Ghana - Multiple Indicator Cluster Survey - 2008

Publication date: 2008

MICS Consolidated Report for Central, Northern, Upper East and Upper West Regions M ICS C o n so lid ated R ep o rt Consolidated Report High Impact Rapid Delivery (HIRD) Supplementary Survey, 2007/2008 (District MICS) High Impact Rapid Delivery Supplementary Survey, 2007/2008 (District MICS) H igh Im pact R apid D elivery Supplem entary Survey, 2007/2008 (D istrict M IC S) High Impact Rapid Delivery (HIRD) Supplementary Survey (District MICS), 2007/2008 June, 2009 CONSOLIDATED REPORT FOR CENTRAL, NORTHERN, UPPER EAST AND UPPER WEST REGIONS Summary Table of Findings - CENTRAL REGION MICS and MDG Indicators Topic MICS Indi cator Number MDG Indicator Number Indicator Value 1 13 Under-five mortality rate Per thousand Child mortality 2 14 Infant mortality rate Per thousand 6 4 Underweight prevalence Percent 7 Stunting prevalence Percent Nutritional status 8 Wasting prevalence Percent 45 Timely initiation of breastfeeding Percent 15 Exclusive breastfeeding rate Percent Continued breastfeeding rate at 12-15 months Percent 16 at 20-23 months Percent 17 Timely complementary fee ding rate Percent 18 Frequency of complementary feeding Percent Breastfeeding 19 Adequately fed infants Percent Salt iodization 41 Iodized salt consumption Percent 42 Vitamin A supplemen tation (under-fives) PercentVitamin A 43 Vitamin A supplementation (post-partum mothers) Percent 9 Low birth weight infants PercentLow birth weight 10 Infants weighed at birth Percent 25 Tuberculosis immuniza tion coverage Percent 26 Polio immunization co verage Percent 27 DPT immunization cove rage Percent 28 15 Measles immunization coverage Percent 31 Fully immunized children Percent 29 Hepatitis B immunization cove rage Percent Immunization 30 Yellow fever immunization coverage 33 Use of oral dehydration therapy (ORT) Percent 34 Home management of diarrhoea Percent 23 Care seeking for suspected pneumonia Percent Care of illness 22 Antibiotic treatment of su spected pneumonia Percent Percent Tetanus toxoid 32 Neonatal tetanus protection Percent CHILD HEALTH NUTRITION 83 55 18.6 20.6 4.6 32.6 58.1 94.3 33.3 69.0 48.3 52.6 21.5 83.3 40.0 8.5 32.3 94.9 87.8 89.1 86.1 71.8 89.1 84.4 78.5 30.4 27.5 26.8 38.6 Solid fuel use 24 29 Solid fuels Percent 36 Household availability of insecticide- nets (ITNs)treated Percent 37 22 Under-fives sleeping under insecticide- netstreated Percent 38 Under-fives sleeping under mosquito nets Percent Malaria 39 40 22 Antimalarial treatment (under-fives) Women receiving IPT for malaria during pregnancy Percent Percent 90.1 37.8 40.9 42.6 32.7 53.1 CHILD MORTALITY 2 96 Source of supplies (from public sources) Insecticide treated nets Percent Antimalarials Percent 97 Cost of supplies (median costs) Insecticide treated nets public sources GHC Private sources GHC Antimalarials public sources GHC Source and cost of supplies Private sources GHC 11 30 Use of improved drinking water sources Percent 13 Water treatment Percent 12 31 Use of improved sanitation facilities Percent Water and Sanitation 14 Disposal of child's faeces Percent Contraception and unmet need 21 19c Contraceptive prevalence Percent 20 Antenatal care PercentMaternal and newborn health 44 Content of antenatal care Blood test taken Percent Blood pressure measured Percent Urine specimen taken Percent Weight measured Percent 4 17 Skilled attendant at deli very Percent 5 Institutional deliveries Percent 46 Support for learning Percent 47 Father's support for learning Percent 48 Support for learning: children’s books Percent 49 Support for learning: non-children’s books Percent 50 Support for learning: materials for play Percent Child development 51 Non-adult care Percent CHILD DEVELOPMENT ENVIRONMENT REPRODUCTIVE HEALTH EDUCATION 52 Pre-school attendance Percent 53 School readiness Percent 54 Net intake rate in primary education Percent 55 6 Net primary school attendance rate Percent 56 Net secondary school attendance rate Percent 58 Transition rate to secondary school Percent 59 7b Primary completion rate Percent Education 61 9 Gender parity index primary school secondary school Ratio Ratio Literacy 60 8 Adult literacy rate (youth) women Percent 83.7 52.4 2.0 2.0 3.0 1.0 79.2 1.5 64.0 42.9 17.2 92.7 81.5 92.3 84.9 91.6 49.1 47.5 24.5 40.7 7.7 43.3 17.8 20.2 65.8 95.4 59.6 87.6 52.5 98.3 33.6 1.00 0.92 75.5 3 82 19b Comprehensive knowledge about HIV prevention among young women 15-24 years Percent 89 Knowledge of mother-to-child transmission of HIV Women Percent 86 Attitude towards women with HIV/AIDS Percent 87 Women who know where to be tested for HIV Percent 88 Women who have been tested for HIV Percent 90 Counselling coverage for the prevention of mother-to-child transmission of HIV Percent HIV/AIDS knowledge and attitudes 91 Testing coverage for the prevention of mother-to-child transmission of HIV Percent 84 Sex before age 15 women Percent 92 Age-mixing among sexual partners Percent 83 19a Condom use with non-regular partners Women Percent Sexual behaviour 85 Higher risk sex in the last year women Percent 75 Prevalence of orphans Percent 78 Children’s living arrangements Percent Support to orphaned and vulnerable children 77 20 School attendance of orphans versus non-orphans Ratio Birth registration 62 Birth registration Percent 71 Child labour Percent 72 Labourer students Percent Child labour 73 Student labourers Percent Child discipline 74 Child discipline Any psychological/physical punishment Percent 67 Marriage before age 15 Marriage before age 18 Percent Percent 68 Young women aged 15-19 currently married/in union Percent 70 Polygamy Percent Early marriage and polygyny 69 Spousal age difference women aged 15-19 women aged 20-24 Percent Percent 66 Approval for FGM/C PercentFemale genital mutilation/ cutting 63 Prevalence of female genital mutilation/cutting (FGM/C) Percent Domestic violence 100 Attitudes towards domestic violence Women Percent Disability 101 Child disability Percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN CHILD PROTECTION 59.6 25.8 96.1 25.9 84.3 4.5 32.5 11.4 13.8 14.5 13.4 1.5 0.4 61 11.7 16.5 74.3 2.8 47.2 11.8 37.9 9.1 9.7 35.7 24.3 6.6 17.4 1.04 Registered with NHIS 31.0 PercentNational Health Insurance Scheme Valid card holders 52.3 Percent NATIONAL HEALTH INSURANCE SCHEME 4 Summary Table of Findings - NORTHERN REGION MICS and MDG Indicators Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY 1 13 Under -five mortality rate per thousand Child mortality 2 14 Infant mortality rate per thousand NUTRITION 6 4 Underweight prevalence 29.3 64 120 Percent 7 Stunting prevalence 31.1 Percent Nutritional status 8 Wasting prevalence 8.8 Percent 45 Timely initiation of breastfeeding 43.0 Percent 15 Exclusive breastfeeding rate 67.2 Percent Continued breastfeeding rate at 12-15 months 98.5 Percent 16 at 20-23 months 80.3 Percent 17 Timely complementary feeding rate 53.2 Percent 18 Frequency of complementary feeding 48.3 Percent Breastfeeding 19 Adequately fed infants 58.2 Percent Salt iodization 41 Iodized salt consumption MICS DHS 11.4 11.9 Percent Percent 42 Vitamin A supplementation (under-fives) 50.7 PercentVitamin A 43 Vitamin A supplementation (post-partum mothers) 38.8 Percent 9 Low birth weig ht infants 7.8 PercentLow birth weight 10 Infants weighed at birth 10.3 Percent 25 Tuberculosis immunization coverage 95.4 Percent 26 Polio immunization co verage 84.6 Percent 27 DPTHepbHib immunization coverage 85.9 Percent 28 15 Measles immunization coverage 81.8 Percent 31 Fully immunized children 69.3 Percent Immunization 30 Yellow fever immunization coverage 80.9 Percent Tetanus toxoid 32 Neonatal tetanus protection 71.8 Percent 33 Use of oral dehydration therapy (ORT) 29.0 Percent 34 Home management of diarrhoea 25.6 Percent Care of illness CHILD HEALTH 5 23 Care seeking for suspected pneumonia Percent 22 Antibiotic treatment of suspected pneumonia 25.5 35.6 Percent Solid fuel use 24 29 Solid fuels 97.3 Percent Malaria 36 Household availability of insecticide-treated nets (ITNs) 54.7 49.6 Percent Percent96 Source of supplies (from public sources) Insecticide treated nets 78.0 Percent Antimalarials 55.6 Percent 97 Cost of supplies (median costs) Insecticide treated nets public sources 1.00 GHC private sources 1.50 GHC Antimalarials public sources 2.00 GHC Source and cost of supplies private sources 0.80 GHC ENVIRONMENT 11 30 Use of improved drinking water sources 61.8 Percent 13 Water treatment 3.9 Percent 12 31 Use of improved sanitation facilities 21.4 Percent Water and Sanitation 14 Disposal of child's faeces 5.9 Percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 7.8 Percent 20 Antenatal care 88.9 92.0 PercentMaternal and newborn health 44 Content of antenatal care Blood test taken 54.2 Percent Blood pressure measured 89.0 Percent Urine specimen taken 50.1 Percent Weight measured 89.4 Percent 4 17 Skilled attendant at deli very 19.3 Percent 5 Institutional deliveries 17.5 Percent CHILD DEVELOPMENT 46 Support for learning 19.1 Percent 47 Father's support for learning 52.2 Percent 48 Support for learning: children’s books 4.7 Percent 49 Support for learning: non-children’s books 24.3 Percent 50 Support for learning: materials for play 16.6 Percent Child development 51 Non-adult care 35.4 Percent Percent 6 52 Pre-school attendance 40.2 Percent 53 School readiness 80.4 Percent 54 Net intake rate in primary education 47.5 Percent 55 6 Net primary school attendance rate 60.2 Percent 56 Net secondary school attendance rate 25.1 Percent 58 Transition rate to secondary school 89.1 Percent 59 7b Primary completion rate 14.0 Percent Education 61 9 Gender parity index primary school secondary school 1.00 0.76 Ratio Ratio Literacy 60 8 Adult literacy rate (youth) women 31.5 Percent CHILD PROTECTION Birth registratio n 62 Birth registration 51.6 Percent 71 Child labour 45.1 Percent 72 Labourer students 62.3 Percent Child labour 73 Student labourers 41.4 Percent Child discipline 74 Child discipline Any psychological/physical punishment 84.3 Percent 67 Marriage before age 15 Marriage before age 18 5.6 34.3 Percent Percent 68 Young women aged 15-19 currently married/in union 14.0 Percent 70 Polygamy 42.8 Percent Early marriage and polygyny 69 Spousal age difference women aged 15-19 women aged 20-24 13.6 17.9 Percent Percent 66 Approval for FGM/C 4.7 PercentFemale genital mutilation/ cutting 63 Prevalence of female genital mutilation/cutting (FGM/C) 4.5 Percent Domestic violence 100 Attitudes towards domestic violence women 83.0 Percent Disability 101 Child disability 16.7 Percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 82 19b Comprehensive knowledge about HIV prevention among young women 15-24 years 17.6 Percent 89 Knowledge of mother-to-child transmission of HIVwomen 64.9 Percent 86 Attitude towards women with HIV/AIDS 3.1 Percent 87 Women who know where to be tested for HIV 30.5 Percent 88 Women who have been tested for HIV 5.4 Percent HIV/AIDS knowledge and attitudes EDUCATION 7 90 Counselling coverage for the prevention of mother -to-child transmission of HIV 34.4 Percent 91 Testing coverage for the prevention of mother -to-child transmission of HIV 4.1 Percent 84 Sex before age 15 women 6.6 Percent 92 Age-mixing among sexual partners 13.5 Percent 83 19a Condom use with non-regular partners 34.3 Percent Sexual behaviour 85 Higher risk sex in the last year 31.5 Percent 75 Prevalence of orphans 7.3 PercentSupport to orphaned and vulnerable children 78 Children’s living arrangements 4.9 Percent Women, 15 - 49 years registered with NHIS 28.9 Percent Valid Card holders 60.2 Percent National Health Insurance Scheme NATIONAL HEALTH INSURANCE SCHEME Women Women 8 Summary Table of Findings - UPPER EAST REGION MICS and MDG Indicators Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY 1 13 Under-five mortality rate 93 per thousandChild mortality 2 14 Infant mortality rate 57 per thousand NUTRITION 6 4 Underweight prevalence 24.6 percent 7 Stunting prevalence 23.4 percent Nutritional status 8 Wasting prevalence 8.1 percent 45 Timely initiation of breastfeeding 51.2 percent 15 Exclusive breastfeeding rate 54.9 percent Continued breastfeeding rate at 12-15 months 97.5 percent 16 at 20-23 months 84.3 percent 17 Timely complementary feeding rate 52.7 percent 18 Frequency of complementary feeding 44.7 percent Breastfeeding 19 Adequately fed infants 50.1 percent Salt iodization 41 Iodized salt consumption 11.8 percent 42 Vitamin A supplementation (under -fives) 48.3 percentVitamin A 43 Vitamin A supplementation (post -partum mothers) 61.7 percent 9 Low birth weight infants 8.5 percentLow birth weight 10 Infants weighed at birth 25.4 percent CHILD HEALTH 25 Tuberculosis immunization coverage 96.9 percent 26 Polio immunization coverage 92.1 percent 27 DPT immunization coverage 87.9 Percent 28 15 Measles immunization coverage 90.7 Percent 31 Fully immunized children 79.3 Percent 29 Hepatitis B immunization coverage 87.9 Percent Immunization 30 Yellow fever immunization coverage 89.2 Percent Tetanus toxoid 32 Neonatal tetanus protection 80.7 Percent 33 Use of oral dehydration therapy (ORT) 46.3 Percent 34 Home management of diarrhoea 17.8 Percent 23 Care seeking for suspected pneumonia 47.7 Percent Care of illness 22 Antibiotic treatment of suspected pneumonia 60.4 Percent Solid fuel use 24 29 Solid fuels 94.9 Percent 36 Household availability of insecticide-treated nets (ITNs) 52.5 Percent 37 22 Under-fives sleeping under insecticide-treated nets 56.3 Percent 38 Under-fives sleeping under mosquito nets 61.1 Percent 39 22 Antimalarial treatment (under-fives) 36.5 Percent Malaria 40 Intermittent preventive malaria treatment (pregnant women) 63.8 Percent 96 Source of supplies (from public sources) Insecticide treated nets 86.3 Percent Antimalarials 61.2 Percent 97 Cost of supplies (median costs) Insecticide treated nets public sources 1.00 GHC private sources 3.00 GHC Antimalarials public sources 2.50 GHC Source and cost of supplies private sources 1.00 GHC 9 ENVIRONMENT 11 30 Use of improved drinking water sources 81.7 Percent 13 Water treatment 2.5 Percent 12 31 Use of improved sanitation facilities 11.0 Percent Water and Sanitation 14 Disposal of child's faeces 3.2 Percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 12.6 Percent 20 Antenatal care 94.8 PercentMaternal and newborn health 44 Content of antenatal care Blood test taken 77.7 Percent Blood pressure measured 96.2 Percent Urine specimen taken 71.0 Percent Weight measured 96.9 Percent 4 17 Skilled attendant at delivery 39.9 Percent 5 Institutional deliveries 37.9 Percent CHILD DEVELOPMENT 46 Support for learning 11.4 Percent 47 Father's support for learning 43.8 Percent 48 Support for learning: children’s books 4.6 Percent 49 Support for learning: non-children’s books 32.4 Percent 50 Support for learning: materials for play 19.5 Percent Child development 51 Non-adult care 29.3 Percent EDUCATION 52 Pre-school attendance 42.8 Percent 53 School readiness 84.2 Percent 54 Net intake rate in primary education 57.0 Percent 55 6 Net primary school attendance rate 75.4 Percent 56 Net secondary school attendance rate 29.8 Percent 57 7 Children reaching grade five Percent 58 Transition rate to secondary school 91.5 Percent 59 7b Primary completion rate 14.4 Percent Education 61 9 Gender parity index primary school secondary school 1.02 1.00 ratio ratio Literacy 60 8 Adult literacy rate (youth) women 43.9 CHILD PROTECTION Birth registration 62 Birth registration 59.1 Percent 71 Child labour 30.4 Percent 72 Labourer students 73.5 Percent Child labour 73 Student labourers 28.8 Percent Child discipline 74 Child discipline Any psychological/physical punishment 86.1 Percent 67 Marriage before age 15 Marriage before age 18 5.3 40.1 68 Young women aged 15-19 currently married/in union 11.3 Percent 70 Polygamy 39.6 Early marriage and polygyny 69 Spousal age difference women aged 15-19 women aged 20-24 25.3 25.7 66 Approval for FGM/C 1.3Female genital mutilation/ cutting 63 Prevalence of female genital mutilation/cutting (FGM/C) 19.8 Domestic violence 100 Attitudes towards domestic violence women 74.7 Disability 101 Child disability 14.5 Percent Percent Percent Percent Percent Percent Percent Percent Percent Percent 10 HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 82 19b Comprehensive knowledge about HIV prevention among young women 15 - 24 years 30.8 Percent 89 Knowledge of mother- to-child transmission of HIV women 67.7 Percent 86 Attitude towards women with HIV/AIDS 4.9 Percent 87 Women who know where to be tested for HIV 45.7 Percent 88 Women who have been tested for HIV 9.9 Percent 90 Counselling coverage for the prevention of mother-to-child transmission of HIV 61.3 Percent HIV/AIDS knowledge and attitudes 91 Testing coverage for the prevention of mother -to-child transmission of HIV 13.2 Percent 84 Women who have sex before age 15 4.5 Percent 92 Age-mixing among sexual partners 18.1 Percent 83 19a Women condom use with non-regular partners 63.5 Percent Sexual behaviour 85 Higher risk sex in the last year women 10.3 Percent 75 Prevalence of orphans 8.9 PercentSupport to orphaned and vulnerable children 78 Children’s living arrangements 9.1 Percent NATIONAL HEALTH INSURANCE SCHEME Registered with NHIS 30.9 Percent 59 Percent National Health Insurance Scheme Valid Card holders 11 Summary Table of Findings - UPPER WEST REGION MICS and MDG Indicators Topic MICS Indi cator Number MDG Indicator Number Indicator Value 1 13 Under -five mortality rate Per thousand Child mortality 2 14 Infant mortality rate Per thousand 6 4 Underweight prevalence 18.6 Percent 7 Stunting prevalence 18.9 Percent Nutritional status 8 Wasting prevalence 6.0 Percent 45 Timely initiation of breastfeeding 40.3 Percent 15 Exclusive breastfeeding rate 92.1 Percent Continued breastfeeding rate at 12-15 months 100 Percent 16 at 20-23 months 84.7 Percent 17 Timely complementary fee ding rate 58.7 47.5 66.4 Percent 18 Frequency of complementary feeding Percent Breastfeeding 19 Adequately fed infants Percent Salt iodization 41 Iodized salt consumption 15.0 Percent 42 Vitamin A supplementation (under-fives) 51.7 PercentVitamin A 43 Vitamin A supplementation (post-partum mothers) 66.7 Percent 9 Low birth weight infants 6.3 PercentLow birth weight 10 Infants weighed at birth 22.9 Percent 25 Tuberculosis immunization coverage 97.8 Percent 26 Polio immunization coverage 94.2 Percent 27 DPT immunization coverage 96.2 Percent 28 15 Measles immunization coverage 97.9 Percent 31 Fully immunized children 90.1 Percent 29 Hepatitis B immunization coverage PErcent Immunization 30 Yellow fever immunization coverage 33 Use of oral dehydration therapy (ORT) 41.8 Percent 34 Home management of diarrhoea 7.4 Percent 23 Care seeking for suspected pneumonia 46.7 Percent Care of illness 22 Antibiotic treatment of suspected pneumonia 49.6 Percent Percent Tetanus toxoid 32 Neonatal tetanus protection 73.4 Percent CHILD HEALTH NUTRITION 62 113 36 66.8 Percent 37 22 77.6 Percent 38 79.2 Percent Malaria Household availability of insecticide-treated nets (ITNs) Under -fives sleeping under insecticide-treated nets Under -fives sleeping under mosquito nets 94.6 97.5 CHILD MORTALITY 12 96 Source of supplies (from public sources) Insecticide treated nets 86.7 percent Antimalarials 65.2 percent 97 Cost of supplies (median costs) Insecticide treated nets public sources 2.00 GHC Private sources 2.00 GHC Antimalarials public sources 1.50 GHC Source and cost of supplies Private sources 0.95 GHC 11 30 Use of improved drinking water sources percent 13 Water treatment 2.2 87.1 percent 12 31 Use of improved sanitation facilities 20.9 10.7 percent Water and Sanitation 14 Disposal of child's faeces percent Contraception and unmet need 21 19c Contraceptive prevalence 17.1 percent 20 Antenatal care 91.8 percentMaternal and newborn health 44 Content of antenatal care Blood test taken 75.0 percent Blood pressure measured 89.2 percent Urine specimen taken 60.6 percent Weight measured 90.4 percent 4 17 Skilled attendant at delivery 41.5 percent 5 Institutional deliveries 39.9 percent 46 Support for learning 19.5 Percent 47 Father's support for learning 27.1 Percent 48 Support for learning: children’s books 1.7 Percent 49 Support for learning: non-children’s books 32.3 Percent 50 Support for learning: mat erials for play 11.4 Percent Child development 51 Non-adult care 22.8 percent CHILD DEVELOPMENT ENVIRONMENT REPRODUCTIVE HEALTH EDUCATION 52 Pre-school attendance 47.7 percent 53 School readiness 90.0 percent 54 Net intake rate in primary education 51.8 percent 55 6 Net primary school attendance rate 68.9 percent 56 Net secondary school attendance rate 29.9 percent 57 7 Children reaching grade five 86.9 percent 58 Transition rate to secondary school 90.8 percent 59 7b Primary completion rate 12.4 Percent Education 61 9 Gender parity index primary school secondary school 1.16 1.19 ratio ratio Literacy 60 8 Adult literacy rate (youth) women 49.5 percent 39 22 45.1 percent 40 Anti -malarial treatment (under-fives) Intermittent preventive malaria treatment (pregnant women) 68.8 percent 13 82 19b Comprehensive knowledge about HIV prevention among young women 15-24 years 16.2 PErcent 89 Knowledge of mother- to-child transmission of HIV Women 72.3 Percent 86 Attitude towards women with HIV/AIDS 4.1 Percent 87 Women who know where to be tested for HIV 43.4 Percent 88 Women who have been tested for HIV 11.7 Percent 90 Counselling coverage for the prevention of mother-to-child transmission of HIV 45.9 Percent HIV/AIDS knowledge and attitudes 91 Testing coverage for the prevention of mother-to-child transmission of HIV 12.1 Percent 84 Sex before age 15 women 7.3 Percent 92 Age-mixing among sexual partners 18.4 Percent 83 19a Condom use with non-regular partners Women 64.0 Percent Sexual behaviour 85 Higher risk sex in the last year women 31.2 Percent 75 Prevalence of orphans 7.9 Percent 78 Children’s living arrangements 10.9 PeRcent Support to orphaned and vulnerable children Birth registration 62 Birth registration 53.0 Percent 71 Child labour 48.5 Percent 72 Labourer students 68.9 Percent Child labour 73 Student labourers 45.8 Percent Child discipline 74 Child discipline Any psychological/physical punishment 91.1 Percent 67 Marriage before age 15 Marriage before age 18 10.0 42.8 Percent Percent 68 Young women aged 15-19 currently married/in union 8.3 Percent 70 Polygamy 34.4 Percent Early marriage and polygyny 69 Spousal age difference women aged 15-19 women aged 20-24 28.1 26.3 Percent Percent 66 Approval for FGM/C 5.1 PercentFemale genital mutilation/ cutting 63 Prevalence of female genital mutilation/cutting (FGM/C) 49.4 Percent Domestic violence 100 Attitudes towards domestic violence Women 84.1 Percent Disability 101 Child disability 17.4 Percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN NATIONAL HEALTH INSURANCE SCHEME CHILD PROTECTION Women 15-49 years Registered with NHIS 40.2 Percent Valid card holders 74.8 Percent National Health Insurance Scheme 14 SUMMARY TABLE OF FINDINGS TABLE OF CONTENTS 15 PREFACE 21 ACKNOWLEDGEMENTS EXECUTIVE SUMMARY 23 I. INTRODUCTION 53 II. SAMPLE AND SURVEY METHODOLOGY 55 III. SAMPLE COVERAGE AND CHARACTERISTICS 58 IV INFANT AND CHILD MORTALITY 66 V. NUTRITION 78 VI. CHILD HEALTH 95 Central Region 2 22 Central Region 23 Northern Region 30 Upper East region 38 Upper West Region 45 Background and Objectives 53 Survey Objectives 53 Sample Design 55 Questionnaires 56 Training and Fieldwork 57 Data Processing 57 Sample coverage and Response Rate 58 Household Characteristics 59 Characteristics of Respondents 63 Definitions 66 Assessment of Data Quality 67 Levels and Trends of Early Childhood Mortality 68 Socio-economic Differentials in Childhood Mortality 70 Demographic Characteristics and Childhood Mortality 