Ghana - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

Monitoring the situation of children, women, and men Multiple Indicator Cluster Survey 2006 i Summary table Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY 1 13 Under-five mortality rate 111 per thousand Child mortality 2 14 Infant mortality rate 71 per thousand NUTRITION 6 4 Underweight prevalence 17.8 percent 7 Stunting prevalence 22.4 percent Nutritional status 8 Wasting prevalence 5.4 percent 45 Timely initiation of breas tfeeding 35.2 percent 15 Exclusive breastfeeding rate 54.4 percent Continued breastfeeding rate at 12-15 months 94.6 percent 16 at 20-23 months 56.1 percent 17 Timely complementary feeding rate 58.7 percent 18 Frequency of complementary feeding 49.5 percent Breastfeeding 19 Adequately fed infants 52.1 percent Salt iodization 41 Iodized salt consumption 32.4 percent 42 Vitamin A supplementation (under-fives) 60.2 percent Vitamin A 43 Vitamin A supplementation (post-partum mothers) 54.5 percent 9 Low birth weight infants 9.1 percent Low birth weight 10 Infants weighed at birth 36.1 percent CHILD HEALTH 25 Tuberculosis immunization coverage 94.2 percent 26 Polio immunization coverage 80.1 percent 27 DPT immunization coverage 81.4 percent 28 15 Measles immunization coverage 77.7 percent 31 Fully immunized children 64.4 percent 29 Hepatitis B immunization coverage 81.4 percent Immunization 30 Yellow fever immunization coverage 76.7 percent Tetanus toxoid 32 Neonatal tetanus protection 77.1 percent 33 Use of oral rehydration therapy (ORT) 37.0 percent 34 Home management of diarrhoea 19.0 percent 35 Received ORT or increased fluids, and continued feeding 28.6 percent 23 Care seeking for suspected pneumonia 33.6 percent Care of illness 22 Antibiotic treatment of suspected pneumonia 32.9 percent Solid fuel use 24 29 Solid fuels 85.6 percent 36 Household availability of insecticide-treated nets (ITNs) 18.7 percent 37 22 Under-fives sleeping under insecticide-treated nets 21.8 percent 38 Under-fives sleeping under mosquito nets 32.6 percent 39 22 Antimalarial treatment (under-fives) 48.3 percent Malaria 40 Intermittent preventive malaria treatment (pregnant women) 27.5 percent ii Topic MICS Indicator Number MDG Indicator Number Indicator Value 96 Source of supplies (from public sources) Insecticide treated nets 68.3 percent Antimalarials 47.8 percent 97 Cost of supplies (median costs) Insecticide treated nets public sources 25,000 GHC private sources 30,000 GHC Antimalarials public sources 25,042 GHC Source and cost of supplies private sources 10,000 GHC ENVIRONMENT 11 30 Use of improved drinking water sources 78.1 percent 13 Water treatment 3.3 percent 12 31 Use of improved sanitation facili ties 60.7 percent Water and Sanitation 14 Disposal of child's faeces 43.7 percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 16.6 percent 20 Antenatal care 92.1 percent Maternal and newborn health 44 Content of antenatal care Blood test taken 78.3 percent Blood pressure measured 91.9 percent Urine specimen taken 80.0 percent Weight measured 90.9 percent 4 17 Skilled attendant at delivery 49.7 percent 5 Institutional deliveries 48.7 percent CHILD DEVELOPMENT 46 Support for learning 39.3 percent 47 Father's support for learning 46.9 percent 48 Support for learning: children’s books 12.7 percent 49 Support for learning: non-children’s books 40.0 percent 50 Support for learning: materials for play 28.1 percent Child development 51 Non-adult care 24.8 percent iii Topic MICS Indicator Number MDG Indicator Number Indicator Value EDUCATION 52 Pre-school attendance 51.6 percent 53 School readiness 86.7 percent 54 Net intake rate in primary education 43.3 percent 55 6 Net primary school attendance rate 75.3 percent 56 Net secondary school attendance rate 45.1 percent 57 7 Children reaching grade five 90.1 percent 58 Transition rate to secondary school 97.5 percent 59 7b Primary completion rate 24.2 percent Education 61 9 Gender parity index primary school secondary school 1.00 0.99 ratio ratio Literacy 60 8 Adult literacy rate (youth) women men 67.9 75.4 percent percent CHILD PROTECTION Birth registration 62 Birth registration 51.4 percent 71 Child labour 33.9 percent 72 Labourer students 78.9 percent Child labour 73 Student labourers 32.2 percent Child discipline 74 Child discipline Any psychological/physical punishment 89.2 percent 67 Marriage before age 15 Marriage before age 18 4.4 25.9 percent percent 68 Young women aged 15-19 currently married/in union 8.1 percent 70 Polygyny 21.6 percent Early marriage and polygyny 69 Spousal age difference women aged 15-19 women aged 20-24 12.8 16.8 percent percent 66 Approval for FGM/C 2.3 percent Female genital mutilation/ cutting 63 Prevalence of female genital mutilation/cutting (FGM/C) 3.8 percent Domestic violence 100 Attitudes towards domestic violence women men 46.7 36.6 percent percent Disability 101 Child disability 16.4 percent iv Topic MICS Indicator Number MDG Indicator Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 82 19b Comprehensive knowledge about HIV prevention among young people women 15-24 men 15-24 25.1 33.0 percent percent 89 Knowledge of mother- to-child transmission of HIV women men 69.4 67.2 percent percent 86 Attitude towards people with HIV/AIDS women men 7.6 10.7 percent percent 87 People who know where to be tested for HIV women men 48.3 58.2 percent percent 88 People who have been tested for HIV women men 13.6 8.8 percent percent 90 Counselling coverage for the prevention of mother-to- child transmission of HIV 45.5 percent HIV/AIDS knowledge and attitudes 91 Testing coverage for the prevention of mother-to- child transmission of HIV 10.3 percent 84 Sex before age 15 women men 6.5 4.8 percent percent 92 Age-mixing among sexual partners 12.1 percent 83 19a Condom use with non-regular partners women men 41.6 55.7 percent percent Sexual behaviour 85 Higher risk sex in the last year women men 51.5 87.9 percent percent 75 Prevalence of orphans 7.7 percent 78 Children’s living arrangements 14.3 percent Support to orphaned and vulnerable children 77 20 School attendance of orphans versus non-orphans 1.02 ratio Note: Refer to Annex E for definitions of the above indicators. v Table of contents Summary table i Table of contents v List of tables vii List of abbreviations and acronyms ix Preface x Acknowledgements xi Executive Summary xi I. Introduction 1 Background 1 Survey Objectives 2 The report 2 II. Sample and Survey Methodology 3 Sample Design 3 Questionnaires 3 Training and Fieldwork 5 Data Processing 5 III. Sample Coverage and Characteristics 6 Sample Coverage and Response Rates 6 Characteristics of Households 8 Characteristics of Respondents 11 IV. Child Mortality 15 V. Nutrition 18 Nutritional Status 18 Breastfeeding 20 Salt Iodization 25 Vitamin A Supplements 27 Low Birth Weight 29 VI. Child Health 31 Immunization 31 Tetanus Toxoid 35 Oral Rehydration Treatment 36 Care Seeking and Antibiotic Treatment of Pneumonia 39 Solid Fuel Use 43 Malaria 45 Sources and Costs of Supplies for ITNs and Antimalarials 50 VII. Environment 53 Water and Sanitation 53 Use of improved water sources 53 Household water treatment 55 Time to source water 58 vi Person collecting water 58 Use of sanitary means of excreta disposal 61 Disposal of child’s faeces 61 Use of improved water sources and improved sanitation 63 Durability of Housing 64 VIII. Reproductive Health 65 Contraception 65 Antenatal Care 67 Assistance at Delivery 71 IX. Child Development 73 X. Education 78 Pre-School Attendance and School Readiness 78 Primary and Secondary School Participation 79 Literacy 86 XI. Child Protection 88 Birth Registration 88 Child Labour 88 Child Discipline 93 Early Marriage and Polygyny 94 Female Genital Mutilation/Cutting 100 Domestic Violence 102 Child Disability 106 XII. HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children 108 Knowledge of HIV Transmission 108 Comprehensive knowledge of HIV methods and transmission 111 Knowledge of mother to child transmission 112 Attitude towards people living with HIV and AIDS 113 Knowledge of facility for HIV testing 115 Sexual Behaviour Related to HIV Transmission 119 Condom Use 123 Orphaned and Vulnerable Children 124 List of References 127 Annex A – Sample design 128 Annex B – Personnel 131 Annex C – Sampling errors 133 Annex D – Data quality tables 162 Annex E – Indicators 169 Annex F – Questionnaires 185 vii List of tables III. Sample Coverage and Characteristics Table HH.1: Results of household and individual interviews .7 Table HH.2: Household population by age, sex and place of residence .8 Table HH.3: Household composition .10 Table HH.4: Men’s and women's background characteristics .12 Table HH.4A: Adult literacy.13 Table HH.5: Children's background characteristics .14 IV. Child Mortality Table CM.1: Child mortality .1 Table CM.2: Children ever born and proportion dead.17 V. Nutrition Table NU.1: Child malnutrition.19 Table NU 2: Initiation of breastfeeding.21 Table NU.3: Breastfeeding.22 Table NU.4: Adequately fed infants.24 Table NU.5: Iodized salt consumption (MICS) .25 Table NU.5A: Iodized salt consumption (DHS).26 Table NU.6: Children's vitamin A supplementation .28 Table NU.7: Post-partum Vitamin A supplementation .29 Table NU.8: Low birth weight infants .30 VI. Child Health Table CH.1: Vaccinations in first year of life .32 Table CH.2: Vaccinations by background characteristics.34 Table CH.3: Neonatal tetanus protection .35 Table CH.4: Oral rehydration treatment.37 Table CH.5: Home management of diarrhoea .38 Table CH.6: Care seeking for suspected pneumonia.40 Table CH.7: Antibiotic treatment of pneumonia .41 Table CH.7A: Knowledge of the two danger signs of pneumonia.42 Table CH.8: Solid fuel use .44 Table CH.9: Solid fuel use by type of stove or fire .45 Table CH.10: Availability of insecticide-treated nets .46 Table CH.11: Children sleeping under bednets .47 Table CH.12: Treatment of children with anti-malarial drugs .48 Table CH.13: Intermittent preventive treatment for malaria.49 Table CH.14: Source of supplies for ITNs .51 Table CH.15: Source and cost of supplies for antimalarials.52 VII. Environment Table EN.1: Use of improved water sources .54 Table EN.2: Household water treatment.56 Table EN.3: Time to source of water .57 Table EN.4: Person collecting water.59 Table EN.5: Use of sanitary means of excreta disposal .60 Table EN.6: Disposal of child's faeces.62 Table EN.7: Use of improved water sources and improved sanitation .63 Table EN.8: Durability of housing.64 viii VIII. Reproductive Health Table RH.1: Use of contraception .66 Table RH.2: Antenatal care provider .68 Table RH.3: Antenatal care.70 Table RH.4: Assistance during delivery .72 IX. Child Development Table CD.1: Family support for learning.74 Table CD.2: Learning materials .75 Table CD.3: Children left alone or with other children .77 X. Education Table ED.1: Early childhood education .79 Table ED.2: Primary school entry .80 Table ED.3: Primary school net attendance ratio.81 Table ED.4: Secondary School (JSS, SSS) net attendance ratio .82 Table ED.4A: Secondary School (JSS, SSS) age children attending primary school.83 Table ED.5: Children reaching grade 5 .84 Table ED.6: Primary school completion and transition to secondary education .85 Table ED.7: Education gender parity.86 Table ED.8: Adult literacy .87 XI. Child Protection Table CP.1: Birth registration .89 Table CP.2: Child labour .90 Table CP.3: Labourer students and student labourers.92 Table CP.4: Child discipline.93 Table CP.5: Early marriage.96 Table CP.5A: Marital status and polygyny.97 Table CP.6: Spousal age difference.99 Table CP.7: Female genital mutilation / cutting (FGM/C). 102 Table CP.8: Attitudes toward domestic violence: women . 104 Table CP.8A: Attitudes toward domestic violence: men . 105 Table CP.9: Child disability . 107 XII. HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children Table HA.1: Knowledge of preventing HIV transmission . 109 Table HA.2: Identifying misconceptions about HIV/AIDS. 110 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission . 112 Table HA.4: Knowledge of mother-to-child HIV transmission . 113 Table HA.5: Attitudes toward people living with HIV/AIDS. 114 Table HA.6: Knowledge of a facility for HIV testing and recent testing: Women . 116 Table HA.6A: Knowledge of a facility for HIV testing and recent testing: Men . 117 Table HA.7: HIV testing and counselling coverage during antenatal care. 118 Table HA.8A: Sexual behaviour that increases risk of HIV infection . 121 Table HA.9: Condom use and high -risk sex . 122 Table HA.9A: Premarital sex and condom use during premarital sex. 123 Table HA.9B: High-risk sex and condom use at last high-risk sex . 124 Table HA.10: Children's living arrangements and orphanhood . 125 Table HA.11: School attendance of orphaned children . 126 ix List of abbreviations and acronyms AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CDC Center for Disease Control CSPro Census and Survey Processing System CWIQ Core Welfare Indicator Questionnaire DHS Demographic and Health Survey DPT Diphtheria Pertussis Tetanus (DPT)HH DPT Hepatitis B Haemophilus B EA Enumeration Area EPI Expanded Programme on Immunization FGM/C Female Genital Mutilation/Cutting GDHS Ghana Demographic and Health Survey GPRS Ghana Poverty Reduction Strategy GPRS II Growth and Poverty Reduction Strategy II GPI Gender Parity Index GLLS Ghana Living Standards Survey GSS Ghana Statistical Service HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IQ Intelligence Quotient ITN Insecticide Treated Net IUD Intrauterine Device JSS Junior Secondary School LAM Lactational Amenorrh0ea Method LPG Liquefied Petroleum Gas MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR Measles Mumps Rubella MoH Ministry of Health MTCT Mother-To-Child Transmission NAR Net Attendance Rate NCHS (US) National Center for Health Statistics ORT Oral rehydration treatment ORS Oral Rehydration Salts PEPFAR (US) President’s Emergency Plan for AIDS Relief PHC Population and Housing Census ppm Parts Per Million RHF Recommended Homemade Fluid SD Standard Deviation SPSS Statistical Package for Social Sciences SSS Senior Secondary School STI/D Sexually Transmitted Infection / Disease TBA Traditional Birth Attendant U5MR Under-five Mortality Rate UN United Nations UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization x Preface The Multiple Indicator Cluster Survey (MICS), aims at providing indicators to monitor progress on issues relating to women and children. MICS, developed initially to measure progress towards an internationally agreed set of goals from the 1990 World Summit for Children is now in its third round. At least 50 countries have participated in each round of data collection. The first round of the survey was undertaken around 1995; the second round around 2000 and the third around 2005. The results from these surveys have added to the wealth of data needed to monitor the situation of children and women. Ghana participated in the first round of MICS, and the survey was conducted by Ministry of Health (MoH) with technical assistance from Ghana Statistical Service (GSS). In the third round of MICS, just completed, the survey was conducted by the Ghana Statistical Service in collaboration with the Ministry of Health, UNICEF, Ghana and Macro International. Building on the initial goals for the MICS, the current survey was designed primarily to collect information on a broad set of indicators also needed for monitoring the goals and targets of the Millennium Declaration, the World Fit for Children Declaration and Plan of Action, the United Nations General Assembly special session on HIV/AIDS and of the African summit on malaria. Ghana has embarked on several national strategies in its goal to fight poverty. Since 2000 the main thrust of the programmes have been derived from the Ghana Poverty Reduction Strategy (GPRS), now in its second round, the Growth and Poverty Reduction Strategy GPRS II which began in 2006. The findings from MICS would provide additional data on progress towards goals established by the GPRS II. Furthermore, the availability of the MICS data will enhance the implementation of donor-specific programmes such as the High Impact Rapid Delivery (HIRD), Integrated Management of Childhood Illness (IMCI) and the Untied States Government President’s Emergency Plan for AIDS Relief, among others. Dr. Grace Bediako Government Statistician xi Acknowledgements The Ghana Multiple Indicator Cluster Survey (MICS) 2006 was executed successfully through the invaluable assistance given by all collaborating agencies, institutions, organisations and individuals to whom we owe a great deal of gratitude. We acknowledge the Ministry of Health (MoH) for sourcing substantial funds for the survey, releasing staff to serve on the secretariat and participating in the fieldwork, as well as providing the logistical support for the exercise. We also thank the Dutch Government sincerely for providing funds through MoH for the MICS. The MICS project was initiated by UNICEF, and we appreciate their effort in the organisation of the survey, which involved the staff from the New York and Ghana offices. We are also grateful to them for their immense and diverse contributions ranging from expert visits, international training programmes, local technical assistance, procurement and administration. The international training opportunities provided by UNICEF, made it possible for the MICS team to meet and work with colleagues from the other National Statistics offices and helped build capacity in our institutions. In implementing the Ghana MICS, there was collaboration with MEASURE DHS/Macro International, Inc. and USAID, under the US President’s Emergency Plan for AIDS Relief (PEPFAR), providing significant technical assistance and funding, in particular, with regard to the inclusion of the male questionnaire. We sincerely thank them, as well as the Ghana AIDS Commission, for their effort to expand on the HIV/AIDS module of the survey and also made the collaboration with DHS/Macro possible. We appreciate the work done by the Ghana MICS 2006 Steering Committee for their immense contribution in the implementation of the survey. We are grateful to the entire project staff of the Ghana MICS for their tireless work, dedication to duty and other contributions in the different phases of the survey. We give our sincerest gratitude to the field survey personnel for their dedication and professionalism that has produced data of very good quality. The contribution of other staff in the Statistical Service who worked behind the scenes in various ways to assist the Secretariat is acknowledged. Their names have been printed in the appendix in acknowledgement of their contribution. We thank the contributors to this report for the good work done. Their names have been mentioned individually in the report. The final and sincere thanks go to all respondents who readily made themselves available to be interviewed and contributed to the 2006 Ghana MICS successful. xii Executive Summary Household Characteristics · Proportion of children aged less than 15 years is 40.5 percent · Twenty-nine percent of households are headed by women with urban (32 percent)/rural (26 percent) · At least there is one child less than 5 years old in 37 percent of households in urban areas and 45 percent in rural areas; whereas three-quarters of all households have a child under 18 and/or a woman aged 15-49 years. · Twenty-nine percent of households have a household size of 4-5 members and 28 percent has 2-3 household members. Characteristics of Respondents · The largest proportions of women and men are in 15-19 years and 20-24 years age groups. Thirty-nine percent of females and 44 percent of males are in the age group 15-24 year. · About 3 in 5 women and about half of men are currently married or living together. However, 3 in 10 women and one in two men have never married. · Out of 3 women, 2 have given birth at least once and one out of two men has ever fathered a child. · Men are slightly more likely to live in rural areas (56 percent) than women (53 percent). Sixty-five percent of children under five live in rural areas and 36 percent live in urban areas. · Twenty-six percent of women and 15 percent of men have no education. Twenty percent of women and 15 percent of men have only primary education. Thirty-eight percent of women and 47 percent of men have only middle/JSS level of education. On the other hand, 16 percent of women and 25 percent of men have attained secondary or higher levels of education. · Fifty percent of women and 65 percent of men are literate. In the richest wealth quintile, 68 percent and 75 percent of women and men respectively are literate while in the poorest wealth quintile, 17 percent and 32 percent of women and men respectively are literate. 60 percent of women and 75 percent of men in urban areas are literate; but in the rural areas, only 40 percent of women and 60 percent of men are literate. The highest percentage of female literates (65 percent) is found in Greater Accra Region and the lowest (15 percent) is found in Upper West Region. Among men the highest percent of literates is found in Ashanti Region (77 percent) while the lowest (31 percent) is found in the Northern and Upper West regions. Child Mortality · Infant mortality rate is 71 deaths per 1,000 live births and under-five mortality rate is 111 deaths per 1,000 live births · Under-five mortality rate experienced by female children (89 deaths per 1,000 live births) is about two deaths of what is experienced by male children (131 deaths per 1,000) · Mortality among rural children is 72 percent and 114 percent for both infant and under-five children. It is however 68 percent and 106 percent respectively for urban children. xiii Nutritional Status · Eighteen percent and 3 percent of children under-five are under weight and severely underweight respectively; overweight is not a problem among children under-five, only 1 percent are overweight. · Malnourishment peaks at age 12-23 months; 22 percent of children are stunted and 5 percent wasted. Children in the Upper East and Northern regions of the country are more underweight, stunted and wasted. Boys are more slightly underweight, stunted and wasted than girls. Breastfeeding · About 55 percent of children less than six months are exclusively breastfed with 65 percent for those children aged 0-3 months · Among children 6-9 months, 69 percent receive breast milk and solid or semi-solid foods; at 12-15 months, 95 percent are still being breastfed and by age 20-23 months 56 percent are still being breastfed. Salt Iodization · Salt is not iodized in 45 percent of households tested. 