Ghana - Multiple Indicator Cluster Survey - 2011
Publication date: 2011
1 FINAL REPORT Government of Ghana Ghana Statistical Service Ghana Health Service United Nations Children’s Fund United Nations Population Fund Japan O�cial Development Assistance USAID GHANA Multiple Indicator Cluster Survey with an enhanced Malaria Module and Biomarker 2011 MONITORING THE SITUATION OF CHILDREN AND WOMEN IN GHANA GHANA STATISTICAL SERVICE 4 5 Anumber of organizations and individuals contributed to the development and implementation of this survey with their professional knowledge, personal enthusiasm and commitment to ensure a better life for all children and women in Ghana. The Ghana Statistical Service would particularly like to acknowledge the technical and financial assistance received from the United Nations Children’s Fund (UNICEF) at various stages of this survey. UNICEF staff from the Ghana Office, Regional Office and Headquarters, as well as UNICEF Consultants, supported the Ghana MICS from the planning stage to the sample design, training, data collection, and the data processing phases to ensure that the final report was of high quality. The US Government for International Development (USAID), the Japanese Government, the United Nations Population Fund (UNFPA), and the Center for Disease Control (CDC) also deserve special mention. Without their financial and technical support, the objectives of this survey would not have been achieved. The National Malaria Control Programme (NMCP) and the Navrongo Health Research Centre of the Ghana Health Service and ICF/Macro were mainly responsible for the implementation of the enhanced Malaria Module and Biomarker component of the survey. NMCP provided financial and technical assistance towards these critical aspects of the survey and their support is highly appreciated and acknowledged. The Navrongo Health Research Centre (NHRC) implemented the biomarker component of the survey on behalf of the Malaria Partners – this included collecting blood smears from the field, and conducting the malaria microscopy, laboratory analysis of the results and preparation of the report writing on this component. The ICF/Macro provided technical support towards the development and implementation of the malaria module and biomarker component – from questionnaire design, training, field monitoring, data analysis and report writing. The titration of salt samples was carried out by the Nutrition and Food Science Department of the University of Ghana, Legon, and we are very grateful for their assistance. We would also like to express our sincere gratitude to Consultants and Experts from relevant government ministries and agencies, other UN agencies, and international partners who were part of the Steering and Technical Committees for the MICS survey. The invaluable advice, comments and inputs received from them during the organization of the survey, questionnaire development and report writing has helped to improve the quality of the final output derived from the survey. Furthermore, we would like to commend the hard work and dedication of Ghana Statistical Service staff, both at the Headquarters and the regions, for successfully completing this survey and making the results available to users on a timely basis. Special thanks also go to all the interviewers, editors, supervisors and other participants in the survey for their hard work and the long working hours they committed towards the completion of the survey. The names of those who supported the survey in various ways are included in Appendix C. Finally, the data collection would not have been possible without the respondents in the selected households in Ghana who generously opened their homes to the field officers and gave their time to the realization of this survey. Dr. Philomena Nyarko Ag. Government Statistician Acknowledgements Multiple Indicator Cluster Survey with an enhanced Malaria Module and Biomarker 2011 Publisher: Ghana Statistical Service Proofreading: Marie Melocco Design and Layout: Art Excel Ghana Cover photo: c UNICEF/Nyani Quarmyne, 2012 Printed by: Redbow Investment Limited Published in December, 2012 The Ghana Multiple Indicator Cluster Survey (MICS) was carried out in 2011 by the Ghana Statistical Service (GSS). Financial and technical support was provided by UNICEF, USAID, UNFPA, the Japanese Government, ICF/MACRO, the Ministry of Health/National Malaria Control Programme, and the Navrongo Health Research Centre. MICS is an international household survey programme developed by UNICEF. The Ghana MICS was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Ghana Statistical Service, 2011. Ghana Multiple Indicator Cluster Survey with an Enhanced Malaria Module and Biomarker, 2011, Final Report. Accra, Ghana. iv v VI. CHILD HEALTH 65 Vaccinations 65 Neonatal Tetanus Protection 68 Oral Rehydration Treatment 71 Care Seeking and Antibiotic Treatment of Pneumonia 77 Solid Fuel Use 80 VII. MALARIA AND BIOMARKER 85 Background of Malaria in Ghana 85 Malaria: Causes and Transmission 85 National strategies for Malaria Control 86 Malaria PRevention 88 Insectiside Treated Mosquito Nets (ITNs) 88 Brief History of ITN Distribution in Ghana 89 Household Ownership Mosquito Nets 90 USe of Mosquito Nets by Persons on the Household 93 USe of Mosquito Nets by Children Under Five Years 95 USe of Mosquito Nets by Pregnant Women 98 Source, Cost and Disposal of ITNs 101 Indoor Residual Spraying Against Mosquitoes 101 Intermitent Preventive Treatment of Malaria in Pregnancy 103 Prevalence, Diagnosis, and Treatment of Fever in Children Under-Five 105 Type and Timing of Antimalarial Drug Use for Children 109 Knowledge of Malaria Symptoms 111 Knowledge of Causes of Malaria 112 Knowledge of ways to avoid Malaria 114 Specific Messages Seen or Heard about Malaria 116 Malaria Biomarkers: Anaemia and Malaria in Children Aged 6-59 Months 120 Anaemia Prevalence in Children 122 VIII. WATER AND SANITATION 131 Water 131 Sanitation 131 Use of Improved Water Sources 131 Use of Improved Sanitation Facilities 140 Handwashing 147 IX. REPRODUCTIVE HEALTH 153 Fertility 153 Contraception 156 Unmet Need 156 Antenatal Care 161 Assistance at Delivery 167 Place of Delivery 168 Post-Natal checks 170 Table of Content TABLE OF CONTENT Acknowledgement iii List of Tables vii List of Figures xi List of Abbreviations xiii Executive Summary xxi I. INTRODUCTION 1 Background 1 Survey Objectives 2 II. SAMPLE AND SURVEY METHODOLOGY 5 Sample Design 5 Questionnaires 5 Training and Fieldwork 7 Data Processing 7 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 9 Sample Coverage 9 Characteristics of Households 10 Characteristics of Female Respondents 15-49 Years of Age, Male 15-59 years and Children Under-5 15 IV. CHILD MORTALITY 23 Assessment of Data Quality in childhood mortality 24 Levels and Trends of Early Childhood Mortality 25 Early childhood mortality rates by region, residence and socio-economic characteristics 27 Residence and Socio-economic Differentials in Childhood Mortality 30 Demographic Characteristics and Childhood Mortality 31 V. NUTRITION 35 Nutritional Status 35 Breastfeeding and Infant and Young Child Feeding 38 Salt Iodization 52 Rapid Test Kits Results 53 Salt Sample for analysis 54 Agreement between Rapid Test Kits and Titration in identifying adequately and inadequately Iodized salts 56 Children’s Vitamin A Supplementation 57 Low Birth Weight 60 Anaemia and Diet Diversity in Children aged 6-59 months 63 Table of Content vi vii Table HH.1: Results of household, women’s and under-5 interviews Table HH.2: Household age distribution by sex Table HH.3: Household composition Table HH.3: Household composition Table HH.3: Household composition y residence Table HH.4: Women’s background characteristics Table HH.4M: Men’s background characteristics Table HH.5: Under-5’s background characteristics Table HH.A1: Household age distribution by sex and residence Table HH.A2: Housing Characteristics Table NU.1: Nutritional status of children Table NU.2: Initial breastfeeding Table NU.3: Breastfeeding Table NU.3A: Infant feeding patterns by age Table NU.4: Duration of breastfeeding Table NU.5: Age-appropriate breastfeeding Table NU.6: Introduction of solid, semi-solid or soft food Table NU.7: Minimum meal frequency Table NU.8: Bottle feeding Table NU.9: Iodized salt consumption Table NU.9A: Iodized salt consumption using titration method Table NU.9B: Iodized salt consumption. Comparison between rapid test kits and titration method Table NU.10: Children’s vitamin A supplementation Table NU.11: Low birth weight infants Table NU.12: Prevalence of anaemia in children Table NU.13: Prevalence of anaemia and dietary diversity in children Table NU.14: Prevalence of haemoglobin <8.0 g/dL and dietary diversity in children Table CH.1: Vaccinations in first year of life Table CH.2: Vaccinations by background characteristics Table CH.3: Neonatal tetanus protection Table CH.4: Oral rehydration solutions and recommended homemade fluids Table CH.5: Feeding practices during diarrhoea Table CH.6: Oral rehydration therapy with continued feeding and other treatments Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia Table CH.8: Knowledge of the two danger signs of pneumonia Table CH.9: Solid fuel use Table CH.10: Solid fuel use by place of cooking List of Tables X. CHILD DEVELOPMENT 183 Early Childhood Education and Learning 183 Early Childhood Development 190 XI. LITERACY AND EDUCATION 195 Literacy among Young Women 195 School Readiness 196 Primary and Secondary School Participation 198 XII. CHILD PROTECTION 213 Birth Registration 213 Child Discipline 216 Types of Disciplinary Methods 218 Early Marriage and Polygyny 218 Female Genital Mutilation/Cutting 226 Attitudes toward Domestic Violence 230 Children’s living arrangements and Orphanhood 234 XIII. HIV/AIDS, SEXUAL BEHAVIOUR 239 Knowledge about HIV Transmission and Misconceptions about HIV/AIDS 239 Comprehensive knowledge of HIV methods and transmission 240 Knowledge of Mother to Child Transmission of HIV 246 Accepting Attitudes toward People Living with HIV & AIDS (PLHIV) 249 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care 252 Sexual Behaviour Related to HIV Transmission 260 XIV. NATIONAL HEALTH INSURANCE 273 National Health Insurance Registration 273 Reasons why individuals (women, children and men) did not have a valid NHIS card 277 Achievement of Membership 280 Opinion on the quality of service offered to the NHI valid card holders, compared to other clients 283 XV. ACCESS TO MASS MEDIA AND ICT TECHNOLOGY 289 Access to Mass Media 289 Use of Computers and Internet 292 List of References 297 Appendix A. Sample Design 310 Appendix B. Malaria Biomarkers: Anaemia and Malaria in Children Aged 6-59 Months 309 Appendix C. List of Personnel Involved in the Survey 313 Appendix D. Estimates of Sampling Errors 318 Appendix E. Data Quality Tables 354 Appendix F. MICS4 Indicators: Numerators and Denominators 371 Appendix G. Questionnaires 382 Table of Content viii ix Table RH.13: Post-natal care (PNC) visits for newborns within one week of birth Table RH.14: Post-natal health checks for mothers Table RH.15: Post-natal care (PNC) visits for mothers within one week of birth Table RH.16: Post-natal health checks for mothers and newborns Table CD.1: Early childhood education Table CD.2: Support for learning Table CD.3: Learning materials Table CD.4: Inadequate care Table CD.5: Early child development index Table CD.A1: Early child development items Table ED.1: Literacy among young women and men Table ED.2: School readiness Table ED.3: Primary school entry Table ED.4: Primary school attendance Table ED.5: Secondary school attendance Table ED.6: Children reaching last grade of primary school Table ED.7: Primary school completion and transition to secondary school Table ED.8: Education gender parity Table ED.9: Education attainment of household population Table ED.10: School attendance Table ED.11: Gross attendance ratio: primary school Table ED.12: Gross attendance ratio: secondary school Table ED.13: Grade repetition rate Table CP.1: Birth registration Table CP.2: Child discipline Table CP. A1: Detail child disciplining methods Table CP.3: Early marriage and polygyny among women Table CP.3M: Early marriage and polygyny among men Table CP.4: Trends in early marriage for men Table CP.4M: Trends in early marriage for men Table CP.5: Spousal age difference Table CP.6: Female genital mutilation/cutting (FGM/C) among women Table CP.7: Female genital mutilation/cutting (FGM/C) among daughters Table CP.8: Approval of female genital mutilation/cutting (FGM/C) Table CP.9: Attitudes toward domestic violence; women Table CP.9M: Attitudes toward domestic violence; men Table CP.10: Children’s living arrangements and orphanhood Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensiveknowledge about HIV transmission; women Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission; men List of Tables Table MB.1: Regional distributions of Insecticide Treated Bed Nets in 2010-11 Table MB.2: Household possession of mosquito nets Table MB.3: Use of mosquito nets by persons in the household Table MB.4: Use of mosquito nets by children under 5 years of age Table MB.5: Use of mosquito nets by pregnant women Table MB.6: Source and cost of insecticide treated nets (ITNs) Table MB.7: Indoor residual spraying against mosquitoes Table MB.8: Intermittent preventative treatment by women during pregnancy (IPTp) Table MB.9: Prevalence, diagnosis and prompt treatment of children with fever Table MB.10: Treatment of fever in children, by type of facility Table MB.11: Type and timing of antimalarial drugs Table MB.12: Knowledge of symptoms of malaria Table MB.13: Knowledge of causes of malaria Table MB.14: Knowledge of ways to protect from malaria Table MB.15: Specific malaria messages seen or heard on television or radio Table MB.16: Knowledge of ACT with green leaf to treat malaria, and source of message Table MB.17: Coverage of testing for anaemia and malaria in children Table MB18: Prevalence of anaemia (haemoglobin <8.0 g/dL) in children age 6-59 months Table MB.19: Prevalence of malaria parasitaemia in children age 6-59 months Table WS.1: Use of improved water sources Table WS.2: Household water treatment Table WS.3: Time to source of drinking water Table WS.4: Person collecting water Table WS.5: Types of sanitation facilities Table WS.6: Use and sharing of sanitation facilities Table WS.7: Disposal of child’s faeces Table WS.8: Drinking water and sanitation ladders Table WS.9: Water and soap at place for handwashing Table WS.10: Availability of soap Table WS.A2: Use of improved and unimproved drinking water sources and sanitation facilities Table WS.A3: Drinking water sources, sanitation facilities and availability of soap Table RH.1: Adolescent birth rate and total fertility rate Table RH.2: Early childbearing Table RH.3: Trends in early childbearing Table RH.4: Use of contraception Table RH.5: Unmet need for contraception Table RH.6: Antenatal care coverage Table RH.7: Number of antenatal care visits Table RH.8: Content of antenatal care Table RH.9: Assistance during delivery Table RH.10: Place of delivery Table RH.11: Post-partum stay in health facility Table RH.12: Post-natal health checks for newborns List of Tables x xi Figure HH.1: Age and sex distribution of household population Figure CM.1: Trends in Childhood Mortality Rates, MICS4 Figure CM.2: Trends in Under-five Mortality Rates, various sources of data Figure CM.3: Infant and Under-five mortality rates by region and residence Figure CM.4: Percent contribution of Neonatal mortality rate to Infant mortality rate by Region Figure CM.5: Under-5 mortality rates by socio-economic background characteristics Figure CM.6: Under-5 mortality rates by Demographic Characteristics Figure NU.1: Percentage of children under age 5 who are underweight, stunted and wasted Figure NU.2: Infant feeding patterns by age. Percentage distribution of children aged under 3 years by feeding pattern by age group Figure NU.3: Pie chart showing 85% agreement and 15% disagreement between spot kit and salt titration result Figure CH.1: Vaccinations in first year of life. Percentage of children age 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday Figure CH.2: Percentage of women age 15-45 years with a live birth in the last 2 years who are protected against neonatal tetanus Figure CH.3: Percentage of children under age 0-59 months with diarrhoea in the last two weeks who received oral rehydration treatment Figure CH.4: Percentage of children under age 0-59 months with diarrhoea in the last two weeks who received ORT , with continued feeding Figure MB.1: Map of Ecological Zones and Regions Figure MB.2: Trends in Ownership of ITNs: Percentage of Households with at Least One ITN by region Figure MB.3: Trends in ownership of ITNs: Percentage of households with at least one ITN, Ghana Figure MB.4: Trends in proportion of children under 5 who slept under an ITN previous night by region Figure MB.5: Trends in proportion of children under 5 who slept under ITN previous night, Ghana Figure MB.6 Differentials in ITN Usage among Children Under 5 Figure MB.7 Trends in proportion of pregnant women age 15-49 who slept under an ITN previous night Figure MB.8 Trends in Intermittent Preventive Treatment (IPTp) by Women during Pregnancy Figure MB.9: Malaria Prevalence among Children 6-59 Months, by Age of the Child Figure MB.10: Map of Malaria Prevalence among Children 6-59 Months, by Region Figure MB.11: Map of Malaria Prevalence among Children 6-59 Months by Ecologic Zone Figure MB.12: Malaria prevalence among children 6-59 months by residence, mother’s education, and wealth quintile Figure WS.1: Percentage of the population using improved sources of drinking water by region, area of residence and wealth quintile Figure WS.2: Percentage of households with soap anywhere in the dwelling List of Figures Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission among young people; young women Table HA.2M: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission; young men Table HA.3: Knowledge of mother-to-child HIV transmission (women) Table HA.3M: Knowledge of mother-to-child HIV transmission (men) Table HA.4: Accepting attitudes toward people living with HIV/AIDS (women) Table HA.4M: Accepting attitudes toward people living with HIV/AIDS (men) Table HA.5: Knowledge of a place for HIV testing (women) Table HA.5: Knowledge of a place for HIV testing (men) Table HA.6: Knowledge of a place for HIV testing among sexually active young women Table HA.6: Knowledge of a place for HIV testing among sexually active young men Table HA.7: HIV counselling and testing during antenatal care Table HA.8: Sexual behaviour that increases the risk of HIV infection (women) Table HA.8M: Sexual behaviour that increases the risk of HIV infection (men) Table HA.9: Sex with multiple partners (women) Table HA.9M: Sex with multiple partners (men) Table HA.10: Sex with multiple partners (young women) Table HA.10M: Sex with multiple partners (young men) Table HA.11: Sex with non-regular partners (women) Table HA.11M: Sex with non-regular partners (men) Table CM.1: Early childhood mortality rates Table CM.2: Early childhood mortality rates by background characteristics Table CM.3: Early childhood mortality rates by demographic characteristics Table NHIS.1A: Membership of NHIS among women Table NHIS.1B: Membership of NHIS among men Table NHIS.IC: membership of NHIS among children under – 5 years Table NHIS.2A: Reasons for not having valid card among women Table NHIS.2B: Reasons for not having a valid card among men Table NHIS.2C: Reasons for not having a valid card among children Table NHIS.3A: Achievement of membership among women Table NHIS.3B: Achievement of membership among men Table NHIS.4A: Opinion on quality of service provided to NHIS card holders Table NHIS.4B: Opinion on quality of service provided to NHIS holders Table NHIS.5A: NHIS registration; women Table NHIS.5B: NHIS registration; men Table NHIS.5C: NHIS registration; children Table MT.1: Exposure to mass media; women Table MT.1M: Exposure to mass media; men Table MT.2: Use of computers and internet; young women Table MT.2M: Use of computers and internet; young men List of Tables xii xiii ACT Artemisinin Combination Therapy AIDS Acquired Immune Deficiency Syndrome AMFm Affordable Medicines Facility for Malaria ANC Antenatal Care BCG Bacillis-Cereus-Geuerin (Tuberculosis) CDC Centers for Disease Control and Prevention CSPro Census and Survey Processing System DHS Demographic and Health Survey DPT Diphteria Pertussis Tetanus ECCD Early Childhood Care and Development ECDI Early Child Development Index eMTCT elimination of mother-to-child transmission of HIV EPI Expanded Programme on Immunization FGM/C Female genital mutilation/cutting GAR Gross Attendance Ratio GHS Ghana Health Service GPI Gender Parity Index GPRS Ghana Poverty Reduction Strategy GSGDA Ghana Shared Growth and Development Agenda GSS Ghana Statistical Service HIV Human Immunodeficiency Virus HSMTDP Health Sector Medium-term Development Plan ICT Information and Communications Technology IDD Iodine Deficiency Disorders IRS Indoor Residual Spraying IPTp Intermittent Preventative Treatment by women during Pregnancy ITN Insecticide Treated Net IUD Intrauterine Device JMP Joint Monitoring Programme JSS Junior Secondary School LAM Lactational Amenorrhea Method LLIN Long-Lasting Insecticidal Net MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH Ministry of Health NAR Net Attendance Rate NHIS National Health Insurance Scheme NHRC Navrongo Health Research Centre NMCP National Malaria Control Programme NMR Neonatal Mortality Rate ORT Oral rehydration treatment PMI President’s Malaria Initiative PNC Post-natal Care PNMR Post-neonatal Mortality Rate Figure CD.1: Percentage of children aged 36-59 months currently attending early childhood education by region Figure CD.2: Types of toys children play with by region Figure CP.1: Percentage of children under age 5 by whether birth is registered and percentage with birth certificate Figure CP.2: Percentage of women who married before 15 years by age group and residence Figure CP.3: Percentage of women who were first married/union before age 18 by age group and residence Figure CP.4: Percentage of children living with both parents, not living with a biological parent and one or both parents dead Figure HA.1: Percentage of young women and men age 15-24 years who have comprehensive knowledge of HIV/AIDS transmission by