Kenya - Multiple Indicator Cluster Survey - 2009

Publication date: 2009

Kenya Coast Province Mombasa - Informal Settlements Monitoring the situation of children and women Multiple Indicator Cluster Survey 2009 Kenya National Bureau of Statistics United Nations Children’s Fund UNICEF-MICS Sticky Note Please note that a problem has been noticed with the calculation of the Early Childhood Development Index (ECDI). The value of the ECDI or MICS4 Indicator 6.6 has changed from 40.2 percent to 37.2 percent. This affects the following references to the ECDI values throughout the report: 1) Reference to the "child development index score," on page xii of the Executive Summary. 2) MICS4 Indicator 6.6 in the Summary Table of Findings, page XV. 3) References to the ECDI on page 59 of Section 9.4 (Child Development Index). 4) Table 9.4 (Child Development Outcomes) on page 60 of Chapter 9. An updated Table 9.4 with the corrected ECDI values has been appended at the end of the report. MICS Team - 17 March 2016 Administrator Sticky Note Accepted set by Administrator Kenya Coast Province Mombasa - Informal Settlements Monitoring the situation of children and women Multiple Indicator Cluster Survey 2009 The MICS4 in Mombasa Informal Settlements in Kenya was carried out by Kenya National Bureau of Statistics (KNBS). Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). The survey has been conducted as part of the fourth round of MICS Surveys (MICS4). Survey tools are based on the MICS4 Pilot version, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project and the newer versions of the MICS4 tool may be obtained from www.childinfo.org. Recommended citation: Kenya National Bureau of Statistics, 2010. Mombasa Informal Settlement Survey, Kenya, 2009. Nairobi: Kenya National Bureau of Statistics. Contents iii LIST OF TABLES . V LIST OF FIGURES . VII LIST OF ABBREVIATIONS .VIII FOREWORD .IX EXECUTIVE SUMMARY . X SUMMARY TABLE OF FINDINGS .XIV INTRODUCTION . 1 1.1 BACKGROUND .1 1.2 SURVEY OBJECTIVES .2 SAMPLE AND SURVEY METHODOLOGY . 3 2.1 SAMPLE DESIGN .3 2.2 QUESTIONNAIRES .3 2.3 TRAINING AND FIELDWORK .4 2.4 DATA PROCESSING .4 SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . 5 3.1 SAMPLE COVERAGE .5 3.2 CHARACTERISTICS OF HOUSEHOLDS .5 3.3 CHARACTERISTICS OF FEMALE RESPONDENTS .8 3.4 CHARACTERISTICS OF CHILDREN UNDER-FIVE .9 CHILD MORTALITY . 11 4.1 LEVELS OF CHILDHOOD MORTALITY . 11 NUTRITION . 12 5.1 NUTRITIONAL STATUS .12 5.2 BREASTFEEDING .14 5.3 MEAL FREQUENCY .16 5.4 SALT IODIZATION .18 5.5 VITAMIN A SUPPLEMENTS .18 5.6 LOW BIRTH WEIGHT .21 CHILD HEALTH . 23 6.1 IMMUNIZATION .23 6.2 TETANUS TOXOID .25 6.3 ORAL REHYDRATION TREATMENT .26 6.4 CARE SEEKING AND ANTIBIOTIC TREATMENT OF PNEUMONIA .28 6.5 SOLID FUEL USE .30 6.6 MALARIA .31 ENVIRONMENT . 37 7.1 WATER.37 7.2 SANITATION .42 7.3 HAND WASHING PRACTICES.45 Table of Contents iv Contents REPRODUCTIVE HEALTH . 47 8.1 FERTILITY .47 8.2 TEENAGE PREGNANCY AND MOTHERHOOD .48 8.3 CONTRACEPTION .49 8.4 UNMET NEED .49 8.5 ANTENATAL CARE .51 8.6 ASSISTANCE AT DELIVERY .53 CHILD DEVELOPMENT . 56 9.1 ADULT PARTICIPATION IN CHILDHOOD DEVELOPMENT .56 9.2 AVAILABILITY OF LEARNING MATERIALS .56 9.3 CHILD CARE .57 9.4 CHILD DEVELOPMENT INDEX .59 EDUCATION . 61 10.1 PRE-SCHOOL ATTENDANCE AND SCHOOL READINESS .61 10.2 PRIMARY AND SECONDARY SCHOOL PARTICIPATION .62 10.3 ADULT LITERACY .65 CHILD PROTECTION . 66 11.1 BIRTH REGISTRATION .66 11.2 CHILD LABOUR .67 11.3 CHILD DISCIPLINE .69 11.4 EARLY MARRIAGE AND POLYGYNY .70 11.5 SPOUSAL AGE DIFFERENCE .73 11.6 FEMALE GENITAL MUTILATION/CUTTING .73 11.7 DOMESTIC VIOLENCE .76 11.8 CHILD DISABILITY .78 HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN . 80 12.1 KNOWLEDGE OF HIV TRANSMISSION AND CONDOM USE .80 12.2 SEXUAL BEHAVIOUR RELATED TO HIV TRANSMISSION .86 12.3 ORPHANS AND VULNERABLE CHILDREN .88 LIST OF REFERENCES . 94 APPENDIX A: SAMPLE DESIGN . 95 APPENDIX B: LIST OF PERSONNEL INVOLVED IN THE SURVEY . 97 APPENDIX C: ESTIMATES OF SAMPLING ERRORS . 99 APPENDIX D: DATA QUALITY TABLES .102 APPENDIX E: ADDITIONAL TABLES .110 APPENDIX F: MICS4 INDICATORS - NUMERATORS AND DENOMINATORS .112 APPENDIX G: QUESTIONNAIRES .124 Tables v Table 3.1: Results of household and individual interviews (HH.1) . 5 Table 3.2: Household age distribution by sex (HH.2) . 6 Table 3.3: Household composition (HH.3) . 7 Table 3.4: Women’s background characteristics (HH.4) .8 Table 3.5: Children’s background characteristics (HH.5) . 10 Table 4.1: Child mortality . 11 Table 5.1: Child malnourishment (WHO Standard) . 13 Table 5.2: Initial breastfeeding (NU.2) . 15 Table 5.3: Breastfeeding and supplementary feeding . 16 Table 5.4: Minimum meal frequency (NU.7) . 17 Table 5.5: Iodized salt consumption (NU.5) . 18 Table 5.6: Children’s vitamin A supplementation (NU.6) . 19 Table 5.7: Post-partum mothers’ vitamin A supplementation (NU.7) . 20 Table 5.8: Low birth weight infants (NU.8) . 22 Table 6.1: Vaccinations among children (CH.1) . 25 Table 6.2: Vaccinations by sex of the child (CH.2) . 26 Table 6.3: Neonatal tetanus protection (CH.3) . 27 Table 6.4: Oral rehydration treatment (CH.4) . 28 Table 6.5: Home management of diarrhoea (CH.5) . 29 Table 6.6: Suspected pneumonia (CH.6) . 30 Table 6.7: Care seeking for pneumonia . 31 Table 6.8: Solid fuel use (CH.8) . 32 Table 6.9: Household possession of mosquito nets (TN01) . 33 Table 6.10: Children sleeping under bednets (TN02) . 34 Table 6.11: Women sleeping under bednets (TN03) . 35 Table 6.12: Treatment of children with anti-malarial drugs (CH.12) . 36 Table 6.13: Intermittent preventive treatment for malaria (CH.13) . 37 Table 7.1: Use of improved water sources (EN.1) . 38 Table 7.2: Household water treatment (EN.2) . 39 Table 7.3: Time to source of water (EN.3) . 41 Table 7.4: Person collecting water (EN.4) . 42 Table 7.5: Use of sanitary means of excreta disposal (EN.5) . 43 Table 7.6: Disposal of child’s faeces (EN.6) . 44 Table 7.7: Use of improved water sources and improved sanitation (EN.7) . 45 Table 7.8: Water and soap at place for handwashing (CH.17) . 46 Table 7.9: Availability of soap (CH.18) . 46 Table 8.1: Current fertility . 47 Table 8.2: Children ever born and living (RH.11) . 48 Table 8.3: Teenage pregnancy and motherhood (RH.12) . 48 Table 8.4: Use of contraception (RH.1) . 50 Table 8.5: Unmet need for contraception (RH.2) . 51 Table 8.6: Antenatal care provider (RH.3) . 52 Table 8.7: Antenatal care (RH.4) . 53 Table 8.8: Number of antenatal care visits (RH.7) . 54 Table 8.9: Assistance during delivery (RH.5) . 55 Table 9.1: Family support for learning (CD.1) . 57 Table 9.2: Learning materials for children (CD.2) . 58 Table 9.3: Children left alone or with other children (CD.3) . 59 Table 9.4: Child development outcomes (CD5 – MICS4) . 60 List of Tables vi Tables Table 10.1: Early childhood education (ED.1). 61 Table 10.2: Primary school entry (ED.2) . 62 Table 10.3: Primary school net attendance ratio (ED.3) . 63 Table 10.4: Secondary school net attendance ratio (ED.4) . 64 Table 10.5: Secondary school age children attending primary school (ED.4w) . 64 Table 10.6: Adult literacy (ED.8) . 65 Table 11.1: Birth registration (CP.1) . 67 Table 11.2: Child labour (CP.2) . 68 Table 11.3: Labourer students and student labourers (CP.3) . 69 Table 11.4: Child discipline (CP.4) . 70 Table 11.5: Early marriage (CP.5) . 72 Table 11.6: Spousal age difference (CP.6). 73 Table 11.7: Female genital mutilation/cutting (FGM/C) (CP.7). 74 Table 11.8: Attitude towards female genital mutilation/cutting (FGM/C) (CP.7) . 75 Table 11.9: Female genital mutilation/cutting (FGM/C) among daughters (CP.8) . 76 Table 11.10: Attitudes toward domestic violence (CP.9) . 77 Table 11.11: Reported child disability (CP.10) . 79 Table 12.1: Knowledge of preventing HIV transmission (HA.1) . 81 Table 12.2: Identifying misconceptions about HIV/AIDS (HA.2) . 81 Table 12.3: Comprehensive knowledge of HIV/AIDS transmission (HA.3) . 82 Table 12.4: Knowledge of mother-to-child HIV transmission (HA.4) . 83 Table 12.5: Attitudes toward people living with HIV/AIDS (HA.5) . 84 Table 12.6: Knowledge of a facility for HIV testing (HA.6) . 85 Table 12.7: HIV testing and counseling coverage during antenatal care (HA.7) . 86 Table 12.8: Sexual behaviour that increases risk of HIV infection (HA.8) . 87 Table 12.9: Condom use at last high-risk sex (HA.9) . 88 Table 12.10: Children’s living arrangements and orphanhood (HA.10) . 90 Table 12.11: Prevalence of orphanhood and vulnerability among children (HA.11) . 91 Table 12.12: School attendance of orphaned and vulnerable children (HA.12) . 