved or shared 20.5 3.2 2,516 Residence Urban 17.4 1.6 1,039 Rural 21.3 4.0 1,692 Region Western 15.3 1.7 260 Central 19.3 1.2 268 Greater Accra 12.4 0.0 329 Volta 5.1 2.5 237 Eastern 17.3 2.5 240 Ashanti 20.2 3.8 510 Brong Ahafo 28.4 1.1 260 Northern 32.5 8.0 413 Upper East 19.5 4.9 142 Upper West 23.6 4.0 72 Mother’s education No education 23.8 4.4 888 Primary 19.8 3.5 668 Middle/JSS 19.0 2.3 920 Secondary + 9.1 0.5 252 Wealth quintile Lowest 25.3 5.1 693 Second 21.4 4.0 610 Middle 21.5 3.2 507 Fourth 16.4 1.7 528 Highest 10.2 0.1 393 Total 19.8 3.1 2,731 Note: Total includes cases with information missing on type of toilet facility and mother’s education that are not shown separately. 1 See Table 2.7 for definition of categories. 2 See Table 2.8 for definition of categories. Child Health | 173 Table 10.8 Diarrhoea treatment Among children under age five who had diarrhoea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Ghana 2008 Background characteristic Percentage of children with diarrhoea for whom advice or treatment was sought from a health facility or provider1 Oral rehydration therapy (ORT) In- creased fluids ORT or in- creased fluids Other treatments Missing No treat- ment Number of children with diarrhoea ORS packets Recom- mended home fluids (RHF) Either ORS or RHF Anti- biotic drugs Anti- motility drugs Zinc supple- ments Home remedy/ other Age in months <6 (35.2) (33.4) (1.9) (35.2) (26.3) (50.7) (11.4) (2.3) (2.1) (22.9) (0.0) (32.1) 31 6-11 44.3 34.6 13.2 41.1 22.0 53.7 27.7 1.7 2.0 27.6 0.5 21.3 82 12-23 48.6 53.8 15.4 62.6 42.2 76.9 41.5 0.5 1.8 29.3 0.6 9.0 180 24-35 37.5 45.4 10.2 51.2 46.4 68.6 39.3 0.9 0.9 31.2 1.6 7.4 110 36-47 34.5 45.3 14.6 55.7 38.9 69.4 30.4 6.9 2.7 18.7 0.0 13.4 74 48-59 31.9 34.2 15.6 40.8 33.7 57.1 36.9 1.6 1.7 29.3 4.6 4.8 65 Sex Male 40.1 44.5 12.9 50.8 38.1 66.5 35.6 1.9 2.2 29.3 0.4 11.0 274 Female 41.9 44.5 13.4 53.0 37.0 67.0 34.7 1.9 1.3 25.9 1.9 13.0 268 Type of diarrhoea Non bloody 37.8 42.1 13.9 50.0 36.6 65.0 33.1 1.1 2.1 27.6 1.3 12.4 457 Bloody 58.0 57.7 8.9 62.3 42.6 76.4 46.4 6.2 0.0 27.5 0.0 9.7 85 Residence Urban 37.5 49.2 12.8 55.5 35.9 70.5 38.4 1.7 2.2 23.3 0.5 8.8 181 Rural 42.8 42.2 13.3 50.1 38.4 64.9 33.5 2.0 1.6 29.8 1.5 13.6 361 Mother’s education No education 41.3 42.7 8.0 47.3 36.4 64.2 29.4 2.7 1.9 27.4 2.3 13.9 212 Primary 36.8 44.2 15.1 52.5 31.0 67.2 31.5 1.7 0.5 25.5 0.9 12.4 132 Middle/JSS 42.2 45.5 17.4 55.6 43.3 69.9 43.5 1.2 2.9 29.9 0.0 9.2 175 Secondary+ * * * * * * * * * * * * 23 Wealth quintile Lowest 41.2 40.8 8.7 43.6 34.1 58.3 27.3 3.4 2.2 27.8 3.0 15.5 176 Second 39.0 42.6 20.2 57.4 39.0 73.0 37.8 1.1 0.7 30.0 0.0 8.5 131 Middle 39.0 47.5 12.7 54.7 40.6 70.8 40.9 2.0 0.7 26.4 0.0 9.3 109 Fourth 42.9 51.1 9.1 55.5 35.4 68.6 40.5 0.7 2.7 26.1 0.0 14.3 86 Highest (48.0) (45.1) (19.3) (54.9) (44.7) (69.0) (34.1) (0.0) (4.1) (25.6) (2.0) (10.4) 40 Total 41.0 44.5 13.1 51.9 37.6 66.8 35.2 1.9 1.8 27.6 1.1 12.0 542 Note: ORT includes solution prepared from oral rehydration salts (ORS) and recommended home fluids (RHF). 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 Excludes pharmacy, shop, and traditional practitioner Overall, 41 percent of children with diarrhoea were taken to a health provider for treatment of diarrhoea. Children age 6-23 months are more likely to be taken to a health facility for treatment (44-49 percent) than children age over two years (32-38 percent). Differences in treatment-seeking behaviour by gender of child, urban-rural residence, and mother’s education are small. Children in the highest wealth quintile are more likely than other children to be taken to a health provider for treatment when they have diarrhoea. Oral rehydration therapy (ORT), which involves giving children with diarrhoea a solution prepared from oral rehydration salts (ORS) or recommended home fluids (RHF)—usually a home- made sugar-salt-water solution—is a simple and effective response to diarrhoeal illness. In the 2008 GDHS, more than half (52 percent) of children with diarrhoea were treated with either ORS (45 percent) or RHF (13 percent). Thirty-eight percent of children were given increased fluids. Overall, 67 percent of children under five with diarrhoea were treated with ORS, RHF, or increased fluids. Children under 12 months of age and children age 48-59 months are less likely to receive ORT than other children. Children in rural areas, children whose mothers have no education, and children in the lowest wealth quintile are also less likely to receive ORT. 174 | Child Health Antibiotics are generally not recommended for use in treating non-bloody diarrhoea in young children. In the 2008 GDHS, just over one-third of children with diarrhoea (35 percent) were treated with antibiotics, with a notable difference between bloody and non-bloody diarrhoea (46 percent and 33 percent, respectively). Giving antibiotics to treat diarrhoea is more likely in children age 12-23 months and children in urban areas. There is a steady increase in the use of antibiotics by mother’s level of education and household wealth quintile except for the highest wealth quintile. Home remedies were given to 28 percent of children with diarrhoea, and 2 percent each received anti- motility drugs and zinc supplements. One in eight children with diarrhoea was given no treatment at all. 10.6.2 Feeding Practices Mothers are encouraged to continue normal feeding of children with diarrhoea and to increase the amount of fluids given. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea on the child’s nutritional status. Mothers interviewed in the 2008 GDHS were asked whether they gave the child less, the same amount, or more fluids and food than usual when their child had diarrhoea. Table 10.9 shows the percent distribution of children under five who had diarrhoea in the two weeks preceding the survey by feeding practices, according to background characteristics. Thirty-eight percent of children with diarrhoea were given more to drink than usual, 35 percent were given the same as usual, and 26 percent were given less to drink than usual or nothing at all. It is particularly unfortunate that 10 percent of children with diarrhoea were given much less or nothing to drink. Food intake is curtailed even more than fluid intake during episodes of diarrhoea. Only 9 percent of children with diarrhoea were given more to eat than usual, 29 percent were given the same amount of food as usual, and 56 percent were given less food to eat than usual or none at all. These patterns reflect a gap in practical knowledge among some mothers regarding the nutritional requirements of children during diarrheal episodes. The 2008 GDHS findings indicate a need for further health education efforts to reduce the number of children that become dehydrated or malnourished because of improper feeding practices during diarrhoea. Overall, 24 percent of children with diarrhoea were given increased fluids and continued feeding, and 45 percent were given increased fluids, continued feeding, and ORT. Children age 24-35 months were more likely than other children to be given increased fluids, continued feeding, and ORT during the last episode of diarrhoea. Differentials in these indicators by other background characteristics are not large; however, there was an increase in both indicators (recommended feeding practices during diarrhoea) with increasing wealth quintile. T ab le 1 0. 9 F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d ist rib ut io n of c hi ld re n un de r ag e fiv e w ho h ad d ia rr ho ea in th e tw o w ee ks p re ce di ng th e su rv ey b y am ou nt o f l iq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, th e pe rc en ta ge o f c hi ld re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh oe a ep iso de , an d th e pe rc en ta ge o f ch ild re n w ho c on tin ue d fe ed in g an d w er e gi ve n O RT a nd /o r in cr ea se d flu id s du rin g th e ep iso de o f di ar rh oe a, b y ba ck gr ou nd c ha ra ct er ist ic s, G ha na 2 00 8 B ac kg ro un d ch ar ac te ris tic A m ou nt o f l iq ui ds o ffe re d A m ou nt o f f oo d of fe re d Pe rc en ta ge gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g1 ,2 Pe rc en ta ge w ho co nt in ue d fe ed in g an d w er e gi ve n O RT a nd /o r in cr ea se d flu id s3 N um be r o f ch ild re n w ith di ar rh oe a M or e Sa m e as u su al So m e- w ha t le ss M uc h le ss N on e D on ’t kn ow / m iss in g To ta l M or e Sa m e as u su al So m e- w ha t le ss M uc h le ss N on e N ev er ga ve fo od D on ’t kn ow / m iss in g To ta l A ge in m on th s < 6 (2 6. 3) (3 2. 9) (1 6. 2) (1 3. 7) (1 0. 9) (0 .0 ) 10 0. 0 (1 1. 4) (2 5. 1) (1 7. 7) (6 .3 ) (0 .0 ) (3 4. 6) (4 .8 ) 10 0. 0 (2 2. 3) (3 4. 6) 31 6- 11 22 .0 37 .4 20 .8 18 .0 1. 8 0. 0 10 0. 0 3. 6 23 .6 31 .1 16 .3 12 .6 12 .8 0. 0 10 0. 0 11 .5 28 .7 82 12 -2 3 42 .2 35 .0 15 .7 6. 5 0. 5 0. 1 10 0. 0 8. 8 30 .8 21 .8 24 .5 10 .0 3. 9 0. 1 10 0. 0 21 .2 45 .2 18 0 24 -3 5 46 .4 29 .0 16 .0 6. 1 0. 0 2. 5 10 0. 0 10 .9 28 .7 35 .3 18 .1 5. 4 0. 0 1. 6 10 0. 0 39 .0 55 .1 11 0 36 -4 7 38 .9 39 .2 13 .1 8. 8 0. 0 0. 0 10 0. 0 4. 4 23 .8 38 .2 24 .7 7. 2 0. 0 1. 9 10 0. 0 25 .1 49 .0 74 48 -5 9 33 .7 40 .9 15 .2 8. 1 0. 0 2. 1 10 0. 0 18 .0 34 .8 21 .8 17 .4 5. 9 0. 0 2. 1 10 0. 0 23 .1 44 .9 65 S e x M al e 38 .1 34 .8 16 .4 9. 0 1. 2 0. 5 10 0. 0 10 .3 28 .9 24 .2 23 .2 7. 0 5. 8 0. 6 10 0. 0 23 .0 42 .9 27 4 Fe m al e 37 .0 35 .8 15 .9 9. 2 1. 0 1. 2 10 0. 0 7. 9 28 .1 31 .8 16 .8 9. 0 4. 7 1. 7 10 0. 0 25 .4 46 .3 26 8 T yp e of d ia rr ho ea N on -b lo od y 36 .6 38 .0 14 .8 8. 5 1. 3 0. 7 10 0. 0 9. 2 30 .8 25 .6 19 .9 7. 1 6. 0 1. 4 10 0. 0 24 .0 43 .3 45 7 Bl oo dy 42 .6 20 .9 23 .3 12 .0 0. 0 1. 2 10 0. 0 8. 3 16 .1 40 .5 21 .0 13 .1 1. 0 0. 0 10 0. 0 24 .7 51 .1 85 R es id en ce U rb an 35 .9 43 .5 12 .1 7. 8 0. 7 0. 0 10 0. 0 7. 1 37 .8 29 .5 15 .9 6. 8 2. 9 0. 0 10 0. 0 25 .9 53 .2 18 1 Ru ra l 38 .4 31 .2 18 .1 9. 8 1. 3 1. 2 10 0. 0 10 .1 23 .8 27 .2 22 .2 8. 6 6. 4 1. 7 10 0. 0 23 .3 40 .2 36 1 M ot he r’ s ed uc at io n N o ed uc at io n 36 .4 31 .3 18 .8 10 .6 1. 3 1. 6 10 0. 0 4. 9 21 .9 32 .1 21 .6 8. 7 7. 9 3. 0 10 0. 0 22 .2 39 .2 21 2 Pr im ar y 31 .0 41 .4 17 .8 8. 6 0. 6 0. 8 10 0. 0 14 .6 32 .7 25 .9 16 .5 4. 4 5. 9 0. 0 10 0. 0 21 .0 50 .4 13 2 M id dl e/ JS S 43 .3 35 .5 11 .6 8. 2 1. 4 0. 0 10 0. 0 10 .0 32 .3 23 .7 21 .9 10 .2 1. 9 0. 0 10 0. 0 27 .4 46 .2 17 5 Se co nd ar y+ * * * * * * 10 0. 0 * * * * * * * 10 0. 0 * * 23 W ea lth q ui nt ile Lo w es t 34 .1 29 .8 22 .6 9. 8 1. 3 2. 5 10 0. 0 7. 3 18 .3 34 .6 20 .9 8. 6 6. 6 3. 6 10 0. 0 17 .6 33 .7 17 6 Se co nd 39 .0 29 .9 18 .1 12 .3 0. 7 0. 0 10 0. 0 10 .0 22 .3 27 .5 25 .0 8. 4 6. 8 0. 0 10 0. 0 22 .6 43 .7 13 1 M id dl e 40 .6 42 .6 9. 7 6. 0 1. 2 0. 0 10 0. 0 12 .3 33 .4 22 .8 21 .9 7. 0 2. 6 0. 0 10 0. 0 30 .4 50 .2 10 9 Fo ur th 35 .4 41 .1 13 .0 8. 7 1. 7 0. 0 10 0. 0 7. 4 40 .5 26 .5 14 .2 5. 5 5. 9 0. 0 10 0. 0 27 .8 54 .8 86 H ig he st (4 4. 7) (4 4. 9) (5 .6 ) (4 .8 ) (0 .0 ) (0 .0 ) 10 0. 0 (8 .8 ) (5 4. 0) (1 7. 6) (7 .6 ) (1 2. 0) (0 .0 ) (0 .0 ) 10 0. 0 (3 3. 0) (5 7. 3) 40 T ot al 37 .6 35 .3 16 .1 9. 1 1. 1 0. 8 10 0. 0 9. 1 28 .5 28 .0 20 .1 8. 0 5. 3 1. 2 10 0. 0 24 .1 44 .6 54 2 N ot e: A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 E qu iv al en t t o th e U N IC EF /W H O in di ca to r " H om e m an ag em en t o f d ia rr ho ea ." M IC S In di ca to r 3 4 2 “ C on tin ue d fe ed in g” in cl ud es c hi ld re n w ho w er e gi ve n m or e, s am e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh oe a ep iso de . 3 E qu iv al en t t o U N IC EF M IC S In di ca to r 3 5. | 175Child Health 176 | Child Health 10.7 KNOWLEDGE OF ORS PACKETS As mentioned earlier, a simple and effective response to dehydration caused by diarrhoea is a prompt increase in the child’s fluid intake through some form of ORT, which may include the use of a solution prepared from packets of oral rehydration salts (ORS). To ascertain how widespread knowledge of ORS is in Ghana, mothers were asked whether they know about ORS packets. Table 10.10 shows the percentage of mothers with a birth in the five years preceding the survey who know about ORS packets for treatment of diarrhoea, by background characteristics. Knowledge of ORS is widespread in Ghana, with 90 percent of mothers having heard of it. Younger mothers are slightly less likely to know about ORS than older mothers. Knowledge of ORS is higher among urban mothers and it increases with level of education and wealth quintile of mothers. Mothers in the Northern region are less likely than mothers in other regions to have heard of ORS. 10.8 STOOL DISPOSAL If human faeces are left uncontained, disease can spread by direct contact or by animal contact with the faeces. Hence, the proper disposal of children’s stools is important in preventing the spread of disease. Table 10.11 shows the percent distribution of mothers who have their youngest child under age five living with them, by the way in which the child’s stools are disposed of, according to background characteristics and type of toilet facilities in the household. The most common method of disposing of young children’s stools is rinsing the stools into a toilet or latrine (37 percent), followed by throwing them into the garbage (36 percent). Other methods of disposal include putting them into a drain or ditch (12 percent), or burying them (5 percent). Six percent of children are using a toilet or latrine, and 3 percent of children have their stools left in the open (not contained). Overall, less than half (48 percent) of children have their stools disposed of safely. There are marked differences in the way children’s stools are disposed of, according to background characteristics. For example, older children are more likely than younger children to have their stools disposed of safely. As expected, children in urban areas and children living in households with an improved toilet facility are more likely to have safe disposal of their stools than children in rural areas and those in households without such facilities. By region, the proportion of children whose stools are disposed of safely ranges from 19 percent in the Upper West region to 83 percent in the Eastern region. Safe disposal of children’s stools increases with mother’s level of education and household wealth quintile. Table 10.10 Knowledge of ORS packets or pre-packaged liquids Percentage of mothers age 15-49 with a birth in the five years preceding the survey who know about ORS packets or ORS pre- packaged liquids for treatment of diarrhoea, by background characteristics, Ghana 2008 Background characteristic Percentage of women who know about ORS packets or ORS pre- packaged liquids Number of women Age 15-19 82.9 100 20-24 88.8 405 25-34 92.0 982 35-49 89.8 612 Residence Urban 96.2 844 Rural 86.3 1,255 Region Western 87.2 189 Central 88.9 200 Greater Accra 96.7 262 Volta 96.3 181 Eastern 95.1 185 Ashanti 96.3 396 Brong Ahafo 91.6 218 Northern 72.6 291 Upper East 87.1 119 Upper West 92.3 58 Education No education 79.6 647 Primary 92.5 511 Middle/JSS 96.2 738 Secondary+ 97.6 201 Wealth quintile Lowest 75.2 480 Second 91.6 461 Middle 94.7 400 Fourth 95.9 436 Highest 97.9 322 Total 90.3 2,099 Note: Total includes cases with information missing on mother’s education that are not shown separately. ORS = Oral rehydration salts Child Health | 177 Table 10.11 Disposal of children’s stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of the child’s last faecal matter (stools), and percentage of children whose stools are disposed of safely, according to background characteristics, Ghana 2008 Background characteristic Manner of disposal of children’s stools Total Percentage of children whose stools are disposed of safely Number of mothers Child used toilet or latrine Put/ rinsed into toilet or latrine Buried Put/ rinsed into drain or ditch Thrown into garbage Left in the open Other Missing Age in months <6 1.0 27.3 3.3 35.5 27.7 3.2 1.9 0.2 100.0 31.6 308 6-11 0.0 35.4 4.6 17.1 38.4 3.8 0.4 0.5 100.0 39.9 297 12-23 2.6 39.9 5.2 7.6 41.4 2.5 0.0 0.8 100.0 47.7 530 24-35 3.6 41.7 6.6 5.3 39.2 3.0 0.0 0.8 100.0 51.8 358 36-47 13.2 35.9 7.0 1.7 37.1 3.8 0.0 1.3 100.0 56.1 275 48-59 23.9 34.6 4.1 4.0 26.3 5.1 0.7 1.2 100.0 62.6 222 Toilet facility Improved, not shared1 15.1 49.3 2.6 11.9 20.0 1.1 0.0 0.0 100.0 67.0 154 Non-improved or shared 5.1 35.5 5.4 11.6 37.5 3.5 0.5 0.8 100.0 46.1 1,828 Residence Urban 6.1 46.6 4.2 12.9 28.2 1.2 0.4 0.5 100.0 56.8 802 Rural 5.9 29.6 5.9 10.9 41.5 4.8 0.5 0.9 100.0 41.4 1,187 Region Western 2.1 55.2 0.9 15.9 25.0 0.0 0.0 0.9 100.0 58.2 181 Central 3.2 30.7 0.0 17.6 41.8 2.8 2.0 2.0 100.0 33.9 187 Greater Accra 9.2 42.9 2.5 12.2 30.5 2.7 0.0 0.0 100.0 54.6 251 Volta 6.8 37.6 12.8 5.3 31.3 6.1 0.0 0.0 100.0 57.2 173 Eastern 8.7 71.4 2.9 7.4 7.5 0.6 0.0 1.4 100.0 83.0 174 Ashanti 6.6 36.1 0.0 13.6 41.5 0.2 1.3 0.7 100.0 42.7 373 Brong Ahafo 4.5 40.1 1.2 6.9 46.6 0.8 0.0 0.0 100.0 45.8 206 Northern 2.3 10.6 11.8 11.6 51.2 11.4 0.0 1.1 100.0 24.6 276 Upper East 16.0 17.6 24.7 12.9 25.6 1.4 0.0 1.7 100.0 58.4 114 Upper West 1.4 8.5 8.8 11.7 55.6 14.0 0.0 0.0 100.0 18.7 54 Education No education 5.0 20.4 8.8 11.4 47.3 6.0 0.0 1.1 100.0 34.2 619 Primary 4.8 34.4 5.5 12.7 37.9 2.7 1.3 0.8 100.0 44.7 477 Middle/JSS 6.8 47.5 2.2 11.5 29.2 2.1 0.4 0.3 100.0 56.5 699 Secondary+ 8.6 52.9 3.5 11.1 21.6 1.1 0.0 1.2 100.0 65.0 193 Wealth quintile Lowest 5.8 16.0 12.6 9.4 46.8 7.9 0.0 1.4 100.0 34.4 460 Second 5.7 29.4 4.2 13.8 41.5 4.1 0.6 0.7 100.0 39.3 438 Middle 5.6 41.5 3.2 12.5 34.8 1.1 0.7 0.7 100.0 50.2 373 Fourth 3.7 50.8 2.7 10.7 30.1 1.7 0.0 0.4 100.0 57.2 411 Highest 10.2 52.0 1.2 12.6 22.1 0.4 1.0 0.4 100.0 63.5 306 Total 6.0 36.5 5.2 11.7 36.1 3.3 0.4 0.8 100.0 47.6 1,989 Note: Total includes cases with information missing on type of toilet facility and mother’s education that are not shown separately. 1 Non-shared facilities that are of the following types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; pit latrine with a slab; and a composting toilet. Nutrition of Children and Adults | 179 NUTRITION OF CHILDREN AND ADULTS 11 This chapter covers nutritional concerns for children and women. The 2008 GDHS collected information from respondents 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. Adequate nutrition is critical to child development. The period from birth to two years of age is important for optimal growth, health, and development. Unfortunately, this period is often marked by growth faltering, micronutrient deficiencies, and common childhood illnesses such as diarrhoea and acute respiratory infections (ARI). Optimal feeding practices reported in this chapter include early initiation of breastfeeding, exclusive breastfeeding during the first 6 months of life, continued breastfeeding for up to two years of age and beyond, timely introduction of complementary feeding at 6 months of age, frequency of feeding solid/semisolid foods, and the diversity of food groups fed to children between 6 and 23 months of age. A summary indicator that describes the quality of infant and young child (age 6-23 months) feeding practices (IYCF) is included. A woman’s nutritional status has important implications for her health as well as the health of her children. Malnutrition in women results in reduced productivity, an increased susceptibility to infections, slow recovery from illness, and heightened risks of adverse pregnancy outcomes. For example, a woman who has poor nutritional status—as indicated by a low body mass index (BMI), short stature, or other micronutrient deficiencies—has a greater risk of obstructed labour, of having a baby with low birth weight, of producing lower quality breast milk, of dying from post-partum haemorrhage, and of contracting diseases along with her baby. 11.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2008 GDHS permit the measurement and evaluation of the nutritional status of young children in Ghana. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. 11.1.1 Measurement of Nutritional Status among Young Children The 2008 GDHS collected information on the nutritional status of children by measuring the height and weight of all children under six years of age. The measurements were collected with the aim of calculating three indices—weight-for-age, height-for-age, and weight-for-height—all of which take age and sex into consideration. Weight measurements were obtained using lightweight, electronic Seca scales with a digital screen, designed and manufactured under the guidance of the United Nations Children’s Fund (UNICEF). Height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down (recumbent length) on the board while standing height was measured for older children. For the 2008 GDHS, the nutritional status of children is calculated using new growth standards published by the World Health Organisation (WHO) in 2006. These new growth standards were generated using data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). Each of the three nutritional status indicators described below is expressed in standard deviation units from the median of the WHO Child Growth Standards. The indices are not comparable with those based on the previously used NCHS/CDC/WHO Reference. 180 | Nutrition of Children and Adults For the purposes of comparison with previous surveys, Appendix Table C.7 includes indices expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO international reference population, which was in use prior to the new WHO Child Growth Standards. Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides different information about growth and body composition that is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) 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 effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children with Z-scores below -2 SD are considered thin (wasted) 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 -3 SD 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 -2 SD are classified as underweight. Children whose weight-for-age is below -3 SD are considered severely underweight. 11.1.2 Results of Data Collection Height and weight measurements were obtained for all children under age six living in half of the households selected for the GDHS sample. The results include children who were not biological offspring of the women interviewed in the survey. Although data were collected for all children under age six, for purposes of comparability, the analysis is limited to children under age five. Valid height and weight measurements were obtained for 87 percent of the 2,912 children under age five in the GDHS households. Measurements were missing for 7 percent of the children, presumably because the child was not present, the parents refused, or the child was ill. Another 6 percent of children were considered to have implausibly high or low values for the height or weight measures, and less than 1 percent lacked data on age in months. The following analysis focuses on the children for whom complete and plausible anthropometric and age data were collected. Table 11.1 and Figure 11.1 show the percentage of children under age five classified as malnourished according to height-for-age, weight-for-height, and weight-for age indices, by the child’s age and other selected demographic characteristics. Figure 11.1 shows that the level of stunting increases drastically in the second year of life when children are weaned, indicating chronic malnutrition over a long period of time. The level of wasting peaks at about 7 months of age at the time when complementary food in addition to breast milk is introduced. The level of undernutrition increases steadily and peaks at about 11 months of age and then levels off to the second year of life until the age of about 27 months before it starts to decline. Nutrition of Children and Adults | 181 Table 11.1 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 2008 Background characteristic Height-for-age Weight-for-height Weight-for-age Number of children Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Age in months <6 2.2 4.3 0.3 6.0 16.1 5.8 -0.5 3.7 7.8 4.0 -0.2 200 6-8 5.1 10.3 0.1 5.8 28.9 5.6 -1.0 4.8 16.0 0.3 -0.8 123 9-11 6.3 16.7 -0.3 5.5 20.8 7.2 -0.7 7.7 17.8 3.9 -0.8 146 12-17 6.4 22.5 -0.8 4.2 12.8 6.2 -0.5 3.4 14.9 3.5 -0.7 282 18-23 12.8 39.9 -1.4 2.5 9.6 3.5 -0.4 6.7 19.0 2.0 -1.0 223 24-35 12.6 32.6 -1.5 0.7 3.8 5.4 0.0 2.3 13.6 2.1 -0.8 487 36-47 13.8 33.4 -1.5 0.6 4.1 6.2 -0.0 2.2 15.1 1.8 -0.9 511 48-59 8.9 32.3 -1.4 0.7 3.4 3.8 -0.1 1.4 11.2 0.3 -0.9 553 Sex Male 11.0 29.6 -1.2 2.2 9.2 5.0 -0.3 3.7 15.4 1.5 -0.8 1,282 Female 8.6 26.2 -1.0 2.2 7.7 5.5 -0.2 2.6 12.4 2.4 -0.7 1,243 Birth interval in months2 First birth3 8.7 29.7 -1.2 2.1 9.5 5.0 -0.2 3.4 14.3 2.3 -0.8 513 <24 15.0 33.9 -1.3 2.1 8.4 8.2 -0.1 3.6 16.8 1.4 -0.8 237 24-47 9.9 28.3 -1.1 2.1 9.1 5.0 -0.3 3.1 13.9 1.3 -0.8 907 48+ 6.9 21.8 -0.9 2.9 8.2 4.8 -0.3 2.5 11.7 2.9 -0.7 608 Size at birth2 Very small 10.1 38.2 -1.5 7.6 12.7 1.9 -0.8 6.3 32.9 0.6 -1.4 91 Small 10.6 34.1 -1.3 2.4 11.7 6.7 -0.5 4.4 21.6 1.1 -1.0 214 Average or larger 9.2 26.2 -1.0 2.1 8.3 5.3 -0.2 2.8 11.8 2.1 -0.7 1,938 Mother’s interview status Interviewed 9.3 27.5 -1.1 2.3 8.9 5.3 -0.3 3.1 13.7 1.9 -0.8 2,265 Not interviewed but in household 14.8 30.3 -1.1 3.8 8.9 4.0 -0.1 3.5 15.6 4.0 -0.7 42 Not interviewed, and not in the household4 13.7 32.7 -1.2 0.5 4.4 5.2 -0.1 4.0 15.5 1.4 -0.8 218 Mother’s nutritional status5 Thin (BMI <8.5) 9.1 32.3 -1.2 3.4 16.9 6.1 -0.6 3.8 21.6 1.3 -1.1 158 Normal (BMI 18.5-24.9) 10.8 30.6 -1.2 2.3 9.2 4.3 -0.3 3.5 15.3 1.3 -0.9 1,470 Overweight/obese (BMI ≥25) 5.9 19.2 -0.7 1.9 6.2 7.2 -0.1 1.8 8.0 3.6 -0.4 645 Residence Urban 6.8 21.1 -0.9 1.5 7.6 6.7 -0.2 1.6 10.6 2.6 -0.6 975 Rural 11.7 32.3 -1.2 2.6 9.1 4.3 -0.3 4.1 16.0 1.5 -0.9 1,550 Region Western 10.8 27.0 -1.2 2.2 5.6 5.9 -0.0 2.5 10.3 1.0 -0.7 236 Central 14.1 33.7 -1.3 1.7 12.0 9.7 -0.2 5.4 17.2 2.8 -0.9 246 Greater Accra 2.5 14.2 -0.6 0.5 5.9 4.9 -0.1 0.5 6.5 2.4 -0.4 277 Volta 8.1 26.8 -1.1 2.2 5.2 7.9 -0.2 3.6 13.6 4.1 -0.8 228 Eastern 12.3 37.9 -1.4 3.7 6.4 12.0 0.3 2.0 8.7 3.5 -0.6 216 Ashanti 7.4 26.5 -0.9 2.6 9.2 3.7 -0.3 4.2 12.1 2.1 -0.7 507 Brong Ahafo 8.0 25.2 -1.1 0.0 5.4 2.8 -0.3 1.4 13.5 0.3 -0.8 274 Northern 15.4 32.4 -1.2 3.4 12.9 2.0 -0.6 3.4 21.8 0.8 -1.1 360 Upper East 13.8 36.0 -1.4 2.9 10.8 1.3 -0.5 5.5 27.0 1.5 -1.2 116 Upper West 7.9 24.6 -1.0 3.9 13.9 3.0 -0.6 3.3 13.1 0.0 -1.0 66 Mother’s education6 No education 11.8 29.6 -1.2 3.5 11.4 4.6 -0.4 3.7 17.2 1.5 -1.0 738 Primary 10.4 31.6 -1.2 2.1 7.7 4.8 -0.2 3.4 13.5 2.0 -0.8 545 Middle/JSS 7.4 25.1 -1.0 1.7 8.3 5.5 -0.2 2.8 12.4 2.2 -0.7 783 Secondary+ 5.3 17.5 -0.6 1.1 5.4 7.9 0.1 0.6 6.8 3.3 -0.3 218 Wealth quintile Lowest 13.9 35.1 -1.4 2.8 9.4 3.2 -0.4 4.1 19.2 0.7 -1.0 623 Second 12.4 34.1 -1.3 2.3 10.1 3.9 -0.3 4.2 17.4 1.4 -0.9 573 Middle 8.8 28.3 -1.1 2.7 9.4 6.0 -0.2 3.6 12.5 1.9 -0.8 468 Fourth 6.0 21.4 -0.9 1.6 6.1 7.9 -0.1 2.0 8.4 3.3 -0.6 504 Highest 5.3 14.4 -0.5 1.0 6.6 6.3 -0.1 0.8 8.6 3.3 -0.3 356 Total 9.8 28.0 -1.1 2.2 8.5 5.3 -0.2 3.1 13.9 1.9 -0.8 2,525 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO Reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes cases with information missing on size at birth, mother’s nutritional status, and mother’s education and are not shown separately. 1 Includes children who are below –3 standard deviations (SD) from the WHO Child Growth Standards 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 Includes children whose mothers are deceased 5 Excludes children whose mothers were not weighed and measured. Mother’s nutritional status in terms of BMI (Body Mass Index) is presented in Table 11.9. 6 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers were not listed in the Household Questionnaire 182 | Nutrition of Children and Adults Figure 11.1 Nutritional Status of Children by Age Note: Stunting reflects 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. # # ## ## # ### ################################################# ) ) ) ) )) )))) ) ) )))))))))))))))))))))))))))))))) ))))))))))))))) 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 Age (months) 0 10 20 30 40 Percent Stunted average Wasted average Underweight average) # Vulnerable Period GDHS 2008 11.1.3 Levels of Malnutrition The results show that 28 percent of children under five are stunted (below -2 SD), with 10 percent being severely stunted (-3 SD). Children 18-23 months (40 percent) are most likely to be stunted and those less than 6 months are the least likely to be stunted (4 percent). Male children are slightly more likely to be stunted than female children (30 percent, compared with 26 percent). The extent of stunting decreases as the birth interval and size at birth increase, and as the mother’s Body Mass Index (BMI) increases. The level of stunting is higher in the rural areas (32 percent) than in the urban areas (21 percent). Stunting varies by region; it is highest in the Eastern and Upper East regions (38 and 36 percent, respectively) and lowest in the Greater Accra region (14 percent). Stunting decreases as mother’s level of education and wealth quintile increase. The weight-for-height index gives information about children’s recent experience with food intake. Wasting represents failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of recent illness or of seasonal variations of food. Overall, 9 percent of children under five are wasted, with 2 percent severely wasted. Wasting is highest among children age 6-8 months (29 percent) and is lowest among children age 48-59 months (3 percent). The level of wasting does not vary much with sex, birth interval, or urban-rural residence. The extent of wasting decreases as the size at birth increases and mother’s nutritional status improves. Wasting is more common in the Upper West (14 percent), Northern (13 percent) and Central (12 percent) regions than elsewhere. Wasting generally decreases as mother’s level of education and wealth quintile increase. Table 11.1 highlights another problem among young children in Ghana: 5 percent are over- weight [Z-scores are above two standard deviations (+2 SD)]. The highest proportion of overweight children is in age group 9-11 months, with 7 percent of children in that age group being overweight. A higher proportion of children in urban areas are overweight than children in rural areas (7 and 4 percent, respectively). Looking at regional patterns, the prevalence of overweight children ranges from 1 percent in the Upper East region to 12 percent in the Eastern region. Although variations by mother’s level of education and wealth quintile are not large, the highest proportions of overweight children are seen among the most educated mothers and mothers who live in wealthier households. Nutrition of Children and Adults | 183 Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are considered underweight. The measure reflects the effects of both acute and chronic malnutrition. Overall, 14 percent of Ghanaian children are underweight, with 3 percent classified as severely underweight. Peak levels of low weight-for-age are found among children age 18-23 months (19 percent), followed by those age 9-11 months (18 percent). Male children are slightly more likely to be underweight than female children (15 and 12 percent, respectively). The percentage of children who are underweight decreases as birth interval, size at birth and mother’s nutritional status increase. Children living in rural areas are more likely to be underweight than urban children (16 and 11 percent, respectively). The proportion of underweight children ranges from 7 percent in the Greater Accra region to 27 percent in the Upper East region. Children born to mothers with little or no education are substantially more likely to be underweight than children of more educated women. For example, the proportion of underweight children born to women with no education is 17 percent, compared with 7 percent among children born to women with secondary education or higher. Similarly, children from households in the two wealthiest quintiles are the least likely to be underweight (8-9 percent). 11.1.4 Trends in Children’s Nutritional Status The results of the 2008 GDHS on children’s nutritional status can be compared with the results from four earlier surveys conducted in Ghana. However, several factors make this comparison difficult. In the 1988, 1993, and 1998 GDHS surveys, anthropometric measurements were restricted to children born to women interviewed with the Woman’s Questionnaire. However, these data are not representative of all children, because 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 individual interview. To overcome these biases, the 2003 and 2008 GDHS surveys included height and weight measurements of all children born in the five years preceding the survey and listed in the Household Questionnaire, irrespective of the interview status of their mother. Second, the 2008 GDHS analysis is based on the new WHO child growth reference standards, while all the earlier surveys used the older National Centre for Health Statistics (NCHS) reference standard. As mentioned above, for comparison purposes, data from the 2008 GDHS were also tabulated according to the older reference population (Appendix Table C.7). Finally, for comparison purposes in this section, data from the 1988, 1993, 1998, 2003, and 2008 GDHS surveys were all re-calculated according to the new reference population, but restricted to children born to women interviewed with the Women’s Questionnaire and living with an interviewed mother. Figure 11.2 shows that the proportion of children under five who are stunted decreased from 34 percent in 1988 to 31 percent in 1998, and then peaked at 35 percent in 2003 before decreasing to 28 percent in 2008. The proportion of children who are wasted has also decreased over the past 15 years from 14 percent in 1993 to 9 percent in 2008, with no marked change over the past five years. The proportion of underweight children decreased from 23 percent in 1988 and 1993 to 14 percent in 2008. Regarding overweight, the proportion of children whose weight-for-height is above plus two standard deviations (+2 SD) has not changed in the past five years. However, the percentage of children who are overweight has increased steadily over the past 20 years from less than 1 percent in 1988 to 5 percent in 2008. 184 | Nutrition of Children and Adults 34 9 23 1 33 14 23 3 31 10 20 2 35 8 18 4 28 9 14 5 Stunting Wasting Underweight Overweight 0 10 20 30 40 50 60 Percent 1988 1993 1998 2003 2008 Figure 11.2 Trends in Nutritional Status of Children under Five Years Note: Based only on children whose mothers were interviewed 11.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the contraction of the uterus and reduces post-partum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 11.2 shows the percentage of all children born in the five years preceding the survey ever breastfed and for last-born children ever breastfed, the timing of initial breastfeeding, by background characteristics. Overall, 98 percent of children born in the past five years have been breastfed at some time. For last-born children ever breastfed, 52 percent started breastfeeding within one hour of birth and 82 percent started breastfeeding within the first 24 hours after delivery. There are no major differentials in the percentage of children ever breastfed by background characteristics. The results from the 2008 GDHS show that there is no difference in early initiation of breastfeeding by sex of child. Children in urban areas (55 percent) are slightly more likely to receive breast milk during the first hour after birth than children in rural areas (50 percent). The proportion of children who receive early breastfeeding varies by type of assistance at delivery and place of delivery. Whereas 56 percent of newborns of mothers who received assistance at delivery from a health professional were breastfed within an hour of birth, only 33 percent of newborns whose mothers receive no assistance at delivery received the same attention. Similarly, children of women who gave birth in a health facility (56 percent) are more likely to initiate breastfeeding early than women who deliver at home (47 percent). The proportion of women initiating breastfeeding within an hour of birth is highest in the Upper East region (68 percent). Early initiation of breastfeeding is below 50 percent for children residing in the Brong Ahafo, Eastern, and Northern regions. Nutrition of Children and Adults | 185 Table 11.2 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and for last- born children in the past five years who were ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth, and the percentage who received a prelacteal feed, by background characteristics, Ghana 2008 Background characteristic Breastfeeding among children born in past five years Among last-born children ever breastfed: Percentage of children ever breastfed Number of children born in past five years 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 last-born children ever breastfed Sex Male 97.6 1,510 52.2 81.1 18.2 1,067 Female 97.5 1,399 52.5 83.7 17.9 993 Residence Urban 97.2 1,104 55.4 85.5 17.5 827 Rural 97.7 1,806 50.2 80.3 18.4 1,234 Assistance at delivery Health professional3 97.1 1,706 56.0 85.6 15.7 1,264 Traditional birth attendant (trained) 97.1 470 49.8 80.0 19.2 308 Traditional birth attendant (untrained) 98.8 409 43.9 77.4 21.2 261 Other 98.6 236 48.9 74.7 29.7 168 No one 99.2 74 33.0 69.3 16.7 58 Place of delivery Health facility 97.2 1,662 56.0 85.6 15.5 1,235 At home 97.9 1,223 47.3 77.9 21.8 816 Other * 13 * * * 10 Region Western 98.6 271 58.0 79.7 26.4 187 Central 98.3 292 55.5 79.1 24.8 198 Greater Accra 96.0 346 52.8 81.5 17.7 256 Volta 99.1 244 53.4 97.3 6.8 180 Eastern 98.6 254 47.7 82.1 14.5 182 Ashanti 96.0 545 49.6 78.5 26.9 384 Brong Ahafo 98.8 272 46.6 81.2 13.1 215 Northern 97.1 456 48.2 80.4 9.5 286 Upper East 98.5 148 67.8 91.0 25.7 117 Upper West 95.7 82 60.2 83.2 2.3 57 Mother’s education No education 97.3 952 50.8 80.5 15.7 636 Primary 96.7 722 53.8 82.4 20.2 493 Middle/JSS 97.9 970 53.3 83.1 18.5 728 Secondary+ 99.1 263 49.4 85.5 19.2 201 Wealth quintile Lowest 97.9 744 51.2 81.9 18.3 475 Second 98.0 641 45.6 75.7 17.7 452 Middle 97.4 549 52.6 83.8 21.9 393 Fourth 97.0 560 57.0 86.4 14.5 426 Highest 96.9 415 57.0 85.3 18.3 315 Total 97.5 2,909 52.3 82.4 18.1 2,061 Note: Table is based on births in the past five years whether the children were living or dead at the time of interview. Total includes cases with information missing on assistance at delivery, place of delivery, and mother’s education that 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 3 Doctor, nurse/midwife, auxiliary midwife, or community health officer 186 | Nutrition of Children and Adults The survey results indicate that more than one in five (18 percent) last-born babies ever breastfed received a prelacteal feed, i.e., received something other than breast milk during the first three days of life. Children whose births were assisted by someone other than a health professional or a traditional birth attendant, and children born at home, are more likely to receive a prelacteal feed than children whose births were assisted by a health provider, and children born in a health facility. The practice of giving the baby a prelacteal feed is more common in the Ashanti, Western, Upper East, and Central regions, where more than one in four children are given a prelacteal feed. It is also practiced more commonly among children in households in the middle wealth quintile (22 percent). Recent trends in breastfeeding indicate that the percentage of children ever breastfed has remained stable at 97-98 percent over the past five years. On the other hand, the percentage of children who started breastfeeding within one hour of birth has increased from 46 to 52 percent over the period, and the percentage who started breastfeeding within 1 day of birth increased from 75 to 82 percent. The proportion of children who received prelacteal feeds decreased slightly from 20 percent to 18 percent between 2003 and 2008. 