35 percent have salt that contains 15 parts per million (ppm) or more of iodine and 20 percent have less than 15 ppm. The use of adequately iodized salt is twice as high in urban as compared to rural areas. Vitamin A Supplement · Sixty percent of children aged 6-59 months receive a high dose of Vitamin A supplement while 7 percent never received the supplement Low Birth Weight · Out of 40 percent of weighed live births, approximately 9% of weighed live births are below 2500 grams Immunization · Sixty-four percent of children aged 12-23 months are fully immunized before the age of 12 months and more than 73 percent of children 12-23 months have all the required vaccinations · About 94 percent of children aged 12-23 months receive a BCG vaccination by the age of 12 months · First dose of (DPT)HH is given to 94 percent of children aged 12-23 months, 89 percent of the same age group receive second dose and 81 percent of the same age group receive the third dose · Ninety-six percent of children aged 12-23 months receive polio by age 12 months and third dose, only 80 percent. Tetanus Toxoid · Protection level of women who have had a live birth within the last 2 years against tetanus is generally high peaking at 81 percent at age 30-34 years. · Sixty-four percent of women receive at least 2 doses during the last pregnancy xiv Oral Rehydration Treatment · Nineteen percent of children aged 0-59 months with diarrhoea are managed at home. Only 9 percent of infants under 12 months are managed at home as compared to 31 percent of those 24-35 months Care Seeking and Antibiotic Treatment of Pneumonia · Thirty-three percent of children under-five years with suspected pneumonia receive an antibiotic treatment. Generally treatment of suspected pneumonia with an antibiotic is very low among poor households Solid Fuel Use · Eighty-six percent of households are using solid fuels for cooking. Its use is slightly lower in the urban areas (74 percent) than in the rural areas (96 percent). · The higher the educational level of the head of household, the lower the use of solid fuels for cooking (58%); similarly, the percentage is lowest among the wealthiest households (49%) Malaria · Forty-nine percent of households have at least one mosquito net but, only 19% of households have insecticide treated net (ITN). · Thirty-three percent of children under-five sleep under a mosquito net but 22 percent sleep under an ITN · The use of ITN is higher in the rural areas (25%) than in the urban areas (16%) · Twenty-two percent of children under-five were ill with fever. The prevalence of fever is lowest among infants 0-11 months old but peaked at 12-23 months old children (27 percent) · The most widely used appropriate anti-malarial drugs are chloroquine used by 42 percent of children aged 0-59 months with fever and armodiaquine used by 14 percent. Of children with fever, 61 percent are treated with an appropriate anti- malarial drug and 48 percent receive the drug within 24 hours of onset of symptoms. Water and Sanitation · Thirty-eight percent of the population has access to pipe-borne water in their dwelling, yard or plot or public tap · Twenty-nine percent and 6 percent of the population get their drinking water from boreholes and protected wells respectively. · Five percent depend on sachet water for drinking water and only 0.1 percent drink bottled water. · Seventy-eight percent of the population has improved sources of drinking water. Time to Source Water · The mean time for accessing water by households that do not have water in dwelling is 18 minutes. Rural households get to the source and back in 21 minutes but urban households spend 13 minutes Person Collecting Water · Adult women are more likely to fetch water than men and children. In 64 percent of households, adult women collect water either alone or with children compared to 17 percent in which adult men do the fetching xv · In 16 percent of households, children are those who collect water, whether male or female. Use of Sanitary Means of Excreta Disposal · Sixty-one percent of the population is using improved sanitation facilities. The improved sanitation is however more prevalent in urban areas (83 percent) than in rural areas (50 percent) Disposal of child’s faeces · About two out of every five children’s stool are put or rinsed into a toilet or latrine; 20 percent are thrown into garbage (solid waste). Only 2 percent of children are made to use the toilet/latrine themselves. Use of Improved Water Sources and Improved Sanitation · Forty-eight percent of households use improved sources of drinking water and sanitary means of disposing excreta. · In the urban areas 68 percent of households use both improved sources of drinking water and sanitary means of excreta disposal while only 38 percent of rural households use both methods. Durability of Dwelling · No house is located in a hazardous area; however, 10 percent of all dwellings is in poor condition and one in fifty are vulnerable to accidents. · About three percent of the dwellings are considered non-durable and 4 percent have natural floor materials (earth/mud/mud bricks). Contraception · Approximately 17 percent of women currently married or in union, are using contraception · The most popular method of contraception currently used is the injection and it is used by 6 percent of the married women. Pill use accounts for 5 percent of married women. · The condom is used by less than two percent of partners of married women. Antenatal Care · Coverage of antenatal care is relatively high with, 92 percent of pregnant women aged 15-49 years receiving medical care at least once from a skilled provider. · Higher antenatal care by professional health personnel is recorded in the urban areas of the country (96 percent) than in the rural areas (90 percent). · Ten percent of pregnant women have their blood pressure checked and weight measured · Eighty percent have their urine tested, and 78 percent have a blood sample taken respectively for laboratory examination. Assistance at Delivery · Fourth-one percent of births are delivered with the assistance of a nurse/midwife while doctors assisted with 9 percent of births. Trained TBAs and untrained TBAs that assisted with deliveries were 21% and 10% respectively. xvi Child Development · On average household members are engaged with children in three activities that promote learning. Forty-seven percent of the children have their fathers involved in one or more activities. · Thirty percent of children are living in a household without their biological fathers. · The proportion of children 0-59 months with whom an adult household member engaged in 4 or more activities is 50 percent in urban areas and 34 percent in rural areas. · Most households do not have children’s and non-children’s books. 40 percent of children live in households with at least 3 non-children’s books. But 13 percent of those under-five have children’s books. · Twenty-eight percent of children under-five years have three or more playthings to play with in their homes but 17 percent do not have any. Thirty-four percent of children aged 0-23 months have no playthings, while 5 percent of those aged 24-59 months do not have. · During the week preceding the survey, 25 percent of children had inadequate care. Female children under-five are more likely to be left with inadequate care than male children. Also 29 percent of rural children are with inadequate care compared to 17 percent of urban children. Pre-school Attendance and School Readiness · Fifty-two percent of children aged 36-59 months are attending pre-school; 71 percent in urban areas compared to 41 in rural areas. Eighty-four percent of children whose mothers have attained at least secondary level attend early childhood education compared to 35 percent whose mothers had no education. Primary and Secondary School participation · Forty-three percent of children of primary school entry age are attending first grade. · Only 75 percent of children of primary school age are attending school. · Eighty-five percent of urban children attend school as against 70 percent rural children · Forty-five percent of children of secondary school age are attending JSS or higher while 55 percent are either out of school or are in primary school. 57 percent urban children and 36 percent rural children are attending secondary school. · Ninety percent of all children starting grade one eventually reach grade five. · There is no difference in school attendance between boys and girls (gender parity for primary and JSS for boys and girls is 1.00 and 0.99 respectively) Literacy · Sixty-four percent of women and 71 percent of men are literate. In the richest wealth quintile, 81 percent of women and 85 percent of men are literates while in the poorest wealth quintile, 30 percent of women and 38 percent of men are literate. Birth Registration · The births of 51 percent of children under-five years have been registered. Seventy- nine percent of births to mothers with secondary and higher are registered while only 41 percent of births to mothers with no education are registered. · Seven out of every ten children born in urban areas are registered compared to four out of ten of children born in rural areas. xvii Child Labour · Thirty-four percent of children 5-14 years are engaged in child labour. Children aged 5-11 engaged in child labour were more (39%) compared to those aged 12-14 (22%). · While only 14 percent of children from the richest wealth quintile are engaged in child labour, 48 percent of those from the poorest quintile are engaged. · Of 83 percent of children 5-14 years of age attending school, 32 percent are also involved in child labour activities. Child Discipline · Eighty-nine percent of children aged 2-14 years are subjected to a form of psychological or physical punishment. · Ten percent are subjected to severe physical punishment and 69 percent to minor punishment. Early Marriage and Polygyny · Four percent of 15-49 years women in marriage or union were married before age 15 and 26 percent of women aged 20-49 married before age 18. · By age of 25, more than half of the women are married or cohabiting with a partner while at 30 years of age over 90 percent of women are in union. · Half of the men marry or cohabit with a woman by the age of 30 years and after the age of forty years, 95 percent marry or cohabit with a woman. Female Genital Mutilation/Cutting (FGM/C) · Four percent of women aged 15-49 years have had some form of FGM/C. The practice of FGM/C is most prevalent dominant in the two upper regions. Upper West Region is leading with 56 percent while Upper East followed with 13 percent. · Ninety-three percent of women aged 15-49 years believe that the practice should be discontinued; whiles only 2 percent believe otherwise. Domestic Violence (DV) · Acceptance of domestic violence is highest in the Upper West Region (76 percent) of Ghana and lowest in Greater Accra (28 percent) · Forty-seven percent of women aged 15-49 believe that a husband is justified in beating his wife. This belief, is held among a higher proportion of women in the rural areas (57 percent) than the urban areas (36 percent) · Thirty-six percent of men believe wife beating is justified. This belief is held among a higher proportion of men in rural areas (44%) than those in urban areas (27%). Child Disability · Sixteen percent of children aged 2-9 years have at least one form of disability. Knowledge of HIV Transmission · Ninety-eight percent of men and 97 percent of women have heard of AIDS. · Sixty percent and 56 percent of men and women respectively know of all three main ways of preventing HIV transmission. · Forty-one percent of men and 28 percent of women know that a healthy-looking person can be infected. · Ninety-two percent of men and 93 percent of women know that HIV can be transmitted from mother to child. xviii Attitude towards People Living with HIV/AIDS (PLWHA) · Education, wealth, and type of resident are strongly related to negative attitudes towards those who are HIV-positive. Rural residents, less educated people and those in lower wealth quintiles are most likely to have discriminatory attitudes towards the HIV-positives than educated people living in urban areas and are in the upper wealth quintiles. Knowledge of Facility for HIV Testing · Fifty-eight percent and 48 percent of men and women respectively know where to be tested while 9 percent of men and 14 percent of women have actually ever been tested · Women in 25-29 years age group and men in the 35-39 years age group recorded the highest proportions of those that have been tested. Sexual Behaviour Related to HIV Transmission · Young women have sex earlier than their male counterparts. Seven percent of young women and 5 percent of young men aged 15-19 years had sex before age 15. · Two percent of women and 6 percent of men had sex with more than one partner. · Forty percent of women and 60 percent of men use condom during sexual intercourse. Orphans and Vulnerable Children · Fourteen percent of all children are not living with a biological parent. · Eight percent of all children have one or both parent’s dead. · Sixty percent of children under 18 years are living with both parents; 21 percent of these children live with only their mother, 4 percent live with only their father, and 15 percent live with neither parent. xix 1 I. Introduction Background This report is based on the Ghana Multiple Indicator Cluster Survey, conducted in 2006 by Ghana Statistical Service and the Ministry of Health. The survey provides valuable information on the situation of women, men and children in Ghana. It was based largely on the need to monitor progress towards goals and targets emanating from recent international agreements, the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000 and the Plan of Action of A World Fit for Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. In signing these international agreements, governments committed themselves to improving conditions for children and to monitor progress towards this end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” Ghana in its drive to fight poverty has embarked on national strategies – the Ghana Poverty Reduction Strategy (GPRS) in 2000 and the Growth and Poverty Reduction Strategy GPRS II) from 2006. Findings from Multiple Indicator Cluster Survey (MICS) would provide up-to- date information on progress towards goals established by the GPRS II. In addition to the 2 national strategy, donor-specific programmes were also implemented including the High Impact Rapid Delivery (HIRD), Integrated Management of Childhood Illness (IMCI), and the United States Government President’s Emergency Plan for AIDS Relief, etc. This final report presents the results and findings of the survey. Survey Objectives The MICS 2006 has the following primary objectives: · To provide up-to-date information for assessing the health situation of women and children in Ghana; · To present the current level of knowledge and behavioural indicators regarding HIV/AIDS and malaria; · To furnish data needed for monitoring progress toward the Millennium Development Goals, and the goals of A World Fit for Children (WFFC) as a basis for future action; such as the US President’s Emergency Plan for AIDS Relief (PEPFAR). · To contribute to the formation of baselines for the GPRS II and the Ministry of Health (MoH) Plan of Work 2007-2011, and to provide progress monitoring for other policies and programmes in Ghana; · To contribute to the improvement of data and monitoring systems in Ghana and to strengthen technical expertise in the design, implementation, and analysis of such systems. The report The report is divided into chapters as outlined in the table of contents. A number of annexes serve as reference and background information to the report. Please note that most tables refer to “MICS Indicators”. The computations of these are explained in detail in Annex E, further referencing the survey questionnaires in Annex F. 3 II. Sample and Survey Methodology Sample Design The sample for the MICS 2006 was designed to provide estimates on a large number of indicators of the health status of women, men, and children at the national level, for urban and rural areas, as well as for the 10 administrative regions in the country. A representative probability sample of 6,302 households was selected nationwide. The list of enumeration areas (EAs) from the Ghana Living Standards Survey 5 (GLSS 5) served as a frame for the MICS sample. The frame was first stratified into the 10 administrative regions in the country, then into urban and rural EAs. The MICS 2006 used a two-stage stratified sample design. At the first stage of sampling, 300 census enumeration areas (124 urban and 176 rural EAs) were selected. These are a sub- sample of the 660 EAs (281 urban and 379 rural) selected for the GLSS 5. The clusters in each region were selected using systematic sampling with probability proportional to their size. The distribution of EAs between regions is not proportional to the 2000 Population and Housing Census, mainly due to over-sampling in the number of EAs for Northern, Upper East and Upper West Regions. A complete household listing exercise covering all EAs in the GLSS 5 was carried out in May through July 2005 with a few selected EAs listed in early 2006. At the second stage, a systematic sampling of households was selected based on this list. The MICS households were selected systematically from the household listing provided by GLSS 5 after eliminating from the list households previously selected by the GLSS 5 (20 per EA). The reason for selecting different households is that the GLSS 5 interviews are long and demanding for respondents. It therefore seemed preferable to keep the two household samples separate in order to avoid respondent fatigue and possible high rates of refusal in the households falling in both samples as they were being conducted concurrently. For the MICS, 20 households per EA were selected except for rural EAs in Northern, Upper East and Upper West regions, where 20 households per EA were selected per urban EA and 25 households selected per rural EA. The objective of this exercise was to ensure an adequate number of complete interviews to provide estimates for important population characteristics with acceptable statistical precision per region. Due to the fixed sample size per EA, the disproportional number of EAs and different sample sizes selected per EA among regions, the MICS 2006 household sample is not self-weighting at the national level. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Four sets of questionnaires were used in the survey: · a household questionnaire which was used to collect information on all de jure household members and household characteristics and to identify eligible individuals; · a women’s questionnaire administered in each household to all women aged 15-49 years; · a men’s questionnaire administered in every third selected household to all men aged 15- 49 years; and · an under-5 questionnaire, administered to mothers or caretakers of all children under 4 five years1 living in the household. The questionnaires included the following modules: Household Questionnaire: o Household Listing o Education o Water and Sanitation o Durability of Housing o Malaria-related questions o Child Labour o Child Discipline o Disability o Salt Iodization Women Questionnaire: o Child Mortality o Tetanus Toxoid o Maternal and Newborn Health o Marriage and Union o Security of Tenure o Contraception o Attitudes Towards Domestic Violence o Female Genital Mutilation/Cutting o Sexual Behaviour o HIV Knowledge Men Questionnaire: o Marriage and Union o Sexual Behaviour o Contraception o HIV/AIDS and other Sexually Transmitted Infections (STIs) Under-five Questionnaire: o Birth Registration and Early Learning o Child Development o Vitamin A o Breastfeeding o Care of Illness o Malaria o Immunization o Anthropometry The questionnaires are based on the MICS model questionnaires2 and modified to fit the Ghanaian survey standards and conditions. The questionnaires were pre-tested in the Greater Accra Region in June 2006. The training for the pre-test was conducted by GSS staff for 22 interviewers for 13 days. This was followed by the formation of four teams consisting of a supervisor and four interviewers that conducted the pilot survey in four selected localities (2 urban and 2 rural) in the same region to test the entirety of survey procedures. 1 The terms “children under five”, “children age 0-4 years”, “under-fives”, and children age 0-59 months” are used interchangeably in this report. 2 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. 5 Based on the results of the pre-test and pilot, further modifications were made to wording and flow of the questions and the survey plan. A copy of the MICS 2006 questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine level, and measured the heights and weights of all children less than 5 years (0-59 months). Training and Fieldwork A total of 80 interviewers and 10 data entry operators participated in the main fieldwork training, conducted from 17th – 31st July, 2006. Data entry operators were invited to the main training to get a better understanding of the questionnaires and the survey techniques. The training included lectures on interviewing techniques, discussion of the questionnaires, and mock interviews among trainees to acquire skills in asking questions. All interviewers were further trained in testing iodine in salt and taking the height and weights of all under-five children. Towards the end of the training period, trainees spent three days conducting field interviews in 16 EAs (8 urban and 8 rural). Urban and rural areas were selected to provide the field staff a better understanding of working in different environments. Supervisors and interviewers were selected based on their performance in the field practices, participation in class, assessment tests and fluency in the Ghanaian languages. The data were collected by nine teams; each was comprised of four interviewers, one driver, one editor (who edited the questionnaires and took height and weight measurement) and a supervisor. Fieldwork began in August, 2006 and lasted for three months. Data Processing Data were captured using the CSPro software. The data were entered on 10 computers by 10 data entry operators and two data entry supervisors. In order to ensure quality control, all questionnaires were double entered and 4 secondary editors complemented the efforts of entry supervisors to perform internal consistency checks. Procedures and standard programmes developed under the global MICS Project and adapted to the Ghana questionnaire were used throughout the processing. Data processing began shortly after the commencement of fieldwork on 23rd August, 2006 and lasted for three months. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program and the model syntax and tabulation plans developed by UNICEF. 6 III. Sample Coverage and Characteristics This section presents information on the sample coverage, socio-economic and demographic characteristics of the household population, focusing on age, sex, region, place of residence, and socio-economic conditions of households. Sample Coverage and Response Rates Response rates are important as high non-response may affect the reliability of the survey results. Table HH.1 presents information on the results of the household and individual interviews. A total of 6,302 households were selected for the MICS. Of these, 6,264 were found to be occupied and interviews were completed for 5,939 households which represents a 95 percent response rate. A total of 6,240 women age (15-49) were identified from every selected household, while 1,909 eligible men (age 15-49) from every third selected household were identified for the individual interviews. Interviews were successfully completed for 5,891 women and 1,743 men, yielding response rates of 94 percent and 91 percent respectively. In addition, 3,545 children under five years were listed in the households. Questionnaires were completed for 3,466 children, corresponding to a response rate of 98 percent. Taking into account the non-response at the household level, the overall response rates for women, men and children under five were 90 percent, 87 percent and 93 percent respectively. Regional differentials in response rates regarding household interviews, eligible women, and children were similar (around 90 percent or higher). However, overall response rates for women, men and children varied slightly by place of residence. The response rates are higher for the rural than the urban sample and among women than men. The main reason for non- response among households and eligible individuals was the failure to find these individuals at home despite several visits to the households. 7 Table HH.1: Results of household and individual interviews Numbers of households, women, men, and children under five by results of the household, women's, men’s and under-five's interviews, and household, women's, men's and under-five's response rates, Ghana, 2006 Area Region Total Urban Rural Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Sampled households 2,480 3,822 580 520 861 480 641 940 480 710 580 510 6,302 Occupied households 2,470 3,794 577 520 856 478 637 936 476 706 574 504 6,264 Interviewed households 2,327 3,612 561 510 802 447 589 881 442 673 561 473 5,939 Household response rate 94.2 95.2 97.2 98.1 93.7 93.5 92.5 94.1 92.9 95.3 97.7 93.8 94.8 Eligible women 2,546 3,694 560 434 939 414 606 850 471 824 632 510 6,240 Interviewed women 2,385 3,506 537 426 859 375 565 808 452 790 598 481 5,891 Women response rate 93.7 94.9 95.9 98.2 91.5 90.6 93.2 95.1 96.0 95.9 94.6 94.3 94.4 Women's overall response rate 88.3 90.4 93.2 96.3 85.7 84.7 86.2 89.5 89.1 91.4 92.5 88.5 89.5 Eligible men 739 1,170 165 121 277 133 176 303 133 260 193 148 1,909 Interviewed men 660 1,083 154 118 237 117 163 272 120 248 179 135 1,743 Men response rate 89.3 92.6 93.3 97.5 85.6 88.0 92.6 89.8 90.2 95.4 92.7 91.2 91.3 Men's overall response rate 84.1 88.1 90.8 95.7 80.2 82.3 85.6 84.5 83.8 90.9 90.7 85.6 86.6 Eligible children under-five 1,030 2,515 319 263 330 245 346 426 245 595 399 377 3,545 Mother/Caretaker Interviewed 1,012 2,454 316 262 326 236 337 415 242 576 389 367 3,466 Child response rate 98.3 97.6 99.1 99.6 98.8 96.3 97.4 97.4 98.8 96.8 97.5 97.3 97.8 Children's overall response rate 92.6 92.9 96.3 97.7 92.6 90.1 90.1 91.7 91.7 92.3 95.3 91.4 92.7 8 Characteristics of Households The age and sex distribution of the survey population is presented in Table HH.2 and the population pyramid in Figure HH.1. The survey successfully interviewed 5,939 households, consisting of 24,947 household members of whom 12,176 were males and 12,771 females yielding an estimated average household size of 4.2 and a sex ratio of 95.3 (data not shown). The five-year age distribution for both sexes has a higher proportion of persons in the lower age groups (0-19 years) than for those in the higher age groups (20 and above) which is indicative of a youthful population. Table HH.2: Household population by age, sex and place of residence Percent distribution of household population by five-year age groups, according to sex and residence, Ghana 2006 Urban Rural Total Male Female Total Male Female Total Male Female Total Age-group 0-4 12.8 10.0 11.3 14.7 14.2 14.4 13.9 12.4 13.2 5-9 12.4 11.2 11.8 15.7 15.0 15.4 14.4 13.4 13.9 10-14 13.0 13.1 13.0 14.7 12.7 13.7 14.0 12.8 13.4 15-19 12.3 11.8 12.0 12.0 8.9 10.5 12.1 10.1 11.1 20-24 9.2 9.8 9.5 7.3 8.1 7.7 8.1 8.8 8.4 25-29 8.0 8.8 8.4 6.0 7.5 6.8 6.8 8.0 7.4 30-34 6.9 7.3 7.1 5.1 5.4 5.2 5.8 6.2 6.0 35-39 5.5 6.7 6.1 4.3 5.9 5.1 4.7 6.2 5.5 40-44 4.8 4.9 4.9 4.1 4.4 4.3 4.4 4.6 4.5 45-49 4.2 4.4 4.3 4.2 3.9 4.1 4.2 4.1 4.2 50-54 2.9 3.4 3.2 2.8 4.4 3.6 2.8 4.0 3.4 55-59 2.3 2.4 2.4 2.2 2.5 2.4 2.3 2.5 2.4 60-64 1.7 1.9 1.8 2.1 1.9 2.0 2.0 1.9 1.9 65-69 1.2 1.7 1.5 1.5 1.8 1.7 1.4 1.7 1.6 70-74 1.3 1.1 1.2 1.1 1.2 1.2 1.2 1.2 1.2 75-79 0.5 0.5 0.5 0.8 0.6 0.7 0.7 0.6 0.6 80+ 0.6 1.0 0.8 0.9 1.2 1.0 0.8 1.1 0.9 Missing/DK 0.3 0.2 0.2 0.5 0.3 0.4 0.4 0.3 0.3 Broad age groups <15 38.2 34.3 36.2 45.1 41.9 43.5 42.4 38.7 40.5 15-64 57.8 61.4 59.7 50.1 52.9 51.5 53.2 56.5 54.9 65+ 3.7 4.2 3.9 4.3 4.8 4.5 4.0 4.5 4.3 Missing/DK 0.3 0.2 0.2 0.5 0.3 0.4 0.4 0.3 0.3 Children aged 0-17 45.5 41.7 43.5 52.6 47.4 50.0 49.8 45.0 47.3 Adults 18+/Missing/ Don’t Know 54.5 58.3 56.5 47.4 52.6 50.0 50.2 55.0 52.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Census results have shown that the proportion of children less than 15 years remains more than 40 percent declining from 45.0 percent in 1984 to 41.3 percent in 2000. The MICS results further show that the proportion of children less than 15 years is 40.5 percent. This is consistent with the 2000 Population and Housing Census results. In spite of this slight reduction in the proportion of age 0-14 years old, the proportion is still high and has serious repercussions for social infrastructure as well as the economic development of the country. 9 Figure HH.1: Population Pyramid The dependent population (0-14 years and 65+) declined from 49.0 percent in 1984 to 47 percent in 2000 and further down to 45 percent in the MICS results. This translates into an age dependency ratio of 82 compared to 87 percent in 2000. Data from the MICS show an excess of children in the 5-9 age group and a deficit in the 0-4 year old age-group, probably due to preference for reporting age 5 and under-reporting for age 0-4 years. The sex composition of a population is influenced largely by the sex ratio at birth, differences between the sexes in death rates and differences between sexes in net migration (GSS 2005). In most populations, there is a slight excess of males than females at birth. This results in males usually outnumbering females at the younger ages while the reverse is true at the older ages due to higher male death rates at all ages. The results of the MICS are consistent with this observation. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, region, place of residence, number of household members, and households with at least one child (0-17 years) are shown in the table. 0 1 2 3 4 5 6 7 8012345678 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80+ Male Female Percent 10 The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The table also shows that 72 percent of households reported at least one child aged under 18 years and 40 percent have at least one child under five years. Living arrangements among society groups are largely influenced by socio-cultural factors such as kinship types, marriages, family and household formation. In Ghana, the structure, composition and size of households differ among the various ethnic groups. The sex of the head of household, size and household composition are important factors that have an impact on household welfare. Furthermore, the number of people who constitute a household can provide useful insights for policy-makers in ensuring equitable distribution of resources. At the national level, women head 29 percent of Ghanaian households, a pattern that is consistent with the 2000 Population and Housing Census (31 percent) and the 2003 Core Welfare Indicator Questionnaire (CWIQ) (29 percent) results. This may be influenced by the prevailing kinship and inheritance system in the country, i.e., the patrilineal and matrilineal. In the patrilineal system, inheritance and descent are traced from the father’s line and household heads are mostly men. In the matrilineal systems, inheritance is traced from the mother’s lineage, and a large proportion of households are headed by women. There are modest differences in female-headed households between urban (32 percent) and rural areas (26 percent) (data not shown). The most common household size is 4-5 household members, (29 percent of households), followed by 2-3 household members (26 percent). Single-member households constitute almost one in five households. Table HH.3: Household composition Percent distribution of households by selected characteristics, Ghana 2006 Weighted percent Number of households weighted Number of households unweighted Sex of household head Male 70.9 4,210 4,344 Female 29.1 1,730 1,595 Region Western 10.4 617 561 Central 9.7 576 510 Greater Accra 16.9 1,004 802 Volta 8.2 486 447 Eastern 12.8 758 589 Ashanti 16.6 988 881 Brong Ahafo 9.3 552 442 Northern 10.6 630 673 Upper East 3.4 202 561 Upper West 2.1 126 473 Residence Urban 45.3 2,692 2,327 Rural 54.7 3,247 3,612 Number of household members 1 17.8 1,057 966 2-3 26.2 1,558 1,445 4-5 28.6 1,696 1,715 6-7 17.1 1,018 1,096 8-9 6.5 386 430 10+ 3.8 224 287 At least one child aged < 18 years 72.2 5,939 5,939 At least one child aged < 5 years 40.0 5,939 5,939 At least one woman aged 15-49 years 72.1 5,939 5,939 Total 100.0 5,939 5,939 11 Characteristics of Respondents Tables HH.4, HH.4A and HH.5 provide information on the background characteristics of female and male respondents 15-49 years of age and of children under age 5. In all tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women, men and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female and male respondents 15-49 years of age. The table includes information on the distribution of women and men according to region, urban-rural areas, age, marital status, motherhood and parenthood status, education3, and wealth index quintiles4. The age distribution shows that 2 in 5 females (39 percent) and males (44 percent) are in the 15-24 age-group. While the proportion in each group tends to decrease with increasing age, the largest proportions are in the 15-19 and 20-24 age groups. Data show that 3 in 5 women (59 percent) and almost half of men (45 percent) are currently married or living together. One in two men has never been married compared to 3 in 10 women. Every 2 in 3 women have given birth at least once, compared to 1 in 2 men who have ever fathered a child. The distribution of respondents by urban-rural residence shows that men are slightly more likely to live in rural areas (56 percent) than women (53 percent). Regionally, the distribution of respondents varies significantly. For example, one-fifth of female respondents are from Greater Accra (19 percent) with 18 percent of men each from Greater Accra and Ashanti regions. Only 2 percent of respondents are from Upper West Region. Overall, men are more educated than women. Twenty-six percent of women and 15 percent of men have no education. About one-fifth of women and 15 percent of men have only primary education, and almost half of men (47 percent) have only middle/JSS level of education compared to almost 2 in 5 women (38 percent). Almost a quarter of men have attained secondary or higher levels of education, while only 16 percent of women have. Adult literacy is also an MDG indicator, relating to both men and women, and is an important background characteristic of respondents. In MICS, literacy was assessed on the ability of women and men to read a short simple statement or questions on school attendance. The questions on literacy were asked only of respondents who had not attended school or attended primary or middle/JSS only. The percent literate is presented in Table HH.4A. 3 Unless otherwise stated, “education”, when it is used as a background variable, refers to the highest educational level attended by the respondent. 4 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: Persons per sleeping room; type of floor, roof, wall, cooking fuel, and sanitary facility; household assets; and source of drinking water). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. 12 Just over half of women and close to 3 out of four of men are literate, hence men are more likely to be literate than women. There is a strong relationship between wealth and literacy levels. Ninety-five percent of men and 85 percent of women categorized in the richest wealth quintile are literate compared with only 18 percent of women and 32 percent of men in the poorest wealth quintile. Seventy percent of women and 87 percent of men in urban areas are literate, compared to smaller proportions in rural areas (42 percent of women and 61 percent of men). Regional variations in the level of literacy are marked, ranging from a high of 79 percent among women in Greater Accra to a low of 19 percent among women in the Upper West Region. Eighty- eight percent of men in Greater Accra Region are literate, compared with 36 percent in the Upper West Region. There is a marked difference between literacy in the three northern regions compared to the rest of Ghana. Table HH.4: Men’s and women's background characteristics Percent distribution of men and women aged 15-49 years by background characteristics, Ghana, 2006 Number of men and women Weighted percent Weighted Unweighted Background characteristic Men Women Men Women Men Women Region Western 10.1 10.1 176 593 154 537 Central 7.0 7.7 122 455 118 426 Greater Accra 17.8 19.1 311 1,125 237 859 Volta 7.7 7.2 135 426 118 375 Eastern 12.0 12.6 210 741 164 565 Ashanti 17.8 15.1 310 888 272 808 Brong Ahafo 8.8 9.7 154 569 120 452 Northern 13.2 12.6 231 745 247 788 Upper East 3.5 3.7 62 218 178 598 Upper West 2.0 2.2 35 130 134 481 Residence Urban 44.0 47.1 767 2,775 659 2,385 Rural 56.0 52.9 977 3,115 1,083 3,504 Age 15-19 27.0 20.6 471 1,218 475 1,200 20-24 16.6 18.3 290 1,075 279 1,009 15-24 43.6 38.9 761 2,293 754 2,209 25-29 14.3 16.8 249 987 247 960 30-34 13.1 13.2 229 777 223 828 35-39 10.4 12.7 181 746 184 760 40-44 9.4 9.8 164 577 170 583 45-49 9.2 8.6 160 509 164 549 Marital/Union status Currently married/in union 44.7 58.8 778 3,465 802 3,627 Formerly married/in union 7.2 11.0 126 648 117 573 Never married/in union 48.1 30.2 837 1,778 821 1,689 Parenthood status Ever had a child 46.6 66.9 812 3,939 823 4,038 Never had a child 53.4 33.1 932 1,951 919 1,851 Education None 14.5 26.3 253 1,549 337 2,026 Primary 15.2 19.7 265 1,162 291 1,108 Middle/JSS 46.7 38.0 816 2,237 728 1,924 Secondary + 23.6 15.9 411 937 386 827 Wealth index quintiles Poorest 18.0 16.2 313 954 434 1,363 Second 16.5 17.6 287 1,037 339 1,217 Middle 18.9 19.5 330 1,149 286 995 Fourth 23.8 22.0 415 1,298 349 1,087 Richest 22.9 24.6 400 1,451 334 1,227 Total 100.0 100.0 1,745 5,890 1,742 5,889 13 Some background characteristics of children under-five are presented in Table HH.5. These include distribution of children by sex, age in months, region and place of residence, mother’s or caretaker’s education, and wealth index quintiles. Among children under age 5, there are slightly more boys than girls. Children are evenly divided in each of the 5 one-year age groups (one-fifth in each). The first year (0-11 months) has been split into two (<6 and 6-11 months) reporting 11 percent and 10 percent respectively. Sixty-four percent of the children under five live in rural areas while 36 percent live in urban areas. The largest proportions of children reside in Northern (17 percent) and Ashanti (15 percent) Regions, while the smallest proportions are in the Upper West (3 percent) and Upper East (4 percent) Regions. Table HH.4A: Adult literacy Percentage of women and men aged 15-49 years that are literate’, Ghana, 2006 Men Women Percentage literate* Number of men aged 15-49 years Percentage literate* Number of women aged 15- 49 years Region Western 79.3 176 61.2 593 Central 73.8 122 53.9 455 Greater Accra 88.0 311 78.5 1,125 Volta 69.4 135 48.9 426 Eastern 76.3 210 58.7 741 Ashanti 83.9 310 65.9 888 Brong Ahafo 79.6 154 57.8 569 Northern 39.0 231 19.4 745 Upper East 39.3 62 21.0 218 Upper West 36.2 35 18.7 130 Residence Urban 86.9 767 70.4 2,775 Rural 61.3 977 42.0 3,115 Education None 0.0 253 0.1 1,549 Primary 14.9 265 7.5 1,162 Middle/JSS 100.0 816 100.0 2,237 Secondary+ 100.0 411 100.0 937 Age 15-19 73.3 471 71.0 1,218 20-24 78.9 290 64.3 1,075 25-29 76.8 249 52.4 987 30-34 68.5 229 48.4 777 35-39 67.9 181 44.5 746 40-44 70.8 164 47.8 577 45-49 65.3 160 40.4 509 Wealth index quintiles Poorest 32.3 313 17.5 954 Second 58.0 287 36.6 1,037 Middle 78.8 330 51.0 1,149 Fourth 86.6 415 69.5 1,298 Richest 94.9 400 84.6 1,451 Total 72.6 1,745 55.4 5,890 ‘ Percentage of respondents who are able to read a short simple statement about every day life or who attended secondary or higher education. * MICS indicator 60; MDG indicator 7 ** The percentage not known includes those for whom no sentence in the required language was available or for whom no response was reported. 14 Table HH.5: Children's background characteristics Percent distribution of children under five years of age by background characteristics, Ghana, 2006 Background characteristic Urban Rural Total Number of children weighted Number of children unweighted Sex Male 53.6 50.5 51.6 1,789 1,781 Female 46.4 49.5 48.4 1,678 1,687 Region Western 8.2 11.0 10.0 347 316 Central 8.9 8.6 8.7 302 262 Greater Accra 30.8 3.0 12.9 448 326 Volta 4.5 9.2 7.5 261 236 Eastern 9.3 15.6 13.3 463 337 Ashanti 20.2 11.5 14.6 506 415 Brong Ahafo 8.9 9.0 9.0 311 242 Northern 6.8 22.1 16.7 579 578 Upper East 1.2 5.9 4.2 146 389 Upper West 1.2 4.0 3.0 105 367 Age < 6 months 12.0 10.5 11.1 383 384 6-11 months 8.3 10.3 9.6 332 328 12-23 months 19.2 21.0 20.4 706 715 24-35 months 20.4 18.6 19.2 667 664 36-47 months 23.0 19.5 20.7 718 728 48-59 months 17.2 20.1 19.1 661 649 Mother's/caretaker’s education None 23.6 47.1 38.7 1,343 1,677 Primary 21.2 22.0 21.7 753 672 Middle/JSS 40.3 27.8 32.3 1,120 902 Secondary+ 14.8 3.0 7.2 251 217 Wealth index quintiles Poorest 1.5 34.4 22.7 786 1,035 Second 6.9 33.4 23.9 830 922 Middle 20.5 19.3 19.7 684 575 Fourth 32.3 10.0 18.0 623 503 Richest 38.8 2.9 15.7 544 433 Total 35.7 64.3 100.0 3,467 3,468 Mothers or caretakers of 2 in 5 children have no education, a fifth of mothers or caretakers of children under the age of 5 have only primary education and one third have attained middle/JSS levels. Only seven percent of mothers/caretakers of children under the age of 5 years have attained secondary or higher education. Sixteen percent of children live in the richest households, while approximately 47 percent of children under five come from households in the two poorest quintiles. 15 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from women’s birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that can be comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. The infant mortality rate is the probability of dying before the first birthday and the under- five mortality rate is the probability of dying before the fifth birthday. In MICS surveys, infant and under-five mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). The data used in the estimation are: the mean number of children ever born for five-year age groups of women from age 15 to 49, and the proportion of these children who are dead, also for five-year age groups of women. The technique converts these data into probabilities of dying by taking Box CH.1: Mortality estimates - Direct vs. Indirect method How do we measure it? - Vital registration - Population census - Data from birth histories as from DHS - Data from “Brass methods” as from MICS What is the birth history method? - The name comes from the exercise; all surveyed women provide detailed information on all their births, creating a birth history. - All children are recorded whether dead or alive, by name, sex, birthday, and if dead, the date of death. - With an appropriate sample size, the mortality rates in five-year intervals preceding the survey can be directly derived. This is called direct estimation. - The mid-point of the interval is called the reference point. The reference point for the birth history for the most recent five-year period is then 2.5 years before the fieldwork of the survey. What is the Brass method? - William Brass was the first to develop a procedure for converting the proportion dead of children ever born, reported by women in age groups 15-19, 20-24, etc., into estimates of the probability of dying before attaining certain exact childhood ages. The method has been refined over the years. - All births are recorded and sorted as living and dead, by sex and by other relevant variables. - By using a complex model with country specific variations, the mortality rate estimates are indirectly derived. - The most recent and statistically sound reference point is about 6 years before the survey fieldwork. What has been done in Ghana? - Four DHS have been conducted, all using birth histories. The latest was conducted in mid-2003. This gives a reference point of early 2001. - The MICS of 2006 presents a reference point just a few months before, i.e. estimating the mortality at the same time as the GDHS. The so- called ‘North’-model of indirect estimation (a Brass-type model) has been recommended and applied. Besides the technical model, it implies using the average mortality estimates based on 25-34 year old women. - Mortality is the only result from MICS 2006 that has such a long time span, i.e. all other results are dated as of 2006. You may read the timeframe of each indicator is indicated in its table title. - MICS 2006 doubled the sample size of the three northern regions compared to GDHS 2003 to get better confidence intervals at regional level. All survey data come with a confidence interval. - At national level the GDHS2003 U5MR was recorded at 111. One may ‘confidently’ say that with 95 percent certainty the U5MR was between 99 and 123. - At regional level, the sample is smaller resulting in higher confidence intervals. The GDHS 2003 U5MR for Upper East was recorded as 79. The interval for this figure is 45 to 112. In MICS2006 the U5MR for Upper East Region is estimated at 106, which is one third higher than the estimate from GDHS 2003. Apart from measuring a shorter time-span and with a different methodology, the result is within the confidence interval of GDHS 2003. 