92 Table 12.13: Support for children orphaned and vulnerable due to AIDS (HA.13) . 93 Table SE.1: Indicators selected for sampling error calculations . 100 Table SE.2: Sampling errors . 101 Table DQ.1: Age distribution of household population . 102 Table DQ.2: Age distribution of eligible and interviewed women . 103 Table DQ.3: Age distribution of eligible and interviewed under-5s . 103 Table DQ.4: Age distribution of under-5 children . 104 Table DQ.5: Heaping on ages and periods . 105 Table DQ.6: Completeness of reporting . 106 Table DQ.7: Presence of mother in the household and the person interviewed for the under-5 questionnaire . 107 Table DQ.8: School attendance by single age . 108 Table DQ.9: Sex ratio at birth among children ever born and living . 109 Table DQ.10: Distribution of women by time since last birth . 109 Table E.1: Child malnourishment (NU.1) – NCHS Standard . 110 Table E.2: Primary school completion and transition to secondary education (ED.6) . 111 Table E.3: Education gender parity (ED.7) . 111 Figures vii Figure 3.1: Age and sex distribution of household population . 6 Figure 5.1: Percentage of children under-5 who are undernourished . 14 Figure 6.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months . 24 Figure 6.2: Percentage of households having an insecticide treated net (ITN) . 32 Figure 7.1: Percentage distribution of household members by source of drinking water . 38 Figure 7.2: Percentage of household members using appropriate water treatment method . 41 Figure 12.1: Percent of women who have comprehensive knowledge of HIV/AIDS transmission by level of education . 83 Figure 12.2: Sexual behaviour that increases risk of HIV infection by wealth index, Mombasa Informal Settlemnet Survey, Kenya, 2009 . 87 List of Figures viii Abbreviations AIDS Acquired Immune Defi ciency Syndrome ASFRs Age Specifi c Fertility Rates BCG Bacillus Calmette Guerin (Tuberculosis) CSPro Census and Survey Processing System CDC Center for Disease Control NCHS National Centre for Health Statistics DHS Demographic Health Survey DPT Diphtheria Pertussis Tetanus DSO District Statistical Offi cer EA Enumeration Areas EPI Expanded Programme on Immunization ERS Economic Recovery Strategy FGM/C Female Genital Mutilation/Cutting GoK Government of Kenya GPI Gender Parity Index HIV Human Immunodefi ciency Virus IDD Iodine Defi ciency Disorders IPT Intermittent Preventive Treatment ITN Insecticide Treated Net IUD Intrauterine Device KDHS Kenya Demographic Health Survey KEPI Kenya Expanded Programme on Immunizations KESSP Kenya Education Sector Support Programme KNBS Kenya National Bureau of Statistics LAM Lactational Amenorrhea Method LPG Liquefi ed Petroleum Gas MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH Ministry of Health NAR Net Attendance Rate NPA National Programme of Action ORS Oral Re-hydration Therapy ORT Oral Rehydration Treatment PPM Parts Per Million PRS Poverty Reduction Strategy RHF Recommended Home Fluid SPSS Statistical Package for Social Sciences STIs Sexually Transmitted Infections TFR Total Fertility Rates TT Tetanus Toxoid U5MR Under-5 Mortality 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 WASH Water, Sanitation and Hygiene WFFC World Fit For Children WHO World Health Organization WSC World Summit for Children Abbreviations Foreword ix Following the Multiple Indicator Cluster Survey 4 (MICS4) Global Pilot exercise in Mombasa and Kwale districts in the Cost Province of Kenya during January-February 2009, the Mombasa Informal Settlement Survey 2009 was conducted in sampled clusters of informal settlements in the district using the same set of trained investigators and tools. The Informal Settlement Survey covered 1,080 households selected using appropriate statistical procedures. The objective of the Mombasa Informal Settlement Survey 2009 is to provide estimates relating to the well being of children and women living in the informal settlements of Mombasa, to create baseline information and to enable policymakers, planners, researchers, and program managers to take actions based on credible evidence. In Mombasa Informal Settlement Survey 2009, information on specifi c areas such as, reproductive health, child mortality, child health, nutrition, child protection, childhood development, water and sanitation, hand washing practices, education, and HIV/AIDS and orphans were collected. The results indicate that the conditions of people living in the informal settlements are very poor and need immediate attention. For example, the infant and under fi ve mortality rates in Mombasa informal settlements (IMR - 70 and Under-fi ve mortality rate- 91 per 1,000 live births) are much higher than the national total fi gures observed in the recently published Kenya Demographic Health Survey (KDHS) 2008-09 estimates (IMR - 52 and Under-fi ve mortality rate – 74). The proportion of children fully immunised is also much below the national average of 77 per cent (KDHS, 2008-09) vis-a-vis 56 per cent in Mombasa informal settlements. I wish to acknowledge the efforts of various organisations and individuals who contributed immensely towards the success of the Mombasa Informal Settlement Survey 2009. First, I would like to acknowledge the technical and fi nancial assistance from the United Nations Children’s Fund (UNICEF) to this survey and also for choosing Mombasa for its MICS4 Global Pilot exercise. I also commend the hard work and dedication of Kenya National Bureau of Statistics (KNBS) and UNICEF Kenya Country Offi ce staff in successfully completing the survey and making results available. Finally, I am grateful to the respondents who generously gave their time to provide the information and allowing the survey teams to measure the weights and heights of children below 5 years of age. Anthony K.M. Kilele, MBS Director General Kenya National Bureau of Statistics Foreword x Executive Summary The Mombasa Informal Settlement Survey 2009 is a representative sample survey drawn using the informal settlement classifi cation of 1999 Census Enumeration Areas (EAs) as the sample frame. The classifi cation of 1999 Census EAs was carried out in major cities of Kenya by the Kenya National Bureau of Statistics (KNBS) under a project funded by United Nations Environment Program (UNEP) in 2003. The 45 EAs were sampled using the probability proportional to size (PPS) sampling methodology, and information from a total of 1,080 households were collected using structured questionnaires. The Mombasa informal settlement survey is one of the largest household sample surveys ever conducted exclusively for the informal settlements in Mombasa district. The survey used a two stage design. In the fi rst stage, EAs were selected and in the second stage households were selected circular systematically using a random start from the list of households1. The data was collected by three teams comprising of six members each (one supervisor, one editor, one measurer and three investigators). The survey was implemented by the Kenya National Bureau of Statistics (KNBS) with support from UNICEF. The summary of fi ndings from the survey is presented below. Child Mortality The mortality rates for children under-fi ve were calculated using the birth history data for the 10 year period preceding the survey. The under-fi ve mortality rate is 91 per 1,000 live births and infant mortality rate is 70 per 1,000 live births. This shows a much higher mortality rate among children born to mothers living in these informal settlements compared with national estimates (IMR - 52 and under-5 mortality rate - 74 per 1,000 live births). Nutritional Status and Breastfeeding Based on the new WHO standards, 14 per cent of children under-fi ve years old in Mombasa informal settlements are severely or moderately under- weight and a much higher proportion were stunted (24 per cent). The proportion of wasted children stands at fi ve per cent. Only 37 per cent of the children are timely breastfed (given breast milk within an hour of birth), and a meagre seven per cent of children age 0-5 months are exclusively breastfed. Overall, one in four (25 per cent) infants in Mombasa informal settlements are appropriately fed for their age. Little more than four out of fi ve (81 per cent) children under 5 years who live in Mombasa informal settlements were reportedly weighed at the time of birth and the low birth weight prevalence was at 12 per cent. In 87 per cent of the sampled households the cooking salt was tested for iodine content and of those, 90 per cent were found to have adequate iodine content (15ppm or more). Immunisation Only 49 per cent of children age 12-23 months received full vaccination (BCG, 3 doses of Polio, 3 doses of DPT and measles) before reaching age 12 months. BCG is given to 94 per cent of children age 12-23 months and the measles vaccine is received by 85 per cent. The dropout rate of DPT and polio vaccines from fi rst dose to third dose was substantial, 19 and 31 per cent respectively. 