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first 6 months of life and that children be given solid or semi-solid complementary foods in addition to continued breastfeeding from 6 months until age 24 months or more when the child is fully weaned. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to pathogens and increases their risk of infection, especially diarrhoeal diseases. Second, it decreases infants’ intake of breast milk and therefore suckling, which reduces breast milk production. Third, in low-resource settings, supplementary food is often nutritionally inferior. Information on complementary feeding was obtained by asking mothers about the current breastfeeding status of all children under five years of age and—for the youngest child born in the three-year period before the survey and living with the mother—foods and liquids given to the child the day and night before the survey. Table 11.3 shows the percent distribution of youngest children under three years of age living with the mother by breastfeeding status, and the percentage of all children under three years using a bottle with a nipple, according to age in months. The results presented in Table 11.3 and Figure 11.3 show that breastfeeding duration is long in Ghana. All children under six months in Ghana are breastfed and at age 12-15 months, the vast majority of children (95 percent) are still breastfeeding. By age 20-23 months, 56 percent of children have been weaned. While breastfeeding extends for a long time in Ghana, exclusive breastfeeding has short duration; 84 percent of children under 2 months of age are exclusively breastfed; by age 4-5 months, only 49 percent are still being exclusively breastfed. Overall, 63 percent of children under 6 months are exclusively breastfed, which is far less than the 100 percent recommended. In addition to breast milk, 3 percent of children under 6 months are given other (non-breast) milk, 17 percent are given water, less than 1 percent are given non-milk liquids or juice, and 17 percent are given complementary food in the form of solid or mushy food. At age 6-9 months, nearly all Ghanaian children are still being breastfed but three in four breastfeeding children are receiving complementary foods in addition to breast milk. Similar patterns are observed for older children; 96 percent of children age 9-11 months are still breastfeeding while 86 percent are receiving complementary foods. Nutrition of Children and Adults | 187 Table 11.3 Breastfeeding status by age Percent distribution of youngest children under three years who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under three years using a bottle with a nipple, according to age in months, Ghana 2008 Age in months Not breast- feeding Breastfeeding and consuming: Total Percentage currently breast- feeding Number of youngest child under three years Percentage using a bottle with a nipple1 Number of all children under three years Exclu- sively breast- fed Plain water only Non- milk liquids/ juice Other milk Comple- mentary foods <2 0.0 84.3 9.4 0.0 2.9 3.4 100.0 100.0 82 5.4 85 2-3 0.0 60.3 22.5 0.4 3.7 13.0 100.0 100.0 117 13.9 122 4-5 0.0 49.4 17.1 1.3 1.1 31.1 100.0 100.0 109 10.8 111 6-8 2.2 5.3 18.8 0.0 0.9 72.8 100.0 97.8 147 21.1 150 9-11 4.0 0.9 8.3 0.8 0.5 85.6 100.0 96.0 150 12.0 152 12-17 7.0 1.2 1.4 0.6 0.4 89.4 100.0 93.0 305 9.3 312 18-23 46.6 0.0 1.8 0.0 0.7 50.9 100.0 53.4 224 8.7 239 24-35 89.8 0.0 0.0 0.0 0.0 10.2 100.0 10.2 358 3.9 496 0-3 0.0 70.2 17.1 0.2 3.4 9.1 100.0 100.0 198 10.4 206 0-5 0.0 62.8 17.1 0.6 2.6 16.9 100.0 100.0 308 10.5 317 6-9 2.9 4.1 15.9 0.7 1.1 75.3 100.0 97.1 188 20.3 191 12-15 5.5 1.5 2.3 0.0 0.7 90.0 100.0 94.5 191 11.9 194 12-23 23.8 0.7 1.6 0.3 0.5 73.1 100.0 76.2 530 9.1 552 20-23 56.1 0.0 0.9 0.0 0.0 42.9 100.0 43.9 138 11.3 152 Note: Breastfeeding status refers to a 24-hour period (yesterday and the past night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/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 non-milk liquids and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Children who receive complementary foods are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years Figure 11.3 Infant Feeding Practices by Age <2 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 24 -2 5 26 -2 7 28 -2 9 30 -3 1 32 -3 3 34 -3 5 Age in months 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and nonmilk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding GDHS 2008 Percent 188 | Nutrition of Children and Adults It can be noted that the data reported here on proportion of children less than 6 months who are exclusively breastfed cannot be compared with data from the previous DHS, because the questions on food intake were different in the current survey. The 2008 GDHS asked about more supplementary food items, which could have helped mothers better recall foods given to the infants. Use of a bottle with a nipple for infant feeding is not widespread in Ghana, which is encouraging because of problems of hygiene that can cause contamination and illness in the child: only 5 percent of the youngest infants (under 2 months) are bottle-fed. This proportion peaks at 21 percent among children age 6-8 months before declining. The percentage of young children bottle- fed has not changed over the past five years. In the 2008 GDHS, 11 percent of children under six months were given a feeding bottle with a nipple, compared with 12 percent of children in the 2003 GDHS. 11.4 DURATION AND FREQUENCY OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by selected background character- istics. The estimates of median and mean durations of breastfeeding are based on current status data, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of any breastfeeding in Ghana is long—20 months, although the median duration of exclusive breastfeeding is short—only 3 months. Differences in both these durations by background characteristics are small. Children in rural areas are breastfed somewhat longer than children in urban areas (21 months, compared with 19 months). The median duration of any breastfeeding decreases with increasing level of education and increasing wealth quintile. Almost all children under 6 months of age (96 percent) are breastfed at least six times a day. On average, children are fed more frequently during the day (about 9 times) than during the night (about 6 times). The frequency of breastfeeding varies only slightly by background characteristics. 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the introduction of solid foods to infants around the age of 6 months because by that age breast milk alone is no longer sufficient to maintain a child’s optimal growth. In the transition to eating the same food as the rest of the family, children from the age of 6 months should be fed small quantities of solid and semi-solid foods throughout the day. During this transition period (age 6-23 months), the prevalence of malnutrition increases substantially in many countries because of increased infections and poor feeding practices. Nutrition of Children and Adults | 189 Table 11.4 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 2008 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Frequency of breastfeeding among children under six months of age2 Any breast- feeding Exclusive breast- feeding Predominant breast- feeding3 Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 20.2 3.6 5.6 97.3 9.1 5.7 163 Female 20.3 3.2 4.8 94.7 8.5 5.4 143 Residence Urban 18.9 3.9 5.4 99.5 8.8 5.7 127 Rural 21.3 2.9 5.1 93.6 8.8 5.5 179 Mother’s education No education 21.8 3.5 5.5 97.7 9.1 6.1 92 Primary 19.9 3.0 4.6 94.3 8.6 5.1 76 Middle/JSS 19.6 2.9 5.0 94.3 8.4 5.4 99 Secondary+ (19.8) (4.6) (6.0) 100.0 9.4 5.6 39 Wealth quintile Lowest 23.9 3.3 5.5 95.4 8.8 5.8 70 Second 20.8 2.8 4.5 92.0 9.2 5.4 62 Middle 20.1 3.0 5.2 100.0 9.4 6.2 61 Fourth 19.2 3.7 5.6 95.0 7.9 5.1 67 Highest (17.1) (3.9) (5.2) (98.7) (8.9) (5.4) 47 Total 20.2 3.3 5.2 96.1 8.8 5.6 306 Mean for all children 20.4 4.4 6.2 na na na na Note: Median and mean durations are based on the distribution at the time of the survey of the proportion of births, by months since birth. Includes both living children and children who were dead at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. The total includes cases with information missing on mother’s education that are not shown separately. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only 190 | Nutrition of Children and Adults Table 11.5 provides information on the types of foods given to the youngest children under three years of age, living with their mother, on the day and night preceding the interview, according to breastfeeding status. Overall, 68 percent of breastfeeding children received solid or semi-solid foods. The most common complementary foods were made from grain (64 percent); meat, fish, poultry, and eggs (47 percent); fruits and vegetables other than those rich in vitamin A (37 percent); fruits and vegetables rich in vitamin A (33 percent); and foods made from roots and tubers (30 percent). Consumption of anything cooked with butter, fat, or oil generally begins at 4-5 months (3 percent), increasing to 55 percent at 24-35 months. Table 11.5 shows that almost 100 percent of non-breastfeeding children under three years received solid or semi-solid foods in the day and night preceding the interview, indicating that con- sumption of complementary foods is generally higher among non-breastfeeding children than breast- feeding children. Ninety-six percent of non-breastfeeding children received foods made from grains; almost nine in ten (89 percent) were given meat, fish, poultry, or eggs; 65 percent ate fruits and vegetables other than those rich in vitamin A; 59 percent ate fruits and vegetables rich in vitamin A; and 63 percent consumed food made from roots and tubers. Six in ten non-breastfeeding children under three years consumed food made with oil, fat, or butter, while about half (49 percent) ate sugary foods. Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview Percentage of youngest children under three years of age who are living with the mother, by type of foods consumed in the day and night preceding the interview, according to breastfeeding status and age, Ghana 2008 Age in months Liquids Solid or semi-solid foods Any solid or semi- solid food Food made with oil, fat, or butter Sugary foods Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry, and eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 2.9 1.4 0.0 0.0 2.0 0.0 0.0 0.0 0.0 0.0 1.5 3.4 0.0 0.0 82 2-3 6.8 3.7 1.1 0.5 7.9 0.7 0.0 0.7 1.7 0.5 2.2 12.1 0.0 0.9 117 4-5 6.7 13.5 3.3 5.4 29.1 3.7 1.0 2.9 6.5 4.4 3.6 31.1 2.5 5.7 109 6-8 13.7 17.9 11.2 18.2 71.4 22.6 31.6 16.6 9.7 28.4 2.9 74.4 18.1 19.7 144 9-11 11.9 20.4 18.7 21.9 84.9 41.6 49.5 34.0 12.7 59.4 9.4 89.2 32.7 31.6 144 12-17 7.2 22.4 30.1 10.9 89.3 54.6 63.3 51.4 25.8 78.6 6.7 95.7 47.9 37.0 284 18-23 1.1 14.8 27.2 1.9 91.3 58.8 57.9 52.3 27.9 81.0 5.1 95.3 36.4 29.9 120 24-35 0.0 10.4 29.9 8.4 98.3 56.8 52.0 53.7 19.2 87.0 4.5 100.0 55.3 27.6 37 6-23 8.5 19.7 23.3 13.1 85.0 46.0 52.9 40.7 20.1 64.6 6.2 89.9 36.6 31.1 691 Total 7.4 15.5 17.1 9.7 64.3 33.2 37.3 29.5 15.0 46.7 5.1 68.4 26.6 22.4 1,035 NON-BREASTFEEDING CHILDREN 6-17 (19.0) (40.5) (34.1) (33.5) (98.3) (68.6) (56.2) (43.8) (16.8) (82.6) (20.6) (99.1) (57.9 ) (48.9) 30 18-23 13.0 39.3 43.2 10.6 96.0 56.5 63.6 61.9 30.0 86.2 12.7 99.0 58.1 54.9 105 24-35 3.3 23.7 40.7 7.8 95.2 59.0 66.4 65.4 26.0 89.9 9.9 99.7 60.8 47.1 322 6-23 14.4 39.6 41.1 15.7 96.5 59.2 62.0 57.9 27.0 85.4 14.5 99.1 58.0 53.6 135 Total 6.6 28.4 40.8 10.1 95.6 59.1 65.1 63.2 26.3 88.6 11.2 99.5 60.0 49.0 456 Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and the past night). Figures in parentheses are based on 25-49 unweighted cases. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk 2 Does not include plain water 3 Includes fortified baby food 4 Includes fruits and vegetables such as pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A Nutrition of Children and Adults | 191 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Infant and young child feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older, while maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months (PAHO/WHO, 2003; WHO, 2005). Table 11.6 presents the results of the 2008 GDHS according to IYCF practices for breastfed and non-breastfed children living with their mother. The indicators focus on the percentage of children for whom feeding practices meet minimum standards with respect to— • Food diversity (i.e., the number of food groups consumed), • Feeding frequency (i.e., the number of times a child is fed), and • Consumption of breast milk or other milks or milk products. Breastfed children are considered fed in accordance with the minimum IYCF standards if they consume at least three food groups1 and receive foods other than breast milk at least twice per day in the case of children age 6-8 months and at least three times per day in the case of children age 9-23 months. Non-breastfed children are considered to be fed in accordance with the minimum IYCF standards if they consume milk or milk products, are fed four food groups (including milk products), and are fed at least four times per day. Among breastfed children age 6-23 months, about seven in ten (68 percent) were given foods from three or more food groups in the 24 hours preceding the survey, and half were fed the minimum number of times in the past 24 hours. More than four in ten breastfed children (41 percent) fall into both categories, i.e., their feeding practices meet minimum standards with respect to food diversity and feeding frequency (Figure 11.4). The proportion of breastfed children age 6-23 months who receive the recommended variety of foods the minimum number of times a day increases with children’s age from 28 percent among children age 6-8 months to 50 percent among those age 18-23 months. There are slight variations in the proportion of breastfed children who meet both criteria by sex of child and urban-rural residence; however, the differentials by region are larger. The percentage of breastfed children who are fed from three or more food groups the minimum number of times a day ranges from 24 percent in the Northern region to 72 percent in Volta. There is no clear pattern in the proportion of breastfed children who meet the IYCF criteria by mother’s level of education and household wealth quintile. Among non-breastfed children age 6-23 months, 43 percent are given milk or milk products, 74 percent are given food from at least four food groups, and 22 percent are fed four or more times per day. However, only about one-tenth (11 percent) of non-breastfeeding children are fed in accordance with all three IYCF practices (data not shown). 1 Food groups used in the assessment of minimum standard of feeding practices include: infant formula, milk other than breast milk, cheese or yogurt or other milk products; foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; fruits and vegetables rich in vitamin A; other fruits and vegetables; eggs; meat, poultry, fish, and shellfish (and organ meats); beans, peas, and nuts; and foods made with oil, fat, or butter. 192 | Nutrition of Children and Adults Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices, by breastfeeding status, number of food groups consumed and number of times they were fed during the day and night preceding the survey, by background characteristics, Ghana 2008 Background characteristic Among breastfed children 6-23 months, percentage fed: Number of breast- fed children 6-23 months Among all children 6-23 months, percentage fed: Number of all children 6-23 months 3+ food groups1 Minimum times or more2 Both 3+ food groups and minimum times or more Breast milk or milk products3 3+ or 4+ food groups4 Minimum times or more5 With all 3 IYCF practices Age 6-8 33.0 55.1 28.3 144 97.8 34.5 53.9 27.7 147 9-11 67.7 43.9 37.4 144 99.3 68.2 43.6 36.7 150 12-17 80.0 50.1 45.7 284 96.1 79.2 47.8 43.7 305 18-23 81.0 53.1 50.1 120 73.0 78.0 39.3 31.3 224 Sex Male 69.0 48.8 40.2 337 92.2 71.4 46.1 36.5 403 Female 66.8 51.9 42.0 354 89.3 66.6 45.5 35.9 424 Residence Urban 71.6 52.3 42.1 235 88.8 73.7 46.6 36.2 311 Rural 65.9 49.3 40.6 456 91.9 66.0 45.3 36.2 516 Region Western 74.3 36.3 29.6 60 90.3 72.5 31.7 26.4 75 Central (67.5) (47.8) (39.6) 62 81.4 72.2 36.6 30.6 84 Greater Accra 75.5 66.5 55.1 64 87.4 77.9 57.2 44.5 87 Volta 76.1 82.1 72.4 70 97.4 76.5 81.3 69.6 75 Eastern 68.3 37.8 32.2 60 85.2 66.7 32.2 26.1 79 Ashanti 62.3 55.3 40.4 130 87.6 65.1 50.1 34.2 162 Brong Ahafo 67.6 61.6 49.0 69 98.0 66.7 58.6 46.3 77 Northern 56.6 29.0 23.9 109 94.7 56.9 27.9 22.4 117 Upper East 75.6 34.9 29.0 43 99.1 76.5 33.5 27.9 45 Upper West 75.2 55.0 49.1 24 97.1 74.8 53.4 47.7 25 Mother’s education No education 64.0 44.0 37.2 235 92.2 63.9 40.0 33.8 259 Primary 66.2 53.0 43.7 155 84.8 68.1 45.5 34.7 199 Middle/JSS 71.7 55.2 44.1 244 92.1 73.0 51.2 39.2 295 Secondary+ 71.9 48.6 37.4 57 96.3 72.9 45.4 36.5 72 Wealth quintile Lowest 63.2 47.0 38.4 193 97.5 63.2 45.9 37.0 201 Second 67.7 51.1 43.6 163 87.2 66.7 44.6 37.7 189 Middle 69.0 52.2 41.9 131 92.4 69.8 46.8 37.3 153 Fourth 68.7 49.9 42.3 126 85.1 71.4 41.9 33.3 166 Highest 76.2 55.1 39.4 78 90.7 77.9 51.8 35.2 117 Total 67.9 50.4 41.1 691 90.7 68.9 45.8 36.2 826 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Food groups: a) infant formula, milk other than breast milk, cheese or yogurt or other milk products; b) foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c) vitamin A-rich fruits and vegetables (and red palm oil); d) other fruits and vegetables; e) eggs; f) meat, poultry, fish, and shellfish (and organ meats); g) legumes and nuts; h) foods made with oil, fat, or butter. 2 At least twice a day for breastfed infants age 6-8 months and at least three times a day for breastfed children age 9-23 months 3 Includes commercial infant formula, fresh, tinned, and powdered animal milk, and cheese, yogurt and other milk products 4 3+ food groups for breastfed children and 4+ food groups for non-breastfed children 5 Fed solid or semi-solid food at least twice a day for infants 6-8 months, 3+ times for other breastfed children, and 4+ times for non-breastfed children Nutrition of Children and Adults | 193 41 11 36 59 89 64 Breastfed Non-breastfed All 0 20 40 60 80 100 Percentage of all children 6-23 months Fed with all IYCF practices Not fed with all IYCF practices Figure 11.4 Infant and Young Child Feeding (IYCF) Practices GDHS 2008 The results in Table 11.6 indicate that a large majority of young children in Ghana are not being fed appropriately. Overall, feeding practices meet the minimum standards for only 36 percent of children age 6-23 months. The most common problem with feeding practices is inadequate number of feedings. More than nine in ten (91 percent) children age 6-23 months received breast milk or milk products and about seven in ten (69 percent) received foods from the recommended number of food groups for their age. However, only 46 percent were fed the minimum number of times. Appropriate feeding practices are more common for breastfed children than non-breastfed children (41 and 11 percent, respectively). Children age 12-17 months (44 percent) are the most likely to be fed according to all three IYCF practices, while those age 6-8 months (28 percent) are the least likely to be fed according to IYCF practices. There is very little difference in feeding practices between girls and boys or by urban-rural residence. Among regions, the percentage of children who are fed appropriately is highest in Volta region (70 percent) and lowest in Northern region (22 percent). Again, the relationship between the proportion of children who are fed appropriately and mother’s level of education and household wealth quintile does not show a clear pattern. 11.7 ANAEMIA IN CHILDREN Anaemia is a condition characterised by a reduction in the red blood cell volume and a decrease in the concentration of haemoglobin in the blood. Haemoglobin is necessary for transporting oxygen to tissues and organs in the body. About half of the global burden of anaemia is due to iron deficiency. Iron deficiency, in turn, is largely due to an inadequate dietary intake of bioavailable iron, increased iron requirements during rapid growth periods (such as pregnancy and infancy), and increased blood loss due to hookworm or schistosome infestation. Nutritional anaemia includes the anaemia burden due to deficiency in iron plus deficiencies in folate, vitamins B and B12, and certain trace elements involved with red blood cell production. Anaemia in children is associated with impaired mental and physical development and with increased morbidity and mortality. Anaemia can be a particularly serious problem for pregnant women, leading to premature delivery and low birth weight. 194 | Nutrition of Children and Adults The most common causes of anaemia in Ghana are inadequate dietary intake of iron, malaria, and intestinal worm infestation (GHS, 2003). 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 important measures to reduce the anaemia burden among vulnerable groups. The 2008 GDHS included anaemia testing of children age 6-59 months and women age 15-49 in every second household selected for the 2008 GDHS sample. Anaemia levels were determined by measuring the level of haemoglobin in the blood, with a decreased concentration characterising anaemia. For haemoglobin measurements, a drop of capillary blood was taken with a finger prick (using sterile, disposable instruments). Haemoglobin concentration was measured using the HemoCue photometer system. As described in Chapter 1, trained personnel with each 2008 GDHS interviewing team performed the testing procedures on eligible, consenting respondents. Table 11.7 presents anaemia prevalence for children age 6-59 months. The results are based on tests of 2,313 (de facto) children present at the time of testing, whose parents consented to their being tested, and whose haemoglobin results represented plausible data. Children are classified into three groups according to the level of haemoglobin in their blood:2 • Mild: haemoglobin concentration 10.0-10.9 g/dL • Moderate: haemoglobin concentration 7.0-9.9 g/dL • Severe: haemoglobin concentration less than 7.0 g/dL Overall, 78 percent of children age 6-59 months in Ghana have some level of anaemia, in- cluding 23 percent of children who are mildly anaemic, 48 percent who are moderately anaemic, and 7 percent of children with severe anaemia. Prevalence of any anaemia increases with age to peak at 88 percent for the age groups 9-11 months and 12-17 months, after which it declines to 70 percent for the age group 48-59 months. Anaemia is slightly more common in boys (79 percent) than in girls (77 percent). Children in rural areas (84 percent) are more likely than children in urban areas (68 percent) to be anaemic. By region, children in the Upper East and Upper West regions (89 and 88 percent, respectively) are the most likely to be anaemic, while children in the Greater Accra region are the least likely to be anaemic (62 percent). The percentage of children with anaemia decreases as the level of mother’s education increases. For example, the prevalence of anaemia is 83 percent among children of uneducated mothers, compared with 58 percent among children of mothers with secondary or higher education. Similarly, the prevalence of anaemia in children decreases with increasing wealth quintile from 87 percent among children in the lowest wealth quintile to 61 percent among children in the highest quintile. The prevalence of anaemia among children has increased slightly over the past five years, from 76 percent in 2003 to 78 percent in 2008 (Figure 11.5). 2 The classification is based on criteria developed by WHO (DeMaeyer et al., 1989). Because haemoglobin levels vary by altitude, each child’s result should be adjusted based on altitude measurements taken in the sample cluster where they were measured. However, in the GDHS 2008, adjustments for altitude were not made because none of the children were living above 1,000 metres. Nutrition of Children and Adults | 195 Table 11.7 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Ghana 2008 Background characteristic Anaemia status by haemoglobin level Any anaemia Number of children Mild (10.0-10.9 g/dL) Moderate (7.0-9.9 g/dL) Severe (below 7.0 g/dL) Age in months 6-8 16.5 53.5 6.0 76.0 103 9-11 18.8 57.1 11.8 87.8 139 12-17 19.1 58.2 10.9 88.3 293 18-23 23.2 48.0 9.4 80.7 222 24-35 21.9 49.1 8.6 79.7 482 36-47 26.5 42.9 6.0 75.4 512 48-59 24.4 41.3 4.3 70.0 562 Sex Male 23.1 48.2 7.8 79.1 1,186 Female 22.6 46.9 7.1 76.6 1,126 Mother’s interview status Interviewed 22.5 47.8 7.7 77.9 2,037 Not interviewed but in household 19.4 57.0 7.2 83.6 45 Not interviewed, and not in the household1 27.1 44.0 5.6 76.7 231 Residence Urban 24.8 37.7 5.4 67.9 887 Rural 21.7 53.8 8.7 84.1 1,426 Region Western 16.7 52.5 11.2 80.4 218 Central 22.8 56.8 4.9 84.5 219 Greater Accra 31.7 26.2 4.2 62.1 267 Volta 20.1 53.3 5.3 78.7 198 Eastern 26.1 45.3 1.8 73.1 211 Ashanti 23.3 44.8 9.8 77.9 453 Brong Ahafo 25.0 47.1 6.2 78.3 249 Northern 16.0 53.5 11.9 81.4 326 Upper East 31.4 51.4 5.7 88.5 109 Upper West 13.7 64.2 10.3 88.2 62 Mother’s education2 No education 17.9 54.5 10.2 82.6 668 Primary 23.5 50.1 6.9 80.5 501 Middle/JSS 25.0 44.8 6.8 76.6 699 Secondary+ 26.3 28.5 2.9 57.7 189 Wealth quintile Lowest 20.9 55.1 11.4 87.4 570 Second 21.8 52.1 9.7 83.6 543 Middle 21.7 54.0 5.8 81.5 418 Fourth 21.4 41.1 5.2 67.8 457 Highest 31.7 27.7 1.8 61.2 325 Total 22.9 47.6 7.4 77.9 2,313 Note: Table is based on children who slept in the household the night before the interview. Haemoglobin in grams per decilitre (g/dL). Total includes cases with information missing on mother’s education that are not shown separately. 1 Includes children whose mothers are dead 2 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers were not listed in the Household Questionnaire. 196 | Nutrition of Children and Adults Figure 11.5 Trends in Anaemia Status among Children under Five Years 23 47 6 76 23 48 7 78 Mild anaemia Moderate anaemia Severe anaemia Any anaemia 0 20 40 60 80 100 Percent 2003 2008 The World Health Organisation considers the level of anaemia observed among young children in Ghana to be a major public health concern.3 Compared with estimates from recent Demographic and Health Surveys conducted in the region, the prevalence of any anaemia among children in Ghana (78 percent) is similar to the prevalence in Benin: 78 percent in 2006 (INSAE and Macro International Inc., 2007), Guinea: 76 percent in 2005 (DNS and ORC Macro, 2006), and Sierra Leone: 76 percent in 2008 (SSL and ICF Macro, 2009), but lower than the prevalence in Mali: 81 percent in 2006 (CPS/MS, DNSI/MEIC and Macro International Inc., 2007), Senegal: 83 percent in 2005 (Ndiaye and Ayad, 2006), and Niger: 84 percent in 2006 (INS and Macro International Inc., 2007). 11.8 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a serious contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. Table 11.8 shows indicators used to measure children’s intake of several key micronutrients. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency can cause eye damage. Vitamin A deficiency can also increase the severity of infections such as measles and diarrhoeal diseases in children and slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, yellow-orange sweet potatoes, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for 4-6 months. Periodic dosing (usually every 6 months) of vitamin A supplements is one method of ensuring that children at risk do not develop vitamin A deficiency. 3 WHO considers anaemia prevalence of over 40 percent in a population as a major public health problem, from 20-40 percent is considered a medium-level public health problem, and 5-19.9 percent is a mild public health problem (World Health Organisation, 2001). Nutrition of Children and Adults | 197 Table 11.8 Micronutrient intake among children Among youngest children age 6-35 months living with their mother, the percentage who consumed vitamin A-rich and iron-rich foods in the day and night preceding the survey, and among all children age 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, the percentage who were given iron supplements in the past seven days, and the percentage who were given de-worming medication in the six months preceding the survey, by background characteristics, Ghana 2008 Background characteristic Among youngest children age 6-35 months living with the mother: Among all children age 6-59 months: Percentage who consumed foods rich in vitamin A in past 24 hours1 Percentage who consumed foods rich in iron in past 24 hours2 Number of children Percentage given vitamin A supplements in past 6 months Percentage given iron supplements in past 7 days Percentage given de-worming medication in past 6 months3 Number of children Age in months 6-8 36.5 30.0 147 67.8 23.3 7.5 150 9-11 70.3 60.3 150 78.4 27.0 20.0 152 12-17 86.0 78.7 305 68.9 30.9 38.6 312 18-23 89.5 83.5 224 64.4 32.7 43.5 239 24-35 93.2 89.6 358 52.8 32.6 48.3 496 36-47 na na na 49.3 23.3 47.6 506 48-59 na na na 43.9 24.0 47.6 559 Sex Male 81.3 76.0 589 57.6 27.4 42.9 1,243 Female 80.2 73.0 596 53.9 27.7 40.9 1,171 Breastfeeding status Breastfeeding 72.9 65.7 728 69.5 26.4 26.3 743 Not breastfeeding 93.1 88.5 454 49.8 28.3 49.6 1,637 Mother’s age 15-19 77.1 70.7 61 52.7 30.4 39.9 82 20-29 79.4 73.1 617 56.2 29.1 43.2 1,150 30-39 82.0 76.3 406 58.1 26.5 42.7 908 40-49 85.7 78.2 100 47.3 23.6 34.7 274 Residence Urban 82.0 79.0 444 57.8 34.2 52.8 906 Rural 79.9 71.8 740 54.6 23.5 35.4 1,508 Region Western 79.5 77.8 112 60.3 34.7 42.0 225 Central 80.9 75.7 121 58.7 29.9 49.8 229 Greater Accra 85.0 83.2 134 53.9 35.8 55.6 289 Volta 82.3 76.8 99 56.6 20.1 29.6 208 Eastern 81.1 73.7 106 50.1 32.7 48.6 216 Ashanti 80.1 72.0 230 65.3 36.5 61.7 468 Brong Ahafo 79.3 74.7 115 49.7 19.3 39.8 234 Northern 76.5 68.7 166 41.2 16.3 13.8 357 Upper East 85.8 74.3 64 67.3 13.9 16.2 125 Upper West 81.6 67.3 36 66.4 17.1 40.2 63 Mother’s education No education 78.1 69.7 374 51.1 17.3 23.9 791 Primary 81.4 77.4 294 56.0 27.1 41.4 590 Middle/JSS 83.2 76.0 416 59.0 36.4 54.5 819 Secondary+ 78.2 78.2 100 60.8 32.4 61.6 213 Wealth quintile Lowest 80.2 69.1 291 48.4 16.4 21.2 621 Second 77.7 69.4 270 57.1 23.5 39.8 546 Middle 80.1 75.9 215 54.3 30.3 47.7 441 Fourth 81.9 78.6 237 63.1 37.8 54.3 459 Highest 85.6 84.4 171 59.4 36.7 58.9 347 Total 80.7 74.5 1,184 55.8 27.5 41.9 2,414 Note: Information on vitamin A and iron supplements and de-worming medication is based on the mother’s recall. Total includes cases with information missing on breastfeeding status and mother’s education that are not shown separately. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A 2 Includes meat (including organ meat), fish, poultry, and eggs 3 De-worming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 198 | Nutrition of Children and Adults Iron is essential for cognitive development. Low iron intake can also contribute to anaemia. Iron requirements are greatest between the ages of 6 and 12 months, when growth is extremely rapid. The 2008 GDHS collected information on the consumption of foods rich in vitamin A and foods rich in iron. Table 11.8 shows that more than eight in ten (81 percent) children age 6-35 months living with the mother consumed foods rich in vitamin A in the 24 hours preceding the survey, and three- fourths consumed foods rich in iron. There is a steady increase with age in the proportion of children who eat foods rich in vitamin A and iron, from 37 percent of children 6-8 months to 93 percent of those age 24-35 months for foods rich in vitamin A and from 30 percent of children 6-8 months to 90 percent of those 24-35 months for foods rich in iron. Male children are slightly more likely to have consumed foods rich in iron than female children. Children who are not breastfeeding are more likely to consume foods rich in vitamin A and iron, compared with their breastfeeding counterparts, presumably because they are older than breastfeeding children. Children born to the youngest mothers (15-19) are somewhat less likely to consume vitamin A-rich foods or iron-rich foods (77 and 71 percent, respectively), compared with those born to older women. Consumption of foods rich in vitamin A or iron is higher among children in urban areas than children in rural areas. Consumption of vitamin A foods is highest among children in the Upper East region (86 percent) and lowest in the Northern region (77 percent). Consumption of iron-rich foods ranges from 67 percent in the Upper West region to 83 percent in the Greater Accra region. Consumption of vitamin A or iron-rich foods among children age 6-35 months generally increases with increasing wealth quintile. Mother’s level of education is not clearly related to consumption of these foods by young children. The 2008 GDHS also collected information on vitamin A supplementation and iron supplementation. As shown in Table 11.8, more than half (56 percent) of all children age 6-59 months received vitamin A supplements in the six months preceding the survey. Supplementation is higher among younger children age 6-23 months than older children age 24-59 months. Male children are more likely to have received a vitamin A supplement in the past 6 months than female children (58 and 54 percent, respectively), and children who are breastfeeding are more likely than non- breastfeeding children to have received a vitamin A supplement (70 and 50 percent, respectively). Children of the oldest mothers age 40-49 are the least likely (47 percent) to have received a vitamin A supplement, compared with children of younger mothers (53-58 percent). Children in urban areas (58 percent) are slightly more likely to receive a vitamin A supplement than children in rural areas (55 percent). The proportion of children receiving vitamin A supplements is highest in the Upper East (67 percent), Upper West (66 percent), and Ashanti (65 percent) regions and lowest in the Northern region (41 percent). The proportion of children receiving a vitamin A supplement is lowest for children of uneducated mothers (51 percent) and children in households in the lowest wealth quintile (48 percent). The proportion of children age 6-59 months who received vitamin A supplementation in the preceding 6 months has declined substantially, from 78 percent in 2003 to 56 percent in 2008. However, in 2008, twice as many children under three who live with their mother consumed fruits and vegetables rich in vitamin A, compared with their counterparts in 2003 (81 and 41 percent, respectively). Regarding iron supplementation, only 28 percent of children age 6-59 months received an iron supplement in the seven days preceding the survey. Contrary to vitamin A supplementation, iron supplementation is slightly higher among non-breastfeeding children than among children who are breastfeeding. Children in urban areas are more likely than children in rural areas to have received iron supplementation in the past seven days (34 and 24 percent, respectively). Consumption of iron supplements ranges from 14 percent in the Upper East region to 37 percent in the Ashanti region. Nutrition of Children and Adults | 199 Because intestinal worms can contribute to both anaemia and vitamin A deficiency, the 2008 GDHS collected information on whether children age 6-59 months had been given de-worming medication. The results, shown in Table 11.8, indicate that 42 percent of children age 6-59 months received de-worming medication in the six months preceding the survey. Older children age 24-59 months, non-breastfeeding children, children in urban areas and in the Ashanti and Greater Accra regions, and children whose mothers have more education and are in the higher wealth quintiles are more likely to receive de-worming medication than other children. 