16 into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Ghana, the North model life table was selected as most appropriate. These estimates were calculated by averaging mortality estimates obtained from women age 25-29 and 30-34, with the reference point around mid-2001. Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the mortality rates for the national total. The infant mortality rate is estimated at 71 deaths per 1,000 live births while the under-five mortality rate is 111 deaths per 1,000 births. This means that one in nine children born in Ghana dies before its fifth birthday and approximately two-thirds of all these deaths occur during their first year of life. There seems to be a marked difference between the probabilities of dying among males and females. The under-five mortality rate experienced by female children (89 deaths per 1,000 live births) is about two-thirds of what is experienced by male children (131 deaths per 1,000) of the same cohort. The biological advantage enjoyed by female children over male children in the first few years of life may account for this. Mortality among rural children is consistently higher than that for urban children with respect to both infant and under-five mortality. At the regional level, differences in mortality are also quite marked, although these figures, in particular, should be interpreted with caution since sampling errors associated with mortality estimates at regional disaggregation are large. The infant mortality rate varies from 45 to 114 deaths per 1,000 live births. Infant and under-5 mortality rates are lowest in the Western Region (infant, 45 per 1,000 live births; under-5, 66 per 1,000 live births), while the figures for Upper West Region (infant, 114 per 1,000 live births; under- 5, 191 per 1,000 live births) are almost three times higher than Western Region. There are also significant differences in mortality in terms of mothers’ educational level and socio-economic status of the household in general. Children of mothers with no education Table CM.1: Child mortality Infant and under-five mortality rates, Ghana, 2006 Background characteristic Infant mortality rate* Under-five mortality rate** Sex Male 84 131 Female 56 89 Region Western 45 66 Central 69 108 Greater Accra 60 92 Volta 57 86 Eastern 61 93 Ashanti 72 113 Brong Ahafo 88 142 Northern 83 133 Upper East 68 106 Upper West 114 191 Residence Urban 68 106 Rural 72 114 Mother's/Caretaker’s education None 78 124 Primary 65 102 Middle/JSS 52 77 Secondary+ 65 101 Wealth index quintiles Poorest 75 118 Second 79 126 Middle 65 100 Fourth 65 101 Richest 64 100 Total 71 111 * MICS indicator 2; MDG indicator 14 ** MICS indicator 1; MDG indicator 13 17 are more likely to die in infancy (78 deaths per 1,000 live births) than children of women with some form of education (52 to 65 deaths per 1,000 live births). Contrary to expectation, children of mothers with middle school or JSS education have lower mortality then children whose mothers have secondary education. This is likely attributed to the large confidence intervals associated with the rates among women with higher education, due to only 16 percent of all women sampled with secondary or higher education and this finding should be treated with caution. There are also differences in mortality in terms of wealth index quintile. In particular, the probabilities of dying among children living in the richest 60 percent of households are lower than the national average. Differentials in under-5 mortality rates by background characteristics are shown in Figure CM.1. Table CM.2: Children ever born and proportion dead Mean number of children ever born, children surviving and proportion dead by age of women, Ghana, 2006 Mean number of children ever born Mean number of children surviving Proportion dead Number of women Age 15-19 0.099 0.089 0.099 1,218 20-24 0.843 0.760 0.099 1,075 25-29 1.927 1.725 0.105 987 30-34 3.228 2.889 0.105 777 35-39 4.288 3.743 0.127 746 40-44 5.229 4.543 0.131 577 45-49 5.575 4.716 0.154 509 Total 2.461 2.154 0.125 5,890 Figure CM.1: Infant and under-five mortality rates by sex and area, Ghana, 2006 71726856 84 111114 106 89 131 0 25 50 75 100 125 150 Male Female Urban Rural Ghana Deaths per 1,000 live births 0 25 50 75 100 125 150 Infant mortality rate Under-five mortality rate 18 V. Nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are well-nourished. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Undernutrition in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization. Each of the three nutritional status indicators comprising weight-for- age, height-for-age and weight-for-height gives different information about growth and body composition. They are used to assess nutritional status and can be expressed in standard deviation units (Z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight- for-age is below minus two standard deviations (-2 SD) from the median of the reference population are considered as underweight, while those whose weight-for-age is less than minus three standard deviations (-3 SD) from the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age and are classified as stunted. Those whose height-for-age is below minus three standard deviations (-3 SD) from the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and/or recurrent chronic illness. Children whose weight-for-height is below minus two standard deviations (-2 SD) from the median of the reference population are classified as wasted, while those who fall below minus three standard deviations (-3 SD) from the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Table NU.1 shows the percentage of children under five years classified as malnourished according to the three categories, by background characteristics using the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children whose weight-for-height is above plus two standard deviations (+2 SD) from the median of the reference population and are classified as overweight. Almost one in five children under age five in Ghana is underweight (18 percent) and 3 percent are classified as severely underweight (Table NU.1). Nearly a quarter of children (22 percent) are stunted or too short for their age and 5 percent are wasted or too thin for their height. 19 Table NU.1: Child malnutrition Percentage of under-five children who are severely or moderately undernourished, Ghana, 2006 Weight for age Height for age Weight for height Background characteristic Percent below -2 SD* Percent below -3 SD Percent below -2 SD** Percent below -3 SD Percent below -2 SD*** Percent below -3 SD Percent above +2 SD Number of children Sex Male 18.3 3.4 23.0 7.4 5.6 1.0 1.0 1,642 Female 17.1 2.8 21.7 7.2 5.1 0.7 1.7 1,523 Region Western 14.6 1.1 20.7 5.5 6.5 0.5 0.9 326 Central 16.3 1.6 26.4 4.6 3.7 0.0 1.6 267 Greater Accra 7.7 1.7 9.8 2.7 3.1 1.1 1.3 406 Volta 20.3 5.4 20.9 8.1 4.8 2.1 0.4 231 Eastern 17.8 3.3 22.0 9.1 4.4 0.3 0.7 430 Ashanti 17.3 2.6 22.6 6.8 5.9 0.8 1.5 468 Brong Ahafo 13.3 1.7 22.2 4.9 3.1 0.5 3.5 288 Northern 26.8 5.9 30.5 12.4 7.1 1.1 1.1 529 Upper East 29.1 5.9 28.4 12.4 11.6 2.8 1.6 127 Upper West 19.1 2.6 22.5 6.0 7.7 0.3 1.4 94 Residence Urban 11.5 1.8 13.2 3.4 4.9 1.0 1.7 1,159 Rural 21.4 3.9 27.8 9.6 5.7 0.8 1.1 2,006 Age < 6 months 2.4 0.7 5.0 1.6 3.9 0.1 5.5 361 6-11 months 18.2 3.8 8.6 2.7 8.7 1.6 1.2 322 12-23 months 28.1 4.3 27.6 8.0 11.1 1.3 1.2 667 24-35 months 22.1 5.3 28.1 10.0 4.1 1.2 0.3 632 36-47 months 15.7 2.6 25.2 8.9 2.4 0.7 0.3 629 48-59 months 12.5 1.2 26.0 8.2 2.3 0.2 1.2 554 Mother's/Caretaker’s education None 23.2 4.8 29.9 11.3 6.2 1.1 1.1 1,210 Primary 16.7 2.8 20.1 6.0 6.1 1.1 0.8 693 Middle/JSS 14.1 2.2 18.2 5.1 4.3 0.5 1.9 1,038 Secondary+ 8.1 0.0 8.7 0.9 3.7 0.6 1.8 225 Wealth index quintiles Poorest 24.8 5.1 30.9 12.0 6.7 1.1 1.5 685 Second 21.3 3.8 29.4 10.7 5.5 0.8 1.3 763 Middle 19.8 3.1 23.0 5.6 5.6 0.6 0.3 626 Fourth 11.2 2.0 15.5 3.9 4.8 0.7 1.8 594 Richest 7.8 0.9 7.4 2.0 3.6 1.1 1.9 498 Total 17.8 3.1 22.4 7.3 5.4 0.9 1.3 3,166 * MICS indicator 6; MDG indicator 4 ** MICS indicator 7 *** MICS indicator 8 ‘ Includes children who are below -3 standard deviations (SD) of the NCHS/CDC/WHO International Reference Population median. Table NU. 1 shows that children in the Upper East and Northern regions are more likely to be underweight, stunted and wasted, than children in other regions. Additionally, the percentage of children who are underweight and stunted is higher in the rural than the urban area. Children whose mothers have secondary or higher education are the least likely to be underweight (8 percent) and stunted (9 percent) compared to children of mothers with no education. The age pattern shows that a higher percentage of children aged 12-23 months are undernourished in comparison to children who are younger and older (Figure NU.1). This indicates that malnutrition peaks at this age band, which could be attributed to poor feeding practices that lead to inadequate food intake. This pattern is expected and is related 20 to the age at which many children cease to be breastfed (weaning period) and are exposed to contamination in water, food, and the environment. Overweight is not a problem among children under five in Ghana (1 percent). Figure NU.1: Percentage of children under-5 who are undernourished, Ghana, 2006 0 5 10 15 20 25 30 0 6 12 18 24 30 36 42 48 54 60 Age (in months) Percent Underweight Stunted Wasted Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The World Health Organization (WHO) recommends that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. Table NU.2 provides information on the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). 21 The data indicate that nearly 3 in 4 women in Ghana breastfeed their children within one day of birth and a little over a third start breastfeeding within one hour of birth. Initiation of breastfeeding varies among regions. The proportion of infants that are breastfed within one hour of birth ranges from 17 percent in the Eastern Region to 46 percent in Greater Accra. Brong Ahafo has the lowest percentage of infants who started breastfeeding within one day of birth (63 percent), while Upper East (83 percent) has the highest. Women with secondary education or higher are more likely to breastfeed their children within one hour of birth (49 percent) than women with no education (36 percent). Initiation of breastfeeding within one day of birth increased with mothers’ level of education and wealth quintiles. The practice increases from 67 percent among infants of women in the poorest wealth quintile to 79 percent among infants of women in the highest quintile. In Table NU.3, breastfeeding status is based on reports children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows the practise of exclusive breastfeeding of infants during the first six months of life separately for 0-3 months and 0-5 months. It also describes complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 months and 20-23 months of age. Fifty-four percent of children aged less than six months are being exclusively breastfed and the percentage is higher (65) for children 0-3 months (Table NU.3). Girls are slightly less likely to be exclusively breastfed than boys. Among children age 6-9 months, 59 percent are receiving breast milk and solid or semi-solid foods. At age 12-15 months, 95 percent of children are still being breastfed. This decreases to 56 percent by age 20-23 months. Table NU 2: Initiation of breastfeeding Percentage of women aged 15-49 years with a birth in the 2 years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Ghana, 2006 Background characteristic Percentage who started breastfeeding within one hour of birth* Percentage who started breastfeeding within one day of birth Number of women with live birth in the two years preceding the survey Region Western 43.4 72.3 144 Central 39.4 79.7 105 Greater Accra 46.3 80.2 167 Volta 19.9 68.3 97 Eastern 17.3 74.9 182 Ashanti 34.9 65.5 207 Brong Ahafo 25.0 63.0 107 Northern 45.0 75.2 260 Upper East 36.4 83.2 58 Upper West 28.5 46.6 37 Residence Urban 39.1 77.9 468 Rural 33.1 69.6 897 Months since last birth < 6 months 34.4 71.1 364 6-11 months 30.9 76.0 319 12-23 months 37.1 71.2 651 Mother's/Caretaker’s Education None 35.9 70.9 503 Primary 32.5 71.5 300 Middle/JSS 33.3 73.8 465 Secondary+ 48.6 76.7 97 Wealth index quintiles Poorest 38.8 67.4 313 Second 24.6 69.2 325 Middle 30.1 71.7 260 Fourth 38.1 78.1 267 Richest 49.4 79.1 199 Total 35.2 72.5 1,365 * MICS indicator 45 22 Table NU.3: Breastfeeding Percent of living children according to breastfeeding status at each age group, Ghana, 2006 Children 0-3 months Children 0-5 months Children 6-9 months Children 12-15 months Children 20-23 months Background characteristic Percent exclusively breastfed Number of children Percent exclusively breastfed * Number of children Percent receiving breastmilk and solid/mushy food ** Number of children Percent breastfed*** Number of children Percent breastfed *** Number of children Sex Male 64.2 113 52.8 202 63.5 125 96.6 112 55.4 106 Female 65.9 106 56.1 181 53.0 107 92.6 121 56.7 116 Residence Urban 68.4 89 59.9 148 66.3 73 85.6 70 34.2 72 Rural 62.7 130 50.9 235 55.2 159 98.4 163 66.6 150 Mother's/Caretaker’s education None 68.8 91 61.1 135 45.8 86 94.9 87 73.3 84 Primary (65.3) 42 53.3 73 62.4 63 95.0 62 (58.0) 38 Middle/JSS 60.7 77 51.2 143 68.8 74 96.9 71 41.8 86 Secondary+ * 10 (43.2) 32 * 10 * 13 * 14 Wealth index quintiles Poorest (76.2) 44 60.8 80 40.4 55 97.5 58 (75.5) 49 Second 53.1 58 45.3 100 58.6 57 97.9 51 65.1 51 Middle (60.6) 42 54.1 63 (73.9) 40 (100.0) 46 (66.3) 47 Fourth (64.8) 46 51.6 81 60.1 54 (85.6) 44 (33.1) 48 Richest (78.5) 29 64.9 59 (71.2) 26 (88.7) 34 (27.2) 27 Total 65.0 219 54.4 383 58.7 232 94.6 233 56.1 222 * MICS Indicator 15; ** MICS Indicator 17; *** MICS Indicator 16 An asterisk ‘*’ indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parenthes es ‘( )’ are based on 25 – 49 unweighted cases. 23 Figure NU.2 shows the detailed pattern of breastfeeding by age in months. Even at the earliest ages, many children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is below 12 percent. Only about 20 percent of children are receiving breast milk after 2 years. Figure NU.2: Infant feeding patterns by age. Percent distribution of children aged under 3 years by feeding pattern by age group, Ghana, 2006 0 10 20 30 40 50 60 70 80 90 100 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 24-25 26-27 28-29 30-31 32-33 34-35 Age (in Months) Percent Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed Information on adequacy of infant feeding in children less than 12 months old is provided in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they are receiving breast milk and complementary food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they are receiving breast milk and eating complementary food at least three times a day. Fifty-four percent (54 percent) of infants age 0-5 months and 9-11 months respectively are considered adequately fed. Compared to these age groups, only 50 percent of children aged 6-11 months are being adequately fed. Overall, 52 percent of children aged 0-11 months are appropriately fed based on the age-specific feeding recommendations. With regard to background characteristics of mother, those with middle/JSS education are more likely to feed their children adequately compared to other groups. 24 Table NU.4: Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6-11 months who are breastfed and who ate solid / semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, Ghana, 2006 Background characteristic 0-5 months exclusively breastfed Number of children 0- 5 months 6-8 months who received breastmilk and complementary food at least 2 times in prior 24 hours Number of children 6-8 months 9-11 months who received breastmilk and complementary food at least 3 times in prior 24 hours Number of children 9- 11 months 6-11 months who received breastmilk and complementary food at least the minimum recommended number of times per day* Number of children 6- 11 months 0-11 months who were appropriately fed** Number of infants aged 0- 11 months Sex Male 52.8 202 49.8 91 52.0 75 50.8 166 51.9 368 Female 56.1 181 37.6 71 56.2 95 48.2 166 52.3 348 Residence Urban 59.9 148 46.7 57 (60.6) 45 52.9 102 57.0 251 Rural 50.9 235 43.2 106 52.1 124 48.0 230 49.5 465 Mother's/Caretaker’s education None 61.1 135 40.4 62 50.9 60 45.6 122 53.7 257 Primary 53.3 73 (46.3) 44 (40.0) 38 43.4 82 48.0 155 Middle/JSS 51.2 143 50.2 51 65.7 56 58.2 107 54.2 250 Secondary* (43.2) 32 * 6 * 15 * 21 46.6 53 Wealth index quintiles Poorest 60.8 80 (39.0) 36 (43.8) 43 41.6 80 51.3 160 Second 45.3 100 (44.3) 41 (59.6) 44 52.2 85 48.5 184 Middle 54.1 63 (68.7) 30 (55.1) 28 62.2 58 58.0 121 Fourth 51.6 81 (31.4) 37 (55.0) 33 42.5 70 47.4 151 Richest 64.9 59 * 18 * 22 (53.4) 40 60.3 99 Total 54.4 383 44.4 162 54.4 169 49.5 332 52.1 715 * MICS indicator 18 ** MICS indicator 19 An asterisk ‘*’ indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses ‘( )’ are based on 25 – 49 unweighted cases. 25 Salt Iodization Iodine Deficiency Disorder (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth, neonatal mortality and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and work performance. The international goal was to achieve sustainable elimination of iodine deficiency by 2005 by encouraging people to use salt that is fortified with iodine. The indicator is the percentage of households consuming adequately iodised salt (>15 parts per million). Calculation of the percentage of households consuming iodised salt is done using two different methodologies. The MICS approach factors in households without salt in the denominator, whereas the DHS approach does not. Both results are shown below, the MICS estimate in Table NU.5 and the DHS estimate in NU.5A. For direct comparison to GDHS 2003 one should use Table NU.5A and similarly, for comparison to other MICS countries, Table NU.5 should be used. It can be observed that the two methodologies do not produce significantly different results. Table NU.5: Iodized salt consumption (MICS) Percentage of households consuming adequately iodized salt, Ghana, 2006 Percent of households with salt test result Background characteristic Percent of households in which salt was tested Number of households interviewed Percent of households with no salt Not iodized 0 < 15 PPM 15+ PPM* Total Number of households in which salt was tested or with no salt Region Western 89.9 617 8.4 39.9 11.6 40.0 100.0 606 Central 88.3 576 11.1 48.4 23.9 16.7 100.0 571 Greater Accra 88.9 1,004 10.4 19.2 21.2 49.3 100.0 997 Volta 93.5 486 6.0 77.9 4.0 12.0 100.0 483 Eastern 93.5 758 6.1 58.6 16.4 18.9 100.0 754 Ashanti 89.3 988 9.8 23.1 19.4 47.7 100.0 978 Brong Ahafo 91.9 552 7.3 17.7 22.2 52.8 100.0 546 Northern 97.3 630 2.7 71.1 14.8 11.4 100.0 630 Upper East 94.8 202 4.6 61.7 21.5 12.3 100.0 201 Upper West 97.8 126 1.8 18.1 59.2 20.8 100.0 126 Residence Urban 88.2 2,692 11.0 26.5 17.9 44.6 100.0 2,668 Rural 94.3 3,247 5.1 53.9 18.8 22.2 100.0 3,225 Education of household head None 94.6 1,830 4.5 57.2 20.4 17.8 100.0 1,813 Primary 92.2 802 7.5 50.1 20.8 21.5 100.0 800 Middle/JSS 89.8 2,203 9.4 35.5 19.5 35.6 100.0 2,183 Secondary+ 89.5 1,104 9.9 21.1 11.1 57.8 100.0 1,097 Wealth index quintiles Poorest 96.2 949 3.4 69.8 19.8 6.9 100.0 946 Second 94.5 1,147 5.1 56.1 21.6 17.2 100.0 1,141 Middle 90.0 1,285 9.0 45.6 20.0 25.4 100.0 1,271 Fourth 88.0 1,341 11.3 31.1 17.2 40.4 100.0 1,330 Richest 90.7 1,217 8.4 12.5 13.9 65.2 100.0 1,205 Total 91.5 5,939 7.7 41.5 18.4 32.4 100.0 5,893 *MICS indicator 41 26 In Ghana, the campaign on iodised salt consumption is one of the programmes aimed at reducing micronutrient deficiencies among young children and women. According to data in Table NU.5A, salt used for cooking was tested in 92 percent of households interviewed in the MICS 2006 sample. The salt was tested for iodine content by using salt test kits and testing for the presence of potassium iodide and potassium iodate. Only in 8 percent of the households there was no salt available. For 35 percent of households tested, salt was found to contain 15 parts per million (ppm) or more of iodine, and in 1 in 5 households, less than 15 parts per million (ppm). In 45 percent of households tested, salt was not iodized. Use of salt with 15 or more ppm was lowest in Northern, Volta, and Upper East regions (around 12 percent), and highest in Brong Ahafo, Greater Accra and Ashanti regions (around 55 percent). The likelihood of using adequately iodized salt is twice as high in urban areas compared to rural areas. Table NU.5A: Iodized salt consumption (DHS) Percentage of households consuming adequately iodized salt, Ghana, 2006 Percent of households with salt test result Background characteristic Percent of households in which salt was tested Number of households interviewed Not iodized <15 PPM 15+ PPM Total Number of households in which salt was tested Region Western 89.9 617 43.6 12.7 43.7 100.0 555 Central 88.3 576 54.4 26.9 18.8 100.0 508 Greater Accra 88.9 1,004 21.4 23.7 55.0 100.0 893 Volta 93.5 486 82.9 4.3 12.8 100.0 454 Eastern 93.5 758 62.4 17.5 20.1 100.0 708 Ashanti 89.3 988 25.6 21.5 52.9 100.0 882 Brong Ahafo 91.9 552 19.1 24.0 56.9 100.0 507 Northern 97.3 630 73.0 15.2 11.7 100.0 613 Upper East 94.8 202 64.6 22.5 12.9 100.0 192 Upper West 97.8 126 18.4 60.3 21.2 100.0 124 Residence Urban 88.2 2,692 29.8 20.1 50.1 100.0 2,375 Rural 94.3 3,247 56.8 19.8 23.4 100.0 3,061 Education of household head None 94.6 1,830 60.0 21.4 18.6 100.0 1,731 Primary 92.2 802 54.2 22.5 23.3 100.0 740 Middle/JSS 89.8 2,203 39.2 21.5 39.3 100.0 1,978 Secondary+ 89.5 1,104 23.4 12.3 64.2 100.0 987 Wealth index quintiles Poorest 96.2 949 72.3 20.5 7.2 100.0 913 Second 94.5 1,147 59.1 22.8 18.2 100.0 1,083 Middle 90.0 1,285 50.2 21.9 27.9 100.0 1,156 Fourth 88.0 1,341 35.1 19.4 45.5 100.0 1,180 Richest 90.7 1,217 13.6 15.2 71.2 100.0 1,104 Total 91.5 5,939 45.0 19.9 35.1 100.0 5,436 27 Figure NU.3: Percentage of households consuming adequately iodized salt by region, Ghana, 2006 12 13 13 20 21 35 44 53 55 57 19 0 10 20 30 40 50 60 Northern Volta Upper East Central Eastern Upper West Ghana Western Ashanti Greater Accra Brong Ahafo Note: Figure is based on Table NU.5A (DHS) Vitamin A Supplements Vitamin A is an essential micronutrient for the normal functioning of the eye, resistance to diseases and proper functioning of the immune system. It is found in foods such as liver, eggs, red and orange coloured fruits, palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. Providing young children with two high dose vitamin A capsules a year is a safe, cost- effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of vitamin A, which are depleted during pregnancy and lactation. Within the six months prior to the MICS, 60 percent of children aged 6-59 months received a high dose Vitamin A supplement (Table NU.6). A quarter of the children (26 percent) did not receive the supplement in the last 6 months but did receive one prior to that time. Seven percent of children never received a Vitamin A supplement and five percent received one but mothers were not sure when. There are markedly regional differences in Vitamin A supplementation coverage in the 6 months prior to survey ranging from 33 percent in Greater Accra Region to 76 percent in the Brong Ahafo region. The age pattern of Vitamin A supplementation shows that supplementation in the last six months rises from 63 percent among children aged 6-11 months to 68 percent among children aged 12-23 months and then declines steadily with age to 54 percent among the oldest group age 48-59 months. 