73 High-risk Fertility Behavior 76 Nutritional Status 78 Breastfeeding 80 Salt Iodization 87 Vitamin A Supplement 90 Low Birth Weight 93 Immunization 95 Tetanus toxoid 97 Oral Rehydration Treatment 99 Care seeking and Antibiotic Treatment of Children with Suspected Pneumonia 101 Northern Region 5 Upper East Region 9 Upper West Region 12 LIST OF TABLES 17 LIST OF FIGURES 19 LIST OF ABBREVIATIONS AND ACRONYMS 20 Table of Contents 15 Solid Fuel Use 106 Malaria 109 Sources and Costs of Supplies for ITNs and Antimalarials 114 Use of improved and unimproved water sources 116 Household water treatment 118 Use of sanitary means of excreta disposal 122 Disposal of child's faeces 124 Use of improved water sources and improved sanitation 125 Durability of Housing 127 Antenatal care 130 Children left alone or with other children 140 Pre-School Attendance and School Readiness 141 Primary and Secondary School Participation 143 Adult Literacy 150 Births registration 152 Child Labour 154 Student labourers 155 Domestic violence 164 Child disability 166 Knowledge of HIV Transmission 168 Comprehensive knowledge of HIV methods and transmission 170 Knowledge of mother to child transmission 171 Attitude towards people living with HIV and AIDS 173 Knowledge of facility for HIV testing 175 Sexual Behaviour Related to HIV Transmission 178 Orphans and Vulnerable Children 182 National Health Insurance Registration 184 Validity of National Health Insurance Card 185 National Health Insurance Benefits 187 VII. ENVIRONMENT 116 VIII. REPRODUCTIVE HEALTH 128 IX. CHILD DEVELOPMENT 137 X. EDUCATION 141 XI. CHILD PROTECTION 152 XII. HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 168 XIII. NATIONAL HEALTH INSURANCE 184 Assistance at Delivery 135 Early marriage and polygamy 158 Spousal age difference 161 Female genital mutilation/cutting 162 Annex A: Sampling Calculations 190 Annex B: List of Personnel involved in Survey 193 Annex C: Sampling Errors 196 Annex D: Data Quality Tables 209 Annex E: Indicators for Global and National Reporting 217 Annex F: Questionaires 228 LIST OF REFERENCES 189 ANNEXES 190 16 Table HH1: Results of Household and Individual Interviews 59 Table HH2: Household age distribution by sex 60 Table HH3: Household Composition 62 Table HH4: Women's Background characteristics 63 Table HH4A: Adult Literacy 64 Table HH5: Children's background Characteristics 65 Table CM.1 Early childhood mortality rates 69 Table CM.2 Early childhood mortality rates by socioeconomic characteristics 71 Table CM.3 Early childhood mortality rates by demographic characteristics 74 Table CM.5 High-risk fertility behavior 77 Table NU1: Child malnutrition 79 Table NU2: Initial Breastfeeding 81 Table NU3: Breastfeeding 84 Table NU4: Adequately fed infants 86 Table NU5: Iodized Salt consumption (MICS) 88 Table NU5A: Iodized salt consumption (DHS) 90 Table NU6: Children's Vitamin A Supplementation 92 Table NU7: Post-partum mother's Vitamin A Supplementation 93 Table NU8: Low Birth Weight Infants 94 Table CH1: Vaccination in first year of life 95 Table CH2: Vaccination by background characteristics 97 Table CH3: Neonatal tetanus protection 98 Table CH4: Home Management of Diarrhea 100 Table CH7: Antibiotic treatment of pneumonia 104 Table CH8: Solid Fuel Use 107 Table CH9: Solid fuel use by type of stove or fire 108 Table CH10: Availability of Mosquito and insecticide treated nets 109 Table CH11: Children sleeping under bed nets 110 Table CH12: Treatment of children with anti-malaria drugs 112 Table CH13: Intermittent preventive treatment for malaria 113 Table CH14: Source of supplies for ITNs 114 Table CH15: Source and Cost of supplies for Anti-malarials 115 Table EN1: Use of improved water source 117 Table EN2: Household water treatment 119 Table EN3: Time to source of water 120 Table EN4: Person collecting water 121 Table EN5: Use of sanitary means of excreta disposal 123 Table EN5A: Shared use of improved sanitation facilities 124 Table EN6: Disposal of Children's faeces 125 Table EN7: Use of improved water sources and improved sanitation 126 Table EN8: Durability of housing 127 Table RH1: Use of contraception 129 Table RH2: Antenatal care provider 131 Table RH3: Antenatal care content 132 Table RH3.1: utilization Table CH 5: Source and cost of supplies of oral rehydration salts 101 Table CH6: Care Seeking for suspected Pneumonia 103 Antenatal care 134 List of Tables 17 Table RH5: Assistance during delivery 136 Table CD1: Family support for learning 138 Table CD2: Learning materials 139 Table CD3: Children left alone or with other children 140 Table ED1: Early childhood education 143 Table ED2: Primary school entry 144 Table ED3: Primary school net attendance ratio 145 Table ED4: Secondary school attendance ratio 146 Table ED4A: Secondary school aged children attending primary school 147 Table ED5: Children reading grade 5 148 Table ED6: Primary school completion and transition to secondary education 149 Table ED7: Education gender parity 150 Table ED8: Adult Literacy 151 Table CP1: Birth Registration 153 Table CP2: Child Labour 155 Table CP3: Labourer students and student labourers 156 Table CP4: Child Discipline 158 Table CP5: Early marriage and polygyny 159 Table CP5A: Marital Status and polygyny 160 Table CP6: Spousal age difference 161 Table CP7: Female Genital Mutilation/Cutting (FGM/C) 163 Table CP9: Attitudes towards domestic violence 165 Table CP10: Child Disability 167 Table HA1: Knowledge of preventing HIV transmission 169 Table HA2: Identifying misconceptions about HIV/AIDS 170 Table HA3: Comprehensive knowledge of HIV/AIDS transmission 171 Table HA4: Knowledge of mother to child HIV transmission 172 Table HA5: Attitude towards people living with HIV/AIDS 174 Table HA6: Knowledge of facility for HIV Testing 176 Table HA7: HIV Testing and Counselling coverage during antenatal care 177 Table HA8: Sexual Behaviour that increase risk of HIV infection 179 Table HA9A: Condom use at last high risk sex 180 Table HA9B: Condom use at last high risk sex 181 Tab le HA10: Children's living arrangements and orphanhood 183 Table WNH.1: National Health Insurance Scheme registration 185 Table WNH.2: National Health Insurance Scheme registration and card validity 186 Table WNH.3: National Health Insurance Scheme registration and benefits received 188 18 List of Figures Figure HH1: Population Pyramid by age and sex 61 Figure CM.1: Trends in Under-five Mortality at 0-4 years, 5-9 years and 10-14 years before Survey 70 Figure CM.2: Under-five Mortality by Area of Residence 72 Figure CM.3: Under-5 Mortality by selected Demographic Characteristics 75 Figure NU.1: Percentage of Children under-five who are undernourished 80 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth 82 Figure NU3: Infant feeding patterns by age: Percent distribution of children aged less than 3 years by feeding pattern by age group 85 Figure NU4: Percent of households consuming adequately iodized salt 89 Figure CH.1: Percentage of children 12-23 months immunized against childhood diseases before their first birthday 96 19 AIDS Acquired Immune Deficiency Syndrome AMA Accra Metropolitan Authority 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 KMA Kumasi Metropolitan Authority 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 List of Abbreviations and Acronyms 20 T his report presents the results of the district level Multiple Indicators Cluster Survey (MICS) con- ducted May to December, 2007 to provide indicators for the High Impact Rapid Delivery (HIRD) programme. The survey was preceded by the 2006 MICS, which was conducted by the Ghana Statistical Service with support from the Ministry of Health and UNICEF Ghana, and provided national and regional statistics and indicators. A number of new interventions have been implemented by the Government in the recent past, which will have an impact on indicators and are expected to change over a short period of time. The Ministry of Health has put a strong emphasis on scaling-up of the High Impact Rapid Delivery approach (HIRD) to achieving MDGs 4 and 5 which was adopted for national implementation after the successful evaluation and docu- mentation of the lessons learnt from the Upper East pilot. As a supplementary MICS survey, the current survey responds to the need to have baseline data to support the implementation of the HIRD intervention in the Upper West, Northern and Central Regions. To this end, it was designed to provide district level indicators to monitor progress on issues relating to women and children in these regions. The HIRD Supplementary Survey was developed within the framework of the MICS, and employed the same methodologies with minor modifications made to the 2006 MICS questionnaire. It was implemented by UNICEF with technical assistance from the Ministry of Health (MOH) and the Ghana Statistical Service (GSS). The survey findings present a wealth of data for monitoring the situation of women and children, in gen- eral, and in the particular context of the Millennium Development Goals (MDGs), for these target regions. They would also enhance the effectiveness of implementation of programmes, such as the Integrated Management of Childhood Illness (IMCI) and the United States Government President's Emergency Plan for AIDS Relief and malaria, among others. Dr. Grace Bediako Government Statistician Preface 21 The successful execution of the High Impact Rapid Delivery (HIRD) Supplementary survey (District MICS), 2007/2008 was due to the invaluable assistance given by all collaborating agencies, institutions, organisations and individuals to whom we owe a great deal of gratitude. UNICEF Ghana initiated and funded the project, and we appreciate its effort in helping to organise the survey, which involved staff from New York. We are also grateful to it for its immense and diverse contributions ranging from expert visits, local technical assistance, procurement and administration. We also thank the Danish Government for financing the National Health Insurance module through the Ministry of Health. We appreciate the work done by the Survey Steering Committee for its immense contribution to the implementation of the survey. We acknowledge the Ministry of Health (MoH) for its substantial contribution to the survey, releasing staff to serve on the secretariat and participating in the fieldwork. We are grateful to the entire project staff of the survey for its tireless work, dedication to duty and other contributions in the different phases of the survey. We give our sincerest gratitude to field survey personnel for their dedication and professionalism that has produced data of very good quality. The contribution of other staff in the Ghana Statistical Service and Ministry of Health who worked behind the scenes in various ways to assist the survey team is acknowledged. Their names have been printed in the appendix in recognition of their contribution. We thank the contributors to the survey and 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 success of the 2007/2008 HIRD Supplementary Survey. Acknowledgements 22 Household Characteristics Characteristics of Respondents Child Mortality Nutritional Status � � � � � � � � � � � � � � � � Children less than 15 years account for 42 percent of the population of Central region. Forty percent of households are headed by women in the region. Thirty-six of the households in the region reported at least one child under 5 years and 66 percent have at least one child under 18 years. 2-3 households members constitute one-third of all households, and 4-5 household members consti- tute 26 percent of households in the Central region. Sixty-four percent of women live in the rural areas. The age distribution shows that only 4 percent of respondents are in the 15-24 age group. Results also reveal that two out of every three women are currently married or in union. Five percent of women have never been married and 88 percent have given birth at least once. About one in every four women in the region have primary education, 6 percent have a secondary or higher education, and 51 percent of the women are categorized as literate in Central region. Infant mortality rate is 55 deaths per 1,000 live births and under-five mortality rate is 83 deaths per 1,000 live births. Neonatal mortality is estimated at 29 deaths per 1,000 live births. This means that one out of every four under-fiv deaths in region occur during the neonatal period. Under-five mortality experienced by male children (100 deaths per 1,000 live births) is 18 percent higher than that experienced by female children (82 deaths per 1,000 live births). Birth interval also affects survival of children; when there is less than two years between pregnancies; infant mortality for children born less than two-year birth interval is 100 deaths per 1,000, and reduces to 55 deaths per 1,000 live births (an estimated 46percent reduction) when the birth interval is 2 or 3 years. First births and higher order births generally face an elevated risk of mortality. Infant mortality for birth order seven and higher is 79 deaths per 1,000 live births, compared to 48 deaths per 1,000 live births order 2-3. Approximately one in every five children below the age of 5 years in Central region is underweight. Twenty-one percent of children in the region are stunted or too short for their age, while five percent are wasted or too thin for their height. Very few (one percent) of under five children in the region can be said to be overweight. Underweight is more prevalent in male children (21 percent) compared to female children (17 percent). The same can be said of the other forms of malnutrition. A higher percentage of children aged 12-23 months are malnourished compared to children who are younger and older. Executive Summary - Central Region 23 Breastfeeding Salt Iodization Vitamin A Supplement Low Birth Weight Immunization Tetanus Toxoid Oral Rehydration Treatment Care Seeking and Antibiotic Treatment of Pneumonia � � � � � � � � � � � � � � � � Thirty-three percent of women breastfed their new-born within an hour of birth, while 77 percent breastfed their children within one day of birth. Fifty-eight percent of children aged less than six months are exclusively breastfed. Sixty-nine percent of children aged 6-9 months are receiving breast milk and solid or semi-solid foods. One in every five households was found to consume adequately iodised salt. About 21 percent of house- holds consumed iodated salt that had less than 15 parts per million (ppm), and in as high as 48 percent of households salt was not iodised. Use of adequately iodised salt is higher in urban households (31 percent), compared to rural households (16 percent). There is also a direct relationship between consumption of adequately iodised salt and education level of household head. Survey results reveal that 83 percent of children aged 6-59 months had received a high dose of Vitamin A supplement within the six months prior to the survey; five percent of children aged 6-59 months had never received Vitamin A supplement. Forty percent of women with a birth two years prior to the survey had received a high dose of Vitamin A supplement before their baby was 8 weeks old. Overall, only one in three births in the region were weighed at birth and nine percent of the infants weigh below 2500 grams. Seventy-two percent of children aged 12-23 months are fully immunized before their first birthday and more than 81 percent of children 12-23 months have all the required vaccinations against childhood diseases. Approximately 95 percent of children aged 12-23 months received a BCG vaccination by the age of 12 months. The coverage for measles vaccines by 12 months is lower than other vaccines at 86 percent, while immunization against measles by second birthday increases to 93 percent. Ninety-nine percent of children aged 12-23 months receive polio 1 by age 12 months and the third dose, this reduces to 88 percent. Polio dose given at birth is just above 50 percent. Sixty-eight percent of mothers in the Central region received at least two doses of tetanus toxoid vaccine during their last pregnancy, and 78 percent of mothers were fully protected against tetanus. Fourteen percent of children in Central region had diarrhoea in the two weeks prior to the survey, and 28 percent of children with diarrhoea were managed at home. Two percent of children with diarrhoea were given the recommended homemade fluids while 29 percent were given fluid from the ORS packet. Twenty-seven percent of children under-five years with suspected pneumonia were taken to an appropriate provider. 24 Solid Fuel Use Malaria Water and Sanitation Time to Source Water Person Collecting Water Use of Sanitary Means of Excreta Disposal � � � � � � � � � � � � � � � � � � � � Overall, 90 percent of all households in the Central region are using solid fuels for cooking. Education level of head of households also gives a clear indication that higher education has a positive relationship with the use of open stove. Forty percent of households had at least one mosquito net, of which, 38 percent are insecticide treated nets (ITNs). Forty-one percent of the children under-five years sleep under an ITN. The use of ITN is higher in the rural areas (43 percent) than in the urban areas (37 percent). For households with ITNs, 84 percent obtained them from the public sector. Eighteen percent of children under-five were ill with fever two weeks preceding the survey. Preva- lence of fever peaked at 12-23 months old (22 percent). Sixteen percent of children with fever were given chloroquine and less than two percent were given SP. Of children with fever, 43percent are treated with an appropriate anti-malarial drug and 33 percent received the drug within 24 hours of onset of symptoms. Urban children are more likely than rural children to be treated appropriately for fever. Seventy-eight percent of women in the Central region who gave birth in preceding two years received medicine to prevent malaria during pregnancy. Seventy-nine percent of households in Central region have improved sources of drinking water. Boreholes constitute 36 percent of the improved sources, while 5 percent of the population have water piped into own dwelling or piped into yard or plot. Thirty-two percent of households access improved water through public taps/standpipe. Unprotected wells constitute the largest proportion of unimproved sources (4 percent). Ninety-seven percent of households in Central region do not apply any appropriate water treatment method to their drinking water. Almost half (47 percent) of the households in Central region have water on the premises or within 15 minutes. The mean time for accessing water by households that do not have water in dwelling is 19 minutes. Rural households get to the source and back in 21 minutes, while urban households spend 17 minutes. Less than 5 percent of households that do not have water in own dwelling spend an hour or more to source drinking water. Adult women are more likely to be responsible for fetching drinking water than men and children. In 47 percent of households, adult women collect household water alone, compared to only 18 percent of adult men. In six percent of the households, children normally collect water, although female children are more likely to collect water (4 percent) compared to male children. Sixty-four percent of the population is using improved sanitation facilities; Improved sanitation is more prevalent in urban areas (78 percent) than in rural areas (57percent). Households whose heads have little or no education are less likely to use improved health facilities (60 percent) compared with households whose head has secondary or higher education (79 percent). Out of the proportion using any of the categories classified as improved, 90 percent share the facility with other households. 25 � � � � � � � � � � � � � � � � � � � About 67 percent of the households share a toilet facility among ten or more households, 12 percent among 2-4 households and 9 percent among 5-9 households. Forty-three percent of children's stool is disposed off safely in the Central region. The most common form of disposal is by throwing the faeces into the garbage (38 percent). In Central region, slightly over half of the households use both improved drinking water sources and sanitary means of disposal of excreta. Sixty-seven percent of households in the urban areas have both improved sources of drinking water and excreta disposal, compared to only 44 percent of rural households. No house in urban areas in the Central region is located in a hazardous location; however, 5 percent of the dwellings are in poor condition and 1 percent of households live in dwellings considered non durable. Majority of women aged 15-49 years married or in union do not use any form of contraception (83 percent). Fifteen percent of women using contraceptives use modern methods, compared to 2 percent using traditional methods. Both the pill and injections are the most popular methods of contraception used in Central region, each used by 6 percent of married women. The percentage of women using any method of contraception rises from 12 percent among those with little or no education to 24 percent among women with secondary or higher education. Ninety-three percent of women received antenatal care one or more times during their last pregnancy. Seventy-two percent of the pregnant women made at least the four antenatal care visits recommended by WHO. Most of the pregnant women in the region had all the assessments done; 82 percent had blood sample taken, 85 percent had urine specimen taken, 92 percent had blood pressure taken, while 92 percent had their weight measured. Majority (85 percent) of the women aged 15-49 years were provided with antenatal care by a nurse or midwife. Women living in urban areas were more likely to be provided with ANC by a medical doctor (13 percent) than their rural counterpart (5 percent). Half of all births in Central region were delivered with the assistance of skilled personnel (medical doctor, nurse/midwife). Forty-five percent of the births in two years prior to the survey were delivered with assistance of a nurse or midwife, while doctors assisted with the delivery of 5 percent of births. Thirty-one percent of births were delivered by trained traditional birth attendants. In Central region, 48 percent of all births that occurred in the two years prior to the survey took place in a health facility; women in urban areas are more likely to delivery in health facilities (62 percent) compared to women in rural areas (41 percent). Mothers with education and living in urban areas and from the richest households are more likely to have skilled personnel assisting them during deliveries and also deliver in a health facility. Disposal of child's faeces Use of Improved Water Sources and Improved Sanitation Durability of Dwelling Contraception Antenatal Care Assistance at Delivery 26 Child Development Pre-school Attendance and School Readiness Primary and Secondary School participation Literacy Birth Registration Child Labour Child Discipline � � � � � � � � � � � � � � � � � � On average, 25 percent of household members are engaged with children under-five years in four activities that promote learning and school readiness. In the Central region, household members in urban areas engage more with children than their rural counterparts (27 and 23 percent respectively). There is greater engagement by adults with higher education than those with little or no education. One in five children under-five years were left with inadequate care and 7 percent were left along the week preceding the survey. Sixty-six percent of children aged 36-59 months are attending pre-school in Central region. Children whose mothers have secondary or higher education are more likely to attend pre-school (83 percent), compared to children whose mothers have little or no education (57 percent. Of children who are of primary school entry age in Central region, 60 percent are attending the first grade of primary school. Eight-eight percent of children of primary school age in Central region are attending primary school or secondary school. Twelve percent of children are out of school when they are supposed to be participat- ing in school. Secondary school net attendance ratio is just over 50 percent in Central region. The gender parity index (GPI) for primary school is 1.0, indicating there is no difference in school attendance between boys and girls. GPI for secondary school is 0.92, indicating that there are more boys attending school compared to girls. Two in every three females aged 15-24 years in the Central region is literate. The literacy rate is strongly and positively associated with urban residence, higher levels of education, and higher household wealth. The births of 60 percent of children under-five years in Central region have been registered. Birth registration is higher for children in urban areas (66 percent), compared to those in rural areas (57 percent). 