11.9 NUTRITIONAL STATUS OF WOMEN Anthropometric data on height and weight were collected for interviewed women age 15-49. Two indicators of nutritional status based on these data are presented in this report: the percentage of women with very short stature (less than 145 cm) and body mass index (BMI). BMI or the Quetelet index, is used to measure thinness or obesity. BMI is defined as weight in kilograms divided by height squared in metres (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socio-economic status and nutrition during childhood and adolescence. Low pre-pregnancy BMI and short stature are risk factors for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is a leading risk factor for preventable death and diseases. Table 11.9 presents the mean values of the two indicators of nutritional status and the proportions of women falling into high-risk categories, according to background characteristics. Respondents 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. The analysis of height is based on 4,820 women, and the analysis of BMI is based on 4,381 women age 15-49 years. The data show that just 1 percent of women age 15-49 in Ghana are less than 145 cm in height. There are no major variations by background characteristics, except for residence. Women in rural areas are somewhat more likely than women in urban areas to be shorter than 145 cm, and women in the Central region are more likely than women in other regions to be very short. The mean BMI for women 15-49 in Ghana is 23.6. Analysis by background characteristics shows that the mean BMI falls in the normal range (18.5-24.9) for all categories of background characteristics. At the national level, 9 percent of women are considered to be thin (BMI < 18.5); however, only 2 percent of women are considered to be moderately or severely thin (BMI < 17). The highest proportions of women with a BMI less than 18.5 are observed among younger women age 15- 19 (16 percent), women living in rural areas (11 percent), and those in the Upper East, Northern, and Volta regions (15, 12 and 11 percent, respectively). The percentage of thin women tends to decrease as woman’s level of education increases, and as wealth quintile increases. The proportion of overweight or obese women stands at 30 percent, with 9 percent of women considered to be obese (BMI ≥30.0). The proportion of overweight or obese women is positively correlated with women’s age; the proportion increases from 10 percent among women age 15-19 to a high of 44 percent for the age group 40-49. Urban women are twice as likely to be overweight or obese (40 percent) as rural women (20 percent). A regional comparison shows that the Upper West, Northern, and Upper East regions have the lowest proportion of overweight or obese women (13, 14, and 15 percent, respectively), while the Greater Accra region has the highest proportion (45 percent). The proportion of women who are overweight or obese increases with level of education and wealth quintile. 200 | Nutrition of Children and Adults Table 11.9 Nutritional status of women Among women age 15-49, the percentage with height under 145 centimetres, mean Body Mass Index (BMI), and the percentage with specific BMI levels, by background characteristics, Ghana 2008 Background characteristic Height Body Mass Index1 Percent- age below 145 cm Number of women Mean Body Mass Index (BMI) Normal Thin Overweight/obese Number of women 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moderately and severely thin) ≥25.0 (total over- weight or obese) 25.0-29.9 (over- weight) ≥30.0 (obese) Age 15-19 1.7 990 21.3 73.5 16.2 11.9 4.3 10.3 8.8 1.6 947 20-29 1.4 1,688 23.1 67.3 6.9 5.3 1.6 25.8 20.9 4.9 1,468 30-39 1.2 1,265 24.9 53.0 5.7 4.5 1.2 41.3 26.5 14.8 1,120 40-49 1.4 877 25.2 48.9 7.1 4.6 2.5 44.0 25.8 18.2 845 Residence Urban 0.9 2,341 24.7 53.7 6.1 4.8 1.3 40.3 26.2 14.0 2,160 Rural 1.9 2,478 22.5 69.0 11.1 8.0 3.1 19.9 15.3 4.6 2,220 Region Western 1.2 444 23.7 57.9 8.6 6.4 2.1 33.5 23.6 9.9 397 Central 2.9 416 23.8 59.3 8.7 6.3 2.4 31.9 24.4 7.5 374 Greater Accra 0.6 836 25.6 51.0 4.5 4.0 0.5 44.5 25.1 19.4 766 Volta 2.3 418 23.3 61.0 11.0 8.4 2.6 28.0 19.1 8.9 381 Eastern 2.1 474 24.0 59.1 7.1 4.7 2.4 33.8 24.0 9.8 448 Ashanti 1.4 999 23.6 59.8 9.5 7.2 2.2 30.7 22.5 8.2 912 Brong Ahafo 1.1 423 22.6 72.2 7.5 3.7 3.8 20.2 15.8 4.4 394 Northern 1.0 455 21.7 74.5 11.7 9.2 2.5 13.8 11.5 2.4 385 Upper East 0.8 236 21.8 69.9 14.8 11.4 3.4 15.3 11.7 3.7 215 Upper West 1.1 119 21.8 77.5 9.8 6.8 3.0 12.7 10.3 2.4 108 Education No education 1.4 1,017 22.7 68.9 9.8 7.4 2.4 21.3 16.1 5.2 896 Primary 2.2 971 23.5 59.9 9.9 6.8 3.1 30.1 20.9 9.2 877 Middle/JSS 1.4 2,002 23.7 60.3 8.8 6.4 2.4 30.9 20.7 10.2 1,832 Secondary+ 0.7 826 24.4 57.0 5.4 4.8 0.6 37.6 25.8 11.8 772 Wealth quintile Lowest 1.5 757 21.6 75.7 12.6 9.5 3.1 11.7 9.7 2.1 668 Second 1.9 877 22.0 69.9 14.3 9.7 4.6 15.8 12.6 3.2 776 Middle 2.2 961 23.0 67.8 9.0 6.6 2.4 23.3 18.5 4.8 875 Fourth 1.1 1,111 24.6 53.6 5.2 4.2 1.0 41.2 29.5 11.7 1,031 Highest 0.7 1,114 25.7 48.3 4.9 3.9 1.0 46.8 27.0 19.8 1,030 Total 1.4 4,820 23.6 61.4 8.6 6.4 2.2 29.9 20.7 9.3 4,381 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). Total includes cases with information missing on mother’s education that are not shown separately. 1 Excludes pregnant women and women with a birth in the past 2 months Looking at trends over the past five years, most of the nutritional status indicators for women have remained stable; however, the proportion of women who are overweight or obese has increased, from 25 percent in 2003 to 30 percent in 2008 (Figure 11.6). 11.10 FOODS CONSUMED BY MOTHERS The quality and quantity of foods consumed by mothers has a direct impact on their health and that of their children, especially the health of breastfeeding children. The 2008 GDHS included questions on the types of foods consumed by mothers of children under age three during the day and night preceding the interview. Table 11.10 shows the foods most commonly consumed by mothers with a child less than three years living with them. These foods include meat, fish, shellfish, poultry, and eggs (88 percent); foods made from grains (86 percent); foods made from roots and tubers and fruits and vegetables that are not rich in vitamin A (65 percent, each); and vitamin A-rich fruits and vegetables (61 percent). Foods cooked with oil, fat, or butter are consumed by about half of these Nutrition of Children and Adults | 201 Figure 11.6 Trends in Nutritional Status among Women 15-49 Years 11 11 9 9 25 30 GDHS 1993 GDHS 1998 GDHS 2003 GDHS 2008 0 10 20 30 40 Percent Thin Overweight or obese na na Note: Undernutrition BMI <18.5 and overnutrition BMI >25.0 na = Not applicable women (52 percent), while foods made from legumes (26 percent) and other solid or semi-solid foods (27 percent) are consumed by about one in four women. Differences in consumption of these food groups by background characteristics are not large, although the consumption of grains, proteins, and foods cooked with oil, fat or butter is somewhat higher among women in urban areas than those in rural areas, while the reverse is seen for the consumption of roots or tubers, legumes, and vitamin A- rich foods. With a few exceptions (grains, roots or tubers, and legumes), the consumption of each food type increases with level of education and household wealth quintile. Consumption of meat, fish, shellfish, poultry, and eggs is particularly high among women in the Greater Accra region (96 percent). The findings indicate that only 17 percent of mothers consumed milk in the 24 hours preceding the interview. Women in urban areas (28 percent) are more likely to drink milk than those in rural areas (11 percent). At the regional level, the percentage of women drinking milk is highest in the Greater Accra region (37 percent) and lowest in the Upper West and Volta regions (8 and 9 percent, respectively). Twenty-one percent of women drank tea or coffee, and 16 percent drank other liquids. 202 | Nutrition of Children and Adults Table 11.10 Foods consumed by mothers in the day and night preceding the interview Among mothers age 15-49 with a child under age three years living with them, the percentage who consumed specific types of foods in the day and night preceding the interview, by background characteristics, Ghana 2008 Background characteristic Solid or semi-solid foods Foods made with oil/fat/ butter Sugary foods Number of mothers Foods made from grains Foods made from roots/ tubers Foods made from legumes Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt Vitamin A-rich fruits/ vege- tables1 Other fruits/ vege- tables Other solid or semi- solid food Liquids Milk Tea/ coffee Other liquids Age 15-19 11.4 21.5 14.2 86.6 69.9 25.4 89.9 4.6 64.0 68.1 25.5 42.6 23.2 90 20-29 19.0 21.7 15.7 86.2 63.0 23.9 88.0 7.8 59.0 63.4 26.2 52.0 18.0 766 30-39 17.8 21.8 16.3 86.0 67.4 30.7 88.6 8.3 63.5 66.0 27.7 53.4 15.6 518 40-49 7.1 15.8 12.2 84.0 67.0 24.1 85.0 2.7 66.0 66.4 27.6 55.5 7.2 118 Residence Urban 27.9 31.7 21.1 88.2 59.0 24.2 93.5 12.4 59.2 68.9 27.5 59.8 22.8 571 Rural 10.5 14.8 12.2 84.7 69.1 27.7 84.8 4.3 62.8 62.3 26.4 47.5 12.8 921 Region Western 17.5 21.1 20.5 87.4 67.0 22.9 85.9 6.9 56.2 61.4 19.9 63.2 14.9 147 Central 13.6 18.7 19.7 88.0 77.9 31.2 92.8 6.5 47.8 66.7 11.2 64.4 20.2 159 Greater Accra 37.1 33.6 28.8 90.5 43.5 26.8 96.2 18.4 52.4 68.2 26.6 62.2 31.2 175 Volta 8.9 17.5 9.5 92.4 66.5 28.3 91.8 4.5 62.8 85.0 40.2 48.0 10.4 128 Eastern 18.1 17.9 23.4 90.2 73.9 31.2 86.7 9.0 65.2 65.7 12.7 44.0 22.9 130 Ashanti 15.1 10.1 12.4 79.6 70.2 14.2 90.6 5.4 66.4 57.6 24.0 57.8 15.2 270 Brong Ahafo 10.5 15.8 15.5 73.9 83.4 17.7 84.5 6.6 55.9 66.7 18.3 34.7 11.6 141 Northern 17.4 33.4 5.9 83.7 61.6 35.5 80.8 3.9 60.5 61.5 25.9 33.9 10.4 217 Upper East 15.4 23.1 7.7 96.5 41.9 35.0 82.7 5.4 95.5 57.2 70.6 59.4 14.6 81 Upper West 8.2 26.4 8.1 95.1 43.0 40.4 81.8 7.7 78.5 63.4 78.5 67.2 10.5 44 Education No education 12.5 20.9 7.2 87.2 63.1 33.0 82.0 3.9 64.3 60.9 29.0 45.1 11.9 466 Primary 10.2 14.1 15.1 85.3 65.7 21.9 90.4 4.0 58.3 61.4 28.0 53.1 12.0 370 Middle/JSS 18.6 21.7 18.7 85.9 70.0 23.1 89.4 10.5 60.0 68.2 21.8 54.3 20.0 516 Secondary+ 45.7 39.5 33.4 83.9 53.4 28.2 97.5 16.6 65.5 74.4 35.1 66.4 32.5 139 Wealth quintile Lowest 7.7 15.3 7.9 84.4 61.5 28.5 79.9 2.2 68.6 59.1 31.8 39.9 8.6 362 Second 7.0 14.6 9.8 87.5 71.8 25.5 84.9 4.7 61.9 62.2 23.3 47.8 9.2 333 Middle 15.2 22.4 15.4 86.9 73.5 24.3 90.4 5.3 52.6 63.5 21.1 56.0 21.6 277 Fourth 22.5 24.2 21.1 85.6 66.8 26.4 93.9 9.0 63.3 66.7 26.8 57.3 20.6 303 Highest 43.8 36.1 29.7 85.8 48.7 26.8 95.8 20.7 57.4 77.7 31.3 67.5 29.5 217 Total 17.2 21.3 15.6 86.0 65.2 26.4 88.1 7.4 61.4 64.8 26.8 52.2 16.6 1,492 Note: Foods consumed in the past 24-hour period (yesterday and the past night). Total includes cases with information missing on education that are not shown separately. 1 Includes fruits and vegetables such as 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 11.11 ANAEMIA IN WOMEN The same equipment and procedures used to measure anaemia in children were employed to measure anaemia in women. Three levels of severity of anaemia are distinguished: mild anaemia (10.0-10.9 grams/decilitre for pregnant women and 10.0-11.9 g/dL for non-pregnant women), moderate anaemia (7.0-9.9 g/dL), and severe anaemia (less than 7.0 g/dL). Appropriate adjustments in these cut-off points should be made for respondents living at altitudes above 1,000 metres and respondents who smoke, because both of these groups require more haemoglobin in their blood (Centres for Disease Control and Prevention, 1998). These adjustments were made for respondents who smoke, however adjustments for altitude were not made because none of the respondents was living at altitudes above 1,000 metres. Table 11.11 shows the prevalence of anaemia in women age 15-49. Anaemia is less prevalent among women than children, 59 percent of women in Ghana have some level of anaemia, compared with 78 percent in children. The great majority of women are mildly anaemic (39 percent), while 18 percent are moderately anaemic, and 2 percent are severely anaemic. The prevalence of anaemia is highest among younger women age 15-19 (63 percent). As expected, the prevalence of anaemia is higher among pregnant (70 percent) and breastfeeding (62 percent) women than among those who are Nutrition of Children and Adults | 203 neither pregnant nor breastfeeding (57 percent). Prevalence of any anaemia is higher among women in rural areas (62 percent) than women in urban areas (55 percent). Regional variation in the prevalence of anaemia among women ranges from 48 percent in the Upper East region to 71 percent in the Western region. The level of anaemia among women age 15-49 in Ghana has increased over the past five years from 45 percent in 2003 to 59 percent in 2008, with the most noticeable increase occurring in the prevalence of moderate anaemia (9 percent in 2003 and 18 percent in 2008) (Figure 11.7). Table 11.11 Prevalence of anaemia in women Percentage of women age 15-49 with anaemia, by background characteristics, Ghana 2008 Anaemia status by haemoglobin level Any Number of women Mild Moderate Severe Background characteristic Not pregnant: 10.0-11.9 g/dL 7.0-9.9 g/dL <7.0 g/dL <12.0 g/dL Pregnant: 10.0-10.9 g/dL 7.0-9.9 g/dL <7.0 g/dL <11.0 g/dL Age 15-19 43.7 17.5 1.8 63.0 993 20-29 37.3 18.7 1.6 57.6 1,649 30-39 38.5 18.3 1.6 58.3 1,242 40-49 36.4 16.3 3.6 56.2 863 Number of children ever born 0 40.1 17.0 1.6 58.7 1,586 1 36.8 18.0 1.7 56.5 650 2-3 37.7 18.7 2.2 58.6 1,152 4-5 37.7 18.7 2.7 59.1 785 6+ 40.8 17.6 2.2 60.6 574 Maternity status Pregnant 23.4 40.0 6.6 70.0 351 Breastfeeding 43.9 16.2 1.7 61.8 1,004 Neither 38.8 16.1 1.6 56.6 3,392 Residence Urban 36.6 17.1 1.5 55.3 2,290 Rural 40.8 18.6 2.4 61.8 2,458 Region Western 42.6 25.2 3.4 71.2 423 Central 47.4 15.1 1.2 63.7 408 Greater Accra 36.4 13.1 1.2 50.7 833 Volta 38.1 17.4 2.5 58.1 418 Eastern 41.6 14.3 2.4 58.3 468 Ashanti 37.6 19.7 2.6 59.9 971 Brong Ahafo 34.8 21.3 1.7 57.8 423 Northern 36.3 21.9 1.1 59.3 450 Upper East 36.8 10.5 1.1 48.4 235 Upper West 40.4 22.7 3.9 66.9 120 Education No education 38.0 20.4 1.4 59.9 1,008 Primary 40.3 20.1 3.1 63.5 962 Middle/JSS 39.8 16.8 2.2 58.7 1,979 Secondary+ 35.3 14.9 1.0 51.1 795 Wealth quintile Lowest 39.5 19.0 2.3 60.7 754 Second 42.5 17.5 3.0 63.0 867 Middle 38.2 18.9 2.3 59.5 959 Fourth 38.2 18.0 1.7 57.9 1,086 Highest 36.3 16.6 1.0 53.9 1,081 Total 38.8 17.9 2.0 58.7 4,747 Note: Prevalence is adjusted for smoking status if known using CDC formulas (CDC, 1998). Total includes cases with information missing on education that are not shown separately. 204 | Nutrition of Children and Adults Figure 11.7 Trends in Anaemia Status among Women 15-49 Years 35 9 1 45 39 18 2 59 Mild anaemia Moderate anaemia Severe anaemia Any anaemia 0 20 40 60 80 Percent 2003 2008 Compared with estimates from recent Demographic and Health Surveys, the prevalence of any anaemia among women age 15-49 in Ghana (59 percent) is higher than the prevalence in Sierra Leone: 45 percent in 2008 (SSL and ICF Macro, 2009), Niger: 46 percent in 2006 (INS and Macro International Inc., 2007) and Guinea: 53 percent in 2005 (DNS and ORC Macro, 2006), similar to that observed in Senegal: 59 percent in 2005 (Ndiaye and Ayad, 2006), but lower than the prevalence in Benin: 61 percent in 2006 (INSAE and Macro International Inc., 2007), or in Mali: 69 percent in 2006 (CPS/MS, DNSI/MEIC and Macro International Inc., 2007). 11.12 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for them and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects the mother and infant against anaemia. It is estimated that one-fifth of perinatal mortality and one-tenth of maternal mortality are attributable to iron deficiency anaemia. Anaemia also results in an increased risk of premature delivery and low birth weight. Finally, iodine deficiency is related to a number of adverse pregnancy outcomes. Table 11.12 presents a number of measures that are useful in assessing the extent to which women are receiving adequate intake of vitamin A and iron, and the proportion who take de-worming medication during pregnancy. The first two columns show the percentage of women with children under three years who reported that they consumed foods rich in vitamin A and iron during the 24- hour period before the interview. The results indicate that 94 percent of mothers with young children consumed vitamin A-rich foods during the 24 hours preceding the interview, and 88 percent consumed iron-rich foods. Nutrition of Children and Adults | 205 Table 11.12 Micronutrient intake among mothers Among women age 15-49 with a child under age three years living with them, the percentages who consumed vitamin A-rich and iron-rich foods in the 24 hours preceding the survey; and among women age 15-49 with a child under five years, the percentage who received a vitamin A dose post- partum (within two months of the last birth), the percentage with night blindness during pregnancy for the last birth, the number of days women took iron tablets or syrup during pregnancy for the last birth, and the percentage who took de-worming medication during pregnancy for the last birth, by background characteristics, Ghana 2008 Background characteristic Women with a child under three years living with them Among women whose last birth is a child under five years Percentage who received vitamin A dose post- partum3 Percentage with night blindness during pregnancy for last birth Number of days women took iron tablets or syrup during pregnancy for last birth Percentage who took de-worming medication during pregnancy for last birth Number of women Percentage consumed vitamin A- rich foods1 Percentage consumed iron-rich foods2 Number gof women None <60 60-89 90+ Don’t know/ missing Reported Adjusted4 Age 15-19 94.2 89.9 90 58.7 16.0 1.6 9.6 37.7 9.5 35.4 7.8 34.1 100 20-29 94.0 88.0 766 60.2 13.3 1.9 12.6 29.2 9.8 40.7 7.6 34.6 957 30-39 94.3 88.6 518 60.8 14.7 1.3 11.2 26.6 10.3 44.1 7.9 35.9 791 40-49 93.7 85.0 118 60.3 14.2 2.2 18.1 25.9 10.5 38.4 7.0 33.1 251 Residence Urban 96.0 93.5 571 63.8 11.8 1.4 8.7 19.7 9.8 52.6 9.2 34.4 844 Rural 92.9 84.8 921 58.0 15.6 1.9 15.2 34.0 10.3 34.0 6.6 35.2 1,255 Region Western 90.7 85.9 147 44.6 12.9 1.7 7.3 39.5 21.1 29.7 2.4 39.1 189 Central 94.7 92.8 159 46.7 22.6 3.3 10.4 34.7 12.2 37.0 5.7 41.4 200 Greater Accra 98.1 96.2 175 65.6 5.9 0.6 4.3 4.6 9.5 68.1 13.5 14.5 262 Volta 96.7 91.8 128 68.2 21.4 1.5 9.6 26.3 10.5 51.9 1.6 33.7 181 Eastern 92.9 86.7 130 49.3 13.3 2.3 10.5 27.2 5.5 46.0 10.8 38.0 185 Ashanti 96.7 90.6 270 56.4 14.5 1.5 7.7 21.4 7.6 60.2 3.1 37.4 396 Brong Ahafo 89.3 84.5 141 68.9 8.1 0.0 14.5 34.6 11.1 31.5 8.2 51.0 218 Northern 89.6 80.8 217 67.8 16.0 2.5 29.7 45.0 6.7 11.7 7.0 25.7 291 Upper East 99.3 82.7 81 80.3 13.3 3.3 13.7 28.5 13.6 19.6 24.6 35.9 119 Upper West 93.9 81.8 44 63.1 16.7 0.8 29.1 23.0 5.1 31.4 11.3 51.5 58 Education No education 90.4 82.0 466 59.3 13.8 1.8 19.9 35.1 9.4 26.0 9.6 30.4 647 Primary 96.2 90.4 370 56.4 17.1 1.2 11.6 28.8 12.8 41.0 5.8 35.2 511 Middle/JSS 94.7 89.4 516 62.1 13.7 2.0 7.9 25.4 9.0 51.3 6.5 39.3 738 Secondary+ 98.5 97.5 139 67.2 8.8 1.5 9.0 15.5 9.6 55.8 10.2 32.1 201 Wealth quintile Lowest 91.3 79.9 362 61.2 17.1 2.0 21.3 38.5 9.6 20.6 10.0 30.9 480 Second 93.0 84.9 333 54.1 13.4 1.8 15.0 34.8 11.4 35.6 3.2 40.9 461 Middle 94.4 90.4 277 57.5 18.9 1.9 11.8 31.6 10.5 41.3 4.8 37.2 400 Fourth 95.5 93.9 303 65.3 11.1 1.1 6.5 19.6 8.3 56.5 9.0 35.4 436 Highest 98.0 95.8 217 65.0 8.7 1.6 5.5 11.0 10.7 60.7 12.2 28.7 322 Total 94.1 88.1 1,492 60.4 14.1 1.7 12.6 28.2 10.1 41.5 7.6 34.9 2,099 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A 2 Includes meat (and organ meat), fish, poultry, and eggs 3 In the first two months after delivery of last birth 4 Women who reported night blindness but did not report difficulty with vision during the day The fourth column in Table 11.12 shows the percentage of women with a child under five years who received vitamin A supplements after giving birth to their most recent child. Six in ten mothers with young children reported that they had received a post-partum vitamin A dose within 2 months of delivery, but this varies with residence, region, level of education, and wealth quintile. Women in urban areas (64 percent) are more likely to receive vitamin A supplements than those in rural areas (58 percent). At the regional level, the percentage of women who reported receiving a post- partum vitamin A dose is highest in the Upper East region (80 percent) and lowest in the Western and Central regions (45 and 47 percent, respectively). Women with higher education and those in the two highest wealth quintiles are more likely to receive a vitamin A dose post-partum than other women. The percentage of women with a child born in the five years preceding the survey who took vitamin A supplements post-partum increased from 43 percent in 2003 to 60 percent in 2008. 206 | Nutrition of Children and Adults Table 11.12 shows that 14 percent of women with a child born in the past five years reported night blindness during pregnancy for the last birth. Night blindness was reported by nearly one in four women in the Central region (23 percent), compared with less than one in ten women in the Greater Accra and Brong Ahafo regions (6 and 8 percent, respectively). Women with the most education and those in the higher wealth quintiles are the least likely to report night blindness. When the results were adjusted for blindness not attributed to vitamin A deficiency during pregnancy, only 2 percent of women experienced night blindness during their last pregnancy. There are no major variations in the adjusted percentage of women who reported night blindness by background characteristics. With regard to iron supplementation during pregnancy, 13 percent of women did not take iron tablets or syrup during pregnancy. Although about eight in ten women said they took iron tablets, 28 percent of women took iron for fewer than 60 days. More than four in ten women (42 percent) took the iron tablets or syrup for the recommended 90 or more days. Iron intake varies by background characteristics. Older women, those living in rural areas, and women in the Northern and Upper West regions are more likely to have not taken iron supplements during pregnancy than other women. The percentage of women who did not take any iron during pregnancy decreases as level of education and wealth quintile increase. The proportion of women who did not take any iron decreased somewhat over the past five years, from 19 percent in 2003 to 13 percent in 2008. Thirty-five percent of mothers said they took de-worming medication during their most recent pregnancy. The proportion is highest among women in the Upper West (52 percent) and Brong Ahafo (51 percent) regions. 11.13 REGENERATIVE HEALTH Ghana, like many African countries, faces a double burden of disease. In addition to the impact of communicable diseases, there is a growing epidemic of non-communicable diseases. Epidemiological data shows a steady increase in prevalence rates since the 1950s (DeGraft Aikins, 2007). As part of efforts to reduce the burden of non-communicable diseases, the Ministry of Health in 2006 initiated the Regenerative Health and Nutrition (RHN) programme. The aim of this programme is to transform the health, lives, and development of Ghanaians. Specifically, it seeks to reduce the risk of the occurrence of diseases and disorders among individuals, households, and communities, to contribute to the development of a healthier, more productive population that can create wealth for itself and the country. The RHN programme focuses on four key interventions: diet, exercise, rest, and hygiene. The interventions proposed are central to current international health perspectives on preventing diseases, especially chronic conditions, through a healthy lifestyle (WHO, 2005). All respondents interviewed in the GDHS 2008 were asked a series of questions on vigorous physical activity, hours of rest including naps and sleep both during day and night, and average consumption of water, fruits and vegetables. Tables 11.13.1 through Table 11.19 present these results. 11.13.1 Vigorous Physical Activity The sedentary lifestyle has been associated with chronic disease burden in Ghana, and it is more prevalent in urban than rural settings (Amoah, 2003). The urban lifestyle with its prevalence of office jobs and use of cars is markedly different from the traditional rural life style “in which the daily work of the rural farmer incorporates long-distance walking and the physical exertion of farming” (MOH/PPME, 2008). Nutrition of Children and Adults | 207 In an effort to assess the prevalence of physical activity, women and men in the 2008 GDHS were asked: “In the past 7 days, on how many days did you do vigorous physical activity that lasted for at least 15 minutes each time?” In the same question vigorous physical activities were broadly defined to the respondents as the “activities you do at work, as part of your house and yard work, to get from place to place in your spare time, exercise or sport, activities that make you breathe much harder than normal and may include heavy lifting, digging, jogging, or fast bicycling”. Tables 11.13.1 and 11.13.2 show the results for women and men age 15-49, respectively. The Ministry of Health recommends exercising at least 30 minutes three times a week. During the week before the survey, about one in three women (30 percent) and one in two men (50 percent) were engaged three or more days in vigorous physical activity that lasted at least 15 minutes. However, during the same period, one in two women (53 percent) and one in four men (26 percent) were not engaged in any vigorous activity that lasted at least 15 minutes. There are some differences in frequency of vigorous physical activity by background characteristics. Women age 45-49 and those who are currently employed are generally more likely to be engaged in vigorous physical activity three or more times a week than women of other age groups and unemployed women. Formerly married respondents are more likely to exercise three or more times a week, compared with those of other marital status or women who are not married. As expected, more rural women than urban women reported vigorous physical activity three or more days a week (37 and 24 percent, respectively). In terms of regional variations, women in the Upper East region (61 percent) are the most likely to be engaged in vigorous physical activity three or more days a week, while women in the Greater Accra region are the least likely (22 percent). Level of education and wealth quintile are negatively associated with regular vigorous physical activity. For example, only 25 percent of women with higher education engage in vigorous physical activity three or more days a week, compared with 39 percent of women with no education. Similarly, women in the lowest wealth quintile (44 percent) are twice as likely as women in the highest wealth quintile (22 percent) to engage in vigorous physical activity three or more days a week. The differentials on vigorous physical activity for men indicate that never-married and currently married men, men age 30-34, and men employed for cash are more likely to report vigorous physical activity three or more days a week than formerly married men, men in other age groups, and men not employed for cash. As with women, rural men, men in the Upper East region, men with no education, and men in the poorest households are more likely to engage in vigorous physical activity three or more days a week than other men. Women age 20-29 and men age 45-49, urban respondents, those living in the Central and Greater Accra regions, and those in the higher wealth quintiles are most likely to report that they did not engage in any type of vigorous physical activity during the seven days preceding the survey. 208 | Nutrition of Children and Adults Table 11.13.1 Frequency of vigorous physical activity: Women Percent distribution of women age 15-49 by frequency of vigorous physical activity lasting at least 15 minutes in the seven days preceding the survey, according to background characteristics, Ghana 2008 Background characteristic Frequency of vigorous physical activity1 in past 7 days Number of women 0 days 1-2 days 3-4 days 5+ days Don’t know Missing Total Age 15-19 51.2 20.0 15.5 12.1 1.1 0.1 100.0 1,025 20-24 58.0 16.5 9.5 15.1 0.7 0.2 100.0 878 25-29 57.6 13.0 12.6 15.5 1.4 0.0 100.0 832 30-34 54.1 12.0 13.6 17.9 2.3 0.2 100.0 644 35-39 50.9 15.1 12.2 21.2 0.5 0.1 100.0 638 40-44 49.1 13.9 13.7 22.9 0.4 0.0 100.0 470 45-49 47.7 12.7 13.1 26.2 0.2 0.0 100.0 429 Employment (past 12 months) Not employed 59.6 16.5 12.4 9.9 1.4 0.2 100.0 1,094 Employed for cash 52.4 14.3 12.8 19.7 0.6 0.1 100.0 3,140 Employed, not for cash 47.8 17.8 13.6 18.6 2.1 0.0 100.0 677 Marital status Never married 52.7 19.5 12.7 14.0 0.9 0.1 100.0 1,593 Married or living together 54.2 13.6 12.6 18.4 1.2 0.1 100.0 2,876 Divorced/separated/widowed 49.9 11.2 15.0 23.2 0.6 0.0 100.0 446 Residence Urban 59.6 16.3 9.8 13.8 0.5 0.0 100.0 2,383 Rural 47.4 14.3 15.8 20.8 1.5 0.2 100.0 2,533 Region Western 54.2 13.3 10.1 21.6 0.8 0.0 100.0 447 Central 61.0 14.3 11.4 11.6 1.3 0.3 100.0 424 Greater Accra 60.0 17.3 7.6 14.8 0.4 0.0 100.0 853 Volta 58.9 16.9 10.3 13.1 0.2 0.5 100.0 431 Eastern 42.2 13.7 22.1 21.1 0.8 0.0 100.0 483 Ashanti 56.6 14.0 11.1 17.6 0.5 0.1 100.0 1,011 Brong Ahafo 54.9 14.2 16.9 13.3 0.7 0.0 100.0 425 Northern 48.8 17.8 13.6 15.6 4.3 0.0 100.0 467 Upper East 21.2 16.5 23.7 36.8 1.5 0.3 100.0 253 Upper West 51.4 14.6 12.6 21.1 0.3 0.0 100.0 122 Education No education 45.5 13.0 14.9 24.3 2.1 0.2 100.0 1,042 Primary 54.9 12.6 13.9 18.3 0.4 0.0 100.0 988 Middle/JSS 57.5 14.7 12.7 14.1 0.8 0.1 100.0 2,039 Secondary+ 51.1 22.8 9.4 15.7 0.9 0.1 100.0 844 Wealth quintile Lowest 39.9 13.1 18.9 25.4 2.5 0.2 100.0 783 Second 48.0 15.3 16.5 19.1 0.8 0.2 100.0 900 Middle 53.8 15.2 12.8 17.6 0.6 0.0 100.0 979 Fourth 60.0 15.0 9.9 14.2 0.8 0.0 100.0 1,119 Highest 59.8 17.2 8.8 13.5 0.7 0.1 100.0 1,135 Total 53.3 15.3 12.9 17.4 1.0 0.1 100.0 4,916 Note: Total includes cases with information missing on employment and education that are not shown separately. 1 Physical activity that lasts at least 15 minutes and causes the respondent to breathe harder than normal; may include, among other activities, heavy lifting, digging, jogging, and fast bicycling. Nutrition of Children and Adults | 209 Table 11.13.2 Frequency of vigorous physical activity: Men Percent distribution of men age 15-49 by frequency of vigorous physical activity lasting at least 15 minutes in the seven days preceding the survey, according to background characteristics, Ghana 2008 Background characteristic Frequency of vigorous physical activity1 in past 7 days Number of men 0 days 1-2 days 3-4 days 5+ days Don’t know Missing Total Age 15-19 21.6 29.2 20.4 28.2 0.6 0.0 100.0 911 20-24 21.5 25.9 21.2 30.5 0.7 0.2 100.0 704 25-29 22.4 25.9 19.3 31.4 1.1 0.0 100.0 624 30-34 30.3 15.2 18.5 35.8 0.3 0.0 100.0 533 35-39 28.8 22.0 14.3 34.0 0.9 0.0 100.0 528 40-44 30.4 19.1 14.9 35.1 0.3 0.1 100.0 394 45-49 34.9 20.7 13.9 29.6 1.0 0.0 100.0 364 Employment (past 12 months) Not employed 25.9 29.9 17.2 26.6 0.4 0.1 100.0 781 Employed for cash 27.2 22.7 18.0 31.6 0.5 0.0 100.0 2,655 Employed, not for cash 20.2 19.7 20.1 38.0 2.0 0.0 100.0 619 Marital status Never married 21.2 27.4 21.0 29.7 0.6 0.1 100.0 1,936 Married or living together 29.9 19.7 15.4 34.2 0.8 0.0 100.0 1,950 Divorced/separated/widowed 32.2 24.9 18.1 24.0 0.7 0.0 100.0 172 Residence Urban 28.5 24.5 16.0 30.4 0.5 0.1 100.0 1,866 Rural 23.5 22.8 20.1 32.7 0.9 0.0 100.0 2,191 Region Western 28.0 19.2 21.1 31.3 0.5 0.0 100.0 403 Central 32.8 22.8 17.2 26.4 0.8 0.0 100.0 326 Greater Accra 30.0 28.0 15.2 26.5 0.3 0.0 100.0 649 Volta 27.2 28.0 27.0 17.8 0.0 0.0 100.0 373 Eastern 14.0 38.4 16.2 31.2 0.2 0.0 100.0 411 Ashanti 28.6 24.5 17.5 29.2 0.2 0.0 100.0 785 Brong Ahafo 26.0 14.7 18.6 39.6 1.1 0.0 100.0 347 Northern 26.1 20.4 15.7 33.8 3.5 0.4 100.0 435 Upper East 14.5 7.4 17.0 61.1 0.0 0.0 100.0 219 Upper West 14.1 11.8 21.4 52.5 0.2 0.0 100.0 108 Education No education 29.2 12.6 14.1 41.7 2.2 0.1 100.0 540 Primary 24.2 20.9 20.6 33.6 0.7 0.0 100.0 619 Middle/JSS 24.7 26.8 19.8 28.3 0.4 0.0 100.0 1,721 Secondary+ 26.9 25.3 16.4 30.9 0.3 0.1 100.0 1,167 Wealth quintile Lowest 19.8 17.0 17.9 43.4 1.9 0.1 100.0 708 Second 24.6 20.5 20.9 33.0 1.0 0.0 100.0 738 Middle 26.2 28.8 18.6 26.0 0.4 0.0 100.0 699 Fourth 27.8 25.5 18.0 28.6 0.1 0.1 100.0 974 Highest 29.1 25.2 16.3 29.0 0.4 0.0 100.0 939 Total 15-49 25.8 23.6 18.2 31.6 0.7 0.0 100.0 4,058 50-59 37.6 17.1 11.8 32.3 1.1 0.0 100.0 510 Total men 15-59 27.2 22.9 17.5 31.7 0.7 0.0 100.0 4,568 Note: Total includes cases with information missing on employment and education that are not shown separately. 1 Physical activity that lasts at least 15 minutes and causes the respondent to breathe much harder than normal; may include, among other activities, heavy lifting, digging, jogging, and fast bicycling. 210 | Nutrition of Children and Adults 11.13.2 Duration of Rest To assess the duration of rest, women and men in the 2008 GDHS were asked: “How many hours do you rest a day, including naps and sleep both during the day and night?” Tables 11.14.1 and 11.14.2 show the results for women and men, respectively. The majority of Ghanaian women and men have plenty of rest. Fifty-nine percent of women and 54 percent of men rest at least 7 hours a day, and 27 percent of respondents rest for more than 10 hours. Only one in ten women (13 percent) and one in five men (18 percent) are resting less than 7 hours a day. Women living in the Northern region (20 percent) and men in the Greater Accra and Volta regions are more likely to rest just 4-6 hours a day. Overall, urban respondents, respondents in the older age groups, employed respondents, formerly married respondents, respondents in the highest wealth quintiles, and men with secondary or higher education rest for shorter durations than other respondents. Table 11.14.1 Daily duration of rest: Women Percent distribution of women age 15-49 by duration of rest (in hours) in a typical day including naps and all sleep during the day and night, according to background characteristics, Ghana 2008 Background characteristic Duration of rest in a typical day Number of women 1-3 hours 4-6 hours 7-9 hours 10+ hours Don’t know Missing Total Age 15-19 1.8 6.9 57.7 32.6 0.9 0.1 100.0 1,025 20-24 0.5 8.7 57.5 32.7 0.6 0.0 100.0 878 25-29 2.1 10.0 57.0 28.4 2.5 0.1 100.0 832 30-34 1.6 15.2 57.2 24.7 0.9 0.4 100.0 644 35-39 2.1 14.3 61.9 20.9 0.8 0.0 100.0 638 40-44 0.9 14.7 64.9 18.1 0.7 0.7 100.0 470 45-49 2.2 17.0 60.5 18.8 1.4 0.0 100.0 429 Employment (past 12 months) Not employed 1.9 6.1 54.3 36.2 1.5 0.1 100.0 1,094 Employed 1.5 13.0 60.3 24.0 1.0 0.2 100.0 3,822 Marital status Never married 1.0 7.7 60.8 29.9 0.5 0.1 100.0 1,593 Married or living together 2.1 12.8 58.2 25.2 1.6 0.2 100.0 2,876 Divorced/separated/widowed 0.3 16.1 57.5 25.5 0.5 0.1 100.0 446 Residence Urban 1.4 13.6 60.5 23.8 0.6 0.1 100.0 2,383 Rural 1.8 9.4 57.5 29.5 1.6 0.2 100.0 2,533 Region Western 0.2 7.1 62.8 29.9 0.0 0.0 100.0 447 Central 1.1 8.9 51.7 38.1 0.2 0.0 100.0 424 Greater Accra 0.6 13.9 62.7 22.4 0.4 0.0 100.0 853 Volta 0.0 15.3 54.3 29.2 0.4 0.8 100.0 431 Eastern 0.4 9.8 64.8 24.9 0.0 0.0 100.0 483 Ashanti 0.9 10.4 54.0 34.2 0.4 0.1 100.0 1,011 Brong Ahafo 4.0 10.6 62.7 22.2 0.5 0.0 100.0 425 Northern 8.4 19.6 49.3 15.0 7.8 0.0 100.0 467 Upper East 0.0 3.6 75.4 18.2 1.8 0.9 100.0 253 Upper West 0.2 8.1 67.4 22.0 2.2 0.2 100.0 122 Education No education 3.2 14.2 59.5 18.9 3.8 0.5 100.0 1,042 Primary 1.6 11.0 56.8 30.0 0.5 0.0 100.0 988 Middle/JSS 0.9 9.7 58.6 30.2 0.4 0.1 100.0 2,039 Secondary+ 1.3 12.6 61.8 24.1 0.2 0.0 100.0 844 Wealth quintile Lowest 3.8 10.2 59.3 22.6 3.7 0.3 100.0 783 Second 2.0 7.8 53.2 35.3 1.5 0.2 100.0 900 Middle 1.2 11.2 56.5 30.5 0.3 0.3 100.0 979 Fourth 0.9 12.3 60.8 25.2 0.7 0.0 100.0 1,119 Highest 0.7 14.4 63.6 21.1 0.2 0.0 100.0 1,135 Total 1.6 11.4 59.0 26.8 1.1 0.1 100.0 4,916 Note: Total includes cases with information missing on employment and education that are not shown separately. Nutrition of Children and Adults | 211 Table 11.14.2 Daily duration of rest: Men Percent distribution of men age 15-49 by duration of rest (in hours) in a typical day including naps and sleep during the day and night, according to background characteristics, Ghana 2008 Background characteristic Duration of rest in a typical day Number of men 1-3 hours 4-6 hours 7-9 hours 10+ hours Don’t know Missing Total Age 15-19 1.0 10.8 55.6 31.4 0.8 0.3 100.0 911 20-24 1.7 15.8 54.9 26.4 0.6 0.6 100.0 704 25-29 1.4 17.0 51.3 29.8 0.3 0.2 100.0 624 30-34 1.3 21.2 51.9 24.4 0.5 0.7 100.0 533 35-39 0.8 21.1 52.7 24.1 0.6 0.6 100.0 528 40-44 1.7 18.4 57.6 21.5 0.4 0.3 100.0 394 45-49 1.9 17.8 55.8 23.7 0.4 0.4 100.0 364 Employment (past 12 months) Not employed 0.8 9.5 56.5 32.1 0.5 0.6 100.0 781 Employed 1.5 18.4 53.6 25.5 0.6 0.4 100.0 3,276 Marital status Never married 1.1 13.2 55.3 29.5 0.6 0.3 100.0 1,936 Married or living together 1.6 19.6 53.0 24.8 0.6 0.5 100.0 1,950 Divorced/separated/widowed 0.9 23.1 55.6 19.1 0.0 1.3 100.0 172 Residence Urban 1.2 18.3 56.6 23.2 0.2 0.5 100.0 1,866 Rural 1.5 15.3 52.1 29.8 0.9 0.5 100.0 2,191 Region Western 0.8 15.1 62.5 21.1 0.5 0.0 100.0 403 Central 0.8 15.2 39.1 44.7 0.0 0.3 100.0 326 Greater Accra 0.4 24.6 55.8 18.1 0.3 0.7 100.0 649 Volta 0.6 27.3 67.9 4.2 0.0 0.0 100.0 373 Eastern 3.8 19.9 63.7 12.3 0.0 0.3 100.0 411 Ashanti 0.6 16.8 63.6 19.0 0.0 0.0 100.0 785 Brong Ahafo 2.7 13.4 53.3 30.5 0.0 0.0 100.0 347 Northern 2.2 5.1 34.2 53.9 2.0 2.6 100.0 435 Upper East 1.9 8.4 34.1 51.3 4.1 0.2 100.0 219 Upper West 0.2 4.0 30.9 64.0 0.8 0.0 100.0 108 Education No education 1.4 13.3 41.9 40.3 2.1 1.0 100.0 540 Primary 1.6 13.0 52.8 30.9 1.0 0.7 100.0 619 Middle/JSS 1.2 16.2 59.2 22.8 0.2 0.3 100.0 1,721 Secondary+ 1.4 21.1 53.5 23.6 0.1 0.3 100.0 1,167 Wealth quintile Lowest 1.8 11.2 46.1 37.8 1.9 1.1 100.0 708 Second 1.6 15.9 51.6 29.9 0.8 0.1 100.0 738 Middle 1.0 16.2 54.4 27.9 0.0 0.4 100.0 699 Fourth 1.3 17.1 57.6 23.5 0.1 0.5 100.0 974 Highest 1.1 21.4 58.5 18.5 0.2 0.2 100.0 939 Total 15-49 1.4 16.7 54.2 26.8 0.5 0.5 100.0 4,058 50-59 2.1 18.4 52.0 26.6 0.7 0.2 100.0 510 Total 15-59 1.4 16.9 53.9 26.7 0.6 0.4 100.0 4,568 Note: Total includes cases with information missing on education that are not shown separately. 