28 Mother’s or caretaker’s level of education is usually positively related to the likelihood of receiving Vitamin A supplementation but in the MICS 2006, the results say otherwise. The percentage receiving a supplement in the last six months decreases from children whose mothers have no education or have middle/JSS level of education (62 percent) to 57 percent of those whose mothers have primary education and 53 percent among children of mothers with secondary or higher education. Table NU.6: Children's vitamin A supplementation Percent distribution of children aged 6-59 months by whether they received a high dose Vitamin A supplement in the last 6 months, Ghana, 2006 Percent of children who received Vitamin A: Background characteristic Within last 6 months* Prior to last 6 months Not sure when Not sure if received Never received Vitamin A Total Number of children aged 6-59 months Sex Male 59.5 25.9 5.7 1.5 7.4 100.0 1,587 Female 60.8 25.7 4.9 1.5 7.0 100.0 1,496 Region Western 63.2 21.7 7.5 2.6 5.0 100.0 301 Central 53.5 38.2 0.8 1.9 5.7 100.0 265 Greater Accra 33.4 58.8 4.2 0.1 3.5 100.0 396 Volta 62.7 20.8 6.5 2.4 7.5 100.0 237 Eastern 63.0 27.5 1.2 2.0 6.4 100.0 422 Ashanti 70.7 17.7 2.9 1.5 7.2 100.0 452 Brong Ahafo 75.9 12.9 0.4 0.5 10.2 100.0 273 Northern 60.8 14.7 13.5 1.3 9.7 100.0 512 Upper East 58.1 22.0 5.8 2.1 12.0 100.0 133 Upper West 66.8 11.9 11.6 1.0 8.9 100.0 93 Residence Urban 55.1 34.9 3.8 1.1 5.0 100.0 1,088 Rural 62.9 20.8 6.2 1.7 8.4 100.0 1,996 Age 6-11 months 62.8 5.2 2.8 2.8 26.4 100.0 332 12-23 months 67.5 22.3 3.9 0.8 5.6 100.0 706 24-35 months 62.9 26.1 5.8 0.7 4.5 100.0 667 36-47 months 55.2 32.7 5.5 1.0 5.5 100.0 718 48-59 months 53.7 32.1 7.3 2.9 3.9 100.0 661 Mother's/Caretaker’s education None 61.8 21.1 7.3 1.6 8.2 100.0 1,208 Primary 57.4 28.4 3.6 2.2 8.3 100.0 680 Middle/JSS 61.7 27.8 3.6 1.1 5.8 100.0 977 Secondary+ 52.9 34.7 7.1 0.7 4.7 100.0 219 Total 60.2 25.8 5.3 1.5 7.2 100.0 3,084 * MICS indicator 42 29 As seen from Table NU.7, one in 2 mothers with a birth in the two years before the MICS received a vitamin A supplement within eight weeks of the birth. This percentage is highest in the Ashanti Region (68 percent) and lowest in the Eastern and Northern regions at 36 percent and 38 percent respectively. The likelihood of Vitamin A supplementation increases with the education of the mother or other caretaker from 47 percent among women with no education to 71 percent among women with secondary or higher education. Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) makes a child susceptible to a range of grave health risks. Babies who were undernourished in the womb face an increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and may suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. Table NU.7: Post-partum Vitamin A supplementation Percentage of women aged 15-49 years with a birth in the 2 years preceding the survey who received a high dose Vitamin A supplement before the infant was 8 weeks old, Ghana, 2006 Background characteristic Received vitamin A supplement* Not sure if received vitamin A Number of women with a birth in 2 years before survey Region Western 66.3 0.0 144 Central 49.1 0.5 105 Greater Accra 64.7 1.2 167 Volta 64.6 0.0 97 Eastern 36.4 0.0 182 Ashanti 67.9 0.7 207 Brong Ahafo 60.8 1.3 107 Northern 38.0 3.3 260 Upper East 56.3 1.4 58 Upper West 60.1 0.0 37 Residence Urban 64.9 0.9 468 Rural 49.1 1.2 897 Mother's/Caretaker’s Education None 47.0 1.8 503 Primary 52.4 0.5 300 Middle/JSS 60.5 0.9 465 Secondary+ 70.7 0.4 97 Wealth index quintiles Poorest 41.8 2.1 313 Second 47.1 1.0 325 Middle 59.6 0.0 260 Fourth 66.6 0.5 267 Richest 63.7 1.8 199 Total 54.5 1.1 1,365 * MICS indicator 43 Data refer to the most recent birth only. 30 Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth5. Overall, nearly 2 in 5 babies were weighed at birth and approximately 9 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.8). There was no significant variation in low birth weight by background characteristics (Table NU.8 and Figure NU.4). The percentage of low birth weight does not vary much by urban and rural areas or by mother’s education. Figure NU.4 Percentage of Infants Weighing Less Than 2,500 Grams at Birth, Ghana, 2006 10.4 7.9 9.3 9.5 10.1 8.5 7.6 9.0 9.9 (8.8) 9.1 0 2 4 6 8 10 12 Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Ghana Note: Figure in parenthesis is based on 25-49 unweighted cases Percent 5 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. Table NU.8: Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2,500 grams at birth, Ghana, 2006 Percent of live births: Background characteristic Below 2,500 grams* Weighed at birth** Number of live births Region Western 10.4 34.3 144 Central 7.9 19.2 105 Greater Accra 9.3 74.3 167 Volta 9.5 30.6 97 Eastern 10.1 23.8 182 Ashanti 8.5 40.6 207 Brong Ahafo 7.6 36.8 107 Northern 9.0 27.8 260 Upper East 9.9 38.9 58 Upper West 8.8 20.4 37 Residence Urban 9.2 58.6 468 Rural 9.1 24.4 897 Mother’s/Caretaker’s education None 9.4 21.9 503 Primary 9.0 29.3 300 Middle/JSS 9.0 47.1 465 Secondary + 8.8 78.0 97 Wealth index quintiles Poorest 8.5 19.2 313 Second 9.7 18.9 325 Middle 8.7 28.9 260 Fourth 10.0 53.2 267 Richest 8.5 77.3 199 Total 9.1 36.1 1,365 * MICS indicator 9 ** MICS indicator 10 Data refer to the most recent birth only. 31 VI. Child Health Immunization The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key role in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure 90 percent of children under one year of age are fully immunized at national level, with at least 80 percent coverage in every district. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination for protection against tuberculosis; three doses of (DPT)HH against diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza type B; three doses of polio vaccine, and a dose of MMR (measles, mumps and rubella) vaccination by the age of 12 months. In the survey, information on vaccination coverage was obtained in two ways – from health cards and from mothers’ or caretakers’ verbal reports. All mothers or caretakers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS 2006 questionnaire. If a vaccination was not recorded on the card, the mother or caretaker was asked to recall whether the particular vaccination had been given and how many times. The percentage of children aged 12 to 23 months who received each of the vaccinations before the age of 12 months is shown in Table CH.1 and Figure CH.1. Ninety-four percent of children aged 12-23 months received a BCG vaccination by the age of 12 months and the first dose of (DPT)HH was given to 94 percent. The percentage declines for subsequent doses of (DPT)HH to 89 percent for the second dose, and 81 percent for the third dose. Similarly, 96 percent of children received Polio 1 by age 12 months and this declines to 80 percent by the third dose. Consequently, only 64 percent of Ghanaian children are fully immunized before the age of 12 months. This is far short of the 90 percent goal. 32 Table CH.1: Vaccinations in first year of life Percent of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, Ghana, 2006 Percent of children who received: BCG* Polio0 Polio1 Polio2 Polio3*** MMR**** (DPT)HH1 (DPT)HH2 (DPT)HH3** All***** Yellow fever****** None Number of children aged 12-23 months Vaccinated at any time before the survey According to: Vaccination card 83.4 53.0 83.9 81.8 76.4 74.5 84.0 81.8 77.8 69.7 73.9 0.0 706 Mother's report 10.8 8.2 12.3 9.7 6.1 10.9 10.2 8.5 5.7 3.7 10.5 2.4 706 Either 94.3 61.2 96.2 91.5 82.4 85.4 94.2 90.3 83.5 73.4 84.4 2.5 706 Vaccinated by 12 months of age 94.2 61.1 95.8 90.5 80.1 77.7 93.8 89.2 81.4 64.4 76.7 2.5 706 * MICS indicator 25 ** Combined: MICS indicator 27 and MICS indicator 29 *** MICS indicator 26 **** MICS indicator 28; MDG indicator 15 ***** MICS indicator 31 ****** MICS indicator 30 33 Figure CH.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months, Ghana, 2006 94.2 93.8 89.2 81.4 95.8 90.5 80.1 77.7 64.4 0 20 40 60 80 100 BC G (DP T)H H1 (DP T)H H2 (DP T)H H3 Pol io1 Pol io2 Pol io3 MM R All Percent Table CH.2 shows vaccination coverage rates among children 12-23 months by background characteristics at any time before the survey. More than 73 percent of children 12-23 months currently have all the required vaccinations. Predictably, children in wealthier households are much more likely to have all the necessary vaccinations. Eighty-four percent of children were vaccinated against yellow fever; Central Region recorded the lowest (61 percent) and Ashanti the highest of 95 percent. Generally, there is a strong association between mother’s level of education and residence and the likelihood of child’s receiving vaccinations. Children 12-23 months with mothers with more than primary education and residing in urban areas are more likely to be vaccinated. 34 Table CH.2: Vaccinations by background characteristics Percentage of children aged 12-23 months currently vaccinated against childhood diseases, Ghana, 2006 Background characteristic BCG Polio0 Polio1 Polio2 Polio3 MMR (DPT)HH1 (DPT)HH2 (DPT)HH3 All Yellow fever None Percent with health card Number of children aged 12- 23 months Sex Male 92.8 59.3 95.6 91.2 81.8 85.7 92.2 89.2 82.5 73.7 85.0 3.5 82.5 351 Female 95.7 63.1 96.7 91.8 83.1 85.1 96.1 91.4 84.5 73.1 83.8 1.4 87.8 355 Region Western 92.1 67.1 96.7 93.3 86.0 91.5 94.1 90.2 86.1 81.6 91.5 3.3 81.8 78 Central (85.3) (60.3) (88.2) (83.3) (69.1) (68.6) (87.6) (81.4) (71.0) (61.8) (61.1) (2.7) (84.5) 45 Greater Accra 98.1 79.0 99.5 92.2 80.8 89.4 96.2 94.8 85.0 74.4 89.4 0.5 70.9 84 Volta (86.0) (51.9) (88.7) (75.4) (63.7) (76.3) (87.9) (73.3) (64.2) (55.7) (72.2) (6.1) (70.3) 48 Eastern 93.9 51.2 93.9 92.0 88.3 83.1 93.9 92.0 85.1 76.2 83.8 6.1 87.9 102 Ashanti 98.6 71.4 100.0 98.8 90.6 95.4 98.6 95.8 91.9 83.2 95.4 0.0 91.1 110 Brong Ahafo 97.9 58.5 97.9 93.4 80.5 78.4 95.5 95.5 89.4 65.0 78.4 2.1 91.4 56 Northern 93.4 48.7 97.1 90.6 79.6 83.2 93.1 87.5 78.3 67.7 81.3 1.7 89.3 135 Upper East 96.3 62.8 95.4 91.5 88.5 88.2 95.4 92.7 92.7 82.6 89.6 0.8 93.8 31 Upper West 97.3 75.0 97.3 95.6 92.4 91.5 94.2 94.2 92.9 86.5 91.5 2.7 92.4 18 Area Urban 96.7 74.1 98.8 94.1 85.4 88.1 95.8 92.9 87.6 77.6 86.7 0.8 81.6 237 Rural 93.1 54.8 94.9 90.1 80.9 84.0 93.3 89.0 81.4 71.2 83.3 3.3 87.0 469 Mother's/Caretaker's education None 89.7 51.2 92.7 86.5 75.0 80.2 89.3 84.0 77.2 65.7 79.7 4.9 83.0 264 Primary 94.0 55.1 96.8 92.1 83.6 82.3 94.3 89.6 83.2 69.4 79.9 1.3 82.8 160 Middle/JSS 98.4 70.7 98.9 95.2 87.9 91.9 98.4 96.2 88.1 82.0 91.2 1.1 88.0 236 Secondary+ (100.0) (91.4) (100.0) (98.7) (93.3) (92.3) (100.0) (98.7) (96.9) (86.9) (92.3) (0.0) (91.7) 46 Wealth index quintiles Poorest 88.7 46.4 92.5 86.6 76.7 78.6 89.2 83.9 75.7 62.1 78.5 5.4 85.7 162 Second 91.5 49.4 94.3 87.6 77.1 83.1 92.0 86.2 79.0 71.7 80.6 3.7 83.7 159 Middle 95.8 60.1 96.5 95.1 86.4 86.4 96.3 93.6 87.3 76.2 86.4 1.6 86.8 151 Fourth 98.1 78.2 99.6 93.5 87.1 84.6 95.8 93.0 88.1 75.8 82.7 0.4 87.5 129 Richest 100.0 83.2 100.0 97.1 88.1 98.7 100.0 98.3 91.3 86.4 98.7 0.0 81.3 104 Total 94.3 61.2 96.2 91.5 82.4 85.4 94.2 90.3 83.5 73.4 84.4 2.5 85.2 706 Figures in parentheses ‘( )’ are based on 25-49 unweighted cases. 35 Tetanus Toxoid One of the strategies in the MDGs for the reduction of maternal mortality is the elimination of maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1000 live births in every district. A World Fit for Children goal was to eliminate maternal and neonatal tetanus by 2005. One measure of prevention of maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: · Received at least two doses of tetanus toxoid vaccine, the last within the prior 3 years; · Received at least 3 doses, the last within the prior 5 years; · Received at least 4 doses, the last within 10 years; · Received at least 5 doses during lifetime. Table CH.3: Neonatal tetanus protection Percentage of mothers with a birth in the last 2 years protected against neonatal tetanus, Ghana, 2006 Background characteristic Received at least 2 doses during last pregnancy Received at least 2 doses, the last within prior 3 years Received at least 3 doses, the last within 5 years Received at least 4 doses, the last within 10 years Received at least 5 doses during lifetime Protected against tetanus * Number of mothers Region Western 69.6 18.6 0.0 0.6 0.0 88.8 144 Central 70.9 8.3 1.3 1.3 0.0 81.8 105 Greater Accra 68.6 15.6 0.0 0.0 0.0 84.2 167 Volta 47.8 10.8 0.0 0.0 0.0 58.6 97 Eastern 53.4 15.4 1.3 0.0 0.0 70.1 182 Ashanti 63.0 11.3 0.0 1.1 0.0 75.4 207 Brong Ahafo 61.2 14.7 0.8 0.0 1.1 77.8 107 Northern 69.5 7.5 0.3 0.0 0.0 77.4 260 Upper East 66.5 13.0 0.6 0.0 0.0 80.1 58 Upper West 59.6 10.7 0.0 0.0 0.0 70.3 37 Residence Urban 67.1 13.6 0.6 0.7 0.0 82.0 468 Rural 62.1 11.9 0.3 0.1 0.1 74.6 897 Age 15-19 60.9 4.6 0.0 0.0 0.0 65.5 89 20-24 65.9 10.1 0.5 0.0 0.0 76.5 317 25-29 66.6 11.6 0.2 0.4 0.0 78.8 380 30-34 64.1 16.5 0.9 0.0 0.0 81.4 269 35-39 59.2 15.5 0.0 0.9 0.0 75.6 210 40-44 60.0 14.5 0.0 1.9 1.6 78.0 75 45-49 (51.3) (9.4) (3.3) (0.0) (0.0) (64.0) 25 Mother's/Caretaker’s education None 62.1 10.9 0.5 0.4 0.0 74.0 503 Primary 56.3 12.7 0.0 0.3 0.0 69.3 300 Middle/JSS 67.7 14.4 0.7 0.3 0.3 83.3 465 Secondary+ 76.7 11.0 0.0 0.0 0.0 87.7 97 Wealth index quintiles Poorest 60.1 12.5 0.7 0.0 0.4 73.7 313 Second 59.4 12.0 0.3 0.4 0.0 72.1 325 Middle 62.4 10.8 0.5 0.4 0.0 74.1 260 Fourth 69.9 10.9 0.5 0.4 0.0 81.8 267 Richest 70.2 17.4 0.0 0.7 0.0 88.4 199 Total 63.8 12.5 0.4 0.3 0.1 77.1 1,365 * MICS Indicator 32 Figures in parenthesis ‘( )’ are based on 25 – 49 unweighted cases. 36 Table CH.3 and Figure CH.2 show the level of protection status from tetanus of women who have had a live birth within the last 2 years by major background characteristics. Overall, 64 percent of women received at least 2 doses during the last pregnancy. Five out of the ten administrative regions in Ghana (Volta, Eastern, Ashanti, Brong Ahafo and Upper West) are below the national average (64 percent). The results also showed that women with at least secondary education are more likely to receive at least 2 doses during last pregnancy. Protection level against tetanus is generally high except for the Volta Region which is below 60 percent. Among the age groups, protection level peaks at 81 percent at age 30-34. Urban women are more likely to be protected than their rural counterparts. Figure CH.2: Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus, Ghana, 2006 88.8% 81.8% 84.2% 58.6% 70.1% 75.4% 77.8% 77.4% 80.1% 82.0% 74.6% 74.0% 69.3% 83.3% 87.7% 77.1% (70.3%) 0% 20% 40% 60% 80% 100% Region Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Area Urban Rural Education No education Primary Middle/JSS Secondary + Ghana Note: Figure in parenthesis is based on 25-49 unweighted cases Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one-half deaths due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two-thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. 37 The indicators are: · Prevalence of diarrhoea · Oral Rehydration Therapy (ORT) · Home management of diarrhoea · ORT or increased fluids AND continued feeding In the MICS questionnaire, mothers (or caretakers) were asked to report whether the child had had diarrhoea in the two weeks prior to the survey. If so, they were asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, 15 percent of under-five children had diarrhoea in the two weeks preceding the survey (Table CH.4). Diarrhoea prevalence was lower in the southern part of Ghana with Volta Region recording the lowest rate of 9 percent. The peak of diarrhoea prevalence occurs in the weaning period, among children age 6-23 months. Table CH.4: Oral rehydration treatment Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), Ghana, 2006 Background characteristic Had diarrhoea in last two weeks Number of children aged 0-59 months Fluid from ORS packet Recommended homemade fluid No treatment ORT use rate * Number of children aged 0-59 months with diarrhoea Sex Male 16.7 1,789 28.4 11.0 61.9 38.1 299 Female 14.1 1,678 29.4 6.3 64.5 35.5 236 Region Western 10.6 347 (28.0) (9.3) (62.8) (37.2) 37 Central 10.7 302 (56.5) (2.9) (40.6) (59.4) 32 Greater Accra 11.5 448 39.1 19.0 41.8 58.2 52 Volta 8.6 261 * * * * 22 Eastern 14.5 463 30.0 6.7 63.3 36.7 67 Ashanti 16.9 506 26.0 7.0 69.3 30.7 86 Brong Ahafo 18.8 311 20.3 7.6 72.1 27.9 59 Northern 22.4 579 21.6 10.9 68.8 31.2 129 Upper East 21.7 146 (41.8) (5.5) (52.7) (47.3) 32 Upper West 18.7 105 * * * * 20 Residence Urban 14.7 1,236 36.6 13.2 52.3 47.7 182 Rural 15.8 2,231 24.9 6.7 68.5 31.5 353 Age < 6 months 8.9 383 (6.8) (2.3) (90.9) (9.1) 34 6-11 months 19.4 332 22.6 10.8 66.5 33.5 65 12-23 months 24.1 706 35.8 10.0 55.8 44.2 170 24-35 months 16.0 667 24.3 4.6 72.1 27.9 107 36-47 months 13.4 718 24.6 11.5 63.9 36.1 96 48-59 months 9.5 661 42.4 11.2 47.0 53.0 63 Mother's/Caretaker’s education None 17.1 1,343 24.2 9.9 66.4 33.6 230 Primary 18.3 753 27.6 6.2 66.9 33.1 138 Middle/JSS 12.6 1,120 34.2 8.9 56.8 43.2 141 Secondary+ 10.5 251 (47.2) (14.3) (45.6) (54.4) 26 Total 15.4 3,467 28.8 8.9 63.0 37.0 535 * MICS Indicator 33 An asterisk (*) indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses ‘( )’ are based on 25 – 49 unweighted cases. 38 Table CH.4 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. About 29 percent received fluids from ORS packets; and 9 percent received recommended homemade fluids. Children of mothers with at least secondary education are more likely to receive oral rehydration treatment than other children. As many as 63 percent of children with diarrhoea received no ORS or recommended home made fluid (RHF). Table CH.5: Home management of diarrhoea Percentage of children aged 0-59 months with diarrhoea in the last two weeks who took increased fluids and continued to feed during the episode, Ghana, 2006 Background characteristic Had diarrhoea in last two weeks Number of children aged 0- 59 months Children with diarrhoea who drank more Children with diarrhoea who drank the same or less Children with diarrhoea who ate somewhat less, same or more Children with diarrhoea who ate much less or none Home management of diarrhoea * Received ORT or increased fluids AND continued feeding ** Number of children aged 0- 59 months with diarrhoea Sex Male 16.7 1,789 30.7 68.7 48.3 51.7 18.1 29.1 299 Female 14.1 1,678 38.6 60.0 51.2 48.2 20.1 27.8 236 Area Urban 14.7 1,236 33.8 64.7 48.3 51.7 18.7 29.1 182 Rural 15.8 2,231 34.4 65.0 50.2 49.4 19.2 28.3 353 Age 0-11 months 13.8 715 22.0 76.7 42.9 56.4 9.2 15.0 99 12-23 months 24.1 706 34.7 64.6 40.7 59.3 16.3 27.2 170 24-35 months 16.0 667 49.8 48.8 61.4 38.6 31.1 36.8 107 36-47 months 13.4 718 32.4 67.3 51.9 48.1 19.9 29.8 96 48-59 months 9.5 661 28.1 70.7 60.3 38.5 19.8 37.6 63 Mother's/Caretaker’s education None 17.1 1,343 36.6 62.4 54.3 45.0 21.3 31.2 230 Primary 18.3 753 36.5 62.4 40.3 59.7 18.5 25.6 138 Middle/JSS 12.6 1,120 28.9 70.2 51.2 48.8 17.0 27.7 141 Secondary+ 10.5 251 (29.2) (70.8) (47.5) (52.5) (12.1) (26.1) 26 Wealth index quintiles Poorest 19.8 786 39.0 60.7 54.5 45.3 21.8 30.9 155 Second 16.6 830 31.4 66.7 44.0 55.8 15.6 22.2 138 Middle 15.2 684 25.0 74.3 44.5 54.8 11.9 20.5 104 Fourth 12.6 623 41.3 58.7 53.6 46.4 29.5 42.3 78 Richest 10.9 544 34.8 63.1 53.3 46.7 18.0 33.2 60 Total 15.4 3,467 34.2 64.9 49.6 50.2 19.0 28.6 535 * MICS indicator 34 ** MICS indicator 35 Figures in parentheses ‘( )’ are based on 25 – 49 unweighted cases. About one third (34 percent) of under-five children with diarrhoea drank more than usual while 65 percent drank the same or less (Table CH.5). Half of under-five children with diarrhoea ate somewhat less, same or more (continued feeding), and also half ate much less or ate nothing. Combining the information in Table CH.5 and Table CH.4 on oral rehydration therapy, it is observed that 29 percent of children either received ORT or increased fluid intake, and at the same time, feeding was continued, as is the recommendation. 39 Nineteen percent of children with diarrhoea were managed at home. There are significant differences in the home management of diarrhoea by background characteristics. Infants under 12 months are less likely to be managed at home (9 percent) compared to those age 24- 35 months (31 percent). Figure CH.3: Percentage of children aged 0-59 with diarrhoea who received ORT or increased fluids, AND continued feeding, Ghana, 2006 29.1% 27.8% 29.1% 28.3% 31.2% 25.6% 27.7% 28.6% (26.1%) 0% 5% 10% 15% 20% 25% 30% 35% Sex Male Female Area Urban Rural Mother's Education No education Primary Middle/JSS Secondary + Ghana Note: Figure in parenthesis is based on 25-49 unweighted cases Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-five children with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were due to a problem in the chest or both problem in the chest and a blocked nose. If the child only had a blocked nose, the symptoms could be due to a cold only. The indicators are: · Prevalence of suspected pneumonia · Care seeking for suspected pneumonia · Antibiotic treatment for suspected pneumonia · Knowledge of the danger signs of pneumonia Table CH.6 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Five percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, only a third (34 percent) were taken to an appropriate health provider. 