1 The household listing was carried out by three teams, each team comprised of a lister and mapper. Executive Summary Executive Summary xi The yellow fever vaccination coverage among children age 12-23 months in the informal settlements was low at 31 per cent. Seventy nine per cent of the mothers who gave birth during the year preceding the survey reportedly received adequate protection against tetanus (i.e., received two or more doses of TT injection during the two year period prior to delivery). Care of illness Reported prevalence of diarrhoea during the last two weeks preceding the survey among children aged 0-59 months stood at 19 per cent. Among the reported diarrhoea cases, 43 per cent received oral re-hydration therapy and 10 per cent reported home management of diarrhoea. One in ten children under-fi ve years reportedly had acute respiratory infection (ARI) during the two weeks prior to the survey. Little more than three out of four (76 per cent) children who had suspected pneumonia reportedly sought treatment, however only 29 per cent reported that the child was given antibiotic treatment. Malaria prevention In Mombasa Informal Settlements, 73 per cent of the households have at least one mosquito net, but only 64 per cent have at least one treated net. The mean number of mosquito nets per household is 1.2 and that of treated net is 1.1. Sixty three per cent of children below 5 years slept under any type of mosquito net and 57 per cent slept under a treated net the previous night. The proportion of pregnant women who reported sleeping under a treated net the previous night of the survey was 48 per cent. More than one in four (27 per cent) children under fi ve had fever during the two weeks preceding the survey. Of those who had fever, 30 per cent were given appropriate anti-malarial treatment. Seventy two per cent of mothers who gave birth during two years preceding the survey reported intermittent preventive treatment for malaria during pregnancy. Water and sanitation Eighty seven per cent of the population living in Mombasa informal settlements use drinking water from an improved source and 49 per cent are reportedly treating the drinking water. More than 80 per cent of the households take less than 15 minutes to fetch drinking water. Among those households who fetch water, in 54 per cent cases an adult man, in 44 per cent cases an adult woman and in less than two per cent cases, a child below 15 years is usually engaged. Sixty seven per cent of the population is using improved sanitation facilities, 38 per cent using a pit latrine with slab, 12 per cent use pit latrine with fl ush, 10 per cent use fl ush to piped sewer system and eight per cent use fl ush to septic tank. The pit latrine without a slab is used by 24 per cent of the population who live in the informal settlements. In 89 per cent of cases, stool of children below 3 years of age are disposed off safely. Only six per cent of the households in Mombasa informal settlements have a designated place for hand washing. However, 76 per cent of the households reportedly use soap for washing hands. Reproductive health The total fertility rate (TFR) in Mombasa informal settlements for the three year preceding the survey is 3.4 children per woman, which is higher than the national urban TFR of 2.9 reported by the latest KDHS 2008-09. Teenage pregnancy is 20 per cent, i.e., proportion of women age 15-19 years who began child bearing, of these 16 per cent are pregnant with their fi rst child. Little more than one in three (35 per cent) married women aged 15-49 years who live in Mombasa informal settlements use any modern contraceptive method and another fi ve per cent use a traditional method of contraception. The unmet need for contraception is very high at 24 per cent (14 per cent for spacing and 10 per cent for limiting). This implies that less than two in three women have their contraceptive demand met/satisfi ed (62 per cent). xii Executive Summary The antenatal care is near universal in Mombasa informal settlements, 94 per cent of mothers who gave birth in the past 2 years had an antenatal check-up and 57 per cent had four or more antenatal care visits. Sixty seven per cent of the deliveries during the 2 year period preceding the survey were assisted by a skilled personnel. Childhood development Twenty six per cent of children below fi ve years of age received support from any household member by engaging in four or more activities with the child during the three days preceding the survey that promote learning and school readiness. In 33 per cent of cases children have three or more types of playing things. About one in fi ve children (19 per cent) below fi ve years of age who live in Mombasa informal settlements were left with inadequate care some time during the week preceding the survey. Sixty two per cent of children aged 36-59 months currently attend any early childhood education and the child development index score is 40. Child development index is calculated as the per centage of children who are developmentally on target in at least three of the four component domains such as language-cognitive, physical, social-emotional, and approaches to learning. Education More than 90 per cent of the primary school entry age children in Mombasa informal settlement are attending primary school. However, the secondary school net attendance rate is only 27 per cent. Female adult literacy rate in Mombasa informal settlements is 84 per cent. Child protection Seven out of ten children (69 per cent) under fi ve years who live in Mombasa informal settlements have their births registered. Of those not registered, the major reasons for not registering births were, 39 per cent reported that they ‘don’t know the place to register’ the child birth followed by 27 per cent who ‘don’t know that child birth is to be registered’. Six per cent of children aged 5-14 years in Mombasa informal settlements are engaged in child labour. Little more than three out of four children (78 per cent) aged 2-14 years received some form of psychological or physical punishment during one month prior to the survey. Sixty eight per cent received minor physical punishment while 19 per cent received severe physical punishment. In Mombasa informal settlements 20 per cent of the women in the adolescent age group 15-19 years are married or in union. Among married women aged 15-24 years, one in fi ve (20 per cent) have partners who are 10 or more years older than their age. Disability among children Twenty nine per cent of children aged 2-9 years in Mombasa informal settlements reported to have at least one disability. Delay in sitting/standing/ walking is reported by 13 per cent and seven per cent can’t speak or understand in words. Female genital mutilation/cut- ting (FGM/C) and domestic vio- lence Eighty eight per cent of women aged 15-49 years in Mombasa informal settlements had heard about FGM/C and 12 per cent had some form of FGM/C. Of those who had FGM/C, 13 per cent reportedly had an extreme form of FGM/C. Among those women age 15-49 years with at least one living daughter, only two per cent reported that their daughter had some form of FGM/C. Of those women aged 15-49 years who have heard about FGM/C, only 4 per cent believe that the practice should be continued. Forty seven per cent of women in Mombasa informal settlements agree to wife beating under various circumstances. For example, 34 per cent of women believe that a husband can beat his wife if she neglects children and 24 per cent support beating if she argues with her husband. Executive Summary xiii HIV and AIDS Almost all women aged 15-49 years (99 per cent) in Mombasa informal settlement have heard about HIV. However, only 43 per cent have comprehensive knowledge about HIV prevention. Knowledge about mother-to-child transmission of HIV is near universal in Mombasa informal settlements, with 97 per cent reporting that ‘HIV can be transmitted from mother-to-child’. Sixty nine per cent of women age 15-49 years reported that they had been tested for HIV. Of those reportedly tested for HIV in