11.13.3 Consumption of Water The Ministry of Health recommends drinking at least 8 glasses of water a day. All women and men in the 2008 GDHS were asked: How many glasses of water do you drink in one day on average? Only one in six women (17 percent) and about one in three men (30 percent) reported drinking 8 or more glasses of water a day, 19 percent of women and 23 percent of men drink 6 or 7 glasses of water a day. Nearly two-thirds of women (64 percent) and almost half of men (47 percent) drink less than 6 glasses of water a day (data not shown). 212 | Nutrition of Children and Adults 11.13.4 Consumption of Fruits The Ministry of Health recommends eating fruits on a daily basis. All women and men in the 2008 GDHS were asked: In a typical week, on how many days do you eat fruits, for example mangoes, paw paw, banana, orange, avocados, tomatoes, passion fruit, etc? Those who provided an affirmative response were further asked: On a day when you eat fruits, how many servings do you eat on average? Tables 11.15.1 and 11.15.2 show the results for women and men, respectively. Consumption of fruits on a daily basis (7 days) is reported by 28 percent of women and 21 percent of men; most women and men eat fruits 3-6 days a week (35 and 40 percent, respectively). About one-third of respondents consume fruits 0-2 days a week. Urban respondents, those in the highest wealth quintiles, and those with secondary and higher education are more likely to eat fruits on a daily basis. Consumption of fruits on a daily basis is substantially lower among women in the Upper West and Eastern regions (15 and 16 percent, respectively) and among men in the Upper East and Volta regions (7 and 14 percent, respectively). Table 11.15.1 Weekly consumption of fruits: Women Percent distribution of women age 15-49 by number of days fruits are consumed in a typical week, according to background characteristics, Ghana 2008 Background characteristic Number of days fruits consumed in a typical week Number of women 0-2 days 3-6 days 7 days Don’t know Missing Total Age 15-19 31.4 40.3 25.9 2.3 0.1 100.0 1,025 20-24 30.5 39.1 28.1 2.2 0.2 100.0 878 25-29 32.8 35.0 29.4 2.8 0.1 100.0 832 30-34 34.1 31.1 32.0 2.5 0.2 100.0 644 35-39 37.3 32.3 28.8 1.6 0.0 100.0 638 40-44 35.2 33.5 29.4 1.8 0.1 100.0 470 45-49 41.5 30.5 25.4 2.6 0.0 100.0 429 Employment (past 12 months) Not employed 31.9 36.6 28.1 3.4 0.1 100.0 1,094 Employed 34.4 35.1 28.4 2.0 0.1 100.0 3,822 Marital status Never married 28.6 39.6 29.4 2.2 0.1 100.0 1,593 Married or living together 35.9 34.1 27.5 2.4 0.1 100.0 2,876 Divorced/separated/widowed 39.4 28.9 30.1 1.6 0.0 100.0 446 Residence Urban 34.8 32.1 30.7 2.2 0.1 100.0 2,383 Rural 32.9 38.6 26.1 2.3 0.1 100.0 2,533 Region Western 33.0 40.6 25.2 1.2 0.0 100.0 447 Central 33.8 37.4 27.8 0.9 0.0 100.0 424 Greater Accra 34.1 31.9 30.5 3.3 0.2 100.0 853 Volta 25.1 29.8 40.0 5.1 0.0 100.0 431 Eastern 24.0 58.9 16.3 0.7 0.0 100.0 483 Ashanti 31.9 37.6 30.0 0.2 0.2 100.0 1,011 Brong Ahafo 31.2 26.6 41.1 1.2 0.0 100.0 425 Northern 50.5 22.2 18.7 8.5 0.0 100.0 467 Upper East 34.6 37.6 27.2 0.5 0.1 100.0 253 Upper West 64.0 20.8 14.5 0.7 0.0 100.0 122 Education No education 45.2 27.6 23.2 4.0 0.0 100.0 1,042 Primary 33.9 37.7 26.4 1.9 0.0 100.0 988 Middle/JSS 30.3 39.9 28.1 1.5 0.2 100.0 2,039 Secondary+ 28.1 31.9 37.6 2.4 0.0 100.0 844 Wealth quintile Lowest 43.6 32.2 20.3 3.8 0.0 100.0 783 Second 33.1 39.6 25.8 1.4 0.2 100.0 900 Middle 31.0 38.6 28.4 2.0 0.0 100.0 979 Fourth 33.1 35.2 30.0 1.5 0.2 100.0 1,119 Highest 30.9 31.9 34.3 2.9 0.0 100.0 1,135 Total 33.8 35.4 28.4 2.3 0.1 100.0 4,916 Note: Total includes cases with information missing on employment and education that are not shown separately. Nutrition of Children and Adults | 213 Table 11.15.2 Weekly consumption of fruits: Men Percent distribution of men age 15-49 by number of days fruits are consumed in a typical week, according to background characteristics, Ghana 2008 Background characteristic Number of days fruits are consumed in a typical week Number of men 0-2 days 3-6 days 7 days Don’t know Missing Total Age 15-19 35.7 43.2 18.8 2.4 0.0 100.0 911 20-24 37.7 38.7 20.9 2.5 0.2 100.0 704 25-29 36.0 40.2 20.7 3.1 0.0 100.0 624 30-34 35.7 37.6 21.6 5.2 0.0 100.0 533 35-39 32.7 39.9 23.8 3.5 0.0 100.0 528 40-44 36.5 41.9 19.4 2.3 0.0 100.0 394 45-49 34.7 38.8 21.4 5.1 0.0 100.0 364 Employment (past 12 months) Not employed 36.7 42.8 18.0 2.3 0.1 100.0 781 Employed 35.5 39.7 21.4 3.5 0.0 100.0 3,276 Marital status Never married 36.1 41.6 19.7 2.5 0.1 100.0 1,936 Married or living together 35.5 38.6 21.8 4.1 0.0 100.0 1,950 Divorced/separated/widowed 33.4 44.3 20.5 1.8 0.0 100.0 172 Residence Urban 36.2 38.4 22.5 2.9 0.1 100.0 1,866 Rural 35.3 41.8 19.3 3.6 0.0 100.0 2,191 Region Western 34.5 41.2 22.9 1.4 0.0 100.0 403 Central 29.3 49.2 21.0 0.5 0.0 100.0 326 Greater Accra 33.9 41.1 21.8 3.3 0.0 100.0 649 Volta 43.5 42.5 13.8 0.3 0.0 100.0 373 Eastern 14.7 64.1 18.0 3.2 0.0 100.0 411 Ashanti 31.9 35.7 31.9 0.6 0.0 100.0 785 Brong Ahafo 35.2 39.6 19.8 5.4 0.0 100.0 347 Northern 48.8 24.4 13.6 12.9 0.3 100.0 435 Upper East 65.5 23.5 7.2 3.8 0.0 100.0 219 Upper West 39.5 40.1 18.9 1.4 0.0 100.0 108 Education No education 47.5 31.2 13.0 8.3 0.0 100.0 540 Primary 36.3 40.4 19.9 3.4 0.0 100.0 619 Middle/JSS 33.0 43.8 21.0 2.2 0.0 100.0 1,721 Secondary+ 33.9 39.0 24.5 2.5 0.1 100.0 1,167 Wealth quintile Lowest 47.2 32.1 13.7 7.0 0.0 100.0 708 Second 32.9 44.5 20.1 2.6 0.0 100.0 738 Middle 29.6 46.7 21.5 2.3 0.0 100.0 699 Fourth 36.1 40.0 20.8 2.9 0.1 100.0 974 Highest 33.4 38.6 26.0 2.0 0.0 100.0 939 Total 15-49 35.7 40.3 20.8 3.3 0.0 100.0 4,058 50-59 36.2 38.9 21.8 3.2 0.0 100.0 510 Total men 15-59 35.7 40.1 20.9 3.2 0.0 100.0 4,568 Note: Total includes cases with information missing on education that are not shown separately. Tables 11.16.1 and 11.16.2 show that majority of women and men report a low consumption of fruits; 78 percent of women and 87 percent of men typically have 0-2 servings of fruits on a day when fruits are consumed. Only 3 percent of women and less than 1 percent of men reported having the recommended 5 or more servings of fruit a day. Eighteen percent of women and 11 percent of men have 3-4 servings of fruits a day when fruits are consumed. Respondents in the Brong Ahafo region are more likely to consume 3-4 servings of fruits a day (29 percent of women and 19 percent of men), compared with respondents in the Greater Accra and Upper West regions. Consumption of 3-4 servings of fruits a day is substantially lower among men in the Greater Accra and Northern regions (3 and 6 percent, respectively), compared with men in the Eastern region (24 percent) and women in the Western and Ashanti regions (at least 25 percent). 214 | Nutrition of Children and Adults Table 11.16.1 Number of servings of fruits consumed: Women Percent distribution of women age 15-49 who consume fruits by number of servings of fruits eaten on a typical day when fruits are consumed, according to background characteristics, Ghana 2008 Background characteristic Number of servings of fruits consumed Number of women 0-2 3-4 5+ Don’t know Missing Total Age 15-19 79.2 17.0 2.6 1.0 0.1 100.0 1,001 20-24 73.5 21.2 4.4 0.8 0.1 100.0 858 25-29 75.1 19.4 4.1 0.9 0.5 100.0 809 30-34 77.2 18.3 2.5 1.1 0.9 100.0 628 35-39 78.6 17.7 2.6 0.4 0.7 100.0 628 40-44 82.3 13.2 3.5 0.3 0.7 100.0 462 45-49 80.6 16.1 2.5 0.4 0.4 100.0 417 Employment (past 12 months) Not employed 80.1 16.4 2.2 0.9 0.4 100.0 1,057 Employed 76.9 18.4 3.5 0.7 0.5 100.0 3,747 Marital status Never married 77.2 18.5 3.3 0.8 0.1 100.0 1,558 Married or living together 77.8 17.7 3.1 0.8 0.6 100.0 2,807 Divorced/separated/widowed 77.4 18.2 3.5 0.4 0.5 100.0 439 Residence Urban 80.9 15.2 2.9 0.6 0.4 100.0 2,330 Rural 74.4 20.6 3.5 0.9 0.5 100.0 2,474 Region Western 66.5 25.0 7.1 1.2 0.2 100.0 442 Central 85.8 12.5 0.7 0.6 0.4 100.0 420 Greater Accra 89.9 9.0 0.4 0.7 0.0 100.0 825 Volta 83.3 15.2 0.6 0.9 0.0 100.0 409 Eastern 83.9 13.6 2.1 0.0 0.3 100.0 479 Ashanti 66.0 26.5 6.0 0.4 1.2 100.0 1,008 Brong Ahafo 59.4 29.2 9.4 0.7 1.3 100.0 420 Northern 83.9 13.2 1.0 2.0 0.0 100.0 427 Upper East 82.3 17.5 0.2 0.0 0.0 100.0 252 Upper West 88.8 7.3 0.3 3.3 0.3 100.0 122 Education No education 81.2 14.8 2.6 1.0 0.4 100.0 1,000 Primary 78.3 17.2 3.5 0.3 0.7 100.0 969 Middle/JSS 75.3 20.5 3.1 0.5 0.5 100.0 2,008 Secondary+ 78.0 16.5 4.0 1.5 0.0 100.0 823 Wealth quintile Lowest 78.3 17.3 2.7 1.3 0.4 100.0 753 Second 70.1 23.3 5.6 0.4 0.6 100.0 888 Middle 76.4 18.6 3.7 0.8 0.5 100.0 960 Fourth 80.2 15.9 2.6 0.7 0.6 100.0 1,101 Highest 81.5 15.7 1.9 0.8 0.2 100.0 1,102 Total 77.6 18.0 3.2 0.8 0.5 100.0 4,804 Note: Total includes cases with information missing on employment and education that are not shown separately. Nutrition of Children and Adults | 215 Table 11.16.2 Number of servings of fruits consumed: Men Percent distribution of men age 15-49 who consume fruits by number of servings of fruits consumed on a typical day when fruits are consumed, according to background characteristics, Ghana 2008 Background characteristic Number of servings of fruits consumed Number of men 0-2 3-4 5+ Don’t know Missing Total Age 15-19 86.6 11.4 0.8 1.2 0.0 100.0 889 20-24 87.0 10.2 0.9 1.6 0.3 100.0 687 25-29 86.8 9.8 1.4 2.0 0.0 100.0 604 30-34 88.5 10.4 0.0 1.1 0.1 100.0 505 35-39 86.5 9.6 1.5 2.3 0.0 100.0 510 40-44 88.4 9.6 1.1 0.9 0.0 100.0 385 45-49 83.8 13.2 0.9 2.1 0.0 100.0 345 Employment (past 12 months) Not employed 86.8 10.6 1.0 1.5 0.1 100.0 763 Employed 86.9 10.6 0.9 1.6 0.0 100.0 3,162 Marital status Never married 87.3 10.4 0.8 1.5 0.1 100.0 1,888 Married or living together 86.1 10.9 1.2 1.8 0.0 100.0 1,869 Divorced/separated/widowed 90.9 8.5 0.6 0.0 0.0 100.0 169 Residence Urban 90.2 7.8 0.8 1.1 0.1 100.0 1,813 Rural 84.0 12.9 1.0 2.0 0.0 100.0 2,113 Region Western 83.8 12.9 2.4 0.7 0.2 100.0 398 Central 84.7 13.8 1.1 0.4 0.0 100.0 325 Greater Accra 96.3 3.2 0.1 0.4 0.0 100.0 628 Volta 92.4 7.0 0.3 0.3 0.0 100.0 372 Eastern 74.6 24.1 1.3 0.0 0.0 100.0 398 Ashanti 90.3 8.4 0.9 0.4 0.0 100.0 781 Brong Ahafo 79.4 19.0 1.5 0.0 0.0 100.0 328 Northern 79.3 6.4 1.2 12.8 0.3 100.0 379 Upper East 91.8 7.5 0.0 0.7 0.0 100.0 211 Upper West 90.7 8.3 0.0 0.7 0.3 100.0 107 Education No education 87.2 6.9 1.1 4.8 0.1 100.0 496 Primary 87.1 10.1 0.9 2.0 0.0 100.0 598 Middle/JSS 85.8 12.6 0.9 0.7 0.0 100.0 1,683 Secondary+ 88.2 9.4 0.9 1.3 0.2 100.0 1,138 Wealth quintile Lowest 85.8 9.6 0.7 3.9 0.0 100.0 659 Second 80.1 16.3 1.3 2.3 0.0 100.0 719 Middle 84.1 13.5 1.4 1.0 0.0 100.0 683 Fourth 89.6 9.3 0.7 0.3 0.1 100.0 945 Highest 92.1 6.0 0.8 1.0 0.1 100.0 920 Total 15-49 86.9 10.6 0.9 1.6 0.1 100.0 3,925 50-59 85.5 11.5 1.6 1.1 0.3 100.0 494 Total men 15-59 86.7 10.7 1.0 1.5 0.1 100.0 4,420 Note: Total includes cases with information missing on education that are not shown separately. 11.13.5 Consumption of Vegetables All women and men in GDHS were also asked about consumption of vegetables: In a typical week, on how many days do you eat vegetables, for example carrots, cabbage, dark green leafy vegetables (e.g. kontomire), pumpkin, squash, etc? Those who responded in the affirmative were further asked: On a day when you eat vegetables, how many servings do you eat on average? 216 | Nutrition of Children and Adults Tables 11.17.1 and 11.17.2 show the results for women and men, respectively. A substantial proportion of respondents reported low consumption of vegetables during a typical week; 34 percent of women and 25 percent of men eat vegetables 0-2 days a week. Consumption of vegetables on a daily basis (7 days) is reported by only 24 percent of women and 30 percent of men; most women and men eat vegetables 3-6 days a week (41 and 44 percent, respectively). Older respondents, those living in urban areas, respondents who are currently married, those in the highest wealth quintiles, and respondents with secondary and higher education are more likely to eat vegetables on a daily basis than other respondents, and the differences are more pronounced for men than women. Consumption of vegetables on a daily basis is very low among women in the Volta region (7 percent) and among men in the Eastern region (10 percent). Table 11.17.1 Weekly consumption of vegetables: Women Percent distribution of women age 15-49 by number of days vegetables are consumed in a typical week, according to background characteristics, Ghana 2008 Background characteristic Number of days vegetables are consumed in a typical week Number of women 0-2 days 3-6 days 7 days Don’t know Missing Total Age 15-19 36.9 40.8 21.4 0.9 0.1 100.0 1,025 20-24 37.3 39.1 22.7 0.9 0.0 100.0 878 25-29 32.7 42.2 24.5 0.4 0.1 100.0 832 30-34 31.1 41.5 26.0 1.2 0.2 100.0 644 35-39 36.1 41.4 22.0 0.5 0.0 100.0 638 40-44 34.8 39.5 25.1 0.6 0.0 100.0 470 45-49 25.1 46.3 27.2 1.4 0.0 100.0 429 Employment (past 12 months) Not employed 34.1 39.9 24.4 1.4 0.2 100.0 1,094 Employed 34.2 41.7 23.5 0.6 0.0 100.0 3,822 Marital status Never married 37.1 39.4 22.6 0.8 0.1 100.0 1,593 Married or living together 32.1 42.5 24.5 0.9 0.1 100.0 2,876 Divorced/separated/widowed 37.0 40.4 22.2 0.4 0.0 100.0 446 Residence Urban 39.1 35.4 24.6 0.8 0.1 100.0 2,383 Rural 29.5 46.8 22.8 0.8 0.1 100.0 2,533 Region Western 38.2 40.7 20.3 0.8 0.0 100.0 447 Central 48.3 37.2 14.2 0.3 0.0 100.0 424 Greater Accra 33.8 26.4 38.6 1.0 0.1 100.0 853 Volta 44.4 47.8 6.8 0.8 0.3 100.0 431 Eastern 26.5 57.9 15.6 0.0 0.0 100.0 483 Ashanti 32.9 43.3 23.7 0.0 0.1 100.0 1,011 Brong Ahafo 30.9 29.3 38.8 1.0 0.0 100.0 425 Northern 37.0 42.7 16.4 3.8 0.0 100.0 467 Upper East 9.3 59.5 31.1 0.2 0.0 100.0 253 Upper West 29.3 53.7 16.8 0.3 0.0 100.0 122 Education No education 31.4 47.5 19.2 1.7 0.1 100.0 1,042 Primary 36.0 39.2 24.2 0.6 0.0 100.0 988 Middle/JSS 36.0 40.7 22.6 0.6 0.0 100.0 2,039 Secondary+ 30.8 37.2 31.2 0.6 0.1 100.0 844 Wealth quintile Lowest 26.5 47.9 23.5 1.9 0.2 100.0 783 Second 30.3 45.1 24.2 0.3 0.1 100.0 900 Middle 35.8 43.3 20.4 0.4 0.0 100.0 979 Fourth 39.7 39.2 20.4 0.8 0.0 100.0 1,119 Highest 35.6 33.9 29.5 0.8 0.1 100.0 1,135 Total 34.2 41.3 23.7 0.8 0.1 100.0 4,916 Note: Total includes cases with information missing on employment and education that are not shown separately. Nutrition of Children and Adults | 217 Table 11.17.2 Weekly consumption of vegetables: Men Percent distribution of men age 15-49 by number of days vegetables are consumed in a typical week, according to background characteristics, Ghana 2008 Background characteristic Number of days vegetables consumed in a typical week Number of men 0-2 days 3-6 days 7 days Don’t know Missing Total Age 15-19 29.5 46.6 22.9 0.9 0.1 100.0 911 20-24 25.0 42.6 29.3 3.0 0.2 100.0 704 25-29 28.1 40.0 30.2 1.7 0.0 100.0 624 30-34 22.5 40.0 35.0 2.5 0.0 100.0 533 35-39 21.2 45.7 30.8 2.4 0.0 100.0 528 40-44 19.6 44.6 34.4 1.5 0.0 100.0 394 45-49 18.8 46.0 32.4 2.8 0.0 100.0 364 Employment (past 12 months) Not employed 29.3 42.9 26.2 1.5 0.1 100.0 781 Employed 23.5 43.8 30.5 2.2 0.0 100.0 3,276 Marital status Never married 27.9 43.1 27.2 1.7 0.1 100.0 1,936 Married or living together 21.3 43.8 32.5 2.4 0.0 100.0 1,950 Divorced/separated/widowed 25.3 48.1 26.1 0.5 0.0 100.0 172 Residence Urban 25.4 38.3 33.5 2.8 0.1 100.0 1,866 Rural 23.9 48.2 26.5 1.4 0.0 100.0 2,191 Region Western 22.7 38.7 38.3 0.2 0.0 100.0 403 Central 28.5 36.8 34.3 0.4 0.0 100.0 326 Greater Accra 26.6 30.9 36.9 5.6 0.0 100.0 649 Volta 33.6 44.2 21.8 0.3 0.0 100.0 373 Eastern 19.2 66.9 9.7 4.2 0.0 100.0 411 Ashanti 21.8 52.0 26.2 0.0 0.0 100.0 785 Brong Ahafo 11.7 33.8 53.0 1.5 0.0 100.0 347 Northern 42.2 29.8 23.2 4.4 0.5 100.0 435 Upper East 8.5 64.3 26.8 0.3 0.0 100.0 219 Upper West 19.5 54.2 26.3 0.0 0.0 100.0 108 Education No education 24.7 42.5 29.7 3.1 0.0 100.0 540 Primary 27.7 47.3 23.8 1.2 0.0 100.0 619 Middle/JSS 23.1 47.1 27.5 2.2 0.1 100.0 1,721 Secondary+ 25.0 37.3 35.9 1.8 0.1 100.0 1,167 Wealth quintile Lowest 25.1 48.9 24.3 1.5 0.1 100.0 708 Second 19.8 49.2 29.3 1.7 0.0 100.0 738 Middle 26.6 46.9 25.6 0.9 0.0 100.0 699 Fourth 25.7 40.9 31.3 1.9 0.1 100.0 974 Highest 25.2 35.8 35.4 3.6 0.0 100.0 939 Total 15-49 24.6 43.7 29.7 2.0 0.1 100.0 4,058 50-59 23.0 43.0 32.7 1.4 0.0 100.0 510 Total men 15-59 24.4 43.6 30.0 2.0 0.0 100.0 4,568 Note: Total includes cases with information missing on education that are not shown separately. Tables 11.18.1 and 11.18.2 show that majority of women (82 percent) and men (86 percent) reported consuming 0-2 servings of vegetables on a typical day when vegetables are consumed. Only 2 percent of women and 1 percent of men consumed the recommended 5 or more servings of vegetables a day. Sixteen percent of women and 11 percent of men had 3-4 servings of vegetables a day. The proportion of respondents with average intake of 3-4 servings of vegetables a day is particularly low among women in the Volta region (4 percent) and among men in the Ashanti region (6 percent). Daily consumption of 3-4 servings of vegetables is somewhat lower among the most educated and wealthiest respondents, and the differences are more pronounced among men than women. 218 | Nutrition of Children and Adults Table 11.18.1 Number of servings of vegetables consumed: Women Percent distribution of women age 15-49 by number of servings of vegetables consumed on a typical day when vegetables are consumed, according to background characteristics, Ghana 2008 Background characteristic Number of servings of vegetables consumed Number of women 0-2 3-4 5+ Don’t know Missing Total Age 15-19 81.1 16.6 1.6 0.4 0.2 100.0 1,016 20-24 84.0 14.4 1.1 0.4 0.0 100.0 870 25-29 81.7 14.5 1.8 1.5 0.5 100.0 829 30-34 80.9 15.4 2.3 1.2 0.2 100.0 636 35-39 81.1 16.3 2.1 0.5 0.0 100.0 635 40-44 81.2 16.1 1.8 0.5 0.3 100.0 467 45-49 80.4 17.2 1.2 0.9 0.2 100.0 423 Employment (past 12 months) Not employed 82.6 15.5 0.8 0.8 0.2 100.0 1,079 Employed 81.4 15.7 2.0 0.7 0.2 100.0 3,798 Marital status Never married 84.8 13.5 1.2 0.3 0.2 100.0 1,580 Married or living together 79.8 16.9 2.0 1.0 0.2 100.0 2,851 Divorced/separated/widowed 82.5 15.2 1.2 0.9 0.4 100.0 445 Residence Urban 85.6 11.9 1.6 0.7 0.2 100.0 2,365 Rural 78.0 19.1 1.8 0.9 0.2 100.0 2,512 Region Western 80.8 18.8 0.0 0.4 0.0 100.0 444 Central 84.9 13.4 0.9 0.8 0.0 100.0 422 Greater Accra 88.6 7.9 2.4 0.5 0.7 100.0 844 Volta 95.7 3.5 0.0 0.5 0.3 100.0 428 Eastern 84.0 15.8 0.2 0.0 0.0 100.0 483 Ashanti 83.6 13.1 2.5 0.4 0.4 100.0 1,011 Brong Ahafo 53.2 39.1 6.2 1.5 0.0 100.0 421 Northern 79.9 16.5 1.2 2.4 0.0 100.0 449 Upper East 66.1 33.9 0.0 0.0 0.0 100.0 253 Upper West 88.5 6.8 0.8 3.8 0.0 100.0 122 Education No education 78.2 18.3 1.7 1.5 0.3 100.0 1,025 Primary 81.7 15.6 1.7 0.7 0.2 100.0 982 Middle/JSS 81.8 15.7 1.7 0.5 0.3 100.0 2,027 Secondary+ 85.4 12.3 1.6 0.6 0.0 100.0 839 Wealth quintile Lowest 73.0 23.9 1.0 1.7 0.4 100.0 768 Second 78.9 17.7 2.9 0.4 0.1 100.0 897 Middle 80.6 16.7 1.9 0.7 0.2 100.0 975 Fourth 85.1 12.6 1.4 0.9 0.1 100.0 1,110 Highest 87.3 10.5 1.4 0.4 0.4 100.0 1,126 Total 81.7 15.6 1.7 0.8 0.2 100.0 4,876 Note: Total includes cases with information missing on employment and education that are not shown separately. Nutrition of Children and Adults | 219 Table 11.18.2 Number of servings of vegetables consumed: Men Percent distribution of men age 15-49 by number of servings of vegetables consumed on a typical day when vegetables are consumed, according to background characteristics, Ghana 2008 Background characteristic Number of servings of vegetables consumed Number of men 0-2 3-4 5+ Don’t know Missing Total Age 15-19 89.1 8.0 1.3 1.6 0.0 100.0 902 20-24 84.8 13.2 0.2 1.6 0.2 100.0 683 25-29 84.4 12.1 1.4 2.1 0.0 100.0 613 30-34 84.5 12.8 0.7 1.9 0.0 100.0 520 35-39 83.5 10.9 1.9 3.7 0.0 100.0 516 40-44 83.7 13.6 1.2 1.5 0.0 100.0 388 45-49 85.8 11.6 0.7 1.8 0.0 100.0 354 Employment (past 12 months) Not employed 88.3 8.6 1.2 1.8 0.1 100.0 770 Employed 84.8 12.1 1.1 2.0 0.0 100.0 3,206 Marital status Never married 86.8 10.6 0.8 1.8 0.1 100.0 1,902 Married or living together 84.0 12.3 1.4 2.3 0.0 100.0 1,902 Divorced/separated/widowed 88.9 10.7 0.0 0.4 0.0 100.0 171 Residence Urban 87.5 9.8 1.1 1.5 0.1 100.0 1,815 Rural 83.8 12.7 1.0 2.4 0.0 100.0 2,161 Region Western 89.7 10.3 0.0 0.0 0.0 100.0 402 Central 87.5 10.9 1.1 0.5 0.0 100.0 325 Greater Accra 90.5 8.3 0.7 0.5 0.0 100.0 613 Volta 90.9 8.9 0.0 0.3 0.0 100.0 371 Eastern 75.4 24.4 0.2 0.0 0.0 100.0 394 Ashanti 93.6 6.0 0.2 0.2 0.0 100.0 785 Brong Ahafo 77.7 19.3 0.5 2.5 0.0 100.0 342 Northern 69.5 8.3 7.4 14.6 0.3 100.0 416 Upper East 84.9 14.0 0.2 0.8 0.0 100.0 219 Upper West 83.1 16.7 0.0 0.2 0.0 100.0 108 Education No education 78.2 12.5 3.4 5.9 0.0 100.0 524 Primary 85.9 11.9 0.7 1.4 0.0 100.0 612 Middle/JSS 87.0 11.5 0.5 1.0 0.0 100.0 1,683 Secondary + 86.3 10.5 1.2 1.9 0.1 100.0 1,146 Wealth quintile Lowest 80.0 13.2 2.2 4.7 0.0 100.0 698 Second 81.7 14.7 1.6 1.9 0.0 100.0 725 Middle 84.8 11.7 1.0 2.6 0.0 100.0 692 Fourth 88.0 10.5 0.7 0.6 0.1 100.0 955 Highest 90.7 8.1 0.3 0.9 0.0 100.0 905 Total 15-49 85.5 11.4 1.1 2.0 0.0 100.0 3,976 50-59 85.9 11.8 1.2 1.0 0.0 100.0 503 Total men 15-59 85.6 11.4 1.1 1.9 0.0 100.0 4,479 Note: Total includes cases with information missing on education that are not shown separately. 11.13.6 Types of Cooking Oil Used in Ghana Solid fats, such as animal fat, butter, and red palm oil, traditionally used for cooking in many parts of the world are high in cholesterol-elevating fatty acids that increase the risk of heart disease. In an effort to assess what type of oil is used in Ghana for cooking, all respondents to the Household Questionnaire in the 2008 GDHS were asked: What type of oil does your household mainly use for cooking? As expected, every second household in Ghana is using palm oil (Table 11.19). Frytol, fortified vegetable oil is used by 27 percent of households. Less than 10 percent of the households use 220 | Nutrition of Children and Adults other vegetable oil or shea butter (7 and 9 percent, respectively). Lard, suet, and other oils high in saturated fats are used by less than 1 percent of households combined. Rural households favour palm oil over other types of oil. For example, six in ten rural house- holds use palm oil, compared with one in five rural households that use either frytol or other vegetable oil. Urban households, however, use frytol and other vegetable oil (48 percent) almost as frequently as they use palm oil (45 percent). Regional variations show that palm oil is used in all regions, except the three northern regions where shea butter is preferred. The Central region has the highest proportion of households using palm oil for cooking (80 percent), while households in the Greater Accra region prefer frytol (48 percent) to palm oil (41 percent), or any other oil. Over 77 percent of households in the Upper East and Upper West regions use shea butter for cooking, compared with 45 percent of households in the Northern region; more than one in four households (27 percent) in the Northern region use other vegetable oil. Although there is convincing evidence that consumption of palm oil contributes to an increased risk of cardiovascular diseases, caution should be used regarding efforts to reduce the intake of palm oil; this is because palm oil is a better solid fat to use in foods than animal fat, which would likely be chosen to replace palm oil in many households. Table 11.19 Types of cooking oil used in Ghana Percent distribution of households by type of oil used for cooking, according to background characteristics, Ghana 2008 Background characteristic Type of oil used for cooking Total Number of households Palm oil Frytol/ fortified vegetable oil Other vegetable oil Shea butter Lard, suet, butter, margarine, or other Missing No food cooked in household Residence Urban 45.1 39.3 9.1 1.9 0.2 0.1 4.3 100.0 5,627 Rural 62.3 14.8 4.2 15.6 0.6 0.2 2.4 100.0 6,150 Region Western 71.1 21.5 4.4 0.0 0.1 0.0 2.8 100.0 1,184 Central 80.3 14.6 2.4 0.0 0.3 0.2 2.1 100.0 1,279 Greater Accra 40.8 47.7 7.6 0.0 0.4 0.2 3.3 100.0 1,951 Volta 69.3 24.7 3.9 0.0 0.8 0.0 1.4 100.0 991 Eastern 78.3 18.7 1.0 0.0 0.1 0.4 1.5 100.0 1,260 Ashanti 55.4 31.9 5.8 0.1 0.1 0.1 6.5 100.0 2,263 Brong Ahafo 57.9 26.4 6.1 3.9 0.1 0.2 5.4 100.0 1,154 Northern 10.1 14.9 26.5 45.0 2.0 0.1 1.5 100.0 928 Upper East 0.6 15.3 3.7 78.5 0.3 0.2 1.5 100.0 540 Upper West 5.1 7.9 8.8 76.5 0.3 0.0 1.3 100.0 228 Wealth quintile Lowest 36.8 7.4 7.3 46.0 1.3 0.3 0.9 100.0 1,813 Second 74.8 10.7 5.2 6.8 0.5 0.1 2.0 100.0 2,250 Middle 66.9 19.4 6.3 2.1 0.3 0.2 4.8 100.0 2,548 Fourth 51.8 35.8 5.8 0.7 0.1 0.2 5.7 100.0 2,646 Highest 37.3 51.8 8.3 0.1 0.2 0.1 2.3 100.0 2,520 Total 54.0 26.5 6.6 9.0 0.4 0.2 3.3 100.0 11,777 Malaria | 221 MALARIA 12 Malaria is hyper-endemic in Ghana and constitutes 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 3 to 3.5 million cases of suspected malaria are reported each year in public health facilities, representing 30-40 percent of outpatient attendance. Of this figure, over 900,000 are children under the age of five. Malaria also accounts for about 61 percent of hospital admissions of children under five years and 8 percent of admissions of pregnant women. It is estimated that malaria accounts for 22 percent of under-five mortality and 9 percent of maternal deaths (The President’s Malaria Initiative, 2007). Ghana’s efforts to control malaria date back to the pre-independence era, when various strategies were employed at different times. In 1999, the country adopted the Roll Back Malaria initiative and has since been implementing a combination of curative and preventive interventions. Ghana subscribed to the Abuja Accord of the year 2000, by African Heads of States, which sought to achieve 60 percent coverage of malaria interventions by the year 2005, focusing particularly on pregnant women and children under five in need of access to suitable and affordable combinations of personal and community protective and curative measures such as insecticide-treated mosquito nets (ITNs) and prompt, effective treatment for malaria. The Abuja Accord sought to ensure that at least 60 percent of all pregnant women at risk of malaria, especially those in their first pregnancies, have access to appropriate chemoprophylaxis or intermittent preventive treatment (IPT). In Ghana, children less than five years of age and pregnant women are targeted for the distribution of insecticide-treated bed nets (ITNs). These groups are considered the most vulnerable and hence the focus of this preventive method. Ghana adopted a multiple approach for the distribution of the ITNs. A voucher scheme with Global Fund support within the framework of public-private partnership was implemented initially in four of the ten regions. The Ghana Health Service (GHS) distributes subsidised ITNs through the child welfare and antenatal clinics of the public health facilities. Occasionally, the Ministry of Health distributes free bed nets to pregnant women and children under five as part of immunisation campaigns and other health programmes. The Ghana Health Service provides sulphadoxine-pyrimethamine to pregnant women as IPT free of charge and as directly observed therapy (DOT) at both public and private antenatal services delivery points across the country. Because of the emergence of chloroquine-resistant strains of the malaria parasite, Plasmodium falciparum, in Ghana, the country embarked on a process to change the then existing Anti-Malaria Drug Policy. Guided by WHO criteria and recommendations, the process ended with the adoption of Artesunate-Amodiaquine, an Artemisinin-based Combination Therapy (ACT) as the drug of choice for the treatment of uncomplicated malaria across the country. Implementation of the new treatment policy began in the last quarter of 2005 with countrywide training of health care providers in both private and public sectors. Unlike chloroquine, the use of Artesunate-Amodiaquine for the home management of malaria in children less than five years of age was not recommended because of the complexity of the dosage/weight calculations and the limited data available on its safety. The GHS strongly advised caregivers of young children with the signs and symptoms of malaria to access treatment at the nearest health facility. Unfortunately, after introduction of the new drug, adverse reactions of varying degrees of severity were reported across the country, and the situation impaired confidence of the population in the new treatment policy. The MOH and GHS have since addressed the identified lapses and revised the policy to include two alternative ACT drugs, namely Artemether- Lumefantrine and Dihydroartemisinin-Piperaquine for those who remain hypersensitive to 222 | Malaria Artesunate-Amodiaquine. Implementation of the revised policy is expected to begin in 2009 with training of health workers on the revised treatment guidelines. The Ghana Health Service conducts information, education, and communication (IEC) activities on these malaria control interventions, using a variety of communication media and strategies. Findings from the 2008 GDHS can be used to assess the implementation of these malaria control strategies. 12.1 MOSQUITO NETS 12.1.1 Ownership of Mosquito Nets One of the cardinal principles of controlling vector-borne diseases is to break the host-vector link. The use of bed nets in malaria control does just that by creating a physical barrier between humans and the female Anopheles mosquito, which feeds primarily at night. Treating the bed nets with an insecticide that leaves a residual effect has the added advantage of repelling and/or killing the mosquitoes. This leads to a reduction in the vector population and, eventually, to termination of their ability to transmit malaria. The Ghana Health Service therefore promotes the ownership and use of insecticide-treated mosquito nets, particularly the (factory-treated) long-lasting, insecticide-treated nets (LLIN), as one of the primary interventions for reducing malaria transmission and morbidity in the country. In Ghana, various types of ITNs have been on the market. They include the long-lasting, insecticide-treated nets (LLINs) that require re-treatment only after about four years or twenty washes, and the standard insecticide-treated nets (ITNs) 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. Development partners have also contributed by supplying some ITNs for distribution at subsidised costs to pregnant women and children under five in disadvantaged areas of the country. These nets are distributed through routine public health services. Table 12.1 shows the percentage of households with at least one and with more than one mosquito net (treated or untreated), and the percentage of households that have at least one and more than one ITN, by background characteristics. The data show that 45 percent of households in Ghana own a mosquito net whether treated or untreated, and 19 percent of households own more than one net. Rural households are more likely to own at least one or more than one net than urban households. Mosquito net ownership is highest in the Upper West region (72 percent) and lowest in the Greater Accra (32 percent) region. The percentage of households with at least one net generally decreases with increasing household wealth quintile. The average number of mosquito nets per household is 0.7. Four in ten households own at least one ever-treated net or an insecticide-treated net (ITN). Households in the Upper West region report the highest level of ownership of ITNs (71 percent); the lowest level of ownership is in households in the Greater Accra (30 percent) region. Households in the lowest and second wealth quintiles are more likely to own at least one mosquito net than households in the other wealth quintiles. The average number of ITNs per household is 0.6. Malaria | 223 Table 12.1 Ownership of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), ever-treated mosquito net, and insecticide- treated net1 (ITN), and the average number of nets per household, by background characteristics, Ghana 2008 Background characteristic Any type of mosquito net Ever-treated mosquito nets1 Insecticide-treated mosquito nets (ITNs)2 Number of house- holds Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ever- treated nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Residence Urban 37.2 12.9 0.5 35.5 12.1 0.5 34.7 11.6 0.5 5,627 Rural 53.0 23.7 0.9 49.2 20.7 0.8 48.1 19.9 0.8 6,150 Region Western 43.3 17.1 0.6 41.7 16.0 0.6 41.1 15.8 0.6 1,184 Central 43.9 13.2 0.6 42.6 12.8 0.6 41.8 12.5 0.6 1,279 Greater Accra 32.1 11.5 0.5 30.6 10.9 0.4 29.8 10.2 0.4 1,951 Volta 60.8 35.7 1.1 45.3 22.8 0.8 42.8 20.5 0.7 991 Eastern 37.3 11.2 0.5 36.3 10.8 0.5 36.0 10.7 0.5 1,260 Ashanti 41.2 13.4 0.6 40.2 13.1 0.6 39.7 12.5 0.6 2,263 Brong Ahafo 56.9 21.6 0.8 52.6 17.9 0.7 51.3 17.1 0.7 1,154 Northern 57.1 28.6 1.0 54.9 26.9 0.9 53.5 26.2 0.9 928 Upper East 55.0 32.5 1.0 54.6 32.4 1.0 52.9 31.1 1.0 540 Upper West 71.7 45.5 1.5 71.0 44.7 1.5 70.8 44.3 1.4 228 Wealth quintile Lowest 56.4 29.2 1.0 51.6 24.6 0.9 50.2 23.6 0.8 1,813 Second 51.5 20.4 0.8 47.1 17.4 0.7 46.0 16.6 0.7 2,250 Middle 43.4 15.4 0.6 40.9 13.8 0.6 40.1 13.4 0.6 2,548 Fourth 38.4 13.5 0.5 36.9 12.6 0.5 36.5 12.2 0.5 2,646 Highest 41.6 17.7 0.7 40.1 17.2 0.6 39.0 16.3 0.6 2,520 Total 45.4 18.6 0.7 42.7 16.6 0.6 41.7 15.9 0.6 11,777 1 An ever-treated net is 1) a pre-treated net or a non-pre-treated which has subsequently been soaked with insecticide at any time 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months 12.1.2 Use of Mosquito Nets by Children Age is an important factor in determining levels of acquired immunity against malaria. For the first six months of life, antibodies acquired from the mother during pregnancy protect children from malaria. This immunity is gradually lost as children start developing their own immunity over a period of time. Unlike some other infectious diseases, immunity against malaria is not permanent and protection from being infected requires the regular use of the protective interventions. The use of ITNs confers some protection if the child uses the net on a regular basis. In determining ITN usage, only children reported to have slept under a net the night before the survey were considered users of ITNs. In the 2008 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 12.2 presents information on the use of mosquito nets by children under five years in all households, and in households with an ITN, by background characteristics. The results show that 41 percent of children under five years in all households slept under a mosquito net (treated or untreated) the night before the survey; 40 percent slept under an ever-treated net; and 39 percent slept under an ITN. In households that own at least one ITN, a substantially larger proportion of children under age five slept under an ITN the night before the survey (58 percent). 