40 Table CH.6: Care seeking for suspected pneumonia Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks taken to a health provider, Ghana, 2006 Children with suspected pneumonia who were taken to: Public sources Private sources Other sources Background characteristic Had acute respiratory infection Number of children aged 0- 59 months Govt. hospital Govt. health centre Govt. health post Village health worker Mobile/outreach clinic Other public Private hospital/clinic Private physician Pharmacy Relative or friend Chemical Shop Any appropriate provider * Number of children aged 0-59 months with suspected pneumonia Sex Male 4.8 1,789 14.8 12.4 1.8 0.1 0.0 1.0 4.1 0.0 6.7 0.1 21.3 34.1 85 Female 5.3 1,678 14.1 6.4 1.7 0.2 2.9 0.0 6.3 1.5 7.0 1.3 15.0 33.0 89 Area Urban 3.8 1,236 (14.4) (3.1) (2.0) (0.0) (0.0) (0.0) (5.5) (0.0) (20.4) (0.0) (16.0) 24.9 47 Rural 5.7 2,231 14.5 11.6 1.7 0.2 2.0 0.7 5.1 1.0 1.8 1.0 18.9 36.7 128 Age 0-11 months 4.6 715 (10.4) (15.7) (1.3) (0.5) (7.8) (0.0) (8.0) (0.0) (0.0) (3.7) (15.7) (43.8) 33 12-23 months 6.8 706 (22.2) (5.7) (1.9) (0.2) (0.0) (1.8) (1.6) (2.7) (9.4) (0.0) (12.6) (36.1) 48 24-35 months 4.3 667 (13.7) (12.8) (1.3) (0.0) (0.0) (0.0) (0.0) (0.0) (5.3) (0.3) (24.4) (27.8) 29 36-47 months 4.9 718 (8.3) (8.0) (3.3) (0.0) (0.0) (0.0) (7.3) (0.0) (6.9) (0.0) (22.1) (26.8) 35 48-59 months 4.5 661 (14.5) (6.4) (0.6) (0.0) (0.0) (0.0) (10.3) (0.0) (11.6) (0.0) (18.7) (31.8) 30 Mother's/Caretaker’s education None 5.1 1,343 12.8 9.0 3.2 0.1 0.8 0.0 3.1 0.0 4.0 0.0 19.5 29.0 68 Primary 6.3 753 (13.3) (11.5) (0.0) (0.4) (4.2) (0.0) (7.6) (2.7) (9.3) (0.2) (22.8) (39.7) 48 Middle/JSS 4.9 1,120 12.6 8.4 1.7 0.0 0.0 1.6 6.1 0.0 8.7 2.2 13.5 30.4 55 Secondary+ 1.6 251 * * * * * * * * * * * * 4 Total 5.0 3,467 14.4 9.3 1.8 0.2 1.5 0.5 5.2 0.8 6.8 0.7 18.1 33.6 175 * MICS indicator 23 An appropriate provider excludes pharmacy and other sources An asterisk ‘*’ indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parenthesis ‘( )” are based on 25 – 49 unweighted cases. 41 Findings in Table CH.7 show the percentage of children treated for pneumonia symptoms with antibiotics. At 33 percent, the children receiving antibiotics is in line with the findings of Table CH.6. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 3 percent of mothers / caretakers recognised both of the two danger signs of pneumonia (fast and difficult breathing) as reasons to take the child immediately to a health facility. The most commonly identified symptom for taking a child to a health facility is fever. The next most common symptoms identified by mothers/caretakers are child becoming more sick (46 percent) and bloody stools (14 percent), with 37 percent listing other symptoms. Table CH.7: Antibiotic treatment of pneumonia Percentage of children aged 0-59 months with suspected pneumonia who received antibiotic treatment, Ghana, 2006 Background characteristic Percentage of children aged 0-59 months with suspected pneumonia who received antibiotics in the last two weeks * Number of children aged 0-59 months with suspected pneumonia in the two weeks prior to the survey Sex Male 32.3 85 Female 33.4 89 Area Urban (30.4) 47 Rural 33.7 128 Mother's/Caretaker’s education None 27.7 68 Primary (44.6) 48 Middle/JSS 28.0 55 Secondary+ * 4 Wealth index quintiles Poorest (29.6) 46 Second 30.4 55 Middle (35.1) 43 Fourth * 18 Richest * 13 Total 32.9 175 * MICS indicator 22 An asterisk ‘*’ indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parenthesis ‘( )” are based on 25 – 49 unweighted cases. 42 Table CH.7A: Knowledge of the two danger signs of pneumonia Percentage of mothers/caretakers of children aged 0-59 months who know of types of symptoms for taking a child immediately to a health facility, and percentage of mothers/caretakers who recognize fast and difficult breathing as signs for seeking care immediately, Ghana, 2006 Percentage of mother/caretakers of children aged 0-59 months who think that a child should be taken immediately to a health facility if the child: Background Characteristic Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has difficulty breathing Has blood in stool Is drinking poorly Has other symptoms Mothers/caretakers who recognize the two danger signs of pneumonia Number of mothers/caretakers of children aged 0-59 months Region Western 20.0 51.0 85.4 2.2 7.7 26.6 8.3 19.1 0.3 347 Central 15.7 58.6 83.6 6.8 2.9 5.9 4.5 53.6 0.3 302 Greater Accra 11.2 40.2 84.3 5.7 8.3 18.2 5.4 34.0 3.7 448 Volta 9.3 7.5 81.7 0.8 2.7 7.2 2.9 67.8 0.0 261 Eastern 4.4 40.2 82.5 1.4 3.8 1.7 2.0 46.0 0.9 463 Ashanti 0.6 40.6 83.5 3.0 6.5 13.0 3.9 27.4 0.9 506 Brong Ahafo 11.6 85.6 82.5 13.9 11.3 17.8 18.5 18.3 6.0 311 Northern 35.1 53.1 83.3 13.8 14.1 18.0 12.2 34.7 4.6 579 Upper East 19.0 42.2 87.6 23.4 25.9 21.6 11.1 36.8 16.5 146 Upper West 15.0 18.7 89.8 1.9 3.4 0.3 1.0 55.8 0.0 105 Area Urban 11.4 44.2 84.8 5.4 8.2 12.7 6.6 37.7 2.6 1,236 Rural 16.0 47.2 83.2 7.6 8.4 14.3 7.5 36.4 2.9 2,231 Mother's/Caretaker’s education None 20.9 50.1 85.4 9.5 10.0 14.6 8.8 35.9 3.2 1,343 Primary 11.8 39.7 81.1 6.6 7.1 13.5 6.2 36.2 2.7 753 Middle/JSS 8.4 47.1 83.4 3.7 7.1 13.4 6.3 36.5 1.9 1,120 Secondary+ 13.0 40.5 84.8 6.9 8.7 11.1 5.1 46.2 4.2 251 Total 14.3 46.1 83.8 6.8 8.3 13.7 7.2 36.9 2.8 3,467 43 Solid Fuel Use Cooking with solid fuels (biomass and coal) leads to high levels of indoor pollution and is a major cause of ill-health in the world, particularly among under-five children, in the form of acute respiratory illness. Table CH.8 presents the distribution of households by type of cooking fuel. The three main sources of cooking fuel in the country are wood (50 percent), charcoal (35 percent) and LPG (10 percent). Overall, 86 percent of households in Ghana are using solid fuels for cooking. Use of solid fuels varies across the 10 regions of the country from 61 percent in Greater Accra to 98 percent in Northern and Upper East regions. In addition the use of solid fuel for cooking is slightly lower in urban areas (74 percent) than rural households, where almost every household (96 percent) uses solid fuel for cooking. Use of solid fuel differentials with respect to the educational level of the head of household and household wealth index are also significant. The higher the educational level of the household head, the lower the use of solid fuels for cooking. In addition, the table clearly shows that the percentage is lowest among wealthiest households. 44 Table CH.8: Solid fuel use Percent distribution of households according to type of cooking fuel, and percentage of households used solid fuels for cooking, Ghana, 2006 Type of fuel using for cooking Electricity Liquefied Petroleum Gas (LPG) Biogas Kerosene Charcoal Wood Crop residue/sawdust None, no cooking Other Total Solid fuels for cooking * Number of households Region Western 0.0 7.7 0.4 0.5 37.7 51.2 0.0 2.5 0.0 100.0 88.9 617 Central 0.2 6.3 0.0 0.7 31.9 56.3 0.1 4.5 0.0 100.0 88.3 576 Greater Accra 0.6 31.4 0.5 1.9 58.5 2.3 0.0 4.9 0.0 100.0 60.8 1,004 Volta 0.0 5.9 0.0 0.3 26.6 65.2 0.4 1.6 0.0 100.0 92.2 486 Eastern 0.0 5.8 0.0 0.3 31.4 60.4 0.0 2.2 0.0 100.0 91.7 758 Ashanti 0.1 10.4 0.0 0.6 37.4 45.8 0.0 5.4 0.2 100.0 83.2 988 Brong Ahafo 0.0 5.0 0.0 0.3 28.6 64.3 0.5 1.3 0.0 100.0 93.5 552 Northern 0.0 0.7 0.0 0.0 19.7 78.3 0.2 1.1 0.0 100.0 98.2 630 Upper East 0.2 0.6 0.0 0.0 16.3 66.1 15.5 1.2 0.0 100.0 97.9 202 Upper West 0.0 3.1 0.0 0.3 11.6 84.2 0.0 0.8 0.0 100.0 95.8 126 Residence Urban 0.3 19.7 0.2 1.3 57.7 15.8 0.2 4.8 0.0 100.0 73.7 2,692 Rural 0.0 2.5 0.0 0.1 15.9 78.6 1.0 1.7 0.1 100.0 95.5 3,247 Education of household head None 0.1 1.1 0.0 0.0 22.2 73.7 1.5 1.4 0.0 100.0 97.4 1,830 Primary 0.0 2.2 0.0 0.1 35.6 58.4 0.5 3.2 0.0 100.0 94.5 802 Middle/JSS 0.0 8.6 0.2 0.8 42.4 43.8 0.1 4.0 0.1 100.0 86.3 2,203 Secondary+ 0.6 35.0 0.3 1.7 40.2 17.7 0.4 4.1 0.0 100.0 58.3 1,104 Wealth index quintiles Poorest 0.0 0.0 0.0 0.0 0.7 96.6 2.3 0.4 0.0 100.0 99.6 949 Second 0.0 0.0 0.0 0.0 5.9 91.4 0.9 1.7 0.0 100.0 98.3 1,147 Middle 0.0 0.5 0.1 0.2 36.7 58.3 0.2 3.8 0.2 100.0 95.3 1,285 Fourth 0.0 5.1 0.1 1.1 70.4 18.4 0.1 4.8 0.0 100.0 88.8 1,341 Richest 0.7 44.1 0.4 1.8 47.7 1.4 0.1 3.8 0.0 100.0 49.2 1,217 Total 0.1 10.3 0.1 0.6 34.8 50.2 0.6 3.1 0.0 100.0 85.6 5,939 * MICS indicator 24; MDG indicator 29 45 Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while an open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Information on the type of stove used with solid fuel is depicted in Table CH.9. Sixty percent of households use open fires while 40 percent use open stoves. Almost all households (92 percent) in the Upper West Region use open fires for cooking, compared with only 5 percent in Greater Accra. The reverse is true for open stove (i.e. Greater Accra 95 percent and Upper West, 7 percent). Malaria Malaria continues to be a major public health concern. It is one of the leading causes of morbidity and mortality, especially among children under age five and pregnant women in Ghana. It also contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of mosquito nets treated with insecticide (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. The survey incorporated questions on the use of bednets, both at household level and among children under five years of age, as well as use of anti-malarial treatment, and intermittent preventive therapy for malaria. Table CH.9: Solid fuel use by type of stove or fire Among households using solid fuels for cooking, percent distribution by type of stove or fire, Ghana, 2006 Food cooked on stove or open fire Open fire Open stove Closed stove Missing Total Number of households using solid fuels for cooking Region Western 57.7 42.1 0.3 0.0 100.0 549 Central 63.1 36.3 0.6 0.0 100.0 508 Greater Accra 5.3 94.5 0.2 0.0 100.0 610 Volta 76.2 23.6 0.0 0.2 100.0 448 Eastern 66.1 33.5 0.4 0.0 100.0 695 Ashanti 54.5 44.8 0.6 0.2 100.0 822 Brong Ahafo 70.3 29.7 0.0 0.0 100.0 516 Northern 79.7 20.2 0.0 0.1 100.0 619 Upper East 84.0 16.0 0.0 0.0 100.0 198 Upper West 92.4 7.4 0.0 0.2 100.0 121 Residence Urban 23.4 76.1 0.4 0.0 100.0 1,984 Rural 83.4 16.4 0.1 0.1 100.0 3,102 Education of household head None 77.7 22.2 0.0 0.1 100.0 1,783 Primary 63.4 36.3 0.2 0.0 100.0 758 Middle/JSS 51.6 47.9 0.3 0.1 100.0 1,901 Secondary+ 31.7 67.7 0.7 0.0 100.0 644 Wealth index quintiles Poorest 99.3 0.6 0.0 0.1 100.0 945 Second 94.4 5.4 0.0 0.2 100.0 1,127 Middle 62.3 37.5 0.2 0.0 100.0 1,224 Fourth 21.8 77.7 0.4 0.0 100.0 1,191 Richest 4.5 94.6 0.9 0.0 100.0 599 Total 60.0 39.7 0.3 0.1 100.0 5,086 46 According to data in Table CH.10, almost a third of households have at least one mosquito net (30 percent) and 19 percent have at least one insecticide treated net (ITN). The likelihood of possessing a mosquito net or an ITN is 15 percent higher in rural areas than in urban areas. Possession of ITNs is also relatively high in Upper West and Upper East regions, and is low in Western Region. Although ownership of ITNs is higher in households with better educated household heads, interestingly, there are few differences by wealth quintile. Table CH.11 indicates that 33 percent of children under the age of five slept under any mosquito net the night prior to the survey and 22 percent slept under an insecticide treated net. The use of bednets among children under five declines steadily with age. The use of the ITNs or bednets is higher in rural than urban areas. There were no significant gender disparities in bednet and ITN use among children under five. Table CH.10: Availability of insecticide-treated nets Percentage of households with at least one mosquito net and percentage with at least one insecticide-treated net (ITN), Ghana, 2006 Percentage of households with at least one mosquito net Percentage of households with at least one insecticide- treated net (ITN)* Number of households Region Western 10.7 8.0 617 Central 21.2 14.7 576 Greater Accra 19.1 12.9 1,004 Volta 60.7 23.0 486 Eastern 28.0 17.0 758 Ashanti 24.5 20.0 988 Brong Ahafo 39.7 28.3 552 Northern 43.0 24.0 630 Upper East 42.4 30.6 202 Upper West 51.6 31.7 126 Residence Urban 21.4 15.3 2,692 Rural 36.7 21.6 3,247 Education of household head None 31.5 16.3 1,830 Primary 30.0 18.0 802 Middle/JSS 27.5 18.1 2,203 Secondary+ 31.4 24.5 1,104 Wealth index quintiles Poorest 40.5 19.4 949 Second 33.4 20.0 1,147 Middle 28.0 16.6 1,285 Fourth 26.0 18.1 1,341 Richest 24.1 19.8 1,217 Total 29.8 18.7 5,939 * MICS Indicator 36 47 Table CH.11: Children sleeping under bednets Percentage of children aged 0-59 months who slept under an insecticide treated net during the previous night, Ghana, 2006 Slept under a bednet * Sleep under an insecticide treated net ** Slept under an untreated net Slept under a net but don't know if treated Don't know if slept under a net Did not sleep under a bednet Number of children aged 0-59 months Sex Male 33.3 22.1 10.3 0.9 0.2 66.4 1,789 Female 31.8 21.6 9.8 0.4 0.2 68.0 1,678 Region Western 15.0 11.5 3.2 0.3 0.7 84.3 347 Central 25.8 19.8 6.0 0.0 1.0 73.2 302 Greater Accra 24.2 16.3 6.7 1.2 0.0 75.8 448 Volta 54.2 21.5 30.0 2.7 0.0 45.8 261 Eastern 32.2 24.9 6.7 0.5 0.0 67.8 463 Ashanti 26.5 21.8 4.2 0.5 0.2 73.3 506 Brong Ahafo 39.3 25.7 13.6 0.0 0.0 60.7 311 Northern 36.7 21.9 14.4 0.4 0.0 63.3 579 Upper East 51.5 39.3 11.3 0.9 0.2 48.2 146 Upper West 55.0 37.1 16.3 1.5 0.0 45.0 105 Residence Urban 22.4 16.4 5.4 0.6 0.2 77.5 1,236 Rural 38.3 24.8 12.7 0.7 0.2 61.5 2,231 Age 0-11 months 37.9 27.8 9.3 0.9 0.0 62.1 715 12-23 months 36.2 24.5 10.9 0.8 0.3 63.5 706 24-35 months 31.3 19.6 11.0 0.8 0.2 68.5 667 36-47 months 29.9 20.6 8.9 0.4 0.3 69.8 718 48-59 months 27.3 16.3 10.5 0.5 0.2 72.5 661 Wealth index quintiles Poorest 41.4 24.4 16.4 0.7 0.0 58.5 786 Second 34.5 22.2 11.9 0.5 0.4 65.1 830 Middle 29.0 19.2 9.3 0.5 0.3 70.7 684 Fourth 29.0 20.8 6.7 1.5 0.0 71.0 623 Richest 25.7 22.2 3.3 0.2 0.2 74.1 544 Total 32.6 21.8 10.1 0.7 0.2 67.2 3,467 * MICS indicator 38 ** MICS indicator 37; MDG indicator 22 Questions on the prevalence and treatment of fever were asked for all children under age five. Almost a quarter (22 percent) of under-five children were ill with fever in the two weeks preceding the interview (Table CH.12). Fever prevalence was lowest among infants 0-11 months old, and peaked at 12-35 months (26-28 percent). Regional differences show Northern Region recording the highest (32 percent) and Central Region recording the lowest (17 percent) rates of fever prevalence. 48 Table CH.12: Treatment of children with anti-malarial drugs Percentage of children 0-59 months of age who were ill with fever in the last two weeks who received anti-malarial drugs, Ghana, 2006 Children with a fever in the last two weeks who were treated with Anti-malarials: Other medications: Had a fever in last two weeks Number of children aged 0- 59 months SP/Fansidar Chloroquine Amodiaquine Quinine Artemisinine based combinations Other Any appropriate anti- malarial drug Paracetamol/ Panadol/ Acetaminophan Aspirin Ibuprofen Other Don't know Any appropriate anti- malarial drug within 24 hours of onset of symptoms * Number of children with fever in last two weeks Sex Male 22.6 1789 0.3 42.3 11.7 0.6 5.7 3.9 59.8 78.2 1.7 1.3 18.8 3.5 48.3 404 Female 22.1 1678 0.8 41.9 15.5 0.9 3.0 3.4 62.0 75.7 1.5 3.2 17.5 1.3 48.4 371 Region Western 23.4 347 0.0 40.8 26.6 0.0 5.6 0.0 66.7 70.7 1.8 2.7 14.6 3.7 46.2 81 Central 16.8 302 (0.0) (37.1) (8.7) (0.0) (11.5) (0.0) (57.3) (96.4) (0.0) (3.2) (36.2) (2.4) (46.5) 51 Greater Accra 17.5 448 (0.0) (36.4) (15.8) (0.0) (17.4) (5.8) (69.3) (76.7) (6.7) (6.6) (19.4) (0.0) (66.3) 78 Volta 17.1 261 (0.0) (75.4) (4.4) (0.0) (0.0) (4.7) (79.4) (89.4) (4.5) (2.4) (7.6) (0.0) (57.6) 45 Eastern 20.7 463 0.0 38.0 8.8 0.0 1.6 1.0 46.8 81.1 0.0 0.0 27.1 5.1 32.1 96 Ashanti 20.9 506 0.0 30.1 12.4 0.9 1.2 4.0 48.6 70.7 2.0 0.0 13.1 3.6 35.4 106 Brong Ahafo 22.5 311 0.0 17.6 39.0 0.0 0.0 9.8 61.9 66.5 0.0 6.1 24.3 1.6 48.8 70 Northern 31.7 579 2.1 56.5 5.2 1.2 4.0 5.4 66.9 76.7 1.0 1.4 16.2 1.7 56.6 183 Upper East 27.0 146 1.2 59.0 2.3 2.6 0.2 0.0 64.5 79.7 0.0 0.9 8.9 3.6 52.9 39 Upper West 24.4 105 0.7 18.3 20.0 4.6 0.0 0.0 42.2 74.5 0.0 0.0 7.6 1.3 34.4 26 Area Urban 19.7 1236 0.2 37.2 20.7 0.1 12.0 5.1 68.7 80.6 2.2 3.3 22.3 0.8 58.0 243 Rural 23.8 2231 0.7 44.4 10.2 1.0 0.9 3.1 57.2 75.3 1.4 1.7 16.3 3.2 43.9 531 Age 0-11 months 13.4 715 0.0 34.6 9.6 0.0 2.2 2.2 45.9 72.2 1.0 0.4 20.8 0.6 28.6 96 12-23 months 27.6 706 0.6 43.1 17.3 0.4 4.9 6.0 66.7 74.4 2.4 0.6 20.6 3.5 53.8 195 24-35 months 26.2 667 0.3 47.5 7.8 0.8 3.3 3.5 61.3 81.5 0.7 3.6 18.1 2.4 54.4 174 36-47 months 24.0 718 1.7 37.1 14.7 1.2 6.6 2.7 59.5 79.8 2.8 4.3 14.4 1.8 46.4 172 48-59 months 20.8 661 0.0 45.5 16.7 1.0 3.8 3.1 64.0 74.8 0.7 1.5 17.7 3.1 49.0 138 Total 22.4 3467 0.6 42.1 13.5 0.7 4.4 3.7 60.8 77.0 1.6 2.2 18.2 2.4 48.3 775 MICS indicator 39; MDG indicator 22 Figures in parentheses ‘( )’ are based on 25-49 unweighted cases. 49 Mothers and caretakers were asked to report all the medicines given to a child to treat the fever, including both medicine given at home, and medicines given or prescribed at a health facility. Overall, 61 percent of children with fever in the last two weeks were treated with an “appropriate” anti-malarial drug and 48 percent received anti-malarial drugs within 24 hours of onset of symptoms. “Appropriate” anti-malarial drugs include chloroquine, SP/fansidar, amodiaquine, quinine, artemisinine combination drugs and others. In Ghana, the most widely used were chloroquine (42 percent) and amodiaquine (14 percent). Over three-quarters of children were given other types of medicines that are not antimalarials, including paracetamol (77 percent). Children with fever in the Volta Region are the most likely (4 out of 5) to have received an appropriate anti-malaria drug while those in the Upper West Region are the least (2 out of 5) to have received an appropriate drug. Urban children are more likely than rural children (69 versus 57 percent) to be treated appropriately. Little difference was noted between boys and girls in receiving appropriate anti-malarial drugs. Table CH.13: Intermittent preventive treatment for malaria Percent distribution of women aged 15-49 years with a birth in two years preceding the survey who received intermittent preventive therapy (IPT) for malaria during pregnancy, Ghana, 2006. Medicine to prevent malaria during pregnancy SP/Fansidar only one time SP/Fansidar two or more times * Chloroquine Other medicines Don't know medicine Number of women who gave birth in the preceding two years Region Western 74.4 19.7 31.0 25.8 1.2 2.2 144 Central 64.0 15.0 16.1 30.2 1.8 2.8 105 Greater Accra 79.3 15.2 37.3 17.9 10.2 2.8 167 Volta 65.7 11.9 25.0 36.3 2.7 2.0 97 Eastern 56.2 9.9 18.1 23.9 2.4 3.7 182 Ashanti 64.5 12.8 21.9 26.4 4.3 4.1 207 Brong Ahafo 76.7 8.7 34.2 45.8 4.6 4.1 107 Northern 57.6 10.4 27.7 12.9 2.5 7.7 260 Upper East 81.3 10.8 40.3 16.1 1.6 13.4 58 Upper West 73.0 8.9 43.7 15.3 0.0 5.2 37 Residence Urban 75.9 14.3 34.6 22.5 5.8 3.9 468 Rural 62.2 11.7 23.8 25.0 2.4 4.9 897 Mother's/Caretaker’s Education None 59.3 11.1 25.1 18.4 2.2 6.6 503 Primary 65.4 12.8 22.8 28.8 2.2 4.1 300 Middle/JSS 73.7 14.1 30.3 29.0 3.6 3.3 465 Secondary+ 78.2 12.4 40.4 16.6 14.8 1.1 97 Total 66.9 12.6 27.5 24.2 3.6 4.5 1,365 * MICS Indicator 40 Figures in parenthesis ‘( )” are based on 25 – 49 unweighted cases. Findings on intermittent preventive treatment for malaria in pregnant women who gave birth in the two years preceding the survey is presented in Table CH.13. Two-thirds ( 67 percent) of women who gave birth in the preceding 2 years received medicine to prevent malaria during pregnancy. The rate ranges from 56 percent in Eastern to 81 percent in Upper East. Just over one quarter of women with recent births reported having received two or more doses of SP(Fansidar) during their last pregnancy; this is considered as intermittent preventive treatment. A quarter received chloroquine to prevent malaria during pregnancy. 50 Sources and Costs of Supplies for ITNs and Antimalarials In the survey, questions were included to collect information on the sources and costs of four types of supplies: insecticide treated nets, antimalarials, antibiotics, and oral rehydration salts. Such information is very important in the sense that it makes possible a population- based assessment of the reach of programs and the extent to which particular target groups are covered by the programs. Such information is also useful for monitoring the provision of free or subsidized supplies, and for the assessment of costs of supplies, since prices of supplies can be a barrier to use of the supplies. For programme managers who want to find out public and private shares in the provision of the supplies, and of the relative importance of each source, information on sources and costs of supplies can be crucial. The source and cost of supplies for insecticide treated nets (ITNs) is provided in Table CH.14. The table provides information on whether the ITNs are obtained from public or private sources, the percentage of households that have obtained the ITNs for free, and the median cost of ITNs for those households which have paid for them. The results reveal that the public sector is the dominant source of insecticide treated nets (ITNs) with about 68 percent of households obtaining their ITNs from the public sector. Three of the most deprived regions (Northern 80 percent; Upper West 84 percent and Upper East 85 percent) depend heavily on the public sector for their supplies. Very few households obtained ITNs for free. The median costs of an ITN was 25,000 cedis for those who obtained nets from government sources and 30,000 for those abstaining nets in the private sector. The source and cost of supplies for antimalarials for children under five years of age are presented in Table CH.15. Unlike the ITNs, the source of supplies for antimalarials is fairly balanced between the public, and private and other sources. 51 Table CH.14: Source of supplies for ITNs Percentage of households obtaining ITNs from public or private sources, percentage obtaining nets for free, and median cost of ITNs for those paying for nets by type of source of net, Ghana, 2006. Source of insecticide treatment nets Percentage free Median cost for those not free Public* Private medical Other private Total Number of households with at least one ITN Public Number Private Number Public** Private** Region Western (70.9) (13.4) (15.8) 100.0 49 (5.5) 35 * 7 35,000 37,982 Central 71.6 8.2 20.1 100.0 85 2.5 61 * 7 20,000 20,000 Greater Accra 48.9 16.2 34.9 100.0 130 7.9 63 * 21 35,000 42,056 Volta 54.8 2.5 42.7 100.0 112 3.2 61 * 3 26,192 45,000 Eastern 60.2 9.2 30.6 100.0 129 0.0 78 * 12 25,000 20,599 Ashanti 65.9 7.9 26.2 100.0 198 6.5 130 * 16 35,000 30,300 Brong Ahafo 79.4 3.0 17.6 100.0 156 3.8 124 * 5 30,000 46,964 Northern 80.0 2.3 17.8 100.0 151 18.3 121 * 3 21,381 40,000 Upper East 85.0 1.1 13.9 100.0 62 9.1 53 * 1 5,000 5,000 Upper West (83.5) (0.0) (16.5) 100.0 40 (5.1) 33 * 0 (20,000) (0) Residence Urban 69.1 7.5 23.4 100.0 411 7.3 284 (8.8) 31 30,000 40,000 Rural 67.9 6.1 26.0 100.0 700 6.6 475 (0.0) 43 25,000 30,000 Education of household head None 70.4 3.6 26.1 100.0 298 10.1 210 * 11 20,000 29,388 Primary 61.9 3.9 34.2 100.0 144 11.3 89 * 6 25,000 30,000 Middle / JSS 65.6 8.7 25.7 100.0 398 3.8 261 (4.0) 35 25,000 33,928 Secondary+ 73.4 8.4 18.1 100.0 271 5.5 199 * 23 30,000 30,000 Wealth index quintiles Poorest 71.0 2.3 26.7 100.0 184 13.8 131 * 4 20,000 45,155 Second 69.4 8.5 22.1 100.0 229 4.9 159 * 19 25,000 30,000 Middle 60.1 6.1 33.8 100.0 214 7.3 128 * 13 25,000 20,000 Fourth 74.9 4.6 20.5 100.0 243 3.5 182 * 11 25,000 40,000 Richest 65.8 10.7 23.5 100.0 241 6.6 159 * 26 35,000 31,330 Total 68.3 6.6 25.1 100.0 1,111 6.9 759 3.7 74 25,000 30,000 * MICS indicator 96 ** MICS indicator 97 An asterisk ‘*’ indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parenthesis ‘( )” are based on 25 – 49 unweighted cases. 