'Birth registration costs too much' (29 percent) and 'Didn't know child should be registered' (17 per- cent) were the two main reasons for non-registration of births. The type of labour activity engaged in by children include unpaid work (6 percent), household chores for 28+ hours/ week (2 percent) and working for family business (21 percent). Twenty-six percent of children in the region are engaged in activities that amount to child labour. More children in the rural areas (28 percent) than children in urban (18 percent) participate in child labour-related activities . Eighty-four percent of children aged 2- 14 years were subjected to at least one form psychological or physical punishment by their mothers/caretakers or other household members. Sixty-four percent are subjected to minor physical punishment, whereas 5 percent are subjected to severe physical punishment. 27 Early Marriage and Polygyny Female Genital Mutilation/Cutting (FGM/C) Domestic Violence (DV) Child Disability Knowledge of HIV Transmission Attitude towards People Living with HIV/AIDS (PLWHA) Knowledge of Facility for HIV Testing � � � � � � � � � � � � � � � � � � Five percent of women aged 15-49 years in marriage or union were married before 15 years and 33 percent before their 18th birthday. The proportion of currently married women and those in polygamous marriages is higher for women with little or no education. Nine percent of women 15-24 years who are married/in union are in polygynous unions. In Central region, less than one percent of women aged 15-49 have had some form of Female Genital Mutilation/Cutting. The practice is higher among women with little or no education, and women living in the poorest households. More than 80 percent of women aged 15-49 years believe that the practice should be discontinued. Sixty-one percent of women affirmed that a husband was justified to beat his wife for any of the given reasons. Acceptance of domestic violence is highest among women with little or no education (71 percent) compared to those with secondary or higher education (30 percent). Twelve percent of children aged 2-9 years of age had at least one form of disability as reported by their Mothers/caretakers. Nearly all the women aged 15-49 years in Central region have heard of AIDS. Sixty-eight percent of women 15-49 years know all three main ways of preventing HIV transmission, and 17 percent have comprehensive knowledge (identify 2 prevention methods and 3 misconception of HIV transmission). Knowledge of mother-to-child transmission of HIV is also high; 96 percent of women 15-49 years know HIV can be transmitted from mother to child, and two out of every three women know all the three ways of mother to child transmission. The percentage of those who agree with at least one discriminatory statement is high (92 percent). Only 3 percent of women agree with none of the discriminatory statements hence have an accepting attitude towards persons living with HIV and AIDS. Education and place of residence are strongly related to negative attitudes towards those who are HIV- positive; rural residents and less educated women in the region are more likely to have discriminatory attitudes towards people who are HIV positive as compared to the residents of urban and the more educated. Eighty-eight percent of women who have heard of AIDS indicated that they would not buy from a shopkeeper or food vendor/seller with HIV/AIDs, and half of the women indicated that if a family member had HIV, they would like to keep it a secret. Nearly half of the women aged 15-49 years know a place to get tested, and 12 percent have actually ever been tested. Only 3 percent of the respondents in the region were tested in the last 12 months and received their results. Thirty-eight percent of women 15-49 years who gave birth in the two years preceding the survey were 28 provided information about HIV prevention during ANC visit; 13 percent were tested for HIV at ANC visit, and 9 percent received results of their test. More people in urban areas know a place to get HIV testing compared with those in the rural areas. Ten percent of young women aged 15-19 in the Region had sex before age 15. Also, 10 percent of women 15-24 years had sex in the 12 months preceding the survey with a man 10 or more years older. Twenty-four percent of women aged 15-24 years had sex with non-marital, non-cohabiting partner in the last year, and 36 percent of them used condoms during the last such sex. Forty-eight percent of children are living with both parents, and 17 percent do not live with a biological parent. Less than one percent of children aged 0-17 years have lost both parents, and 7 percent have one or both parents dead. One in every three women interviewed is registered with the National Health Insurance Scheme (NHIS) in Central region, and half of these are valid NHIS card holders. Those not registered with NHIS gave 'premium too expensive (56 percent) as the main reason for non- registration. Four out of every five women registered with NHIS have benefited from the scheme, majority indicat- ing that they have saved money from paying hospital bills, and that they can use health services to prevent illness becoming severe. Virtually all of the women who are valid NHIS card holders said they would continue renewing their membership. � � � � � � � � � Sexual Behaviour Related to HIV Transmission Orphans and Vulnerable Children National Health Insurance 29 Executive Summary - Northern Region Household Characteristics Characteristics of Respondents Child Mortality Nutritional Status � � � � � � � � � � � � � � � � � Proportion of children less than 15 years is 47 percent. Nine percent of households are headed by women in the region. Sixty percent of the households in the region reported at least one child under 5 years and 83 percent have at least one child under 18 years. 4-6 household members constitute one in every three households, 6-7 households members make up 22 percent of households and 2-3 household members make up 20 percent of all households. Sixty-nine percent of women live in the rural area. The age distribution shows 32 percent respondents are in the 15-24 age group. The survey also reveals that 78 percent are currently married or in union. Nineteen percent of women have never been married and 79 percent have given birth at least once. Nearly 3 out of 4 women in the region have little or no education, 11 percent have primary education, 10 percent Middle/JSS, and 5 percent have secondary or higher education. Thirty-eight percent of women categorized as literate are from the richest wealth quintile, whereas only 5 percent of those literate fall under the poorest wealth quintile. Infant mortality rate is 64 deaths per 1,000 live births and under-five mortality rate is 120 deaths per 1,000 live births. Neonatal mortality is estimated at 29 deaths per 1,000 live births. This means that for children who die before their first birthday, nearly one out of every two die within the first month of life. Under-five mortality experienced by children in rural areas (135 deaths per 1,000 live births) is almost 10 percent higher than that experienced by children residing in urban areas (123 deaths per 1,000 live births). Birth interval also affects survival of children when there is less than two years between pregnancies. Infant mortality for children born less than a two-year birth interval is 124 deaths per 1,000, and reduces to 57 deaths per 1,000 live births (an estimated 54 percent reduction) when the birth interval is 3 years. First births and higher order births generally face an elevated risk of mortality. Under-five mortality for birth order seven and higher is 153 deaths per 1,000 live births, compared to 114 deaths per 1,000 live births for order 2-3. Approximately one in three children under age 5 in the Northern Region is underweight with 7 percent classified as severely underweight. Thirty percent of children in the region are stunted or too short for their age, while 9 percent are wasted or too thin for their height. Very few (about one percent) of under five children in the region can be said to be overweight. Little differences exist between males (28 percent) and females (30 percent) in the levels of underweight among children under five years. The same can be said of the other forms of malnutrition. Children whose mothers have some form of education are likely to be less malnourished than children whose mothers' have no or little education. 30 Breastfeeding Salt Iodization Vitamin A Supplement Low Birth Weight Immunization Tetanus Toxoid � � � � � � � � � � � � � � � � � � Forty-three percent of women breastfed their new-born within an hour of birth, while 78 percent breastfed their children within one day of birth. Sixty-seven percent of children aged less than six months are exclusively breastfed. Breastfeeding pattern by the socio-economic status of the household indicate that exclusive breastfeed- ing of a child less than six months is positively associated with household richer households. The higher the educational level of the mother as well as the higher the socio-economic status of the household the higher the proportion of adequately fed infants. Only 11 percent of households were found to consume adequately iodised salt. Almost 16 percent of households consumed iodated salt that had less than 15 parts per million (ppm), and in as high as 69 percent of households, salt was not iodised. Use of salt adequately iodised salt is higher in urban households (24 percent), compared to rural households (5 percent). There is also a direct relationship between consumption of adequately iodised salt and household wealth, and education of household head. Results show that only 51 percent of children aged 6-59 months had received a high dose Vitamin A supplement within the six months prior to the survey. Ten percent of children aged 6-59 months had never received Vitamin A supplement. Thirty-nine percent of women with a birth in 2 years preceding the survey received a high dose of Vitamin A supplement. Overall, only one of ten births in the region was weighed at birth and of these nearly 8 percent of infants weigh below 2500 grams. Almost 70 percent of children aged 12-23 months were fully immunized before the age of 12 months and more than 78 percent of children 12-23 months have all the required vaccinations against child- hood diseases. Approximately 95 percent of children aged 12-23 months received a BCG vaccination by the age of 12 months. The coverage for measles vaccines by 12 months is 82 percent, while immunization against measles by second birthday increases to 90 percent. Ninety-eight percent of children aged 12-23 months receive polio 1 by age 12 months and third dose, this reduces to 87 percent. Polio dose given at birth is low at 43 percent. Children vaccinated by 12 months of age against yellow fever is 81 percent. A little over 62 percent of mothers in the Northern region received at least two doses of tetanus toxoid vaccine during the last pregnancy with the highest of 80 percent recorded in Central Gonja, and lowest (47 percent) in Nanumba North. About 72 percent of mothers were protected against tetanus. Women with secondary education as well as women in wealthiest households are more likely to be protected against tetanus. 31 Oral Rehydration Treatment Care Seeking and Antibiotic Treatment of Pneumonia Solid Fuel Use Malaria Water and Sanitation Time to Source Water � � � � � � � � � � � � � � � � � � About 26 percent of children with diarrhoea were managed at home. Twenty-five percent of children under-five years with suspected pneumonia two weeks before the survey receive an antibiotic treatment. Thirty-six percent of children under-five with suspected pneumonia were taken to any appropriate health provider. Overall, 97 percent of all households in the Northern region are using solid fuels for cooking. Education level of head of households also gives a clear indication that higher education has a positive relationship with the use of open stove. Sixty percent of households had at least one mosquito net, of which, 55 percent are insecticide treated nets (ITNs). Fifty percent of the children under-five years sleep under a mosquito net, out of which 47 percent sleep under an ITN. The use of ITN is higher in the rural areas (49 percent) than in the urban areas (40 percent). Twenty-three percent of children under-five were ill with fever two weeks preceding the survey. Prevalence of fever is lowest among infants 0-11 months (16 percent), but peaks at 12-23 months old (30 percent). Twenty percent of children with fever were given chloroquine and about one percent were given SP. Of children with fever, 51 percent were treated with an appropriate anti-malarial drug and 36 percent received the drug within 24 hours of onset of symptoms. Urban children are more likely than rural children to be treated appropriately as are the children of mothers with secondary or higher education. Seventy-one percent of women in the Northern region who gave birth in preceding two years received medicine to prevent malaria during pregnancy. Sixty-two percent of households in Northern region has improved sources of drinking water. Forty- one percent of the improved source is boreholes, while 14 percent of the access is through public tap/standpipe. About 3 percent have pipe-borne water in their dwelling, yard or plot. River/stream and dam/lake/pond/canal constitutes the largest proportion of unimproved sources (32 percent). Sixty-five percent of households in the region do not apply any appropriate water treatment method to their drinking water. Households whose heads have little or no education are less likely to treat their water compared with households with primary or higher education. The mean time for accessing water by households that do not have water in dwelling is 25 minutes. Rural households get to the source and back in 26 minutes, while urban households spend 23 minutes. About 7 percent of households that do not have water in own dwelling spend an hour or more to source drinking water. Thirtyseven percent of households have water on the premises or within 15 minutes in the region. 32 Person Collecting Water Use of Sanitary Means of Excreta Disposal Disposal of child's faeces Use of Improved Water Sources and Improved Sanitation Durability of Dwelling Contraception � � � � � � � � � � � � � � � � � � � � � Adult women are more likely to be responsible for fetching drinking water than men and children. In fifty-four percent of households, adult women collect household water compared to only 8 percent of adult men. In two percent of the households, children normally collect water, although female children are more likely to collect water (1.3 percent) compared to male children (0.5 percent). Twenty-one percent of the population is using improved sanitation facilities. Improved sanitation is more common in urban areas (47 percent) than in rural areas (11 percent). Households whose heads have little or no education are less likely to use improved health facilities (17 percent) compared with households whose head has secondary or higher education (49 percent). About one percent of population in poorest households use improved sanitation facilities, compared to 52 percent of population in richest households. Out of the proportion using any of the categories classified as improved facility, 89 percent share the facility with other households. About 67 percent of the households share a toilet facility among ten or more households, 7 percent among 2-4 households and 4 percent among 5-9 households. Only 6 percent of children's stool is disposed of safely in the Northern region. The most common form of disposal is by throwing the faeces into the garbage (38 percent). Only 17 percent of households use both improved drinking water sources and sanitary means of disposal of excreta . Forty-two percent of households in the urban areas have both improved sources of drinking water and excreta disposal, compared to only 7 percent of rural households. No house in the Northern region is located in a hazardous location; however, 15 percent of all dwellings are in poor condition. Few dwellings (3 percent) are considered non durable, and 11 percent, have natural floor material. Majority of women aged 15-49 years married or in union do not use any form of contraception (92 percent). Current use of contraception was reported by 8 percent of women currently married or in union. The most popular method is injections which are used by four percent of married women in the North- ern Region. Seven percent of women using contraceptives use modern methods, compared to one percent using traditional methods. The percentage of women using any method of contraception rises from 6 percent among those with little or no education to 11 percent among women with primary education, and to 27 percent among women with secondary or higher education. Women from the poorest households are less likely to use any method of contraception (5 percent), compared to those from richest households (14 percent). 33 Antenatal Care Assistance at Delivery Child Development Pre-school Attendance and School Readiness Primary and Secondary School participation � � � � � � � � � � � � � � � � � � � � Pregnant women receiving ANC one or more times during pregnancy is 92 percent. Sixty-five percent of the pregnant women make at least the four visits recommended by WHO. Forty-two percent made their first ANC visit during their first trimester, 54 percent during their second trimester and about 4 percent during their last trimester. Most of the women in the region had all the assessments done; 54 percent had blood sample taken, 50 percent had urine specimen taken and 89 percent had blood pressure taken, while 89 percent had their weight measured. Majority (83 percent) of the women aged 15-49 years were provided with antenatal care by a nurse or midwife, while 6 percent were provided ANC by a doctor. Women living in urban areas were more likely to access ANC (97 percent) than their rural counterpart (91 percent). Twenty percent of births in Northern region were delivered with the assistance of a skilled personnel (medical doctor, nurse/midwife). Fifteen percent of the births occurring in two years prior to the survey were delivered with assistance of a nurse or midwife, while doctors assisted with the delivery of 3 percent of births. Twenty-nine percent of births were delivered by trained traditional birth attendants. About 18 percent of pregnant women delivered in health facilities; women in urban areas are more likely to delivery in health facilities (39 percent) compared to women in rural areas (10 percent). Mothers with education and living in urban areas and from the richest households are more likely to have skilled personnel assisting them during deliveries and also deliver in a health facility. On average household members are engaged with children under-five years in four activities that promote learning. Fifty-two percent of the children have their fathers involved in one or more activi- ties. In the Northern region, household members in urban areas (27 percent) engage more with children than their rural counterparts (17 percent). There is greater engagement by adults with higher education than those with little or no education. About 35 percent of children under-five years were left with inadequate care the week preceding the survey. Forty percent of children aged 36-59 months are attending pre-school in the region; the figure is 55 percent in the urban areas, compared to 35 percent in rural areas. Sixty-four percent of children living in the wealthiest households attend pre-school, while the figure drops to 24 percent in poor households. Of children who are of primary school entry age in the Northern region, 48 percent are attending the first grade of primary school. Sixty percent of children of primary school age in the Northern region are attending primary school or secondary school. In wealthiest households, children are more likely to attend Grade 1 in a timely manner at 58 percent compared to 38 percent among children living in the poorest households. Seventy percent of children attend school in the urban areas while in rural areas, 57 percent attend. Children in the poorest households (44 percent) are less likely to attend school as compared to 73 percent in the wealthiest households. 34 � � � � � � � � � � � � � � � � � � � Secondary school net attendance ratio is only 25 percent in all districts of Northern region. Forty-three percent of children in the wealthiest quintile attend secondary schools at the correct age, compared to only 12 percent from the poorest quintile. The literacy rate among females aged 15-24 years is 32 percent. The literacy rate is strongly and positively associated with urban residence, higher levels of education, and higher household wealth. The births of 52 percent of children under-five years in the Northern region have been registered. Birth registration is higher for children in urban areas (73 percent), compared to those in rural areas (45 percent). Children whose mothers have a secondary or higher education had a higher registration of 91 percent, compared to children whose mothers had little or no education (50 percent). 