224 | Malaria Table 12.2 Use of mosquito nets by children Among children under five years in all households, the percentage who, on the night preceding the interview, slept under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide- treated net (ITN), and among children under five years in households with at least one ITN, the percentage who slept under an ITN the past night, by background characteristics, Ghana 2008 Background characteristic Among children under five in all households, percentage who, the past night Among children under five in households with an ITN2 Percentage who slept under an ITN the past night2 Number of children Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of children Age (in years) <1 51.2 49.6 49.0 1,156 68.0 833 1 47.8 45.8 44.6 1,072 61.9 771 2 39.3 37.5 36.4 1,110 55.5 727 3 37.8 36.6 35.8 1,193 55.3 773 4 30.6 29.4 29.2 1,260 47.7 770 Sex Male 39.8 38.3 37.5 2,963 56.8 1,958 Female 42.4 40.8 40.0 2,827 59.0 1,916 Residence Urban 34.2 33.2 32.6 2,229 53.3 1,362 Rural 45.4 43.4 42.6 3,561 60.4 2,513 Region Western 38.0 37.5 37.5 534 54.0 371 Central 30.7 30.3 29.4 569 40.9 409 Greater Accra 31.3 29.8 29.6 679 50.3 399 Volta 55.1 46.3 43.7 474 64.1 323 Eastern 39.7 39.4 39.2 513 60.6 332 Ashanti 39.4 38.8 38.1 1,060 60.6 668 Brong Ahafo 60.5 58.0 56.9 611 74.0 470 Northern 33.5 32.7 31.8 869 49.5 559 Upper East 42.9 42.7 41.7 317 66.2 200 Upper West 65.6 63.9 63.8 165 73.0 144 Wealth quintile Lowest 47.0 44.0 42.6 1,427 63.9 952 Second 42.1 40.6 40.1 1,252 58.4 860 Middle 40.0 39.2 38.4 1,128 56.5 767 Fourth 37.6 36.5 36.2 1,110 55.4 725 Highest 35.7 34.8 34.0 874 52.1 570 Total 41.1 39.5 38.7 5,790 57.9 3,875 1 An ever-treated net is 1) a pre-treated net or a non-pre-treated which has subsequently been soaked with insecticide at any time 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment, or (2) a pre-treated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months Among children under five, those less than one year of age are most likely to have slept under any net (51 percent), an ever-treated net (50 percent), or an ITN (49 percent) the night before the survey. Children in rural areas are more likely than those in urban areas to have slept under any net, an ever-treated net, or an ITN. The proportion of children who slept under any type of mosquito net is highest in the Upper West region (66 percent) and lowest in the Central and Greater Accra regions (31 percent each). The proportion of children who slept under a mosquito net generally decreases with increasing wealth quintile, thus while 47 percent of children in the lowest wealth quintile slept under a net the night before the survey, only 36 percent of children in the highest wealth quintile slept under a net. The proportion of children who slept under an ITN was highest in the Upper West region (64 percent) and lowest in the Central and Greater Accra regions (30 percent each). Malaria | 225 In households that own at least one ITN, there are small differences by background characteristics in the proportion of children under age five who slept under an ITN the night before the survey. Children age four years (48 percent), male children (57 percent), children in urban areas (53 percent), and those in the highest wealth quintile (52 percent) were less likely than other children to sleep under ITNs the night before the interview. The percentage of children in the households with ITNs who slept under an ITN is highest in Brong Ahafo region (74 percent) and lowest in the Central region (41 percent). 12.1.3 Use of Mosquito Nets by Women Pregnant women are one of the groups most vulnerable to malaria. The disease adversely affects birth outcomes and can lead to a spontaneous abortion, pre-term labour, low birth weight, and stillbirth. Pregnancy on its part affects the prognosis of malaria and enhances progression to the severe form of the disease. This has prompted many advocacy campaigns to educate not only pregnant women, but also the general public on the importance of preventing malaria during pregnancy. In Ghana, two key malaria preventive methods employed during pregnancy are the provision of intermittent preventive treatment (IPT) and the use of ITNs. As with children under age five, pregnant women in Ghana have been targeted for bed net distribution over the past five years, and those who slept under an ITN the night before the survey were considered regular users of an ITN. Tables 12.3.1 and 12.3.2 show the percentage of all women and pregnant women, respec- tively, in all households who slept under a mosquito net (treated or untreated) the night before the survey, and in households that own at least one ITN, the proportions of women and pregnant women who slept under an ITN the night before the survey, by background characteristics. The results show some differences between all women and pregnant women in the use of nets. Overall, 26 percent of all women and 32 percent of pregnant women slept under any net the night before the interview; 24 percent and 28 percent, respectively, slept under an ever-treated net, and 24 percent and 27 percent, respectively, slept under an ITN. As with children under five, in households that own at least one ITN, a substantially larger proportion of women slept under an ITN the night before the survey (48 percent of all women and 52 percent of pregnant women). For all women, those living in rural areas (35 percent) are more likely to have slept under a mosquito net the night before the survey than urban women (17 percent); the same pattern is seen for pregnant women, although the proportions are higher (41 and 18 percent, respectively). As with children, use of any mosquito net by all women is highest in the Upper West region (49 percent) and lowest in the Greater Accra region (13 percent); use of an ITN is highest in Upper West (48 percent) and lowest in the Greater Accra region (12 percent). Education is inversely related to sleeping under a mosquito net. While 33 percent of women with no education slept under a net the night before the survey, only 18 percent of women with secondary or higher education did. Similarly, women in the highest wealth quintile are the least likely to have slept under an ever-treated net, or an ITN. This pattern is probably related to the fact that many women in wealthier households, those who are better educated, and women in urban areas live in houses with mosquito screening on the windows and doors, hence the redundancy of using a mosquito net. 226 | Malaria Table 12.3.1 Use of mosquito nets by women Among all women age 15-49 in all households, the percentage who slept the past night under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN); and among all women age 15-49 in households with at least one ITN, the percentage who slept the past night under an ITN, by background characteristics, Ghana 2008 Background characteristic Among women age 15-49 in all households, percentage who, the past night: Women age 15-49 in households with an ITN2 Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of women Percentage who slept under an ITN2 the past night Number of women Residence Urban 16.5 15.7 15.4 5,214 37.4 2,141 Rural 35.2 32.0 31.3 5,475 55.6 3,083 Region Western 24.1 23.0 22.8 973 44.7 496 Central 22.2 22.0 21.4 967 43.2 480 Greater Accra 12.8 12.0 11.7 1,804 32.7 647 Volta 38.6 27.8 26.3 945 52.0 478 Eastern 24.0 23.7 23.6 1,037 53.2 459 Ashanti 21.8 21.5 21.2 2,074 47.5 925 Brong Ahafo 40.5 35.2 34.1 993 58.4 580 Northern 30.4 28.9 28.1 1,052 48.4 612 Upper East 32.0 31.8 31.2 576 52.8 340 Upper West 49.0 48.1 47.9 268 62.0 207 Education No education 33.0 29.9 29.3 2,515 54.9 1,342 Primary 29.9 27.4 26.5 2,076 52.1 1,055 Middle/JSS 23.3 21.8 21.4 4,252 45.3 2,014 Secondary+ 18.3 17.5 17.1 1,838 38.7 810 Wealth quintile Lowest 40.0 35.6 34.6 1,794 59.4 1,045 Second 34.3 31.0 30.5 1,912 55.3 1,053 Middle 26.9 25.2 24.7 2,130 51.0 1,034 Fourth 19.8 18.9 18.8 2,322 43.9 993 Highest 14.9 14.4 13.8 2,532 31.8 1,099 Total 26.0 24.1 23.5 10,689 48.2 5,224 Note: Total includes women missing information on education who are not shown separately. 1 An ever-treated net is 1) a pre-treated net or a non-pre-treated which has subsequently been soaked with insecticide at any time 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. Malaria | 227 Table 12.3.2 Use of mosquito nets by pregnant women Among pregnant women age 15-49 in all households, the percentage who slept the past night under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN); and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept the past night under an ITN, by background characteristics, Ghana 2008 Background characteristic Among pregnant women age 15-49 in all households, percentage who, the past night: Pregnant women age 15-49 in households with an ITN2 Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of women Percentage who slept under an ITN2 the past night Number of women Residence Urban 18.4 18.0 18.0 145 41.6 63 Rural 40.6 35.5 33.9 208 57.4 123 Education No education 36.1 33.0 32.2 90 51.6 56 Primary 38.8 30.6 28.9 72 (50.0) 42 Middle/JSS 25.2 23.6 22.7 150 53.7 63 Secondary+ (31.4) (31.4) (31.4) 41 * 24 Wealth quintile Lowest 49.8 43.6 40.4 65 62.9 42 Second 34.7 29.5 29.5 82 50.4 48 Middle 29.5 26.1 24.3 68 (54.1) 31 Fourth 25.2 24.4 24.4 64 (50.1) 31 Highest 19.0 19.0 19.0 74 (41.2) 34 Total 31.5 28.3 27.4 353 52.1 186 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 An ever-treated net is 1) a pre-treated net or a non-pre-treated which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. 12.1.4 Trends in Household Ownership and Use of Mosquito Nets Figure 12.1 shows that household ownership of mosquito nets increased substantially between the 2003 GDHS and the 2008 GDHS. During the five-year period, ownership of a mosquito net (treated or untreated) increased from 18 to 45 percent, and household ownership of more than one net increased from 6 to 19 percent. In 2008, 42 percent of households own at least one ITN, compared with 3 percent of households in 2003. These increases demonstrate remarkable improvements in Ghana’s bed-net distribution programmes in just five years. 228 | Malaria 18 6 3 1 45 19 42 16 ANY TYPE OF MOSQUITO NET Percentage with at least one net Percentage with more than one net INSECTICIDE-TREATED NET (ITN) Percentage with at least one ITN Percentage with more than one ITN 0 10 20 30 40 50 Percent GDHS 2003 GDHS 2008 Figure 12.1 Trends in Household Ownership of Mosquito Nets GDHS 2003 and GDHS 2008 The increase in the use of mosquito nets by women and children is consistent with the overall increase in ownership of ITNs (Figure 12.2). For example, the proportion of children under age five, in all households, who slept under an ITN the night before the survey, has increased 35 percentage points from 4 percent in 2003 to 39 percent in 2008. Similarly, the proportion of pregnant women, in all households, who slept under an ITN the night before the survey, has increased 24 percentage points from 3 percent in 2003 to 27 percent in 2008. 15 10 4 3 41 32 39 27 Children under age 5 Pregnant women Children under age 5 Pregnant women 0 10 20 30 40 50 Percent GDHS 2003 GDHS 2008 Figure 12.2 Trends in Use of Mosquito Nets by Children under Five and Pregnant Women (Any Net and ITNs) GDHS 2003 and GDHS 2008 Slept the night before the survey under any type of mosquito net (treated or untreated) Slept the night before the survey under Insecticide-treated net (ITN) Malaria | 229 12.2 INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY 12.2.1 Malaria Prophylaxis during Pregnancy In malaria endemic areas, adults acquire partial immunity that protects them from repeated malaria infection. However, pregnant women—especially those pregnant for the first time—are more susceptible to malaria infection. In some cases, malaria infections remain asymptomatic but may lead to the development of anaemia. Malaria infection during pregnancy can also interfere with the maternal-foetus exchange, which can lead to intra-uterine growth restriction, and ultimately lead to low birth weight or even stillbirth. One of the interventions the MOH and the Ghana National Malaria Control Programme have adopted to control malaria in pregnancy is Intermittent Preventive Treatment (IPT) with sulphadoxine-pyrimethamine (SP), which has several brand names including Fansidar and Malafan. According to this policy, from the second trimester of pregnancy (after quickening), pregnant women attending antenatal clinics are expected to be given three doses of SP as directly observed therapy (DOT), at monthly intervals (GHS, 2003b) (GSS, NMIMR, and ORC Macro, 2004: 200). This replaces the former policy of giving a full dose of chloroquine for treatment at the first antenatal visit, followed by two tablets weekly until 6 weeks post-partum (GHS, 2003c) (GSS, NMIMR, and ORC Macro, 2004: 200). In the 2008 GDHS, women who had a live birth in the two years preceding the survey were asked whether they had taken any drugs to prevent them from getting malaria during the pregnancy for their most recent birth and, if yes, which drug. If they had taken SP, they were further asked how many times they took it and whether they had received it during an antenatal care visit. Table 12.4 shows for women age 15-49 with a live birth in the two years preceding the survey, the percentage who took any anti-malarial drug for prevention during the pregnancy, the percentage who took SP/Fansidar, or any other anti-malaria drugs, and the percentage who received Intermittent Preventive Treatment (IPT). The survey results show that nearly two-thirds (65 percent) of women 15-49 with a live birth in the two years preceding the survey took some kind of anti-malarial medicine for prevention of malaria during the last pregnancy. Over half (58 percent) of the women said they took SP/Fansidar— the recommended drug for prevention of malaria during pregnancy in Ghana—at least once during the pregnancy. Less than half (46 percent) of pregnant women said they took SP twice during the pregnancy. Women in urban areas (74 percent) are more likely to take anti-malarial drugs during pregnancy than rural women (60 percent). The Volta and Brong Ahafo regions (79 and 76 percent, respectively) have the highest proportions of women taking any anti-malarial drug, while the Upper East and Northern regions (43 and 45 percent, respectively) have the lowest proportions. The use of anti-malarial drugs during pregnancy increases with increasing levels of education and increasing wealth quintile. Differences by background characteristics in the proportion of treated women who took any dose of SP and who took 2 or more doses of SP are not large, although the proportions are smaller for women who took 2 or more doses of SP. The patterns are similar for women who took any anti- malarial drugs during pregnancy, although, as expected, those proportions are larger. Intermittent Preventive Treatment (IPT) using SP/Fansidar was introduced in Ghana in 2003 as a replacement for chloroquine prophylaxis because of the high levels of chloroquine resistance. Some pregnant women may have received chloroquine prophylaxis because the drug was still in stock for some time after the change of anti-malarial drug policy. Over half (56 percent) of women with a birth in the two years preceding the survey who used IPT received SP/Fansidar during an antenatal visit. Most of them were from the Volta and Brong Ahafo regions (73 and 74 percent, respectively). 230 | Malaria Table 12.4 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy Among women age 15-49 with a live birth in the two years preceding the survey, percentage who during their pregnancy received any anti-malarial drug for prevention; percentage who received any SP/Fansidar/Malafan and two or more doses of SP/Fansidar/Malafan; and percentage who received Intermittent Preventive Treatment (IPT), by background characteristics, Ghana 2008 Background characteristic Percentage who took any anti-malarial drug SP/Fansidar/Malafan Intermittent Preventive Treatment1 Number of women with a live birth in the two years preceding the survey Percentage who took any SP/Fansidar/ Malafan Percentage who took 2+ doses Percentage who received any SP/Fansidar/ Malafan during an ANC visit Percentage who received 2+ doses, at least one during an ANC visit Residence Urban 73.9 64.7 49.6 60.9 46.3 455 Rural 60.1 54.1 42.9 52.9 42.1 723 Region Western 62.5 54.2 46.5 53.2 45.5 111 Central 72.3 68.1 46.7 66.1 45.7 123 Greater Accra 64.8 50.3 37.1 40.9 29.4 133 Volta 78.6 73.2 59.8 73.2 59.8 107 Eastern 66.7 60.5 44.6 56.7 40.8 105 Ashanti 72.8 66.6 51.8 65.7 50.8 215 Brong Ahafo 75.8 73.9 63.7 73.9 63.7 107 Northern 45.0 39.8 29.0 38.2 27.9 177 Upper East 42.8 26.0 26.0 26.0 26.0 63 Upper West 75.7 64.5 53.3 63.0 52.5 36 Education No education 50.0 45.5 36.0 43.8 34.5 363 Primary 64.2 54.3 42.2 52.4 40.7 288 Middle/JSS 77.3 70.4 55.2 67.5 52.6 412 Secondary+ 74.6 64.0 49.3 62.3 48.6 113 Wealth quintile Lowest 48.6 42.0 31.9 40.5 31.2 283 Second 62.9 56.6 43.4 55.7 42.6 261 Middle 69.8 64.7 52.0 63.0 50.3 222 Fourth 74.4 67.6 51.6 64.9 49.2 243 Highest 78.8 65.7 54.1 60.6 49.8 169 Total 65.4 58.2 45.5 56.0 43.7 1,178 Note: Total includes women with information missing on education that are not shown separately 1 Intermittent Preventive Treatment (IPT) during pregnancy is preventive treatment with a dose of sulfadoxine- pyrimethamine (SP/Fansidar/Malafan) at each scheduled antenatal visit after the first trimester, but not more frequently than once a month. The MOH and the Ghana National Malaria Control Programme recommend that pregnant women receive at least two doses of SP/Fansidar during pregnancy as IPT against malaria. In the 2008 GDHS, only 44 percent of women reported receiving two or more doses, at least one of which was during an ANC visit. By inference, 56 percent of respondents who were eligible did not get the recommended doses of SP. IPT coverage increases with mother’s level of education, from 35 percent among those with no education, to 53 percent among those with middle/JSS education, and 49 percent among those with some secondary or higher education. Similarly, IPT coverage increases with wealth quintile, from 31 percent among those in the lowest wealth quintile to 50 percent among those in the highest wealth quintile. 12.2.2 Prevalence and Management of Childhood Malaria A common manifestation of malaria is fever, and the presence of fever is used as an entry point to assess and classify a sick child’s condition under the Home Management of Malaria approach. In the 2008 GDHS, mothers were asked whether their children under age five had a fever in Malaria | 231 the two weeks preceding the survey. Although fever can occur year-round, malaria is more prevalent during the rainy season. Such temporal factors should 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 onset of fever. Table 12.5 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 received anti-malarial drugs and the percentage who took anti-malarial drugs the same or next day, by background characteristics. One in five children under five years (20 percent) had a fever in the two weeks preceding the survey. Of these, 43 percent of children received an anti-malarial drug. Only 24 percent of children received the anti-malarial drug on the same or the next day after the onset of the fever. Table 12.5 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, the percentage who received anti-malarial drugs and the percentage who received the drugs the same or next day following onset of fever, by background characteristics, Ghana 2008 Background characteristic Children under five Children under five with fever Percentage with fever in the two weeks preceding the survey Number of children Percentage who received anti-malarial drugs Percentage who received anti-malarial drugs same or next day Number of children Age (in months) <12 11.9 619 31.5 19.2 74 12-23 26.1 552 45.9 24.5 144 24-35 24.3 496 38.5 20.9 120 36-47 23.3 506 48.2 24.6 118 48-59 15.7 559 47.0 28.8 88 Sex Male 20.9 1,412 43.7 25.9 294 Female 18.9 1,320 42.1 21.1 249 Residence Urban 19.0 1,039 52.6 26.8 197 Rural 20.5 1,692 37.5 22.0 347 Region Western 10.3 260 (34.7) (19.8) 27 Central 23.3 268 35.3 25.1 62 Greater Accra 12.5 329 (43.6) (21.7) 41 Volta 18.5 237 (48.9) (28.1) 44 Eastern 15.7 240 (32.0) (17.8) 38 Ashanti 25.0 510 46.0 19.9 128 Brong Ahafo 27.2 260 49.5 35.7 71 Northern 21.3 413 36.9 11.5 88 Upper East 21.8 142 (60.4) (52.6) 31 Upper West 20.3 72 41.1 20.2 15 Mother’s education No education 19.4 888 31.7 16.7 173 Primary 22.8 668 41.9 25.0 152 Middle/JSS 18.4 920 49.9 25.1 169 Secondary+ 19.9 252 61.5 39.3 50 Wealth quintile Lowest 19.7 693 27.9 13.8 136 Second 22.3 610 38.9 22.7 136 Middle 22.0 507 47.5 26.4 111 Fourth 19.6 528 63.5 33.8 104 Highest 14.3 393 42.4 26.3 56 Total 19.9 2,731 43.0 23.7 544 Note: Total includes children with information missing on mother’s education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 232 | Malaria The highest prevalence of fever is reported among children age 12-23 months (26 percent), followed by those age 24-35 months (24 percent). Fever is less common among children age less than 12 months (12 percent) and those age 48-59 months (16 percent).The proportion of children with fever differs little by urban-rural residence. The Brong Ahafo and Ashanti regions have the highest proportions of children with fever (27 and 25 percent, respectively), while the Western region has the lowest proportion (10 percent). The prevalence of fever is highest among children of mothers with primary level education and children of mothers in the second and middle wealth quintiles. Older children are slightly more likely to be given anti-malarial drugs for the treatment of fever and to receive the drugs the same or the next day. Children living in urban areas are slightly more likely to be given anti-malarial drugs (and within a day or two) than children in rural areas. Children of more educated mothers and children of mothers in the higher wealth quintiles are more likely than other children to be given anti-malarial drugs and to receive these drugs the same or next day as the onset of the fever. Table 12.6 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 the drugs the same or next day after developing fever, by background characteristics. Artemisinin Combination Therapy (ACT) is by far the most common anti-malarial drug given to children for fever (22 percent), followed by chloroquine (9 percent), Fansidar (4 percent) and Camoquine (2 percent). Quinine, which is reserved for treatment of severe and complicated malaria cases in health facilities, was taken by less than 2 percent of children with fever. Four percent of children were given other anti-malarial drugs. There are large differences in the anti-malarial drugs used to manage fever in children under five years by background characteristics. Older children (26 percent), those living in urban areas (30 percent), children of mothers with secondary or higher education (47 percent), and children in households in the fourth wealth quintile (34 percent) are more likely than other children to be given ACT to treat fever. In contrast, rural children (10 percent) are more likely than urban children (6 percent) to have received chloroquine to treat fever, and to have received the drug within a day or two following the onset of fever (7 and 4 percent, respectively). It is noteworthy that chloroquine was withdrawn from the Ghana market in 2003 because of the high level of resistance to the drug. In the majority of cases, the fever was not managed appropriately, with ACT not being given as recommended in the national policy. Because of the need to treat malaria quickly, it can be useful for parents to have anti-malarial drugs at home. The GDHS findings show that anti-malarial drugs were at home when the child became ill in only 19 percent of cases (data not shown). The proportion with the anti-malarial drugs at home was highest for children treated with chloroquine (25 percent); mothers of 13 percent of the children treated with ACT reported having had the drug at home when the child became ill with fever. Malaria | 233 Table 12.6 Type and timing of anti-malarial drugs Among children under age five with fever in the two weeks preceding the survey, percentage who received specific anti-malarial drugs and the percentage who received the drugs the same or next day after developing fever, by background characteristics, Ghana 2008 Background characteristic Percentage of children who received specific anti-malarial drugs Percentage of children who received anti-malarial drugs the same or next day Number of children with fever SP/Fan- sidar/ Malafan Chloro- quine Camo- quine Qui- nine Artemi- sinin ACT1 Other anti- malarial SP/Fan- sidar/ Malafan Chloro- quine Camo- quine Qui- nine Artemi- sinin ACT1 Other anti- malarial Age (in months) <12 5.8 6.3 4.2 0.0 2.0 11.8 1.4 2.6 5.5 0.0 0.0 0.5 9.1 1.4 74 12-23 5.5 7.7 2.1 1.4 1.8 23.6 3.9 2.2 4.7 0.0 0.8 0.0 13.8 3.2 144 24-35 3.5 10.4 1.3 4.5 0.0 18.1 3.6 2.5 6.2 0.0 2.8 0.0 9.5 1.2 120 36-47 1.2 8.1 3.5 1.3 2.5 25.1 7.5 1.2 6.1 0.6 0.0 1.5 12.2 4.0 118 48-59 7.1 10.6 0.0 0.0 0.0 26.0 4.8 5.4 8.2 0.0 0.0 0.0 15.2 1.5 88 Sex Male 4.2 10.0 2.4 1.4 0.7 21.0 4.9 2.3 7.7 0.2 1.0 0.7 12.0 2.8 294 Female 4.7 7.1 1.9 1.9 2.0 22.1 3.8 3.1 4.0 0.0 0.6 0.0 12.2 1.9 249 Residence Urban 5.6 6.1 1.8 3.2 1.1 29.9 6.3 2.5 3.9 0.4 1.5 0.0 17.1 2.8 197 Rural 3.8 10.2 2.4 0.8 1.4 16.7 3.4 2.7 7.2 0.0 0.4 0.6 9.3 2.2 347 Mother’s education No education 3.3 8.1 1.9 1.9 1.9 14.0 2.1 1.3 6.4 0.0 0.2 0.2 8.5 1.4 173 Primary 5.0 12.8 1.5 1.7 0.7 14.9 6.9 4.2 7.5 0.5 0.9 0.0 7.9 4.9 152 Middle/JSS 5.7 7.3 3.7 0.9 1.7 27.7 3.0 3.4 5.1 0.0 0.7 1.0 13.5 1.4 169 Secondary+ 2.1 3.0 0.0 3.1 0.0 46.5 9.8 0.0 3.0 0.0 3.1 0.0 32.2 1.7 50 Wealth quintile Lowest 4.9 13.4 1.2 0.7 0.0 7.5 1.3 3.1 8.1 0.0 0.0 0.0 2.9 0.0 136 Second 5.2 5.7 1.2 2.0 0.3 20.1 4.5 3.5 2.8 0.0 0.3 0.3 12.2 3.6 136 Middle 2.4 7.8 3.4 1.1 5.1 26.6 2.2 2.4 6.7 0.0 0.0 1.6 15.6 0.0 111 Fourth 6.3 10.4 4.7 2.6 0.0 33.6 8.3 2.5 8.6 0.7 2.6 0.0 16.0 5.7 104 Highest 1.9 2.9 0.0 2.6 1.8 26.6 9.3 0.0 2.3 0.0 2.6 0.0 19.9 4.1 56 Total 4.4 8.7 2.2 1.6 1.3 21.5 4.4 2.6 6.0 0.1 0.8 0.4 12.1 2.4 544 1 Artemisinin Combination Therapy (ACT) = Artesunate with Amodiaquine combination, or Artemether-Lumefantrine combination This finding may be a reflection of two factors: the use of Artesunate-Amodiaquine at the household level was not initially encouraged because of the difficulty in calculating doses for infants on the basis of weight; instead, caregivers were advised to seek help at the nearest health facility when their child developed a fever. Second, there was reluctance on the part of many people to use the drug for fear of adverse reactions, which were observed in the initial stages of the drug’s introduction. Overall, the 2008 GDHS results highlight the large gap between the national targets set for 2005 in the Roll Back Malaria (RBM) initiative and the present intervention coverage. Advocacy programmes need to be implemented to increase the use of insecticide-treated mosquito nets, their re- treatment, management of paediatric fevers, and uptake of IPT. 234 | Malaria 12.3 EXPOSURE TO MESSAGES ON MALARIA Malaria has been a topical health issue for several decades and it is a common occurrence to hear, read, or watch a message on malaria in any of the mass communication media. The practice was intensified in the early 2000s when the country changed the treatment policy and introduced and scaled up IPT and ITN use. The 2008 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 in various media sources. They were also asked specifically whether they had listened to the radio programme He Ha Ho. This information is shown in Table 12.7. Table 12.7 Sources of messages on malaria Percentage of household respondents who heard or saw a message about malaria in the media or received a message through a health worker or a community volunteer, and percentage who ever listened to the radio programme He Ha Ho, by source of messages and background characteristics, Ghana 2008 Background characteristic Percentage of household respondents who received malaria message through: Percentage who ever listened to ‘He Ha Ho’ Number of household respondents TV Radio News- paper/ magazine Poster Leaflets/ brochures Health worker Community volunteer No media exposure Residence Urban 73.2 83.2 28.0 54.0 16.5 41.5 19.9 6.5 31.6 5,627 Rural 35.7 79.6 10.3 37.1 7.7 42.5 23.6 12.0 40.3 6,150 Region Western 58.3 87.7 19.9 51.5 11.1 29.0 15.1 6.5 48.5 1,184 Central 59.2 83.7 17.1 48.9 15.4 41.4 23.0 8.0 27.9 1,279 Greater Accra 79.4 78.8 33.6 54.9 16.8 29.4 11.2 7.7 24.4 1,951 Volta 24.1 82.2 10.5 35.1 7.9 53.1 25.3 10.2 77.1 991 Eastern 50.2 74.6 18.4 36.6 9.4 46.0 24.2 14.1 24.8 1,260 Ashanti 59.2 85.7 18.1 51.4 12.3 43.7 15.5 6.0 15.5 2,263 Brong Ahafo 48.7 86.9 11.9 54.4 10.6 46.2 32.9 6.7 39.8 1,154 Northern 37.2 71.0 13.4 22.6 10.5 55.9 40.8 16.7 56.6 928 Upper East 24.3 72.5 12.8 27.2 6.7 43.9 24.8 21.0 54.6 540 Upper West 30.0 78.6 9.2 25.2 7.3 50.6 37.0 8.3 64.1 228 Wealth quintile Lowest 13.3 69.3 3.9 20.7 2.9 40.3 28.4 20.3 44.5 1,813 Second 28.0 80.3 6.5 35.2 5.9 41.0 23.0 11.7 40.0 2,250 Middle 46.4 80.4 10.8 43.2 8.1 43.6 21.4 10.5 34.8 2,548 Fourth 75.9 86.2 23.5 54.8 14.4 42.2 20.5 5.1 32.9 2,646 Highest 89.3 86.5 43.4 63.5 25.0 42.4 17.9 3.0 31.5 2,520 Total 53.6 81.3 18.8 45.2 11.9 42.0 21.9 9.4 36.2 11,777 Not surprisingly, the majority of household respondents said they had heard about malaria on the radio (81 percent), 54 percent had seen a message about malaria on the television, and more than two in five respondents had seen a poster on malaria. One-fifth of respondents had read about malaria in a newspaper or magazine and 12 percent had seen leaflets or brochures on malaria. At the same time, nearly two-thirds (64 percent) of household respondents said they heard about malaria from a health worker or community volunteer. Thirty-six percent of respondents reported having heard the radio programme He Ha Ho. This is a decline since 2003 when 42 percent of respondents to household questionnaire had heard about the programme. Except for radio, which is widely available in most communities, exposure to media messages about malaria from other sources is more common in urban areas than in rural areas. It should be noted that exposure to radio messages shows little difference by residence, but it is considerably lower Malaria | 235 among respondents in the lowest wealth quintile. There are also large differences by wealth quintile in the proportion of respondents who received malaria messages through TV, leaflets, posters, and newspapers or magazines. There were no differences by wealth quintile in exposure to messages from health workers; however, there were substantial differences by wealth quintile for no media exposure: 20 percent for the lowest wealth quintile, compared with 3 percent for the highest wealth quintile. Rural respondents were slightly more likely than those in urban areas to have received a message on malaria from a community volunteer (24 and 20 percent, respectively), and the Northern and Upper West regions were more likely to receive messages on malaria from a community volunteer (41 and 37 percent, respectively) than other regions. Regarding malaria messages received from a health worker, respondents in Volta, Northern, and Upper West regions were the most likely to cite this source (53, 56, and 51 percent, respectively); respondents in the Western and Greater Accra regions were the least likely to receive messages on malaria from a health worker (29 percent each). 12.3.1 Exposure to Specific Messages on Malaria In Ghana, messages on malaria in the mass media are so varied that they can be misleading or confusing. This is particularly the case regarding FM radio stations because of widespread commercials on local herbal preparations claiming to have a cure for malaria, and a litany of mosquito coils purported to repel or kill mosquitoes and protect against malaria. Household respondents in the 2008 GDHS were asked about exposure to specific messages about malaria that were officially sanctioned for dissemination by the Ministry of Health and the Ghana Health Service. Table 12.8 summarises the results. Interestingly, and contrary to the low level of ITN usage, 93 percent of household respondents have heard messages that families should sleep under an ITN to protect them from mosquito bites and hence malaria. Seventy-seven percent have heard that pregnant women should attend antenatal clinics and take three doses of SP or Fansidar for IPT. Seventy-six percent have heard that treatment should be sought from health facilities within 24 hours of the onset of childhood fever; 63 percent have heard that the GHS recommends Artesunate-Amodiaquine for treatment of malaria; and more than half were aware that the full course of Artesunate-Amodiaquine should be completed. The proportion of respondents who have heard the messages about malaria in Table 12.8 appears to increase with household wealth except for message on IPT but does not appear to be influenced by urban-rural residence, except for ACT (rural is lower). The Upper East, Upper West, and Eastern regions are more likely to have heard messages on the recommended treatment for malaria and the need to seek prompt care. Respondents in the Central region are least likely to have heard messages on the recommended treatment for malaria, and the need to seek prompt care, and to complete the full course of treatment. Less than half of respondents in the Central region (47 percent) know that pregnant women should go to the antenatal clinic for IPT, compared with 94 percent of respondents in the Upper East region. The 2008 GDHS results on the malaria messages heard or seen by household respondents point to an interesting behavioural pattern if viewed against the results of ITN use, IPT uptake, and the management of fever in children under age five. The findings show a gap between what people in Ghana know about malaria and its treatment, and what they actually do when a young child has a fever and the situation demands action. 236 | Malaria Table 12.8 Exposure to specific messages on malaria Percentage of household respondents who heard or saw a message about malaria, by specific message and background characteristics, Ghana 2008 Background characteristic Message Number of household respondents The Ghana Health Service recommends Artesunate and Amodiaquine as a drug for malaria Treatment should be sought from health facility within 24 hours of onset of fever, especially for a child under 5 years The full course of the malaria drug Artesunate and Amodiaquine should be completed Pregnant women should attend ANC and take 3 doses of SP/Fansidar during pregnancy to prevent malaria Families should sleep under an insecticide- treated mosquito net to protect them from mosquito bites that lead to malaria, especially pregnant women and children under 5 years Residence Urban 67.8 76.5 64.2 76.5 93.6 5,627 Rural 58.9 75.3 53.4 78.2 91.6 6,150 Region Western 65.9 82.3 61.1 85.1 91.9 1,184 Central 50.8 69.0 38.2 46.7 94.0 1,279 Greater Accra 65.9 72.4 64.5 68.6 92.4 1,951 Volta 65.3 75.3 57.2 82.2 90.9 991 Eastern 71.4 80.3 62.4 79.3 92.3 1,260 Ashanti 63.6 79.4 61.1 83.2 92.5 2,263 Brong Ahafo 61.5 78.4 61.0 86.9 95.0 1,154 Northern 52.0 61.8 46.5 83.2 88.5 928 Upper East 70.0 82.8 72.4 93.8 95.5 540 Upper West 72.3 79.9 72.3 85.9 94.5 228 Wealth quintile Lowest 54.0 69.4 49.7 82.2 89.1 1,813 Second 56.0 74.4 50.5 75.9 91.2 2,250 Middle 57.1 75.2 50.8 74.5 91.8 2,548 Fourth 64.7 77.9 60.3 76.5 94.1 2,646 Highest 80.6 80.3 78.1 79.1 95.2 2,520 Total 63.1 75.8 58.6 77.4 92.5 11,777 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 237 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 Acquired Immune Deficiency Syndrome (AIDS) was first recognised internationally in 1981 and in Ghana in 1986. AIDS is caused by the human immunodeficiency virus (HIV) which compro- mises the immune system and makes the body prone to opportunistic infections. In 2000, the Government of Ghana, with the objective of ensuring effective management and a unified response to the HIV and AIDS epidemic, adopted a multi-sectoral approach to address the developmental challenges of the epidemic. The HIV and AIDS response in Ghana is guided by the National Strategic Framework 2006-2010 (GAC, 2006). The National HIV/AIDS and STI policy underpins the National Strategic Framework. Currently, the national response involves the participation of entities at national and decentralised levels such as by ministries, departments and agencies, regional coordinating councils, district assemblies, civil society organisations, the private sector and research and academic institutions. Ghana is considered a lower prevalence country with the main route of transmission being heterosexual. Results from the 2003 GDHS indicate that 2 percent of Ghanaian adults age 15-49 are HIV positive (2.7 percent women and 1.5 percent men) (GSS and ORC Macro, 2004). The median HIV prevalence from antenatal clinic (ANC) sentinel surveillance has also remained fairly stable at around 3 percent (varying between 2.3-3.6 percent) since 1992, despite an increase in the number of sites from 8-40 and the rural-urban mix. In 2008, the median HIV prevalence from antenatal clinic (ANC) sentinel surveillance was 2.2 percent. The prevalence of HIV among young people age 15-24, which is used as a marker for new cases, has decreased from 3.2 percent in 2002 to 1.9 percent in 2008 (NACP, 2009). There are various factors that have worked in favour of the stable HIV prevalence in the country. For example, in Ghana it is believed that the high levels of male circumcision are likely to have been a major factor containing the spread of HIV. Furthermore, with the increased accessibility and affordability of anti-retroviral therapy (ART), coupled with the increased uptake of counselling and testing, there is a window of opportunity to ensure a more effective and efficient response to the spread of HIV (GAC, 2009) Challenges exist nevertheless. Stigma and discrimination against persons living with HIV is quite high, coupled with misconceptions about the disease. High levels of sero-discordance, high levels of consensual unions or marriage, and low levels of knowledge of HIV status among persons living with HIV present an unwanted window for transmission within the general population, in addition to sex with female sex workers, their clients, and non-paying partners (GAC, 2009b). In Ghana, gender issues are basic to confronting the HIV/AIDS epidemic. Ghanaian women often experience relative powerlessness, compared with men, because of poor economic empowerment and negative social norms. As a result, they are often subject to the will of their partners and husbands. This powerlessness, along with limited life choices, makes it difficult to decline sexual advances without facing coercion or violence, and limits women’s ability to negotiate condom use and gain access to health services. Many interventions have been developed and implemented to address gender equity so that men and women have full access to information and services that can help reduce vulnerability to infection and/or mitigate the effects of HIV and AIDS (GAC, 2009b). The Ghana DHS 2008 collected a variety of information on HIV/AIDS-related knowledge including social stigmatisation, risk behaviour modification, access to high-quality services for sexually transmitted infections (STI), provision and uptake of HIV counselling and testing, and the prevalence of male circumcision. The principal objective of this chapter is to establish the level of relevant knowledge, perceptions, and behaviours at the national level, and within geographic and socio-economic sub-populations. Such information should go a long way toward better targeting of interventions for effective prevention, treatment, care and support for those groups most in need of information and most at risk of HIV. 238 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.1 KNOWLEDGE OF AIDS Respondents in the 2008 GDHS were asked whether they had heard of AIDS. Those who reported having heard of AIDS were asked a series of questions about whether AIDS can be avoided and how. Table 13.1 shows the percent distribution of women and men age 15-49 who have heard of AIDS, by background characteristics. As high as 98 percent of women and 99 percent of men have heard about AIDS, indicating that awareness of AIDS in Ghana is nearly universal. Knowledge of HIV/AIDS does not vary much by background characteristics. Nevertheless, there are some differences in the level of knowledge by region, education, and wealth quintile. As can be seen from Table 13.1, awareness of AIDS is lowest among women and men in the Northern region and highest among women in the Eastern region and men in the Central region. Awareness of AIDS increases with level of education. All women and men with at least middle/JSS have heard about AIDS, compared with 94 percent of women and 97 percent of men who have no education. Similarly, women and men in the higher wealth quintiles are more likely to have heard of AIDS than those in the lowest wealth quintile. 