Mombasa informal settlements, 98 per cent were informed about the result. In Mombasa informal settlements, 79 per cent of women who delivered a child in the last 2 years received counselling on prevention of mother-to-child transmission of HIV and 85 per cent had the HIV test done during antenatal care visits. Close to two out of three (64 per cent) women age 15-24 years in Mombasa informal settlements reported to have sex during the year preceding the survey. Of those who had sex, 33 per cent had sex with non-marital/non-cohabitating partner. Among those who had sex with non-marital/non- cohabitating partner, only 54 per cent reported condom use at last sex. Orphans and vulnerable children Eleven per cent of the children under 18 years are not living with any biological parent and 12 per cent have one or both parents dead. xiv Summary Table of Findings Topic MICS4 Indicator Number2 MDG Indicator Number Indicator Value & Unit SAMPLE Households Households interviewed 1,016 Number Women Number of women interviewed 821 Number Children Number of children under-5 years with completed information 454 Number CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 91 Per thousand 1.2 4.2 Infant mortality rate 70 Per thousand NUTRITION Underweight (Weight-for-age) 2.1a 1.8 Underweight prevalence (below -2 SD) 14.4 Percent 2.1b 1.8 Underweight prevalence (below -3 SD) 3.2 Percent Stunting (Height-for-age) 2.2a Stunting prevalence (below -2 SD) 23.5 Percent 2.2b Stunting prevalence (below -3 SD) 7.2 Percent Wasting (Weight-for-height) 2.3a Wasting prevalence (below -2 SD) 6.1 Percent 2.3b Wasting prevalence (below -3 SD) 1.3 Percent Breastfeeding 2.5 Early initiation of breastfeeding 37.3 Percent 2.6 Exclusive breastfeeding rate 7.2 Percent 2.7 Continued breastfeeding rate at 12-15 months 80.6 Percent 2.8 Continued breastfeeding rate at 20-23 months 39.4 Percent Timely complementary feeding rate 94.0 Percent Frequency of complementary feeding 38.0 Percent Adequately fed infants 24.8 Percent Salt iodization 2.16 Iodized salt consumption 89.8 Percent Vitamin A 2.17 Vitamin A supplementation (under-fives) 32.8 Percent Vitamin A supplementation (post-partum mothers) 44.7 Percent Low birth weight 2.18 Low birth weight infants 11.6 Percent 2.19 Infants weighed at birth 80.9 Percent CHILD HEALTH Immunization by 12 months 3.1 Tuberculosis immunization coverage 93.8 Percent 3.2 Polio immunization coverage 65.9 Percent 3.3 DPT immunization coverage 78.1 Percent 3.4 4.3 Measles immunization coverage 84.8 Percent Fully immunized children 48.7 Percent 3.6 Yellow fever vaccination 31.2 Percent Tetanus toxoid 3.7 Neonatal tetanus protection 78.1 Percent Care of illness Use of oral rehydration therapy (ORT) 42.9 Percent Home management of diarrhoea 10.0 Percent 3.8 Received ORT or increased fluids, and continued feeding 20.8 Percent 3.9 Care seeking for suspected pneumonia 75.8 Percent 3.10 Antibiotic treatment of suspected pneumonia 28.5 Percent Solid fuel use 3.11 Solid fuels 44.0 Percent Malaria 3.12 Households having insecticide-treated nets (ITNs) 64.4 Percent 3.14 Under-fives sleeping under mosquito nets 63.6 Percent 3.15 6.7 Under-fives sleeping under insecticide-treated nets 57.5 Percent 3.18 6.8 Anti-malarial treatment (under-fives) 20.2 Percent 3.20 Intermittent preventive malaria treatment (pregnant women) 23.2 Percent Women aged 15-49 years sleeping under insecticide-treated nets 47.2 Percent 3.19 Pregnant women aged 15-49 years sleeping under insecticide-treated nets 48.2 Percent 2 The MICS4 indicator list version 2.1 dated 7 April 2010. See Appendix E for more information about these indicators. Summary Table of Findings Summary Table of Findings xv Topic MICS4 Indicator Number2 MDG Indicator Number Indicator Value & Unit ENVIRONMENT Water and sanitation 4.1 7.8 Use of improved drinking water sources 86.8 Percent 4.2 Water treatment 48.8 Percent 4.3 7.9 Use of improved sanitation facilities 67.4 Percent 4.4 Safe disposal of child's faeces 89.0 Percent 3.21 Place for handwashing 63.1 Percent 3.22 Availability of soap for handwashing 75.8 Percent REPRODUCTIVE HEALTH Contraception and unmet need 5.3 5.3 Contraceptive prevalence 39.5 Percent 5.4 5.6 Unmet need for family planning 23.8 Percent Demand satisfied for family planning 62.3 Percent Maternal and newborn health 5.5a 5.5 Antenatal care by a skilled personnel 93.8 Percent 5.5b 5.5 Four or more antenatal care visits 56.5 Percent Content of antenatal care Blood test taken 89.0 Percent Blood pressure measured 89.5 Percent Urine specimen taken 86.8 Percent Weight measured 91.9 Percent 5.7 5.2 Skilled attendant at delivery 66.9 Percent 5.8 Institutional deliveries 65.4 Percent Total fertility rate 3.4 Rate Adolescent pregnancy (15-19 began child bearing) 20.0 Percent 5.1 5.4 Adolescent birth rate (ASFR 15-19 years) 82 Rate CHILD DEVELOPMENT Child development 6.1 Support for learning 25.6 Percent 6.2 Father's support for learning 38.7 Percent 6.3 Learning materials: children’s books 6.7 Percent 6.4 Learning materials: materials for play 33.1 Percent 6.5 Inadquate care 19.2 Percent 6.6 Early child development index 40.0 Percent 6.7 Pre-school attendance 62.4 Percent EDUCATION Education 7.1 2.3 Adult female literacy rate (female aged 15-24 years) 84.3 Percent 7.3 Net intake rate in primary education 57.4 Percent 7.4 Net primary school attendance ratio 91.2 Percent 7.5 Net secondary school attendance ratio 25.5 Percent 7.7 Primary completion rate 42.0 Percent 7.9 3.1 Gender parity index -primary school 0.98 Ratio 7.10 3.2 Gender parity index -secondary school 0.95 Ratio CHILD PROTECTION Birth registration 8.1 Birth registration 69.1 Percent Child labour 8.2 Child labour 6.4 Percent 8.3 Labourer students 100.0 Percent 8.4 Student labourers 95.1 Percent Child discipline 8.5 Any psychological/physical punishment 77.7 Percent Early marriage and polygyny 8.6 Marriage before age 15 8.9 Percent 8.7 Marriage before age 18 27.1 Percent 8.8 Young women aged 15-19 currently married/in union 20.1 Percent 8.9 Polygyny 12.3 Percent 8.10 Spousal age difference of women aged 15-24 20.3 Percent Female genital mutilation/ cutting 8.11 Approval for FGM/C 3.8 Percent 8.12 Prevalence of female genital mutilation/cutting (FGM/C) 12.4 Percent 8.13 FGM/C prevalence among daughters 2.0 Percent Domestic violence 8.14 Attitudes towards domestic violence 46.5 Percent Disability Reported child disability 29.1 Percent xvi Summary Table of Findings Topic MICS4 Indicator Number2 MDG Indicator Number Indicator Value & Unit HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention among women aged 15-49 years 42.8 Percent 9.2 6.3 Comprehensive knowledge about HIV prevention among women aged 15-24 years 42.1 Percent 9.3 Knowledge of mother- to-child transmission of HIV 52.7 Percent 9.4 Attitude towards people with HIV/AIDS 39.0 Percent 9.5 Women who know where to be tested for HIV 92.9 Percent Women aged 15-49 years tested for HIV 69.2 Percent Young women aged 15-24 years tested for HIV 64.2 Percent 9.8 Counselling coverage for the prevention of mother-to-child transmission of HIV 78.6 Percent 9.9 Testing coverage for the prevention of mother-to-child transmission of HIV 82.8 Percent Sexual behaviour 9.11 Sex before age 15 years among young people 9.2 percent 9.12 Age-mixing among sexual partners 18.8 percent 9.16 Condom use with non-regular partners 54.1 percent 9.15 Higher risk sex in the last year 33.3 percent Support to orphaned and vulnerable children 9.17 Children’s living arrangements 11.3 Percent 9.18 Prevalence of orphans 12.0 Percent Prevalence of vulnerable children 8.2 Percent Introduction 1 Introduction 1 1.1 Background This report is based on the Mombasa Informal Settlement Survey conducted in 2009 by the Kenya National Bureau of Statistics following the MICS4 Global Pilot exercise3. The survey provides valuable information on the situation of children and women in the informal settlements in Mombasa and was informed largely by 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. All the above commitments build upon promises made by the international community at the 1990 World Summit for Children. Kenya is committed to improving the welfare of its people particularly women and children who tend to be more vulnerable to social-economic hardships. With regard to children, the Government of Kenya (GoK) formulated the National Plan of Action (NPA) for children in 1992 soon after the World Summit for Children (WSC) held in 1990. The main objective of this programme was to identify issues affecting children and the