'Didn't know child should be registered' (38 percent) and 'Birth registration costs too much' (23 percent) were the two main reasons for non-registration of births. Forty-five of children in the region are engaged in activities that amount to child labour. The type of labour activity engaged in by children include paid work (3 percent), unpaid work (7 percent), household chores for 28+ hours/ week (3 percent) and working for family business (40 percent). More children in the rural areas (50 percent) than children in urban (33 percent) participate in child labour-related activities. Eighty-four percent of children aged 2- 14 years were subjected to at least one form psychological or physical punishment by their mothers/caretakers or other household members. Sixty-eight percent were subjected to minor physical punishment, whereas 11 percent were subjected to severe physical punishment. Six percent of women aged 15-49 years in marriage or union were married before 15 years and 34 percent before their 18th birthday. The proportion of women in polygamous marriages is higher for women with little or no education. Fourteen percent of young women aged 15-19 years are married/in union; those in rural areas are more likely to be married/in union (16 percent), compared to their counterparts living in urban areas (10 percent). Seventeen percent of women 15-24 years who are married/in union have a husband/partner 10+ years older than them. Five percent of women aged 15-49 have had some form of Female Genital Mutilation/ cut. The practice is higher among women with little or no education, and women living in the poorest households. Eighty-four percent of women aged 15-49 years believe that the practice should be discontinued; while only 2 percent believe otherwise. Literacy Birth Registration Child Labour Child Discipline Early Marriage and Polygyny Female Genital Mutilation/Cutting (FGM/C) 35 Domestic Violence (DV) Child Disability Knowledge of HIV Transmission Attitude towards People Living with HIV/AIDS (PLWHA) Knowledge of Facility for HIV Testing Sexual Behaviour Related to HIV Transmission � � � � � � � � � � � � � � � � Eighty-three percent of women affirmed that a husband was justified to beat his wife for any reason. Acceptance of domestic violence is highest among women with little or no education (86 percent) compared to those with secondary or higher education (50 percent). Seventeen percent of children aged 2-9 years have some form of disability as reported by their moth- ers/caretakers. Ninety-seven percent of women 15-49 years have heard of AIDS. Forty-seven percent of women 15-49 years know all three main ways of preventing HIV transmission, and 18 percent have comprehensive knowledge (identify 2 prevention methods and 3 misconception of HIV transmission). Eighty-eight percent of women 15-49 years know HIV can be transmitted from mother to child. The percentage of those who agree with at least one discriminatory statement is high (89 percent). Only 3 percent of women agree with none of the discriminatory statements hence have an accepting attitude towards persons living with HIV and AIDS. Eighty-three percent of women 15-49 years indicate that they would not buy from a shopkeeper or food vender/seller with HIV/AIDS, 3 out of 4 women believe that a male health worker with HIV should not be allowed to work, while one out of four women indicate that they would not care for a family member who is sick with AIDS. Rural residents and less educated women in the region are more likely to have discriminatory attitudes towards people who are HIV positive as compared to the residents of urban and the more educated. Thirty-one percent of the respondents know a place to get tested, and 5 percent have actually ever been tested. Only one percent of the respondents in the region were tested in the last 12 months and received their results. Thirty-four percent of women 15-49 years who gave birth in the two years preceding the survey were provided information about HIV prevention during ANC visit; Seven percent were tested for HIV at ANC visit, and 4 percent received their results of the test. More women in urban areas (43 percent) know a place to get HIV testing compared with those in the rural areas (25 percent). Nearly seven percent of young women aged 15-19 in the region had sex before age 15. Women of poor economic status are also more likely to have sex with a partner 10 years or older (20 percent) compared to women in the richest wealth index quintiles (10 percent). Thirty-two percent of women aged 15-24 years had sex with non-marital, non-cohabiting partner in the last year, and 34 percent of them used condoms during the last such sex. 36 Orphans and Vulnerable Children National Health Insurance � � � � � � � Eighty three of children 0-17 years are living with both parents. Very few (0.2 percent) of children 0-17 years have lost both father and mother (double orphans), but 5 percent have one or both parents dead. Only two percent of children live with only their mother because their father is dead and less than one percent lives with their father because their mother is dead. Twenty-nine percent of women sampled in the Northern region are registered with the National Health Insurance Scheme (NHIS), and 60 percent of these are valid NHIS card holders. Those not registered with NHIS gave ‘premium too expensive’ (61 percent) as the main reason for non- registration. About 4 out of 5 women registered with NHIS have benefited from the scheme, majority indicating that they have saved money from paying hospital bills, and that they can use health services to prevent illness becoming severe. Virtually all of the women who are valid NHIS card holders said they would continue renewing their membership. 37 Executive Summary - Upper East Region Household Characteristics Characteristics of Respondents Child Mortality Nutritional Status � � � � � � � � � � � � � � � � � � Proportion of children less than 15 years is 44 percent. Seventeen percent of households are headed by women in the region. About half of the households in the region reported at least one child under 5 years and 82 percent of households have at least one child under 18 years. 6-7 households' members constitute one in every five households. Sixty-nine percent of women live in the rural area. The age distribution shows 36 percent respondents are in the 15-24 age group. The results also reveal that 3 in 5 women are currently married or in union. 23 percent of women have never been married and 74 percent have given birth at least once. About one in five women in the region have primary education, while less than 10 percent have secondary or higher education. Forty-seven percent of women in the richest wealth quintiles are categorized literate compared with only 12 percent of women in the poorest wealth quintile. Eighty-one percent of children in the Upper East region live in rural areas. Infant mortality rate is 57 deaths per 1,000 live births and under-five mortality rate is 93 deaths per 1,000 live births. Neonatal mortality is estimated at 29 deaths per 1,000 live births. This means that one out of every four under-five deaths in region occur during the neonatal period. Under-five mortality experienced by male children (107 deaths per 1,000 live births) is 12 percent higher than that is experienced by female children (94 deaths per 1,000 live births) . Birth interval also affects survival of children when there is less than two years between pregnancies infant mortality for children born less than a two-year birth interval is 113 deaths per 1,000, and reduces to 45 deaths per 1,000 live births (an estimated 60 percent reduction) when the birth interval is 3 years. First births and higher order births generally face an elevated risk of mortality infant mortality for birth order seven and higher is 74 deaths per 1,000 live births, compared to 53 deaths per 1,000 live births order 2-3. Approximately one in four children under age 5 in the Upper East region is underweight with five percent classified as severely underweight. Twenty-three percent of children in the region are stunted or too short for their age, while eight percent are wasted or too thin for their height. Very few (less than one percent) of under five children in the region can be said to be overweight. Little differences exist between males (26 percent) and females (24 percent) in the levels of underweight among children under five years. The same can be said of the other forms of malnutrition, although the proportion is slightly higher among males than females. Children whose mothers have some form of education are likely to be less malnourished than children whose mothers' have no or little education. 38 Breastfeeding Salt Iodization Vitamin A Supplement Low Birth Weight Immunization Tetanus Toxoid Oral Rehydration Treatment � � � � � � � � � � � � � � � � � � � Fifty-one percent of women breastfed their new-born within an hour of birth, while 86 percent breastfed their children within one day of birth. Fifty-five percent of children aged less than six months are exclusively breastfed. Breastfeeding pattern by the socio-economic status of the household indicate that exclusive breastfeeding of a child less than six months is positively associated with household richer households. The higher the educational level of the mother as well as the higher the socio-economic status of the household the higher the proportion of approximately or adequately fed infants. Only 12 percent of households were found to consume adequately iodised salt. Almost 13 percent of households consumed iodated salt that had less than 15 parts per million (ppm), and in as high as 73 percent of households salt was not iodised. Use of salt adequately iodised salt is higher in urban households (31 percent), compared to rural households (6 percent). There is also a direct relationship between consumption of adequately iodised salt and household wealth, and education of household head. Results show that only 48 percent of children aged 6-59 months had received a high dose Vitamin A supplement within the six months prior to the survey. Six percent of children aged 6-59 months had never received Vitamin A supplement. Overall, only one of four births in the region were weighed at birth and of these nearly nine (8.5) percent of infants weigh below 2500 grams. Sixty-six percent of children aged 12-23 months are fully immunized before the age of 12 months and more than 88 percent of children 12-23 months have all the required vaccinations against childhood diseases. Approximately 95 percent of children aged 12-23 months received a BCG vaccination by the age of 12 months. The coverage for measles vaccines by 12 months is lower than other vaccines at 73 percent, while immunization against measles by second birthday increases to 95 percent. Ninety-seven percent of children aged 12-23 months receive polio 1 by age 12 months and third dose, this reduces to 90 percent. Polio dose given at birth is low at 50 percent. Seventy-three percent of children were immunized against yellow fever by 12 months of age. A little over 67 percent of mothers in the Upper East region received at least two doses of tetanus toxoid vaccine during the last pregnancy with the highest of 78 percent recorded in Bolgatanga Municipality, and lowest (43 percent) in Builsa. About 81 percent of mothers were fully protected against tetanus. Women with secondary education as well as women in wealthiest households are more likely to be protected against tetanus. About 18 percent of children with diarrhoea were managed at home. Infants less than 12 months are less likely to be managed at home (13.5 percent) as compared to those age 24-35 months (22 percent). 39 Care Seeking and Antibiotic Treatment of Pneumonia Solid Fuel Use Malaria Water and Sanitation Time to Source Water Person Collecting Water � � � � � � � � � � � � � � � � � � � � � � Sixty percent of children under-five years with suspected pneumonia receive an antibiotic treatment. Forty-eight percent of children under-five with suspected pneumonia were taken to any appropriate health provider. Children of mothers with at least a secondary education are more likely to take their children under age 5 with suspected pneumonia to an appropriate provider. Overall, 95 percent of all households in the Upper East Region are using solid fuels for cooking. Education level of head of households also gives a clear indication that higher education has a positive relationship with the use of open stove. More than half (58 percent) of households had at least one mosquito net, of which, 53 percent are insecticide treated nets (ITNs). Sixty-one percent of the children under-five years sleep under a mosquito net, but 56 percent sleep under an ITN. The use of ITN is higher in the rural areas (57 percent) than in the urban areas (53 percent). Twenty-five percent of children under-five were ill with fever two weeks preceding the survey. Prevalence of fever is lowest among infants 0-11 months (18 percent), but peaked at 24-35 months old (30 percent). Twenty-eight percent of children with fever were given chloroquine and less than one percent were given SP. Of children with fever, 53 percent are treated with an appropriate anti-malarial drug and 37 percent receive the drug within 24 hours of onset of symptoms. Urban children are more likely than rural children to be treated appropriately as are the children of mothers with secondary or higher education. Eighty-five percent of women in the Upper East Region who gave birth in preceding two years received medicine to prevent malaria during pregnancy. Eighty-two percent of households in Upper East region have improved sources of drinking water. Seventy percent of the improved source is boreholes, while 8 percent of the population is through pipe- borne water in their dwelling, yard or plot or public tap. Unprotected wells constitute the largest proportion of unimproved sources (16 percent). Forty-eight percent of the poorest households in the region use unimproved sources of water. Ninety- five percent of households in Upper East region do not apply any appropriate water treatment method to their drinking water. Households whose heads have little or no education are less likely to treat their water compared with households with primary and middle school education. The mean time for accessing water by households that do not have water in dwelling is 24 minutes. Rural households get to the source and back in 24 minutes, while urban households spend 22 minutes. Less than 5 percent of households that do not have water in own dwelling spend an hour or more to source drinking water . Thirty four percent of households have water on the premises or within 15 minutes in the region. Adult women are more likely to be responsible for fetching drinking water than men and children. In forty-eight percent of households, adult women collect household water either alone or with children compared to only eight percent of adult men. In three percent of the households, children normally collect water, although female children are more likely to collect water (2 percent) compared to male children (less than 1 percent). 40 Use of Sanitary Means of Excreta Disposal Disposal of child's faeces Use of Improved Water Sources and Improved Sanitation Durability of Dwelling Contraception Antenatal Care � � � � � � � � � � � � � � � � � � � � � � Eleven percent of the population is using improved sanitation facilities. Improved sanitation is more prevalent in urban areas (44 percent) than in rural areas (3 percent). Households whose heads have little or no education are less likely to use improved health facilities (5 percent) compared with households whose head has secondary or higher education (52 percent). Less than 1 percent of population in poorest households use improved sanitation facilities, compared to 41 percent of population in richest households. Out of the proportion using any of the categories classified as improved facility, 72 percent share the facility with other households. About 59 percent of the households share a toilet facility among ten or more households, 7 percent among 2-4 households and 6 percent among 5-9 households. Only 3 percent of children's stool is disposed of safely in the upper east region. The most common form of disposal is by throwing the faeces into the garbage (41 percent). Only one in every ten households use both improved drinking water sources and sanitary means of disposal of excreta. Forty-one percent of households in the urban areas have both improved sources of drinking water and excreta disposal, compared to only 2 percent of rural households. None of the houses in the urban areas of the Upper East region is located in a hazardous location; however, 15 percent of all dwellings are in poor condition and 2 percent are vulnerable to accidents. Few dwellings (8 percent) are considered non durable and 17 percent, have natural floor material. Majority of women aged 15-49 years married or in union do not use any form of contraception (87 percent). Current use of contraception was reported by 13 percent of women currently married or in union. The most popular method is injections which are used by eight percent of married women in the Upper East region. Twelve percent of women using contraceptives use modern methods, compared to less than one percent using traditional methods. The percentage of women using any method of contraception rises from ten percent among those with little or no education to thirteen percent among women with primary education, and to 35 percent among women with secondary or higher education. Women from the poorest households are less likely to use any method of contraception (6 percent), compared to those from richest households (24 percent). Pregnant women receiving ANC one or more times during pregnancy is 98 percent. Eighty-five percent of the pregnant women make at least the four visits recommended by WHO. Most of the women in the region had all the assessments done; 78 percent had blood sample taken, 71 percent had urine specimen taken and over 92 percent had blood pressure taken, while 97 percent had their weight measured. Majority (86 percent) of the women aged 15-49 years were provided with antenatal care by a nurse or midwife. Women living in urban areas were more likely to be provided with ANC by a medical doctor (15 percent) than their rural counterpart (5 percent). 41 Assistance at Delivery Child Development Pre-school Attendance and School Readiness Primary and Secondary School participation Literacy Birth Registration � � � � � � � � � � � � � � � � � � � � � � Forty percent of births in upper east region were delivered with the assistance of any skilled personnel (medical doctor, nurse/midwife). More than one in three of the births (37 percent) in two years prior to the survey were delivered with assistance of a nurse or midwife, while doctors assisted with the delivery of 3 percent of births About 20 percent of births were delivered by trained traditional birth attendants. About 40 percent of pregnant women delivered in health facilities; women in urban areas are more likely to delivery in health facilities (70 percent) compared to women in rural areas (30 percent). Mothers with education and living in urban areas and from the richest households are more likely to have skilled personnel assisting them during deliveries and also deliver in a health facility. On average household members are engaged with children under-five years in four activities that promote learning. Forty-four percent of the children have their fathers involved in one or more activities. In the upper east region, household members in urban areas (16 percent) engage more with children than their rural counterparts (10 percent). There is greater engagement by adults with higher education than those with less or without any education. About 29 percent of children under-five years were left with inadequate care the week preceding the survey. Forty-three percent of children aged 36-59 months are attending pre-school in Upper East region; the figure is as high as 64 percent in the urban areas, compared to 39 percent in rural areas. Seventy-two percent of children living in the wealthiest households attend pre-school, while the figure drops to 33 percent in poor households. Of children who are of primary school entry age in the Upper East region, 57 percent are attending the first grade of primary school. In wealthiest households, children are more likely to attend school in a timely manner at 65 percent compared to 58 percent among children living in the poorest households. Seventy-five percent of children of primary school age in the Upper East region are attending primary school or secondary school. Twenty-five percent of children are out of school when they are supposed to be participating in school. Seventy-seven percent of children attend school in the urban areas while in rural areas 75 percent attend. Children in the poorest households (72 percent) are less likely to attend school as compared to 83 percent in the wealthiest households. Secondary school net attendance ratio is below 50 percent in all districts of Upper East region. Nearly 50 percent of children in the wealthiest quintile attend secondary schools at the correct age, compared to only 20 percent from the poorest quintile. There is no difference in school attendance between boys and girls (gender parity for primary and JSS for boys and girls is 1.02 and 1.00 respectively). The literacy rate among females aged 15-24 years is 44 percent. The literacy rate is strongly and positively associated with urban residence, higher levels of education, and higher household wealth. The births of 59 percent of children under-five years in the Upper East region have been registered. Birth registration is higher for children in urban areas (71 percent), compared to those in rural areas (56 percent). 42 � � � � � � � � � � � � � � � � � � � Children whose mothers have a secondary or higher education had a higher registration of 85 percent, compared to children whose mothers had little or no education (55 percent). 'Birth registration costs too much' (29 percent) and 'Didn't know child should be registered' (28 percent) were the two main reasons for non-registration of births. The type of labour activity engaged in by children include paid work (2 percent), unpaid work (9 percent), household chores for 28+ hours/ week (1 percent) and working for family business (25 percent). Thirty percent of children in the region are engaged in activities that amount to child labour. More children in the rural areas (32 percent) than children in urban (23 percent) participate in child labour-related activities. Eighty-six percent of children aged 2- 14 years were subjected to at least one form psychological or physical punishment by their mothers/caretakers or other household members. Fifty-eight percent are subjected to minor physical punishment, whereas 10 percent are subjected to severe physical punishment. Five percent of women aged 15-49 years in marriage or union were married before 15 years and 40 percent before their 18th birthday. The proportion of currently married women and those in polygamous marriages is higher for women with little or no education. Eleven percent of young women aged 15-19 years are married/in union; those in rural areas are more likely to be married/in union (13 percent), compared to their counterparts living in urban areas (6 percent). Twenty-five percent of women 15-24 years who are married/in union have a husband/partner 10+ years older than them. Twenty percent of women aged 15-49 have had some form of female Genital Mutilation The practice is higher among women with little or no education, and women living in the poorest households. Ninety-four percent of women aged 15-49 years believe that the practice should be discontinued; while only 2 percent believe otherwise. Seventy-five percent of women affirmed the fact that a husband was justified to beat his wife for any reason. Acceptance of domestic violence is highest women with little or no education (79 percent) compared to those with secondary or higher education (54 percent). Fifteen percent of children aged 2-9 years have some form of disability. Ninety-seven percent of women 15-49 years have heard of AIDS. Sixty-two percent of women 15-49 years know all three main ways of preventing HIV transmission, and 31 percent have comprehensive knowledge (identify 2 prevention methods and 3 misconception of HIV transmission). Ninety-one percent of women 15-49 years know HIV can be transmitted from mother to child. Child Labour Child Discipline Early Marriage and Polygyny Female Genital Mutilation/Cutting (FGM/C) Domestic Violence (DV) Child Disability Knowledge of HIV Transmission 43 Attitude towards People Living with HIV/AIDS (PLWHA) Knowledge of Facility for HIV Testing Sexual Behaviour Related to HIV Transmission Orphans and Vulnerable Children National Health Insurance � � � � � � � � � � � � � � � � � � � � � The percentage of those who agree with at least one discriminatory statement is high (91 percent). Five percent of women agree with none of the discriminatory statements hence have an accepting attitude towards persons living with HIV and AIDS. Education and type of residence are strongly related to negative attitudes towards those who are HIV- positive. Rural residents and less educated women in the region are more likely to have discriminatory attitudes towards people who are HIV positive as compared to the residents of urban and the more educated. Forty-six percent of the respondents know a place to get tested, and 10 percent have actually ever been tested. Only one percent of the respondents in the region were tested in the last 12 months and received their results. Sixty-one of women 15-49 years who gave birth in the two years preceding the survey were provided information bout HIV prevention during ANC visit; 21 percent were tested for HIV at ANC visit, and 13 percent received their results of the test. More people in urban areas (63 percent) know a place to get HIV testing compared with those in the rural areas (41 percent). Nearly five percent of young women aged 15-19 in the Region had sex before age 15. There is an indirect relationship between education and age at sexual debut. There is a slight difference in rural women (4.6 percent) and their urban counterparts (4.2 percent) aged 15-19 who had sex before age 15. Women of poor economic status are also more likely to have sex with a partner 10 years or more years older (26 percent) compared with women in the richest (18 percent) wealth index quintiles. 