education background Figure HA.2: Sexual behaviour that increases risk of HIV infection List of Figures List of Abbreviations xiv Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Ghana, 2011 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child Mortality 1.1 4.1 Under-five mortality rate 82.0 percent 1.2 4.2 Infant mortality rate 53.0 percent 1.3 Neonatal mortality rate 32.0 percent 1.4 Post-neonatal mortality rate 21.0 percent 1.5 Child mortality rate 31.0 percent NUTRITION Nutritional status 1.8 Underweight prevalence 2.1a Moderate and Severe (- 2 SD) 13.4 percent 2.1b Severe (- 3 SD) 2.6 percent Stunting prevalence 2.2a Moderate and Severe (- 2 SD) 22.7 percent 2.2b Severe (- 3 SD) 6.8 percent Wasting prevalence 2.3a Moderate and Severe (- 2 SD) 6.2 percent 2.3b Severe (- 3 SD) 1.4 percent Breastfeeding and infant feeding 2.4 Children ever breastfed 98.9 percent 2.5 Early initiation of breastfeeding 45.9 percent 2.6 Exclusive breastfeeding under 6 months 45.7 percent 2.7 Continued breastfeeding at 1 year 90.7 percent 2.8 Continued breastfeeding at 2 years 37.4 percent 2.9 Predominant breastfeeding under 6 months 71.0 percent 2.10 Duration of breastfeeding 20.5 months 2.11 Bottle feeding 13.7 percent 2.12 Introduction of solid, semi-solid or soft foods 74.8 percent 2.13 Minimum meal frequency 57.3 percent 2.14 Age-appropriate breastfeeding 63.9 percent 2.15 Milk feeding frequency for non-breastfed children 13.2 percent Salt iodization 2.16 Iodized salt consumption 34.5 percent Vitamin A 2.17 Vitamin A supplementation (children under age 5) 73.7 percent Low birth weight 2.18 Low-birth weight infants 10.7 percent 2.19 Infants weighed at birth 54.0 percent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage 97.8 percent 3.2 Polio immunization coverage 90.7 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT) 92.1 percent 3.4 4.3 Measles immunization coverage 88.5 percent 3.5 Hepatitis B immunization coverage 92.1 percent 3.6 Yellow fever immunization coverage 88.3 percent Tetanus toxoid 3.7 Neonatal tetanus protection 70.3 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 43.9 percent 3.9 Care seeking for suspected pneumonia 41.3 percent Summary Table of Findings xv ppm Parts Per Million RDT Rapid Diagnostic Test SPSS Statistical Package for Social Sciences TFR Total Fertility Rate 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 USAID United States Agency for International Development VIP Ventilated Improved Pit WFFC World Fit For Children WHO World Health Organization List of Abbreviations xvi xvii Topic MICS4 Indicator Number MDG Indicator Number Indicator Value CHILD PROTECTION Birth registration 8.1 Birth registration 62.5 percent Child Discipline 8.5 Violent discipline 93.6 percent Early marriage and polygyny 8.6 Marriage before age 15 5.8 percent 8.7 Marriage before age 18 27.0 percent 8.8 Young women age 15-19 currently married or in union 7.0 percent 8.9 Polygyny 18.3 percent Spousal age difference 8.10a Women age 15-19 16.4 percent 8.10b Women age 20-24 19.1 percent Female genital mutilation/ cutting 8.11 Approval for female genital mutilation/cutting (FGM/C) 1.5 percent 8.12 Prevalence of female genital mutilation/cutting (FGM/C) among women 3.8 percent 8.13 Prevalence of female genital mutilation/cutting (FGM/C) among girls 0.4 percent Domestic violence 8.14 Attitudes towards domestic violence for women 59.8 percent Attitude towards domestic violence for men 35.9 percent Orphan Prevalence of children with at least one parent dead 7.7 percent Children’s living arrangements 17.1 percent HIV/AIDS, SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention for women 33.8 percent Comprehensive knowledge about HIV prevention for men 39.1 percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young women 36.8 percent Comprehensive knowledge about HIV prevention among young men 38.6 percent 9.3 Knowledge of mother-to-child transmission of HIV for women 57.2 percent Knowledge of mother-to-child transmission of HIV for men 57.3 percent 9.4 Accepting attitude towards people living with HIV for women 6.3 percent Accepting attitude towards people living with HIV for men 15.2 percent 9.5 Women who know where to be tested for HIV 74.0 percent Men who know where to be tested for HIV 73.1 percent 9.6 Women who have been tested for HIV and know the results 16.8 percent Men who have been tested for HIV and know the results 10.0 percent 9.7 Sexually active young women who have been tested for HIV and know the results 17.3 percent Sexually active young men who have been tested for HIV and know the results 8.4 percent Summary Table of Findings Topic MICS4 Indicator Number MDG Indicator Number Indicator Value 3.10 Antibiotic treatment of suspected pneumonia 55.7 percent Solid fuel use 3.11 Solid fuels 81.2 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 79.3 percent 4.2 Water treatment 17.2 percent 4.3 7.9 Use of improved sanitation facilities 15.0 percent 4.4 Safe disposal of child's faeces 36.0 percent 4.5 Place for hand washing 50.0 Percent 4.6 Availability of soap 63.6 Percent REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent birth rate 60 per 1,000 5.2 Early childbearing 16.2 percent 5.3 5.3 Contraceptive prevalence rate 34.7 percent 5.4 5.6 Unmet needs 26.4 percent Maternal and newborns health 5.5 Antenatal care coverage 5.5a At least once by skilled personnel 96.4 percent 5.5b 5.2 At least four times by any provider 86.6 percent 5.6 Content of antenatal care 88.8 percent 5.7 Skilled attendant at delivery 68.4 percent 5.8 Institutional deliveries 67.4 percent 5.9 Caesarean section 11.4 Percent Post-Natal checks Post-natal health checks for newborns 83.3 percent Post-natal health checks for mothers 82.5 percent Post-partum stay in health facility 73.8 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 39.8 percent 6.2 Father's support for learning 29.6 percent 6.3 Learning materials: children’s books 6.2 percent 6.4 Learning materials: playthings 41.1 percent 6.5 Inadequate care 20.7 percent 6.6 Early child development index 73.7 percent 6.7 Attendance to early childhood education 68.2 percent EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women 61.4 percent Literacy among young men 71.3 percent 7.2 School readiness 80.3 percent 7.3 Net intake rate in primary education 31.8 percent 7.4 2.1 Primary school net attendance rate (adjusted) 73.0 percent Literacy and education 7.5 Secondary school net attendance rate (adjusted) 41.6 percent 7.6 2.2 Children reaching last grade of primary 95.4 percent 7.7 Primary completion rate 89.9 percent 7.8 Transition rate to secondary school 75.0 percent 7.9 Gender parity index (primary school) 1.02 ratio 7.10 Gender parity index (secondary school) 1.10 ratio Summary Table of Findings xviii xix Topic MICS4 Indicator Number MDG Indicator Number Indicator Value NATIONAL HEALTH INSURANCE SCHEME (NHIS) Membership Registration with NHIS Women 68.8 percent Men 55.9 percent Children 53.8 percent Card validity NHIS valid cards seen Women 40.3 percent Men 34.4 percent Children 51.0 percent ACCESS TO MASS MEDIA AND ICT Access to mass media Use of computers MT.1 Young women with exposure to newspaper, radio and TV at least once a week 8.3 percent Young men with exposure to newspaper, radio and TV at least once a week 16.8 percent Young women who used a computer during the last 12 months 25.1 percent Use of internet MT.2 Young men who used a computer during the last 12 months 39.2 percent MT.3 Young women who used the internet during the last 12 months 14.7 percent Young women who used the internet during the last 12 months 28.8 percent Summary Table of Findings Topic MICS4 Indicator Number MDG Indicator Number Indicator Value HIV/AIDS knowledge and attitudes 9.8 HIV counselling during antenatal care 58.9 percent 9.9 HIV testing during antenatal care 54.6 percent Sexual behaviour 9.10 Young women who have never had sex 52.3 percent Young men who have never had sex 61.3 percent 9.11 Sex before age 15 among young women 9.7 percent Sex before age 15 among young men 4.9 percent 9.12 Age-mixing among sexual partners for women 12.1 percent Age-mixing among sexual partners for men 0.0 percent 9.13 Sex with multiple partners for women 1.9 percent Sex with multiple partners for men 13.8 percent 9.14 Condom use during sex with multiple partners Women 23.1 percent Men 12.7 percent 9.15 Sex with multiple partners for young people Women 3.3 percent Men 6.3 percent Condom use during sex with multiple partners for young people Women 27.2 percent Men 39.3 percent Sex with non-regular partners Women 56.4 percent Men 88.0 percent 9.16 6.2 Condom use with non-regular partners Women 40.9 percent Men 52.8 percent MALARIA AND BIOMARKER 3.12 Household availability of insecticide-treated nets (ITNs) 48.9 percent 3.14 Children under age 5 sleeping under any mosquito net 41.6 percent 3.13 Indoor residual spraying against mosquitoes and availability of ITNs 51.3 3.15 6.7 Children under age 5 sleeping under insecticide- treated nets (ITNs) 39.0 percent 3.16 Malaria diagnostics usage 15.9 percent 3.17 Antimalarial treatment of children under 5 the same or next day 34.9 percent 3.18 6.8 Antimalarial treatment of children under age 5 52.6 percent 3.19 Pregnant women sleeping under insecticide- treated nets (ITNs) 32.6 percent 3.20 Intermittent preventive treatment for malaria 64.6 percent Prevalence of malaria in children under- five Rapid diagnostic test (RDT) 48.0 Percent Microscopy 28.0 Percent Anaemia 7.4 percent Summary Table of Findings xxMAP OF GHANA BURKINA FASO MAP OF GHANA COTE D’IVOIRE Sekondi Cape Coast AccraCENTRAL WESTERN TOGO R NORTHERN BRONG AHAFO Sunyani Tamale Wa Kumasi ASHANTI EASTERN VOLTA GREATER ACCRA Ho Koforidua UPPER WEST UPPER EAST Bolgatanga R R R R R R R Regional boundary National capital Reginal Capital GHANA HAS 10 REGIONS GHANA ADMINISTRATIVE DIVISIONS R Lawra TumuHamale Navrongo Zebila Bawku Wulugu Nakpanduri Gambaga Wawjawga Gushiago Yendi Zabzugu Bimbila Daboya Japei Damango Gbenshe Sawla Bole Salaga Yeji KintampoBamboi Sampa Berekum Wenchi Bechem Goaso Techiman Atebubu Kwadjokrom Ejura Mampong Agogo Konongo Adriemba Bekwei Obuasi Dunkwa Bibiani Nkawkaw Begoro Kade Oda Asamankese Nsawam Dumbai Kete Krachi Kadjebi Jasikan Hohoe Kpandu Anyirawasi Dzodze Aflao Sogakofe Anloga Keta Shai hills Tema Teshi AdaFoso Twifu Praso Elimina Swedru Winneba Saltpond Wiawso Awaso Asankrangwa Bawdia Bogoso Prestea Enchi Tarkwa Esiama Axim Half Assini Newtown R Executive Summary xxi The Ghana Multiple Indicator Cluster Survey (MICS) 2011, the fourth of its kind, is a nationally representative sample survey of households, women aged 15-49 years, children aged 0-5 years and men aged 15-59 years. In addition to applying the customized version of the MICS4 Questionnaires, an enhanced Malaria Module and Biomarker (for Anaemia and parasitemia in children aged 6-59 months) was included. The Survey was carried out in 2011 by the Ghana Statistical Service with financial and technical support from UNICEF, USAID/CDC, UNFPA, the Japanese Government, and the Ministry of Health/National Malaria Control Programme. ICF/MACRO and the Navrongo Research Centre provided technical support particularly for the malaria module and biomarker component. The results pertain to September-December 2011, when the field work was conducted. Household Characteristics Of the 12,150 households selected for the sample, 11,970 were contacted for interviews. Of these, 11,925 were interviewed, giving a response rate of about 100 percent. In the households interviewed, 10,963 women aged 15–49 years were identified. Of these, 10,627 were duly interviewed, producing a response rate of 97 per cent. Concerning children under the age of 5 years, 7,626 were identified, for whom responses were obtained from their mother or caregiver in 7,550 complete interviews, giving a response rate of 99 percent. For the male survey, 3,511 men aged 15-59 years were identified, and 3,321 successfully interviewed, yielding a response rate of 95 percent. Overall, the survey found that 31 percent of households in Ghana are headed by women. Children less than 15 years constitute 42 percent of the total population. Furthermore, 33 percent of households in urban areas, and 44 percent of households in rural areas have at least one child aged less than five years. The mean household size is 3.5 in urban areas, and 4.3 in rural areas. The most common household size is 2-3 household members (30 percent), followed by 4-5 household members with 27 percent. Characteristics of Respondents The MICS 2011 data show that for both sexes, the largest population age-group is 15-24 years. For women 34 percent are in this category, while for men it is 31 percent. In addition, 3 in 5 women and about half of men are currently married/in union, while 30 percent of women and 40 percent of men have never been married/in union. In Ghana, 70 percent of women have given birth at least once, and 24 percent gave birth in the last two years. Nearly half of the men (46%) and women (47%) live in rural areas; while for children, about 57 percent live in rural areas compared to 44 percent in urban areas. With respect to educational level, 21 percent of women and 13 percent of men have no education; 19 percent of women and 13 percent of men have only primary education; 41 percent of women and 45 percent of men have middle/JSS education; and 19 percent of women and 30 percent of men have secondary or higher levels of education. For children under five, Ghana has roughly the same proportion of girls and boys but there are more children in rural areas than in urban areas (57% against 44%) and they are also slightly more likely to live in the poorest households: 23% of the children under age five live in the poorest households while 17% live in the richest. xxii xxiiiExecutive Summary Child Mortality The Ghana MICS4 was conducted from Mid-September to Mid-December 2011 and childhood mortality rates were estimated using the direct method. The reference point (mid-point interval) for the childhood mortality for the most recent five year period is Mid-March 2009. The results estimate Ghana’s under- five mortality rate at 82 deaths per 1,000 live births. This means that one in every 12 children dies before reaching his or her fifth birthday. The child mortality rate is estimated at 31 deaths per 1,000 children aged 1 year, while the infant mortality rate is estimated at 53 deaths per 1,000 live births. Post neonatal and neonatal mortality rates are estimated at 21 and 32 deaths per 1000 live births, respectively, for the same period. Neonatal mortality rate represents 60 percent of the infant mortality rate in Ghana, meaning that 60 percent of deaths in infancy occur during the first 28 days of a child’s life. This is consistent with the DHS 2008 findings. Children living in rural areas experience higher levels of infant and under-five mortality (56 and 94 deaths per 1,000 live births respectively), compared to those living in urban areas (46 and 72 deaths per 1000 live births respectively). Significant variations are also observed in wealth quintiles for infant and under-five mortality rates. The infant mortality rate is estimated at 61 deaths per 1000 live births for children from the poorest wealth quintile, and 38 deaths per 1000 live births for children in the richest wealth quintile; and the under-5 mortality rate is estimated at 106 deaths per 1,000 live births for children from the poorest households, compared to 52 deaths per 1,000 live births for children belonging to the richest households. Nutrition Status Almost one in seven children (13%) under the age of five years is moderately or severely underweight and 3 percent are classified as severely underweight. The results also reveal that nearly 1 in every 4 children (23%) is moderately or severely stunted, and 7 percent are severely stunted. Six percent of the children are moderately or severely wasted, and 1 percent can be considered severely wasted. Children whose mothers have secondary or higher education are less likely to be underweight (9%) and stunted (13%) compared to children whose mothers have no education (17% and 29%, respectively). Breastfeeding and Infant and Young Child Feeding Less than half (46%) of all children aged 0–6 months in Ghana are exclusively breastfed, a level considerably lower than that recommended by WHO/UNICEF. For children aged 0-35 months, the mean duration for any breastfeeding is 20.5 months, 2.7 months for exclusive breastfeeding, and 5.1 months for predominant breastfeeding. The MICS results also reveal that less than half (46%) of newborn children are breastfed within the recommended period (within one hour after birth); while 84 percent are breastfed in the first day of life. In addition, 74 percent of children aged 6-8 months are currently breastfed and receiving solid, semi-solid or soft foods, and 64 percent of children aged 6-23 months are appropriately breastfed. The results also show that, for children aged 6-23 months currently breastfeeding, 57 percent are receiving solid, semi-solid and soft foods the recommended minimum number of times. For children 6-23 months not currently breastfeeding, 58 percent are receiving solid, semi-solid and soft foods the recommended minimum number of times. Fourteen percent of children aged 0-23 months and 20 percent of children aged 6-11 months are fed using a bottle with a nipple. Results also show that bottle feeding is generally an affluent household phenomenon, with children living in the Greater Accra region (35%), those living in urban areas (21%), those children whose mothers have secondary education (34%) and children from the wealthiest households (33%) being the most likely to be bottle-fed. Salt Iodization Salt used for household cooking was tested in the MICS in two ways: through the use of Rapid Salt Kits, and further testing in a lab using Titration. Use of Titration for iodine testing is considered most accurate. Results from the Rapid Salt Kits reveal that only 35 percent of households were using salt that was adequately iodated (≥15ppm), while in 22 percent of households, salt had no iodine. Households in urban areas are more likely to use adequately iodated salt (45%), compared to households in rural areas (23%). Titration results show that 29 percent of households were using adequately iodated salt (≥15ppm), thus, the Rapid Test Kits overestimated the proportion of adequately iodised salt by 6 percent. Vitamin A Supplement Approximately 3 out of 4 children (74%) aged 6-59 months received a high dose of Vitamin A supplement six months prior to the survey. At 58 percent, Ashanti region had the lowest Vitamin A supplementation coverage, while all other regions had Vitamin A supplementation of over 68 percent. Vitamin A supplementation coverage was highest in Upper East region and Brong Ahafo, both reporting 90 percent coverage, followed by Greater Accra at 84 percent. Low Birth Weight The data from the MICS 2011 show that 54 percent of newborns were weighed at birth. Children from Greater Accra region are most likely to be weighed at birth (82%), and those from Northern region the least likely to be weighed at birth (25%). Children from rural households, those from the poorest households and those whose mothers have no education are less likely to be weighed at birth. It is estimated that 11 percent of children born in Ghana weigh less than 2,500 grams. Immunization According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a measles vaccination by the age of 12 months. In Ghana, the MICS results show that 77 percent of children aged 12-23 months are fully immunized before their first birthday. Furthermore, the coverage rate for all vaccination for children aged 12-23 months is 84 percent, while less than 1 percent of children have not received any vaccinations. Approximately 98 percent of children aged 12-23 months received a BCG vaccination by their first birthday, 89 percent were immunized against measles by their first birthday, and 92 percent received 3 doses of DPT/ HepB/INFL. Also, 91 percent of children aged 12-23 months had received 3 doses of polio, and 94 percent had been immunized against yellow fever. Executive Summary xxiv xxv Tetanus toxoid Seventy percent of women who gave birth in the last two years are protected against tetanus. The majority of them (55%) are protected because they received at least two doses of tetanus toxoid injection during their most recent pregnancy, while 15 per cent of women are protected because they received at least two doses of the vaccine in the last three years. More women in urban areas received the 2 doses during their last pregnancy (61%), compared to their rural counterparts (50%). The Central region has the highest percentage of women who received at least 2 doses of tetanus vaccination during their last pregnancy (66%), while 4 regions have a coverage level of below 50 percent (Brong Ahafo 42%, Volta 45%, Upper East 46%, and Northern 47%). Oral rehydration treatment Thirteen percent of children under-five had diarrhoea in the two weeks prior to the survey. Around one third (35%) of children with diarrhoea were treated with ORS (fluid made with an ORS packet or pre-packaged ORS fluids), and 20 percent received recommended home-prepared fluids. More than half (59%) of children with diarrhea in the two weeks prior to the survey received oral rehydration treatment (ORT), meaning that they received either ORS, or the recommended home-prepared liquids, or increase of fluids. The rate of use of ORT is higher in urban areas (64%) than in rural areas (56%). However, 12 percent of children who had diarrhoea during the last two weeks preceding the survey were not given any treatment or drug, and the highest level was recorded in age-group of 0-11 months (19%). The data also show that 44 percent of children received ORT and, at the same time, feeding was continued, as recommended. Care-seeking and antibiotic treatment of pneumonia Only 3 percent of children aged 0–59 months were reported as presenting symptoms suggestive of pneumonia in the two weeks prior to the survey. Of the children with suspected pneumonia, only 41 percent were taken to an appropriate health provider. In addition, 56 percent of children with suspected pneumonia received antibiotics. Results also show that only 1 percent of mothers and caregivers of children age 0-59 months know the two danger signs of pneumonia – fast and difficult breathing. Malaria and Anaemia More than half of all households (51%) own at least one mosquito net, treated or untreated and 49 percent of all households have an insecticide treated net (ITN), the large majority of which (48%) have a long- lasting insecticidal net (LLIN). The average number of LLIN in households in Ghana is 1. About 1 in every 4 households in Ghana has at least one LLIN net for every two persons who stayed in the household the night prior to the survey. The availability of LLIN is higher in rural areas (60%), than in urban areas (38%). Regions where the LLIN hang-up campaign has already taken place are more likely to have higher LLIN coverage, than those regions where distribution has not taken place. For example, 85 percent of households in Volta region, and 79 percent of households in Eastern region own at least one LLIN. All districts in these regions had fully completed their distribution campaigns 3-12 months prior to the MICS data collection. Almost 40 percent of children under-five in all households slept under an LLIN the night prior to the survey. The use of LLINs is more common in rural areas (46%) than in urban areas (29%). Almost two-thirds (63%) of children under-five in households with at least one ITN slept under an ITN, while 48 percent of persons in households with at least one ITN slept under an ITN. In total, 33 percent of pregnant women slept under an Executive Summary ITN the night prior to the survey and among pregnant women aged 15-49 in households with at least one ITN, 58 percent slept under an ITN. For all household members, children and pregnant women, the use of ITNs is higher in rural areas than in urban areas. The MICS data also show that 42 percent of the ITNs were acquired during a public campaign. Also, only 5 percent of households had undergone indoor residual spraying (IRS) in the past 12 months. The MICS data also reveal that nearly 1 in 5 children under-five (19%) had fever in the two weeks preceding the survey, and 53 percent of them took antimalarial drugs; just over a third of them (35%) took the antimalarial drugs the same or next day. The national malaria microscopy-based prevalence was estimated at 28 percent among children aged 6-59 months. Large variations were observed: Greater Accra had the lowest prevalence rate at 4 percent compared to 51 percent in the Upper West region. The savannah zone has the highest prevalence with 44 percent compared to just 14 percent in the coastal zone. In urban areas the prevalence was 13 percent while rural areas recorded 39 percent. The prevalence for children whose mothers/caretakers have secondary school and higher was only 5 percent compared to 43 percent of children whose mothers/caretakers have no education. Malaria prevalence was estimated at 3 percent for children in the richest wealth quintile, and rose to 52 percent for children in the poorest wealth quintile. Overall, 7 percent of children aged 6-59 months were anaemic. The Eastern region had the lowest prevalence rate of 2 percent compared to 19 percent in the Northern region. The savannah zone had the highest prevalence with 15 percent compared to 4 percent in the coastal zone. In urban areas the prevalence was 4 percent while the rural areas recorded 10 percent. The prevalence for children whose mothers/caretakers have secondary school and higher was only 2 percent compared to 13 percent of children whose mothers/ caregivers have no education. In the richest households, anaemia prevalence was only 1 percent, compared to 16 percent in the poorest households. Water and Sanitation Nearly 80 percent of household members in Ghana are using improved sources of drinking water, which means that Ghana has already achieved the 2015 MDG 7 target of 78 percent of the population using improved drinking water. However, wide variations exist between areas of residence with 91 percent coverage in urban areas and only 69 percent in rural areas. Variations are also noted among regions: with 91 percent of household members in Ashanti using an improved source of drinking water, while only 62 percent of household population in Volta region do so. The great majority of households (91%) do not use any method for treating water. Regarding households with unimproved sources of water, 17 percent of them treat their water using appropriate water treatment method before they drink it. Concerning access to water for those households without water on the premises, for about 44 percent of all households that use an improved drinking water source, it takes less than 30 minutes for the round trip to fetch water, while 9 percent of households spend 30 minutes or more. In the majority of households (64%), the person who fetches water is an adult woman. Adult men collect water in only 19 percent of cases, while for the rest of the households, female or male children under age 15 collect water (11% and 6% respectively). Executive Summary xxvi xxvii The MDGs and the WHO / UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation classify households as using an unimproved sanitation facility if they are using otherwise acceptable sanitation facilities but sharing a facility between two or more households or using a public toilet facility. Taking into account this definition, only 15 percent of household members were using an improved and not shared sanitation facility. Nearly 1 out of 4 (23%) of households in Ghana practices open defecation or have no toilet facility, and this was more pronounced in rural areas (35%) than urban areas (10%). Fertility The adolescent birth rate and total fertility rate (TFR) are respectively 60 per 1000 live births and 4.3 children per woman. The average is 3.3 children per woman in urban areas and 5.5 children per woman in rural areas. Regional variations are also observed with the highest TFR (6.2) in Northern region compared to the lowest TFR (3.2) in Greater Accra. The TFR decreases with educational level and by wealth index quintiles. The lower TFR is observed among women with secondary or higher education (3.1) and in the richest quintile (2.9). Ten percent of women aged 15-19 years had already given birth, 2 percent were pregnant with their first child, so, in total, 12 percent had begun childbearing. Furthermore, 1 percent has had a live birth before the age of 15 and about 16 percent of women aged 20-24 years have had a live birth before age 18. Contraception use and unmet need Only 1 in 3 women (35%) currently married or in union reported using any method of contraception: 24 percent of all women use modern methods and 11 percent use traditional methods. The most popular modern methods are the injectable (9%) and the pill (8%). There is a slight difference in contraceptive use depending on the area of residence, with 37 percent of users in urban areas against 32 percent in rural areas. The unmet need for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth (spacing) or who wish to stop childbearing altogether (limiting). Overall, 26 percent of women aged 15-49 years have an unmet need for contraception. Sixteen percent have an unmet need for spacing and 10 percent have an unmet need for limiting. Antenatal care Ninety-six percent of women aged 15-49 years who gave birth in the 2 years preceding the survey received at least one antenatal care (ANC) visit by skilled health personnel and 87 percent had 4 or more antenatal care visits. Eastern and Greater Accra regions recorded the highest proportions of pregnant women who attended 4 or more antenatal care visits – 93 percent and 92 percent respectively. The Northern region recorded the lowest proportion of pregnant women that had at least 4 antenatal care visits (75%). During their antenatal care, 89 percent of the women had blood pressure measured, a urine specimen taken and a blood test. Assistance at delivery Around two-thirds (68%) of women aged 15-49 years who gave birth in the last two years were assisted by skilled personnel during the delivery. This percentage is highest in Greater Accra Region at 90 percent and lowest in Northern Region at 37 percent. The data also show that 2 in 3 women (67%) delivered in health facilities, and 11 percent had a C-section. Deliveries by C-section are highest among women in the Executive Summary Greater Accra region, where nearly 1 out of 4 women (23%) had a C-section. The Volta (15%), Ashanti (12%), Eastern (12%) and Central (11%) regions all have C-section rates of above 10 percent. Eighty-six percent of newborns and mothers received a post-natal health check. Child Development About 68 percent of children aged 36-59 months in Ghana were attending pre-school, with children in urban areas more likely to attend (81%) than children in rural areas (59%). For 40 percent of children under five, an adult in the household had engaged in activities that promote learning and school readiness during the three days prior to the survey. For about 30 percent of children, their father was involved in this type of activity. In contrast, 30 percent of children are not living with their biological father. Three or more children’s books were available in only 6 percent of households for all children under-five. The data also show that 41 percent of children aged 0-59 months had 2 or more playthings in their homes. However, 1 in 5 children under-five years (21%) was left with inadequate care in the previous week. Finally, the early child development index score for children aged 36-59 months is 74. Literacy and Education Sixty-one percent of young women (aged 15-24 years) and 71 percent of young men (aged 15-24 years) are literate. In the richest wealth quintile, 85 percent and 93 percent of young women and men respectively are literate while in the poorest wealth quintile only 31 percent and 41 percent of young women and men are respectively literate. Eighty percent of children attending first grade attended preschool in the previous year. Only 32 percent of children of primary school entry age entered grade 1, which means that a large proportion of children enter the education system late. Timely entry into school is greater in urban (39%) than in rural areas (26%). The Ghana MICS shows that there is a relationship between timely entry into grade 1 and the educational level of the mother and the household’s economic situation. The primary school net attendance rate (adjusted) is 73 percent. In urban areas, the net attendance rate (adjusted) is 80 percent compared to 68 percent in rural areas. The secondary school net attendance rate (adjusted) is 42 percent, which is 51 percent in urban areas compared to 34 percent in rural areas. In addition, 95 percent of children who enter grade 1 reach grade 6. The primary school completion rate is 90 percent while the transition rate to secondary school is 75 percent. The gender parity ratio for net attendance rate (adjusted) is 1.02 in primary school and 1.10 in secondary school. Birth registration The births of 63 percent of children under-five years have been registered with civil authorities. Seventy-two percent of children in urban areas are registered, compared to 55 percent of children in rural areas. Across regions, children in the Greater Accra region are more likely to be registered (77%), followed by children in the Upper West Region (72%), while those in the Western region are the least likely to be registered (49%). Among children whose births are registered, 58 percent have birth certificates. While birth registration is fully subsidized for children below 12 months, less than half (45%) of children in this age-group are registered, meaning that some parents are still not taking advantage of free registration. Executive Summary xxviii xxix Child Discipline The Ghana MICS results show that 94 percent of children aged 2-14 years were subjected to some form of violent (physical and/or psychological) disciplinary method. Fourteen percent of children aged 2-14 years were subjected to severe physical punishment and 73 percent to minor punishment. Results also show that about 50 percent of respondents believe that a child needs to be physically punished to bring them up properly. Early marriage, polygamy and spousal age difference The MICS data show that the proportion of women aged 15-49 years married before the age of 15 and 18 are respectively 6 percent and 27 percent. Such marriages (before age 15) are higher in rural areas (8%) than in urban areas (4%). Women with higher education and from wealthiest households are less likely to get married before the age of 15 years. For men aged 15-59 years, only 1 percent was married before age 15, and 5 percent before age 18. By the age of 25, 72 percent of women are married or living with a man while at 30 years old, 87 percent of them are married or in union. By age 25, half of men are married or living with a partner while at 30 years old, 79 percent of them are married/in union. The MICS 2011 also show that 18 percent of women aged 15-49 years are in polygynous marriages/unions while 9 percent of men aged 15-59 years are in polygynous marriages/unions. In addition, 16 percent of women aged 15-19 years, and 19 percent of women aged 20-24 years who are currently married/in union, have a spouse who is 10 or more years older than them. Female Genital Mutilation/Cutting Overall, 4 percent of women aged 15-49 years in Ghana have had any form of FGM/C. This practice was found to be most prevalent in Upper West (41%) and Upper East (28%) regions. Only 2 percent of women aged 15- 49 years approve of FGM/C practice, while 94 percent of them believe that it should be discontinued. Among their daughters (0-14 years), FGM/C prevalence is less than 1 percent. Domestic violence The MICS 2011 results reveal that 60 percent of women think that a husband is justified in beating his wife for at least one of the following reasons: when the woman goes out without telling him, if she neglects the children, if she argues with him, if she refuses to have sex with him, if she burns the food, if she insults him, if she refuses to give him food, if she has another partner, if she steals and if she gossips. The highest proportion (84%) is recorded in Northern and Upper West regions, while the lowest proportion (40%) is found in the Greater Accra region. The acceptance of domestic violence is higher in rural areas (70%) than in urban areas (51%). Attitudes of acceptance decrease with women’s educational levels. Overall, men are less likely than women to believe that domestic violence is justified: 36 percent of men agree that it is justifiable to beat their wives/partners for any of the given reasons. Children’s living arrangements and orphanhood Overall, 57 percent of children aged 0-17 years in Ghana live with both their parents, but 17 percent are not living with a biological parent. Eight percent of children in Ghana are orphans of one or both parents, and about 1 percent of the children aged 0-17 years are double orphans. While about 17 percent live with their mother only, just 5 percent live with their father only. For children living with neither of their biological parents, 14 percent have both parents alive, 1 percent has only their father alive, 2 percent have only their Executive Summary mother alive, and for about 1 percent both parents are dead. For children living with their mother only, 17 percent have their father alive, while for 3 percent of them their father is dead. For the 5 percent of all children aged 0-17 years living with only their father, their mothers are dead in almost one in five cases. HIV/AIDS and Sexual Behaviour The MICS 2011 shows that 98 percent of women and 99 percent of men have heard about AIDS, but only 34 percent of women aged 15-49 years and 39 percent of men aged 15-59 years have comprehensive knowledge of AIDS. Specifically, 42 percent of women and 47 percent of men reject the two most common misconceptions about AIDS and know that a healthy looking person can have the AIDS virus. Ninety-eight percent of young women and men (aged 15-24 years) have heard of AIDS, while 37 percent of young women and 39 percent of young men have comprehensive knowledge of the disease. Forty-six percent of young women and 49 percent of young men reject the two most common misconceptions and know that a healthy looking person can have the AIDS virus. Ninety-one percent of both women and men know that HIV can be transmitted from mother to child, and 57 percent of both sexes know all three means of transmission of AIDS from mother to child. Only 6 percent of women 15-49 years and 15 percent of men 15-59 years express accepting attitudes toward people living with HIV/AIDS on all four indicators analysed in the MICS. For both sexes, a positive attitude towards people living with HIV/AIDS is strongly correlated with educational levels, household wealth, and area of residence. This is also true for knowledge of a place for HIV testing. At the national level, 74 percent of interviewed women and 73 percent of men know a place for HIV testing. Among women aged 15-49 years who gave birth in the last 2 years, 59 percent received HIV counselling during antenatal care; and 55 percent were offered an HIV test and were tested for HIV during antenatal care, and received the results. For young women and men who are sexually active, 75 percent of young women know where to get HIV testing, 43 percent have been tested, 20 percent were tested in the 12 months prior to the survey, and 17 percent were told their results. For men, nearly 70 percent of young men know where to get tested, 18 percent have been tested, 10 percent were tested in the 12 months prior to the survey, and about 8 percent were also told their results. Women aged 15-24 years are twice as likely (10%) to have sex before the age of 15 compared to their male counterparts (5%). Twelve percent of young women (aged 15-24) had sex in the last 12 months with a man 10 years or older. On the other hand, virtually none of the young men in the sample had sex with a women 10 years or older. The results also show that about 2 percent of women aged 15-49 years and 14 percent men aged 15-59 years had sex with more than one partner in last 12 months. Among those, 23 percent of women used a condom for higher risk sex, while 13 percent of men did so. For young women and men aged 15-24 years, the proportions of having sex with more than one partner in the last 12 months are respectively 3 percent and 6 percent, and among them, 27 percent of young women and 39 percent of the young men used a condom. Executive Summary xxx xxxi Access to Mass Media and ICT About 8 percent of women aged 15-49 years and 17 percent of men aged 15-59 years are exposed to all three media (newspaper, radio and TV) at least once a week. For both sexes, radio is the most predominant media for 69 percent of women and 80 percent of men. Twenty-five percent of young women and 39 percent of young men aged 15-24 years used a computer during the 12 months prior to the survey. There are some differences in the use of internet in the week preceding the survey between young women (11%) and young men (19%). For both sexes, the exposure to all three media and the use of computer and internet are strongly correlated with educational level, wealth index quintiles and urban residence. National Health Insurance At the national level 69 percent of women aged 15-49 years, 56 percent of men aged 15-59 years and 54 percent of children under-five years have ever been registered with the National Health Insurance Scheme (NHIS). The proportions of valid cards seen are respectively 40 percent, 34 percent and 51 percent. The achievement of membership was mainly done through the following two options: premium paid by a relative or friend (60% for both women and men), and premium paid by self (29% for women and 31% for men). Only 8% of women get free access to NHIS through the free Maternal Care Service. For NHIS card holders, 42 percent of women aged 15-49 years and 39 percent of men aged 15-59 years think that NHIS provides a better quality service when they attend health care facilities, while 26 percent of the women and 22 percent of the men indicate that the quality of services provided was the same as that provided to non-NHIS card holders. Finally, 1 in 5 women and men indicate that the quality of services provided to NHIS card holders is worse while 10 percent of women and 18 percent of men have not used the health services since acquiring their NHIS cards. Executive Summary COTE D’IVOIRE Sekondi Cape Coast Accra TOGO NORTHERN BRONG AHAFO Sunyani Tamale Wa Kumasi ASHANTI EASTERN VOLTAVOLTA GREATER GREATER ACCRAACCRAACCRA Ho Koforidua UPPER WEST UPPER EAST Bolgatanga R R R R R R R Regional boundary National capital Reginal Capital GHANA HAS 10 REGIONS GHANA ADMINISTRATIVE DIVISIONS R Lawra TumuTumuHamaleHamaleHamale NavrongoNavrongoNavrongoNavrongo ZebilaZebila BawkuBawku WuluguWulugu NakpanduriNakpanduriNakpanduriNakpanduriNakpanduri Gambaga Wawjawga Gushiago YendiYendi ZabzuguZabzuguZabzuguZabzugu Bimbila Daboya Japei Damango Gbenshe Sawla Bole SalagaSalaga Yeji KintampoBamboi Sampa Berekum Wenchi BechemBechem GoasoGoaso TechimanTechiman Atebubu Kwadjokrom Ejura Mampong Agogo KonongoKonongo Adriemba Bekwei Obuasi Dunkwa BibianiBibiani Nkawkaw Begoro Kade Oda Asamankese NsawamNsawam Dumbai Kete KrachiKete Krachi KadjebiKadjebiKadjebi JasikanJasikanJasikan Hohoe KpanduKpanduKpanduKpandu Anyirawasi Dzodze Aflao SogakofeSogakofeSogakofeSogakofe Aflao Sogakofe Aflao Anloga Keta Shai Shai hills Tema Teshi AdaFoso Twifu Praso EliminaEliminaElimina Swedru Winneba Saltpond Wiawso AwasoAwaso Asankrangwa Bawdia Bogoso Prestea Enchi Tarkwa Esiama Axim Half Assini Newtown R xxxii 1 Background This report is based on the Ghana Multiple Indicator Cluster Survey, conducted in 2011 by the Ghana Statistical Service (GSS). The survey provides valuable information on the situation of children, women and men in Ghana, and was based, in large part, on the need to monitor progress towards goals and targets emanating from recent international agreements: The Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity- building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60). “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” I. Introduction 1 2 33 In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see text box on previous page). Over the past decades, the government of Ghana has embarked on various plans and strategies aiming at improving the living conditions of its citizenry- the Ghana Poverty Reduction Strategy (GPRS) in 2000, the Growth and Poverty Reduction Strategy (GPRS II) in 2006 and the Ghana Shared Growth and Development Agenda (GSGDA), 2010-2013. Findings from the Multiple Indicator Cluster Survey (MICS 4) would provide up to date information for the formation of informed policies towards the achievement of the established goals. All these policy frameworks require monitoring and assessment of progress. The fourth round of the Multiple Indicator Cluster Survey represents a large source of data for reporting on progress towards the aforementioned goals. The survey provides a rich foundation of comparative data for comprehensive progress reporting, especially regarding the situation of the most vulnerable children, including those from the poorest households, those living in deprived localities, etc. It also provides important information for the new UNICEF Country Programme 2012-2016 as well as the UNDAF 2011-2015. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2011 Ghana Multiple Indicator Cluster Survey has as its primary objectives the following: • To provide more current information for assessing the situation of children, women and men, and reporting on country progress in achieving the GSGDA goals/targets and the MDGs, meet the reporting requirements of other local and international development declarations and agenda, and form the basis for future action; • To provide much-needed data on practices used to treat malaria among children under-five and the use of specific anti-malarial medications, bednet coverage and use, coverage of Intermittent Preventive Treatment for pregnant women, treatment practices for childhood fever, and prevalence of malaria and anaemia among children aged 6-59 months; • To present the current level of knowledge and behavioral indicators regarding HIV and AIDS in Ghana; • To provide a mid-term snapshot on progress on key Health Sector Medium-term Development Plan (HSMTDP) 2010-2013 strategic objectives, and provide nationally and regionally representative data that can inform the development of the next Health Sector Medium-term Plan; • To contribute to the improvement of data and monitoring systems in Ghana and to strengthen technical expertise in the design, implementation, and analysis of such systems; and • To generate data on the situation of children, women and men, including the identification of vulnerable groups and of disparities, which will inform social inclusion and poverty reduction policies and interventions. 2Introduction 4 Sample Design The sample for the Ghana Multiple Indicator Cluster Survey (MICS) was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for 10 regions: Western, Central, Greater Accra, Volta, Ashanti, Brong Ahafo, Northern, Eastern, Upper East and Upper West regions. The urban and rural areas within each region were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size. Since the sampling frame (the 2000 Ghana Population Census) was up-to-date, a new listing of households was not conducted in all the sample enumeration areas prior to a systematic sample selection of 15 households in each selected cluster. The sample was stratified by region, urban and rural areas, and is not self-weighting since Central, Northern, Upper East and Upper West regions were over-sampled. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Four sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members (usual residents), the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; 3) an under-5 questionnaire administered to mothers or caretakers for all children under 5 living in the household; and 4) a men’s questionnaire administered in each third household to all men aged 15-59 years. The contents of the questionnaires are indicated below: The Household Questionnaire included the following modules: ● Household Listing Form ● Education ● Water and Sanitation ● Household Characteristics ● Insecticide Treated Nets ● Indoor Residual Spraying ● Child Labour ● Child Discipline ● Handwashing ● Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the household, and included the following modules: ● Women’s Background ● Access to Mass Media and Use of Information/Communication Technology ● Child Mortality ● Desire for Last Birth ● Maternal and Newborn Health ● Post-natal Health Checks ● Illness Symptoms ● Contraception ● Unmet Need ● Female Genital Mutilation/Cutting II. Sample and Survey Methodology 5 6 7 the place for handwashing and measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 14 days, from 29 August to 11 September 2011. The data entry clerks attended the first week of interviewer training in order to get a better understanding of questionnaires and survey techniques. The training included lectures on interviewing techniques and the contents of the questionnaires, blood testing for malaria and anaemia, and mock interviews between trainees to gain practice in asking questions. All fieldworkers also trained in testing iodine in salt found in selected households as well as taking measurements of weight and height for children under 5 years. The Ghana MICS4 2011 incorporated three “malaria biomarkers,” namely: anaemia testing, malaria testing using rapid diagnostic tests (RDTs), and thick blood smear samples prepared on microscope slides. After obtaining informed consent from caregivers, blood samples were obtained from a heel- or finger-prick from children aged 6 to 59 months to perform on-the-spot anaemia and malaria tests, and to prepare thick blood smears that were later transported and read in the laboratory at NHRC to determine the presence of malaria parasites. The microscopy was used as the gold standard to obtain prevalence rates. The rapid diagnostic test was utilized primarily for ethical reasons, in order to identify and treat malaria in participating children while in the field. The biomarker training was led by a DHS biomarker specialist with assistance from NHRC, NMCP and PMI staff. Towards the end of the training period, trainees spent several hours during 2 half-days in practicing interviews and blood testing in Sunyani East and Sunyani West areas. The data were collected by 20 teams; each team was comprised of 3 interviewers, one driver, one editor, one measurer (health technician) and a supervisor. Fieldwork began on 15 September 2011 and concluded on 14 December 2011. The field monitoring, for quality assurance, was conducted by staff from ICF Macro, USAID, President Malaria Initiative (PMI), NHRC, UNICEF, GSS and NMCP. As described above, each of the 20 field team in the 2011 Ghana MICS4 included a health technician, who was responsible for completing the anthropometry and biomarker portions of the Children Under-Five Questionnaire, and conducting the biomarker tests. In accordance with the Ghana MICS4 biomarker testing protocol pre-approved by the Ghana Health Service Institution Review Board, the health technicians were responsible for ensuring that informed consent was obtained from the children’s caregivers; administering medications for uncomplicated malaria in the field when indicated; and providing medical referrals for clinically severe malaria, severe anaemia, and other conditions when indicated. Data Processing Data were entered using the CSPro software. The data were entered on 20 microcomputers and carried out by 20 data entry operators and 3 data entry supervisors. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS4 programme and adapted to the Ghana questionnaire were used throughout. Data capture began in October 2011 and was completed in January 2012. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 18, and the model syntax and tabulation plans developed by UNICEF were used for this purpose. Sample and Survey Methodology ● Behaviour Change Communication on Malaria ● Attitudes Towards Domestic Violence ● Marriage/Union ● Sexual Behaviour ● HIV/AIDS ● National Health Insurance The Questionnaire for Children Under-Five was administered to mothers or caretakers of children under - 5 years of age1 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases where the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: ● Age ● Birth Registration ● Early Childhood Development ● Breastfeeding ● Diet Diversity ● Care of Illness ● Malaria ● Immunization ● National Health Insurance ● Anthropometry ● Anaemia and Malaria Testing The Questionnaire for Individual Men was administered to all men aged 15-59 years living in each third household, and included the following modules: ● Men’s Background ● Access to Mass media and use of Information/Communication Technology ● Marriage/Union ● Attitude Towards Contraception ● Behaviour Change Communication on Malaria ● Attitudes Towards Domestic Violence ● Sexual Behaviour ● HIV/AIDS ● National Health Insurance The questionnaires are based on the English version of the MICS4 model questionnaire2 . From the MICS4 model, the Ghana questionnaires were customized and pre-tested in two districts: Ga West district in Greater Accra region and Akwapim South district in Eastern region during the period 2 - 5 August 2011. Based on the results of the pre-test, modifications were made to the wording of the questionnaires. A copy of the Ghana MICS4 questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, collected a sample in each male survey household for titration, observed 1 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 2 The model MICS4 questionnaires can be found at www.childinfo.org Sample and Survey Methodology 8 Sample Coverage and Response Rates Of the 12,150 households selected for the sample, 11,970 were found to be occupied. Of these, 11,925 were successfully interviewed for a household response rate of about 100 percent. In the interviewed households, 10,963 women (aged 15-49 years) were identified. Of these, 10,627 were successfully interviewed, yielding a response rate of 97 percent within interviewed households. Also 7,626 children under age five were listed in the household questionnaire. Questionnaires were completed for 7,550 of these children, which corresponds to a response rate of 99 percent within interviewed households. In addition, a men’s questionnaire was used in every third household of the selected sample. For the male survey, 3,511 men aged 15-59 years were identified. Of these, 3,321 were successfully interviewed, yielding a response rate of 94 percent within interviewed households for the male survey. The overall response rate for women (96 percent), for children under- 5 years (98%) and for men (94%) are calculated respectively in Table HH.1. At the regional level, the response rates for household interviews, eligible women, eligible men and children were around 90 percent or higher. Apart from the Western region with men’s overall response rate of 90 percent, all the remaining nine regions recorded response rates of over 92 percent. Also, Eastern region had an overall response rate of 99 percent for both men and women. Table HH.1 also shows that the response rates in the rural areas are higher than that of the urban areas. The under-5’s response rates are similar across all regions and residence. III. Sample Coverage and the Characteristics of Households and Respondents 9 10 11 (47%) in the dependent population and therefore a decrease in the proportion of the active population (aged 15-65 years). The children under 18 years represent 48 percent of Ghanaian population, compared to 47 percent in MICS 2006 and 45 percent in Ghana census 2010. This reflects the fact that Ghanaian population has a young age structure. Also some discrepancies are observed between data from the Ghana 2010 Population and Housing Census and those from MICS 2011 on age distribution for the age-groups from 0-4 years to 30-34 years. Although these discrepancies are not necessarily statistically significant, they need, however, to be investigated and documented. Sample Coverage and the Characteristics of Households and Respondents Table HH.2: Household age distribution by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Ghana, 2011 Background Characteristics Males Females Total Number Percent Number Percent Number Percent Age-group 0-4 3,105 13.9 3,134 13.2 6,239 13.5 5-9 3,369 15.1 3,262 13.7 6,631 14.4 10-14 3,250 14.5 3,258 13.7 6,508 14.1 15-19 2,254 10.1 1,860 7.8 4,114 8.9 20-24 1,477 6.6 1,625 6.8 3,102 6.7 25-29 1,354 6.1 1,706 7.2 3,060 6.6 30-34 1,286 5.8 1,573 6.6 2,858 6.2 35-39 1,273 5.7 1,372 5.8 2,644 5.7 40-44 1,033 4.6 1,173 4.9 2,206 4.8 45-49 978 4.4 998 4.2 1,976 4.3 50-54 788 3.5 1,184 5.0 1,972 4.3 55-59 587 2.6 696 2.9 1,283 2.8 60-64 526 2.4 534 2.2 1,059 2.3 65-69 317 1.4 342 1.4 659 1.4 70-74 323 1.4 357 1.5 681 1.5 75-79 207 0.9 274 1.2 481 1.0 80-84 92 0.4 178 0.7 270 0.6 85+ 131 0.6 204 0.9 335 0.7 Missing/DK 6 0.0 8 0.0 14 0.0 Dependency age groups 0-14 9,723 43.5 9,655 40.7 19,378 42.0 15-64 11,554 51.7 12,721 53.6 24,275 52.7 65+ 1,070 4.8 1,355 5.7 2,425 5.3 Missing/DK 6 0.0 8 0.0 14 0.0 Children and adult populations Children age 0-17 years 11,132 49.8 10,873 45.8 22,005 47.7 Adults age 18+ years 11,215 50.2 12,859 54.2 24,074 52.2 Missing/DK 6 0.0 8 0.0 14 0.0 Total 22,353 100.0 23,739 100.0 46,093 100.0 Sample Coverage and the Characteristics of Households and Respondents Table HH.1: Results of household, women’s, men’s and under-5 interviews Number of households, women, men, and children under 5 by results of the household, women’s, men’s and under-5’s interviews, and household, women’s, men’s and under-5’s response rates, Ghana, 2011 Residence Region Background Characteristics Urban Rural Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West Total Households Sampled 4,635 7,515 780 2,010 1,005 780 780 1,005 780 2,010 1,500 1,500 12,150 Households Occupied 4,570 7,400 760 1,994 999 772 768 996 726 1,979 1,480 1,496 11,970 Households Interviewed 4,545 7,380 757 1,989 989 771 767 993 718 1,972 1,475 1,494 11,925 Household response rate 99.5 99.7 99.6 99.7 99.0 99.9 99.9 99.7 98.9 99.6 99.7 99.9 99.6 Women Eligible 4,183 6,780 675 1,595 862 605 601 829 690 2,025 1,456 1,625 10,963 Women Interviewed 4,056 6,571 640 1,571 829 593 596 813 658 1,938 1,412 1,577 10,627 Women's response rate 97.0 96.9 94.8 98.5 96.2 98.0 99.2 98.1 95.4 95.7 97.0 97.0 96.9 Women's overall response rate 96.4 96.7 94.4 98.2 95.2 97.9 99.0 97.8 94.3 95.4 96.7 96.9 96.6 Men Eligible 1,273 2,238 243 467 278 203 181 271 209 656 458 545 3,511 Men Interviewed 1,189 2,132 219 451 260 198 180 252 195 617 432 517 3,321 Men's response rate 93.4 95.3 90.1 96.6 93.5 97.5 99.4 93.0 93.3 94.1 94.3 94.9 94.6 Men's overall response rate 92.9 95.0 89.8 96.3 92.6 97.4 99.3 92.7 92.3 93.7 94.0 94.7 94.2 Children under 5 Eligible 2,145 5,481 421 1,009 400 402 346 476 410 2,008 997 1,157 7,626 Children under 5 Mother/Caretaker Interviewed 2,117 5,433 414 999 393 400 345 472 407 1,989 988 1,143 7,550 Under-5's response rate 98.7 99.1 98.3 99.0 98.3 99.5 99.7 99.2 99.3 99.1 99.1 98.8 99.0 Under-5's overall response rate 98.2 98.9 97.9 98.8 97.3 99.4 99.6 98.9 98.2 98.7 98.8 98.7 98.6 Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. This distribution is also used to produce the population pyramid in Figure HH.1. In the 11,925 households successfully interviewed in the survey, 46,093 household members were listed. Of these, 22,353 were males and 23,739 were females. The estimated sex ratio is 94 compared to the 95 recorded in the MICS 2006. With respect to children below 15 years (42%), the results are similar to those from the 1984 and 2000 censuses, which indicate that the proportion of children less than 15 years was higher than 40 percent: 45 percent in the 1984 census and 41 percent in the 2000 census. However, the results from Ghana 2010 census show a decline in the proportion of children less than 15 years, with only 35 percent of the population in that age group. The proportion of the aged (65 years and older) is 4 percent compared to 5 percent in the MICS 2011 results. Data from the population censuses (1984 (49%), 2000 (47%) and 2010 (43%), and the MICS 2006 (45%)) indicate a consistent decline in the dependent population (aged 0-14 years and 65+). In contrast, MICS 2011 shows an increase 12 13 Generally, the head of household is considered as the key person because he/she ensures that the needs and well-being of the members are addressed in the household. In Ghana, the proportion of female heads of household is 31 percent while that of males is 69 percent. The proportion of the female heads of household is consistent with MICS 2006 (29%), and the 2000 Ghana Population and Housing Census (31%). However, there is a slight difference with the 2010 Ghana Population and Housing Census (35%). Ashanti and Greater Accra regions constitute about two-fifth of the entire household population in Ghana for both MICS 2011 and the 2010 Ghana Population and Housing Census. The results also show that 20 percent of the population is more likely to live as a single-member household. The most common household size now is 2-3 household members (30%), followed by 4-5 household members (27%). On the other hand, the proportion of households with ten or more members declined from 10 percent in the 2000 Ghana Population Census, 4 percent in MICS 2006, 6 percent in Ghana population census 2010 to 3 percent in 2011. This trend suggests that the population is moving towards a smaller household size. The education of the head of household has an impact on the welfare of the household members. The proportion of heads of households who have never attended any formal education declined from 39 percent in the 2000 population and housing census to 25 percent in MICS 2011. Furthermore, a higher proportion of the household heads have attended only basic education comprising Middle/JSS (39%) and Primary (13%). Only 23 percent of household heads attended secondary school or higher levels of education. The weighted percent of households and respondents received in Table HH.3 was also compared to the data from MICS 2006 and the 2010 Ghana Population and Housing Census. Although not proven to be statistically significant, the main discrepancies observed are the following: • The current share (6%) of Northern region is lower compared to that of MICS 2006 (11 %) and Ghana 2010 population census (10%); • The current share (20%) of Greater Accra region is higher than wha was recorded in MICS 2006 (17%) and 2010 Ghana population census (16%); • The distribution of population by residence is 53 percent for urban areas and 47 percent for rural areas, compared to 56 percent and 44 percent respectively in the 2000 Ghana Population and Housing Census. In terms of ethnicity, the results indicate that the Akan group (49%) constitutes the largest proportion of Ghanaian households, followed by Ewes (15%) and Mole Dagbanis (14%). Sample Coverage and the Characteristics of Households and Respondents Figure HH.1 shows an excess of children aged 5-9 years compared to those aged 0-4 years. This was also the case for MICS 2006. It is probably due to a preference for reporting age 5 and therefore, under-reporting for age-group 0-4 years. The same situation (under-reporting) is observed for women aged 45-49 years compared to those aged 50-54 years). Another explanation is that the person providing the age of each household member (within the household questionnaire) might have “genuinely” rounded ages. Indeed data from the Ghana 2010 Population and Housing Census provide a different structure for age-groups 0-4 years and 5-9 years: for both sexes, the number of children aged 0-4 years exceeds that of children aged 5-9 years. Further indications on these irregularities can be seen in the single year age distribution in Table DQ.1 in Appendix D, Data Quality Tables. Tables HH.3 to HH.5 provide basic information on the households, female respondents aged 15-49 years, children under-5 years and male respondents aged 15-59 years by presenting the unweighted, as well as the weighted numbers. Information on the basic characteristics of households, women, children under-5 and men interviewed in the survey is essential for the interpretation of findings presented later in the report. It also can provide an indication of the representativeness of the survey. The remaining tables in this report are presented only with weighted numbers. See Appendix A for more details about the weighting. Table HH.3 provides basic background information on the households. Within the households, the sex of the household head, region, residence, number of household members, education of household head, respondents and children under 18 years, and ethnicity1 of the household head are shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. Table HH.3 also shows the proportions of households with at least one child under 18 years, at least one child under 5 years, at least one eligible woman aged 15-49 years and at least one eligible man aged 15-59 years. The weighted and unweighted numbers of households are equal, since the sample weights were normalized (See Appendix A). Figure HH.1: Age and sex distribution of household population. Ghana 2011 1 This was determined by asking : To what ethnic group does the head of this household belong? Sample Coverage and the Characteristics of Households and Respondents 02468 2 4 6 8 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-1 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Percent Females Males 14 15 Table HH.3a shows that 38 percent of households have at least one child aged 0-4 years, 68 percent have at least one child aged 0-17 years, 67 percent have at least one woman aged 15-49 years, and 23 percent have at least one man aged 15-59 years. The mean household size at the national level is 3.9 persons. Table HH.3a: Household composition Percent distribution of households by selected characteristics, Ghana, 2011 Background Characteristics Number of households Weighted percent Weighted Unweighted Households with at least: one child age 0-4 years 38.0 11925 11925 Households with at least: one child age 0-17 years 68.4 11925 11925 Households with at least: one woman age 15-49 years 67.2 11925 11925 Households with at least: one man age 15-59 years 22.5 11925 11925 Mean household size 3.9 11925 11925 The data in Table HH.3a were broken down by residence and Table HH.3b shows that households in urban areas have lower proportions of children (aged 0-4 and 0-17 years ), males aged 15-59 years and are smaller (3.5 persons per household) compared to their rural counterparts (with 4.3 people per household. However, there are equal proportions of households with at least one woman aged 15-49 years