strategies to address them. Measuring indicators of progress towards declared goals through proper monitoring and evaluation of projects/programmes and other interventions e.g. emergency response and humanitarian assistance are vital components of the NPA. Proper monitoring and evaluation of targeted projects and programmes by the government and development partners requires a wide range of data to track progress towards achievement of desired outcomes. In this respect, data from the informal settlement survey will be helpful in appraising national programmes such as the Kenya’s Vision 2030 and its sector specifi c Medium Term Plans (MTPs) 2008-2012, among other programmes. Mombasa has been in existence as an established town for some thirty centuries according to records by ancient Phoenicians, Egyptians and Chinese historians. The Town is located on longitude 390 41’ East and latitude 40 3’ South. Mombasa Municipal Council was established in 1928 as a Board by the Local Government amendment Ordinance. The 2009 Kenya Population and Housing Census enumerated a resident population of about 523,183 people. The coastal city of Mombasa is one of Africa’s major tourist destinations, with some of the best beaches in the world. Located on Kenya’s Eastern coastline bordering the Indian Ocean, Mombasa has become popular for its exotic beaches, diverse marine life, world-class hotels and friendly people. Being an important tourist and port city in East Africa, Mombasa attracted a lot of migrant workers from different parts of Kenya and other countries in the region. This infl ux of migrant workers infl uenced the growth of slum/informal settlements in Mombasa. Similar to other such settlements elsewhere in Kenya, the living conditions of Mombasa informal settlements are very poor. As part of Kenya’s Vision 2030, the Government acknowledges the growing challenges of urbanization and the urban poor and is committed to addressing their concerns. So far, the government has developed a slum upgrading strategy which is in line with the poverty reduction programmes and other international goals such as the MDGs. Together with the local authorities and other development partners, the government has initiated the Kenya Slum Upgrading Program that aims to 3 More information on MICS4 Global Pilot can be obtained from www.childinfo.org 2 Introduction improve the living conditions of the residents of informal settlements in the main cities of Kenya. While several specifi c initiatives are planned depending on the priorities identifi ed for each city, in Mombasa the government is working with the municipal council to improve social and physical infrastructure facilities that range from increasing class room blocks, upgrading access roads to medical facilities, and improving street lighting and access to clean water. The GOK /UNICEF Country Programme 2009-2013 has a sizeable component of production of high quality and suffi ciently disaggregated data for effective child friendly policy formulation, equity-focused resource allocation, programme implementation, monitoring and evaluation. However, there is no evidence of any focused study carried out in the Mombasa informal settlements in the recent past to understand the health and wellbeing of children and women living in these settlements. Therefore, this study is a pioneering attempt to create evidence to fi ll this gap, and to assist the program and policy planners in developing strategies to improve the wellbeing of children and women living in these informal settlements. The results from the Mombasa Informal Settlement Survey conducted in 2009 are presented in this report. 1.2 Survey Objectives The 2009 Mombasa Informal Settlement Survey has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Mombasa Informal Settlements; • To contribute to the improvement of data and monitoring systems in Kenya and to strengthen technical expertise in the design, implementation, and analysis of such systems. Sample and survey methodology 3 Sample and Survey Methodology 2 2.1 Sample Design The sample for the Mombasa Informal Settlement Survey (MISS) was designed to provide estimates on a large number of indicators on the situation of children and women living in the informal settlements of Mombasa district, and the sample was selected in two stages. From the list of Enumeration Areas (EAs) classifi ed as informal settlements4, 45 EAs were selected using the probability proportional to population size sampling methodology. A household listing operation was carried out in all the selected enumeration areas and a sample of 24 households was selected circular systematically using a random start in the second stage. For reporting the results, sample weights were calculated and applied in the estimations. A detailed description of the sample design is presented in Appendix A. 2.2 Questionnaires Three types of questionnaires were used in the survey: 1) a household questionnaire was used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; and 3) an under-5 questionnaire, administered to mothers or caretakers of all children under 5 years living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: • Household Listing • Education • Water and Sanitation • Indoor Residual Spraying • Insecticide Treated Mosquito Nets (ITN) • Children Orphaned & Made Vulnerable By HIV/AIDS • Child Labour • Child Discipline • Disability • Handwashing Facility • Salt Iodization The Questionnaire for Individual Women aged 15-49 years living in the households included the following modules: • Child Mortality • Birth history • Tetanus Toxoid • Maternal and Newborn Health • Marriage/Union • Contraception • Attitudes Towards Domestic Violence • Female Genital Mutilation/Cutting • Sexual Behaviour • HIV/AIDS 4 The list of 1999 Census Enumeration Areas in Urban Mombasa classifi ed as informal and other type of settlements by KNBS in 2003-04. 5 The terms “children under-fi ve”, “children aged 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 4 Sample and survey methodology The Questionnaire for Children Under-Five was administered to mothers or caretakers of children under-fi ve years of age5 living in the households. Normally, the questionnaire was administered to mothers of under-fi ve children; in cases where the mother was not listed in the household roster, a primary caretaker for the child was identifi ed and interviewed. The questionnaire included the following modules: • Birth Registration and Early Learning • Child Development • Vitamin A • Breastfeeding • Care of Illness • Malaria • Immunization • Anthropometry The questionnaires used were the same as the MICS4 Pilot version. From the MICS4 Pilot English version, the questionnaires were translated into Kiswahili, the language spoken in Mombasa. In addition to the administration of questionnaires, fi eldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of children aged under-5 (0-59 months). Details and fi ndings of these measurements are provided in the respective sections of the report. 2.3 Training and Fieldwork Training for the fi eldwork was conducted in two parts, two days training for the mapping and listing teams and 10 days training for the main survey teams in January-February 2009. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent one full day in practice interviewing in different locations in Mombasa and the neighbouring district of Kwale. The training sessions were facilitated by experts and staff from UNICEF HQ, UNICEF Regional Offi ce for Eastern and Southern Africa/MICS Unit and KNBS. The household listing was carried out by four teams. Each team comprised of a lister and mapper, and one supervisor for the four teams. The whole listing operation was monitored by the KNBS staff from headquarters and Mombasa. Further, a few UNICEF professionals who were involved in the MICS4 Global Pilot exercise also made fi eld monitoring visits to oversee the household listing operations. The data were collected by three teams; each was comprised of three interviewers, one editor, one measurer and a supervisor. Each team was provided with a vehicle along with driver for the fi eld work operations. Fieldwork was carried out during February-March 2009 in which the initial 8-9 days were spent in collecting information from the MICS4 Global Pilot clusters. 2.4 Data Processing Data were entered using the CSPro software. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed, and the whole process was monitored initially by the MICS Global data processing specialist, followed by KNBS data processing expert. Procedures and standard programs developed under the global MICS project and adapted to the modifi ed questionnaire were used throughout. Data entry began simultaneously with data collection in February 2009 and was completed at the end of March 2009. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, and the model syntax and tabulation plans developed by UNICEF were customized for this purpose. Sample Coverage and Household Characteristics 5 Sample Coverage and the Characteristics of Households and Respondents 3 3.1 Sample Coverage Of the 1,080 households selected for the sample, 1,076 were found occupied. Of these, 1,016 were successfully interviewed yielding a household response rate of 94.4 per cent. In the interviewed households, 878 women (age 15-49) were identifi ed and information collected from 821 women in these households, yielding a response rate of 93.5 per cent. In addition, 464 children under age fi ve were listed in the household questionnaire, and information on 454 children were obtained, which corresponds to a response rate of 97.8 per cent. Overall response rates of 88.3 and 92.4 are calculated for the women’s and under-5’s interviews respectively (Table 3.1). 3.2 Characteristics of Households The age and sex distribution of survey population in Mombasa informal settlements is provided in Table 3.2. The distribution is also used to produce the population pyramid in Figure 3.1. In the 1,016 households successfully interviewed in the survey, 3,219 household members were listed. Of these, 1,742 were males and 1,476 were females. The population pyramid shows a high proportion of the population in the working age groups, i.e., 20-54 years. The proportion of males in the age group 20-24 years is less than that of females in the same group- 13 and 17 per cent respectively. However, the proportion of males aged 30-49 years is much higher than that of females- 29 and 19 per cent respectively. The higher proportion of people in the potential working age groups clearly show the selective migration of young workers from other areas to the informal settlements of Mombasa. Table 3.1: Results of household and individual interviews (HH.1) Number of households, women, and children under 5 by results of the interviews, and household, women's and under-five's response rates, Mombasa Informal Settlement Survey, Kenya, 2009 Number of households Sampled (Hs) 1,080 Occupied (Ho) 1,076 Interviewed (Hi) 1,016 Not found/destroyed 4 Household response rate (Hr) 94.4 Number of women Eligible (We) 878 Interviewed (Wi) 821 Response rate (Wr) 93.5 Overall women response rate (Wor) 88.3 Number of children under 5 Eligible (Ce) 464 Information collected (Ci) 454 Response rate (Cr) 97.8 Overall children response rate (Cor) 92.4 Hr = Hi / Ho Wr = Wi / We ; Wor = Wr x Hr ; Cr = Ci / Ce ; Cor = Cr x Hr Note: This table is un-weighted, however all other tables presented in this report are weighted unless mentioned otherwise. More information about sample design and weights is given in Appendix A. 6 Sample Coverage and Household Characteristics Figure 3.1: Age and sex distribution of household population 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Percent Females Males Table 3.2: Household age distribution by sex (HH.2) Percent distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, Mombasa Informal Settlement Survey, Kenya, 2009 Males Females Total Number Percent Number Percent Number Percent Age 0-4 247 14.2 215 14.6 462 14.4 5-9 173 9.9 172 11.6 345 10.7 10-14 118 6.8 137 9.3 255 7.9 15-19 135 7.8 137 9.3 272 8.5 20-24 222 12.7 252 17.1 474 14.7 25-29 245 14.1 211 14.3 456 14.2 30-34 201 11.5 116 7.9 317 9.9 35-39 148 8.5 81 5.5 229 7.1 40-44 79 4.5 44 3.0 123 3.8 45-49 70 4.0 38 2.6 108 3.4 50-54 42 2.4 31 2.1 74 2.3 55-59 27 1.6 12 0.8 39 1.2 60-64 18 1.0 15 1.0 33 1.0 65-69 6 0.4 4 0.3 10 0.3 70+ 8 0.5 11 0.7 19 0.6 Missing/DK 2 0.1 0 0.0 2 0.1 Dependency age groups <15 years 538 30.9 524 35.5 1062 33.0 15-64 years 1188 68.2 937 63.5 2125 66.0 65+ years 14 0.8 15 1.0 29 0.9 Missing/DK 2 0.1 0 0.0 2 0.1 Child and adult age groups Children aged 0-17 621 35.6 605 41.0 1226 38.1 Adults 18+/ Missing/DK 1122 64.4 872 59.0 1993 61.9 Total 1,742 100.0 1,476 100.0 3,219 100.0 Sample Coverage and Household Characteristics 7 Further, the age distribution from Table 3.2 shows that 33 per cent of the population is below 15 years of age and 66 per cent are aged between 15-64 years. The population aged 65 years and above is only one per cent. The child population aged 0-17 years is 38 per cent. Table 3.3 provides basic background information on the households such as mean household size, sex of the household head and number of household members. The weighted and un-weighted numbers of total households are virtually equal, since sample weights were normalized (See Appendix A). In Mombasa informal settlements, only 18 per cent of the households are female headed which is lower than the urban national average of 29 per cent (KDHS, 2008-2009). Thirty four per cent of the households have at least one child below fi ve years of age and 50 per cent of the households have at least one child below Table 3.3: Household composition (HH.3) Percent distribution of households by selected characteristics, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristics Number of households Weighted percent Weighted Un-weighted Sex of household head Male 81.8 831 832 Female 18.2 185 184 Number of household members 1 27.1 275 275 2-3 39.4 401 401 4-5 20.7 210 211 6-7 7.7 78 77 8-9 2.8 29 29 10+ 2.3 23 23 Mean household size 3.2 NA NA Education of household head None 7.8 79 78 Primary 45.9 466 467 Secondary + 45.3 461 461 Non-standard curriculum 0.7 7 7 DK/missing 0.3 3 3 Wealth index Low 36.1 367 369 Medium 37.8 384 382 High 26.0 265 265 Religion of household head Catholic 20.8 211 212 Other Christian 49.4 502 504 Muslim 27.3 278 275 Other 2.5 25 25 Total 100.0 1016 1016 At least one child aged < 18 years 49.6 1016 1016 At least one child aged < 5 years 33.9 1016 1016 At least one woman aged 15-49 years 64.0 1016 1016 8 Sample Coverage and Household Characteristics 18 years of age. About, two in three households (64 per cent) have at least one woman in the 15-49 years reproductive age group. It is also important to note that more than one in four households in these informal settlements is one-member households and another 39 per cent have 2-3 persons. The mean household size in the Mombasa informal settlements is 3.2 persons. The distribution of the sampled households by educational level of the household head shows that, 46 per cent are primary educated and another 45 per cent are educated up to secondary or higher. The table also shows that 21 per cent of all household heads are Catholics, 49 per cent are other Christian, 27 per cent Muslim and the remaining three per cent have no-religion or belong to other religious groups. 3.3 Characteristics of Female Respondents Table 3.4 provides information on the background characteristics of female respondents aged 15-49 years. The total number of weighted and un-weighted observations is equal, since sample weights have been normalized. In addition to providing useful information on the background characteristics of women, the table also shows the number of observations in each background category. These categories are used in the subsequent tabulations of this report. Table 3.4: Women's background characteristics (HH.4) Percent distribution of women aged 15-49 years by background characteristics, Mombasa Informal Settlement Survey, Kenya, 2009 Weighted percent Number of women Characteristics Weighted Un-weighted Age 15-19 14.3 118 116 20-24 29.5 242 244 25-29 22.7 186 187 30-34 14.7 121 121 35-39 9.0 74 74 40-44 5.3 44 44 45-49 4.4 36 35 Marital/Union status Currently married/in union 58.7 482 483 Formerly married/in union 11.5 94 94 Never married/in union 29.8 245 244 Motherhood status Ever gave birth 69.9 574 575 Never gave birth 30.1 247 246 Education None 8.0 65 66 Primary 55.7 457 458 Secondary + 36.0 295 294 Non-standard/DK/missing 0.4 3 3 Wealth index Low 30.2 248 255 Medium 33.5 275 271 High 36.3 298 295 Religion of household head Catholic 17.1 140 141 Other Christian 50.9 418 422 Muslim 30.1 248 243 Other 1.8 15 15 Total 100.0 821 821 Sample Coverage and Household Characteristics 9 6 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 7 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: number of sleeping rooms, type of fl oor, type of roof, type of walls, type of fuel used for cooking, electricity, radio, television, VCR, air-conditioner, mobile telephone, refrigerator, computer, internet connection, watch, bicycle, motorcycle or scooter, sewing machine source of drinking water and type of sanitation). Each household was then weighted by the number of household members, and the household population was divided into three groups, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. The table includes information on the distribution of women according to age, marital status, motherhood status, education6, and wealth index7. Overall, 59 per cent of the women age 15-49 years in Mombasa District informal settlements are currently married or in union and another 30 per cent are never married or in union. Seventy per cent have ever given birth while eight per cent have no education and 36 per cent have secondary or higher level of education. The wealth index ranked 30 and 34 per cent of the women in the low and medium income categories respectively. 