33 percent of women aged 15-24 years had sex with non-marital, non-cohabiting partner in the last year, and 67 percent of them used condoms during the last such sex. Seventy-six percent of children are living with both parents. Nine percent do not live with a biological parent. Only 0.5 percent of all children have lost both father and mother. Only six percent of children live with only their mother because their father is dead and less than one percent lives with their father because their mother is dead. About one in every three women interviewed is registered with the National Health Insurance Scheme (NHIS) in the Upper East region, and almost 70 percent of these are valid NHIS card holders. Those not registered with NHIS gave 'premium too expensive (63 percent) as the main reason for non- registration. Ninety-one percent of women registered with NHIS have benefited from the scheme, majority indicating that they have saved money from paying hospital bills, and that they can use health services to prevent illness becoming severe. Virtually all of the women who are valid NHIS card holders said they would continue renewing their membership. 44 Executive Summary - Upper West Region Household Characteristics Characteristics of Respondents Child Mortality Nutritional Status � � � � � � � � � � � � � � Proportion of children aged less than 15 years is 45.2 percent. Eighteen percent of households in the region are headed by women. The region is basically rural, with 88 percent of the population living in rural area. Thirty-one percent of households have a household size of 4-5 members and 22 percent has 2-3 house- hold members. The largest proportions of women in the region are in the 15-24 years age group, forming 32 percent of total women population. Three out of four women in the region are married or currently in union, while twenty-one percent have never been married. Seventy-seven percent of women in the region have given birth at least once. About 3 in 5 women in the region have little or no education. Seventeen percent of women aged 15-49 years have primary education, and 18 percent have middle/JSS education. Only 6 percent of women have secondary or higher education. One out of four women in the region is literate. Literacy rate for women 15-24 years is 50 percent, and this reduces with age, with only 8 percent of women 45-49 years being literate. Also, 62 percent of women in urban areas are literate compared to their counterparts in rural areas. Infant mortality rate is 62 deaths per 1,000 live births and under-five mortality rate is 113 deaths per 1,000 live births. Neonatal mortality is estimated at 32 deaths per 1,000 live births. This means that for children who die before their first birthday, nearly one out of every two die within the first month of life. Under-five mortality experienced by children in rural areas (127 deaths per 1,000 live births) is almost 20 percent higher than that experienced by children residing in urban areas (103 deaths per 1,000 live births). Birth interval also affects survival of children when there is less than two years between pregnancies infant mortality for children born less than a two-year birth interval is 145 deaths per 1,000, and reduces to 48 deaths per 1,000 live births (an estimated 67 percent reduction) when the birth interval is 3 years. First births and higher order births generally face an elevated risk of mortality under-five mortality for birth order seven and higher is 148 deaths per 1,000 live births, compared to 105 deaths per 1,000 live births order 2-3. Almost nineteen percent (18.6) and 3 percent of children under-five are underweight and severely underweight respectively; overweight is not an issue among children under-five in the region, less than 1 percent are overweight. Malnutrition peaks at age 12-23 months; 19 percent of children are stunted and 6 percent wasted. The highest recorded form of malnutrition in the region is found in Jirapa-Lambussie, closely followed by Wa West. 45 Breastfeeding Salt Iodization Vitamin A Supplement Low Birth Weight Immunization Tetanus Toxoid Oral Rehydration Treatment Care Seeking and Antibiotic Treatment of Pneumonia � � � � � � � � � � � � � � � � � � Forty percent of children are breastfed within one hour of birth, and 68 percent within one day of birth. Ninety-two percent of children less than six months are exclusively breastfed in the region. Among children 6-9 months, 59 percent receive breast milk and solid or semi-solid foods; at 12-15 months, 100 percent are still being breastfed and by age 20-23 months 85 percent are still breastfed. In 2 in 5 households tested salt is not iodized. Fifteen percent of households consume salt that contains 15 parts per million (ppm) or more of iodine, while 40 percent households consume inadequately iodated salt. The use of adequately iodated salt is four times high in urban residence compared to rural residence in the region. Fifty-two percent of children aged 6-59 months receive a high dose of Vitamin A supplement within last 6 months, while 7 percent never received the supplement. 67 percent of women with a birth 2 years prior to the survey received Vitamin A supplement before the infant was 8 weeks old. Twenty-three percent of children were weighed at birth in the region, 6 percent of weighed live births are below 2500 grams. Eighty-five percent of children aged 12-23 months are fully immunized before their first birthday, and about 90 percent of children aged 12-23 months in the region have all the required vaccinations. Ninety-seven percent of children aged 12-23 months received a BCG vaccination by the age of 12 months. First dose of (DPT)HH is given to 99 percent of children aged 12-23 months, 98 percent of the same age group receive second dose and 95 percent of the same age group receive the third dose. Ninety-nine percent of children aged 12-23 months receive polio 1 by age 12 months and third dose, 93 percent. Protection level of women who have had a live birth within the last 2 years against tetanus is generally high at 73 percent, peaking at 76 percent for women aged 25-29 years in the region. Sixty-two percent of women in the region received at least 2 doses during the last pregnancy. Twenty percent of children under-5 years had diarrhoea in the last two weeks prior to the survey, and 42 percent of these children were given fluid from ORS packet, 2 percent were given recommended homemade fluid and 58 percent received no treatment. Children aged 0-59 months in the region with diarrhea managed at home is 7 percent. Only 3 percent of infants under 12 months are managed at home as compared to approximately 10 percent of those 36-47 months. Fifty percent of children under-five years with suspected pneumonia received an antibiotic treatment in the region. Forty-seven percent of children with suspected pneumonia were taken to an appropriate provider. 46 Solid Fuel Use Malaria Water and Sanitation Time to Source Water Person Collecting Water Use Sanitary Means of Excreta Disposal � � � � � � � � � � � � � � � � � Ninety-eight percent of households are using solid fuels for cooking. Its use is lower in Wa Municipal- ity (93 percent) and in urban areas (92 percent). The higher the educational level of head of household, the lower the use of solid fuels for cooking (90 percent); similarly, the percentage among the wealthiest households in the region is 92 percent. Seventy-one percent of households in the region have at least one mosquito net, of which 67 percent are insecticide treated nets (ITN). Seventy-nine percent of children under-five sleep under a mosquito net, of which 78 percent sleep under an ITN. The use of ITN is higher in the rural areas (79 percent) than in the urban areas (69 percent). Thirty percent of children under-five were ill with fever. The prevalence of fever is lowest among 48-59 months old but peaked at 24-35 months old children (36 percent). The most widely used appropriate anti-malarial drugs are Artemisnin based combinations used by 23 percent of children aged 0-59 months, followed by chloroquine (22 percent) and armodiaquine (13 percent). Of children with fever, 64 percent are treated with an appropriate anti-malarial drug and 45 percent receive the drug within 24 hours of onset of symptoms. Eighty-seven percent of the population in the Upper West region has access to improved drinking water sources; ninety-four percent in the urban area and 80 percent in the rural areas. Use of improved water sources is higher for the wealthiest households (90 percent), compared to households in the poorest wealth quintile (49 percent). Nadawli district recorded the highest percentage of households using an improved source of drinking water (98 percent), and Wa East recorded the lowest (64 percent). Five percent of households have water on own premises and 31 percent access water within 30 minutes. Only 6 percent of households spend more than 1 hour to source of drinking water. The mean time for accessing water by households including waiting to get water and return is 24 minutes. This decreases slightly with education of household head; household heads with little or no education in the region get to the source and back in 26 minutes but household heads with secondary and higher education spend 20 minutes. Adult women are more likely to fetch water than men and children. In 50 percent of households, adult women collect household water alone compared to only 7 percent of adult men. In 31 percent of households, water is collected by adult women with children. Children (both male and female under 15 years) form less than 3 percent of household's members who collect water. Only 20 percent of the population in the region is using improved sanitation facilities. The improved sanitation is more prevalent in the urban areas (78 percent) than in rural areas (15 percent). Out of the proportion using any of the categories classified as improved facility; about 78 percent share the facility with other households. About 56 percent of the households share a toilet facility among ten or more households, 10 percent among 2-4 households and 6 percent among 5-9 households. 47 Disposal of child's faeces Use of Improved Water Sources and Improved Sanitation Durability of Dwelling Contraception Antenatal Care Assistance to Delivery Child Development � � � � � � � � � � � � � � � � � � Seventy percent of children's stool are thrown into garbage (solid waste) and put/rinsed latrine into drain or ditch. Only 3 percent of children's' stools are buried; virtually no child (0.2 percent) uses the toilet/latrine themselves. Nineteen percent of households use both improved sources of drinking water and sanitary means of disposing excreta. In the urban areas 74 percent of households use both improved sources of drinking water and sanitary means of excreta disposal compared to only 13 percent of rural households. Wa Municipality has the highest number of households using both improved sources for drinking water and sanitary means of excreta disposal (38 percent), while Wa East has the lowest (2 percent). No house is located in a hazardous area; however 3 percent of the dwellings are considered non durable but none is vulnerable to accidents in the region. Twenty-eight percent of the dwellings have natural floor materials. Eighty-three percent of currently married/in union women within the region are not currently using any methods of family planning. The most popular method of contraception currently used is the injection, used by 11 percent of the married women, followed by the Pill, used by 4 percent of the women. The condom is used by less than one percent of partners of married women in the region. Coverage of antenatal care in the region is relatively high with 92 percent of pregnant women aged 15- 49 years receiving ANC from skilled personnel. Eighty-nine percent of pregnant women had their blood pressure checked, 90 percent of them had their weight measured and 75 percent had their blood samples taken. However, only 2 out of three women had their urine specimen taken. Medical doctors provided ANC to 2 percent of women, whereas nurse/midwife provided ANC to 89 percent of the women. Nearly four in every five pregnant women received the recommended 4 or more visits during their pregnancy, and over half of the pregnant women (52 percent) made their first ANC visit during the first trimester, while 45 percent made their first visit in the second trimester. Only 3 percent of the women made their first ANC visit in the last trimester. Forty-two percent of births are delivered by skilled personnel, while 40 percent occurred at a health facility, including 7 percent assisted by a medical doctor. Women in urban areas are four times as likely to have their births assisted by a medical personnel and more than twice to deliver at a health facility in the region, compared to women in rural areas. Twenty percent of adults are engaged with children in four or more activities that promote learning and school readiness in the region. Twenty-seven percent of the children have their fathers involved in one or more activities. Twelve 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 four or 48 more activities is 40 percent in urban areas and 18 percent in rural areas. Thirty-two percent of children live in households with at least 3 or more non-children's books but only 2 percent of the children have children's books. Eleven percent of children under-five years have three or more playthings in their homes but 13 percent do not have any. Twenty-nine percent of children aged 0-23 months have no playthings, compared to only one percent of those aged 24-59 months. During the week preceding the survey, in the region, 23 percent of children were left with inadequate care, and 6 percent were left alone. Forty-eight percent of children in the region aged 36-59 months are attending pre-school; 70 percent in urban areas compared to 46 percent in rural areas. Seventy-seven percent of children living in wealthi- est household attend pre-school in the region compared to 31 percent in poor households. Fifty-two percent of children of primary school entry age are attending first grade in the region. Eighty-six percent of urban children attend school as against 49 percent rural children. Sixty-nine percent of children of primary school age in the region are attending primary school or secondary school while 31 percent are out of school. 92 percent of urban children and two-thirds of rural children are attending school. Fifty percent of women aged 15-24 years are literate. In the urban area, 74 percent of women are literate while in the rural area 45 percent are literate. In the wealthiest quintile, 67 percent are literates com- pared to 42 percent of women in the poorest quintile. The births of 53 percent of children under-five years have been registered. Eighty-six percent of chil- dren whose mothers/caretakers have a secondary or higher level of education have their births regis- tered, compared to 45 percent of children whose mothers/caretakers have little or no education. Sixty-nine percent of children residing in urban areas have their births registered compared to 42 percent of children residing in rural areas. Seventy-one percent of children 5-14 years in the region are engaged in some form of child labour. Children aged 5-11 engaged in child labour were more (49 percent) compared to those aged 12-14 (46.7 percent). More children 5-14 years from the poorest households are engaged in some form of child labour (59 percent), compared to children from the richest wealth quintile (31 percent). Of 72 percent of children aged 5-14 years of age attending school, 46 percent are also involved in child labour activities. Ninety-one percent of children aged 2-14 years in the region are subjected to at least one form of psy- chological or physical punishment. Eighty-eight percent are subjected to psychological punishment whiles 71 percent to minor physical punishment and 14 percent to severe physical punishment. � � � � � � � � � � � � � � � Pre-school Attendance and School Readiness. Primary and Secondary School participation Literacy Birth Registration Child Labour Child Discipline 49 Early Marriage and Polygyny Female Genital Mutilation/Cutting (FGM/C) Domestic Violence (DV) Child Disability Knowledge of HIV Transmission Attitude towards People Living with HIV/AIDS (PLWHA) Knowledge of Facility for HIV Testing � � � � � � � � � � � � � � � Seven percent of women aged 15-24 years in marriage or union were married before aged 15 and one- third of women aged 20-24 married before their 18th birthday. A little over one-third of married women are in polygynous unions. One in three married women aged 15-24 in the region have partners who are 0-4 years older than themselves, while 34 percent have partners 5-9 years older and 27 percent have partners aged ten years or older. One in every two women aged 15-49 years have had some form of FGM/C, and 2 percent have had extreme FGM/C. Women in rural areas (52 percent) are more inclined to accept the practice than women in urban areas (32 percent). Eighty-four percent of women aged 15-49 years expressed that the practice should be discontinued; whiles 5 percent believe the practice should be continued. Eighty-four percent of women aged 15-49 believe that a husband is justified in beating his wife for any of the reasons provided. Acceptance of domestic violence is higher among women residing in rural areas (86 percent) than the urban areas (70 percent). It is also higher among women with little or no education, compared to those with primary or higher education. Seventeen percent of children aged 2-9 years in the region have at least one form of disability as reported by their mothers/caretakers. Ninety-three percent of women in the region have heard of AIDS, and 51 percent know of all three main ways of preventing HIV transmission. Only 16 percent of women aged 15-49 years have comprehensive knowledge of HIV/AIDS (identify 2 prevention methods and 3 misconceptions). Almost 88 percent of women know that HIV can be transmitted from mother to child, and 73 percent know all three ways of mother-to-child transmission of HIV. The percentage of those who agree with at least one discriminatory statement is high (93 percent) Only 4 percent of women agree with none of the discriminatory statements hence have an accepting attitude towards persons living with HIV and AIDS. One in five women who have heard of AIDS admit they would not care for a family member who was sick with AIDS, and 57 percent would like to keep the HIV status of a family member secret. Also, two- thirds of the women believe that a female health worker with HIV should not be allowed to work. Education and type of residence are strongly related to negative attitudes towards those who are HIV- positive. Rural residents and less educated women in the region are more likely to have discriminatory attitudes towards people who are HIV-positives, compared to urban residents and women with higher levels of education. Forty-three percent of women know where to be tested, and 12 percent have actually ever been tested, while only 1 percent were tested and received results in the past 12 months. 