in urban and rural areas (67%). Table HH.3b: Household composition by residence Percent distribution of households by selected characteristics, Ghana, 2011 Background Characteristics Residence Urban Rural Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Households with at least: one child age 0-4 years 33.1 6,358 4,545 43.6 5,567 7,380 Households with at least: one child age 0-17 years 63.5 6,358 4,545 74.1 5,567 7,380 Households with at least: one woman age 15-49 years 67.4 6,358 4,545 67.1 5,567 7,380 Households with at least: one man age 15-59 years 22.3 6,358 4,545 22.7 5,567 7,380 Mean household size 3.5 6,358 4,545 4.3 5,567 7,380 Characteristics of Female Respondents aged 15-49 years, Children Under-5 and Male respondents aged 15-59 years Tables HH.4, HH.4M and HH.5 provide information on the background characteristics of female respondents aged 15-49 years, children under age 5 and male respondents aged 15-59 years. In all these tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the number of observations in each background category. These categories are used in the subsequent tabulations of this report. Sample Coverage and the Characteristics of Households and Respondents Table HH.3: Household composition Percent distribution of households by selected characteristics, Ghana, 2011 Weighted percent Number of households Weighted Unweighted Sex of household head Male 69.1 8234 8746 Female 30.9 3691 3179 Region Western 9.4 1116 757 Central 10.4 1236 1989 Greater Accra 19.5 2321 989 Volta 8.3 992 771 Eastern 12.9 1533 767 Ashanti 19.5 2321 993 Brong Ahafo 8.5 1011 718 Northern 6.1 727 1972 Upper East 3.5 414 1475 Upper West 2.1 253 1494 Residence Urban 53.3 6358 4545 Rural 46.7 5567 7380 Number of household members 1 20.3 2424 1860 2 13.6 1617 1351 3 16.3 1946 1663 4 14.3 1708 1644 5 12.4 1479 1566 6 9.5 1135 1302 7 6.1 733 944 8 3.1 370 575 9 1.7 203 344 10+ 2.6 310 676 Education of household head None 25.1 2997 4989 Primary 13.1 1560 1546 Middle/JSS 38.5 4590 3372 Secondary + 23.3 2775 2017 Missing/DK .0 3 1 Ethnicity of household head Akan 48.6 5797 4191 Ga/Dangme 9.3 1111 569 Ewe 14.9 1779 1213 Guan 3.6 427 449 Gruma 3.5 420 659 Mole Dagbani 13.9 1658 3728 Grusi 2.8 331 641 Mande 1.1 136 190 Non-Ghanaian 1.6 193 186 Others .6 73 99 Total 100.0 11925 11925 Sample Coverage and the Characteristics of Households and Respondents 16 17 Table HH.4: Women’s background characteristics Percent and frequency distribution of women age 15-49 years by selected characteristics, Ghana, 2011 Background Characteristics Weighted percent Number of women Weighted Unweighted Region Western 9.6 1022 640 Central 9.8 1044 1571 Greater Accra 19.5 2074 829 Volta 7.7 821 593 Eastern 11.6 1237 596 Ashanti 18.7 1983 813 Brong Ahafo 9.5 1005 658 Northern 7.1 754 1938 Upper East 3.8 404 1412 Upper West 2.7 282 1577 Residence Urban 54.3 5770 4056 Rural 45.7 4857 6571 Age 15-19 17.9 1899 2028 20-24 15.8 1674 1503 25-29 16.6 1768 1650 30-34 15.4 1638 1616 35-39 13.5 1431 1487 40-44 11.2 1195 1231 45-49 9.6 1023 1112 Marital/Union status Currently married/in union 61.9 6574 6926 Widowed 2.1 221 270 Divorced 3.3 354 254 Separated 3.0 323 278 Never married/in union 29.7 3156 2899 Motherhood status Ever gave birth 70.0 7434 7688 Never gave birth 30.0 3193 2939 Births in last two years Had a birth in last two years 23.8 2528 2872 Had no birth in last two years 76.2 8099 7755 Education None 20.9 2224 3945 Primary 19.1 2026 1932 Middle/JSS 40.7 4328 3327 Secondary + 19.3 2049 1423 Wealth index quintiles Poorest 15.6 1659 3860 Second 17.7 1877 2009 Middle 19.8 2101 1640 Fourth 22.1 2345 1616 Richest 24.9 2646 1502 Sample Coverage and the Characteristics of Households and Respondents Tables HH.4 and HH.4M provides background characteristics of female respondents aged 15-49 years and male respondents aged 15-59 years. The tables include information on the distribution of women and men according to region, residence, age, marital status, motherhood status, births in last the two years, education, wealth index quintiles and ethnicity. The age distribution of the respondents shows that 1 in 3 females (34%) and males (31%) are in the 15-24 years age-group. For both sexes, the largest proportion is in the 15-19 years age-group, while the lowest are in the 45-49 years age-group for women and 54-59 years age-group for men. The data also show that 62 percent of women and 56 percent of men are currently married or are in union, while 30 percent and 40 percent respectively have never been married. Seventy percent of women have given birth at least once and 24 percent gave birth in the last two years. The distribution of respondents by residence shows that 54 percent of women and 53 percent of men live in urban areas. Regionally, the distribution of respondents varies significantly. For example, for both sexes, one-fifth of respondents are from Greater Accra (20%) while Upper West region has the lowest proportion (3%). The data show that 21 percent of women and 12 percent of men have no education. The proportions of women and men with basic education are respectively 60 percent and 57 percent. At the same time, 19 percent of women and 30 percent of men have secondary or higher education respectively. Twenty-five percent of women and 26 percent of men are in the richest wealth quintiles while 16 percent of women and men are in the poorest category. The distribution of the respondents by ethnic groupings indicates that the Akans (46% for women and 43% for men) form the largest group, followed by Mole Dagbani (16% for women and 17% for men) and Ewes (14% percent for both men and women). The discrepancies between the data from MICS 2011 and previous censuses and surveys identified in Table HH.3 are also found in Tables HH.4 and HH.4M. However, these seem not to be statistically significant. Sample Coverage and the Characteristics of Households and Respondents 18 19 Table HH.4M (cont’d) Background Characteristics Number of women Weighted percent Weighted Unweighted Education None 12.5 417 808 Primary 12.5 416 549 Middle/JSS 44.6 1483 1229 Secondary + 30.3 1006 735 Wealth index quintiles Wealth index quintiles Poorest 15.6 518 1217 Second 16.8 557 652 Middle 18.7 621 480 Fourth 23.4 779 524 Richest 25.5 847 448 Ethnicity of household head Akan 43.0 1428 970 Ga/Dangme 10.5 349 154 Ewe 13.8 459 331 Guan 4.1 135 128 Gruma 4.0 133 175 Mole Dagbani 16.9 562 1206 Grusi 3.6 121 193 Mande 1.6 53 63 Non-Ghanaian 1.9 62 66 Others .5 18 35 Total 100.0 3321 3321 Some background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by sex, region, residence, age, mothers/caretakers education and household wealth index quintiles. The results in Table HH.5 show that the proportions of girls (50%) and boys (50%) among children under 5 years were equal. The proportions of children are evenly divided in each of the 5 age- groups (one-fifth in each), and this is consistent with MICS 2006. The first age-group (0-11 months) has been split into two (<6 and 6-11 months) and these accounted for 11 percent and 10 percent respectively. The proportion of children under five years living in the rural areas has decreased from 64 percent in MICS 2006 to 57 percent in MICS 2011. On the other hand, the proportion of children under five living in the urban areas has increased from 36 to 43 percent during this period. The largest proportion of children under five reside in the Ashanti region (19%) followed by the Greater Accra region (15%), while the smallest proportion is found in the Upper West region (3%). About one third (33%) of mothers/caretakers of children under five have no education while 22 percent have only primary education. The results also show that 34 percent have attained middle/JSS education and only 12 percent of mothers/caretakers of these children have attained secondary or higher education. Furthermore, only 17 percent of children live in the richest households, while 43 percent come from households in the poorest (23%) and the second (20%) wealth index quintiles. Sample Coverage and the Characteristics of Households and Respondents Table HH.4 (cont’d) Background Characteristics Number of women Weighted percent Weighted Unweighted Ethnicity of household head Akan 46.3 4918 3316 Ga/Dangme 9.8 1040 513 Ewe 14.0 1485 959 Guan 3.6 380 406 Gruma 3.8 405 630 Mole Dagbani 16.0 1700 3714 Grusi 3.0 322 602 Mande 1.2 124 220 Non-Ghanaian 1.7 179 170 Others .7 73 97 Table HH.4M: Men’s background characteristics Percent and frequency distribution of men age 15-59 years by selected background characteristics, Ghana, 2011 Background Characteristics Number of women Weighted percent Weighted Unweighted Region Western 10.6 352 219 Central 8.9 296 451 Greater Accra 20.3 676 260 Volta 7.6 252 198 Eastern 10.8 358 180 Ashanti 19.2 638 252 Brong Ahafo 8.9 296 195 Northern 7.3 243 617 Upper East 3.6 120 432 Upper West 2.7 91 517 Residence Residence Urban 52.6 1746 1189 Rural 47.4 1575 2132 Age of man 15-19 19.8 657 767 20-24 11.4 379 393 25-29 13.7 456 411 30-34 13.3 442 363 35-39 10.9 363 371 40-44 8.7 288 303 45-49 9.4 313 293 50-54 6.7 221 215 55-59 6.1 204 205 Marital/Union status Currently married/in union 55.9 1856 1787 Widowed .8 26 27 Divorced 1.6 54 47 Separated 2.2 72 53 Never married/in union 39.6 1314 1407 Sample Coverage and the Characteristics of Households and Respondents 20 21 Table HH.6: Household age distribution by sex and residence Percent distribution of the household population by five-year age groups, by sex and residence, Ghana, 2011 Background Characteristics Residence Total Ghana census 2010 Urban Rural Number Percent Males Females Males Females Number Percent Number Percent Number Percent Number Percent Percent Age 0-4 1339 12.6 1372 11.8 1766 15.0 1763 14.6 6239 13.5 12.3 5-9 1418 13.4 1400 12.0 1951 16.6 1863 15.4 6631 14.4 11.1 10-14 1400 13.2 1557 13.3 1850 15.7 1702 14.1 6508 14.1 11.1 15-19 1008 9.5 952 8.2 1246 10.6 908 7.5 4114 8.9 10.9 20-24 835 7.9 937 8.0 641 5.5 688 5.7 3102 6.7 10.8 25-29 781 7.4 991 8.5 573 4.9 715 5.9 3060 6.6 9.5 30-34 768 7.2 852 7.3 517 4.4 721 6.0 2858 6.2 7.6 35-39 692 6.5 700 6.0 581 4.9 671 5.6 2644 5.7 6.2 40-44 505 4.8 641 5.5 528 4.5 532 4.4 2206 4.8 5.0 45-49 505 4.8 518 4.4 472 4.0 480 4.0 1976 4.3 3.9 50-54 392 3.7 571 4.9 396 3.4 613 5.1 1972 4.3 3.4 55-59 309 2.9 334 2.9 278 2.4 362 3.0 1283 2.8 2.2 60-64 233 2.2 236 2.0 293 2.5 298 2.5 1059 2.3 1.8 65-69 125 1.2 168 1.4 192 1.6 174 1.4 659 1.4 1.1 70-74 141 1.3 145 1.2 183 1.6 213 1.8 681 1.5 1.2 75-79 82 .8 119 1.0 126 1.1 155 1.3 481 1.0 0.7 80-84 23 .2 81 .7 69 .6 96 .8 270 .6 0.5 85+ 46 .4 83 .7 85 .7 121 1.0 335 .7 0.6 Missing/DK 5 .0 3 .0 1 .0 6 .0 14 .0 0 Total 10607 100.0 11660 100.0 11747 100.0 12080 100.0 46093 100.0 100 Overall, 58 percent of households have 1 sleeping room, 26 percent have 2 sleeping rooms and 16 percent have 3 or more sleeping rooms (Table HH.7). At residence level, 63 percent of households in urban areas have 1 sleeping room compared to 52 percent in rural areas. In contrast, more households in rural areas have 2 sleeping rooms (28%) and 3 or more sleeping rooms (20%) compared to urban areas, which have 25 and 13 percent respectively. Table HH.7: Housing characteristics Percent and weighted number distribution of households by selected housing characteristics, by residence, Ghana, 2011 Background Characteristics Residence Total Urban Rural Number PercentNumber Percent Number Percent Sleeping Rooms 1 room 3988 62.7 2904 52.2 6892 57.8 2 rooms 1565 24.6 1572 28.2 3137 26.3 3+ rooms 806 12.7 1090 19.6 1896 15.9 Total 6358 100.0 5567 100.0 11925 100.0 Sample Coverage and the Characteristics of Households and Respondents Table HH.5: Under-5’s background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Ghana, 2011 Background Characteristics Weighted percent Number of children Weighted Unweighted Sex Male 49.8 3757 3859 Female 50.2 3793 3691 Region Western 10.0 758 414 Central 9.8 740 999 Greater Accra 15.1 1142 393 Volta 8.0 601 400 Eastern 11.0 827 345 Ashanti 18.7 1411 472 Brong Ahafo 8.9 671 407 Northern 11.3 852 1989 Upper East 4.3 325 988 Upper West 3.0 223 1143 Residence Urban 43.5 3283 2117 Rural 56.5 4267 5433 Age 0-5 10.8 818 792 6-11 9.6 725 720 12-23 19.2 1453 1451 24-35 20.6 1553 1518 36-47 20.9 1576 1599 48-59 18.9 1426 1470 Mother’s education None 32.5 2455 4081 Primary 21.6 1628 1363 Middle/JSS 34.1 2578 1565 Secondary + 11.8 889 541 Wealth index quintiles Poorest 22.9 1730 3528 Second 20.5 1551 1499 Middle 20.6 1559 1045 Fourth 18.5 1397 836 Richest 17.4 1313 642 Total 100.0 7550 7550 The results (percentage by age-group of total population) shown in Table HH.6 present some discrepancies compared to the data from the 2010 Ghana Population and Housing Census, especially for the first seven age-groups. This observation has already been made on Table HH.2. Sample Coverage and the Characteristics of Households and Respondents 22 23 Among the overarching objectives of both the MDGs and the World Fit for Children (WFFC) is the need to reduce maternal and childhood mortality Specifically, MDG 4 calls 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. The Ghanaian government, through the Ghana Shared Growth and Development Agenda (GSGDA) and specifically through the Health Sector Medium Term Development Plan (HSMTDP), has developed strategies to reduce childhood mortality, and improve the overall wellbeing of all its citizens. This chapter describes levels, trends, and differentials in early childhood mortality in Ghana. Early childhood mortality rates in general and infant (Summary of Vital Statistics, 2010) mortality rate (Miller and Goldman, 2011) in particular contribute to a better understanding of a country’s socio-economic situation and is a major indicator of the quality of life of the population. The information in this chapter is disaggregated by geographic, socio-economic and demographic characteristics since they help to identify subgroups that are at high risk. Such analyses are thus useful for identifying promising directions for health programmes and for advancing child survival efforts. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. The Ghana MICS 2006 used the indirect estimation technique, known as the Brass method (United Nations, 1983). Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewer performance. However, the indirect methods cannot provide the very important infant mortality rate breakdown (neonatal and postneonatal mortality rates) and the estimate of child mortality rate (4q1); it also does not provide the richness of data collected from female respondents’ birth histories. The Early childhood mortality rates presented in this chapter are computed directly from birth histories collected from the female respondents. Women in the age-group 15-49 years who had ever given birth were asked to provide a detailed history of all their live births in chronological order starting with the first live birth. All children born to the respondents, whether dead or alive, were listed by name, sex, birthday and if dead, the date of death. The data analysis on childhood mortality was limited to a period of 15 years prior to the survey, in order to minimize the effect of the pitfalls of memory lapses and also the truncated rates due to the failure to capture births from old women. Childhood mortality rates measure the risk of dying from birth and before age five. The primary causes of childhood mortality change according to the child’s age, and from biological and environmental factors; childhood mortality rates are, therefore, expressed by age segments and are conventionally defined as follows: ● Neonatal mortality rate (NMR): the probability of dying before the first month of life expressed per 1,000 live births; ● Post-neonatal mortality rate (PNMR): the probability of dying after the first month of life but before reaching the first birthday expressed per 1,000 live births, and calculated as the difference between the infant and neonatal mortality rates; ● Infant mortality rate(1q0): the probability of dying before the first birthday expressed per 1,000 live births; ● Child mortality rate (4q1): the probability of dying between age one and before the fifth birthday expressed per 1,000 children aged 1 year; ● Under-five mortality rate (5q0): the probability of dying before the fifth birthday expressed per 1,000 live births. IV. Child Mortality 24 25 Assessment of Data Quality in childhood mortality In any survey, the quality of early childhood mortality estimates depends on sampling and non-sampling errors. For MICS4, the sampling errors are dealt with in Appendix E. The non-sampling errors have to do with the completeness of data on child mortality and the accuracy of the information provided by mother on the date of birth for all live births, and date of death for deceased children. Typically, three types of non-sampling errors are known to affect the childhood mortality estimates: omission of births and deaths, displacement of dates of births and deaths, and misreporting of age at death. Taking into consideration the different elements described above, some caution is necessary when interpreting the childhood mortality trends suggested by MICS 2011. Different Data Quality Tables presented in Appendix E were reviewed and below are our main observations: Table DQ.2: The focus of this table is the completion rate by age-group. The results show that the completion rate is very high: it goes from 96 percent to 98 percent for the 7 age-groups, with an overall rate of 97 percent for all women aged 15-49 years. However, the ratios of age-groups 15-19 years to 10-14 years and 50-54 years to 45-49 years are 0.57 and 1.19 respectively. This means that some eligible women aged 15-49 years were left out of the MICS4 women’s sample. Table DQ.3: This table shows the household population of children aged 0-7 years, children aged 0-4 years whose mothers/caretakers were interviewed, and the percentage of under-5 children whose mothers/caretakers were interviewed, by single ages. This table suggests that the ratio of the population aged 5 years to the population aged 4 yeas is 1.14. In other words, there is evidence of misreporting of age at birth for some children aged 4 years. Table DQ.17: This table show the number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by year of birth, according to living, dead, and total children. The figures show some discrepancies in the following areas: ● Number of births: For 2011 and 2010, the number of births reported are lower compared to all previous years; ● Percent of dead children with complete birth date: From 1992 to 2009, the percentage of dead children with complete birth date is below 90%; ● Sex ratio at birth: huge variations are noticed for the sex ratio at birth. For all births, for example, the sex ratio at birth ranges from 89.5 in 1997 to 123.8 in 1993; ● Calendar year ratio: major variations are also noted. These range from 23.5 in 1992 to 115.0 in 2004 for all births. Table DQ.18: This table provides information on the distribution of reported deaths under one month of age by age at death in days, and the percentage of neonatal deaths reported to have occurred at ages 0-6 days, by 5-year periods preceding the survey. For the four five-periods considered, the figures show some heaping at ages zero, one, three, seven, fourteen and 21 days. Table DQ.19: The focus of this table is to examine the degree of heaping at ages one and 12 months as these are the cut-off points for specific childhood mortality rates. Although there is evidence of some heaping in the overall figures for the four five-year periods considered, the data do not suggest any heaping at these two cut-off points. Although there is evidence of some typical data issues in different surveys (MICS and DHS) worldwide, there is no apparent major concern regarding the overall data quality in Ghana MICS 2011, and especially for the most recent period of 0–4 years preceding the survey. Child Mortality Levels and Trends of Early Childhood Mortality The Ghana MICS4 was conducted from mid-September to mid-December 2011 and early childhood mortality rates were estimated using the direct method. The reference point (mid-point interval) for the childhood mortality for the most recent five year period is mid-March 2009. Table CM.1 provides child mortality rates computed using the ‘direct’ or ‘birth history’ method of estimation. The Ghana under-five mortality rate is estimated at 82 deaths per 1,000 live births for the most recent five-year period. This means that one in every 12 children dies before reaching their fifth birthday. Child mortality rate (4q1) is estimated at 31 deaths per 1,000 children aged 1 year, while Infant mortality rate is estimated at 53 deaths per 1,000 live births. Postneonatal and neonatal mortality rates are estimated at 21 and 32 deaths per 1000 live births, respectively, for the same period. Table CM.1 also reveals that the proportion of infant deaths occurring during the first month of life is above 60 percent for the three 5-year periods, and these results are more detailed in Table DQ.19, Appendix E. Furthermore, this is consistent with other studies (MoH, 2007; USAID, 2002; DHS 2008, P.138), which indicate that in Ghana neonatal deaths are an important component of infant mortality, representing an estimated 60 percent of all infant deaths. Table CM.1: Early childhood mortality rates Neonatal, Postneonatal, Infant, child and under-five mortality rates by 5 year periods, Ghana, 2011 Years preceding the survey Neonatal mortality rate (NM R)  Post neonatal mortality rate (PNMR)  Infant mortality rate (1q0)  Child mortality rate (4q1)  Under five mortality rate (5q0)  0-4 32 21 53 31 82 5-9 32 19 50 39 87 10-14 36 22 58 47 102 As shown in Figure CM.1, under-five mortality rate declined from 102 deaths per 1,000 live births for the period 10-14 years before the survey to 87 deaths per 1,000 live births during the 5-9 years before the survey, and to 82 deaths per 1,000 live births for the 5-year period prior to the survey. For the 10-14 years before the survey, the infant mortality rate declined from 58 deaths per 1,000 live births to 50 deaths per 1,000 live births for the 5-9 years before the survey. The data further show that for the 0-4 years prior to the survey, the infant mortality rate was estimated at 53 deaths per 1,000 live births. For these 2 five-year periods prior to the survey, neonatal mortality rate remained stable at 32 deaths per 1,000 live births. Child Mortality 26 27 Figure CM. 1 Trends in Childhood Mortality Rates for MICS4, Ghana, 2011 0 20 40 60 32 32 36 80 100 120 21 19 22 53 50 58 31 39 47 82 87 102 Pe rc en t National mortality rate 0-4 years before the survey Post neonatal mortality rate Infant mortality rate Child mortality rate Under �ve mortality rate 10-14 years before the survey 5-9 years before the survey The trend in childhood mortality rates over time can also be assessed by comparing the MICS 2011 data, together with the data from three previous DHS (1998, 2003 and 2008) and the MICS 2006. Figure CM.2 shows childhood mortality trends for the past 30 years using data from the five surveys. Overall, Figure CM.2 reveals that in the past 30 years, under-five mortality rate has declined in Ghana, from 145 deaths per 1,000 live births in DHS 1998 to 82 deaths per 1,000 live births in MICS 2011. The data from DHS 1998, DHS 2008 and MICS 2011 are in line with this trend of under-five mortality rate decline over the last 3 decades. However, those from DHS 2003 and MICS 2006 show stagnation of under-five mortality rate above 100 deaths per 1,000 live births during the period of 18 years (1988 to 2006). The most recent under-five mortality rate estimated from MICS 2011 (82 deaths per 1,000 live births) is about 2 percent higher than the estimate from the Ghana Demographic and Health Survey (DHS 2008). This minor difference is likely to be as a result of sampling errors. Child Mortality Figure CM. 2 Trends in Under-five mortality rates in Ghana, various data sources 20 40 60 80 100 120 140 160 0 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 20 11 Pe rc en t DHS 1998 - U5MR DHS 2003 - U5MR MICS 2006 - U5MR DHS 2008 - U5MR DHS 2011 - U5MR Early childhood mortality rates by region, residence and socio-economic characteristics Table CM.2 provides estimates of childhood mortality by region, residence and other socio-economic characteristics. 