3.4 Characteristics of Children Under-Five Some background characteristics of children under-fi ve are presented in Table 3.5. These include distribution of children by attributes such as sex, age in months, mother’s or caretaker’s education, wealth index and religion of the household head. A higher proportion of male children under-fi ve years (54 per cent) were found in the sample compared to female children (46 per cent). About nine per cent of children below-fi ve years belong to 0-5 months of age and 12 per cent in 6-11 month category. Thirty per cent of the children belong to mothers/care taker having secondary or higher education, 59 per cent belong to mothers having primary education and 10 per cent belong to mothers with no education. The distribution of children below 5 years by the religion of the household head shows that, 14 per cent are Catholics, 49 per cent other Christians and 36 per cent Muslim headed households. These categories are mostly used in the subsequent tabulations of this report. 10 Sample Coverage and Household Characteristics Table 3.5: Children's background characteristics (HH.5) Percent distribution of children under five years of age by background characteristics, Mombasa Informal Settlement Survey, Kenya, 2009 Number of under-5 children Characteristics Weighted percent Weighted Un-weighted Sex Male 54.3 246 246 Female 45.7 208 208 Age < 6 months 8.9 40 41 6-11 months 11.9 54 54 12-23 months 21.9 100 99 24-35 months 16.3 74 75 36-47 months 23.4 106 105 48-59 months 17.7 80 80 Mother’s education None 11.7 53 54 Primary 59.0 268 268 Secondary + 29.3 133 132 Wealth index Low 33.1 150 153 Medium 32.2 146 147 High 34.7 157 154 Religion of household head Catholic 14.1 64 64 Other Christian 48.8 222 222 Muslim 35.6 162 161 Other 1.5 7 7 Total 100.0 454 454 Child Mortality 11 Child Mortality 4 One of the overarching goals of the Millennium Development Goals (MDGs)-Goal 4, Target 5 and the World Fit for Children (WFFC) is to reduce infant and under-fi ve mortality. Specifi cally, the MDGs call for the reduction in under-fi ve mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but diffi cult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. However, the Mombasa Informal Settlement Survey utilised direct measures of child mortality from birth histories which is one of the best ways of obtaining this information. The birth history obtained from women aged 15-49 years includes number of children ever born and living by sex, and date of birth of each child born. If the child is not alive at the time of the survey, information on age of the child at the time of death is also obtained. This method is being used by the Demographic and Health Surveys (DHS) worldwide including the Kenya Demographic and Health Survey (KDHS). This allows us to compare the mortality rates obtained by MICS with those of KDHS. The Infant Mortality Rate (IMR) is the probability of dying before the fi rst birthday. The Under-fi ve Mortality Rate (U5MR) is the probability of dying before the fi fth birthday. The neonatal mortality rate is the probability of dying before one month of life. Post neonatal mortality rate is the probability of dying between one month and one year of life. The child mortality rate refers to probability of dying between one and fi ve year of life. All mortality rates mentioned above are expressed per 1,000 live births, except for child mortality rate, which is expressed per 1,000 children surviving up to 12 months of age. Though direct estimates of mortality obtained from birth histories are the best, the quality of these mortality estimates depend on the completeness of information obtained in the birth histories. In many cases women tend to avoid reporting their dead children and this tends to under estimate the mortality levels. 4.1 Levels of Childhood Mortality Table 4.1 provides estimates of childhood mortality for the ten year period preceding the survey for the Mombasa informal settlements. This permits monitoring of changes in childhood mortality rates among the under privileged population in the urban areas of Mombasa. The infant mortality rate (IMR) is estimated as 70 per thousand live births, while the under-5 mortality rate (U5MR) is 91 per thousand live births. These estimates have been calculated based on births during the ten year period preceding the survey. Based on the recent Kenya Demographic and Health Survey, the infant mortality for Kenya as a whole is 52 and the under-fi ve mortality is 74, which shows higher mortality among children living in the informal settlements of Mombasa (KDHS, 2008-9). Table 4.1: Child mortality Infant, neonatal, post-neonatal, child and under-five mortality rates for 10-year period preceding the survey, Mombasa Informal Settlement Survey, Kenya, 2009 Infant mortality rate1 Neonatal mortality rate Post-neonatal mortality rate Child mortality rate Under-five mortality rate2 Total 70 39 31 22 91 1 MICS indicator 1.2 and MDG indicator 4.2 2 MICS indicator 1.1 and MDG indicator 4.1 12 Nutrition Nutrition 5 Children’s nutritional status is a refl ection of their overall health. Children who are well cared for and have access to an adequate food intake are not prone to repeated illness and are more likely to reach their growth potential and are considered well nourished. 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, they are more likely to experience recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition are only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal 1, Target 1c, is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under fi ve years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the attainment of the goal towards reduction in child mortality. 5.1 Nutritional Status In a well-nourished population, there is a reference distribution of height and weight for children under age fi ve. Under-nourishment in a population can be gauged by comparing children to a reference population. The new WHO reference populations is used in this report, however estimates based on the old WHO/CDC/NCHS reference standards are also shown in Appendix E. 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 less than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is less than three standard deviations below the median are classifi ed as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is less than two standard deviations below the median of the reference population are considered short for their age and are classifi ed as moderately or severely stunted. Those whose height-for-age is less than three standard deviations below the median are classifi ed as severely stunted. Stunting is a refl ection 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 less than two standard deviations below the median of the reference population are classifi ed as moderately or severely wasted, while those who fall less than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional defi ciency. The indicator may exhibit signifi cant seasonal shifts associated with changes in the availability of food or disease prevalence. During the MISS, weights and heights of all children aged 6-59 months were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Nutrition 13 Table 5.1 shows per centages of children classifi ed into each of these categories, based on the anthropometric measurements that were taken during fi eldwork and selected characteristics. 