50 � � � � � � � � � � � Women aged 25-29 are more likely to have been tested in the region. About 7 percent of young women aged 15-19 in the region had sex before age 15, and 40 percent of women aged 20-24 had sex before their 18th birthday. Eighteen percent of women aged 15-24 had sex with men who were ten or older than themselves. Of the women 15-24 years who had sex with more than one partner in the 12 months prior to the survey, 31 percent had sex with a non-marital, non-cohabiting partner. Sixty-four percent of women 15-24 years used a condom at last sex with a non-marital, non-cohabiting partner. Seventy-six percent of children in the region are living with both parents whiles 11 percent are not living with a biological parent. Less than one percent of the children have both parent's dead (double orphans), but 8 percent have lost one or both parents. About one in every five women interviewed is registered with the National Health Insurance Scheme (NHIS) in the Upper West region, and 85 percent of these are valid NHIS card holders. Those not registered with NHIS gave 'premium too expensive (56 percent) as the main reason for non- registration. About 90 percent of women registered with NHIS have benefited from the scheme, majority indicating that they have saved money from paying hospital bills, and that they can use health services to prevent illness becoming severe. Virtually all of the women who are valid NHIS card holders said they would continue renewing their membership. Sexual Behaviour Related to HIV Transmission Orphans and Vulnerable Children National Health Insurance 51 Background and Objectives Survey Objectives This report is based on the High Impact Rapid Delivery (HIRD) Supplementary Survey at the district level (District Multiple Indicator Cluster Survey, or District MICS), carried out by UNICEF in 2007 with assistance from the Ghana Statistical Service (GSS) and the Ministry of Health (MOH). The survey was based on the evaluation of the Accelerated Child Survival and Development (ACSD) being piloted in the Upper East and, in large part, on the need to have baseline data to help in the implementation of the HIRD intervention in the Upper West, Northern and Central regions, which are among the deprived regions in the country. All women aged 15-49 and children below five years were eligible for individual interviews. Caretakers or mothers responded on behalf of under-five children in selected households. The HIRD Survey is designed to provide up-to-date information on the situation of children and women in some deprived regions at district level. In recent decades, several donor-specific programmes and interventions have been implemented in Ghana. The level of implementation of these programmes or interventions at national, regional and district levels differed from one donor to the other. However, the common aim has been to improve the health and socio- economic status of women, children and other vulnerable groups. This report presents a comprehensive analysis of the results of the HIRD Supplementary Survey (District MICS) at regional level, for Central, Northern, Upper East and Upper West Regions. Separate regional reports are available that provides Despite the existence of a number of data sources, one of the challenges faced by policy makers and programme managers in Ghana is the lack of sub-national data. Many national and international agencies are interested in identifying districts with poor socio-economic indicators for intensive intervention but present data sources are unable to meet this demand. A number of new intervention programmes have been implemented by the Government in the recent past, which will have an impact on indicators and are expected to change over a short period of time. For example, the Ghana Poverty Reduction Strategy (GPRS) is focused on poverty reduction and MDGs. The GPRSII Ministry of Health has put a strong emphasis on scaling-up of the High Impact Rapid Delivery approach (HIRD) to achieving MDGs 4 and 5 which was adopted for national implementation after the successful evaluation and documentation of the lessons learnt from the UNICEF supported ACSD pilot. The latest data on these indicators will help programme managers to better plan and monitor development activities. comprehensive analysis by district for the four regions. I. Introduction 53 The HIRD Supplementary Survey (District MICS) has as its primary objectives:2007/2008 � � � � To evaluate programme interventions in the reduction of childhood mortality through the Accelerated Child Survival and Development (ACSD) in the Upper East Region; To collect baseline data for the scale-up of implementation of the High Impact Rapid Delivery (HIRD) programme in the Northern, Upper West, and Central Regions. To analyse urban indicators in the two major cities in the country; Kumasi and Accra; and To contribute to the improvement of data and monitoring systems in Ghana using the MICS and MDG goals as reference. The report is divided into 13 chapters as outlined in the table of contents. A number of annexes serve as reference and background information to this report. Computations of all indicators shown in this report are explained in details in Annex E. Chapter two describes the sample and methodology used for the survey. It also talks about the survey instruments and the various modules of the questionnaires, training and fieldwork and data processing. Chapter three looks at the sample coverage, response rate, characteristics and of the households interviewed and that of respondents. Child and infant mortality results are discussed in chapter four. Chapter five presents results on the nutritional status of children in the region. It looks at the breastfeeding patterns, salt iodisation, vitamin A supplements etc. Immunization, tetanus toxiod, use of ORS in the treatment of diarrhoea, care and treatment of pneumonia among children, treatment of malaria and the cost of obtaining antimalarials and ITN usage is discussed in chapter six. Chapter seven shows results of the survey on solid fuel use, use of improved water and sanitary source and the disposal of child's faeces. Chapters eight and nine shows results on contraception, antenatal care, assistance during delivery and child development whiles, chapter ten discusses results related to education. Birth registration, child labour, child discipline, early marriage and polygyny, female genital mutilation/cutting, domestic violence and child disability are discussed in chapter eleven. HIV/AIDS, sexual behaviour and vulnerable children are discussed in chapter twelve whiles chapter thirteen discusses result on national health insurance registration, reasons for no registering and beneficiaries views of the health scheme. 54 Sample design The sample for the HIRD Supplementary Survey was designed to provide estimates on a large number of indicators of the health status of women and children at the district and regional levels, in the Northern, Upper East, Upper West and Central Regions. The survey results also provides separate estimates for rural- urban areas analysing urban trends using Accra and Kumasi metropolises as a case study for further urban studies and analysis. In each of the first four regions, a sample of households was chosen to provide information for each of the districts in each region. Almost around the time of the HIRD Supplementary Survey, another large survey, Maternal Mortality Survey (MMS) was being implemented nation-wide. Therefore, to reduce household listing costs in the HIRD Supplementary Survey, it was decided to use a number of selected EAs in each district while combining the selected ones in the verbal autopsy survey with household listing material, and additional ones to complete a specific number of EAs with a fresh household listing. The EAs were categorized into urban and rural areas proportionally to the number of households in each area. In each area, the EAs were selected systematically with a probability proportional to size (households). In the Upper East Region sample, the number of current districts is eight (in the 2000 Population and Housing Census, it was six). In each district about 22 EAs were selected, and in each EA a total of 20 households were selected. For the Upper West Region sample, the number of current districts is eight (in the last census it was five). In each district, about 12 EAs were selected, and in each EA a total of 20 households were selected. Again, in the Northern Region sample, the number of current districts is 18 (in the last census it was 13). In each district, about 10 EAs were selected, and in each EA a total of 20 households were selected. For the Central Region sample, the number increased from 12 districts in the last census to 13. In each of the districts, 15 EAs were selected, and in each EA a total of 20 households were selected. In Kumasi and Accra Metropolitan Areas, 45 EAs were selected systematically with probability proportional to size (households) and 20 households were selected in each EA. The list of enumeration areas (EAs) from the 2000 Population and Housing Census served as a frame for the HIRD Supplementary Survey sample. A complete household listing exercise covering all selected Eas from the 2000 Population and Housing Census sampling frame was carried out in May through December, 2007. At the second stage, 20 households were systematically sampled per EA based on this list. 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. A more detailed description of the sample design can be found in Annex A. II. Sample and Survey Methodology 55 Questionnaires Three sets of questionnaires were used in the survey: The questionnaire included the following modules: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � a household questionnaire which was used to collect information on all selected 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; and an under-5 questionnaire, administered to mothers or caretakers of all children under five years1 living in the household. Household listing Education Water and Sanitation Household Characteristics Insecticide Treated Net Working Children Child Discipline Disability National Health Insurance Salt Iodization Infant and Child Mortality Tetanus Toxoid Maternal and Newborn Health Marriage/Union Contraception Female Genital Mutilation/Cutting Domestic Violence Sexual Behaviour HIV/AIDS National Health Insurance Birth Registration and Early Learning Childhood Education and Child Development Vitamin A Breastfeeding Care during Illness Immunization Malaria Anthropometry The questionnaires are based on the Ghana 2006 MICS model questionnaire with some modifications to fit specific survey conditions and standards. The questionnaires, after modification, were pre-tested in July, 2007 in the Greater Accra Region. A 7-day pre-test training session was conducted by staff of the Ghana Statistical Service (GSS), Ministry of Health (MOH) and other selected ministries, departments and agencies Household Questionnaire Questionnaire for Individual Women Questionnaire for Children under Five 56 (MDAs) for 14 interviewers. Two teams consisting of supervisors and six interviewers were formed after the training to pilot the survey in two selected localities (one urban and one rural) in the same region to test the entirety of the survey procedures and the new modules. The final field tools were modified based on the results of the pre-test for the main fieldwork. As part of the process, cooking salt was tested for iodine content and the height and weight of all children less than 5 years (0-59 months) was established. A total of 86 field personnel and three data entry clerks participated in the main fieldwork training conducted from 19th August to 2nd September 2007. Data entry clerks took part in the main training sessions 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 for iodine in salt and taking the height and weight of all under-five children. Towards the end of the training period, trainees spent three days conducting field interviews in 10 Enumeration Areas (EAs) (2 urban and 8 rural). These areas were selected to provide the field staff a better understanding of working in different environments. Supervisors, editors and interviewers were selected based on their performance in the field practices, participation in class, assessment tests, understanding of the questionnaires and fluency in Ghanaian languages. Data were collected by 10 teams, each comprising four interviewers, a driver, an editor/measurer and a supervisor. The editor edited the completed questionnaires in the field and took height and weight measurements. Fieldwork in the three Northern Regions began in early September 2007 and ended in mid- December 2007. The delay in the completion of the fieldwork was due to flooding caused by torrential rains which started two weeks into the fieldwork. In the Central Region, seven teams were formed for the data collection exercise. The teams comprised four interviewers, a driver, an editor/measurer and a supervisor. To minimise errors and mistakes in the filling of questionnaires, field editors went through the questionnaires at the end of each working day. Fieldwork began on the 1st of February, 2008 and ended on the 14th of March, 2008. Throughout the report, the survey is referred to as “ The data were entered on 12 microcomputers using the Census and Survey Programme (CSPro) by 12 data entry operators, three data entry supervisors and an office editor (who received and administered the completed questionnaires for them to be captured). In order to ensure quality control, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed for the 2006 Ghana MICS were adapted to the HIRD Supplementary Survey questionnaire and were used throughout the data processing. Data processing began in early March 2008 and finished in mid- June 2008. Data were analysed using the Statistical Package for Social Sciences (SPSS) software. Model syntax and tabulation plans were developed for this purpose. HIRD Supplementary Survey 2007/2008” since data for the three Northern regions was collected in 2007, and data for Central region was collected in early 2008. Training and Fieldwork Data Processing 57 This section presents information on the sample coverage, socio-economic and demographic characteristics of the household population, focusing on age, sex, district, place of residence, and socio-economic conditions of households. The sample for the HIRD Supplementary Survey 2007/2008 covered the population residing in private households within the selected regions and metropolitan areas. The survey was done to have enough estimates for the various regions which serve as the lowest administrative unit within the country. The 2000 Population and Housing Census served as the sampling frame for the study. The EAs within the regions were stratified by district and urban/rural location. A complete household listing was done and based on the total number of households per EA, a systematic sample of 20 households per each EA were selected and included in the survey. Within these selected households, all females aged 15-49 were identified as eligible for individual interview. In addition, children under five years in selected households were also identified and either their mothers or their caretakers were interviewed on their behalf. Response rates are important as a high level of non-response may affect the reliability of the survey results. A total of 13,440 households were selected for the HIRD Supplementary Survey (District MICS). Of this number, a representative sample of 12,680 households was selected in the four regions. The sample within each region was selected in a manner to permit separate estimates of some key indicators for each region. Table HH.1 presents regional information on the results of the household and individual interviews. A total of 12,680 households were sampled from the four regions and of these, 12,622 were found to be occupied. Interviews were completed for 12,187 households, which represents a 97 percent response rate. A total of 11,962 eligible women (aged 15-49) from every selected household were identified for the individual interviews. Interviews were successfully completed for 11,174 women, yielding a response rate of 93 percent. In addition, 8,691 children aged 0-59 months within the selected households were listed in the household roster and caretakers answered questions on their behalf. Questionnaires were completed for 8,457 out of the 8,691 under-five children identified and this corresponded to a response rate of 97 percent. The overall response rates for women and children under-five were all over 90 percent. Response rate for households, women and children under five also varied by region. Household, women and children interviews for each region had a response rate of over 92 percent. There was no considerable difference in the response rate for households, women and children under five by place of residence. Sample Coverage and Response Rate III. Sample Coverage and Characteristics 58 59 Household Characteristics Table HH.2 and Figure HH.1 gives the age and sex distribution of the survey population and the population pyramid respectively. The survey in the four regions successfully interviewed 111,346 household members consisting of 55,378 males and 55,968 females. This gives an estimated average household size of 9.1 and a sex ratio 98 males per 100 females. This indicates that there are slightly more females than males in the four regions. The four regions have a very youthful population and this is indicated in the five-year age distribution for both sexes. There is a higher proportion (55 percent) of persons in the lower age group (0-19 years) than for those in the higher age group (20 years and above). The 2000 census results showed that the proportion of children less than 15 years old in the four regions was 41.2 percent. The HIRD Supplementary Survey results indicate that the proportion of children less than 15 years old in the four regions increased to 45 percent. The proportion of children between ages 0-17 is 51.4 percent. The dependent population (less than 15 years and 65+) increased slightly from 47.6 percent in 2000 to 49.9 percent in the HIRD Supplementary survey. 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. Generally, in most populations, there is a slight excess of males to females at birth. This results in males usually outnumbering females at younger ages (GSS 2005). The results of the HIRD Supplementary Survey are consistent with this observation. However, for the older age group (60-79 years), the number of males is more than that of females. This is inconsistent with most populations where the reverse is true. Table HH. 1 : Results of household and individual interviews Numbers of households, women, and children under 5 by results of the household, women's, and under- -five's interviews, and household, women's, and underfive's response rates, HIRD Supplementary Survey, 2007/2008 Region Area Central Northern Upper East Upper West Urban Rural Total Sampled households 3880 3520 3460 1820 3500 9180 12680 Occupied households 3872 3511 3429 1810 3487 9135 12622 Interviewed households 3707 3402 3324 1754 3337 8850 12187 Household response rate 95.7 96.9 96.9 96.9 95.7 96.9 96.6 Eligible women 2921 3846 3501 1694 3223 8739 11962 Interviewed women 2765 3545 3288 1576 2993 8181 11174 Women response rate 94.7 92.2 93.9 93.0 92.9 93.6 93.4 Women's overall response rate 90.6 89.3 91.0 90.2 88.9 90.7 90.2 Eligible children under 5 1832 3233 2310 1316 1874 6817 8691 Mother/Caretaker Interviewed 1798 3108 2268 1283 1816 6641 8457 Child response rate 98.1 96.1 98.2 97.5 96.9 97.4 97.3 Children's overall response rate 94.0 93.1 95.2 94.5 92.7 94.4 94.0 Table HH.2: Household age distribution by sex Percentage distribution of household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, HIRD Supplementary Survey, 2007/2008 Urban Rural Total Male Female Total Male Female Total Male Female Total Age 0-4 13.8 13.1 13.5 16.6 16.7 16.7 15.9 15.7 15.8 5-9 14.1 14.6 14.4 17.2 16.2 16.7 16.4 15.7 16.1 10-14 12.8 13.3 13.0 14.0 13.3 13.7 13.7 13.3 13.5 15-19 12.2 9.4 10.8 11.2 7.0 9.1 11.4 7.6 9.5 20-24 8.2 7.1 7.7 6.2 6.2 6.2 6.8 6.5 6.6 25-29 7.3 8.2 7.7 5.9 7.2 6.5 6.2 7.4 6.9 30-34 5.6 6.4 6.0 4.8 6.1 5.4 5.0 6.2 5.6 35-39 5.6 5.2 5.4 4.7 5.4 5.1 4.9 5.4 5.2 40-44 4.2 4.4 4.3 3.6 4.3 3.9 3.8 4.3 4.0 45-49 3.4 3.5 3.5 3.2 3.8 3.5 3.3 3.7 3.5 50-54 3.1 5.3 4.2 2.7 4.7 3.7 2.9 4.9 3.9 55-59 2.5 3.1 2.8 2.1 2.9 2.5 2.2 3.0 2.6 60-64 2.8 2.4 2.6 2.2 2.2 2.2 2.4 2.2 2.3 65-69 1.5 1.6 1.5 1.8 1.5 1.7 1.7 1.6 1.6 70-74 1.4 1.5 1.5 1.6 1.4 1.5 1.6 1.4 1.5 75-79 0.8 0.5 0.7 1.0 0.5 0.8 1.0 0.5 0.7 80+ 0.7 0.4 0.5 0.8 0.6 0.7 0.8 0.5 0.6 Missing/DK 0.1 0.0 0.1 0.1 0.0 0.1 0.1 0.0 0.1 Dependency age groups <15 40.7 40.9 40.8 48.0 46.3 47.2 46.0 44.8 45.4 15-64 54.9 54.9 54.9 46.6 49.7 48.1 48.9 51.1 50.0 65+ 4.3 4.1 4.2 5.3 4.0 4.6 5.0 4.0 4.5 Missing/DK 0.1 0.0 0.1 0.1 0.0 0.1 0.1 0.0 0.1 Age Childrenaged 0-17 47.7 46.7 47.2 55.5 50.5 53.1 53.4 49.5 51.5 Adults 18+ 52.3 53.3 52.8 44.5 49.5 46.9 46.6 50.5 48.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 60 61 Table HH.3 provides background information on households, the sex of the household head, place and area of residence, number of household members, and households with at least one child (0-17 years). Socio-cultural factors such as kinship types, marriage, family and household formation largely influence living arrangements among society groups in Ghana in general. Ethnicity in Ghana also has great impact on the composition and the size of households. The sex of the head of household, size and household composition are also 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 (GSS, 2005). Figure HH.1: Population Pyramid by age and sex, HIRD Supplementary Survey, 2007/2008 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 10 ,0 00 9, 00 0 8, 00 0 7, 00 0 6, 00 0 5, 00 0 4, 00 0 3, 00 0 2, 00 0 1, 00 0 - - 1, 00 0 2, 00 0 3, 00 0 4, 00 0 5, 00 0 6, 00 0 7, 00 0 8, 00 0 9, 00 0 10 ,0 00 FemaleMale Source: HIRD Supplementary Survey, 2007/2008 The 2007/2008 HIRD Supplementary Survey results in the four regions indicate that 22 percent of households are headed by women. This is slightly lower than the national average in the 2006 MICS (29 percent). In the four regions, the most common household size is 4-5 members, representing 29 percent, followed by 2-3 household members (25 percent). The larger households might be due to socio-cultural factors in the three northern regions (Northern, Upper East and Upper West). Thirteen percent of the households are single-member households. Nearly half of the households in the four regions have at least one child less than 5 years old. About 3 in 5 households have at least one child under 18 years old, and 72 percent of households have at least one woman aged 15-49 years (Table HH.3). Table HH.3: Household composition Percentage distribution of households by selected characteristics, HIRD Supplementary Survey, 2007/2008 Weighted percentage Number of households weighted Number of households unweighted Sex of household head Male 78.0 9507 9535 Female 22.0 2688 2652 Region Central 30.4 3707 3707 Northern 28.0 3410 3402 Upper East 27.3 3324 3324 Upper West 14.4 1754 1754 Area Urban 28.2 3440 3337 Rural 71.8 8755 8850 Number of household members 1 13.3 1627 1621 2-3 24.6 2999 2966 4-5 28.6 3488 3460 6-7 19.2 2336 2353 8-9 8.1 989 1014 10+ 6.2 755 773 At least one child aged < 18 years 77.1 12195 12187 At least one child aged < 5 years 48.5 12195 12187 At least one woman aged 15-49 years 71.9 12195 12187 Total 100.0 12,195 12,187 62 1 2 Unless otherwise stated, “education”, when it is used as a background variable, refers to the highest educational level attended by the respondent. 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. 63 Characteristics of respondents Table HH.4 provide information on the background characteristics of female respondents aged 15-49 years and of children under five years old. The Table also provide u s e f u l i n f o r m a t i o n o n t h e distribution of women according to district, urban-rural location, age, marital status, motherhood and parenthood status, education , and wealth index quintiles of female respondents aged 15-49. Seventy-six percent of women respondents are married or currently in union while 19 percent of women have never been married. Eighty percent of women interviewed have given birth at least once. Generally, the proportion of respondent decreases with age. The 15-24 age group form 31 percent of the total respondents in the four regions. Seventy-one percent of total respondents reside in rural areas of the four regions. One in five women are from the richest wealth index quintile while, 18 percent are from the poorest wealth index quintile. 