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.2 are calculated for a ten-year period (2001-2011) preceding the survey. Note that the longer reference period allows the inclusion of more cases in the calculation and makes it possible to obtain more precise estimates. The data presented in Table CM.2 and Figure CM.3 reveal that under-5 mortality rate is lowest in the Greater Accra region (56 deaths per 1,000 live births), followed by Eastern region (61 deaths per 1,000 live births). Under-5 mortality rate is highest in the Northern region (124 deaths per 1,000 live births). Other regions with Under-5 mortality rate of over 100 deaths per 1,000 live births include Brong Ahafo (104 deaths per 1,000 live births), and Upper West (108 deaths per 1,000 live births). Also, Greater Accra (37 deaths per 1,000 live births) and Eastern region (38 deaths per 1,000 live births) have the lowest infant mortality rates. Regions with the highest infant mortality rates are Volta (68 deaths per1000 live births), Upper West (67 deaths per 1000 live births), Northern and Brong Ahafo (both with 66 deaths per 1000 live births). The data also reveal that Volta (47 deaths per 1,000 live births), Brong Ahafo (44 deaths per 1000 live births) and Upper West (41 deaths per 1000 live births) have the highest neonatal mortality rates in Ghana, while Greater Accra (20 deaths per 1,000 live births) has the lowest. Child Mortality 28 29 Table CM.2: Early childhood mortality rates by background characteristics Neonatal, post neonatal, Infant and Under-five mortality rates for the 10-year period preceding the survey by background characteristics, Ghana, 2011 Background Characteristics Neonatal mortality rate (NMR)  Post neonatal mortality rate (PNMR)  Infant mortality rate (1q0)  Child mortality rate (4q1)  Under five mortality rate (5q0)  Residence Urban 30 16 46 28 72 Rural 33 23 56 40 94 Region Western 27 24 50 17 67 Central 36 19 55 36 88 Greater Accra 20 17 37 19 56 Volta 47 21 68 22 89 Eastern 25 14 38 24 61 Ashanti 27 16 43 45 86 Brong Ahafo 44 21 66 41 104 Northern 39 27 66 63 124 Upper East 34 24 58 43 98 Upper West 41 26 67 44 108 Mother's/Caretaker’s education None 28 26 54 45 97 Primary 36 18 54 31 83 Middle/JSS 34 16 50 28 76 Secondary + (28) (2) (30) (5) (35) Wealth index quintiles Poorest 35 25 61 48 106 Second 28 22 50 37 85 Middle 35 19 54 30 83 Fourth 37 15 52 36 86 Richest 24 14 38 15 52 Total 32 21 53 31 82  MICS indicator 1.3  MICS indicator 1.4  MICS indicator 1.1; MDG indicator 4.1  MICS indicator 1.5;  MICS indicator 1.2, MDG indicator 4.2 Figures in parentheses ‘()’ are based on 250-499 unweighted exposed persons. Child Mortality Figure CM.3: Infant and Under-five mortality rates by region, Ghana, 2011 20 40 60 80 100 120 140 0 Pe rc en t Western Central Greater Accra Volta Eastern Ashanti Brong Ahafo Northern Upper East Upper West 67 32 50 88 89 86 104 124 43 66 66 98 108 58 68 61 38 55 56 37 67 Under-�ve mortality rate Infant mortality rate As child mortality drops across the world, due to commitment and action, evidence shows that reductions are predominantly made in deaths occurring past infancy and, increasingly, there is a demand for precision in and analysis of the period where most deaths occur (UNICEF and all., 2012). Figure CM.4 provides analysis of the contribution of neonatal mortality rate to the overall infant mortality rate by region. The analysis shows that the neonatal mortality rate represents more than 60 percent of infant mortality rate in 6 regions out of 10. This means that in those 6 regions (Volta, Brong Ahafo, Central, Eastern, Ashanti, and Upper West), over 60 percent of all infant deaths occur in the first month of life. Figure CM.4: Percent contribution of Neonatal mortality rate to overall Infant mortality rate by Region, Ghana, 2011 0 10 20 30 40 50 60 70 63 53 65 53 65 69 68 59 59 61 80 90 100 W es te rn Ce nt ra l Gr ea te r A cc ra Vo lta Ea ste rn As ha nt i Br on g Ah af o Up pe r E as t Up pe r W es t No rth er n Pe rc en t Child Mortality 30 31 Residence and Socio-economic Differentials in Childhood Mortality Table CM.2 also show differentials in childhood mortality rates by residence and two socio-economic variables: mother’s education and wealth quintiles. From the results, it is apparent that infant and child survival are associated with the residence and the socio-economic characteristics of mothers. Generally, mortality in urban areas is consistently lower than in rural areas. Under-5 mortality is estimated at 72 deaths per 1,000 live births in urban areas, and 94 deaths per 1,000 live births in rural areas. For infant mortality, this is estimated at 46 deaths per 1,000 live births in urban areas, and 56 deaths per 1,000 live births in rural areas. The urban-rural difference is more pronounced for post neonatal mortality and child mortality rates. Studies have demonstrated a strong relationship between a mother’s level of education and the survival of her child (Hobcraft, 1993), and this is fairly consistent for all childhood mortality indicators, except neonatal mortality rate. The results show that under-5 mortality rate is estimated at 97 deaths per 1000 live births for children whose mothers have no education and at 76 deaths per 1,000 live births for mothers with middle/JSS education. For children whose mothers have no education and/or primary education, infant mortality rate is estimated at 54 deaths per 1000 live births, and at 50 deaths per 1000 live births for children whose mothers have middle/JSS education. Due to the fewer exposures (250-499), analysis for children whose mothers have secondary or higher education has not been presented. While childhood mortality tends to be differentiated among socio-economic groups, in the MICS 2011, significant variations are only noted for mortality of children in the poorest 20 percent of households, and the richest 20 percent of households. The MICS 2011 data reveal that children from the richest households have lower mortality rates, compared to children from the poorest households (Table CM.2 and Figure CM.5). For example, infant mortality is estimated at 61 per 1000 live deaths for children from the poorest wealth quintile, and 38 deaths per 1000 live deaths for children in the richest wealth quintile. This means that the children from the poorest wealth quintile are more (1.60 times) likely to die before their first birthday compared to those from the richest wealth quintile. Under-5 mortality is estimated at 106 deaths per 1,000 live births for children from the poorest households, compared to 52 deaths per 1,000 live births for children belonging to the wealthiest households. This means that the children from the poorest households are more than twice as likely to die before their fifth birthday as those from the richest households (Figure CM.5). However, for the other three wealth quintiles, an erratic pattern is observed, and in some cases, little differences are noted for all the childhood indicators. This is obviously due to sampling errors. Child Mortality Figure CM.4: Under-5 mortality rates by residence and socio-economic characteristics, Ghana, 2011 Demographic Characteristics and Childhood Mortality Demographic factors such as the sex of the child, age of the mother at birth, birth order, and length of the preceding birth interval, 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 and Figure CM.6 show the relationships between childhood mortality and these demographic variables. For all variables, childhood mortality rates 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 for all childhood mortality indicators (Figure CM.6). For example, under-five mortality rate is estimated at 94 deaths per 1,000 live births for boys, and 75 deaths per 1,000 live births for girls. This means that male children are 1.25 times more likely to die before the fifth birthday than females. Neonatal mortality rate is estimated at 37 deaths per 1000 live births for male children, and 27 deaths per 1000 live births for female children, which means that male children are 1.37 times more likely to die during the first month of life than their female counterparts. Research has 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 shown in Table CM.3 and Figure CM.6. For mothers aged below 20 years, infant mortality rate is estimated at 64 deaths per 1,000 live births, compared to 48 deaths per 1,000 live births for mothers aged 20-34 years. Infant mortality is also higher for children born to women aged 35-49 years (59 deaths per 1,000 live births). The under-five mortality rate is estimated at 105 deaths per 1,000 for women below the age of 20 years, 79 deaths per 1,000 live births for women aged 20-34 years, and 92 deaths per 1,000 live births for women aged 35-49 years. Child Mortality 32 33 First births and higher order births generally face an elevated risk of mortality. Data from the MICS 2011 confirm this pattern for the most part. Birth orders seven and higher experience the highest levels of childhood mortality, while mortality is lowest for second and third order births. For example, under-5 mortality rate is estimated at 114 deaths per 1,000 live births for birth order seven and higher, 75 deaths per 1,000 live births for birth orders 2-3, and 89 deaths per 1,000 live births for birth order 1 (Figure CM.6). The birth interval also affects survival when there is an interval of less than two years between pregnancies, demonstrating the importance of spacing on child survival. This is fairly consistent in all childhood mortality indicators. For example, infant mortality rate for children born at less than a two-year interval is 75 deaths per 1,000 live births and 37 deaths per 1,000 live births when the birth interval is 3 years. This means that the children born at less than a two-year interval are more than twice likely to die before their first birthday compared to the ones born at 3 years interval. Under-five mortality rate is 112 deaths per 1,000 live births for birth intervals of less than 2 years and 69 deaths per 1,000 live births when a birth occurs 3 years after a previous birth. Children born at less than a two-year interval are more (1.6 times) likely to die before their fifth birthday compared to the ones born at 3 years interval. Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post neonatal, Infant and Under-five mortality rates for the 10-year period preceding the survey by demographic characteristics, Ghana, 2011 Background Characteristics Neonatal mortality rate (NMR)  Post neonatal mortality rate (PNMR)  Infant mortality rate(1q0)  Child mortality rate (4q1)  Under five mortality rate (5q0)  Sex of child Male 37 21 58 39 94 Female 27 18 45 31 75 Mother’s age <20 35 29 64 44 105 20-34 29 19 48 33 79 35-49 41 18 59 36 92 Birth order 1 35 20 56 35 89 2-3 24 17 41 36 75 4-6 34 20 55 32 85 7+ 48 28 76 41 114 Previous birth intervals <2 46 29 75 40 112 2 years 26 16 42 41 81 3 years 21 15 37 34 69 4+ years 25 13 38 21 59 Total 32 21 53 31 82  MICS indicator 1.3  MICS indicator 1.4  MICS indicator 1.1; MDG indicator 4.1  MICS indicator 1.5;  MICS indicator 1.2, MDG indicator 4.2 Child Mortality Figure CM. 6: Under-5 mortality rates by demographic characteristics, Ghana, 2011 Child Mortality 34 35V. Nutrition 35 Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, the distribution of height and weight for children under age five is similar to that of a reference population. Hence under-nourishment in a population can be gauged by comparing children’s anthropometric measurements with that of a reference population. The reference population used in this report is based on new WHO growth standards1 . Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. 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 moderately or severely 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. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as 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. In Ghana MICS4, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (www.childinfo.org). Findings in this section are based on the results of these measurements. 1 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf 36 37 Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population, and mean z-scores for all three anthropometric indicators. Children whose full birth date (month and year) were not obtained, and children whose measurements are outside the plausible range are excluded from Table NU.1. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever is applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the Data Quality Tables DQ.6 and DQ.7 in Appendix D. Overall, 99 percent of children had both their weights and heights measured (Table DQ.6). Less than two percent did not have their weight measured. One percent of children did not have their months of birth recorded. However, there was no case of children with neither year nor month missing. Table DQ.7 shows that due to incomplete dates of birth, implausible measurements, and missing weight and/or height, 3 percent of children have been excluded from the calculations of the weight-for-height indicator. Thirteen percent of children under age five in Ghana are moderately or severely underweight and 3 percent are classified as severely underweight (Table NU.1). Twenty-three percent of the children are moderately or severely stunted or too short for their age, and 7 percent are severely stunted. Also, 6 percent of the children under five are moderately or severely wasted or too thin for their height, while 1 percent is severely wasted. Children in Northern and Upper East regions are more likely to be underweight and stunted than children in other regions (see Table NU.1). In contrast, the percentage of wasting is highest in Upper West and Volta regions (9% for each region). Furthermore, the percentage of children who are underweight and stunted are higher in the rural than the urban area. Those children whose mothers have secondary or higher education are less likely to be underweight (9%) and stunted (13%) compared to children whose mothers have no education (17% and 29%, respectively). Boys appear more likely to be underweight (15%), stunted (25%), and wasted (7%) than girls (11%, 20% and 5% respectively). The age pattern shows that children aged 12-23 months are more likely to be underweight, in comparison to children who are younger and older; children aged 24-35 months are more likely to be stunted in comparison to children who are younger or older; and children aged 0-11 months are more likely to be wasted in comparison to children who are older (Figure NU.1). This pattern is expected for underweight and stunting as it is related to the ages at which many children cease to be breastfed and are exposed to contamination in water, food, and the environment. 36Nutrition Table NU.1: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height Ghana, 2011 Background Characteristics Weight for age: Weight for age: Weight for age: Weight for age: Height for age: Height for age: Height for age: Height for age: Weight for height: Weight for height: Weight for height: Weight for height: Weight for height: % below -2 sd  % below -3 sd  Mean Z-Score (SD) Number of children % below -2 sd  % below -3 sd  Mean Z-Score (SD) Number of children % below -2 sd  % below -3 sd  % above +2 sd Mean Z-Score (SD) Number of children Sex Male 15.4 3.1 -.9 3665 25.3 8.3 -1.1 3636 7.2 1.9 2.7 -.4 3665 Female 11.3 2.1 -.7 3710 20.3 5.3 -1.0 3703 5.2 .9 2.5 -.3 3716 Residence Urban 10.5 1.6 -.7 3196 18.1 4.2 -.9 3194 5.7 1.5 2.4 -.3 3191 Rural 15.5 3.4 -.9 4178 26.3 8.8 -1.2 4145 6.6 1.4 2.8 -.3 4190 Region Western 14.3 2.9 -.8 718 22.6 7.0 -1.1 713 7.7 1.8 3.0 -.3 722 Central 13.5 3.1 -.9 727 23.1 7.3 -1.1 723 5.4 1.6 1.4 -.3 727 Greater Accra 8.3 .7 -.6 1110 13.7 3.7 -.7 1110 3.1 .4 3.2 -.3 1119 Volta 10.9 1.6 -.8 590 22.2 6.7 -.9 589 8.5 1.9 2.1 -.5 597 Eastern 10.5 1.9 -.7 816 21.3 4.4 -.9 812 6.8 .7 2.4 -.3 812 Ashanti 11.9 2.1 -.7 1377 21.7 6.6 -1.0 1370 6.6 2.4 4.6 -.2 1366 Brong Ahafo 11.8 1.7 -.8 660 19.3 4.9 -1.1 655 3.2 .5 1.7 -.2 662 Northern 24.2 6.2 -1.3 836 37.4 13.3 -1.7 834 8.1 1.7 1.1 -.4 840 Upper East 20.0 4.9 -1.2 323 31.5 9.8 -1.5 318 7.2 1.2 1.6 -.5 319 Upper West 15.0 3.4 -1.0 219 23.1 7.5 -1.1 215 9.2 1.8 2.0 -.5 215 Age 0-5 6.7 1.7 -.2 800 7.8 1.9 .0 795 11.4 3.6 4.7 -.4 795 6-11 15.8 2.1 -.8 716 12.5 2.3 -.4 714 11.3 1.9 2.1 -.8 714 12-23 16.5 3.4 -.9 1422 26.5 9.0 -1.2 1411 7.7 1.9 3.4 -.4 1418 24-35 13.5 2.8 -.9 1519 28.2 8.7 -1.3 1515 4.7 1.0 2.4 -.2 1520 36-47 13.7 3.1 -.9 1534 27.9 8.5 -1.3 1522 2.8 .4 2.0 -.2 1531 48-59 12.2 1.8 -1.0 1384 21.3 5.7 -1.2 1382 4.6 1.0 1.7 -.3 1403 Mother's education None 17.3 4.3 -1.0 2403 29.2 10.6 -1.3 2390 7.8 1.8 2.3 -.4 2405 Primary 13.7 2.6 -.8 1603 25.2 6.1 -1.2 1590 5.1 1.1 3.3 -.3 1605 Middle/JSS 10.8 1.4 -.7 2524 18.2 5.1 -.9 2515 5.2 1.5 2.0 -.3 2526 Secondary + 9.2 1.1 -.5 845 13.2 2.7 -.6 844 6.6 .7 3.9 -.3 844 Wealth index quintile Poorest 20.0 4.9 -1.1 1687 33.2 12.5 -1.5 1670 7.6 1.3 2.6 -.4 1694 Second 14.8 3.6 -.9 1532 26.7 8.4 -1.2 1522 7.3 1.8 3.3 -.3 1531 Middle 13.2 2.6 -.9 1526 22.8 6.9 -1.1 1528 6.0 2.1 2.2 -.3 1529 Fourth 10.3 .9 -.7 1372 15.8 2.8 -.8 1364 4.8 .9 .9 -.4 1372 Richest 6.3 .3 -.4 1258 11.6 1.5 -.5 1256 4.8 .8 4.2 -.2 1254 Total 13.4 2.6 -.8 7375 22.7 6.8 -1.1 7338 6.2 1.4 2.6 -.3 7381  MICS indicator 2.1a and MDG indicator 1.8  MICS indicator 2.1b  MICS indicator 2.2a,  MICS indicator 2.2b  MICS indicator 2.3a,  MICS indicator 2.3b Nutrition 38 39 Figure NU.1: Percentage of Children under-5 who are underweight, stunted and wasted Ghana, 2011 Marked differences are observed in all three indices with regard to the wealth status of households. For example, one in three (33%) children from the poorest households is stunted, compared to 12 percent of children from the richest households. Also, while 20 percent of children from the poorest wealth quintile are underweight, this reduces to 14 percent for children in the middle wealth quintile, and to 7 percent for children in the richest wealth quintile. Children from the poorest households are at least twice more likely to be underweight, stunted or wasted in comparison with children from the wealthiest households. Overweight is not a big problem among children under five in Ghana. Overall, about 3 percent of the children were found to be overweight – these are the children whose weight for height is above 2 standard deviations from the median of the reference population (Table NU.1). Breastfeeding and Infant and Young Child Feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: ● Early initiation of breastfeeding within the first hour of birth; ● Exclusive breastfeeding for the first six months; ● Continued breastfeeding for two years or more; ● Safe, appropriate and adequate complementary foods beginning at 6 months; and ● Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds. Nutrition Percentage of Children under-5 who are underweight, stunted and wasted Ghana, 2011 Age (in Months) 5 10 15 20 25 30 35 40 0 0 6 12 24 36 48 Underweight Stunted Wasted Pe rc en t The indicators related to recommended child feeding practices are as follows: ● Early initiation of breastfeeding (within 1 hour of birth); ● Exclusive breastfeeding rate (< 6 months); ● Predominant breastfeeding (< 6 months); ● Continued breastfeeding rate (at 1 year and at 2 years); ● Duration of breastfeeding ● Age-appropriate breastfeeding (0-23 months) ● Introduction of solid, semi-solid and soft foods (6-8 months) ● Minimum meal frequency (6-23 months) ● Minimum diet diversity (6-23 months) ● Minimum acceptable diet (frequency and diet diversity) ● Milk feeding frequency for non-breastfeeding children (6-23 months) ● Bottle feeding (0-23 months) Table NU.2 provides the proportion of children born in the last two years who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed. Although a very important step in the management of lactation and establishment of a physical and emotional relationship between the baby and the mother, less than half (46%) of babies are breastfed for the first time within one hour of birth, while 84 percent of new-borns in Ghana start breastfeeding within one day of birth. Initiation of breastfeeding varies among regions. The proportion of infants that are breastfed within one hour of birth is higher in the Western and Upper West Regions at just over 60 percent, and lower in Greater Accra Region (29%). Greater Accra Region again has the lowest percentage of infants who started breastfeeding within one day of birth (68%). Ashanti, Upper East, Upper West and Eastern regions all