13.2 KNOWLEDGE OF HIV PREVENTION METHODS In Ghana, HIV in adults is mainly transmitted by heterosexual contact between a partner who is HIV positive and a partner who is HIV negative. Consequently, HIV prevention programmes focus their messages and efforts on three important aspects of behaviour: using condoms, limiting the number of sexual partners or staying faithful to one partner, and delaying sexual debut for young persons (abstinence). To ascertain whether programmes have effectively communicated these messages, the 2008 GDHS respondents were specifically asked if people can reduce their chances of getting the AIDS virus by using a condom every time they have sex, by having just one HIV-negative sexual partner who has no other sexual partners, and by not having sexual intercourse at all. Table 13.2 shows that 76 percent of women and 82 percent of men age 15-49 know that consistent use of condoms is a means of preventing the spread of HIV. About 85 percent of women and 88 percent of men know that limiting sexual intercourse to one HIV-negative and faithful partner can reduce the chances of contracting HIV. The proportion of men who said that people can reduce the chances of getting the AIDS virus by using condoms and limiting sex to one HIV-negative partner is higher (77 percent) than that of women (69 percent). Thus, knowledge is higher among men than women for each of the three specified prevention methods. Almost equal proportions of women (80 percent) and men (81 percent) age 15-49 know that abstinence is a way of reducing the chances of getting HIV. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Ghana 2008 Background characteristic Women Men Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 98.2 1,902 98.8 1,615 15-19 97.6 1,025 98.2 911 20-24 98.9 878 99.5 704 25-29 99.1 832 99.3 624 30-39 97.5 1,283 99.7 1,061 40-49 98.7 899 99.7 758 Marital status Never married 98.7 1,593 98.9 1,936 Ever had sex 99.3 819 99.7 984 Never had sex 97.9 774 98.0 952 Married/living together 98.0 2,876 99.6 1,950 Divorced/separated/ widowed 98.5 446 100.0 172 Residence Urban 99.5 2,383 99.8 1,866 Rural 97.0 2,533 98.8 2,191 Region Western 97.1 447 99.5 403 Central 98.3 424 100.0 326 Greater Accra 99.2 853 99.9 649 Volta 99.4 431 99.5 373 Eastern 100.0 483 99.8 411 Ashanti 99.6 1,011 99.7 785 Brong Ahafo 99.4 425 99.5 347 Northern 91.4 467 95.5 435 Upper East 99.5 253 99.6 219 Upper West 93.1 122 99.2 108 Education No education 94.3 1,042 97.0 540 Primary 98.0 988 98.9 619 Middle/JSS 99.6 2,039 99.6 1,721 Secondary+ 100.0 844 99.9 1,167 Wealth quintile Lowest 93.9 783 97.5 708 Second 97.9 900 99.0 738 Middle 98.7 979 99.5 699 Fourth 99.4 1,119 99.8 974 Highest 99.9 1,135 100.0 939 Total 15-49 98.2 4,916 99.2 4,058 50-59 na na 99.0 510 Total 15-59 na na 99.2 4,568 Note: Total includes cases with information missing on education that are not shown separately. na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 239 Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not HIV positive and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Ghana 2008 Background characteristic Percentage of women who say HIV can be prevented by: Number of women Percentage of men who say HIV can be prevented by: Number of men Using condoms1 Limiting sexual intercourse to one HIV- negative partner2 Using condoms and limiting sexual intercourse to one HIV- negative partner1,2 Abstaining from sexual intercourse Using condoms1 Limiting sexual intercourse to one HIV- negative partner2 Using condoms and limiting sexual intercourse to one HIV- negative partner1,2 Abstaining from sexual intercourse Age 15-24 74.9 82.3 65.9 79.8 1,902 82.5 87.3 76.1 80.4 1,615 15-19 73.8 80.6 63.9 78.7 1,025 82.4 85.9 75.4 80.5 911 20-24 76.1 84.4 68.3 81.0 878 82.5 89.1 77.1 80.4 704 25-29 80.2 88.4 73.7 80.4 832 82.4 89.3 77.9 82.0 624 30-39 76.0 85.9 69.7 79.3 1,283 83.7 88.9 78.6 81.9 1,061 40-49 73.8 87.1 67.9 81.6 899 80.4 89.3 74.9 81.3 758 Marital status Never married 75.3 83.2 66.3 80.0 1,593 83.3 88.0 77.5 81.5 1,936 Ever had sex 78.6 86.8 71.7 80.3 819 85.7 91.1 81.4 83.6 984 Never had sex 71.8 79.4 60.6 79.6 774 80.9 84.9 73.4 79.4 952 Married/living together 75.7 85.9 69.4 79.9 2,876 81.8 89.1 76.7 81.2 1,950 Divorced/separated/ widowed 78.8 87.4 71.6 81.6 446 79.0 84.4 71.6 78.4 172 Residence Urban 79.3 88.1 72.8 82.4 2,383 82.8 89.6 77.5 82.2 1,866 Rural 72.6 82.4 64.6 78.0 2,533 82.1 87.4 76.2 80.4 2,191 Region Western 84.1 75.0 65.2 82.1 447 80.4 92.1 75.5 71.8 403 Central 84.2 90.7 79.7 86.2 424 92.2 95.3 88.2 92.7 326 Greater Accra 75.8 88.3 71.1 84.3 853 85.0 88.6 79.3 86.9 649 Volta 80.2 92.5 76.4 80.6 431 91.5 95.4 88.3 88.3 373 Eastern 78.5 83.0 69.0 78.8 483 73.9 76.6 61.1 69.0 411 Ashanti 76.6 84.1 67.9 75.2 1,011 84.1 91.4 80.1 83.7 785 Brong Ahafo 78.4 86.4 70.6 84.4 425 86.2 93.6 82.9 84.3 347 Northern 58.2 78.7 54.2 74.7 467 61.6 73.2 53.6 66.6 435 Upper East 68.3 92.6 65.9 83.1 253 90.4 90.5 86.1 90.1 219 Upper West 59.7 76.8 54.6 66.5 122 89.1 91.7 83.5 82.8 108 Education No education 64.7 80.1 58.8 74.8 1,042 71.0 81.1 64.8 76.1 540 Primary 77.3 83.9 68.7 78.1 988 84.4 86.3 78.0 84.4 619 Middle/JSS 79.2 86.5 71.5 82.0 2,039 83.1 88.8 76.8 80.0 1,721 Secondary+ 79.7 89.5 73.5 84.4 844 85.7 92.2 81.9 83.7 1,167 Wealth quintile Lowest 62.8 77.5 55.6 73.2 783 77.1 81.8 70.3 76.7 708 Second 77.3 82.8 67.6 78.2 900 80.5 86.7 72.9 78.7 738 Middle 76.7 85.5 69.4 81.1 979 83.1 90.3 78.7 82.1 699 Fourth 81.3 87.5 74.4 81.7 1,119 84.1 90.4 79.3 82.3 974 Highest 77.6 89.7 71.8 84.0 1,135 85.7 91.3 80.8 84.8 939 Total 15-49 75.9 85.2 68.6 80.1 4,916 82.4 88.4 76.8 81.2 4,058 50-59 na na na na na 82.0 92.3 79.2 82.3 510 Total 15-59 na na na na na 82.4 88.8 77.1 81.4 4,568 Note: Total includes cases with information missing on education that are not shown separately. na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 240 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Among men, there is no clear association between age and knowledge of HIV prevention. For women, however, with exception of knowledge of abstinence, women age 25-29 have the highest level of knowledge of HIV prevention. Awareness of HIV prevention methods by marital status shows that women who have never had sex, and divorced/separated/widowed men, are among the least likely to report knowledge of ways to prevent the transmission of HIV. Knowledge of HIV prevention methods is higher among respondents in urban areas, better educated respondents, and those in the higher wealth quintiles. Both women and men in the Northern region are less likely to know that using condoms and limiting sex to one HIV-negative partner can reduce the risk of getting HIV. Among both women and men, knowledge of ways to prevent AIDS is consistently higher in the Central region, compared with other regions. 13.3 BELIEFS ABOUT AIDS In addition to knowing about effective ways to avoid contracting HIV, it is also useful to be able to identify incorrect beliefs about AIDS to eliminate misconceptions. Misconceptions about AIDS and HIV transmission are among the factors that result in discrimination and stigmatisation. The 2008 GDHS included questions on common misconceptions about HIV/AIDS. Misconceptions about AIDS in Ghana include the idea that HIV-positive people always appear ill, the belief that the virus can be transmitted through mosquito bites, by sharing food with someone who is HIV positive, and by witchcraft and other supernatural means. Respondents were asked about these four misconceptions and the results are presented in Tables 13.3.1 and 13.3.2 for women and men, respectively. The results in Tables 13.3.1 and 13.3.2 indicate that many Ghanaian adults have accurate knowledge about the ways in which the AIDS virus can and cannot be transmitted. About 82 percent of women and 86 percent of men know that a healthy-looking person can have the AIDS virus. Over two-thirds of respondents are aware that the AIDS virus cannot be transmitted through mosquito bites. Furthermore, 60 percent of men and 48 percent of women correctly believe that the AIDS virus cannot be transmitted by supernatural means, and 78 percent of men and 74 percent of women know that the AIDS virus cannot be contracted by sharing food with a person who has AIDS. Overall, about one-third of women (33 percent) and 41 percent of men reject two of the most common local misconceptions about the transmission of the AIDS virus in Ghana—namely, that the AIDS virus can be transmitted through mosquito bites and by supernatural means—and believe that a healthy-looking person can have the AIDS virus. These proportions are slightly higher than those in the 2003 GDHS (28 percent for women and 39 percent for men). Tables 13.3.1 and 13.3.2 provide an assessment of the level of comprehensive knowledge of HIV/AIDS prevention and transmission. Comprehensive knowledge is defined as: 1) knowing that both condom use and limiting sexual partners to one HIV-negative person are HIV/AIDS prevention methods, 2) being aware that a healthy-looking person can have HIV, and 3) rejecting the two most common local misconceptions. The 2008 GDHS results indicate that only one in four women (25 percent) and one in three men (33 percent) in Ghana have comprehensive knowledge of HIV/AIDS prevention and transmission. Tables 13.3.1 and 13.3.2 document substantial variation in knowledge about AIDS by background characteristics. The proportions of women and men who reject the most common misconceptions and know that a healthy-looking person can have the AIDS virus, or who have comprehensive knowledge about AIDS, are highest among younger respondents. For all indicators, the proportions of women and men with correct knowledge about HIV/AIDS prevention and transmission are higher in urban areas than in rural areas. Variations in knowledge of AIDS are also seen by region. Women in the Upper West and Northern regions (17 percent each) have the lowest level of comprehensive knowledge about AIDS, while women in the Greater Accra region (36 percent) have the highest level. Among men, comprehensive knowledge ranges from 21 percent in the Western region to 47 percent in the Greater Accra region. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 241 Table 13.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about HIV/AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Ghana 2008 Background characteristic Percentage of women who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a compre- hensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super- natural means A person cannot get the AIDS virus by sharing food with a person who has AIDS Age 15-24 79.1 71.8 55.8 77.4 38.5 28.3 1,902 15-19 75.6 71.3 59.5 75.8 39.1 27.7 1,025 20-24 83.3 72.3 51.5 79.3 37.9 29.0 878 25-29 84.5 68.7 46.4 73.7 33.9 27.5 832 30-39 83.8 57.6 43.5 71.7 29.4 22.9 1,283 40-49 82.4 58.3 40.9 68.3 27.5 20.8 899 Marital status Never married 80.4 75.4 59.3 80.0 41.6 30.3 1,593 Ever had sex 84.3 75.1 55.9 82.7 40.7 31.1 819 Never had sex 76.3 75.9 62.9 77.1 42.6 29.4 774 Married/living together 82.6 60.1 43.7 69.9 30.1 23.6 2,876 Divorced/separated/ widowed 81.9 60.5 38.3 74.9 24.6 19.6 446 Residence Urban 85.7 76.0 55.6 82.2 42.0 32.2 2,383 Rural 78.2 54.8 41.3 65.5 25.2 19.0 2,533 Region Western 69.5 67.8 48.2 74.9 31.0 25.7 447 Central 86.0 56.8 34.1 71.7 25.1 22.1 424 Greater Accra 87.4 80.3 62.3 85.5 49.4 36.1 853 Volta 89.7 56.8 49.9 61.0 37.1 30.5 431 Eastern 87.4 66.9 47.8 79.0 32.3 23.5 483 Ashanti 83.9 72.6 41.0 76.9 27.6 20.2 1,011 Brong Ahafo 84.5 58.2 45.6 78.9 32.0 24.2 425 Northern 63.3 45.0 48.2 52.9 24.5 17.4 467 Upper East 86.1 62.4 54.7 69.7 38.5 31.0 253 Upper West 60.7 43.7 51.9 58.0 24.8 17.1 122 Education No education 71.1 41.4 36.1 52.4 19.6 13.6 1,042 Primary 78.2 57.6 41.1 66.9 24.3 18.3 988 Middle/JSS 84.8 71.4 48.2 80.4 33.2 26.1 2,039 Secondary+ 92.4 87.9 71.4 91.3 60.9 46.5 844 Wealth quintile Lowest 67.0 44.1 40.9 53.8 19.2 13.3 783 Second 80.2 56.9 41.5 65.1 25.7 19.7 900 Middle 81.3 62.8 44.6 73.8 29.6 22.4 979 Fourth 86.0 70.7 48.8 80.1 36.7 29.5 1,119 Highest 89.8 82.5 61.2 87.5 49.0 36.7 1,135 Total 81.9 65.1 48.2 73.6 33.3 25.4 4,916 Note: Total includes cases with information missing on education that are not shown separately 1 Two most common local misconceptions: ‘AIDS can be transmitted by mosquito bites’ and ‘AIDS can be transmitted by supernatural means’. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV/AIDS transmission or prevention. 242 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Ghana 2008 Background characteristic Percentage of men who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a compre- hensive knowledge about AIDS2 Number of men A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by super- natural means A person cannot get the AIDS virus by sharing food with a person who has AIDS Age 15-24 81.8 71.0 62.6 79.0 41.9 34.2 1,615 15-19 77.8 69.0 60.4 77.2 37.6 30.4 911 20-24 87.1 73.5 65.3 81.4 47.5 39.1 704 25-29 89.2 67.7 58.6 78.0 43.3 36.7 624 30-39 89.5 65.5 59.3 78.8 40.8 32.6 1,061 40-49 86.7 60.2 56.2 75.7 36.1 28.9 758 Marital status Never married 83.9 71.8 63.0 79.5 43.9 36.4 1,936 Ever had sex 89.1 71.7 63.0 80.7 45.4 39.6 984 Never had sex 78.5 71.9 63.0 78.3 42.3 33.1 952 Married/living together 87.8 62.7 57.8 77.1 38.4 30.8 1,950 Divorced/separated/ widowed 86.3 61.9 49.2 76.3 31.9 24.3 172 Residence Urban 90.7 74.9 66.2 84.5 50.8 41.2 1,866 Rural 81.8 60.4 54.6 72.8 32.2 26.4 2,191 Region Western 94.0 56.3 42.4 74.9 26.6 20.7 403 Central 93.9 66.6 44.4 87.4 33.5 29.0 326 Greater Accra 94.6 79.8 69.3 88.7 57.7 47.4 649 Volta 90.4 72.1 64.4 67.8 47.8 43.3 373 Eastern 82.1 63.3 58.1 80.2 34.0 26.3 411 Ashanti 83.6 69.0 62.0 79.8 40.3 32.0 785 Brong Ahafo 86.8 68.1 53.8 78.4 40.5 35.2 347 Northern 67.9 59.4 69.9 60.2 36.9 22.8 435 Upper East 76.5 60.7 60.9 84.9 38.3 36.9 219 Upper West 82.7 54.3 69.3 73.9 39.8 34.6 108 Education No education 73.9 48.9 51.9 60.3 24.9 19.0 540 Primary 80.2 49.1 47.5 70.0 25.7 21.1 619 Middle/JSS 86.6 66.1 56.9 78.9 35.8 28.5 1,721 Secondary+ 93.3 86.4 74.7 89.7 63.4 53.2 1,167 Wealth quintile Lowest 71.2 49.3 52.5 64.3 24.4 20.1 708 Second 82.1 58.5 53.4 72.5 30.8 24.7 738 Middle 87.0 66.5 58.2 77.4 38.6 30.1 699 Fourth 90.6 72.8 61.9 81.0 45.5 37.3 974 Highest 94.1 81.5 69.8 90.8 57.5 47.7 939 Total 15-49 85.9 67.0 59.9 78.2 40.7 33.2 4,058 50-59 86.8 62.0 63.9 76.2 41.7 37.0 510 Total 15-59 86.0 66.5 60.4 78.0 40.8 33.6 4,568 Note: Total includes cases with information missing on education that are not shown separately 1 Two most common local misconceptions: ‘AIDS can be transmitted by mosquito bites’ and ‘AIDS can be transmitted by supernatural means’. 2 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV/AIDS transmission or prevention. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 243 Education and wealth status are directly related to correct knowledge about common misconceptions about AIDS and comprehensive knowledge of HIV/AIDS prevention and transmission. Among women, for example, 47 percent of women with secondary or higher education have comprehensive knowledge about prevention and transmission of HIV/AIDS, compared with 14 percent of women with no education. Similarly, among men, the level of comprehensive knowledge is 53 percent among men with secondary or higher education, compared with 19 percent among men with no education. Looking at wealth status, 13 percent of women in the lowest quintile have comprehensive knowledge about AIDS, compared with 37 percent of women in the highest wealth quintile. Among men, the level of comprehensive knowledge about AIDS also increases with wealth quintile (20 percent in the lowest quintile, compared with 48 percent in the highest). 13.4 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing the level of general knowledge of transmission of HIV from mother to child and reducing the risk of transmission using antiretroviral drugs is critical to the prevention of mother-to- child transmission (MTCT) of HIV. In Ghana, at the end of 2008, there were 117 antiretroviral sites and 524 PMTCT/CT sites established and operational (NACP, 2009). To assess MTCT knowledge, respondents in the 2008 GDHS were asked if the virus that causes AIDS can be transmitted from a mother to her baby during pregnancy, delivery, or breastfeeding and whether they know of any special drugs a mother with HIV can take to reduce the risk of transmission to the baby. Table 13.4 shows that women are slightly more likely than men to know of the risk of mother-to-child transmission of HIV through breastfeeding (85 and 78 percent, respectively). About one in two women (50 percent) and two in five men (44 percent) know that the risk of mother-to-child transmission of HIV can be reduced by the mother taking special drugs during pregnancy. Although low, these levels of knowledge about the special drugs that can prevent transmission of HIV to babies are a substantial increase from the 16 percent for both sexes in 2003. Pregnant women are just slightly more likely to know about drugs to reduce the risk of mother-to-child transmission than women who are not pregnant (50 and 47 percent, respectively). Women and men in urban areas, those with higher education, and those from wealthier households are more likely to know about special drugs to prevent mother-to-child transmission than other respondents. Knowledge of drugs to prevent MTCT varies by region. For women, it is lowest in the Northern region (28 percent) and highest in the Brong Ahafo region (63 percent). Overall, about one in two women (47 percent) and one in three men (38 percent) know that HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by the mother taking special drugs during pregnancy. Knowledge is lowest among respondents who are married or living together. A larger proportion of women in urban areas than in rural areas know about MTCT and the use of special drugs to reduce the risk of MTCT (51 and 43 percent, respectively). The same pattern is seen for men: 42 percent of men in urban areas know about MTCT and the use of special drugs to reduce the risk of MTCT, compared with 35 percent of men in rural areas. By region, this knowledge among women ranges from 26 percent in the Northern region to 61 percent in the Brong Ahafo region. Among men, this knowledge ranges from 23 percent in the Volta region to 52 percent in the Central region. As seen earlier, respondents’ socio-economic status, as measured by level of education and wealth quintile, has a positive correlation with knowledge of MTCT. 244 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.4 Knowledge of prevention of mother to child transmission of HIV Percentage of women and men who know that HIV can be transmitted from mother to child by breastfeeding 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 2008 Background characteristic Percentage of women who know that: Number of women Percentage of men who know that: Number of men HIV can be transmitted by breast- feeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breast- feeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Age 15-24 82.2 47.8 44.2 1,902 72.8 39.6 33.0 1,615 15-19 78.2 43.0 39.5 1,025 70.6 35.2 29.4 911 20-24 86.9 53.3 49.7 878 75.5 45.4 37.7 704 25-29 87.6 56.6 53.7 832 79.5 45.3 40.9 624 30-39 87.0 51.4 48.7 1,283 81.3 47.6 42.0 1,061 40-49 87.4 46.7 44.0 899 80.9 45.9 40.8 758 Marital status Never married 81.2 47.9 43.6 1,593 73.7 41.2 34.7 1,936 Ever had sex 84.1 51.4 46.5 819 75.8 46.2 38.2 984 Never had sex 78.0 44.1 40.5 774 71.5 36.1 31.1 952 Married/living together 87.3 51.4 49.0 2,876 81.3 46.1 40.8 1,950 Divorced/separated/ widowed 87.4 48.6 45.7 446 79.1 45.4 43.7 172 Currently pregnant Pregnant 84.1 54.2 49.5 360 na na na na Not pregnant or not sure 85.4 49.7 46.8 4,556 na na na na Residence Urban 87.5 55.3 51.0 2,383 75.9 49.4 41.5 1,866 Rural 83.2 45.0 43.1 2,533 79.0 38.9 35.1 2,191 Region Western 85.8 45.7 43.5 447 70.7 47.9 39.2 403 Central 85.9 47.5 44.9 424 71.6 62.6 51.7 326 Greater Accra 87.5 53.7 49.6 853 77.7 48.7 40.6 649 Volta 92.7 35.4 35.2 431 76.6 23.9 22.6 373 Eastern 87.6 56.9 54.6 483 85.3 41.0 39.6 411 Ashanti 85.5 54.9 49.2 1,011 81.3 45.5 39.5 785 Brong Ahafo 86.3 63.4 61.0 425 77.7 55.8 47.3 347 Northern 70.7 28.0 25.9 467 77.8 29.3 26.6 435 Upper East 90.2 61.0 60.1 253 70.7 39.5 37.3 219 Upper West 72.0 46.8 45.4 122 79.3 36.0 31.7 108 Education No education 79.6 37.2 36.6 1,042 75.7 30.2 28.3 540 Primary 85.0 46.5 44.4 988 77.0 35.1 30.8 619 Middle/JSS 87.5 52.9 49.5 2,039 78.7 42.1 37.5 1,721 Secondary+ 87.4 62.6 56.3 844 77.3 57.0 47.3 1,167 Wealth quintile Lowest 75.9 35.8 34.7 783 76.8 30.3 28.8 708 Second 84.0 46.1 44.1 900 76.7 36.1 31.9 738 Middle 86.5 48.1 45.4 979 80.2 42.7 38.4 699 Fourth 89.9 53.9 51.0 1,119 77.9 49.6 42.1 974 Highest 87.4 60.8 55.0 1,135 76.4 54.6 45.4 939 Total 15-49 85.3 50.0 47.0 4,916 77.6 43.8 38.0 4,058 50-59 na na na na 72.9 47.2 36.8 510 Total 15-59 na na na na 77.0 44.1 37.9 4,568 Note: Total includes cases with information missing on education that are not shown separately. na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 245 13.5 STIGMA ASSOCIATED WITH AIDS AND ATTITUDES RELATED TO HIV/AIDS Widespread stigma and discrimination in a population can adversely affect people’s willingness to be tested for HIV as well as their adherence to antiretroviral therapy. Reduction of stigma and discrimination in a population is, thus, an important impetus to the success of programmes targeting HIV/AIDS prevention and control. To assess the level of stigma, GDHS respondents who had heard of AIDS were asked if they would be willing to care for a family member with AIDS virus in their home, if they would buy fresh vegetables from a shopkeeper who has the AIDS virus, if they thought a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and if they would not want to keep secret that a family member has the AIDS virus. Tables 13.5.1 and 13.5.2 show the results for women and men, respectively. Both women and men tended to express more positive attitudes about caring for a family member with the AIDS virus in the respondent’s home than buying vegetables from a shopkeeper with AIDS, allowing an HIV-positive teacher to continue teaching, or keeping secret a relative’s HIV- positive status. About three-fourths of both women and men (75 and 79 percent, respectively) would be willing to care for a family member sick with AIDS in their home. It is encouraging to see that nearly half (49 percent) of women and 58 percent of men would not want to keep secret that a family member has HIV. These results indicate that individuals are generally supportive in providing a caring environment for their family members if they were to get HIV. Respondents in their early 20s and women in their 40s, those who are never-married but have ever had sex, urban respondents, those with secondary or higher education, and respondents in the wealthiest households are somewhat more likely to say that they would be willing to care for a family member with AIDS in their home, compared with other respondents. There are marked regional variations, especially among women. Respondents in the Central region are the least likely to say they would take care of a family member with AIDS in their home (60 percent), compared with 93 percent of women in the Upper East region. Empowering persons living with AIDS is also a critical programme area. Survey data show that only 32 percent of women and 43 percent of men would buy fresh food from a shopkeeper with the AIDS virus, while 62 percent of women and 66 percent of men said that an HIV-positive teacher should be allowed to continue teaching. The percentage expressing accepting attitudes on all four measures is just 11 percent for women and 19 percent for men age 15-49. Higher education and urban residence are generally associated with more accepting attitudes towards non-relatives who are HIV-positive and to greater willingness to care for family members with AIDS in their own home. For instance, the percentage of women expressing accepting attitudes towards a female teacher who is HIV-positive but not sick is 70 percent among urban women, compared with 54 percent among rural women; it is 52 percent among women with no education, compared with 83 percent among those with secondary or higher education. Likewise, 76 percent of urban men and 84 percent of men with secondary or higher education are likely to express accepting attitudes towards a female teacher who is HIV-positive but not sick. On the other hand, among both women and men, respondents in rural areas, those in households in the lower wealth quintiles, and those with no education are generally more likely to say that they would not want to keep secret that a family member is HIV positive. Household wealth status is correlated with accepting attitudes towards persons who are HIV positive; the higher the wealth status, the more likely it is that the respondent has an accepting attitude for all four indicators of acceptance. These results indicate that individuals are generally supportive in providing a caring environment for their family members, if they were to get HIV. This support can ensure early diagnosis and treatment, and is actively encouraged by the national programme in Ghana. 246 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes towards people with AIDS, by background characteristics, Ghana 2008 Background characteristic Percentage of women who: Percentage expressing accepting attitudes on all four indicators Number of women who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus who is not sick should be allowed to continue teaching Would not want to keep secret that a family member has the AIDS virus Age 15-24 75.1 35.4 64.2 43.5 11.1 1,868 15-19 74.6 34.4 63.8 43.9 11.3 1,000 20-24 75.6 36.6 64.6 43.0 10.8 868 25-29 71.5 32.6 63.0 51.5 11.2 825 30-39 74.7 30.2 59.6 53.4 11.7 1,250 40-49 75.5 28.9 59.5 54.5 11.9 887 Marital status Never married 77.7 39.7 68.0 41.7 12.5 1,572 Ever had sex 79.5 42.0 68.0 40.3 12.1 814 Never had sex 75.8 37.3 68.1 43.3 12.8 758 Married/living together 73.1 29.0 59.6 53.7 11.2 2,818 Divorced/separated/ widowed 71.6 28.1 55.4 49.2 8.5 440 Residence Urban 78.0 38.9 70.0 44.4 13.2 2,372 Rural 71.0 26.1 54.2 54.3 9.7 2,458 Region Western 82.3 33.3 61.5 48.4 12.1 434 Central 59.8 25.1 55.2 40.1 5.7 416 Greater Accra 77.3 40.1 70.3 44.6 14.3 846 Volta 71.7 38.5 65.8 77.1 24.5 428 Eastern 75.3 26.3 53.2 50.1 9.9 483 Ashanti 70.2 35.9 59.5 47.6 9.5 1,006 Brong Ahafo 76.2 26.8 57.8 38.3 5.6 423 Northern 71.5 22.5 55.1 65.8 9.1 427 Upper East 92.9 31.2 79.5 36.0 12.0 252 Upper West 85.7 31.1 73.1 41.5 10.8 114 Education No education 69.9 18.2 52.1 57.1 7.2 982 Primary 68.3 25.7 51.8 51.1 8.1 968 Middle/JSS 75.6 33.7 62.7 47.3 10.7 2,032 Secondary+ 84.0 53.4 83.1 43.7 21.6 844 Wealth quintile Lowest 70.3 18.2 51.6 56.1 7.9 736 Second 67.9 22.0 49.8 53.1 6.5 881 Middle 74.4 31.4 59.7 51.0 11.9 967 Fourth 76.2 40.0 67.5 46.8 14.1 1,112 Highest 80.6 43.2 74.6 43.4 14.5 1,133 Total 74.5 32.4 61.9 49.4 11.4 4,830 Note: Total includes cases with information missing on education that are not shown separately. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 247 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes towards people with HIV/AIDS, by background characteristics, Ghana 2008 Background characteristic Percentage of women who: Percentage expressing acceptance attitudes on all four indicators Number of men who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus who is not sick should be allowed to continue teaching Would not want to keep secret that a family member has the AIDS virus Age 15-24 78.5 42.0 66.1 53.7 17.7 1,595 15-19 76.4 38.3 62.2 52.6 15.2 894 20-24 81.1 46.6 71.1 55.1 20.8 700 25-29 79.3 46.8 67.3 56.6 20.1 619 30-39 78.8 42.7 67.5 59.6 19.3 1,058 40-49 77.6 41.8 63.5 63.5 19.5 755 Marital status Never married 79.0 44.7 68.2 53.8 18.9 1,914 Ever had sex 80.0 48.3 70.5 53.4 21.0 980 Never had sex 77.9 40.9 65.8 54.2 16.7 933 Married/living together 78.6 41.4 64.6 61.2 18.9 1,941 Divorced/separated/ widowed 72.2 39.9 60.8 58.2 17.3 172 Residence Urban 80.2 49.8 75.6 51.7 20.6 1,862 Rural 77.1 36.9 58.1 62.6 17.3 2,165 Region Western 74.3 43.1 65.7 54.9 17.4 401 Central 68.8 44.1 69.6 54.1 15.8 326 Greater Accra 76.9 50.5 73.1 51.3 17.6 649 Volta 80.8 56.1 59.6 75.8 34.1 371 Eastern 74.2 39.5 61.8 56.8 15.6 410 Ashanti 80.5 38.4 73.4 46.3 14.6 783 Brong Ahafo 85.0 46.2 56.8 56.7 20.7 345 Northern 75.8 28.1 53.9 70.8 13.9 416 Upper East 90.3 46.9 65.8 77.6 34.5 218 Upper West 93.6 30.7 79.9 47.8 12.7 107 Education No education 73.0 21.9 46.5 67.1 11.2 524 Primary 74.5 31.3 52.2 58.0 12.5 612 Middle/JSS 76.1 40.4 64.8 56.4 16.7 1,714 Secondary+ 87.0 62.0 84.2 54.6 28.8 1,166 Wealth quintile Lowest 74.8 27.0 48.2 68.6 13.3 690 Second 75.7 32.6 54.8 59.4 14.9 730 Middle 79.2 40.6 65.3 59.6 18.4 695 Fourth 79.7 51.2 75.0 54.5 21.9 972 Highest 81.8 55.6 79.6 49.5 23.1 939 Total 15-49 78.5 42.9 66.1 57.5 18.8 4,027 50-59 77.8 44.5 67.6 65.3 22.2 505 Total 15-59 78.5 43.1 66.3 58.4 19.2 4,532 Note: Total includes cases with information missing on education that are not shown separately. 13.6 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent it are of little use if people feel powerless to negotiate safer sex practices with their partners. In an effort to assess the ability of women to negotiate safer sex with a spouse who has an STI, women and men were asked if they thought that a wife is justified in refusing to have sexual intercourse with her husband or asking that he uses condoms, if she knows he has an STI. 248 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.6 shows that the majority of respondents (86 percent of women and 91 percent of men) agree that a woman is justified in refusing to have sexual intercourse with her husband if she knows he has an STI. Approximately nine in ten respondents (87 percent of women and 93 percent of men) think that a woman is justified in asking her husband to use a condom if he has an STI. Nearly all respondents (94 percent of women and 96 percent of men) agree with one or both statements. Table 13.6 Attitudes towards negotiating safer sexual relations with husband Percentage of women and men age 15-49 who think that, if a husband has a sexually transmitted disease, his wife is justified in refusing to have sexual intercourse with him or asking that they use a condom, by background characteristics, Ghana 2008 Background characteristic Percentage of women who think that a woman is justified in: Number of women Percentage of men who think that a woman is justified in: Number of men Refusing to have sexual intercourse Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Refusing to have sexual intercourse Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Age 15-24 85.9 86.5 93.2 1,902 88.8 92.1 95.5 1,615 15-19 85.7 84.0 91.8 1,025 87.9 90.9 94.8 911 20-24 86.1 89.4 94.7 878 90.0 93.7 96.4 704 25-29 86.5 88.6 94.3 832 90.5 93.3 96.2 624 30-39 86.7 88.4 95.1 1,283 92.5 95.1 97.2 1,061 40-49 86.4 85.4 94.7 899 93.0 92.6 96.5 758 Marital status Never married 87.2 87.9 93.9 1,593 89.5 92.5 95.8 1,936 Ever had sex 88.4 92.2 96.8 819 89.8 94.2 96.2 984 Never had sex 85.9 83.4 90.8 774 89.2 90.7 95.5 952 Married/living together 85.7 86.7 94.2 2,876 92.2 94.1 96.8 1,950 Divorced/separated/ widowed 87.1 87.1 94.7 446 90.4 90.3 94.3 172 Residence Urban 88.5 91.7 96.1 2,383 91.0 93.6 96.7 1,866 Rural 84.2 82.9 92.4 2,533 90.7 92.8 95.9 2,191 Region Western 93.4 92.2 97.6 447 90.5 93.4 94.7 403 Central 86.4 90.9 94.6 424 93.9 96.6 97.8 326 Greater Accra 91.5 96.1 98.5 853 88.7 93.3 97.3 649 Volta 86.6 87.2 93.4 431 92.7 95.0 97.6 373 Eastern 89.0 94.6 97.1 483 83.5 89.0 90.9 411 Ashanti 84.7 84.9 93.6 1,011 94.3 93.5 97.7 785 Brong Ahafo 81.1 84.5 90.5 425 89.6 92.7 97.5 347 Northern 76.8 67.2 88.3 467 88.5 90.5 93.9 435 Upper East 86.9 80.2 90.5 253 95.8 96.0 97.1 219 Upper West 78.8 82.1 88.1 122 95.6 94.9 98.9 108 Education No education 81.7 77.0 89.9 1,042 89.5 89.8 94.4 540 Primary 85.5 83.8 92.0 988 89.2 92.4 95.3 619 Middle/JSS 87.2 91.0 95.7 2,039 90.4 92.6 95.8 1,721 Secondary+ 90.7 94.3 98.3 844 92.9 95.9 98.2 1,167 Wealth quintile Lowest 79.2 72.2 87.3 783 90.1 90.6 94.5 708 Second 84.9 83.9 93.0 900 89.9 91.4 95.4 738 Middle 85.8 87.6 93.8 979 91.4 94.4 97.6 699 Fourth 88.9 93.4 97.6 1,119 90.4 94.5 96.3 974 Highest 90.2 93.4 96.8 1,135 92.2 94.2 97.1 939 Total 15-49 86.3 87.1 94.2 4,916 90.8 93.2 96.2 4,058 50-59 na na na na 92.8 93.2 96.8 510 Total 15-59 na na na na 91.0 93.2 96.3 4,568 Note: Total includes cases with information missing on education that are not shown separately. na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 249 The data show relatively small differences by background characteristics of the respondents. In terms of regional variations, women in the Greater Accra (99 percent), Western (98 percent), and Eastern (97 percent) regions appear to be most supportive of a woman refusing to have sexual intercourse with her husband if she knows he has an STI, or requesting her husband to use a condom, while women in the Northern and Upper West regions are the least supportive (88 percent each). On the other hand, men in the Upper West region (99 percent) are the most supportive of a woman refusing to have sexual intercourse or requesting her husband to use a condom, and men in the Eastern region are the least supportive (91 percent). Respondents with more education and those in wealthier households are slightly more supportive than other respondents of women negotiating safer sex with their husbands. 