1 2 Table HH.4: Women's background characteristics Percent distribution of women aged 15-49 years by background characteristics, HIRD Supplementary Survey, 2007/2008 Weighted percent Number of women weighted Number of women unweighted Region Central 19.2 2003 1981 Northern 34.1 3554 3545 Upper East 31.6 3288 3288 Upper West 15.1 1576 1576 Area Urban 28.6 2979 2628 Rural 71.4 7442 7762 Age 15-19 15.9 1743 1642 20-24 15.1 1657 1511 15-24 31.0 3399 3153 25-29 13.8 1513 1393 30-34 15.8 1729 1613 35-39 13.8 1511 1513 40-44 11.1 1214 1251 45-49 9.6 1055 1026 Marital/Union status Currently married/in union 76.2 7936 7790 Formerly married/in union 5.4 558 774 Never married/in union 18.5 1927 1826 Motherhood status Ever gave birth 79.8 8320 8452 Never gave birth 20.2 2101 1938 Education None 64.4 6715 6009 Primary 15.0 1562 1906 Middle/JSS 14.8 1547 1880 Secondary + 5.7 597 595 Wealth index quintiles Poorest 18.4 1913 2063 Second 20.9 2175 2089 Middle 20.3 2120 2075 Fourth 20.3 2120 2088 Richest 20.1 2093 2075 Total 100.0 10421 10390 Adult literacy is an MDG indicator, and is an important background characteristic of respondents. In this survey, literacy was assessed on the ability of a respondent 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. Table HH.4A show the percent literate is the regions. One in four women in the four regions is literate. There are considerable differences in literacy levels among the four regions. A little over half of the women in Central region are literate. Within the three Northern regions, women in Upper West region are more literate (26 percent) than those in Upper East and Northern regions. Northern region has the least proportion of literate women (17 percent). As expected, the possibility of a person living in an urban area to be literate is higher (34 percent) than for women living in the rural area (15 percent). Literacy levels decreases with age – for example, 45 percent of women aged 15-19 year are literate compared to 12 percent of those in the 45-49 year group. Women in the richest wealth index quintile (31 percent) are more likely to be literate than their counterpart in the poorest wealth index quintile (23 percent). Table HH.5 presents further background characteristics such as distribution of children by sex, age (months), region and place of residence, mother's or caretaker's education of children under-five and wealth index quintiles. There are no considerable differences in the proportion of girls to boys among under-five years in the four regions. There are however, slightly more (51 percent) boys than girls residing in urban areas. Children are evenly divided in each of the five one-year age groups. One in five children in the four regions is less than one year. About one-third of children under-five years in all four regions are in the Northern region. Upper East region is second with 27 percent of children under five years, followed by Central region with 21 percent of the children. Upper West region has the least proportion (15 percent) of children under-five years in the four regions. A high proportion of mothers or caretakers of children under five have little or no education (83 percent). One out of ten mothers has primary level education, 5 percent have middle/JSS education and about 3 percent have secondary or higher education. Table HH.4A: Adult literacy Percentage of women aged 15-49 years that are literate, HIRD Supplementary Survey, 2007/2008 Percentage literate * Number of women aged 15-49 years Region Central 50.8 2003 Northern 16.5 3554 Upper East 23.1 3288 Upper West 25.8 1576 Area Urban 38.4 2979 Rural 15.2 7442 Education None 0.1 6715 Primary 8.2 1562 Middle/JSS 100.0 1547 Secondary + 100.0 597 Age 15-19 45.2 1657 20-24 28.9 1575 25-29 21.5 1951 30-34 13.6 1644 35-39 12.4 1437 40-44 11.9 1154 45-49 11.5 1003 Wealth index quintiles Poorest 23.1 1913 Second 20.8 2175 Middle 23.3 2120 Fourth 24.3 2120 Richest 30.9 2093 Total 24.5 10421 * MICS Indicator 60; MDG Indicator 8 64 65 Table HH. 5: Children's background characteristics Percentage distribution of children under five years of age, by background characteristics, HIRD Supplementary Survey, 2007/2008 Total Number of under-5 children weighted Number of under-5 children unweighted Sex Male 49.5 4193 4198 Female 50.5 4273 4259 Region Central 21.2 1798 1798 Northern 36.8 3117 3108 Upper East 26.8 2268 2268 Upper West 15.2 1283 1283 Age < 6 months 10.7 910 904 6-11 months 11.1 940 939 12-23 months 19.5 1654 1670 24-35 months 19.9 1689 1666 36-47 months 20.8 1762 1770 48-59 months 17.8 1511 1508 Mother's education None 82.5 6985 3896 Primary 10.0 844 2173 Middle/JSS 48 405 1672 Secondary+ 2.7 232 716 Wealth index quintiles Poorest 21.7 1837 1685 Second 19.7 1670 1693 Middle 19.0 1605 1679 Fourth 19.3 1637 1703 Richest 20.3 1717 1696 Total 100.0 8466 8457 IV. Infant and Child Mortality 66 This chapter describes levels, trends, and differentials in early childhood mortality and high-risk fertility behavior of women in the Upper East, Upper West, Northern and Central regions of Ghana. One of the overarching objectives of the MDGs and World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for a two-thirds reduction in the mortality rate for under fives between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Childhood mortality in general and under-five mortality in particular contributes to a better understanding of a country's socio-economic situation and sheds light on the quality of life of the population. Such analyses are thus useful for identifying promising directions for health programmes and for advancing child survival efforts. Measures of childhood mortality are also useful for population projections. The information in this chapter is disaggregated by socio-economic and demographic characteristics since studies have shown the existence of differentials in mortality by these characteristics, and the disaggregation helps to identify subgroups that are at high risk. Preparation, implementation, and monitoring and evaluation of population, health, and other socio-economic programs and policies depend to a large extent on target population identification. The mortality rates presented in this chapter are computed using direct measures from birth histories collected from the female respondents, to produce robust estimates that are comparable with the ones obtained from other sources in the country like the Ghana Demographic and Health Surveys (GDHS). Women in the age group 15-49 were asked if they had ever given birth, and if they had, they were asked to report the number of sons and daughters living with them, the number living elsewhere, and the number who had died. A detailed history of all live births was gathered in chronological order starting with the first live birth. Women were asked whether a live birth was single or multiple; the sex of the child; the date of birth (month and year); survival status; age of the child on the date of the interview if alive; and if not alive, the age at death of each child born alive. Childhood mortality estimates measure the risk of dying from birth upto age five. Since the primary causes of childhood mortality change as children agefrom biological factors to environmental factorschildhood mortality rates are expressed by age categories and are customarily defined as follows: Neonatal mortality (NN) : the probability of dying between birth and the first month of life Postneonatal mortality (PNN) : the difference between infant and neonatal mortality Infant mortality (1q0) : the probability of dying between birth and exact age one Child mortality (4q1) : the probability of dying between exact ages one and five Under-five mortality (5q0) : the probability of dying between birth and exact age five. All rates are expressed per 1,000 live births, except child mortality, which is expressed per 1,000 children surviving to 12 months of age. Definitions 67 Assessment of Data Quality The reliability of mortality estimates depends on the sampling variability of the estimates and on nonsampling errors. Sampling variability and sampling errors are discussed in details in this Report (Annex A and C). Nonsampling errors depend on the extent to which the date of birth and age at death are accurately reported and recorded and the completeness with which child deaths are reported. Omission of births and deaths affects mortality estimates, displacement of birth and death dates impacts mortality trends, and misreporting of age at death may distort the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths of children who were dead at the time of the survey. When selective omission of childhood deaths occurs, it is usually most severe for deaths in early infancy. If early neonatal deaths are selectively underreported, the result is a low ratio of deaths under seven days to all neonatal deaths and a low ratio of neonatal to infant deaths. Under-reporting of early infant deaths is most commonly observed for births that occurred longer before the survey; hence, it is useful to examine the ratios over time. Inspection of these ratios (Annex B, Table DQ.11) indicates that no significant numbers of early infant deaths were omitted in the HIRD Supplementary Survey. Firstly, the proportion of neonatal deaths occurring in the first week of life is estimated at 83 percent for the sampled regions (0-4 years before the survey). Further, while the proportion seems significantly lower after the 0-4 years period (74 percent), which may indicate omission of dead children born in the 5-9 and 10-14 years prior to the survey, this is still plausible since a ratio of about 70 percent is often considered as normal . The results are also similar to those found in other surveys, which shows that in Ghana, an estimated 40 percent of neonatal deaths occur in the first 24 hours and 75 percent in the first 7 days of life (GHS, 2008). Secondly, the proportion of infant deaths occurring during the first month of life is plausible (53 percent), and is stable over the 15 years before the survey. This is also consistent with other studies that reveal that in Ghana, newborn deaths are an important component of child mortality, representing an estimated 40 percent of all deaths (GHS, 2008). Heaping of the age at death on certain digits is another problem that is inherent in most retrospective surveys. This phenomenon introduces biases in rate calculation, if the net result is to shift deaths from one age segment to another. Thus, heaping at 12 months causes concern because a certain fraction of deaths, though reported to occur after infancy (i.e. at ages 12-23 months), may have actually occurred during infancy (i.e., at ages 0-11 months). In such a case, the infant mortality rate will be biased downwards and child mortality upwards. Table DQ.12 (Annex D) presents the distribution of deaths reported at ages 0-24 months by reported age at death for three 5-year periods preceding the survey. Distinct 'heaps' of deaths are evident at 6, 12 and 18 months of age, with corresponding deficits in the adjacent months. More troublesome are the large number of deaths reported at '1 year', which are likely as a result of digit preference and misreporting or not probing of interviewers. This 'heaping' took place in spite of the care taken in the HIRD Supplementary Survey to minimize errors of this nature by insisting that age at death be recorded in days if the death took place within one month after birth, in months if the child died within 24 months of birth, and in years if the child died between ages two and five. Nevertheless, this is not markedly different from the levels of 'heaping' seen in other retrospective surveys. 3 3 There are no models for mortality patterns during the neonatal period. However, one review of data from developing countries concluded that at levels of neonatal mortality of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). 68 In sum, internal consistency checks indicate that the mortality data from the HIRD Supplementary Survey are of reasonable quality. The imprecise reports of ages at death, especially the reports of '1 year', may introduce a small downward bias in the estimation of infant mortality and an upward bias in the estimation of child mortality. However, the evaluation of trends in the survey would not be affected. Finally, as the periods covered extend further into the past, the resulting censoring of information becomes progressively more severe. To minimize the effect of censoring, analysis of child mortality trends is limited to a period no more than 15 years prior to the survey. Table CM.2 provides estimates of childhood mortality for the 15 years preceding the survey in three five- year periods for the four regions. Central region had the lowest infant mortality and under-five mortality rates among the four regions. For the most recent five-year period, corresponding approximately to 20032007/2008, the infant mortality rate was estimated at 55 per 1,000 live births, while the under-five mortality rate was estimated at 83 per 1,000 live births for the Central Region. The Northern region had the highest rates for the two indicators 64 and 120 per 1,000 live births respectively. For the Upper East region, the infant mortality rate was estimated at 57 per 1,000 live births, while the under-five mortality rate was estimated at 93 per 1,000 live births. Infant mortality for the Upper West region was 62 deaths per 1,000 live births, while the under-five mortality was 113 per 1,000 live births. Neonatal mortality in the four regions was fairly consistent (29 per 1,000 live births for Central, Northern and Upper East regions, and 32 for Upper West region). This means that neonatal deaths are still a key component of all infant and under-five deaths in the four regions and Ghana in general. In the Central region, the survey results reveal that for the 15-year period preceding the survey, under-five mortality declined by about 14 percent from 97 to 83 deaths per 1,000 live births. Infant mortality declined by 8 percent from 60 to 55 deaths per 1,000 live births. In the region, child mortality had the largest decline of 28 percent from 40 to 29 deaths per 1,000 live births (Table CM.2 and Figure CM.1). In the Northern region, for the 15-year period preceding the survey, the findings show a decline in under- five mortality by about 33 percent from 178 to 120 deaths per 1,000 live births. Infant mortality declined by 26 percent from 87 to 64 deaths per 1,000 live births. Child mortality had the largest decline of 39 percent from 99 to 60 deaths per 1,000 live births. During the same period, neonatal mortality decreased from 42 to 29 deaths per 1,000 live births, marking a 31 percent reduction. In the Upper East region, during the 15-year period preceding the survey, the findings show a decline in under-five mortality by about 32 percent from 136 to 93 deaths per 1,000 live births. Infant mortality declined by 28 percent from 79 to 57 deaths per 1,000 live births, and neonatal mortality decreased from 38 to 29 deaths per 1,000 live births, marking a 24 percent reduction.In the Upper West region, the findings show a decline in under-five mortality of about 34 percent from 170 to 113 deaths per 1,000 live births in the 15- year period preceding the survey. Infant mortality declined by 24 percent from 82 to 62 deaths per 1,000 live births. During the same period, neonatal mortality decreased from 45 to 32 deaths per 1,000 live births, marking a 13 percent reduction (Table CM.2 and Figure CM.1). Levels and Trends of Early Childhood Mortality 69 Table CM.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for periods preceding the survey, five-year HIRD Supplementary Survey, 2007/2008 Central Region Years preceding the survey Approximate calendar period Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0)* Child mortality (4q1) Under-five mortality (5q0)** 0-4 2004-2008 29 26 55 29 83 5-9 1999-2003 38 28 66 36 100 10-14 1994-1998 31 29 60 40 97 Northern Region 0-4 2003-2007 29 34 64 60 120 5-9 1998-2002 33 41 74 78 146 10-14 1993-1997 42 45 87 99 178 Upper East Region 0-4 2003-2007 29 28 57 38 93 5-9 1998-2002 40 24 63 48 109 10-14 1993-1997 38 41 79 62 136 Upper West Region 0-4 2003-2007 32 30 62 55 113 5-9 1998-2002 32 43 74 66 135 10-14 1993-1997 45 37 82 95 170 * MICS indicator 2; MDG indicator 14 ** MICS indicator 1; MDG indicator 13 70 Figure CM.1: Trends in Under-five Mortality at 0-4 years, 5-9 years and 10-14 years before Survey, HIRD Supplementary Survey, 2007/2008 178 170 136 97 146 135 109 100 120 113 93 83 0 20 40 60 80 100 120 140 160 180 200 Northern Upper West Upper East Central Regions D ea th s p er 1, 00 0 li v e b ir th s 10-15 yrs 5-9 yrs 0-4 yrs Socio-economic Differentials in Childhood Mortality Tables CM.3 show differentials in childhood mortality by three socio-economic variables: residence (urban- rural), mother's education and wealth quintiles for the four regions where the survey was conducted. To minimize sampling errors associated with mortality estimates and to ensure a sufficient number of cases for statistical reliability, the mortality rates shown in Table CM.3 are calculated for a ten-year period (19982007/8) preceding the survey. From Table CM.2 it is apparent that infant and child survival are associated with the socio-economic characteristics of mothers. Generally, mortality in urban areas is consistently lower than in rural areas for Central, Northern and Upper West regions. In the Upper East region, no significant differences in under- five mortality between urban and rural residences are observed; the rate is estimated at 99 and 101 per 1,000 live births respectively (Figure CM.2). The urban-rural difference is even more pronounced in the Upper West region, where there is an 18 percent difference between rural and urban under-five mortality (127 and 103 deaths per 1,000 live births). 71 Table CM.2 Early childhood mortality rates by socioeconomic characteristics Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 31 26 57 30 85 Rural 35 28 63 33 94 Mother's education No education 43 30 73 36 106 Primary 24 28 53 28 79 Secondary + 35 25 59 32 90 Wealth quintile Poorest 32 26 58 40 95 Second 32 25 57 25 81 Middle 40 24 65 29 91 Fourth 30 24 54 28 81 Highest 34 35 69 38 104 Residence Urban 29 37 66 61 123 Rural 32 38 70 70 135 Mother's education No education 31 38 69 69 133 Primary 30 43 72 62 130 Secondary + (42) 25 66 64 126 Wealth quintile Poorest 17 37 54 65 116 Second 30 39 69 78 141 Middle 40 44 84 77 155 Fourth 37 36 73 73 141 Highest 35 32 67 50 113 Residence Urban 36 29 65 37 99 Rural 34 25 59 45 101 Mother's education No education 34 23 58 42 97 Primary 33 33 66 53 116 Secondary + (37) 32 69 37 103 Wealth quintile Poorest 41 33 74 60 129 Second 36 23 60 48 104 Middle 33 23 56 37 91 Fourth 31 24 54 32 85 Highest 30 26 56 38 91 Total 34 26 60 43 101 Residence Urban 27 22 49 57 103 Rural 32 38 70 61 127 Mother's education No education 33 34 67 64 127 Primary (26) 43 68 47 112 Secondary + (31) 44 74 48 119 Wealth quintile Poorest (48) 41 90 59 143 Second 32 33 65 74 134 Middle 34 35 68 69 133 Fourth 29 39 68 56 120 Highest (19) 35 54 32 84 Figures in parentheses '( )' are based on 250-499 exposed persons Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, HIRD Supplementary Survey, 2007/2008 CENTRAL REGION NORTHERN REGION UPPER EAST REGION UPPER WEST REGION 72 Numerous studies have demonstrated a strong relationship between a mother's level of education and the survival of her child. However, according to the HIRD Supplementary Survey, the pattern is not consistent in all four regions. For example, in the Upper East region, childhood mortality rates are higher for women with secondary and higher education, and lowest for mothers with little or no education. In the Central region, while mortality is consistently higher for mothers with little or no education for all childhood mortality, there is an irregular pattern for mothers with primary, secondary or higher education. In the Upper West region, infant mortality is 67 per 1,000 live births for mothers with little or no education, and increases slightly to 74 per 1,000 live births for children whose mothers have secondary or higher education. In the Northern region, the pattern is also not consistent. For example, little variations are observed between infant mortality and mother's education. For mothers with little or no education, infant mortality is 69 per 1,000 live births, for mothers with primary education, infant mortality is estimated at 72 deaths per 1,000 live births, while for those with secondary or higher education, infant mortality is 66 per 1,000 live births (Table CM.3). The survey found that in the 3 Northern regions, more than 60 percent of women had little or no education, less than 20 percent had primary education, and about 5 percent had secondary or higher education (Table HH.4). It is generally expected that more educated women are less likely to under-report the number of deaths and misquote the actual age at death than those less educated. The aberrant patterns may likely be attributed to the large sampling errors associated with the rates among women with higher education, and need to be treated with caution. Figure CM.2: Under-five Mortality by Area of Residence, HIRD Supplementary Survey, 2007/2008 135 127 101 94 123 103 99 85 0 20 40 60 80 100 120 140 160 Northern Upper West Upper East Central Regions D ea th s p er 1, 00 0 li v e b ir th s Rural Urban 73 Demographic Characteristics and Childhood Mortality Studies have shown that a number of demographic factors are strongly associated with the survival chances of young children. These factors include sex of the child, age of the mother at birth, birth order and length of the preceding birth interval. Table CM.3 shows the relationships between childhood mortality and these demographic variables. For all variables, mortality estimates are calculated for a ten-year period before the survey to reduce sampling variability. Childhood mortality rates are generally higher for males than females in the four regions (Table CM.3). With the exception of neonatal mortality which is fairly similar between boys and girls, male mortality exceeds female mortality at all levels in the Upper East region. Studies have also shown that births to young mothers and older mothers experience an elevated risk of mortality. Mother's age at the time of child birth influences child survival in all periods as seen in Table CM.3, exhibiting the expected U-shaped relationship with mother's age high for women in the young age groups, low for women in the middle age groups, and high for women in the older age groups. In the Northern region for example, the infant mortality rate for women under 20 years when they gave birth is estimated at 99 deaths per 1,000 live births. The rate decreases for women who gave birth at age 20-29 years and 30-39 years (62 and 64 deaths per 1,000 live births respectively), and then rises to 96 deaths per 1,000 live births for women who gave birth at age 40-49 years. The higher rates may be related to biological factors that lead to complications during pregnancy and delivery. Table CM.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, HIRD Supplementary Survey, 2007/2008 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) CENTRAL REGION Child's sex Male 44 26 70 33 100 Female 23 28 52 32 82 Mother's age at birth <20 (35 ) 33 68 32 98 20-29 33 26 59 29 86 30-39 33 23 56 41 95 40-49 (42) 64 106 * 106 Birth order 1 39 25 64 35 97 2-3 25 23 48 24 71 4-6 39 28 67 40 104 7+ 35 44 79 34 110 Previous birth interval <2 years (67) 33 100 23 121 2 years 27 27 54 38 90 3 years 23 32 54 28 81 4+ years 23 22 46 32 76 NORTHERN REGION Child's sex Male 38 38 76 75 145 Female 25 37 62 61 120 Mother's age at birth <20 46 53 99 57 150 20-29 25 37 62 66 124 30-39 32 32 64 78 137 40-49 (49) 47 96 53 143 Birth order 1 38 45 83 64 142 2-3 25 33 59 59 114 4-6 29 35 65 77 137 7+ 41 43 84 75 153 Previous birth interval <2 years 61 62 124 105 216 2 years 31 38 69 75 139 3 years 26 31 57 65 118 4+ years 12 21 33 38 70 UPPER EAST REGION Child's sex Male 34 27 61 49 107 Female 35 24 59 37 94 Mother's age at birth <20 38 26 64 43 105 20-29 34 26 60 41 99 30-39 33 25 58 42 97 40-49 (39) 29 68 77 139 Birth order 1 41 32 73 36 107 2-3 31 22 53 34 85 4-6 29 27 56 51 105 7+ 52 22 74 62 132 Previous birth interval <2 years (74) 39 113 84 187 2 years 37 31 68 57 121 3 years 23 22 45 36 80 4+ years 24 16 40 25 64 74 75 The birth interval also affects survival when there is less than two years between pregnancies, demonstrating the importance of spacing on child survival. This is consistent in all four regions. In the Central region for example, infant mortality for children born at less than a two-year interval is 100 deaths per 1,000, and reduces to 54 deaths per 1,000 live births, an estimated 46 percent reduction when the birth interval is 2 or 3 years. Under-five mortality reduces by 33 percent from 121 deaths per 1,000 live births (birth interval less than 2 years) to 81 deaths per 1,000 live births when a birth occurs 3 years after a previous birth. First births and higher order births generally face an elevated risk of mortality. Data from the four regions confirm this pattern for the most part. In the Upper West region for example, birth order seven and higher experiences the highest levels of childhood mortality; and mortality is lowest for second and third order births. 