have the highest proportion of newborns first breastfeeding within one day of birth (about 90%). Little differences are observed by education background of the mothers with respect to breastfeeding their children within one hour or one day of birth. An irregular pattern is observed in initial breastfeeding and household wealth. For example, 50 percent of mothers in the second wealth quintile breastfed their infants within one hour of birth, compared to 43 percent of mothers in the poorest wealth quintile, and 42 percent of mothers in the richest wealth quintile. Similarly, mothers from the poorest and richest wealth quintiles are less likely to breastfeed their babies within one day of birth, compared to mothers from the other wealth categories. Also, infants delivered in a public sector health facility are more likely to be breastfed within one hour of birth (51%) and within one day of birth (87%) than infants delivered in a private sector health facility, at home, or other places. Nutrition 40 41 Table NU.2: Initial breastfeeding Percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Ghana, 2011 Background Characteristics Percentage ever breastfed  Percentage who were first breastfed: Within one hour of birth  Percentage who were first breastfed: Within one day of birth Percentage who received a prelacteal feed Number of last-born children in the two years preceding the survey Region Western 99.5 61.9 89.3 20.5 270 Central 98.4 53.2 84.4 19 246 Greater Accra 99.6 28.6 67.9 26.6 397 Volta 99.2 41.7 89.7 4.9 189 Eastern 98.5 49.7 83.7 9.7 288 Ashanti 99 51.3 90.9 26 449 Brong Ahafo 97.5 36.3 78.2 22.4 227 Northern 98.5 39 84.2 14.6 283 Upper East 99.6 55.6 90.9 15 105 Upper West 98.4 61.1 90.9 6.8 75 Residence Urban 99.3 44.9 84.4 17.8 1068 Rural 98.5 46.6 83.2 19.4 1460 Months since last birth 0-11 months 98.5 46.1 84 17.6 1077 12-23 months 99.3 48.7 85.7 17.3 907 Assistance at delivery Skilled attendant 99.2 48.3 85.6 15.8 1729 Traditional birth attendant 99.1 47.1 82.9 32.2 403 Other 98.9 33.5 79.6 16.7 314 Missing 90.8 35.5 64 22.9 83 Place of delivery Public sector health facility 99.2 50.7 86.6 13.9 1434 Private sector health facility 99.2 38.7 82.7 24.2 269 Home 99 40.3 80 25.3 793 Other/Missing (76.2) (29.1) (56) (29.5) 32 Mother's education None 98.6 44.9 83.4 17.7 733 Primary 99.5 45.8 82.3 17.6 565 Middle/JSS 98.4 46.7 85.2 18.7 886 Secondary + 99.6 45.8 82.7 23 344 Wealth index quintiles Poorest 99.4 42.5 80.7 16.8 560 Second 97.4 50.4 86.6 20.9 546 Middle 98.6 47.9 88.4 13.2 500 Fourth 99.5 45.4 83.7 19.5 455 Richest 99.6 43 78.9 23.9 467 Total 98.9 45.9 83.7 18.8 2528  MICS indicator 2.4 MICS indicator 2.5 Figures in parentheses ‘()’ are based on 25-49 unweighted cases Nutrition Figure NU.2: Infant feeding patterns by age Percentage distribution of children aged under 3 years by feeding pattern by age group, Ghana, 2011 In Table NU.3, breastfeeding status is 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, as well as continued breastfeeding of children at ages 12-15 and 20-23 months of age. Nutrition : Infant feeding patterns by age Percentage distribution of children aged under3 years by feeding pattern by age group, Ghana, 2011 Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed Age (in Months) 0 0- 1 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 10 20 30 40 50 60 70 80 90 100 Pe rc en t 42 43 Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Ghana, 2011 Children 0-5 months Children 12-15 months Children 20-23 months Background Characteristics Percent exclusively breastfed  Percent predominantly breastfed  Number of children Percent breastfed (Continued breastfeeding at 1 year)  Number of children Percent breastfed (Continued breastfeeding at 2 years)  Number of children Sex Male 46.2 72.1 418 86.6 234 38.1 227 Female 45.1 69.8 400 94.1 288 36.7 205 Region Western (46.8) (76.7) 72 (98.5) 62 * 40 Central 39.5 66.7 73 89.8 40 35.1 57 Greater Accra (21.1) (38.1) 110 (75.0) 93 * 62 Volta (49.1) (80.3) 64 * 34 * 19 Eastern (42.6) (74.0) 107 * 42 * 46 Ashanti 39.0 61.9 172 (90.9) 108 (25.9) 81 Brong Ahafo 69.8 91.1 82 * 47 (41.4) 42 Northern 63.6 90.4 79 98.3 63 85.1 49 Upper East (58.4) (92.0) 35 95.5 19 76.6 22 Upper West 67.0 81.6 23 91.2 14 87.7 15 Residence Urban 48.9 68.5 344 85.9 242 20.5 177 Rural 43.3 72.7 473 94.9 280 49.3 255 Mother's education None 55.0 82.6 234 96.4 143 64.9 145 Primary 43.1 75.4 177 93.7 118 38.1 87 Middle/JSS 39.9 63.4 307 89.9 201 18.4 161 Secondary + 46.1 59.3 100 (74.5) 60 (13.2) 40 Wealth index quintile Poorest 53.7 80.4 169 96.5 109 78.9 97 Second 39.7 73.8 163 98.3 126 39.8 113 Middle 45.1 73.0 186 95.3 113 18.1 75 Fourth 41.7 62.8 135 91.0 80 28.6 84 Richest 47.2 62.8 164 (68.3) 94 (4.6) 64 Total 45.7 71.0 818 90.7 522 37.4 432  MICS indicator 2.6  MICS indicator 2.9  MICS indicator 2.7  MICS indicator 2.8 An asterisk (*) indicates that figure is based on fewer than 25 unweighted cases, and has been suppressed. Figures in parentheses ‘()’ are based on 25-49 unweighted cases. Approximately 46 percent of children aged less than six months are exclusively breastfed, a level considerably lower than that recommended by the WHO/UNICEF. By age 12-15 months, 91 percent of children are still being breastfed, and by age 20-23 months, 37 percent are still breastfed. Little differences are observed in exclusive breastfeeding by sex of the child - 46 percent for boys and 45 percent for girls. In contrast, girls aged 12 – 15 months (94%) are more likely to continue breastfeeding at one year than boys (87%). Given the small number of children in the sample, it is not possible to have meaningful comparisons for all 10 regions. Nutrition In terms of area of residence, infants aged 0-5 months in urban area (49%) are more likely to be exclusively breastfed than their counterparts in rural areas (43%). The reverse is true for infants in the 12-15 months and 20-23 months age-groups, where children in the urban areas are less likely to receive continued breastfeeding at year one and two. In all age categories and breastfeeding status, breastfeeding decreases with the mother’s educational level. For example, children 0-5 months whose mothers have no education are more likely to be exclusively breastfed (55%), compared to children whose mothers have secondary or higher education (46%). However, no conclusion can be made for continued breastfeeding at 2 years for children aged 20-23 months, due to the small number with secondary and higher education. Figure NU.2 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the youngest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is below three percent. Only about 35 percent of children are receiving breast milk after 2 years. As already shown in the Table NU.3, and contrary to the WHO/UNICEF recommendation, all children under 6 months in Ghana are not exclusively breastfed. The figure NU.2 indicates that the percentage of “Exclusively breastfed” decreases rapidly from 71 percent (aged 0-1 month) to 49 percent (age 2-3 months), 24 percent (age 4-5 months); and above the age of 6 months, less than 3 percent of the children are still “exclusively breastfed”. For the age-groups 6-7 to 18-19 months, breastfeeding and complementary foods is the predominant infant feeding pattern, with percentages ranging between 69 percent and 89 percent. For age-groups 20-21 and 22-23 months, this proportion is halved due to the huge increase in the percentage of “weaned” children. The percentage of “weaned” increases with age and approximately 64 percent of the children are weaned before turning 2 years old. Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children 0-35 months, the median duration is 20.4 months for any breastfeeding, 2.2 months for exclusive breastfeeding, and 4.2 months for predominant breastfeeding. The median duration of breastfeeding varies among regions for children aged 0-35 months. Greater Accra region has the lowest median duration of breastfeeding for any breastfeeding (17.5 months), exclusive breastfeeding (1.1 months), and predominant breastfeeding (1.7 months). On the other hand, Upper West region has the highest median duration of breastfeeding for any breastfeeding (26.2 months), Brong Ahafo region has the highest median duration for exclusive breastfeeding (4.0 months), and Upper East region has the highest median duration for predominant breastfeeding (7.0 months). In terms of area of residence, the median duration of any breastfeeding is higher for rural areas (21.6 months), than urban areas (18.6 months). Little variation is found between urban and rural areas in the median duration of exclusive breastfeeding and predominant breastfeeding. For all breastfeeding categories, the median duration of breastfeeding decreases with mother’s education level: for example, for any breastfeeding, the median duration is 23.5 months for mothers with no education, compared to 18.0 months for mothers with middle/JSS and Secondary or higher education. For exclusive breastfeeding, the median duration is 2.9 months for mothers with no education, compared to 1.8 months for mothers with Middle/JSS or Secondary and higher education. The median duration decreases with wealth index quintile. The median duration of 25.7 months for any breastfeeding, 2.8 months for exclusive breastfeeding, and 5.7 months for predominant breastfeeding for the poorest wealth quintile is the highest compared to all other wealth quintile groups. Nutrition 44 45 Table NU.4: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Ghana, 2011 Background Characteristics Median duration (in months) of Number of children age 0-35 months Any breastfeeding  Exclusive breastfeeding Predominant breastfeeding Sex Male 20.3 2.3 4.3 2233 Female 20.5 2.1 4.2 2315 Region Western 20.8 2.3 4.0 447 Central 19.6 1.2 3.7 454 Greater Accra 17.4 1.1 1.7 673 Volta 22.1 2.5 5.4 338 Eastern 18.0 2.0 4.0 520 Ashanti 17.9 1.6 3.9 895 Brong Ahafo 21.1 4.0 6.4 411 Northern 25.1 3.5 6.8 491 Upper East 25.5 3.4 7.0 184 Upper West 26.2 3.8 5.9 135 Residence Urban 18.6 2.4 4.0 1978 Rural 21.6 2.1 4.5 2570 Mother's education None 23.5 2.9 5.8 1355 Primary 21.1 2.1 4.8 1007 Middle/JSS 18.0 1.8 3.5 1607 Secondary+ 18.0 1.8 3.3 579 Wealth index quintile Poorest 25.7 2.8 5.7 1011 Second 20.7 1.6 4.4 917 Middle 19.6 2.3 4.8 936 Fourth 18.5 2.1 3.2 868 Richest 15.9 2.1 3.8 815 Median 20.4 2.2 4.2 4548 Mean for all children (0-35 months) 20.5 2.7 5.1 4548  MICS indicator 2.10 Nutrition The adequacy of breastfeeding in children aged 0-23 months is provided in Table NU.5. 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, while infants aged 6-23 months are considered to be adequately fed if they are fed the minimum number of times according to age. For children aged 0-5 months, little differences are observed among male and female children. For children aged 6-23 months, 69 percent males and 73 percent females are currently breastfed and receiving solid, semi-solid or soft foods. Some regional variations are also observed. About 70 percent of children aged 0-5 months are being adequately fed in Brong Ahafo region, the highest proportion compared to about a fifth (21%) for Greater Accra, which has the lowest. Upper West has the highest proportion of children aged 6-23 months (86%) and children aged 0-23 months (81%) that can be considered adequately fed, compared to Greater Accra, which has the lowest at 60 percent of children aged 6-23 months and 51 percent of children aged 0-23 months that are adequately fed. With regard to other background characteristics of the mother, those with no education, and those with primary education are more likely to feed their children adequately compared to mothers with other levels of education. Consequently, only 71 percent of children aged 6-23 months and 64 percent of children aged 0-23 months can be said to be adequately fed. Nutrition 46 47 Table NU.5: Age-appropriate breastfeeding Percentage of children aged 0-23 months who were appropriately breastfed during the previous day, Ghana, 2011 Background Characteristics Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed  Number of children Percent currently breastfeeding and receiving solid, semi-solid or soft foods Number of children Percent appropriately breastfed  Number of children Sex Male 46.2 418 69.0 1077 62.6 1495 Female 45.1 400 72.6 1100 65.3 1500 Region Western (46.8) 72 77.3 243 70.3 315 Central 39.5 73 68.6 236 61.7 309 Greater Accra (21.1) 110 60.3 367 51.3 477 Volta (49.1) 64 77.3 157 69.1 220 Eastern 42.6 107 65.9 245 58.8 352 Ashanti 39.0 172 64.9 346 56.3 518 Brong Ahafo 69.8 82 73.5 177 72.3 259 Northern 63.6 79 80.6 256 76.6 334 Upper East (58.4) 35 82.9 88 75.9 123 Upper West 67.0 23 85.9 64 80.8 87 Residence Urban 48.9 344 65.7 932 61.2 1276 Rural 43.3 473 74.6 1246 66.0 1719 Mother's education None 55.0 234 76.7 643 70.9 877 Primary 43.1 177 74.7 488 66.3 665 Middle/JSS 39.9 307 66.3 743 58.6 1050 Secondary + 46.1 100 63.0 303 58.8 403 Wealth index quintile Poorest 53.7 169 82.9 487 75.4 656 Second 39.7 163 72.0 486 63.9 649 Middle 45.1 186 72.5 406 63.9 592 Fourth 41.7 135 68.4 406 61.8 541 Richest 47.2 164 54.9 393 52.6 557 Total 45.7 818 70.8 2177 63.9 2995  MICS indicator 2.6  MICS indicator 2.14 Figures in parentheses ‘()’ are based on 25-49 unweighted cases. Adequate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and the prevention of under-nutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. This requires that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are aged 9-23 months of age. For children aged 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Nutrition Overall, 75 percent of all infants aged 6-8 months received solid, semi-solid, or soft foods (Table NU.6). Among currently breastfeeding infants, figure is 74 percent. Table NU.6 also shows that infants aged 6-8 months in urban areas (80%) are more likely to receive solid, semi-solid, or soft foods, compared to those in rural areas (71%). Table NU.6: Introduction of solid, semi-solid or soft food Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Ghana, 2011 All Background Characteristics Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods  Number of children age 6-8 months Sex Male 74.0 203 * 3 74.4 206 Female 74.6 192 * 5 75.3 197 Residence Urban 79.8 169 * 3 80.1 172 Rural 70.2 226 * 5 70.9 231 Total 74.3 395 100.0 8 74.8 403  MICS indicator 2.12 An asterisk (*) indicates that figure is based on fewer than 25 unweighted cases, and has been suppressed. Table NU.7 presents the proportion of children aged 6-23 months who received semi-solid or soft foods the minimum number of times or more during the previous day according to breastfeeding status (see the note in Table NU.7 for a definition of minimum number of times for different age groups). Overall, more than half of the children aged 6-23 months (57%) were receiving solid, semi-solid and soft foods the minimum number of times. A slightly higher proportion of male children (59%) were enjoying the minimum meal frequency compared to female children (56%). Among currently breastfed children aged 6-23 months, 57 percent were receiving solid, semi-solid and soft foods the minimum number of times and this proportion was higher among male children (59%) compared to females (56%). Among non-breastfeeding children, 58 percent received solid, semi-solid and soft foods or milk feeds 4 times or more. Nutrition 48 49 Table NU.7: Minimum meal frequency Percentage of children aged 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Ghana, 2011 Currently breastfeeding Currently not breastfeeding All Background Characteristics Percent receiving solid, semi- solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds  Percent receiving solid, semi- solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency  Number of children age 6-23 months Sex Male 59.1 824 13.3 58.8 254 59.0 1077 Female 55.5 883 13.2 56.2 217 55.6 1100 Age 6-8 months 59.4 395 64.5 * 8 59.5 403 9-11 months 53.2 313 62.9 * 9 54.5 322 12-17 months 54.7 668 19.5 61.1 112 55.7 780 18-23 months 63.6 331 8.6 55.1 342 59.3 673 Region Western 46.6 204 3.6 * 39 45.6 243 Central 62.4 173 6.1 57.4 63 61.1 236 Greater Accra 59.2 244 13.2 (59.2) 122 59.2 367 Volta 50.5 134 28.0 * 23 52.4 157 Eastern 55.5 175 10.5 (23.1) 70 46.2 245 Ashanti 73.6 242 22.0 (80.7) 104 75.8 346 Brong Ahafo 61.1 148 8.7 * 29 65.8 177 Northern 49.1 245 13.9 * 11 48.4 256 Upper East 47.7 81 .0 * 7 45.7 88 Upper West 61.0 60 14.5 * 4 60.2 64 Residence Urban 58.2 676 16.7 60.2 255 58.8 932 Rural 56.6 1030 9.2 54.5 216 56.3 1246 Mother's education None 55.0 563 7.9 50.0 81 54.4 643 Primary 52.8 401 2.7 43.4 87 51.1 488 Middle/JSS 59.2 525 15.5 63.9 218 60.6 743 Secondary + 66.4 218 23.2 (63.2) 85 65.5 303 Wealth index quintile Poorest 53.0 451 .0 45.3 36 52.4 487 Second 55.5 390 6.3 45.8 96 53.6 486 Middle 59.8 321 9.0 65.6 85 61.0 406 Fourth 58.2 297 21.9 64.0 109 59.7 406 Richest 63.3 247 17.1 59.0 146 61.7 393 Total 57.2 1707 13.2 57.6 471 57.3 2177  MICS indicator 2.15  MICS indicator 2.13 An asterisk (*) indicates that figure is based on fewer than 25 unweighted cases, and has been suppressed. Figures in parentheses ‘()’ are based on 25-49 unweighted cases. Nutrition Infant and young child feeding (IYCF) practices directly affect the nutritional status of children under two years of age and, ultimately, impact child survival2. Improving infant and young child feeding practices in children aged 6–23 months of age is therefore critical to improved nutrition, health and development of children. Additional to the minimum meal frequency for children aged 6-23 months, the national MICS also included questions on the minimum dietary diversity by asking mothers/caretakers of children aged 6-23 months, if the child had consumed any food items in the following 7 food groups, on the day or night preceding the survey: ● grains, roots and tubers ● legumes and nuts ● dairy products (milk, yogurt, cheese) ● flesh foods (meat, fish, poultry and liver/organ meats) ● eggs ● vitamin-A rich fruits and vegetables ● other fruits and vegetables As per WHO/UNICEF guidelines on feeding practices for children aged 6-23 months, the cut-off of at least 4 of the 7 food groups above was selected because it is associated with better quality diets for both breastfed and non-breastfed children. Consumption of foods from at least 4 food groups on the previous day would also mean that many of the children had a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber). For the Ghana MICS survey, it should be noted that although the quantity of food consumed matters and influences nutrition status, due to measurement challenges, the survey only recorded whether or not the food items were consumed and not the amounts. Table NU.8 presents the percentage of children aged 6-23 months who received at least 4 groups of food the day or night preceding the survey and the percentage of those who received at least four groups and at least the minimum times of feeding according to age. Table NU.8 reveals that for children aged 6-23 months currently breastfeeding, 46 percent consumed food items from at least 4 food groups, and 34 percent consumed food items from 4 or more food groups and were fed the minimum number of times. Consumption of food items from at least 4 food groups increases with age – from 17 percent for children aged 6-8 months, 46 percent for children aged 9-11 months, 57 percent for children aged 12-17 months, and nearly 60 percent for children aged 18-23 months. This age pattern is noteworthy, and although varied food items were available in the households, the younger infants (6-8 months) received much less varied diets compared to older children. Overall, the results show that 31 percent of all children 6-23 months were fed according to the three IYCF practices the day and night prior to the survey, i.e. they received breast milk or milk product, they were fed the minimum number of times according to age, and they received at least four different food groups. Brong Ahafo (41%), Ashanti (39%), Upper West and Volta (38% each) had the highest percentages of children 6-23 months who were fed according to the three IYCF practices, while Northern and Western region had the lowest percentages (21% and 15% respectively). 