13.7 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH Condom use is one of the main strategies for combating the spread of HIV. Social acceptance of condom use among young people is a key factor determining use of condoms to prevent the sexual transmission of HIV and other STIs, as well as to prevent early pregnancy. However, educating youth about condoms is sometimes controversial, with some saying it promotes early sexual experimentation. Others are in favour of teaching youth to abstain from sexual intercourse until they are married. To measure attitudes towards education about condoms, the 2008 GDHS respondents were asked if they thought that children age 12-14 should be taught about using a condom to avoid HIV. The results are shown in Table 13.7. Because the table focuses on adult opinion, results are tabulated for respondents age 18-49. More than half of both men and women agree that children age 12-14 years should be taught about the use of condoms to avoid AIDS (56 percent of men and 53 percent of women). Never married respondents, women in their early 20s, and men younger than age 20 are somewhat more likely than other respondents to agree on safe sex education for children age 12-14. Urban women and men are more likely than their rural counterparts to agree on teaching children age 12-14 about condom use to avoid AIDS. By region, agreement on teaching children age 12-14 about the use of condoms ranges from 43 Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Ghana 2008 Background characteristic Children age 12-14 should be taught about using a condom to avoid AIDS Women 18-49 Men 18-49 Percentage who agree Number of women Percentage who agree Number of men Age 18-24 56.4 1,298 58.8 1,091 18-19 54.0 420 60.0 387 20-24 57.5 878 58.2 704 25-29 56.1 832 56.9 624 30-39 51.2 1,283 58.2 1,061 40-49 48.0 899 47.5 758 Marital status Never married 60.6 1,011 60.4 1,415 Married or living together 50.7 2,856 53.2 1,949 Divorced/separated/ widowed 50.9 444 48.4 170 Residence Urban 58.6 2,093 57.0 1,659 Rural 47.8 2,219 54.8 1,875 Region Western 45.3 396 53.4 354 Central 60.9 358 51.8 291 Greater Accra 61.9 764 57.1 588 Volta 55.8 378 43.4 296 Eastern 49.5 417 54.2 355 Ashanti 46.8 885 62.0 679 Brong Ahafo 50.2 375 60.1 307 Northern 48.3 418 54.1 394 Upper East 62.0 216 55.7 181 Upper West 58.2 105 65.5 91 Education No education 43.1 1,004 49.2 521 Primary 52.7 849 52.0 458 Middle/JSS 52.6 1,669 55.8 1,436 Secondary+ 67.1 786 60.9 1,108 Wealth quintile Lowest 44.3 691 53.9 601 Second 46.3 783 50.6 621 Middle 54.4 858 55.8 602 Fourth 55.3 981 55.2 863 Highest 61.0 998 61.8 847 Total 18-49 53.0 4,311 55.9 3,534 50-59 na na 51.0 510 Total 18-59 na na 55.3 4,044 Note: Total includes cases with information missing on education that are not shown separately. na = Not applicable 250 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour percent of men in the Volta region and 45 percent of women in the Western region to 66 percent of men in the Upper West region and 62 percent of women in the Upper East region. The proportion of respondents who support teaching children age 12-14 about condoms increases with level of education and wealth quintile. For example, 67 percent of women with secondary or higher education agree on instructing children 12-14 years about condoms, compared with 43 percent of women with no education. The comparable figures for men are 61 percent for those with secondary or higher education and 49 percent for those with no education. 13.8 HIGHER-RISK SEX Given that most HIV cases in Ghana are contracted through heterosexual contact, information on sexual behaviour is important in designing and monitoring intervention programmes to control the spread of HIV. The 2008 GDHS included questions on respondents’ sexual partners during their lifetime and in the 12 months preceding the survey. For male respondents, an additional question was asked on whether they paid anyone in exchange for sex during the 12 months preceding the interview. Information on the use of condoms at the last sexual intercourse with each type of partner was collected for women and men. These questions are sensitive, and it is recognised that some respondents may have been reluctant to provide information on recent sexual behaviour. 13.8.1 Multiple Partners and Condom Use Tables 13.8.1 and 13.8.2 show the percentage of all women and all men, respectively, age 15- 49 years who had sexual intercourse with more than one partner in the past 12 months and the percentage who engaged in higher-risk sexual intercourse in the past 12 months. The results indicate that women are less likely than men to report having had two or more sexual partners in the past 12 months (1 percent for all women, compared with 11 percent for all men). Likewise, 16 percent of all women reported having had sex with a person who was neither their spouse nor their cohabiting partner (higher-risk sex) in the year before the survey, compared with 28 percent of all men. Among respondents who had sexual intercourse in the 12 months before the survey, only 2 percent of women reported having more than one sexual partner in that period. This is considerably lower than the 17 percent reported by men. Similarly, 23 percent of women, compared with 42 percent of men, reported that they had sexual intercourse in the past 12 months with someone who was not their spouse or marital partner. Among both women and men who had sexual intercourse in the past 12 months, the proportion having higher-risk sexual intercourse generally decreases as age increases. By definition, sexual intercourse with a person who is not a spouse or a cohabiting partner (higher-risk sex) is more common among women and men who have never married and those who are currently divorced, separated, or widowed. For this reason, almost all (99 percent) never-married women and never- married men who had sexual intercourse in the past 12 months had higher-risk sexual intercourse. One in six (16 percent) of currently married men in Ghana had sexual intercourse with someone other than their wife or partner. Respondents who live in urban areas, men in the Greater Accra region, and women in the Eastern region are more likely than other respondents to have had higher-risk sexual intercourse in the past 12 months. Similarly, higher-risk sexual intercourse generally increases with increasing level of education and wealth quintile. The 2008 GDHS also assessed condom use among women and men with multiple partners or higher-risk sexual intercourse in the 12 months preceding the survey. Although truly effective protection requires condom use at every sexual contact, the sexual contacts covered here are those considered to pose the greatest risk of HIV transmission. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 251 Table 13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women Among all women age 15-49, the percentage who had sexual intercourse with more than one partner and the percentage who had higher-risk sexual intercourse in the past 12 months; among women age 15-49 who had sexual intercourse in the past 12 months, the percentage who had sexual intercourse with more than one partner and the percentage who had higher-risk sexual intercourse; among women who had higher-risk sexual intercourse in the past 12 months, the percentage who used a condom at last higher-risk sexual intercourse; and among women who ever had sexual intercourse, the mean number of sexual partners during lifetime and the mean number of sexual partners in the past month, by background characteristics, Ghana 2008 Background characteristic All women (past 12 months) Women who had sexual intercourse (past 12 months) Women who had higher-risk sexual intercourse1 (past 12 months) Women who ever had sexual intercourse Percent- age who had 2+ partners Percent- age who had higher-risk sexual inter- course1 Number of women Percent- age who had 2+ partners Percent- age who had higher-risk sexual inter- course1 Number of women Percentage who used a condom at last sexual intercourse with that partner Number of women Mean number of sexual partners in lifetime Mean number of sexual partners in past month Number of women Age 15-24 1.4 26.0 1,902 2.8 52.3 946 28.2 495 1.7 0.6 1,156 15-19 1.2 21.3 1,025 4.1 73.6 297 24.4 218 1.4 0.6 381 20-24 1.6 31.5 878 2.2 42.5 649 31.1 276 1.8 0.6 775 25-29 1.7 17.0 832 2.1 20.9 675 31.3 141 2.0 0.7 798 30-39 0.5 7.4 1,283 0.6 9.0 1,060 11.0 95 2.2 0.8 1,265 40-49 0.2 4.9 899 0.3 6.6 666 (6.3) 44 2.2 0.8 893 Marital status Never married 2.1 37.3 1,593 5.6 99.4 598 29.6 595 1.8 0.6 817 Married or living together 0.4 1.6 2,876 0.4 1.7 2,559 (10.7) 45 2.0 0.8 2,856 Divorced/separated/ widowed 1.1 30.3 446 2.5 71.1 191 11.7 135 2.5 0.5 439 Residence Urban 1.2 18.4 2,383 1.8 28.5 1,538 30.4 439 2.1 0.7 1,941 Rural 0.8 13.2 2,533 1.1 18.5 1,809 18.9 336 1.9 0.7 2,171 Region Western 0.9 11.8 447 1.3 17.6 301 14.4 53 1.9 0.7 373 Central 0.5 16.7 424 0.7 22.8 309 28.9 71 2.1 0.7 365 Greater Accra 0.8 19.4 853 1.2 29.6 559 41.4 165 2.2 0.7 682 Volta 0.5 10.6 431 0.7 14.8 307 (13.3) 45 2.0 0.7 358 Eastern 2.4 21.7 483 3.4 31.1 338 32.3 105 2.3 0.8 413 Ashanti 0.2 21.4 1,011 1.7 30.1 719 15.3 216 2.3 0.8 858 Brong Ahafo 0.7 12.5 425 1.0 16.9 314 (16.6) 53 1.9 0.7 376 Northern 0.5 6.1 467 0.9 10.4 271 (20.6) 28 1.3 0.7 381 Upper East 1.1 9.0 253 1.8 14.5 157 (34.9) 23 1.2 0.7 204 Upper West 1.5 12.0 122 2.5 20.1 73 30.6 15 1.4 0.7 102 Education No education 0.2 4.7 1,042 0.3 6.5 756 12.4 49 1.6 0.7 985 Primary 1.1 13.9 988 1.6 19.1 716 11.8 137 2.1 0.8 849 Middle/JSS 1.0 18.2 2,039 1.6 27.3 1,360 22.4 371 2.2 0.7 1,631 Secondary+ 1.7 25.7 844 2.7 42.4 512 41.8 217 2.0 0.6 643 Wealth quintile Lowest 0.5 7.3 783 0.8 11.1 516 23.1 57 1.5 0.7 673 Second 0.8 15.2 900 1.1 21.1 650 14.3 137 2.0 0.8 784 Middle 0.7 19.2 979 1.0 27.8 679 20.2 188 2.1 0.7 829 Fourth 1.1 18.6 1,119 1.6 27.5 756 28.7 208 2.1 0.7 943 Highest 1.6 16.3 1,135 2.5 24.7 748 35.8 184 2.1 0.8 883 Total 1.0 15.8 4,916 1.5 23.1 3,348 25.4 775 2.0 0.7 4,112 Note: Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Sexual intercourse with a non-marital, non-cohabiting partner 252 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men Among all men age 15-49, the percentage who had sexual intercourse with more than one partner and the percentage who had higher-risk sexual intercourse in the past 12 months; among men age 15-49 who had sexual intercourse in the past 12 months, the percentage who had sexual intercourse with more than one partner and the percentage who had higher-risk sexual intercourse; among men who had more than one partner in the past 12 months, the percentage who used a condom at last sexual intercourse; among men who had higher-risk sexual intercourse in the past 12 months, the percentage who used a condom at last sexual higher-risk intercourse with that person; and among men who ever had sexual intercourse, the mean number of sexual partners during lifetime and the mean number of sexual partners in the past month, by background characteristics, Ghana 2008 Background characteristic All men (past 12 months) Men who had sexual intercourse (past 12 months) Men who had 2+ partners (past 12 months) Men who had higher-risk sexual intercourse1 (past 12 months) Men who ever had sexual intercourse Percent- age who had 2+ partners Percent- age who had higher- risk sexual inter- course1 Number of men Percent- age who had 2+ partners Percent- age who had higher- risk sexual inter- course1 Number of men Percent- age who used a condom at last sexual inter- course Number of men Percentage who used a condom at last sexual intercourse with that partner Number of men Mean number of sexual partners in lifetime Mean number of sexual partners in past month Number of men Age 15-24 5.9 29.8 1,615 17.2 86.4 556 42.0 96 46.4 481 3.3 0.7 713 15-19 3.1 15.2 911 19.4 96.2 144 (24.4) 28 40.3 139 2.5 0.6 198 20-24 9.6 48.6 704 16.5 83.0 412 49.2 68 48.9 342 3.5 0.8 516 25-29 16.7 46.4 624 20.4 56.7 510 42.8 104 49.3 289 4.8 0.8 570 30-39 15.5 25.6 1,061 17.4 28.7 947 19.6 165 45.0 272 5.6 0.9 1,023 40-49 12.4 13.4 758 13.7 14.8 688 3.5 94 27.1 102 7.1 0.9 731 Marital status Never married 7.8 38.1 1,936 20.4 99.1 743 52.9 152 49.6 737 3.9 0.7 974 Married or living together 14.8 15.0 1,950 15.7 16.0 1,830 12.9 288 40.7 293 5.8 0.9 1,896 Divorced/ separated/ widowed 11.0 66.1 172 14.6 88.4 128 * 19 26.9 114 7.2 0.7 168 Residence Urban 12.9 32.6 1,866 19.3 48.8 1,245 35.2 241 52.1 608 5.4 0.8 1,408 Rural 9.9 24.4 2,191 15.0 36.7 1,457 16.3 218 37.1 535 5.2 0.9 1,629 Region Western 11.6 24.6 403 16.9 35.9 276 (28.7) 47 36.4 99 5.7 0.8 293 Central 7.1 31.2 326 10.6 46.2 220 * 23 46.3 102 5.6 0.9 242 Greater Accra 15.1 35.4 649 21.2 49.9 460 35.0 98 59.5 230 5.3 0.9 511 Volta 10.9 23.2 373 17.6 37.5 230 (19.9) 41 49.4 86 5.3 0.9 267 Eastern 11.7 30.5 411 16.8 43.8 286 (38.9) 48 45.1 125 6.7 0.9 311 Ashanti 15.0 31.7 785 21.4 45.3 550 22.9 117 36.5 249 5.9 0.9 611 Brong Ahafo 8.3 33.9 347 11.2 45.7 257 (11.6) 29 38.1 118 5.0 0.8 293 Northern 6.6 15.0 435 12.5 28.5 230 (8.8) 29 30.1 65 3.0 0.9 293 Upper East 9.1 22.6 219 15.1 37.4 133 (21.8) 20 61.8 50 3.7 0.7 149 Upper West 6.7 17.6 108 12.4 32.6 58 * 7 52.8 19 4.0 0.7 67 Education No education 7.8 14.9 540 10.8 20.5 393 1.6 42 23.2 80 3.7 0.8 469 Primary 11.2 25.8 619 19.2 44.4 359 18.2 69 30.6 160 4.9 0.8 400 Middle/JSS 11.7 27.0 1,721 17.7 40.8 1,137 22.9 201 38.3 464 5.9 0.9 1,243 Secondary+ 12.5 37.1 1,167 18.1 53.8 805 41.9 146 61.7 433 5.4 0.9 917 Wealth quintile Lowest 8.3 18.8 708 13.5 30.7 435 10.6 59 29.4 133 3.9 0.9 507 Second 9.5 22.7 738 14.5 34.5 485 17.0 70 36.3 167 5.3 0.8 541 Middle 9.5 28.0 699 14.9 43.8 447 21.5 66 41.1 196 5.5 0.8 517 Fourth 13.3 34.3 974 19.5 50.0 668 37.4 130 44.3 334 5.3 0.9 748 Highest 14.2 33.3 939 20.0 46.9 667 29.5 133 59.8 313 6.0 0.9 724 Total 15-49 11.3 28.2 4,058 17.0 42.3 2,702 26.2 459 45.1 1,143 5.3 0.8 3,037 50-59 12.5 10.6 510 14.9 12.7 427 7.9 64 37.9 54 8.0 0.9 482 Total 15-59 11.4 26.2 4,568 16.7 38.3 3,129 24.0 522 44.7 1,197 5.6 0.9 3,519 Note: Total includes cases missing information on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a non-marital, non-cohabiting partner HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 253 Among men who had more than one partner in the 12 months before the survey, 26 percent said they used a condom during the most recent sexual intercourse. Due to small numbers, comparable data are not shown for women. Among women who reported having had higher-risk intercourse in the past 12 months, only 25 percent used a condom at the last higher-risk sex (Table 13.8.1). For men, the comparable figure is again higher—45 percent, indicating that men are nearly twice as likely to practice safe sex as women (Table 13.8.2). The smaller proportions of women with multiple partners, higher-risk sexual intercourse, and condom use, compared with men, may accurately reflect the context, but it may also reflect a bias from some women being shy about reporting behaviour that may not be widely accepted. Condom use by respondents who had higher-risk sexual intercourse in the past 12 months is more likely among urban residents, never-married respondents, young people age 20-29, and respondents in the Upper East region. Condom use during last higher-risk sexual intercourse is higher among respondents with higher levels of education and those in the higher wealth quintiles. Differences in condom use are more pronounced among men than women. The GDHS results show that while the proportion of women who engage in higher-risk sexual intercourse has increased slightly from 21 percent in the 2003 GDHS to 23 percent in 2008 GDHS, the proportion using condoms during last higher-risk sexual intercourse has declined from 28 percent in the 2003 GDHS to 25 percent in the 2008 GDHS. As with women, the proportion of men who engage in higher-risk sexual intercourse has increased slightly from 38 percent in the 2003 GDHS to 42 percent in 2008 GDHS; however, the proportion who used a condom at last higher-risk sexual intercourse has not changed (45 percent in both 2003 and 2008). The findings show that women have an average of 2 partners in their lifetime. There were no significant variations in the number of lifetime partners by background characteristics. The mean number of lifetime sexual partners reported by men is 5, but the figure varies substantially across subgroups. As expected, the number is larger for older men (3 for men age 15-19 compared with 7 for men age 40-49). Divorced, separated, and widowed men have more partners than never-married men (7 and 4 sexual partners, respectively). There are notable differences by region, from 3 sexual partners in the Northern region to nearly 7 in the Eastern region. The mean number of lifetime sexual partners increases with level of education and wealth quintile. Based on these figures, it could be suggested that Ghanaian women are more committed in their sexual partnerships than their male counterparts. However, many other factors are involved including the Ghanaian practice of polygamous marriage. Women and men had an average of one partner in the month before the survey. There were no substantial variations in the number of partners in the past month by background characteristics. 13.8.2 Transactional Sex Transactional sex is the exchange of sex for money, favours, or gifts. Transactional sex is associated with high risk of contracting HIV and other sexually transmitted infections because of compromised power relations and the likelihood of having multiple partners as a result. In the 2008 GDHS, men who had had sex in the past 12 months were asked if they had paid anyone in exchange for sex. 254 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour The results on transactional sex, shown in Table 13.9, indicate that only 2 percent of men paid for sex in the 12 months before the survey. Data show that men age 25-29 were most likely to pay for sex (5 percent) and men age 40-49 were the least likely to engage in transactional sex (less than 1 percent). Divorced, widowed, or separated men are somewhat more likely to have paid for sex in the past 12 months, compared with never-married men and men who are currently married or living with a woman. Looking at regions, men in the Upper East, Upper West, Central, and Volta regions were less likely to pay for sex (less than 1 percent) than men in the other regions (1 to 3 percent). Men in the middle wealth quintile (3 percent) were more likely to pay for sex than men in the lowest quintile (less than 1 percent). Table 13.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men Percentage of men age 15-49 who reported paying for sexual intercourse in the past 12 months, by background characteristics, Ghana 2008 Background characteristic Payment for sexual intercourse in the past 12 months Percentage who paid for sexual intercourse Number of men Age 15-24 1.1 1,615 15-19 0.7 911 20-24 1.6 704 25-29 5.0 624 30-39 1.7 1,061 40-49 0.6 758 Marital status Never married 1.9 1,936 Married or living together 1.5 1,950 Divorced/separated/widowed 3.1 172 Residence Urban 2.1 1,866 Rural 1.4 2,191 Region Western 2.3 403 Central 0.4 326 Greater Accra 2.0 649 Volta 0.4 373 Eastern 1.6 411 Ashanti 3.1 785 Brong Ahafo 2.9 347 Northern 1.1 435 Upper East 0.2 219 Upper West 0.3 108 Education No education 1.3 540 Primary 2.0 619 Middle/JSS 1.8 1,721 Secondary+ 1.8 1,167 Wealth quintile Lowest 0.6 708 Second 1.2 738 Middle 2.7 699 Fourth 2.3 974 Highest 1.8 939 Total 15-49 1.8 4,058 50-59 1.5 510 Total 15-59 1.7 4,568 Note: Total includes cases with information missing on education that are not shown separately. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 255 13.9 COVERAGE OF PRIOR HIV TESTING For persons who are HIV negative, knowledge of their HIV status helps in making specific decisions that will reduce the risk of getting HIV, lead to safer sex practices, and enable them to remain disease free. For those who are HIV positive, knowledge of their HIV status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. In the 2008 GDHS, respondents were asked whether they had ever been tested for HIV. If they had, they were asked when they were most recently tested, whether they had received the results of their last test, and where they had been tested. If they had never been tested, they were asked if they knew a place where they could go to be tested. Tables 13.10.1 and 13.10.2 show that 70 percent of women and 75 percent of men age 15-49 know where to get an HIV test. However, the proportions ever tested are much smaller; only 21 percent of women and 14 percent of men age 15-49 have ever been tested for HIV, and of those who were tested, only 17 percent of women and 12 percent of men received the results of their test. The proportions who received the results of their most recent test are even smaller; only 7 percent of women and 4 percent of men received the results of the last HIV test taken in the past 12 months. The proportion of respondents ever tested for HIV is lowest for the age group 15-19 (7 percent for women and 4 percent for men) and highest among women 25-29 (33 percent) and men 30-39 (16 percent). At all ages, except age group 40-49, women are more likely to go for an HIV test than men. Currently married respondents are more likely to go for an HIV test than those who are never-married. There are regional variations in HIV testing. About one in four women in Brong Ahafo, Central, and Greater Accra regions have ever been tested for HIV, compared with one in ten women in the Northern region. For men, HIV testing by region shows that the Greater Accra region has the highest percentage of men (22 percent) who have ever been tested for HIV; just one in ten men in the Central, Volta, Upper West, and Northern regions have ever been tested. Level of education and wealth quintile are positively related to HIV testing. Knowledge about where to get an HIV test is more common among women and men in urban areas than in rural areas. It is highest for women in the Greater Accra and Eastern regions, and highest for men in the Greater Accra and Central regions. Knowledge of the various sites for HIV testing services is also higher among educated women and men and among those in the higher wealth quintiles. 13.9.1 HIV Testing during Antenatal Care One of the tragic consequences of HIV in women is the transmission of the virus from mother-to-child. This can occur during pregnancy, at the time of delivery, or through breastfeeding. Worldwide, the effects of mother-to-child transmission (MTCT) of HIV are staggering. As part of the strategy for the prevention of mother-to-child transmission of HIV, women are counselled about HIV/AIDS during antenatal care (ANC) visits and offered an HIV test. In the 2008 GDHS, women age 15-49 who gave birth in the two years preceding the survey were asked whether they received counselling during ANC visits for their most recent birth, whether they were offered and accepted a test for HIV as part of their antenatal care, and if tested, whether they received the test results. Table 13.11 shows that, among women who gave birth in the two years preceding the survey, 50 percent received HIV counselling during antenatal care for their most recent birth, and 28 percent of these women were offered and accepted an HIV test and received the results of the test. Overall, 24 percent of women who gave birth in the two years preceding the survey were counselled, were offered and voluntarily accepted an HIV test, and received the test results. Women age 25-39, those living in urban areas, women in the Greater Accra region, those with secondary or higher education, and those in the highest wealth quintile are more likely than other women to have received all three services. 256 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.10.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Ghana 2008 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and whether they received the results of the last test Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of women Ever tested, and received results Ever tested, did not receive results Never tested1 Age 15-24 67.6 9.9 3.5 86.6 100.0 13.4 4.9 1,902 15-19 61.5 4.9 1.8 93.3 100.0 6.7 2.6 1,025 20-24 74.6 15.8 5.4 78.8 100.0 21.2 7.6 878 25-29 78.0 28.3 4.6 67.1 100.0 32.9 12.5 832 30-39 71.1 24.1 4.5 71.4 100.0 28.6 8.0 1,283 40-49 67.0 11.2 1.7 87.1 100.0 12.9 3.7 899 Marital status Never married 70.7 7.8 1.4 90.8 100.0 9.2 3.7 1,593 Ever had sex 76.1 11.7 2.4 85.9 100.0 14.1 5.3 819 Never had sex 65.1 3.8 0.3 96.0 100.0 4.0 1.9 774 Married/living together 70.0 21.9 5.1 73.0 100.0 27.0 8.9 2,876 Divorced/separated/ widowed 69.1 17.8 1.8 80.4 100.0 19.6 4.3 446 Residence Urban 80.5 20.4 3.1 76.5 100.0 23.5 8.6 2,383 Rural 60.4 13.7 4.1 82.2 100.0 17.8 5.1 2,533 Region Western 61.5 14.6 1.7 83.7 100.0 16.3 7.5 447 Central 76.0 18.3 6.0 75.6 100.0 24.4 6.7 424 Greater Accra 83.3 22.0 1.5 76.5 100.0 23.5 7.6 853 Volta 69.5 12.0 4.8 83.2 100.0 16.8 5.9 431 Eastern 83.2 16.6 3.3 80.1 100.0 19.9 5.2 483 Ashanti 73.5 20.1 2.9 77.1 100.0 22.9 9.2 1,011 Brong Ahafo 62.8 20.6 4.1 75.2 100.0 24.8 7.5 425 Northern 39.1 6.6 5.5 87.9 100.0 12.1 2.3 467 Upper East 68.9 12.9 5.6 81.4 100.0 18.6 4.8 253 Upper West 60.0 13.6 6.6 79.8 100.0 20.2 5.9 122 Education No education 48.8 10.6 4.6 84.8 100.0 15.2 3.7 1,042 Primary 62.8 12.0 5.1 82.9 100.0 17.1 4.7 988 Middle/JSS 75.9 18.9 3.3 77.7 100.0 22.3 7.6 2,039 Secondary+ 91.2 25.8 1.3 72.9 100.0 27.1 11.0 844 Wealth quintile Lowest 45.5 10.2 4.4 85.3 100.0 14.7 3.3 783 Second 59.0 10.7 4.6 84.7 100.0 15.3 4.0 900 Middle 70.8 14.6 3.9 81.6 100.0 18.4 5.7 979 Fourth 78.7 19.3 4.2 76.6 100.0 23.4 8.0 1,119 Highest 87.0 26.3 1.4 72.3 100.0 27.7 11.1 1,135 Total 70.2 16.9 3.6 79.4 100.0 20.6 6.8 4,916 Note: Total includes cases with information missing on education that are not shown separately. 1 Includes don’t know/missing. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 257 Table 13.10.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Ghana 2008 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and whether they received the results of the last test Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of men Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 70.9 6.6 1.6 91.8 100.0 8.2 3.4 1,615 15-19 64.0 3.1 1.3 95.6 100.0 4.4 1.6 911 20-24 79.8 11.1 2.1 86.8 100.0 13.2 5.7 704 25-29 78.6 13.8 2.0 84.2 100.0 15.8 4.7 624 30-39 79.3 18.9 2.4 78.7 100.0 21.3 5.7 1,061 40-49 75.6 14.6 1.4 84.0 100.0 16.0 2.9 758 Marital status Never married 73.2 8.1 1.7 90.1 100.0 9.9 3.7 1,936 Ever had sex 79.1 12.7 1.8 85.5 100.0 14.5 5.5 984 Never had sex 67.0 3.4 1.7 94.9 100.0 5.1 1.9 952 Married/living together 76.7 16.7 2.0 81.3 100.0 18.7 4.4 1,950 Divorced/separated/ widowed 79.2 12.4 1.1 86.5 100.0 13.5 5.1 172 Residence Urban 82.4 16.1 2.4 81.4 100.0 18.6 4.8 1,866 Rural 69.0 9.3 1.3 89.4 100.0 10.6 3.5 2,191 Region Western 67.8 9.1 3.0 88.0 100.0 12.0 2.7 403 Central 84.1 8.5 1.5 90.0 100.0 10.0 3.1 326 Greater Accra 83.1 19.2 2.7 78.1 100.0 21.9 5.0 649 Volta 70.3 8.7 1.3 90.0 100.0 10.0 3.8 373 Eastern 72.4 10.1 2.2 87.7 100.0 12.3 3.7 411 Ashanti 74.6 13.9 1.8 84.3 100.0 15.7 4.1 785 Brong Ahafo 80.0 13.3 1.5 85.2 100.0 14.8 5.3 347 Northern 58.9 9.3 1.0 89.6 100.0 10.4 3.6 435 Upper East 91.5 16.6 0.5 82.9 100.0 17.1 6.2 219 Upper West 75.6 9.0 1.2 89.8 100.0 10.2 3.9 108 Education No education 56.5 6.0 0.7 93.3 100.0 6.7 1.3 540 Primary 66.1 6.1 1.0 92.8 100.0 7.2 2.3 619 Middle/JSS 72.4 10.0 1.9 88.1 100.0 11.9 3.0 1,721 Secondary+ 92.6 22.5 2.7 74.8 100.0 25.2 8.0 1,167 Wealth quintile Lowest 61.3 6.5 0.7 92.8 100.0 7.2 1.8 708 Second 65.5 7.8 1.3 90.9 100.0 9.1 3.0 738 Middle 73.0 8.8 1.4 89.8 100.0 10.2 4.1 699 Fourth 80.2 13.7 2.0 84.3 100.0 15.7 4.5 974 Highest 89.5 22.0 3.3 74.7 100.0 25.3 6.4 939 Total 15-49 75.2 12.4 1.8 85.7 100.0 14.3 4.1 4,058 50-59 81.0 14.8 2.4 82.8 100.0 17.2 4.4 510 Total 15-59 75.8 12.7 1.9 85.4 100.0 14.6 4.1 4,568 Note: Total includes cases with information missing on education that are not shown separately 1 Includes don’t know/missing. 258 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.11 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV counselling during antenatal care for their most recent birth, and percentage who accepted an offer of HIV testing by whether they received their test results, according to background characteristics, Ghana 2008 Background characteristic Percentage who received HIV counselling during antenatal care1 Percentage who were offered and accepted an HIV test during antenatal care and who2: Percentage who were counselled, were offered and accepted an HIV test, and who received results2 Number of women who gave birth in the past two years3 Received results Did not receive results Age 15-24 41.6 21.9 9.9 17.0 358 15-19 30.0 18.2 9.4 12.2 80 20-24 44.9 22.9 10.1 18.4 278 25-29 54.7 30.9 4.8 26.9 342 30-39 54.0 32.3 8.1 28.2 392 40-49 46.0 22.7 3.0 21.3 85 Residence Urban 63.9 39.5 8.0 34.8 455 Rural 41.0 20.8 6.9 17.1 723 Region Western 41.1 21.5 2.3 17.3 111 Central 36.7 27.9 14.2 23.6 123 Greater Accra 67.4 49.2 6.1 44.3 133 Volta 43.5 27.5 5.5 24.9 107 Eastern 75.8 39.4 8.8 36.3 105 Ashanti 52.6 23.1 7.8 17.6 215 Brong Ahafo 48.4 42.3 6.3 32.7 107 Northern 30.3 8.9 3.9 8.4 177 Upper East 59.1 27.0 12.4 22.5 63 Upper West 67.7 22.2 12.9 21.4 36 Education No education 35.3 16.2 5.9 13.5 363 Primary 43.2 20.1 9.5 14.4 288 Middle/JSS 61.5 38.6 8.0 34.1 412 Secondary+ 70.7 48.1 3.7 44.6 113 Wealth quintile Lowest 34.8 13.8 5.0 10.8 283 Second 35.6 18.4 8.3 14.4 261 Middle 54.5 26.0 7.0 23.9 222 Fourth 61.0 38.9 10.7 31.4 243 Highest 75.1 53.8 5.3 49.9 169 Total 49.8 28.0 7.3 23.9 1,178 Note: Total includes cases with information missing on education that are not shown separately. 1 In this context, ‘counselled’ means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing the virus, and 3) getting tested for the virus. 2 Only women who were offered the test are included here; women who were either required or asked for the test are excluded from the numerator of this measure. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. 13.10 MALE CIRCUMCISION Circumcision is widely practiced in Ghana for religious, social, and health purposes. As a result, children are circumcised a few days after birth, except for most royal lineages. Recently, male circumcision has been shown to be associated with lower transmission of STIs, including HIV (WHO and UNAIDS, 2007). To examine this relationship, men age 15-59 interviewed in the 2008 GDHS were asked if they were circumcised. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 259 Table 13.12 shows that male circumcision is widespread in Ghana, with more than nine in ten men being circumcised (92 percent). The practice occurs widely in all age groups and in both urban and rural areas; however, there are variations according to region, ethnicity, education, and wealth quintile. Regional variation shows that the proportion of men circumcised ranges from 79 percent in the Upper West and Northern regions to 99 percent in the Volta region. Among the various ethnic groups, male circumcision ranges from 65 percent among the Grumas to 95 percent among Guans. The relationship between circumcision and education shows that 85 percent of men with no education are circumcised compared with 94 percent of men with middle/JSS education. Men in the lowest and highest wealth quintiles are less likely to be circumcised than men in the second to fourth wealth quintiles. 13.11 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS Sexually transmitted infections are closely associated with HIV because they increase the likelihood of contracting HIV and share similar risk factors. In the 2008 GDHS, all respondents who ever had sexual intercourse were asked if they had had a sexually transmitted infection (STI) or symptoms of an STI (including bad-smelling/abnormal genital discharge and genital sore or ulcer) in the 12 months preceding the survey. Table 13.13 shows the self-reported prevalence of STIs and STI symptoms among women and men age 15-49 who have ever had sexual intercourse. The results show that 3 percent of both women and men who have ever had sex reported having had an STI in the 12 months before the survey. A higher proportion of women (16 percent) than men (5 percent) reported having had an abnormal genital discharge. Furthermore, 7 percent of women and 3 percent of men reported having had a genital sore or ulcer in the past 12 months. Overall, 18 percent of women and 7 percent of men have had either an STI or symptoms of an STI in the 12 months preceding the survey. The results presented in Table 13.13 indicate that respondents in the younger age groups are more likely to report having had an STI or an STI symptom than older age groups, especially among women. Never-married women and divorced/separated/widowed men are more likely to report an STI or symptoms of an STI than those of other marital status, the difference being more pronounced among women (31 percent of never-married women compared with 15 percent of currently married women and 12 percent of formerly married women). Among men, those in marital unions are least likely to have an STI or symptoms of an STI (6 percent). A larger proportion of uncircumcised men (12 percent) reported having an STI or symptoms of an STI than circumcised men (6 percent); this supports the current view among researchers and health professionals that circumcision reduces the risk of genital infection in men. Respondents in urban areas were more likely to report having STIs or symptoms of STI than their rural counterparts. Table 13.12 Male circumcision Percentage of men age 15-49 who report having been circumcised, by background characteristics, Ghana 2008 Background characteristic Percentage circumcised Number of men Age 15-24 90.9 1,615 15-19 91.6 911 20-24 90.1 704 25-29 91.0 624 30-39 93.0 1,061 40-49 90.6 758 Residence Urban 91.2 1,866 Rural 91.6 2,191 Region Western 98.2 403 Central 97.4 326 Greater Accra 83.7 649 Volta 98.5 373 Eastern 87.4 411 Ashanti 97.1 785 Brong Ahafo 94.9 347 Northern 79.4 435 Upper East 92.9 219 Upper West 78.5 108 Ethnicity Akan 94.3 1,915 Ga/Dangme 90.8 253 Ewe 91.0 597 Guan 94.5 94 Mole-Dagbani 91.1 685 Grussi 90.8 104 Gruma 64.5 205 Mande * 20 Other 94.9 182 Education No education 84.7 540 Primary 92.0 619 Middle/JSS 93.6 1,721 Secondary+ 91.1 1,167 Wealth quintile Lowest 84.4 708 Second 95.8 738 Middle 95.4 699 Fourth 93.1 974 Highest 88.7 939 Total 15-49 91.4 4,058 50-59 92.6 510 Total 15-59 91.6 4,568 Note: Total includes cases with information missing on education that are not shown separately. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 260 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STIs symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage who report having an STI or symptoms of an STI in the past 12 months, by background characteristics, Ghana 2008 Background characteristic Percentage of women who reported having in the past 12 months: Number of women who ever had sexual intercourse Percentage of men who reported having in the past 12 months: Number of men who ever had sexual intercourse STI Bad- smelling/ abnormal genital discharge Genital sore or ulcer STI/ genital discharge/ sore or ulcer STI Bad- smelling/ abnormal genital discharge Genital sore or ulcer STI/ genital discharge/ sore or ulcer Age 15-24 5.2 24.6 8.7 26.4 1,159 3.4 6.9 1.8 8.3 720 15-19 4.9 27.2 8.4 29.1 383 2.0 6.6 1.0 7.4 200 20-24 5.3 23.2 8.9 25.1 777 3.9 6.9 2.1 8.6 520 25-29 3.5 17.5 6.8 19.4 804 6.2 6.5 4.2 10.5 581 30-39 2.8 12.4 6.3 15.3 1,280 2.6 3.7 3.2 6.2 1,048 40-49 1.9 8.8 3.6 10.0 899 1.4 2.0 1.5 3.2 756 Marital status Never married 6.5 28.7 10.1 30.9 819 4.0 5.9 2.7 8.4 984 Married or living together 2.7 13.3 5.8 15.3 2,876 2.5 3.7 2.5 5.7 1,950 Divorced/separated/ widowed 2.6 9.7 4.4 12.4 446 5.6 6.7 3.6 9.2 172 Male circumcision Circumcised na na na na na 3.2 4.3 2.2 6.4 2,850 Not circumcised na na na na na 2.2 7.4 7.9 12.1 230 Residence Urban 4.3 18.0 6.5 19.9 1,954 3.9 5.2 2.5 7.8 1,446 Rural 2.6 14.2 6.5 16.4 2,188 2.5 4.0 2.8 5.9 1,659 Region Western 0.6 9.2 2.5 10.4 374 2.3 2.7 1.6 3.8 304 Central 1.5 23.5 2.2 23.7 367 3.1 1.1 4.8 6.9 248 Greater Accra 2.7 13.6 3.0 15.8 687 2.1 2.0 1.5 4.9 530 Volta 0.8 12.5 4.5 14.6 360 1.5 1.2 0.8 2.3 268 Eastern 2.1 21.2 6.4 22.2 414 4.3 6.3 3.4 10.3 317 Ashanti 9.0 21.8 15.4 25.8 861 6.1 6.7 3.0 8.0 614 Brong Ahafo 0.5 11.4 0.8 11.6 376 2.4 6.0 2.4 7.3 293 Northern 3.5 10.4 7.8 13.4 391 2.8 10.4 5.1 13.1 307 Upper East 3.7 11.2 6.3 13.0 208 0.3 1.4 0.8 1.4 155 Upper West 2.6 20.4 9.3 23.6 104 1.7 4.1 3.2 5.0 68 Education No education 1.5 8.1 4.6 9.9 995 1.3 5.6 3.3 7.3 483 Primary 3.5 17.7 6.5 19.1 855 3.5 5.0 3.2 7.6 405 Middle/JSS 4.2 18.4 7.4 21.1 1,642 3.7 4.3 3.0 6.8 1,267 Secondary+ 4.2 19.9 7.2 21.8 647 3.1 4.1 1.5 6.1 941 Wealth quintile Lowest 0.9 11.5 6.6 13.8 682 1.1 5.4 3.6 6.5 524 Second 2.6 13.3 6.5 16.0 787 3.6 5.2 2.6 6.9 549 Middle 3.3 16.1 5.3 17.8 838 2.5 4.0 1.5 5.5 518 Fourth 4.2 19.3 8.2 21.1 945 5.5 5.8 3.3 9.9 763 Highest 5.2 18.2 5.7 20.2 891 2.3 2.6 2.1 4.6 752 Total 15-49 3.4 16.0 6.5 18.1 4,142 3.1 4.5 2.6 6.8 3,105 50-59 na na na na na 0.8 1.8 1.4 3.5 507 Total 15-59 na na na na na 2.8 4.2 2.5 6.3 3,612 Note: Total includes cases with information missing on education and on male circumcision that are not shown separately. na = Not applicable One in four women in the Ashanti, Central, and Upper West regions (26-24 percent) and one in five women in the Eastern region (22 percent) reported having STI symptoms, compared with one in ten women in the Western region. Men in the Northern and Eastern regions (13 and 10 percent, respectively) are more likely to report STI symptoms than men in other regions (1-8 percent). There is a positive association between the reported prevalence of an STI or symptoms of an STI and levels of education and wealth among women, but these patterns are not seen among men. For example, 22 percent of women with secondary or higher education reported having had an STI or STI-related symptoms in the past 12 months, compared with 10 percent of women with no education. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 261 Figure 13.1 shows the proportion of women and men who had an STI or symptoms of an STI who sought advice or treatment from various sources. About half of respondents who had an STI or symptoms of an STI sought treatment from a health facility or health professional (48 percent of women and 50 percent of men). However, 40 percent of women and 29 percent of men did not seek any advice or treatment. Figure 13.1 Women and Men Seeking Treatment for STIs 48 7 4 40 50 14 8 29 Clinic/hospital/ private doctor/ other health prof Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment 0 20 40 60 80 Percent Women Men GDHS 2008 Clinic/hospital/ private doctor/ other health professional 13.12 PREVALENCE OF MEDICAL INJECTIONS Injection overuse in a health care setting can contribute to the transmission of blood-borne pathogens because it amplifies the effect of unsafe practices, such as reuse of injection equipment. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2008 GDHS were asked if they had received an injection in the past 12 months, and if so, was their last injection given with a syringe from a new, unopened package. It should be noted that medical injections can be self-administered (e.g., insulin for diabetes). These injections were not included in the calculation. Table 13.14 shows that 33 percent of women and 27 percent of men age 15-49 received a medical injection in the past 12 months. The average number of injections was about 1 among women and men. The potential risk of transmission of HIV associated with such injections is very low because the vast majority of respondents—98 percent of women and men who received medical injections—reported that the syringe and needle were taken from a new, unopened package. These figures are encouraging for Ghanaians and for the Ministry of Health, because contaminated needles can be one means by which HIV is transmitted. Both the likelihood of receiving an injection in the past 12 months and the likelihood that the injection was a safe one, increase with level of education and wealth quintile. Injections are particularly common among urban residents, women in the Upper East region (44 percent), and men in the Ashanti region (37 percent). 262 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.14 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Ghana 2008 Background characteristic Women Men Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the past 12 months Age 15-24 31.0 0.8 1,902 97.6 589 23.6 0.7 1,615 96.3 381 15-19 25.6 0.7 1,025 99.0 262 23.2 0.6 911 94.8 212 20-24 37.2 0.9 878 96.4 327 24.0 0.7 704 98.2 169 25-29 39.5 1.1 832 98.5 329 28.9 1.0 624 97.6 180 30-39 35.4 1.2 1,283 97.3 454 31.8 1.1 1,061 98.3 338 40-49 29.1 1.0 899 96.7 261 27.5 0.7 758 98.3 208 Residence Urban 34.9 1.1 2,383 97.8 832 32.4 1.0 1,866 98.0 605 Rural 31.6 0.9 2,533 97.3 800 22.9 0.7 2,191 96.9 502 Region Western 31.9 1.0 447 98.6 143 35.4 1.2 403 98.0 143 Central 36.8 1.1 424 97.2 156 23.1 0.8 326 100.0 75 Greater Accra 33.2 1.1 853 97.7 283 32.0 0.9 649 99.3 208 Volta 32.2 1.0 431 99.2 139 13.6 0.4 373 99.4 51 Eastern 32.7 1.0 483 96.9 158 29.7 0.9 411 93.5 122 Ashanti 37.3 1.1 1,011 96.0 377 36.8 1.2 785 98.1 289 Brong Ahafo 23.0 0.6 425 97.3 98 21.2 0.5 347 96.2 73 Northern 29.3 0.9 467 97.9 137 19.4 0.5 435 92.8 84 Upper East 43.6 0.9 253 99.6 110 17.2 0.8 219 100.0 38 Upper West 27.1 0.6 122 99.2 33 21.8 0.5 108 98.5 24 Education No education 27.0 0.7 1,042 98.5 282 15.7 0.5 540 97.4 85 Primary 30.5 0.9 988 96.9 301 22.3 0.7 619 97.3 138 Middle/JSS 35.2 1.0 2,039 96.8 718 28.4 0.8 1,721 97.3 489 Secondary+ 39.1 1.4 844 99.0 330 33.9 1.0 1,167 97.9 395 Wealth quintile Lowest 28.0 0.6 783 97.8 220 15.4 0.5 708 95.1 109 Second 28.1 1.0 900 97.0 253 24.0 0.8 738 96.8 177 Middle 32.0 0.9 979 98.0 314 22.9 0.7 699 95.4 160 Fourth 37.2 1.2 1,119 97.2 416 32.1 0.9 974 98.6 313 Highest 37.9 1.2 1,135 97.8 431 37.0 1.2 939 98.7 348 Total 15-49 33.2 1.0 4,916 97.5 1,633 27.3 0.8 4,058 97.5 1,107 50-59 na na 0 na 0 26.0 1.1 510 98.3 132 Total 15-59 na na na na na 27.1 0.9 4,568 97.6 1,239 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist or other health worker. Total includes cases with information missing on education that are not shown separately. na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 263 Respondents who had received an injection in the past 12 months were asked where they obtained their last injection. Three in four women (75 percent) and two in three men (66 percent) age 15-49 received their last medical injection from a public sector facility; 16 percent of women and 22 percent of men received their last injection from a private medical facility (data not shown). 13.13 HIV/AIDS-RELATED KNOWLEDGE AND SEXUAL BEHAVIOUR AMONG YOUTH This section addresses knowledge of HIV/AIDS issues and related sexual behaviour among youth age 15-24. Special attention is paid to this group because it accounts for half of all new HIV cases worldwide (Ross et al., 2006). In addition to knowledge of HIV transmission, results are presented on age at first sex, condom use, age differences between sexual partners, sex related to alcohol use, and voluntary counselling and testing for HIV. 13.13.1 HIV/AIDS-Related Knowledge among Young Adults Young respondents were asked the same set of questions on beliefs about HIV transmission as other respondents. Information on the overall level of knowledge of major methods of avoiding HIV, and rejection of major misconceptions are shown in Tables 13.2, 13.3.1, and 13.3.2. These results indicate the general level of awareness of HIV prevention methods among young people. Table 13.15 shows the level of the composite indicator, comprehensive knowledge about AIDS,1 and knowledge of a source of condoms among young people, by background characteristics. The results show that 28 percent of young women and 34 percent of young men have comprehensive knowledge of AIDS. Comprehensive knowledge is highest among men age 23-24 (42 percent), among never-married young men who have ever had sex (37 percent), young people in urban areas (34 percent among women and 42 percent among men), female youth living in the Volta and Upper East regions (39 percent each) and male youth in the Greater Accra region (51 percent), those with secondary or higher education (42 percent of women and 55 percent of men), and youth in the highest wealth quintile (34 percent of women and 50 percent of men). 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative, faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV/AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 264 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.15 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Ghana 2008 Background characteristic Women age 15-24 Men age 15-24 Percentage with compre- hensive knowledge of AIDS1 Percentage who know a condom source2 Number of women Percentage with compre- hensive knowledge of AIDS1 Percentage who know a condom source2 Number of men Age 15-19 27.7 68.8 1,025 30.4 82.4 911 15-17 26.9 64.4 605 27.6 78.5 524 18-19 28.9 75.2 420 34.3 87.7 387 20-24 29.0 79.9 878 39.1 92.5 704 20-22 28.9 79.5 552 36.5 89.4 399 23-24 29.0 80.5 326 42.4 96.6 305 Marital status Never married 29.1 75.6 1,356 34.7 87.1 1,488 Ever had sex 29.2 85.3 613 37.2 96.6 593 Never had sex 29.0 67.6 743 33.0 80.9 895 Ever married 26.3 69.8 547 28.9 83.6 127 Residence Urban 34.3 86.2 953 41.9 93.7 748 Rural 22.3 61.6 949 27.5 80.9 867 Region Western 26.5 79.3 160 21.5 91.7 152 Central 28.2 70.7 173 31.0 92.1 129 Greater Accra 34.8 89.2 335 51.0 89.5 218 Volta 38.5 72.9 161 45.2 90.7 161 Eastern 27.1 83.1 188 30.7 85.6 172 Ashanti 22.6 80.3 403 32.5 91.7 333 Brong Ahafo 23.9 60.8 162 33.2 86.1 136 Northern 23.5 37.9 176 20.9 65.0 161 Upper East 38.7 75.9 93 38.7 89.7 100 Upper West 20.0 48.5 50 32.1 73.5 53 Education No education 17.8 37.5 202 13.1 60.2 100 Primary 16.2 60.9 380 22.3 76.2 314 Middle/JSS 29.3 77.2 899 28.6 88.2 718 Secondary+ 42.0 96.1 420 55.0 97.3 478 Wealth quintile Lowest 16.7 42.9 263 23.3 69.9 278 Second 21.9 62.1 353 27.4 83.2 307 Middle 29.7 78.8 397 30.5 90.8 306 Fourth 32.9 81.4 461 37.6 92.0 406 Highest 34.4 90.2 427 49.6 94.8 318 Total 15-24 28.3 73.9 1,902 34.2 86.8 1,615 Note: Total includes cases with information missing on education that are not shown separately 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative, faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV/AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 Friends, family members, and home are not considered sources for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 265 13.13.2 Knowledge of Condom Sources among Young Adults Condom use plays an important role in the prevention of STIs and HIV transmission, as well as prevention of unwanted pregnancies. Young adults are often at a higher risk of contracting STIs, because they are more likely to be experimenting with sex before marriage. Knowledge of a source of condoms helps young people to obtain and use condoms. As shown in Table 13.15, there is a gap in knowledge of a condom source between men and women age 15-24; more men than women know at least one source of condoms (87 percent and 74 percent, respectively). Knowledge of a condom source generally increases with age and is highest among young women and men who have ever had sex. For both women and men, knowledge of a condom source is highest among those living in urban areas, women in the Greater Accra region, and men in Central, Western, and Ashanti regions, young adults with secondary or higher education, and those in the highest wealth quintile. 13.13.3 Trends in Age at First Sex Because HIV transmission in Ghana occurs primarily through sexual intercourse between an HIV-positive person and an HIV-negative person, age at first intercourse marks the beginning of the period in which most young adults are exposed to the risk of contracting HIV. Table 13.16 shows the percentage of young women and men who had sexual intercourse before age 15 and before age 18, by background characteristics. More women than men have had sex by age 15 and 18. Eight percent of young women and 4 percent of young men had their first sexual intercourse before the age of 15, while 44 percent of young women and 28 percent of young men had first sexual intercourse by age 18. Differentials by background characteristics are greater among women than men. Ever- married young women and men are substantially more likely to initiate sexual activity by age 15 or by age 18 than those who have never married. The survey results show that urban women are less likely to have sexual intercourse by age 15 (6 percent) or by age 18 (37 percent) than their rural counterparts (10 percent and 52 percent, respectively). Among men, however, there is almost no difference by urban-rural residence in initiation of first sex by age 15 and by age 18. Across regions, young women in the Upper West region (12 percent) and men in the Greater Accra and Ashanti regions (7 percent each) are the most likely to have had sexual debut by age 15. Young women in the Eastern region (55 percent) and young men in the Brong Ahafo region (47 percent) are the most likely to have had sex by age 18. Young women in the Greater Accra region (32 percent) and young men in the Northern region (7 percent) are the least likely to have had sex by age 18. Young men in the Northern region are the least likely to have had sexual intercourse by age 18 (7 percent), and only 2 percent had sex by age 15. For young women, higher educational attainment is associated with a lower likelihood of initiating sexual intercourse at an early age. For example, whereas 11 percent of women age 15-24 with no education and 14 percent of women with primary education had sex by age 15, only 2 percent of women with secondary or higher education had sex by age 15. The proportion of young women initiating sex by age 15 and 18 is lowest among women in the highest wealth quintile. The relationship between early initiation of sex and level of education or wealth quintile seen among young women is less apparent among young men. 266 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.16 Age at first sexual intercourse among youth Percentage of young women and of young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and of young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Ghana 2008 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 8.2 1,025 na na 3.6 911 na na 15-17 7.5 605 na na 4.4 524 na na 18-19 9.3 420 49.5 420 2.5 387 29.2 387 20-24 7.2 878 41.2 878 5.2 704 26.8 704 20-22 7.0 552 42.4 552 3.5 399 25.6 399 23-24 7.6 326 39.3 326 7.4 305 28.4 305 Marital status Never married 4.6 1,356 31.9 773 3.9 1,488 25.7 967 Ever married 15.5 547 61.6 524 8.8 127 43.0 124 Knows condom source1 Yes 7.1 1,406 42.1 1,017 4.7 1,402 28.6 991 No 9.7 496 50.5 281 1.5 213 18.6 100 Residence Urban 6.0 953 36.6 663 5.0 748 28.3 541 Rural 9.6 949 51.5 635 3.7 867 27.1 550 Region Western 6.4 160 39.4 109 2.1 152 26.0 103 Central 10.7 173 45.4 108 0.9 129 24.5 94 Greater Accra 5.7 335 32.1 246 6.6 218 26.7 157 Volta 10.2 161 44.7 108 4.6 161 31.6 84 Eastern 9.7 188 55.1 122 5.0 172 32.8 116 Ashanti 8.5 403 45.8 277 6.7 333 35.2 227 Brong Ahafo 3.7 162 51.7 112 4.3 136 46.9 96 Northern 7.9 176 41.8 127 2.4 161 7.2 119 Upper East 5.7 93 50.8 56 1.1 100 10.7 61 Upper West 11.6 50 51.1 33 1.9 53 18.2 36 Education No education 11.0 202 55.0 164 4.3 100 26.8 81 Primary 13.9 380 61.9 241 4.0 314 30.2 154 Middle/JSS 7.3 899 48.9 530 4.3 718 29.5 433 Secondary+ 1.7 420 19.8 361 4.5 478 25.0 419 Wealth quintile Lowest 10.1 263 52.8 171 3.6 278 23.6 170 Second 11.7 353 52.2 236 3.7 307 30.4 191 Middle 7.3 397 50.2 277 2.9 306 25.7 209 Fourth 7.0 461 41.8 323 4.7 406 31.4 296 Highest 4.3 427 28.3 291 6.2 318 25.6 226 Total 15-24 7.8 1,902 43.9 1,298 4.3 1,615 27.7 1,091 Note: Total includes cases with information missing on education that are not shown separately. na = Not available 1 Friends, family members, and home are not considered sources for condoms. 13.13.4 Condom Use at First Sex Consistent condom use is advocated by HIV control programmes to reduce the risk of sexual transmission of HIV among sexually active young adults. Young adults who use condoms the first time they have sexual intercourse are more likely to sustain condom use later in life. Condom use at first sex serves as an indicator of reduced risk of exposure at the beginning of sexual activity. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 267 Table 13.17 shows that condom use at first sex is not common in Ghana. Among young adults age 15-24 who have ever had sexual intercourse, only 25 percent of females and 32 percent of males used a condom the first time they had sex. Never-married women and men are more likely to use a condom at first sex than those who have been married. It is also markedly higher among respondents who know where to obtain a condom. Young adults who live in urban areas, women in the Upper East region, those with secondary or higher education, and youth in the highest wealth quintiles are more likely to use a condom at first sex than other young adults. Table 13.17 Condom use at first sexual intercourse among youth Among young women and young men age 15-24 who have ever had sexual intercourse, percentage who used a condom the first time they had sexual intercourse, by background characteristics, Ghana 2008 Background characteristic Women age 15-24 Men age 15-24 Percentage who used a condom at first sexual intercourse Number of women who have ever had sexual intercourse Percentage who used a condom at first sexual intercourse Number of men who have ever had sexual intercourse Age 15-19 25.9 383 31.4 200 15-17 27.1 130 31.2 55 18-19 25.3 252 31.4 145 20-24 24.8 777 31.8 520 20-22 26.7 465 29.6 263 23-24 21.8 312 34.0 257 Marital status Never married 31.3 613 33.6 593 Ever married 18.2 546 22.7 127 Knows condom source1 Yes 30.3 904 33.5 678 No 6.9 255 (1.6) 41 Residence Urban 31.6 549 34.5 362 Rural 19.3 610 28.7 357 Region Western 14.6 93 40.6 56 Central 30.3 117 (43.2) 58 Greater Accra 30.4 175 36.8 109 Volta 32.3 93 33.5 60 Eastern 32.5 125 30.5 83 Ashanti 24.1 260 18.9 169 Brong Ahafo 20.9 116 33.4 84 Northern 9.8 100 26.5 48 Upper East 35.8 48 (43.7) 36 Upper West 14.2 32 36.5 17 Education No education 5.2 155 11.4 54 Primary 19.5 249 16.6 104 Middle/JSS 26.0 510 32.7 279 Secondary+ 41.5 244 40.3 281 Wealth quintile Lowest 13.0 162 24.0 102 Second 18.3 242 31.3 124 Middle 27.1 260 24.2 135 Fourth 29.1 294 35.2 210 Highest 34.9 200 39.0 148 Total 25.1 1,159 31.6 720 Note: Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered sources for condoms. 268 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.13.5 Abstinence and Premarital Sex The period between age at first sex and age at marriage is often a time of sexual experimentation. Premarital sex and the length of the interval between sexual initiation and marriage are among the factors contributing to the spread of HIV. Table 13.18 shows, for never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sex in the past 12 months, and among those who had sex in the past 12 months, the percentage who used a condom at last sexual intercourse. Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Ghana 2008 Background characteristic Never-married women age 15-24 Never-married men age 15-24 Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Among women who had sexual intercourse in the past 12 months: Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Among men who had sexual intercourse in the past 12 months: Percentage who used condom at last sexual intercourse Number of women Percentage who used condom at last sexual intercourse Number of men Age 15-19 69.1 22.7 929 25.0 210 78.8 15.2 902 37.6 137 15-17 81.5 13.6 582 26.1 79 90.0 6.9 521 (41.2) 36 18-19 48.4 37.9 346 24.3 131 63.5 26.5 382 36.3 101 20-24 23.7 59.3 427 32.4 253 31.5 51.6 586 48.6 302 20-22 29.2 54.6 298 30.4 163 38.5 47.1 355 48.2 167 23-24 11.1 69.9 130 36.0 91 20.7 58.6 231 48.9 135 Knows condom source1 Yes 49.0 39.7 1,025 32.1 407 55.9 32.9 1,296 46.4 426 No 72.7 17.1 331 7.3 57 89.4 6.9 192 * 13 Residence Urban 53.1 34.6 762 33.8 264 55.0 31.9 702 51.5 224 Rural 57.1 33.6 594 22.8 200 64.8 27.3 786 38.5 215 Region Western 56.3 24.3 120 (21.6) 29 65.6 22.3 148 (35.6) 33 Central 46.3 41.3 122 (30.5) 50 61.6 28.4 115 * 33 Greater Accra 58.4 33.1 274 45.0 91 53.2 31.7 206 50.9 65 Volta 64.8 22.0 105 * 23 68.5 20.4 147 (58.6) 30 Eastern 41.9 43.3 151 46.5 65 54.8 35.8 161 47.9 58 Ashanti 49.6 42.9 287 13.7 123 54.8 33.4 299 42.4 100 Brong Ahafo 48.6 39.9 94 (23.4) 38 42.3 47.9 124 37.9 59 Northern 70.5 19.7 108 * 21 77.2 16.8 146 (27.6) 25 Upper East 70.8 20.3 63 * 13 68.3 28.9 93 (58.0) 27 Upper West 58.9 32.6 31 (34.0) 10 73.3 19.8 49 (45.2) 10 Education No education 68.2 21.8 68 * 15 64.8 26.1 72 (19.3) 19 Primary 58.3 31.7 225 12.4 71 71.3 23.1 295 29.6 68 Middle/JSS 55.9 32.5 697 25.2 226 65.8 25.8 668 42.0 172 Secondary+ 48.1 41.3 366 43.2 151 44.0 39.6 449 56.9 178 Wealth quintile Lowest 67.9 21.3 149 27.4 32 69.8 24.3 251 31.8 61 Second 51.5 37.3 215 18.1 80 66.3 27.1 277 47.8 75 Middle 47.0 41.9 292 23.4 122 60.8 29.1 280 39.0 81 Fourth 50.3 37.2 333 35.1 124 52.5 34.8 374 39.1 130 Highest 61.7 28.8 368 37.2 106 55.6 30.0 306 65.8 92 Total 54.8 34.2 1,356 29.0 463 60.2 29.5 1,488 45.1 439 Note: Total includes cases with information missing on education that are not shown separately. 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 Friends, family members, and home are not considered sources for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 269 In Ghana, never-married young adults age 15-24 show a relatively high level of abstinence: 55 percent of women and 60 percent of men in this age group have never had sexual intercourse. One- third (34 percent) of all never-married women age 15-24 and 30 percent of never-married men age 15- 24 had sexual intercourse in the 12 months preceding the survey. Only 29 percent of never-married women reported using a condom at last sexual intercourse in the past 12 months, compared with 45 percent of the young men. Condom use at last sexual intercourse increases with age, especially among men. It is also higher among respondents who know where to obtain a condom. It is notable that never-married youth in urban areas are more likely to use condoms than youth in rural areas. Condom use at last sexual intercourse is highest among young adults with secondary or higher education and those in the highest wealth quintile. 13.13.6 Higher-risk Sex and Condom Use among Young Adults The most common means of transmission of HIV in Ghana is through unprotected sex with a person who is HIV positive. To prevent HIV/AIDS transmission, it is important that young people practice the recommended ABC methods regarding safe sex (abstinence, being faithful to one HIV- negative partner, and condom use). Tables 13.19.1 and 13.19.2 show for young men and women age 15-24, respectively, who were sexually active in the 12 months preceding the survey, the proportion who engaged in higher- risk sex2 during this period. The tables also show for those who engaged in higher-risk sex, the proportion who used a condom at last higher-risk sex. The results indicate that higher-risk sex is more common among young men (87 percent) than among young women (52 percent), and condom use at last higher-risk sexual intercourse is higher among young men (46 percent) than young women (28 percent). Higher-risk sex is more prevalent among younger respondents and among those who have never married. This is expected because higher-risk sex is, by definition, sexual intercourse with a non-marital partner, and older respondents are more likely to be married. Urban women age 15-24 are more likely to have higher-risk sexual intercourse than rural women (62 percent and 44 percent, respectively). The same pattern is seen for men, but the difference is less pronounced (90 percent for men in urban areas and 83 percent for men in rural areas). Higher-risk sexual intercourse is most prevalent among women in the Eastern (69 percent), Ashanti (60 percent), and Greater Accra regions (60 percent). The proportion of young people age 15-24 who reported higher-risk sexual intercourse in the 12 months preceding the survey increases with level of education and wealth quintile. Condom use at the last higher-risk sex generally follows the same patterns. 2 Sexual intercourse with a non-marital, non-cohabiting partner. 270 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk sexual intercourse in the past 12 months: Women Among young women age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher- risk intercourse in the past 12 months, the percentage who used a condom at last higher-risk sexual intercourse, by background characteristics, Ghana 2008 Background characteristic Women age 15-24 who had sexual intercourse in the past 12 months Women age 15-24 who had higher-risk sexual intercourse in the past 12 months Percentage who had higher-risk intercourse1 Number of women Percentage who used a condom at last higher-risk intercourse1 Number of women Age 15-19 73.6 297 24.4 218 15-17 79.6 101 25.7 80 18-19 70.5 196 23.7 138 20-24 42.5 649 31.1 276 20-22 45.3 387 30.4 175 23-24 38.4 263 32.3 101 Marital status Never married 99.5 463 29.2 461 Ever married 6.9 483 (14.3) 33 Knows condom source2 Yes 57.4 754 31.2 433 No 32.2 192 6.7 62 Residence Urban 62.2 440 33.5 273 Rural 43.7 506 21.6 221 Region Western 46.7 66 (20.3) 31 Central 51.9 100 (29.7) 52 Greater Accra 60.0 151 46.1 91 Volta 39.0 69 (22.4) 27 Eastern 68.6 98 45.0 67 Ashanti 60.1 227 12.3 136 Brong Ahafo 39.4 100 (22.5) 39 Northern 33.6 71 (18.3) 24 Upper East 41.2 39 * 16 Upper West 44.8 25 (30.3) 11 Education No education 14.2 125 (19.1) 18 Primary 40.7 211 11.5 86 Middle/JSS 57.3 413 25.4 236 Secondary+ 78.4 196 42.4 154 Wealth quintile Lowest 33.1 124 26.1 41 Second 44.7 201 16.2 90 Middle 59.0 215 22.6 126 Fourth 53.4 244 33.9 130 Highest 65.8 162 38.6 107 Total 15-24 52.3 946 28.2 495 Note: Total includes cases with information missing on education that are not shown separately. 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 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 271 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk sexual intercourse in the past 12 months: Men Among young men age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher- risk sexual intercourse in the past 12 months, the percentage who used a condom at last higher-risk sexual intercourse, by background characteristics, Ghana 2008 Background characteristic Men age 15-24 who had sexual intercourse in the past 12 months Men age 15-24 who had higher-risk sexual intercourse in the past 12 months Percentage who had higher-risk sexual intercourse1 Number of men Percentage who used a condom at last higher-risk intercourse1 Number of men Age 15-19 96.2 144 40.3 139 15-17 (98.5) 37 (45.1) 37 18-19 95.4 107 38.6 102 20-24 83.0 412 48.9 342 20-22 89.1 205 49.0 182 23-24 77.0 207 48.7 160 Marital status Never married 99.2 439 46.3 435 Ever married 38.7 117 (47.2) 45 Knows condom source2 Yes 88.7 525 47.8 465 No (49.4) 31 * 15 Residence Urban 90.4 268 52.0 242 Rural 82.7 288 40.6 238 Region Western (95.9) 38 (36.0) 36 Central (81.1) 46 (56.1) 37 Greater Accra 90.6 77 52.9 70 Volta (83.1) 42 (61.0) 35 Eastern 91.5 68 48.7 63 Ashanti 87.7 133 41.8 116 Brong Ahafo 90.4 71 37.1 64 Northern (61.9) 38 (28.2) 23 Upper East (83.4) 32 (64.3) 27 Upper West (81.8) 13 (45.6) 10 Education No education 47.7 45 (16.8) 22 Primary 86.3 83 26.8 72 Middle/JSS 86.8 220 45.6 191 Secondary+ 94.5 205 57.8 194 Wealth quintile Lowest 76.8 86 35.2 66 Second 80.2 100 44.4 80 Middle 85.5 107 42.8 91 Fourth 90.5 161 42.0 146 Highest 95.2 103 65.4 98 Total 15-24 86.4 556 46.4 481 Note: Total includes cases with information missing on education that are not shown separately. 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 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. 272 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Figure 13.2 presents the findings on the extent of both risky and safe sex practices among young people in Ghana. Thirty-nine percent of women and 55 percent of men age 15-24 have never had sex, and an additional 11 percent of women and 10 percent of men have had sex but not in the 12 months before the survey. Although 8 percent of women and 11 percent of men 15-24 say they had sex with only one partner in the past 12 months and that they used a condom the last time, the largest proportion of young respondents fall into the category of those who say they had only one partner in the past year but did not use a condom the last time (40 percent of women and 17 percent of men). The proportion of young people who had multiple sexual partners in the past 12 months is not large— less than 2 percent of women and 6 percent of men—however, the proportion who did not use a condom the last time they had sex far exceeds the proportion who did. Figure 13.2 Abstinence, Being Faithful, and Condom Use (ABC) Among Young Women and Men Age 15-24 15-19 20-24 15-24 15-19 20-24 15-24 0 20 40 60 80 100 Percent Never had sex No partners in past year One partner, used condom at last sex One partner, no condom use at last sex Multiple partners, used condom at last sex Multiple partners no condom use at last sex Note: Number of partners refers to the 12 months preceding the survey. GDHS 2008 WOMEN MEN 13.13.7 Age Mixing in Sexual Relationships among Women In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because if a younger, HIV-negative partner has sexual intercourse with an older, HIV-positive partner, the virus can be introduced into a younger, HIV-negative cohort. To examine age differences between sexual partners, women age 15-19 who had sex in the 12 months preceding the survey with someone other than their husband or live-in partner were asked the age of such partners. In the event they did not know a partner’s exact age, they were asked if the partner was older or younger than they were and, if older, whether the partner was 10 or more years older. Only 5 percent of women age 15-19 engaged in higher-risk sexual intercourse with an older male partner in the 12 months preceding the survey (data not shown). Because of the small sample size meaningful differences by background characteristics of respondents are unclear. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 273 13.13.8 Drunkenness during Sex among Young Adults Engaging in sexual intercourse while under the influence of alcohol can impair judgment, compromise power relations, and increase risky sexual behaviour. Respondents who had sex in the 12 months preceding the survey were asked (for each partner) if they or their partner drank alcohol the last time they had sexual intercourse with that partner, and whether they or their partner was drunk. As shown in Table 13.20, very few young people (less than 1 percent of women and 2 percent of men) reported being drunk during their last sexual intercourse and only 3 percent each of young women and men said that either they or their partners were drunk. There is little variation by background characteristics of respondents. Table 13.20 Drunkenness during sexual intercourse among youth Among all young women and young men age 15-24, the percentage who had sexual intercourse in the past 12 months while being drunk and percentage who had sexual intercourse in the past 12 months while drunk or with a partner who was drunk, by background characteristics, Ghana 2008 Background characteristic Women age 15-24 Men age 15-24 Percentage who had sexual intercourse in the past 12 months while drunk Percentage who had sexual intercourse in the past 12 months while drunk or with a partner who was drunk Number of women Percentage who had sexual intercourse in the past 12 months while drunk Percentage who had sexual intercourse in the past 12 months while drunk or with a partner who was drunk Number of men Age 15-19 0.3 1.2 1,025 1.3 1.3 911 15-17 0.0 0.6 605 0.9 0.9 524 18-19 0.8 2.0 420 1.9 1.9 387 20-24 0.9 5.0 878 3.8 4.1 704 20-22 0.6 4.0 552 3.3 3.7 399 23-24 1.3 6.7 326 4.5 4.5 305 Marital status Never married 0.5 1.9 1,356 2.1 2.2 1,488 Ever married 0.9 5.4 547 6.2 6.2 127 Knows condom source1 Yes 0.6 3.1 1,406 2.7 2.8 1,402 No 0.4 2.4 496 0.4 0.4 213 Residence Urban 0.7 2.6 953 2.4 2.4 748 Rural 0.5 3.3 949 2.4 2.6 867 Region Western 1.3 1.7 160 2.3 2.3 152 Central 0.0 1.6 173 0.0 0.0 129 Greater Accra 1.0 3.2 335 3.0 3.0 218 Volta 0.0 5.6 161 0.2 0.2 161 Eastern 0.8 0.8 188 4.0 4.0 172 Ashanti 0.3 5.4 403 3.9 4.3 333 Brong Ahafo 0.0 0.7 162 3.2 3.2 136 Northern 1.0 2.2 176 0.0 0.0 161 Upper East 0.4 0.4 93 4.3 4.3 100 Upper West 1.0 3.6 50 0.5 0.5 53 Education No education 1.1 3.6 202 0.0 1.6 100 Primary 0.6 2.7 380 1.9 1.9 314 Middle/JSS 0.1 2.2 899 3.0 3.0 718 Secondary+ 1.3 4.4 420 2.3 2.3 478 Wealth quintile Lowest 1.0 2.6 263 2.1 2.1 278 Second 0.0 1.3 353 0.4 0.4 307 Middle 0.7 3.8 397 1.7 2.3 306 Fourth 0.4 2.8 461 4.9 4.9 406 Highest 0.9 3.9 427 2.1 2.1 318 Total 15-24 0.6 2.9 1,902 2.4 2.5 1,615 Note: Total includes cases with information missing on education that are not shown separately 1 Friends, family members, and home are not considered sources for condoms 274 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.13.9 Recent HIV Tests among Youth Individuals’ knowledge of their own HIV status can provide motivation to practice safer sexual practices. People who learn that they do not have HIV may decide to take precautions in the future so as not to contract the virus, and those who learn that they are carrying the virus may decide to take precautions to avoid transmitting the virus to others. Table 13.21 shows that young women age 15-24 are slightly more likely than young men the same age to have been tested for HIV in the 12 months preceding the survey and to have received the results (8 and 5 percent, respectively). Table 13.21 Recent HIV tests among youth Among young women and young men age 15-24 who had sexual intercourse in the past 12 months, the percentage who were tested for HIV test in the past 12 months and received the results, by background characteristics, Ghana 2008 Background characteristic Women age 15-24 who had sexual intercourse in the past 12 months Men age 15-24 who had sexual intercourse in the past 12 months Percentage tested for HIV in past 12 months and received results Number of women Percentage tested for HIV in past 12 months and received results Number of men Age 15-19 6.0 297 0.0 144 15-17 1.5 101 (0.0) 37 18-19 8.3 196 0.0 107 20-24 9.1 649 6.3 412 20-22 9.3 387 7.3 205 23-24 8.9 263 5.4 207 Marital status Never married 4.9 463 5.5 439 Ever married 11.2 483 1.6 117 Knows condom source1 Yes 8.4 754 5.0 525 No 6.9 192 (0.0) 31 Residence Urban 9.7 440 4.0 268 Rural 6.8 506 5.3 288 Region Western 7.0 66 (4.6) 38 Central 11.1 100 (12.3) 46 Greater Accra 8.1 151 5.0 77 Volta 7.5 69 (0.0) 42 Eastern 6.1 98 3.7 68 Ashanti 8.7 227 2.8 133 Brong Ahafo 11.1 100 1.6 71 Northern 3.3 71 (3.1) 38 Upper East 7.2 39 (18.8) 32 Upper West 7.5 25 (3.2) 13 Education No education 5.8 125 3.3 45 Primary 4.2 211 4.7 83 Middle/JSS 9.5 413 1.9 220 Secondary+ 11.0 196 8.1 205 Wealth quintile Lowest 7.5 124 5.8 86 Second 3.5 201 4.1 100 Middle 6.5 215 1.9 107 Fourth 10.1 244 3.1 161 Highest 13.6 162 9.8 103 Total 15-24 8.1 946 4.7 556 Note: Total includes cases with information missing on education that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered sources for condoms HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 275 Among young women, recent HIV testing is more common among those who are ever- married, those living in urban areas, and those in the Greater Accra and Brong Ahafo regions. Among young men, recent HIV testing is more common among those who are never-married and those in the Upper West and Central regions. The likelihood that a young person has been tested recently for HIV increases with level of education and wealth quintile. It is also higher among young people who say they know a source for condoms. Women’s Empowerment and Demographic and Health Outcomes | 277 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 14 The 2008 Ghana Demographic and Health Survey (GDHS) collected information on the general background characteristics of respondents (age, education, wealth quintile, and employment status), but also information specific to women’s empowerment such as receipt of cash earnings, the magnitude of a woman’s earnings relative to those of her husband, and control over the use of her own earnings and those of her spouse.1 The 2008 GDHS collected information on women’s participation in household decision- making, the circumstances under which the respondent thinks that a woman is justified in refusing to have sexual intercourse with her husband, and her/his attitude towards wife beating. This report uses the three indices of women’s empowerment developed by DHS to measure women’s and men’s responses to the questions. The first index is based on the number of household decisions in which the woman participates, the second is based on the respondent’s opinion regarding the number of reasons that justify wife beating, and the third is based on the respondent’s opinion on the number of circumstances under which a wife is justified in refusing to have sexual intercourse with her husband. The ranking of women on these three indices is then related to selected demographic and health outcomes including use of contraception; ideal family size; and the use of reproductive health care services during pregnancy, childbirth, and postnatal period. 14.1 EMPLOYMENT AND FORMS OF EARNINGS Employment can be a source of empowerment for both women and men. It is particularly so for women if it puts them in control of the household income. In the 2008 GDHS, respondents were asked whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. Table 14.1 shows that 91 percent of currently married women age 15-49 were employed at the time of the survey or within the 12 months preceding the survey, compared with 99 percent of men. Older married women and men are more likely to be employed than younger respondents. Among currently married respondents employed in the past 12 months, equal proportion of women and men (87 percent) received earnings in cash or cash and in-kind. One in ten currently married respondents employed in the past 12 months were not paid. In general, among this group, the proportion not paid decreases with age. 14.2 CONTROL OVER WOMEN’S AND MEN’S EARNINGS Currently married women who were employed and received cash for their work were asked who the main decision-maker is in the family regarding use of their earnings. They were also asked the relative magnitude of their earnings compared with those of their husband. Women whose husbands were employed for cash were asked who usually decides how his earnings are used. Men were also asked who mainly decides how their earnings are used. These pieces of information 1 The questions were phrased in terms of “husband/partner” (for women) and “wife/partner” (for men), referring to marital partners; however, in this report, the word “partner” has been dropped to simplify the text and tables. 278 | Women’s Empowerment and Demographic and Health Outcomes