98 86 95 106 97 71 104 110 121 90 81 76 0 20 40 60 80 100 120 140 <20 20-29 30-39 40-49 1 2 to 3 4 to 6 7+ <2 years 2 years 3 years 4+ years Deaths per 1,000 live births Prior birth interval Birth order Age of Mother 150 124 137 143 142 114 137 153 216 139 118 70 0 50 100 150 200 250 <20 20-29 30-39 40-49 1 2 to 3 4 to 6 7+ <2 years 2 years 3 years 4+ years Deaths per 1,000 live births Age of Mother Prior birth interval Birth order Central Region Northern Region Figure CM.3: Under-5 Mortality by selected Demographic Characteristics, HIRD Supplementary Survey, 2007/2008 UPPER WEST REGION Rates based on 250-499 exposed persons are in parenthesis '( )' Child's sex Male 36 35 72 60 127 Female 28 37 65 61 122 Mother's age at birth <20 (72) 51 124 72 187 20-29 29 39 68 44 109 30-39 26 29 56 81 132 40-49 (31) (29) 60 52 109 Birth order 1 58 50 108 53 156 2-3 24 34 58 50 105 4-6 23 34 57 65 119 7+ 41 33 74 80 148 Previous birth interval <2 years 66 80 145 97 228 2 years 17 34 51 68 115 3 years 26 22 48 60 105 4+ years 14 15 29 27 55 Table CM.3 Early childhood mortality rates by demographic characteristics (cont.) Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, HIRD Supplementary Survey, 2007/2008 High-risk Fertility Behavior Children's survival chances are associated with certain characteristics of fertility behavior. These characteristics are of particular importance in this section because they are easily avoidable at a relatively low cost. Typically, infants and children have an elevated risk of dying if their mothers are too young (under 18 years of age) or too old (over 35 years old), if they are born after too short a birth interval (less than 24 months), and if their mothers have already had many children. Although first births are commonly associated with higher mortality risk, they are not included in the high-risk category because the risks associated with first births are unavoidable. Table CM.5 shows the percent distribution of children born in the five-years preceding the survey and the percent distribution of currently married women, by risk factors in the Central, Northern, Upper East and Upper West regions. The Table also shows the risk ratio of dying for children, by comparing the proportion of dead children in each risk category with the proportion of dead children not in any high-risk category. The first column in Table CM.5 shows the percentage of births occurring in the five years before the survey that fall into the various risk categories. Slightly more than half (55 percent) of births in the four regions have elevated mortality risks, which are avoidable, and one out of every three births were not in any high-risk category. Among those who are at risk, 32 percent of births are in a single high-risk category, while 24 percent of births are in a multiple high-risk category. In general, risk ratios are higher for children in a multiple high-risk category than for those in a single high-risk category. In the four regions, the most vulnerable births are those to women with a birth interval of less than 24 months and birth order is 3 or higher (3.4). This is followed by women who are age 35 or older, with a birth interval less than 24 months, and birth order three or higher (2.4). Fortunately, only 5 percent of births fall into this category. Twenty-four percent of births occur to mothers who have three or more births, and 18 percent of births occur to mothers who are 35 years or older and have had three or more children. These children are more than twice as likely to die as children without any risk. The last column of Table CM.5 shows the distribution of currently married women who have the potential for having a high-risk birth by category. This was obtained by simulating the distribution of currently married women by the risk category in which a birth would fall if a woman were to conceive at the time of 76 105 99 97 139 107 85 105 132 187 121 80 64 0 20 40 60 80 100 120 140 160 180 200 <20 20-29 30-39 40-49 1 2 to 3 4 to 6 7+ <2 years 2 years 3 years 4+ years Deaths per 1,000 live births Age of Mother Prior birth interval Birth order 187 109 132 109 156 105 119 148 228 115 105 55 0 50 100 150 200 250 <20 20-29 30-39 40-49 1 2 to 3 4 to 6 7+ <2 years 2 years 3 years 4+ years Deaths per 1,000 live births Prior birth interval Birth order Age of Mother Upper East Region Upper West Region Figure CM.3: Under-5 Mortality by selected Demographic Characteristics, HIRD Supplementary Survey, 2007/2008 (cont.) Table CM.5 High-risk fertility behavior Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women 1 Not in any high risk category 29.1 1.0 16.1 a Unavoidable risk category First order births between ages 18 and 34 years 15.9 1.5 4.2 Single high-risk category Mothers's age <18 3.4 1.8 0.3 Mothers's age >34 1.3 0.5 3.6 Birth interval <24 months 3.3 1.9 8.9 Birth order >3 23.6 1.1 14.6 Subtotal 31.6 1.3 27.3 Multiple high-risk category Age <18 & birth interval <24 months 2 0.1 3.7 0.1 Age >34 & birth interval <24 months 0.1 0.0 0.2 Age >34 & birth order >3 18.4 1.6 34.4 Age >34 & birth interval <24 months & birth order >3 1.5 2.4 7.2 Birth interval <24 months & birth order >3 3.4 3.4 10.3 Subtotal 23.5 1.9 52.3 In any avoidable high-risk category 55.0 1.5 79.6 Total 100.0 - 100.0 Number of births/women 9,226 - 8,547 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Na = Not applicable 1Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 moths or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher 2 Includes the category age <18 and birth order >3 a Includes sterilized women Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, HIRD Supplementary Survey, 2007/2008 77 the survey. This column is purely hypothetical and does not take into consideration the protection provided by family planning, postpartum insusceptibility, and prolonged abstinence. However, it provides an insight into the magnitude of high-risk fertility behavior. Four in every five women are potentially at risk of giving birth to a child with an elevated risk of mortality. One in two of these women is or would be too old, and have or would have too many children. A substantially higher proportion of women have the potential of having a birth in a multiple high-risk category than in a single high-risk category. V. Nutrition Nutritional Status Children's nutritional status is a reflection of their overall health. When children have access to adequate food, they are not exposed to repeated illness, they reach their growth potential and are considered well nourished. In a well-nourished population, there is a standard distribution of height and weight for children under age five. Malnourishment in a population can be measured by comparing children to a reference distribution. The reference population used here is the WHO/CDC/NCHS reference, which is recommended for use by UNICEF and the World Health Organization. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of this reference population. Height for age is a measure of linear growth. Children whose height for age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as stunted. Those whose height for age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight for children whose weight for height is more than two standard deviations below the median of the reference population are classified as wasted, while those who fall more than three standard deviations below 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. Finally, weight for age is a measure of both acute and chronic malnutrition. Children whose weight for age is more than two standard deviations below the median of the reference population are considered underweight while those whose weight for age is more than three standard deviations below the median are classified as severely underweight. Table NU.1 shows percentages of children classified in each of these categories, based on the anthropometric measurements that were taken during fieldwork by background characteristics. Additionally, the table includes the percentage of children who are overweight, i.e. those children whose weight for height is above 2 standard deviations from the median of the reference population. Interviews were successfully completed for 8,466 children but about 5 percent was not included in the analysis because of missing height or weight values. Thus, 8,020 children with complete height and weight figures were included in this analysis. Nearly one in four children under age five in the selected regions of study (Central, Northern, Upper East and Upper West) are underweight, with 5 percent classified as severely underweight. Twenty-five percent of children in the study areas are stunted or too short for their age, while seven percent are wasted or too thin for their height. However, one percent of under-five children in these regions can be said to be overweight. 78 79 There are no marked differences between males (25 percent) and females (24 percent) in the levels of underweight among children under five years. However, slightly more males are stunted and wasted than females in the four regions. Regional variations in nutritional status of children are quite substantial. Both Northern and Upper East regions have underweight levels higher than the overall average (29 percent and 25 percent respectively). Children living in the Northern region recorded the highest level of stunting, followed by Upper East, and Central, all with levels above 20 percent, while Upper West recorded the lowest level of stunting at 19 percent. With regards to children that are wasted in the four regions, Northern region again, had the highest level of wasted children under five years old (9 percent) followed by Upper East region then Upper West region. Central region recorded the lowest prevalence of wasted children at five percent. Little variations are observed between educational level and the socio-economic status of the mother and nutritional status of the child. For example, 25 percent of children whose mothers have secondary or higher Table NU.1 : Child malnourishment Percentage of under-five children who are severely or moderately undernourished, HIRD Supplementary Survey, 2007/2008 Weight for age Height for age Weight for height 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 24.6 5.4 26.6 7.7 8.2 0.9 1.1 3,967 Female 23.7 4.0 23.2 7.0 6.4 0.6 0.9 4,053 Region Central 18.6 2.3 20.6 4.6 4.6 0.1 1.1 1,704 Northern 29.3 6.8 31.1 10.4 8.8 1.2 1.1 2,891 Upper East 24.6 5.0 23.4 7.4 8.1 0.8 0.8 2,202 Upper West 18.6 2.5 18.9 4.0 6.0 0.5 0.9 1,223 Area Urban 22.1 4.2 20.6 5.4 8.1 0.7 1.0 1,774 Rural 24.7 4.8 26.1 8.0 7.1 0.7 1.0 6,245 Age < 6 months 2.0 0.5 5.0 1.4 2.0 0.2 3.9 841 6-11 months 23.1 4.8 13.2 3.4 10.0 0.7 1.8 910 12-23 months 38.0 8.2 31.2 8.7 17.8 2.3 0.6 1,616 24-35 months 29.0 7.5 26.4 8.2 6.1 0.6 0.2 1,634 36-47 months 21.3 2.6 29.1 9.1 3.0 0.3 0.4 1,640 48-59 months 19.5 2.2 30.6 9.1 2.9 0.0 0.8 1,378 Mother's education None 25.1 4.8 26.2 7.9 7.3 0.8 1.0 6,593 Primary 20.2 4.4 19.4 5.7 8.3 0.8 0.7 813 Middle/JSS 19.0 2.8 20.1 4.1 4.1 0.3 1.4 391 Secondary+ 17.1 4.2 14.1 3.6 8.3 0.0 1.1 222 Wealth index quintiles Poorest 27.7 5.4 26.8 7.9 8.0 0.9 0.9 1,739 Second 23.9 4.2 26.4 8.1 6.8 0.7 1.2 1,588 Middle 24.0 5.4 25.9 8.8 6.7 0.7 0.8 1,528 Fourth 25.0 4.7 25.7 7.3 7.7 0.9 0.8 1,529 Richest 19.8 3.7 19.8 4.9 7.1 0.5 1.2 1,635 Total 24.1 4.7 24.9 7.4 7.3 0.7 1.0 8,020 * MICS indicator 6; MDG indicator 4; ** MICS indicator 7 *** MICS indicator 8 educations are underweight compared with 28 percent of children whose mothers have little or no education. The age pattern shows that a higher proportion of children aged 12-23 months are underweight, stunted and wasted compared to children who are younger and older. This pattern is expected as most children are weaned at this age, thereby exposing them to contamination in water and food and from the environment and also inadequate amounts of food required for their healthy growth. Figure NU.1 shows underweight, stunting and wasting by age-group of children. The proportion of children underweight is lowest among children aged less than 6 months (2 percent) increases sharply to peak at 12-23 months (42 percent) and declines steadily to 21 percent among children aged 48-59 months. 80 Figure NU.1: Percentage of children under-five who are undernorished, HIRD Supplementary Survey, 2007/2008 .0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 < 6 months 6-11 months 12-23 months 24-35 months 36-47 months 48-59 months Under weight Stunting Wasted A similar pattern exist for wasting among children, rising gradually from virtually two percent to reach a maximum of 19 percent by age 12-23 before decreasing sharply to about 3 percent among the oldest age group. Stunting, on the other hand, rises from a low level of nearly six percent, increases sharply to a peak of 35 percent by age group 12-23, decreases to 29 percent by age-group 24-35 then increases to 33 percent in the oldest group (48-59 months). Appropriate feeding practices are essential for the survival, healthy growth and development of infants as well as for the well-being of their mothers. Breastfeeding for the first few years of life protects children from infection; it is an ideal source of nutrients, and is very 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 goal states that children should be exclusively breastfed for the first six months of lifeWorld Fit for Children Breastfeeding and continue breastfeeding with safe, appropriate and adequate complementary feeding up to 2 years of age and beyond. Breastfeeding is sufficient for infant nutritional status in the first six months of life. It provides all the nutritional requirement of the infant child. It is recommended that breastfeeding be initiated within one hour of birth. Such early initiation of breastfeeding helps the newborn express its innate sucking reflex, thereby stimulating breast milk production. Table NU.2 shows the percentage of women with a child born in the two years preceding the survey who was breastfed within one hour of birth, and infants who were breastfed within one day of birth (which includes those who started within one hour), by some background characteristics. Initiation of Breastfeeding 81 A total of 3,225 women aged 15-49 years had a live birth within the two years preceding the survey and of these, two-fifths breastfed their infants within an hour after birth while 77 percent breastfed within one day after birth. Initiation of breastfeeding varies among the regions. The proportion of infants that were breastfed within one hour of birth ranged from 30 percent in the Central Region to 51 percent in the Upper East region. The proportion of mother's breastfeeding their newborn within one day of birth also shows a different pattern. The Upper West region recorded the lowest proportion (68 percent) of mothers who breastfed their newborn infants within a day of birth whilst Upper East region recorded the highest for the same indicator (86 percent). Table NU.2: Initial 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, HIRD Supplementary Survey, 2007/2008 Percentage who started breastfeeding within one hour of birth* Percentage who started breastfeeding within one day of birth Number of women with a live birth in the two years preceding the survey Region Central 30.3 75.0 762 Northern 42.8 77.4 1341 Upper East 51.2 85.7 914 Upper West 40.3 67.9 508 Area Urban 44.5 82.7 816 Rural 38.0 75.0 2409 Mother's Education None 42.1 76.4 1984 Primary 34.6 74.5 595 Middle/JSS 32.4 79.8 531 Secondary + 55.1 86.4 115 Wealth index quintile Poorest 41.1 78.3 636 Second 38.5 73.9 559 Middle 36.1 72.7 577 Fourth 36.3 75.8 640 Richest 44.3 82.1 812 Total 39.6 77.0 3225 * MICS indicator 45 A higher proportion of infants born to women in urban areas were breastfed within one hour of birth than those born to women in rural areas (45 percent and 38 percent respectively). The same pattern holds for the proportion of infants that were breastfed within one day of birth (83 percent versus 75 percent). The level of a mother's education as well as the socio-economic status of the household did not have a direct relationship with the proportion of infants breastfed within one hour and one day of birth respectively (Table NU.2). Although a higher proportion of mothers with secondary or higher level of education breastfed their infants within one hour than mothers with no education, the same cannot be said of mothers with some form of education. Nonetheless, there is a positive relationship between the level of a mother's education and breastfeeding the child within one day of birth. The proportion increased from 76 percent among mothers with no education to 80 percent among mothers with middle/JSS education, and further to 86 percent among those with secondary or higher education. The Ghana Health Service introduced the Baby Friendly Hospital Initiative (BFHI) in 1993. This has had a positive impact on breastfeeding initiation among Ghanaian women. Expecting and lactating mothers are encouraged to breastfeed their infants exclusively for the first six months and complement the breastfeeding with nutritious foods for at least two years. Supplementing breastfeeding before the sixth month is discouraged because of the high cost of infant formula in the country as well as the unhygienic conditions in which some mothers prepare and give the milk to their infants. Age Pattern of Breastfeeding 82 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 .0 P er ce n t Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth, HIRD Supplementary Survey, 2007/2008 Within one day Within one hour Table NU.3 presents breastfeeding status based on the reports of mothers/caretakers of 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 exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20- 23 months of age. Sixty-seven percent of infants aged less than six months are exclusively breastfed, which is lower than what is recommended by WHO and the Ghana Health Service. At age 6-9 months, 56 percent of infants are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 98 percent of infants are still being breastfed and by age 20-23 months, 73 percent of infants are still breastfed. The proportion of girls exclusively breastfed is higher than that of boys but the reverse is true for the proportions still breastfed over age 6-9 months. 83 84 T a b le N U .3 : B re a st fe e d in g P er ce n ta g e o f li v in g ch il d re n ac co rd in g to b re as tf ee d in g st at u s at ea ch ag e g ro u p , H IR D S u p p le m en ta ry S u rv ey , 2 00 7/ 20 08 C h il d re n 0 -3 m o n th s C h il d re n 0 -5 m o n th s C h il d re n 6 -9 m o n th s C h il d re n 1 2 -1 5 m o n th s C h il d re n 2 0 -2 3 m o n th s P e rc e n t e x c lu s iv e ly b re a s tf e d N u m b e r o f c h ild re n P e rc e n t e x c lu s iv e ly b re a s tf e d * N u m b e r o f C h ild re n P e rc e n t re c e iv in g b re a s t m ilk a n d s o lid /m u s h y fo o d ** N u m b e r o f c h ild re n P e rc e n t b re a s tf e d ** * N u m b e r o f c h ild re n P e rc e n t b re a s tf e d ** * N u m b e r o f c h ild re n S e x M a le 7 6 .6 2 6 8 6 3 .9 4 4 1 5 8 .9 3 4 5 9 8 .2 3 0 1 7 3 .8 2 5 1 F e m a le 7 9 .4 2 9 5 6 8 .8 4 6 9 5 1 .5 2 9 7 9 8 .1 2 6 9 7 1 .8 3 0 8 R e g io n C e n tr a l 7 7 .0 9 2 5 8 .1 1 6 4 6 8 .6 1 3 8 9 4 .3 1 0 0 3 3 .3 1 7 7 N o rt h e rn 7 8 .0 2 4 0 6 7 .4 3 7 2 5 3 .1 2 3 2 9 8 .5 2 4 2 8 0 .3 1 7 2 U p p e r E a s t 7 0 .6 1 5 7 5 4 .9 2 5 8 5 2 .7 1 5 9 97 .5 1 4 5 8 4 .3 1 2 5 U p p e r W e s t 9 6 .2 7 4 9 2 .1 1 1 6 5 9 .1 1 1 3 1 0 0 .0 8 4 8 4 .7 8 5 M o th e r' s e d u c a ti o n N o n e 7 6 .7 4 4 8 6 3 .5 7 2 6 5 3 .0 5 0 3 9 8 .4 4 5 7 7 2 .8 4 6 2 P ri m a ry 7 9 .9 7 0 7 0 .0 1 1 0 6 0 .2 8 8 9 7 .0 6 6 7 1 .1 5 0 M id d le /J S S (7 5 .8 ) 2 7 (6 8 .3 ) 4 4 (5 5 .1 ) 3 4 (9 8 .7 ) 2 9 (7 5 .4 ) 3 1 S e c o n d a ry + * 1 8 (6 6 .3 ) 3 0 * 1 7 * 1 8 * 1 6 W e a lt h in d e x q u in ti le P o o re s t 7 9 .1 1 1 5 6 6 .0 2 0 0 6 3 .0 1 3 7 9 7 .4 1 4 3 6 9 .7 1 1 4 S e c o n d 7 7 .9 1 0 3 6 7 .8 1 7 5 5 4 .9 1 3 3 9 8 .4 1 1 3 7 1 .2 9 9 M id d le 8 3 .5 1 2 6 7 2 .7 1 8 4 5 2 .1 1 3 0 9 7 .6 1 0 0 7 6 .8 1 07 F o u rt h 6 6 .0 9 5 4 9 .8 1 5 0 5 9 .7 1 1 5 9 8 .1 1 1 3 7 3 .0 1 0 5 R ic h e s t 8 0 .0 1 2 2 7 2 .8 2 0 0 4 7 .9 1 2 7 9 9 .1 1 0 1 7 2 .0 1 3 4 T o ta l 7 8 .0 5 6 3 6 6 .5 9 1 0 5 5 .5 6 4 2 9 8 .1 5 7 0 7 2 .6 5 5 9 * M IC S in di ca to r 15 ** * M IC S in di ca to r 16 ; ** M IC S in di ca to r 17 . F ig u re s in a st er is k (* ) a re b a se d o n 25 u n w ei gh te d ca se s a n d h a s b ee n su p p re ss ed 85 Figure NU 3 Infant feeding patterns by age: percent distribution of children aged less. : than 3 years by feeding patterns by group, HIRD Supplementary Survey, 2007/2008 .0 20.0 40.0 60.0 80.0 100.0 120.0 0-1 2-3 4-5 6-7 8-9 10- 12- 14- 16- 18- 20- 22- 24- 26- 28- 30- 32- 34- 11 13 15 17 19 21 23 25 27 29 31 33 35 Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed The adequacy of feeding among infant under 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. Overall, only 57 percent of infants aged less than 12 months are appropriately fed in the surveyed regions. The proportion of adequately fed infants varies slightly by sex with females adequately fed than males in the entire age bracket with the exception of 6-11 months age group where the reverse occurs. Figure NU.3 shows the detailed pattern of breastfeeding by the child's age in months. Even at the earliest ages, some infants are receiving plain water, other liquids or foods other than being exclusively breastfed. Among infants who were less than one month old, only 84 percent were being exclusively breastfed, with 16 percent being given plain water, other liquids and other milk or formula in addition to breast milk. By the end of the fifth month, the proportion of infants exclusively breastfed falls to only 42 percent. Complementary feeding is supposed to start by age six months when breast milk is not sufficient to provide the nutrient requirement for proper and healthy growth of the infant. Most infants within the surveyed regions were exclusively breastfed until 10 months of age. By age 23 months, a little over one-third of infants had been weaned. Breastfeeding decreased rapidly late in the second year of life and by age 35 months virtually all children (92 percent) have been weaned. 86 T a b le N U .4 : A d e q u a te ly fe d in fa n ts 5 m o n th s e x c lu s iv e ly b re a s tf e d N u m b e r o f in fa n ts a g e d 0 -5 m o n th s 6 -8 m o n th s w h o re c e iv e d b re a s tm ilk a n d c o m p le m e n ta ry fo o d a t le a s t 2 ti m e s in p ri o r 2 4 h o u rs N u m b e r o f in fa n ts a g e d 6 -8 m o n th s 9 -1 1 m o n th s w h o re c e iv e d b re a s tm ilk a n d c o m p le m e n ta ry fo o d a t le a s t 3 ti m e s in p ri o r 2 4 h o u rs N u m b e r o f in fa n ts a g e d 9 -1 1 m o n th s 6 -1 1 m o n th s w h o re c e iv e d b re a s tm ilk a n d c o m p le m e n ta ry fo o d a t le a s t th e m in im u m re c o m m e n d e d n u m b e r o f ti m e s p e r d a y * N u m b e r o f in fa n ts a g e d 6 -1 1 m o n th s 0 -1 1 m o n th s w h o w e re a p p ro p ri a te ly fe d ** N u m b e r o f in fa n ts a g e d 0 -1 1 m o n th s 6 3 .9 4 4 0 4 6 .8 2 5 9 4 9 .1 2 4 1 4 7 .9 5 0 0 5 5 .8 9 4 0 6 8 .8 4 6 9 4 1 .9 2 2 2 5 3 .7 2 1 8 4 7 .7 4 4 0 5 8 .6 9 1 0 6 8 .3 1 8 2 4 2 .8 9 2 4 3 .1 1 1 8 4 3 .0 2 1 0 5 5 .8 3 9 2 6 5

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