52 Table CH.15: Source and cost of supplies for antimalarials Percentage of children aged 0-59 months for whom antimalarials were obtained for free, and median cost of antimalarials for those paying for antimalarials, Ghana, 2006. Source of antimalarials Percentage Free Median cost for those not free Public* Private Other Total Number of children with fever in prior 2 weeks who were treated with antimalarials Public Private Public** Private** Sex Male 44.0 49.1 6.9 100.0 241 13.4 3.2 25,621 10,000 Female 51.9 44.4 3.7 100.0 230 13.4 2.5 25,000 10,406 Region Western 47.9 48.2 3.9 100.0 54 5.7 0.0 30,000 10,889 Central (44.5) (52.3) (3.2) 100.0 29 (18.5) (6.3) 20,000 9,754 Greater Accra 46.6 53.4 0.0 100.0 54 11.8 13.1 38,011 25,000 Volta (31.1) (63.2) (5.7) 100.0 36 (0.0) (0.0) 24,854 7,758 Eastern (34.4) (62.8) (2.8) 100.0 45 (26.2) (0.0) 25,704 12,000 Ashanti 37.0 57.7 5.3 100.0 51 6.1 0.0 34,795 13,929 Brong Ahafo (45.4) (43.9) (10.6) 100.0 43 (25.4) (0.0) 7,000 8,000 Northern 60.9 32.6 6.5 100.0 123 12.0 2.4 30,000 14,521 Upper East (64.6) (28.7) (6.7) 100.0 25 (20.1) (9.5) 20,000 10,603 Upper West * * * 100.0 11 * * 12,344 7,850 Residen ce Urban 47.4 50.1 2.5 100.0 167 18.1 6.1 31,448 15,000 Rural 48.1 45.1 6.9 100.0 304 10.9 0.9 25,000 9,837 Mother's/caretaker’s education None 52.3 40.6 7.0 100.0 183 10.1 6.0 25,000 10,000 Primary 47.2 48.2 4.6 100.0 100 7.9 0.0 25,000 9,979 Middle/JSS 45.5 50.0 4.5 100.0 154 20.0 2.5 30,000 11,617 Secondary+ 36.0 61.9 2.1 100.0 34 22.9 0.0 16,498 13,102 Wealth index quintiles Poorest 51.1 36.8 12.1 100.0 98 3.2 0.0 23,765 8,000 Second 47.7 48.4 3.9 100.0 114 11.4 0.0 30,000 8,000 Middle 44.1 51.1 4.8 100.0 96 10.2 2.0 26,107 10,000 Fourth 45.5 50.3 4.2 100.0 92 17.1 10.9 34,060 12,000 Richest 51.5 48.0 0.5 100.0 71 29.8 1.2 34,927 21,881 Total 47.8 46.8 5.3 100.0 471 13.4 2.9 25,042 10,000 MICS indicator 96 ** MICS indicator 97 An asterisk ‘*’ indicates figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parenthesis ‘( )” are based on 25 – 49 unweighted cases. 53 VII. Environment Environmental issues are of increasing concern because the environment is an essential factor contributing to health, productivity and welfare. Against this background and in recognition of its importance to national development, the survey looks at water sources, treatment, excreta disposal, and durability of housing, among other issues. Water and Sanitation Water requires attention in the life of human beings. Safe water is a basic necessity of good health. Unsafe drinking water can be a significant carrier of diseases. The source of drinking water is of great importance to health since the source determines the water quality and can help minimize fatal diseases such as diarrhoea, bilharzia, typhoid, dysentery, guinea worm, and cholera which are common in the country. The availability and accessibility to improved water sources therefore is essential. The various sources of drinking water in Ghana include pipe borne, borehole, protected well and river/spring, among others. Use of improved water sources The distribution of the population by source of drinking water is shown in Table EN 1. Thirty-eight percent of the population has access to pipe borne water either in their dwelling, yard or plot or public tap. Twenty-nine percent and six percent of the population get their drinking water from boreholes and protected wells respectively. While 5 percent of people depend on sachet water as drinking water, only 0.1 percent depend on bottled water. Overall, 78 percent of the population has improved sources of drinking water. The proportion of the household population with access to piped water increases with the level of education of the household head. The same can be said of the socio-economic status of the household in relation to improved sources of drinking water. Members in households in the richest wealth index quintile have their drinking water mainly from piped (72 percent) and sachet water (20 percent). However, three out of every five poorest households drink from boreholes. More disturbing is the fact that 36 percent of those in poorest households have unimproved sources of water. About half of rural households get their drinking water from boreholes or protected well, and two-thirds of members in urban households drink piped water. There are also strong regional variations in overall prevalence of improved source of drinking water ranging between 53 percent (Volta Region) and 95 percent (Upper West Region). The situation in the Volta Region is considerably worse than in other regions. Nearly nine out of every ten households in Upper West region drink water from boreholes. 54 Table EN.1: Use of improved water sources Percent distribution of household population according to main source of drinking water and percentage of household members using improved drinking water sources, Ghana, 2006 Main source of drinking water Improved sources Unimproved sources Piped into dwelling Piped into yard or plot Public tap/standpipe Borehole Protected well Spring Sachet water Bottled water Unprotected well Rainwater collection Tanker- truck River/stream Dam/lake/ pond/canal/ irrigation channel Missing Total Improved source of drinking water* Number of household members Region Western 3.6 7.3 35.5 22.2 11.1 2.4 1.1 0.0 8.5 0.0 1.1 6.9 0.3 0.0 100.0 83.2 2,451 Central 3.9 7.4 48.7 12.5 4.0 0.1 3.3 0.3 2.7 0.4 0.0 15.5 1.1 0.0 100.0 80.2 2,024 Greater Accra 15.1 15.0 30.4 0.8 0.2 0.0 25.9 0.8 0.1 0.2 4.7 1.8 0.0 5.0 100.0 88.1 3,911 Volta 2.2 3.8 27.7 15.8 0.6 0.8 1.8 0.0 17.4 4.4 0.0 12.7 6.1 6.6 100.0 52.7 1,978 Eastern 1.1 9.3 14.1 31.7 7.3 0.0 3.0 0.0 4.2 0.6 0.1 23.0 5.7 0.0 100.0 66.4 3,099 Ashanti 5.0 10.1 32.1 32.6 8.5 0.8 1.0 0.0 3.2 0.0 1.4 4.9 0.4 0.0 100.0 90.0 3,854 Brong Ahafo 2.9 4.2 24.9 32.3 5.7 0.0 1.7 0.0 7.0 0.2 0.0 21.1 0.0 0.0 100. 0 71.7 2,295 Northern 0.9 6.4 11.9 47.7 5.6 0.5 0.0 0.0 6.4 0.1 0.1 17.1 3.1 0.1 100.0 73.0 3,549 Upper East 1.4 2.6 3.9 65.9 9.0 0.1 0.3 0.0 14.8 0.0 0.0 1.9 0.2 0.0 100.0 83.1 1,134 Upper West 0.5 1.0 2.9 86.8 1.8 1.5 0.4 0.0 1.0 0.0 0.2 2.2 1.7 0.0 100.0 94.8 652 Residence Urban 10.1 16.8 38.8 6.5 6.6 0.3 11.3 0.3 3.5 0.2 2.4 0.7 0.0 2.4 100.0 90.7 10,315 Rural 0.7 2.0 15.8 44.1 4.7 0.7 1.0 0.0 7.3 0.7 0.2 18.9 3.2 0.6 100.0 69.1 14,632 Education of household head None 0.7 3.8 20.4 42.6 4.7 0.8 0.8 0.1 7.2 0.5 0.4 14.1 2.8 1.0 100.0 74.0 8,832 Primary 2.7 4.1 27.6 25.7 4.0 0.7 3.5 0.0 7.9 0.5 1.4 15.4 3.3 3.3 100.0 68.2 3,327 Middle/JSS 4.7 9.1 30.9 22.9 7.2 0.4 5.3 0.1 4.9 0.6 1.6 9.9 1.2 1.3 100.0 80.6 8,665 Secondary+ 14.3 18.5 22.3 12.7 4.8 0.2 16.4 0.4 2.5 0.4 1.3 5.4 0.3 0.5 100.0 89.6 4,123 Wealth index quintiles Poorest 0.0 0.1 1.9 56.8 3.6 1.7 0.0 0.0 7.4 0.3 0.0 21.6 6.6 0.0 100.0 64.1 4,992 Second 0.0 0.5 14.0 41.1 7.9 0.6 0.0 0.0 8.8 0.5 0.0 23.7 2.0 1.0 100.0 64.1 4,984 Middle 0.3 1.8 38.3 28.2 7.1 0.3 0.9 0.0 8.8 1.2 1.5 8.6 0.8 2.2 100.0 76.9 4,991 Fourth 3.9 12.2 45.4 15.1 6.8 0.1 5.1 0.0 3.2 0.4 2.3 3.0 0.0 2.5 100.0 88.6 4,995 Richest 18.7 26.1 27.1 1.6 2.0 0.0 20.4 0.7 0.6 0.2 1.7 0.0 0.0 0.9 100.0 96.6 4,986 Total 4.6 8.1 25.3 28.6 5.5 0.5 5.3 0.1 5.7 0.5 1.1 11.4 1.9 1.3 100.0 78.1 24,947 * MICS indicator 11; MDG indicator 30 55 Even though the proportion population with access to improved source of drinking water is encouraging (78 percent), more than one-fifth of all households still drink water from unimproved sources. Household water treatment Water borne and water based diseases arise from water that is infected mainly through environmental degradation and the disease is transmitted when the water is used for drinking or cooking. If the water is not treated it may be a main conduit of many fatal water borne diseases such as diarrhoea, guinea worm, typhoid fever, cholera, schistosomiasis, trachoma and lead poisoning. Table EN.2 shows the percent distribution of the household population according to drinking water treatment method used in the household as well as the percentage of household members that apply appropriate water treatment methods. Ninety-two percent of Ghana’s population live in households that do not apply any appropriate water treatment method to their drinking water. Of those households that treat their drinking water, the most popular method used is straining through a cloth (4 percent) followed by allowing the water to stand and settle by itself (2 percent). Solar disinfection is the least common method used by households. Treatment of all drinking water sources by households range from 1 percent in the Western and Brong Ahafo regions to 6 percent in Volta and Upper East regions. More households in the richest wealth index (5 percent) treat drinking water than the households found in the lower socio-economic categories; however the poorest households (4 percent) closely follow those in the richest category in the treatment of drinking water. A similar pattern is seen in education of household head. Households where the head has secondary or more education are likely to treat drinking water sources (4 percent) followed by those with no education (4 percent). Urban dwellers are more likely to treat their water than rural dwellers. Households are more likely to treat unimproved drinking water sources (5 percent) than improved sources (3 percent). 56 Table EN.2: Household water treatment Percent distribution of household population according to drinking water treatment method used in the household and percentage of household members that applied an appropriate water treatment method, Ghana, 2006 Water treatment method used in the household None Boil Add bleach / chlorine Strain through a cloth Use water filter Solar disinfection Let it stand and settle Other Don't know All drinking water sources: Appropriate water treatment method * Number of household members Improved drinking water sources: Appropriate water treatment method Number of household members Unimproved drinking water sources: Appropriate water treatment method Number of household members Region Western 96.4 0.9 0.1 0.9 0.5 0.0 1.7 0.0 0.0 1.4 2,451 1.1 2,038 2.8 413 Central 93.4 1.0 0.1 0.4 0.6 0.0 3.9 0.5 0.0 1.7 2,024 1.5 1,551 24.0 473 Greater Accra 94.2 1.6 1.0 0.5 0.7 0.0 2.6 0.1 0.0 3.1 3,911 4.1 2,588 1.3 1,323 Volta 84.4 2.3 1.1 8.5 2.8 0.0 0.6 0.6 0.0 6.1 1,978 4.6 1,007 7.7 971 Eastern 93.0 1.5 1.0 2.9 0.0 0.0 1.3 0.5 0.0 2.6 3,099 2.2 1,967 3.1 1,133 Ashanti 93.1 1.5 1.0 2.5 1.6 0.0 1.2 0.0 0.0 3.9 3,854 4.3 3,487 0.3 367 Brong Ahafo 97.0 0.4 0.9 1.0 0.0 0.0 0.9 0.0 0.0 1.4 2,295 1.7 1,606 0.5 689 Northern 83.0 1.6 0.8 11.4 2.1 0.5 3.5 0.0 0.0 4.7 3,549 1.6 2,597 13.3 952 Upper East 91.6 2.1 2.3 2.5 1.0 1.0 2.4 0.3 0.0 6.0 1,134 4.3 939 14.1 195 Upper West 95.2 1.2 0.4 2.3 1.1 0.0 0.0 0.6 0.0 2.3 652 2.3 617 3.0 35 Residence Urban 92.2 1.4 1.0 2.3 1.2 0.1 2.1 0.1 0.0 3.7 10,315 4.2 8,407 1.3 1,908 Rural 91.6 1.4 0.7 4.3 0.9 0.2 1.9 0.3 0.0 3.1 14,632 1.6 9,991 6.1 4,641 Education of household head None 89.5 1.5 0.9 5.9 1.1 0.3 2.0 0.2 0.0 3.7 8,832 2.5 6,493 7.1 2,339 Primary 91.7 1.1 0.8 3.2 0.8 0.0 2.7 0.1 0.0 2.5 3,327 1.8 2,198 4.0 1,129 Middle/JSS 94.0 1.4 0.8 1.6 0.6 0.0 1.8 0.2 0.0 2.8 8,665 2.6 6,652 3.5 2,013 Secondary+ 92.4 1.4 0.8 2.5 2.0 0.0 1.7 0.2 0.0 4.1 4,123 4.6 3,055 2.6 1,068 Wealth index quintiles Poorest 89.0 1.5 0.7 5.7 1.6 0.3 3.2 0.2 0.0 4.1 4,992 1.4 3,200 9.0 1,792 Second 90.9 1.2 0.8 5.3 0.7 0.1 1.2 0.5 0.0 2.8 4,984 2.0 3,192 4.2 1,792 Middle 93.9 1.5 0.9 2.5 0.5 0.0 1.1 0.1 0.0 2.7 4,991 2.2 3,868 4.6 1,122 Fourth 94.7 1.0 0.9 1.7 0.3 0.1 1.6 0.2 0.0 2.2 4,995 2.3 4,285 1.2 709 Richest 90.7 1.7 0.9 2.3 2.2 0.0 2.8 0.0 0.0 4.7 4,986 5.8 3,851 1.1 1,135 Total 91.8 1.4 0.9 3.5 1.1 0.1 2.0 0.2 0.0 3.3 24,947 2.8 18,397 4.7 6,549 * MICS indicator 13 57 Table EN.3: Time to source of water Percent distribution of households according to time to go to source of drinking water, get water and return, and mean time to source of drinking water, Ghana, 2006 Time to source of drinking water Water on premises Less than 15 minutes 15 minutes to less than 30 minutes 30 minutes to less than 1 hour 1 hour or more DK/Missing Total Mean time to source of drinking water (excluding those on premises) Number of households Region Western 10.9 58.2 18.9 9.2 2.8 0.0 100. 0 14.3 617 Central 14.4 52.1 22.4 9.3 1.8 0.0 100. 0 15.6 576 Greater Accra 33.3 54.3 6.9 3.1 2.3 0.2 100. 0 11.3 1,004 Volta 15.5 38.1 17.3 15.9 12.8 0.4 100. 0 24.9 486 Eastern 14.8 32.1 24.0 21.5 7.1 0.6 100. 0 22.7 758 Ashanti 19.4 49.7 17.4 8.7 4.5 0.2 100. 0 15.5 988 Brong Ahafo 8.7 51.0 26.3 10.7 3.3 0.0 100. 0 15.9 552 Northern 9.4 29.9 26.9 24.9 8.7 0.2 100. 0 26.1 630 Upper East 5.3 36.2 27.0 20.4 11.0 0.1 100. 0 23.9 202 Upper West 3.1 29.5 37.9 26.5 3.0 0.0 100. 0 20.6 126 Residence Urban 32.0 47.6 11.4 6.7 2.0 0.2 100. 0 13.4 2,692 Rural 3.8 43.5 26.7 18.0 7.9 0.2 100. 0 21.1 3,247 Education of household head None 6.4 41.7 26.2 18.1 7.3 0.2 100. 0 21.2 1,830 Primary 9.0 48.2 21.0 13.9 7.9 0.1 100. 0 20.0 802 Middle/JSS 17.6 49.6 17.6 11.1 3.8 0.3 100. 0 16.2 2,203 Secondary+ 36.6 40.2 13.1 7.1 3.0 0.1 100. 0 15.1 1,104 Wealth index quintiles Poorest 0.5 34.9 30.7 24.0 9.7 0.2 100. 0 24.6 949 Second 1.5 43.1 27.9 18.3 8.8 0.4 100. 0 21.2 1,147 Middle 5.4 53.1 23.8 12.9 4.6 0.2 100. 0 17.1 1,285 Fourth 22.3 52.7 13.4 8.6 3.0 0.0 100. 0 14.6 1,341 Richest 51.3 38.3 5.8 3.3 1.3 0.1 100. 0 11.4 1,217 Number of households 16.2 45.3 20.0 13.0 5.3 0.2 100. 0 18.4 5,939 58 Time to source water Table EN.3 shows data on the time it takes households to access their drinking water, Sixty- two percent of households have water on the premises or within 15 minutes. Nevertheless, almost one in five households takes 30 minutes or more to go, get water and return home. Urban dwellers (32 percent) are more likely to get water on the premises than rural dwellers (4 percent). About one half of urban households and about two in five rural households take less than 15 minutes to reach their nearest source of drinking water excluding those who fetch water on their premises. More than two-thirds of households in Western, Central, and Greater Accra, Ashanti, and Brong Ahafo regions access their source of water in less than 15 minutes or have water on premises, compared to one-third of households in Upper West. Thirteen percent of households in Volta and 11 percent of households in Upper East spend more than one hour to their various sources. The mean time for accessing water for households that do not have water in the dwelling is 18 minutes. Rural households get to the source of drinking water and back in 21 minutes, while urban households spend 13 minutes to access their source their drinking water. The mean time spent to get to water and return decreases consistently with education of household head (21 minutes for those with no education and 15 minutes for those with secondary and above. A similar pattern is seen for the wealth index quintile. Person collecting water Table EN.4 is the distribution of households according to the person who usually collects water used in the household so as to know whether fetching drinking water is the responsibility of a particular sex or age group. In all, adult women are more likely to be responsible for fetching drinking water than men and children. In 64 percent of households, adult women collect household water either alone or with children, compared to 17 percent in which adult men do the collection. In 16 percent of households, children are the ones who usually collect water, whether male or female. Even though there is no significant difference between urban adult women (43 percent) and rural adult women (42 percent) who go out to collect drinking water. The contribution of women in collecting water is greater in Northern, Upper East and Upper West regions where in almost 90 percent of households, adult women are the ones who usually collect water, either alone or with their children. The contribution of men is relatively higher in Greater Accra and Western regions. In over one-fifth of households in Western, Ashanti, and Brong Ahafo, it is children who usually collect water. In households with better educated heads, men play a relatively larger role in water collection then in households with less educated heads. 59 Table EN.4: Person collecting water Percent distribution of households according to the usual person collecting water used in the household, Ghana, 2006 Person collecting drinking water Adult woman Adult man Female child (under 15) Male child (under 15) Children(both sexes) Adult woman + child(ren) Adult man + child(ren) Other DK/Missing Total Number of households where water is fetched Region Western 40.1 21.3 3.3 2.9 16.1 14.4 0.6 1.4 0.0 100.0 549 Central 45.0 17.7 3.5 1.3 11.5 12.9 1.8 6.4 0.0 100.0 480 Greater Accra 42.2 22.3 2.6 2.1 4.8 22.5 3.1 0.4 0.0 100.0 570 Volta 50.8 15.7 3.1 0.8 9.4 17.6 1.2 0.8 0.5 100.0 410 Eastern 38.0 18.9 3.1 2.6 12.0 18.6 1.4 4.2 1.2 100.0 644 Ashanti 34.8 17.8 5.1 4.8 13.1 18.9 1.9 3.3 0.4 100.0 788 Brong Ahafo 44.7 12.8 4.6 3.7 12.5 20.3 0.9 0.5 0.0 100.0 500 Northern 49.6 5.7 2.2 0.2 2.3 38.4 0.7 1.0 0.0 100.0 571 Upper East 35.9 5.7 1.5 0.9 4.7 49.6 0.9 0.8 0.0 100.0 191 Upper West 49.0 5.2 3.3 0.0 3.2 38.1 0.6 0.2 0.3 100.0 122 Residence Urban 42.7 20.9 3.8 2.9 8.6 17.6 1.5 2.0 0.1 100.0 1,716 Rural 42.0 13.2 3.2 2.0 10.6 24.8 1.4 2.4 0.4 100.0 3,109 Education of household head None 45.4 7.6 3.6 1.4 9.5 28.8 1.3 2.2 0.2 100.0 1,704 Primary 44.5 17.0 3.3 2.0 8.7 20.4 1.6 1.8 0.7 100.0 723 Middle/JSS 39.2 20.4 3.4 3.3 10.9 18.5 1.6 2.5 0.2 100.0 1,765 Secondary+ 39.8 24.7 3.2 2.5 9.7 16.9 1.0 2.0 0.3 100.0 633 Wealth index quintiles Poorest 46.3 9.5 3.2 0.9 6.2 32.2 0.9 0.7 0.1 100.0 944 Second 42.2 13.6 3.6 2.9 9.3 24.6 1.3 2.1 0.4 100.0 1,129 Middle 41.5 15.7 3.5 2.5 14.8 17.2 1.9 2.5 0.4 100.0 1,213 Fourth 41.4 19.8 3.4 2.4 9.5 18.4 1.1 3.7 0.2 100.0 1,017 Richest 38.4 25.6 3.4 3.3 7.4 18.0 2.2 1.7 0.0 100.0 521 Total 42.2 15.9 3.4 2.3 9.9 22.2 1.4 2.2 0.3 100.0 4,825 60 Table EN.5: Use of sanitary means of excreta disposal Percent distribution of household population according to type of toilet used by the household and the percentage of household members using sanitary means of excreta disposal, Ghana, 2006 Type of toilet facility used by household Improved sanitation facility Unimproved sanitation facility Flush to piped sewer system Flush to septic tank Flush to pit (latrine) Ventilated Improved Pit latrine (VIP) Pit latrine with slab Pit latrine without slab/open pit Bucket No facilities or bush or field Missing Total Percentage of population using sanitary means of excreta disposal * Number of household members Region Western 0.5 8.2 0.4 29.5 37.3 11.3 0.0 12.8 0.0 100.0 75.9 2,451 Central 1.4 5.9 1.0 29.6 24.8 17.9 1.3 18.1 0.0 100.0 62.7 2,024 Greater Accra 5.4 19.6 13.0 36.3 11.0 5.4 0.8 8.1 0.3 100.0 85.4 3,911 Volta 0.9 2.9 0.7 25.5 8.9 30.1 0.3 30.8 0.0 100.0 38.8 1,978 Eastern 1.3 3.3 0.5 24.2 20.3 42.0 2.9 5.5 0.0 100.0 49.6 3,099 Ashanti 4.1 9.9 0.6 46.4 26.1 9.0 0.5 3.4 0.1 100.0 87.0 3,854 Brong Ahafo 0.6 1.4 0.6 40.4 36.0 14.5 0.0 6.4 0.0 100.0 79.1 2,295 Northern 0.0 0.5 0.8 19.7 4.1 1.1 0.9 72.9 0.0 100.0 25.1 3,549 Upper East 0.0 0.4 0.0 11.3 5.7 0.6 0.0 81.9 0.0 100.0 17.5 1,134 Upper West 0.0 6.0 0.2 6.6 4.5 3.4 0.0 78.7 0.7 100.0 17.2 652 Residence Urban 3.8 14.9 5.3 46.5 12.0 7.0 1.7 8.7 0.1 100.0 82.6 10,315 Rural 0.6 1.2 0.6 19.0 23.8 19.0 0.2 35.5 0.1 100.0 45.3 14,632 Education of household head None 0.4 1.8 0.7 22.8 14.7 12.4 0.0 47.1 0.0 100.0 40.4 8,832 Primary 0.4 4.5 1.2 30.4 24.6 17.5 0.8 20.4 0.4 100.0 60.9 3,327 Middle/JSS 1.9 7.0 2.4 37.1 23.7 16.4 1.3 10.1 0.1 100.0 72.1 8,665 Secondary+ 6.6 19.6 7.8 32.6 13.3 9.7 1.4 9.0 0.0 100.0 79.9 4,123 Wealth index quintiles Poorest 0.0 0.0 0.0 1.3 15.7 15.6 0.0 67.4 0.0 100.0 17.0 4,992 Second 0.0 0.0 0.0 16.4 29.4 24.2 0.0 30.0 0.1 100.0 45.7 4,984 Middle 0.3 0.8 0.6 43.6 22.8 17.4 0.5 13.7 0.3 100.0 68.1 4,991 Fourth 1.2 5.4 2.2 53.3 18.7 9.2 1.6 8.3 0.1 100.0 80.9 4,995 Richest 8.1 28.2 9.9 37.4 8.1 3.6 2.0 2.6 0.0 100.0 91.7 4,986 Total 1.9 6.9 2.6 30.4 18.9 14.0 0.8 24.4 0.1 100.0 60.7 24,947 * MICS Indicator 12; MDG Indicator 31 61 Use of sanitary means of excreta disposal Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoea and polio. Table EN5 shows the percent distribution of the household population by the type of toilet facility used. Sanitary facilities were classified into improved and unimproved sanitation facilities. Improved sanitation facilities include: flush toilets connected to sewage systems or septic tanks, ventilated improved pit latrines and pit latrines with slabs. Sixty-one percent of the population is using improved sanitation facilities. The table also shows that improved sanitation is more prevalent in urban areas (83 percent); whereas less than half of the rural population has access to improved sanitary facilities. Differentials at the regional level are significant. Use of improved sanitary facilities is highest in Ashanti, Greater Accra, Brong Ahafo, Western and Central Regions. Residents of the three northern regions are significantly less likely than others to use improved facilities. The majority of population in these regions use bush, fields, or have no toilet facilities. In addition, households in which the head has some form of education were more likely to have access to improved sanitary facilities. Disposal of child’s faeces The manner in which a child’s faeces are disposed may pose serious threats to healthy living, contribute to an unhygienic environment, and facilitate easy transmission of diseases. The study therefore examined what was done to dispose of the stools of children. Table EN.6 presents information on the distribution of children 0-2 years according to place of disposal of child’s faeces and the percentage of children 0-2 years whose stools are disposed of safely. For about two out of every five children, stools are put or rinsed into a toilet or latrine, while for one out of every five, stools are thrown into the garbage (solid waste). A few children (2 percent) to use the toilet /latrine themselves. For most urban children (51 percent), the stools are disposed by putting or rinsing into a toilet or latrine. This disposal method is common also in the rural areas (36 percent) followed by throwing the faeces into the garbage (solid waste) (26 percent). Rinsing or putting a child’s faeces into a toilet or latrine ranges between 2 percent in the Upper West Region and 59 percent in Ashanti and Western regions. Twelve percent of residents in the Upper East Region leave stool in the open. Burying as a method used to dispose of a child’s faeces is high among households in Upper East (25 percent), Northern (20 percent), and Volta (15 percent) regions. The high number of “other” methods of disposal, especially in Volta (35 percent), has been investigated. By far, the majority of observations reflect disposal in rivers or lakes. This phenomenon should have been captured in the questionnaire and during data cleaning, but was not. The survey partners will ensure that this is answer category is added to future implementation. 