2 WHO, Indicators for assessing infant and young child feeding practices, Part 1, Definitions, Conclusions of a consensus meeting held 6-8 November 2007, and at- tended by: WHO, USAID, AED, FANTA, UCDAVIS, IFPRI and UNICEF Nutrition 50 51 Table NU.8: Infant and young child feeding (IYCF) practices (based on 4 food groups) Percentage of children aged 6-23 months who are fed according to the three IYCF feeding practices, by breastfeeding status, number of food groups consumed and number of times they were fed during the day and night preceding the survey, Ghana, 2011 Background Characteristics Currently breastfeeding All 4+ food groups Minimum times or more Both 4+ food groups and minimum times or more Number of children age 6-23 months Breast milk or milk product 4+ food groups Minimum times or more With all 3 IYCF practices Number of children age 6-23 months Sex Male 44.6 59.1 32.0 824 85.4 45.3 59.0 29.4 1077 Female 47.0 55.5 35.4 883 87.9 47.7 55.6 32.6 1100 Age (in months) 6-8 16.6 59.4 14.9 395 99.3 16.3 59.5 14.6 403 9-11 46.3 53.2 34.0 313 99.9 46.2 54.5 34.2 322 12-17 56.5 54.7 39.5 668 93.3 55.6 55.7 37.9 780 18-23 58.9 63.6 44.5 331 65.0 54.3 59.3 31.4 673 Region Western 31.6 46.6 16.5 204 86.6 33.4 45.6 15.3 243 Central 52.6 62.4 40.9 173 80.9 51.7 61.1 35.7 236 Greater Accra 48.8 59.2 36.6 244 86.2 50.7 59.2 34.7 367 Volta 66.2 50.5 37.5 134 92.4 66.2 52.4 37.9 157 Eastern 38.0 55.5 29.0 175 81.4 36.3 46.2 23.1 245 Ashanti 48.7 73.6 44.7 242 82.2 49.3 75.8 38.5 346 Brong Ahafo 52.9 61.1 46.8 148 85.2 53.9 65.8 40.7 177 Northern 33.3 49.1 21.4 245 96.8 33.3 48.4 21.3 256 Upper East 53.3 47.7 34.1 81 92.1 54.0 45.7 31.6 88 Upper West 52.8 61.0 39.6 60 95.4 51.9 60.2 38.3 64 Residence Urban 47.3 58.2 35.8 676 87.3 49.8 58.8 34.8 932 Rural 44.9 56.6 32.4 1030 86.1 44.1 56.3 28.2 1246 Mother's education None 42.6 55.0 29.6 563 89.4 41.8 54.4 27.0 643 Primary 45.0 52.8 31.2 401 86.0 43.8 51.1 26.9 488 Middle/JSS 51.6 59.2 38.5 525 82.5 50.8 60.6 34.5 743 Secondary + 42.1 66.4 37.9 218 91.7 50.5 65.5 37.8 303 Wealth index quintile Poorest 44.7 53.0 30.1 451 93.4 46.0 52.4 28.6 487 Second 48.1 55.5 34.0 390 83.3 46.4 53.6 28.9 486 Middle 45.4 59.8 34.7 321 83.2 43.0 61.0 30.0 406 Fourth 42.7 58.2 30.8 297 85.5 45.0 59.7 30.5 406 Richest 48.9 63.3 42.4 247 87.1 52.7 61.7 38.4 393 Total 45.9 57.2 33.8 1707 86.6 46.5 57.3 31.0 2177 Nutrition Children living in urban areas (35%) were also more likely than their rural counterparts (28%) to have been fed according to the three IYCF practices. Also, there is a direct relationship between the proportion of children who are fed according to the IYCF practices and mother’s level of education. For example, only 27 percent of children whose mothers have no education or primary education are fed according to the IYCF practices. This increases to 35 percent for children whose mothers have middle/JSS education, and to 38 percent for children whose mothers have secondary or higher education. Although there is little or no difference in the first 4 wealth quintiles (about 30%), the frequency and diet diversity rates for children in the richest wealth quintile were much higher than the rest (38%). Another notable finding in this survey is the sharp drop in consumption of breastmilk or milk product from above 90% in infants aged 6-17 months to 65% in those aged 18-23 months. Milk is essential for child nutrition during the first 23 months. WHO and UNICEF recommend continued breastfeeding for two years and beyond. This sudden drop may be influenced by heaping observed at ages 12-17 months and 18-23 months. The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in the preparation of the feed. Table NU.9 shows that 14 percent of children aged 0-23 months, and 20 percent of children aged 6-11 months are fed using a bottle with a nipple. The results also show that for children aged 0-23 months fed with a bottle with a nipple, the percentage is higher for female children (15%) than male children (12%). Bottle feeding is generally an affluent household phenomenon, and it is likely that mothers who resorted to bottle feeding are working women, who have to be away from their children for long hours. For example, children living in Greater Accra region (35%), those living in urban areas (21%), those children whose mothers have secondary education (34%) and children from the wealthiest households (33%) are more likely to be fed with a bottle with a nipple, than children from other backgrounds. The identification of reasons behind the current trends in bottle feeding would reinforce interventions to encourage breastfeeding and to reduce bottle feeding practices so that child morbidity and mortality can be reduced. Nutrition 52 53 Table NU.9: Bottle feeding Percentage of children aged 0-23 months who were fed with a bottle with a nipple during the previous day, Ghana, 2011 Background Characteristics Percentage of children age 0-23 months fed with a bottle with a nipple  Number of children age 0-23 months: Sex Male 12.1 1495 Female 15.2 1500 Age 0-5 months 18.6 818 6-11 months 20.4 725 12-23 months 7.5 1453 Region Western 5.8 315 Central 11.4 309 Greater Accra 35.4 477 Volta 8.2 220 Eastern 17.9 352 Ashanti 14.3 518 Brong Ahafo 4.1 259 Northern 3.5 334 Upper East 5.1 123 Upper West 3.1 87 Residence Urban 20.8 1276 Rural 8.4 1719 Mother's education None 4.6 877 Primary 10.8 665 Middle/JSS 15.1 1050 Secondary + 34.3 403 Wealth index quintiles Poorest 4.1 656 Second 7.1 649 Middle 11.2 592 Fourth 16.0 541 Richest 32.9 557 Total 13.7 2995  MICS indicator 2.11 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risk of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Nutrition The Universal Salt Iodisation (USI) regulations mandate salt for human and animal consumption to be iodized. In Ghana, non-iodized salt is banned from sale when it is intended for consumption and people found selling or using non-iodized salt are liable to arrest. Campaigns on iodized salt consumption have also been on-going for several years and iodized salt is readily accessible, at least, in all urban areas. In the Ghana MICS 2011 testing for iodine content in salt used for cooking was done in two ways: using Rapid Test Kits (RTKs), and through Titration in a lab. In the case of titration, a sample of salt was collected in 5 out of 15 households in each cluster, and a titration test was carried out by the Department of Nutrition and Food Science, University of Ghana. The results of the two tests are highlighted below. Additionally, the results from titration were compared to those obtained through the Rapid Test Kits. Rapid Test Kits results In 89 percent of households, salt used for cooking was tested for iodine content by using salt test kits to test for the presence of potassium iodate. Table NU.10 shows that in 10 percent of households there was no salt available. In 35 percent of households, salt was found to be adequately iodated (i.e. 15+ ppm). Use of adequately iodized salt was lowest in Northern (15%), followed by Volta (18%), and Upper East (18%) regions, and was highest in Greater Accra (56%), followed by Brong Ahafo (45%) and Western (44%). Also, households in urban areas are more likely to use adequately iodated salt (45%), compared to households in rural areas (23%). There is a marked variation by household wealth in terms of adequately iodized salt consumption. About 66 percent of the households in the richest wealth quintile use adequately iodated salt compared to 37 percent of households in the fourth wealth quintile, 24 percent for the households in middle wealth quintile, 19 percent households in the second wealth quintile, and 15 percent for households in the poorest wealth quintile. It is also interesting to note that more than one in five households (22%) use salt that was not iodized, and 34 percent used inadequately iodated salt (>0 and <15 ppm). Households in Volta (59%) and those in Northern (56%) are also more likely to use inadequately iodated salt, compared to households in the other regions. Nutrition 54 55 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Ghana, 2011 Background Characteristics Percent of households in which salt was tested Number of households Percent of households with salt test result Total Number of households in which salt was tested or with no salt Percent of households with no salt Not iodized 0 PPM >0 and <15 PPM 15+ PPM  Percent of households with no salt Not iodized 0 PPM >0 and <15 PPM 15+ PPM  Region Western 86.6 1116 12.8 14.5 28.6 44.0 100.0 1108 Central 88.4 1236 10.7 37.3 27.9 24.1 100.0 1225 Greater Accra 87.9 2321 11.5 12.5 19.9 56.1 100.0 2304 Volta 95.6 992 3.8 20.0 58.5 17.7 100.0 986 Eastern 89.4 1533 10.0 32.3 30.4 27.3 100.0 1523 Ashanti 88.8 2321 10.5 25.6 33.8 30.0 100.0 2304 Brong Ahafo 87.3 1011 12.3 10.2 32.2 45.3 100.0 1007 Northern 95.4 727 4.4 23.8 56.4 15.4 100.0 725 Upper East 88.2 414 5.3 29.2 47.3 18.2 100.0 386 Upper West 95.7 253 3.4 21.7 42.9 32.0 100.0 250 Residence Urban 87.7 6358 11.6 16.6 26.9 44.9 100.0 6303 Rural 91.4 5567 7.7 28.6 41.1 22.5 100.0 5516 Wealth index quintiles Poorest 94.8 1763 4.3 32.6 48.4 14.6 100.0 1746 Second 89.8 2244 9.4 29.5 42.2 18.9 100.0 2226 Middle 87.6 2450 11.6 28.0 36.9 23.5 100.0 2429 Fourth 86.3 2639 13.1 19.2 30.4 37.3 100.0 2620 Richest 90.3 2829 8.8 7.8 17.3 66.1 100.0 2799 Total 89.4 11925 9.8 22.2 33.5 34.5 100.0 11819  MICS indicator 2.16 Salt Titration Salt sample for analysis Among the 11,925 households interviewed in the MICS 2011, 10 percent had no salt at the time of survey (Table NU.10). About 90 percent of households provided salt samples for iodine testing using the Rapid Test Kits. As indicated above, one-third of households in each cluster were requested to provide an additional salt sample for further iodine testing using the titration method. A total of 3,439 of these salt samples were delivered to the Department of Nutrition and Food Science, University of Ghana, for titrimetric analysis, and this was equivalent to one in three of all salt samples, which had earlier been tested using the Rapid Test Kits. Some of these salt samples were insufficient in quantity (< 20 or <10gm) and could not be analysed, leaving 3,325 for the titrimetric analysis. After analysis, 62 of the results were identified as duplicates from some households where two different salt samples were collected at the time of survey. Since only one salt sample was to be analysed per household, these 62 extra results were dropped by random sampling, leaving a total of 3,263 samples for the titration analysis. This number is equivalent to 30 percent of the samples tested by Nutrition the Rapid Test Kits. The method of Sullivan et al3 was used for the titrimetry. The results of salt titration are not provided by any other background characteristics in this report (regional, area of residence, education of head of household and wealth index quintile). A stand-alone report will be prepared and this will provide more details of the results and comparisons between the two methods for iodine testing. Table NU.11 provides results of salt iodine content using Titrimetry for Ghana. In line with Pieter’s recommendation, non-iodised salt was that with 0-2 ppm4. Accordingly, results reveal that no salt was found to be totally devoid of iodine (i.e 0-2 ppm iodine). The results also reveal that 29 percent of households had adequately iodised salt (≥ 15 ppm), while the remaining 71 percent of households used inadequately iodated salt (<15 ppm). Considering that the recommended level of salt iodisation at the factory in Ghana is 50 ppm, and the recommended cut-off for human consumption is ≥ 15 ppm, the optimum or desirable range of iodised salt concentration in Ghana is 15 -50 ppm. Table NU.11 shows that 20 percent of the titrated salt is in this range. However, 5 percent of the salt used for cooking had very high levels of iodine concentration (≥ 60 ppm), which points to excessive iodisation. Table NU.11: Iodized salt consumption using Titration Method Percent distribution of households by consumption of iodized salt, Ghana, 2011 Percent of households in which salt was tested Number of households Percent of households with salt test result Percent of households with no salt Salt with no iodine (0 ppm) >0 and15 ppm Inadequately Iodized salt ≥15 ppm Adequately Iodized salt 15 and 50 ppm Optimum Iodized salt Concentration range for Ghana >60 ppm Excessive Iodine. Number of households in which salt was tested for iodine using Titration method Total 89.4 11,925 9.8 0.0 70.7 29.3 20.3 5.0 3,263 Results of the Rapid Test Kits with matching titration results were identified and extracted for comparison with the titration results (Table NU.12). The percent efficiency of the Rapid Test Kits in correctly identifying adequately iodised salts was examined by comparing its results with the titration results. The following results were compared between the two methods: • % salt without iodine (0 ppm) • % inadequately iodised salt (> 0 and < 15 ppm) • % adequately iodised salt (≥ 15 ppm) For salt without iodine, the Rapid Test Kits identified 25 percent of the salt samples as non-iodised, while the titration method found no salt samples as devoid of iodine. The Rapid Test Kits reported 62 percent of salt as inadequately iodised (< 15 ppm) – in this case, 25 percent of salt without iodine (0 ppm), and 37 percent of inadequately iodated salt ( >0 and <15 ppm) were combined to give 62 percent. The titration method, on the other hand, identified 71 percent of salt 3 UNICEF, PAMM, MI, ICCIDD, WHO. Sullivan KM et al., eds. Monitoring universal salt iodization programmes. Atlanta, PAMM, MI, ICCIDD, 1995. 4 Pieter L.J, Emmerentia S.( 2010): Methods for determining Iodine in Urine and Salt. Best Practice & Research Clinical Endocrinology & Metabolism 24 (2010), 77-88 Nutrition 56 57 samples as inadequately iodised (>0 and <15 ppm). For households with salt, the Rapid Test Kits reported 38 percent of salt samples as adequately iodised (≥ 15 ppm), while titration reported 29 percent as adequately iodised5. Thus, the Rapid Test Kits reported approximately 9 percent more salts as adequately iodised in comparison to titration. This represents inadequately iodised salt erroneously reported as adequately iodised, and could paint the erroneous picture that more households are consuming adequately iodised salt. Table NU.12: Iodized salt consumption Percent distribution of households by consumption of iodized salt, comparison between Rapid Test Kits and Titration Method, Ghana, 2011 Percent of households with salt for Analysis Number of households Percent of households with salt test result using Rapid Test Kit Percent of households with salt test result using Titration Method Number of households in which salt was tested for iodine using Titration method Salt with no iodine (0 ppm) 0 and15 ppm Inadequately Iodized salt 15+ PPM Adequately Iodized salt Salt with no iodine (0 ppm) 0 and15 ppm Inadequately Iodized salt 15+ PPM Adequately Iodized salt Total 90.2 10,752 24.6 37.2 38.2 0.0 70.7 29.3 3,263 Agreement between Rapid Test Kits and Titration in identifying adequately and Inadequately Iodized salts While results from a much larger Rapid Test Kits sample size (10,752) was compared to 3,263 titration results in Table NU.12, only 3,215 salt samples were compared in checking the percentage agreement between the two methods. The summary of results of this comparison is shown in Figure NU.3, while comprehensive results will be included in the stand-alone report. As shown above, titrimetry did not detect any of the salt samples as being completely devoid of iodine (0 ppm), and various studies have shown that this is more reliable than the 22 percent reported by the Rapid Test Kits. Natural salts, completely devoid of iodine may, in fact, be difficult to find in Ghana. The titration results of this survey confirmed the presence of traces of iodine in all salt samples tested. The rather high concentration (22%) of non-iodised salts (0 ppm) found through the Rapid Test Kits suggests that, at low iodine concentration levels, the Rapid Test Kits are unable to adequately distinguish between different levels of concentration of iodine in salts. As studies have shown, the Rapid Test Kits are less sensitive than titrimetry. Table NU.12 also shows that the Rapid Test Kits reported that 38 percent of sampled salts were adequately iodised, compared to 29 percent reported by titration. This suggests that the Rapid Test Kits are likely to report about 10 percent of households to be consuming adequately iodised salt while they are, in fact, consuming inadequately iodised salt. The Rapid Test Kit reported a higher percentage of adequately iodised salts by a margin of about 10 percent above titration. 5 Note should be taken of the fact that all RTK results in Table NU.12 are calculated in comparison with the total number of available household salts (n = 10,752), rather than in comparison with the total number of households in the study ( n = 11,925 ) as done in the Table NU.10. The percentages under RTK here are slightly higher in Table .NU.12 than in Table NU.10 Nutrition Figure NU.3: Agreement and disagreement between salt iodization results obtained using the Rapid Test Kit and the results obtained using salt titration, Ghana, 2011 Children’s Vitamin A Supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly’s Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under- five mortality rate by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high- dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 59 months living in affected areas. Providing young children with two high-dose vitamin A capsules Nutrition Agreement and disagreement between salt iodization results obtained using the Rapid Test Kit and the results obtained using salt titration, Ghana, 2011 7% 8% 85% Agree Disagree (Spot Kit<15ppm and Titration>15ppm) Disagree (Spot Kit>15ppm and Titration<15ppm) 7% 8% 85% 58 59 a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first few months of life and helps to replenish the mother’s stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programs, the definition of the indicator is the percent of children 6-59 months of age receiving at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Ghana Ministry of Health recommends that children aged 6-11 months be given one high dose of vitamin A capsules and children aged 12-59 months given a vitamin A capsule every 6 months. In Ghana, vitamin A capsules are linked to immunization services and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a vitamin A supplement within eight weeks of giving birth due to increased vitamin A requirements during pregnancy and lactation. Within the six months prior to the survey, 74 percent of children aged 6-59 months received a high dose of vitamin A supplement (Table NU.13). Overall, 10 percent were based on the Child health book/card/ vaccination card, while 72 percent were based on the mother’s report. At 58 percent, Ashanti region has the lowest vitamin A supplementation coverage, while all other regions have vitamin A supplementation of over 68 percent. For example, vitamin A supplementation coverage is highest in Upper East region and Brong Ahafo, both reporting 90 percent coverage, followed by Greater Accra with 84 percent. The vitamin A supplementation in the last six months shows a general decrease with age: about 78 percent among children aged 6-11 months, and aged 12-23 months, 72 percent among children aged 36-47 months, and 68 percent among children aged 48-59 months. Minimal differentials are noted by other background variables, including residence, mother’s education and household wealth. Nutrition Table NU.13: Children’s vitamin A supplementation Percent distribution of children aged 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Ghana, 2011 Background Characteristics Percentage who received vitamin A according to: Percentage of children who received vitamin A during the last 6 months  Number of children age 6-59 months Child health book/ card/vaccination card Mother's report Sex Male 9.3 70.7 72.4 3339 Female 10.1 73.7 75.0 3393 Region Western 11.6 69.4 73.1 685 Central 8.6 67.0 68.9 667 Greater Accra 9.5 83.6 84.3 1032 Volta 14.6 73.1 75.4 538 Eastern 15.2 67.5 69.4 721 Ashanti 5.0 57.0 58.3 1238 Brong Ahafo 10.9 89.6 89.9 589 Northern 7.9 72.2 73.3 773 Upper East 9.1 90.0 90.4 289 Upper West 8.9 72.0 72.8 200 Residence Urban 8.9 71.8 73.2 2938 Rural 10.3 72.5 74.1 3794 Age 6-11 44.9 67.6 77.8 725 12-23 14.3 77.3 78.7 1453 24-35 4.7 74.1 74.1 1553 36-47 2.1 71.7 72.1 1576 48-59 1.1 67.8 67.8 1426 Mother's education None 8.5 72.2 73.8 2221 Primary 9.5 73.0 74.1 1451 Middle/JSS 9.3 70.5 72.1 2271 Secondary + 14.9 75.7 77.0 789 Wealth index quintiles Poorest 9.2 73.8 74.9 1561 Second 10.7 72.2 74.1 1387 Middle 9.9 69.1 71.4 1372 Fourth 7.8 70.0 71.4 1262 Richest 11.0 75.6 76.9 1151 Total 9.7 72.2 73.7 6732  MICS indicator 2.17 Nutrition 60 61 Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the new- born’s chances of survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of new-borns are not delivered in health facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth6. Overall, 54 percent of births were weighed at birth and approximately 11 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.14). Children from Greater Accra region are most likely to be weighed at birth (82%), and those from Northern region the least likely to be weighed at birth (25%). Children from rural households, those from the poorest households and those whose mothers have no education are also less likely than more advantaged children to be weighed at birth. For example, 73 percent of children in urban households were weighed at birth, compared to 40 percent of children in rural households. Also, children from the wealthiest 6 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16. Nutrition households are more likely to be weighed at birth (91%), compared to children from poorest households (25%). Additionally, the possibility that children are weighed at birth increases with mother’s education – 28 percent for children whose mothers have no education, to 51 percent for children whose mothers have primary education, to 64 percent for children whose mothers have middle/JSS education, and to 90 percent for children whose mothers have secondary or higher education. Brong Ahafo region has the lowest proportion (8%) of children weighing below 2,500 grams. All other regions have low birth weight ranging from 10 – 15 percent. Minimal differentials on low birth weight are recorded for other background variables, including residence, mother’s education and household wealth. Table NU.14: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Ghana, 2011 Background Characteristics Percent of live births: Number of last-born children in the two years preceding the survey Below 2500 grams  Weighed at birth  Region Western 10.7 50.4 270 Central 10.5 46.1 246 Greater Accra 9.9 82.4 397 Volta 10.5 49.7 189 Eastern 10.6 62.6 288 Ashanti 11.4 53.9 449 Brong Ahafo 8.2 51.8 227 Northern 11.9 25.0 283 Upper East 14.5 49.5 105 Upper West 9.5 44.5 75 Residence Urban 10.9 72.7 1068 Rural 10.5 40.4 1460 Mother's education None 11.2 28.2 733 Primary 10.5 50.6 565 Middle/JSS 10.1 63.8 886 Secondary + 11.4 89.6 344 Wealth index quintiles Poorest 11.6 25.1 560 Second 10.3 42.7 546 Middle 11.2 50.6 500 Fourth 10.4 69.0 455 Richest 9.7 91.2 467 Total 10.7 54.0 2528  MICS indicator 2.18  MICS indicator 2.19 Nutrition 62 63 Anaemia and Diet Diversity in Children aged 6-59 months Table NU.15 shows prevalence of anemia in children 6-59 months old by age group, sex, residence, region, ecological zone, mother’s education and wealth quintile. Overall, the prevalence of any anaemia was 57 percent, a significant decline compared to 78 percent in DHS 2008. Children aged 12-23 months had much higher levels at 71 percent, compared to the rest in this age group, while the prevalence in the 48-59 months old group was 48 percent. Male children had a slightly higher level of anemia (60%) than female children (53%). Children living in urban areas had a lower rate of anemia (48%) compared to children living in rural areas (64%). Although there is a notable improvement since 2008, these rates are still above 40 percent, the WHO cut- off point for a severe public health problem. The rates in the three Northern regions are above 75 percent, while in the remaining regions the rates are below 65 percent. The three Northern regions have one rainy season and this negatively affects food security. Besides the strong influence of region, educational level of the mother and wealth quintile, are two other major determinants. Th
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