62 Table EN.6: Disposal of child's faeces Percent distribution of children aged 0-2 years according to place of disposal of child's faeces, and the percentage of children aged 0-2 years whose stools are disposed of safely, Ghana, 2006 What was done to dispose of the stools Child used toilet/ latrine Put/rinsed into toilet or latrine Put/rinsed into drain or ditch Thrown into garbage (solid waste) Buried Left in the open Other DK Missing Total Proportion of children whose stools are disposed of safely * Number of children aged 0-2 years Region Western 2.0 58.7 22.0 11.3 2.7 0.0 3.4 0.0 0.0 100.0 60.7 220 Central 0.7 47.0 17.9 26.2 0.0 0.6 6.2 1.3 0.0 100.0 47.8 166 Greater Accra 2.8 50.5 11.3 23.0 0.7 0.0 3.8 0.0 7.8 100.0 53.3 273 Volta 0.0 33.5 0.7 11.6 14.5 0.0 34.7 0.0 5.0 100.0 33.5 153 Eastern 1.7 55.0 5.2 18.3 2.7 0.3 10.2 0.3 6.4 100.0 56.7 290 Ashanti 4.3 58.7 12.9 19.2 2.4 0.5 0.5 0.4 1.1 100.0 63.0 314 Brong Ahafo 5.1 48.0 30.6 15.9 0.5 0.0 0.0 0.0 0.0 100.0 53.0 169 Northern 1.7 12.7 14.6 38.0 20.1 4.1 5.9 0.0 2.9 100.0 14.4 374 Upper East 0.4 3.9 13.2 31.6 25.0 11.6 8.6 1.7 3.9 100.0 4.4 84 Upper West 0.0 2.2 35.5 38.2 3.0 3.6 16.9 0.0 0.5 100.0 2.2 63 Residence Urban 2.3 50.7 17.2 17.9 3.5 0.2 4.5 0.2 3.4 100.0 53.0 751 Rural 2.2 36.3 13.0 25.6 8.7 2.1 8.7 0.3 2.9 100.0 38.5 1,354 Mother's/Caretaker’s education None 1.3 25.0 17.3 29.3 13.3 3.4 8.3 0.1 2.1 100.0 26.3 778 Primary 1.4 45.9 15.6 19.4 3.9 0.5 9.8 0.4 3.0 100.0 47.3 471 Middle/JSS 3.5 54.0 11.9 18.5 2.6 0.2 4.8 0.4 4.0 100.0 57.5 707 Secondary+ 3.5 54.4 8.8 21.2 2.6 0.6 4.6 0.3 4.1 100.0 57.9 149 Wealth index quintiles Poorest 1.7 17.9 15.3 31.2 16.4 4.3 10.3 0.6 2.3 100.0 19.6 469 Second 1.8 38.6 13.6 25.9 5.7 1.6 10.4 0.0 2.5 100.0 40.4 505 Middle 3.0 45.0 15.5 22.2 4.1 0.4 6.4 0.5 2.7 100.0 48.1 415 Fourth 1.5 56.1 16.8 13.2 4.8 0.2 4.6 0.0 2.7 100.0 57.6 396 Richest 3.5 57.9 10.7 18.7 0.8 0.0 1.9 0.3 6.2 100.0 61.5 319 Total 2.2 41.5 14.5 22.9 6.9 1.5 7.2 0.3 3.1 100.0 43.7 2,105 * MICS indicator 14 63 Use of improved water sources and improved sanitation Table EN.7 gives information on the percentage of the household population using both improved drinking water sources and sanitary means of excreta disposal. Table EN.7: Use of improved water sources and improved sanitation Percentage of household population using both improved drinking water sources and sanitary means of excreta disposal, Ghana, 2006 Percentage of household population using improved sources of drinking water * Percentage of household population using sanitary means of excreta disposal ** Percentage of household population using improved sources of drinking water and using sanitary means of excreta disposal Number of household members Region Western 83.2 75.9 64.8 2,451 Central 80.2 62.7 53.7 2,024 Greater Accra 88.1 85.4 78.4 3,911 Volta 52.7 38.8 26.7 1,978 Eastern 66.4 49.6 38.6 3,099 Ashanti 90.0 87.0 79.7 3,854 Brong Ahafo 71.7 79.1 60.0 2,295 Northern 73.0 25.1 20.7 3,549 Upper East 83.1 17.5 16.5 1,134 Upper West 94.8 17.2 16.4 652 Area Urban 90.7 82.6 76.5 10,315 Rural 69.1 45.3 34.5 14,632 Education of household head None 74.0 40.4 31.7 8,832 Primary 68.2 60.9 47.3 3,327 Middle/JSS 80.6 72.1 62.9 8,665 Secondary+ 89.6 79.9 75.5 4,123 Wealth index quintiles Poorest 64.1 17.0 8.3 4,992 Second 64.1 45.7 32.6 4,984 Middle 76.9 68.1 55.4 4,991 Fourth 88.6 80.9 74.3 4,995 Richest 96.6 91.7 88.7 4,986 Total 78.1 60.7 51.9 24,947 * MICS indicator 11; MDG indicator 30 ** MICS indicator 12; MDG indicator 31 Over half of household members (52 percent) use improved sources of drinking water and sanitary means of excreta disposal. Seventy-seven percent of urban households use both improved sources of drinking water and sanitary means of excreta disposal, while only 35 percent of rural households use both methods. In the regions, use of both facilities varies considerably from 16-17 percent in the two upper regions to 80 percent in Ashanti. There is a marked difference between rich and poor, ranging from less than 10 percent in the poorest to almost 90 percent in the richest quintile. 64 Durability of Housing The quality of dwellings used by people is often associated with health implications. Also, the type of flooring material used, the general condition of the dwelling, its location, and durability are indicators of the socio-economic status of the household. Table EN.8 presents information on the percentage of households and household members living in dwellings in urban areas that are not considered durable by background characteristics. One out of every ten urban dwellings is in poor condition but only one in fifty are vulnerable to accidents. No house is however located in a hazardous area. Few dwellings, about three percent, are considered non durable, and few, about four percent, have natural floor material. Table EN.8: Durability of housing Percentage of households and household members living in dwellings in urban areas that are not considered durable by background characteristics, Ghana, 2006 Background Characteristics Dwelling has natural floor material Dwelling is in poor condition Dwelling is vulnerable to accidents Dwelling located in hazardous location Percent of households living in dwellings considered non durable * Number of households Percent of household members living in dwelling considered non- durable Number of household members Education of household head None 9.0 19.8 1.4 0.0 4.7 490 3.9 2,205 Primary 7.8 9.8 3.4 0.0 6.5 308 4.9 1,161 Middle/JSS 3.6 8.2 2.2 0.0 3.2 1,122 3.4 4,169 Secondary+ 1.2 5.0 1.8 0.0 1.8 773 1.9 2,779 Wealth index quintiles Poorest (72.7) (56.9) (0.0) (0.0) (39.0) 28 30.0 147 Second 23.2 33.1 0.0 0.0 10.8 119 9.1 523 Middle 7.2 16.5 0.9 0.0 2.2 530 2.0 1,925 Fourth 2.8 8.0 3.1 0.0 3.7 929 4.0 3,275 Richest 0.5 3.7 2.1 0.0 2.1 1,085 1.7 4,445 Total 4.4 9.6 2.1 0.0 3.4 2,692 3.3 10,315 * MICS Indicator 94 Figures in parentheses ‘( )’ are based on 25 – 49 unweighted cases. The households with highly educated heads (1 and 5 percent) are not as likely to use natural floor material nor have their dwellings in poor condition as those with household heads without education (9 and 20 percent). Similarly, those household members with high socio- economic status are less likely to use natural floor materials than those with low socio- economic status. This table indirectly shows the disproportionate distribution of wealth as well. The wealth quintiles result in a roughly equal count of households in each quintile for the total sample. The above shows that of the 20 percent of the poorest households in this survey, only a tiny fraction in urban areas. 65 VIII. Reproductive Health Contraception Appropriate family planning is important to the health of women and children by preventing pregnancies that are too early or too late, extending the period between births and limiting the number of children. A World Fit for Children goal is that all couples have access to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Approximately 17 percent of women currently married or in union reported current use of contraception (Table RH.1). Almost 14 percent of the women use a modern method of contraception and three percent practice a traditional method of family planning. The most popular method currently used is the injection which is used by about 6 percent of the married women in Ghana. The next most popular method is the pill, which accounts for 5 percent of married women. The male condom is used by less than two percent of partners of married women. Two percent of married couples use periodic abstinence as a method of contraception. Less than one percent use female sterilisation, female condoms, the IUD, implants, withdrawal, vaginal methods, or the lactational amenorrhea method (LAM). Contraceptive prevalence is highest in the Greater Accra Region (29 percent) with Central Region recording the second highest contraceptive use (23 percent). In terms of modern methods however, Central Region records the highest use of 19 percent compared to Greater Accra (17 percent). For any method of contraception, the Northern Region has the lowest use of eight percent whilst Western Region (7 percent) records the lowest in terms of modern methods. The results further indicate that married women in urban areas (21 percent) are more likely to use contraceptives than those residing in rural areas (13 percent) in Ghana. Only about eight percent of married women aged 15-19 years currently use a method of contraception compared to 15 percent of 20-24-year-olds and seven percent of older women 45-49 years. Use is highest among women age 25-39. Women’s educational level is strongly associated with contraceptive use. The percentage of women using any method of contraception rises from nine among those with no education to 17 among women with primary education, and to 24 among women with middle/JSS education. Surprisingly it declines to 20 percent among women with secondary or higher education. In addition to differences in use, the method mix varies by education. About half of contraceptive users with no education use injectables. For those with primary education, the choice is between the pill and injectables at almost equal proportions. Partners of women with secondary or higher education are likely to use the male condom more than those with lower educational levels. 66 Table RH.1: Use of contraception Percentage of women aged 15-49 years married or in union who are using (or whose partner is using) a contraceptive method, Ghana, 2006 Percent of women (currently married or in union) who are using: Not using any method Female sterilization Pill IUD Injections Implants Condom Female condom Diaphragm/foam/ jelly LAM Periodic abstinence Withdrawal Other Total Any modern method Any traditional method Any method * Number of women currently married or in union Region Western 91.4 0.2 3.7 0.5 2.2 0.2 0.0 0.0 0.0 1.0 0.6 0.3 0.0 100.0 6.7 1.8 8.6 345 Central 77.4 0.4 8.2 0.7 7.8 1.7 0.1 0.0 0.0 1.4 0.6 1.0 0.7 100.0 18.9 3.7 22.6 251 Greater Accra 71.2 0.6 4.0 1.3 6.5 1.2 2.9 0.1 0.7 0.5 9.6 0.4 1.1 100.0 17.3 11.6 28.8 518 Volta 86.6 0.5 2.1 0.0 7.8 0.6 1.0 0.0 0.6 0.0 0.9 0.0 0.0 100.0 12.5 0.9 13.4 315 Eastern 82.1 0.3 4.9 0.0 6.5 0.4 3.7 0.0 0.5 0.0 1.3 0.0 0.3 100.0 16.3 1.6 17.9 414 Ashanti 81.8 0.8 7.1 0.0 4.4 0.3 2.2 0.0 0.2 0.5 2.2 0.2 0.2 100.0 15.0 3.2 18.2 526 Brong Ahafo 82.9 0.4 8.0 0.0 5.5 0.5 1.4 0.0 0.0 0.9 0.0 0.0 0.5 100.0 15.7 1.4 17.1 294 Northern 91.7 0.1 2.2 0.2 5.2 0.0 0.3 0.3 0.0 0.0 0.0 0.0 0.0 100.0 8.3 0.0 8.3 551 Upper East 85.0 0.0 3.5 0.0 10.4 0.6 0.5 0.0 0.0 0.0 0.0 0.0 0.0 100.0 15.0 0.0 15.0 150 Upper West 90.7 0.0 2.6 0.3 6.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 9.3 0.0 9.3 100 Residence Urban 78.7 0.5 5.1 0.8 6.0 0.7 2.5 0.0 0.5 0.5 4.2 0.1 0.5 100.0 16.0 5.3 21.3 1,412 Rural 86.6 0.3 4.4 0.0 5.7 0.5 0.8 0.1 0.1 0.4 0.7 0.2 0.2 100.0 11.9 1.5 13.4 2,053 Age 15-19 91.9 0.0 1.9 0.0 0.8 0.0 3.4 0.0 0.0 0.0 2.1 0.0 0.0 100.0 6.0 2.1 8.1 98 20-24 84.6 0.0 6.5 0.0 3.6 0.7 1.9 0.0 0.2 1.1 0.9 0.3 0.2 100.0 12.9 2.5 15.4 514 15-24 85.8 0.0 5.7 0.0 3.1 0.6 2.1 0.0 0.1 0.9 1.1 0.2 0.2 100.0 11.8 2.4 14.2 613 25-29 80.0 0.0 5.5 0.3 6.3 0.3 2.7 0.0 0.4 0.9 2.9 0.1 0.5 100.0 15.6 4.5 20.0 737 30-34 81.7 0.3 4.0 0.5 7.0 1.3 1.1 0.0 0.0 0.4 3.2 0.0 0.5 100.0 14.3 4.0 18.3 646 35-39 80.0 0.5 5.9 0.5 7.3 0.8 0.5 0.1 0.7 0.0 2.9 0.3 0.6 100.0 16.2 3.8 20.0 608 40-44 84.1 1.0 5.2 0.1 6.6 0.0 1.1 0.3 0.2 0.0 1.2 0.2 0.0 100.0 14.5 1.4 15.9 462 45-49 93.0 0.9 0.2 0.5 3.9 0.0 0.9 0.0 0.0 0.0 0.3 0.2 0.0 100.0 6.4 0.6 7.0 399 Number of living children 0 92.9 0.0 1.2 0.0 0.5 0.0 3.7 0.0 0.0 0.0 1.7 0.0 0.0 100.0 5.4 1.7 7.1 293 1 83.4 0.0 6.4 0.0 3.6 0.6 2.3 0.0 0.2 0.7 2.7 0.2 0.0 100.0 13.1 3.6 16.6 559 2 81.8 0.2 4.5 0.8 5.4 0.9 1.7 0.0 0.5 0.9 2.7 0.2 0.4 100.0 14.0 4.2 18.2 640 3 80.1 0.3 5.4 0.4 8.5 0.9 1.1 0.1 0.3 0.4 1.9 0.0 0.7 100.0 16.9 3.0 19.9 592 4+ 83.4 0.8 4.5 0.3 6.8 0.4 0.7 0.1 0.2 0.2 1.8 0.3 0.3 100.0 13.9 2.6 16.6 1,380 Mother's/Caretaker’s education None 91.0 0.3 2.1 0.2 5.4 0.3 0.3 0.0 0.1 0.2 0.1 0.1 0.0 100.0 8.7 0.3 9.0 1,258 Primary 83.2 0.4 5.4 0.1 5.8 0.6 1.4 0.0 0.3 0.4 1.4 0.0 0.9 100.0 14.1 2.7 16.8 676 Middle/JSS 76.3 0.4 7.1 0.3 6.5 0.9 2.0 0.1 0.5 0.8 4.4 0.4 0.4 100.0 17.7 6.0 23.7 1,200 Secondary+ 80.3 0.7 4.3 1.3 5.0 0.1 4.6 0.1 0.0 0.2 3.0 0.0 0.3 100.0 16.1 3.6 19.7 331 Wealth index quintiles Poorest 92.9 0.0 2.7 0.0 3.4 0.1 0.1 0.0 0.0 0.3 0.2 0.4 0.0 100.0 6.3 0.8 7.1 682 Second 86.7 0.1 3.7 0.0 5.4 1.2 0.9 0.0 0.3 0.1 0.8 0.1 0.7 100.0 11.6 1.7 13.3 703 Middle 84.2 0.8 6.0 0.1 6.3 0.1 1.2 0.0 0.0 0.3 0.9 0.1 0.0 100.0 14.5 1.3 15.8 657 Fourth 78.7 0.3 6.6 0.1 8.1 1.1 1.8 0.2 0.3 0.8 1.5 0.2 0.2 100.0 18.6 2.7 21.3 712 Richest 74.9 0.8 4.4 1.3 5.8 0.1 3.3 0.1 0.7 0.6 7.0 0.1 0.8 100.0 16.6 8.5 25.1 711 Total 83.4 0.4 4.7 0.3 5.8 0.6 1.5 0.1 0.3 0.4 2.1 0.2 0.3 100.0 13.6 3.1 16.6 3,465 * MICS indicator 21; MDG indicator 19C 67 The results also show some association between the number of living children and contraceptive use. Married women with no child are far less likely to use any method of family planning compared with their counterparts with four children or more. Thus, contraceptive use tends to rise with increasing number of living children although for married women with four or more living children, contraceptive use is lower than among those with three living children. Contraceptive use rises from a low of seven percent among married women in the poorest wealth index quintile to a high of 25 percent among those in the richest wealth index quintile. Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their unborn children. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to educate women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections and diseases (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. The World Health Organisation (WHO) recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care and its guidelines are specific on the content on antenatal care visits, which include: · Blood pressure measurement · Urine testing for bateriuria and proteinuria · Blood testing to detect syphilis and severe anaemia · Weight/height measurement 68 Table RH.2: Antenatal care provider Percent distribution of women aged 15-49 who gave birth in the two years preceding the survey by type of personnel providing antenatal care, Ghana, 2006 Person providing antenatal care Medical doctor Nurse/mid-wife Auxiliary midwife Traditional birth attendant Community health worker Relative/Friend Other/missing No antenatal care received Total Any skilled personnel * Num ber of women who gave birth in the preceding two years Region Western 28.2 56.0 5.5 3.6 4.6 0.0 0.0 2.0 100.0 89.8 144 Central 21.0 71.7 0.0 0.0 3.1 0.0 0.0 4.1 100.0 92.8 105 Greater Accra 41.7 52.0 0.0 0.0 0.9 0.0 0.0 5.3 100.0 93.8 167 Volta 17.4 68.3 0.0 0.0 1.9 1.9 0.0 10.5 100.0 85.7 97 Eastern 30.7 60.6 0.0 0.9 0.0 0.0 0.0 7.8 100.0 91.3 182 Ashanti 32.7 59.7 5.1 0.6 0.3 0.0 0.0 1.7 100.0 97.5 207 Brong Ahafo 12.2 77.2 5.1 3.5 0.0 0.0 0.0 2.0 100.0 94.5 107 Northern 10.9 72.7 6.0 0.9 0.0 0.0 0.0 9.4 100.0 89.7 260 Upper East 2.6 83.1 5.3 0.0 1.0 0.0 0.0 8.0 100.0 90.9 58 Upper West 5.3 90.1 0.7 0.0 1.7 0.0 0.8 1.4 100.0 96.0 37 Residence Urban 33.9 60.5 1.6 1.2 0.0 0.0 0.0 2.8 100.0 96.0 468 Rural 17.8 68.4 4.0 1.0 1.7 0.2 0.0 7.0 100.0 90.1 897 Age 15-19 11.1 76.9 2.8 1.1 2.2 0.0 0.0 6.0 100.0 90.7 89 20-24 18.1 69.9 2.5 1.3 1.3 0.0 0.1 6.8 100.0 90.5 317 25-29 24.1 67.4 2.3 0.6 0.5 0.0 0.0 5.1 100.0 93.8 380 30-34 29.4 60.6 4.2 0.8 0.4 0.7 0.0 4.0 100.0 94.1 269 35-39 26.3 62.2 2.6 0.9 2.8 0.0 0.0 5.3 100.0 91.0 210 40-44 25.9 55.1 6.9 3.7 0.2 0.0 0.0 8.3 100.0 87.8 75 45-49 21.6 63.9 8.5 0.0 0.0 0.0 0.0 5.9 100.0 94.1 25 Mother's/Caretaker’s education None 15.3 67.5 5.0 1.2 1.3 0.0 0.1 9.6 100.0 87.9 503 Primary 22.0 67.4 1.9 1.2 0.4 0.3 0.0 6.8 100.0 91.4 300 Middle/JSS 28.3 65.5 2.6 0.8 1.5 0.2 0.0 1.0 100.0 96.4 465 Secondary+ 44.5 52.0 0.0 1.0 0.2 0.0 0.0 2.3 100.0 96.5 97 Wealth index quintiles Poorest 12.8 71.7 3.9 0.2 0.6 0.0 0.1 10.8 100.0 88.4 313 Second 15.9 67.6 5.2 2.0 2.0 0.0 0.0 7.3 100.0 88.7 325 Middle 24.8 62.9 3.9 1.3 2.6 0.7 0.0 3.9 100.0 91.6 260 Fourth 26.3 69.4 1.5 0.7 0.0 0.0 0.0 2.1 100.0 97.1 267 Richest 46.1 51.8 0.0 1.0 0.0 0.0 0.0 1.2 100.0 97.9 199 Total 23.3 65.7 3.1 1.0 1.1 0.1 0.0 5.5 100.0 92.1 1,365 * MICS indicator 20 Figures in parenthesis ‘( )’ are based on 25 – 49 unweighted cases. 69 Coverage of antenatal care is relatively high in Ghana with 92 percent of women receiving antenatal care at least once from a skilled provider during the pregnancy (Table RH.2). Antenatal care coverage in both the urban (96 percent) and rural (90 percent) areas are high. The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding the survey is presented in Table RH.2. The results indicate that 23 percent of all antenatal care in Ghana is provided by a medical doctor, 66 percent from a nurse/midwife and 3 percent from an auxiliary midwife. The Ashanti Region records the highest proportion of antenatal care provision by professional health personnel (98 percent) while the Volta Region has the lowest figure of 86 percent. Adolescents and women aged 40- 44 are also less likely to have antenatal care provided by trained health personnel compared with women 45-49 years. The proportion of antenatal care provision by trained health professionals rises with education of the woman. The types of services pregnant women received are shown in Table RH.3. Overall, nine in 10 pregnant women had their blood pressure checked and weight measured during antenatal care. Eighty percent had their urine tested and 78 percent had a blood sample taken respectively for laboratory examination. For all the four tests/measurements carried out, the Brong Ahafo region records the highest proportion while the lowest is in the Northern Region except for blood measurement which is lower in Volta Region and weight measurement for which Eastern Region records the lowest. Coverage for these types of antenatal care services increases with women’s education and wealth quintile. 70 Table RH.3: Antenatal care Percentage of pregnant women receiving antenatal care among women aged 15-49 years who gave birth in two years preceding the survey and percentage of pregnant women receiving specific care as part of the antenatal care received, Ghana, 2006. Percent of pregnant women who had: Percent of pregnant women receiving ANC one or more times during pregnancy* Blood sample taken Blood pressure measured Urine specimen taken Weight measured Number of women who gave birth in two years preceding survey Region Western 98.0 88.4 92.0 90.6 90.7 144 Central 95.9 85.1 92.9 86.6 92.6 105 Greater Accra 94.7 92.5 93.8 94.0 92.1 167 Volta 89.5 67.8 83.3 69.7 85.8 97 Eastern 92.2 87.1 90.9 89.5 85.1 182 Ashanti 98.3 90.0 96.5 95.0 95.7 207 Brong Ahafo 98.0 93.9 98.0 96.5 98.0 107 Northern 90.6 46.3 87.9 48.0 87.5 260 Upper East 92.0 69.9 88.7 60.5 91.3 58 Upper West 98.6 66.5 97.7 59.1 97.6 37 Residence Urban 97.2 91.0 94.9 92.3 94.4 468 Rural 93.0 71.7 90.4 73.5 89.0 897 Age 15-19 94.0 71.9 87.4 78.3 88.1 89 20-24 93.2 75.0 89.4 76.6 90.9 317 15-24 93.4 74.3 89.0 77.0 90.3 406 25-29 94.9 78.4 93.4 81.0 91.8 380 30-34 96.0 86.7 94.1 87.5 92.6 269 35-39 94.7 78.7 93.5 78.3 91.1 210 40-44 91.7 73.7 87.3 78.5 83.4 75 45-49 (94.1) (62.3) (94.1) (50.5) (87.1) 25 Mother's/Caretaker’s education None 90.4 61.7 87.1 63.3 85.9 503 Primary 93.2 80.8 91.5 83.8 90.9 300 Middle/JSS 99.0 91.2 96.3 92.4 94.8 465 Secondary+ 97.7 95.0 97.7 94.7 97.7 97 Wealth index quintiles Poorest 89.2 58.7 86.7 57.1 86.8 313 Second 92.7 71.9 89.4 77.0 84.5 325 Middle 96.1 84.1 92.7 88.0 94.2 260 Fourth 97.9 89.0 95.6 90.7 95.2 267 Richest 98.8 97.5 98.2 95.9 97.3 199 Total 94.5 78.3 91.9 80.0 90.9 1,365 * MICS indicator 44 Figures in parenthesis ‘( )’ are based on 25 – 49 unweighted cases. 71 Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A World Fit for Children’s goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. About half of births occurring in the 2 years prior to the MICS survey were delivered by skilled personnel (Table RH.4). This percentage is highest in the Greater Accra Region (83 percent) with seven regions below 50. The more educated a woman is, the more likely she is to have delivered with the assistance of a skilled attendant. While there appears to be no consistent pattern by age, adolescents (15-19 years) are less likely to have supervised delivery by skilled personnel. About two in five of the births (41 percent) in the 2 years prior to the MICS survey were delivered with the assistance of a nurse/midwife while doctors assisted with a small proportion (9 percent). 21 percent of births were delivered by trained traditional birth attendants (TBAs) and about one in 10 by untrained TBAs. The highest proportion of 18 and 16 percent of deliveries in Northern and Eastern Regions respectively were done by untrained TBAs. Fifteen percent of births were delivered by either relatives or friends with the highest proportions recorded in Upper West (38 percent) and Volta (31 percent) regions. 72 Table RH.4: Assistance during delivery Percent distribution of women aged 15-49 with a birth in two years preceding the survey by type of personnel assisting at delivery, Ghana, 2006 Person assisting at delivery Medical doctor Nurse/midwife Trained Traditional birth attendant Untrained Traditional birth attendant Relative/friend Other/missing No attendant Total Any skilled personnel * Delivered in health facility ** Number of women who gave birth in preceding two years Region Western 2.0 37.6 42.3 9.2 5.8 0.7 2.3 100.0 39.6 39.4 144 Central 5.9 37.7 35.1 7.1 8.7 1.9 3.6 100.0 43.6 45.0 105 Greater Accra 28.7 54.3 3.7 1.0 8.8 0.0 3.6 100.0 83.0 83.1 1

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