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. Table 5.1: Child malnourishment (WHO Standard) Percentage of children aged 0-59 months who are severely or moderately malnourished, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristics Weight-for-age (Under-weight) Number of children Height-for-age (Stunted) Number of children Weight-for-height Number of children Wasted % above % below % below % below % below % below % below - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD Sex Male 16.2 3.8 242 27.2 8.2 240 7.9 1.6 2.1 241 Female 12.1 2.5 204 19.0 5.9 203 4.1 1.0 2.8 204 Age < 6 months (10.2) (5.5) 39 (13.3) (5.7) 38 (7.7) (2.8) (7.7) 38 6-11 months 10.8 3.7 54 10.7 3.6 53 14.0 1.8 0.0 53 12-23 months 19.0 3.2 98 25.6 6.1 98 6.0 2.0 3.1 99 24-35 months 15.3 4.2 72 32.9 11.0 72 5.6 1.3 2.6 72 36-47 months 8.7 2.0 104 24.2 6.0 104 3.8 0.9 1.0 104 48-59 months 19.8 2.6 78 24.9 9.7 77 3.7 0.0 2.4 78 Mother’s education None 18.6 4.2 53 31.5 8.3 51 1.9 0.0 1.8 52 Primary 16.9 4.3 261 26.9 9.4 260 8.2 1.5 2.7 261 Secondary + 7.6 0.7 131 13.6 2.4 131 3.7 1.5 2.2 131 Wealth index Low 19.5 5.6 146 32.8 11.7 145 5.5 2.0 2.8 146 Medium 12.8 2.9 144 21.1 6.7 143 7.7 0.0 0.0 143 High 11.0 1.3 155 16.9 3.3 154 5.3 1.9 4.3 155 Religion of household head Catholic 11.4 5.0 63 23.9 9.8 63 4.7 1.5 4.6 64 Other Christian 11.4 3.2 218 21.3 4.6 217 4.8 0.9 2.7 217 Muslim 19.6 2.7 158 26.6 9.9 157 8.8 1.9 1.2 158 Total 14.4 3.2 445 23.5 7.2 442 6.1 1.3 2.4 444 1 MICS indicator 2.1a and MDG indicator 1.8, 2 MICS indicator 2.1b, 3 MICS indicator 2.2a, 4 MICS indicator 2.2b 5 MICS indicator 2.3a, 6 MICS indicator 2.3b Columns 1 and 2 refer to children whose weight for age z-scores (i.e., the exact number of standard deviations from the median) fall below -2 standard deviations (moderately underweight) and -3 standard deviations (severely underweight) from the median weight for age of the WHO reference population. Columns 4 and 5 refer to children whose height for age z-scores fall below -2 standard deviations (moderately stunted or short for their age) and -3 standard deviations (severely stunted or short for their age) from the median height for age of the reference population. Stunted children are considered as chronically undernourished. Columns 7 and 8 refer to children whose weight for height z-scores fall -2 standard deviations (moderately wasted) or -3 standard deviations (severely wasted) from the weight for height of the reference population. Wasting is usually the result of a recent nutritional deficiency. The table also 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. The percent ‘below –2 standard deviations’ includes those who fall -3 standard deviations below the median. ( ) Based on 25-49 un-weighted cases. Note: 7 children belong to other religion is not shown separately. 14 Nutrition Fourteen per cent of children below fi ve years of age living in Mombasa informal settlement are underweight (below -2SD from the WHO reference mean) and three per cent are severely underweight (below -3SD from the WHO reference mean). Twenty four per cent are stunted or short for their age and seven per cent are severely stunted or too short for their age. Six per cent of children aged 6-59 months are wasted (below -2SD median weight-for-height) and little more than one per cent are severely wasted. The differentials in the anthropometry indicators by age are shown in Figure 5.1. The nutritional status by sex differentials show a higher proportion of male children being under nourished compared to female children. It is also of interest to note that the malnutrition levels declines with an increase in the levels of the wealth index. For example, 20 per cent of children from low wealth index households are under-weight compared with 11 per cent among those from high wealth index households. A similar pattern is also noticed with respect to educational level of mother and children’s nutritional status. Figure 5.1: Percentage of children under-5 who are undernourished 5.2 Breastfeeding Breastfeeding for the fi rst 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 and traditional feeding practices, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for fi rst six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds Nutrition 15 It is also recommended that breastfeeding be initiated within one hour of birth. This is to ensure that the colostrums available in the fi rst breast milk are received by the child. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate (< 6 months & < 4 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 & 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table 5.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). Only 37 per cent of newborn children in Mombasa informal settlements are receiving breast milk within one hour of their birth and 75 per cent are receiving the breast milk within one day of birth. In other words, one in four children born in Mombasa informal settlements are not receiving breast milk within 24 hours of their birth, implying that these children are receiving something other than breast milk. A higher proportion of children born to mothers with secondary or higher level of education receive breast milk within one hour of birth compared with those born to mothers who are educated up to primary (42 per cent compared to 35 per cent). A similar pattern is observed in case of proportions breastfeeding their child within one day. Table 5.3 presents breastfeeding status based on the reports of mothers/caretakers of children’s consumption of food and fl uids 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 tables show exclusive breastfeeding of infants during the fi rst six months of life, as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Only seven per cent of the children aged 0-5 months in Mombasa informal settlements are exclusively breastfed, which is extremely low. However, 94 per cent of the children aged 6-9 months are receiving breast Table 5.2: Initial breastfeeding (NU.2) Percentage of women aged 15-49 years with a birth in the two years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristics Percentage who started breastfeeding within one hour of birth1 Percentage who started breastfeeding within one day of birth Number of women with a live birth in the two years preceding the survey Months since birth < 6 months (34.8) (77.7) 40 6-11 months 45.0 75.2 63 12-23 months 33.6 73.8 108 Mother’s education Primary 35.4 72.9 122 Secondary + 42.0 77.5 66 Wealth index Low 38.2 79.9 68 Medium 39.0 64.7 69 High 34.8 80.0 73 Religion of household head Catholic (30.7) (68.7) 31 Other Christian 39.4 75.9 111 Muslim 37.6 74.7 65 Total 37.3 75.0 211 1 MICS indicator 2.5 *Not shown, based on less than 25 un-weighted cases. ( ) Based on 25-49 un-weighted cases. Note: 23 women with no education and 4 women belong to other religion are not shown separately. 16 Nutrition milk and solid or semi-solid foods. By age 12-15 months, 81 per cent of children are still being breastfed and by age 20-23 months less than half of that are being breastfed (39 per cent). Little less than two in fi ve (38 per cent) children aged 6-11 months are receiving breast milk and complementary food at least the minimum recommended number (two or more) of times per day. The adequacy of infant feeding in children under 12 months is provided in Table 5.3. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they are receiving breast milk and complementary food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they are receiving breast milk and eating complementary food at least three times a day. Of those aged 0-11 months, 25 per cent were adequately fed. Overall, slightly more male children are fed adequately than female children. 5.3 Meal Frequency It is well recognized that the period from birth to two years of age is the “critical window” for the promotion of good growth, health, and behavioural development among children. Therefore, optimal infant and young child feeding is crucial during this period. In addition to initiation of breastfeeding within one hour of birth and exclusive breastfeeding during the fi rst six months of the child’s life, optimal infant and young child feeding includes continued breastfeeding for two years or more together with safe, age-appropriate feeding of solid, semi-solid and soft foods starting at six months of age. In fact, evidence suggests that even with optimum breastfeeding children may be at risk for stunting if they do not receive suffi cient quantities of quality complementary foods after six months of age. Adequate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and the prevention of undernutrition. Childhood undernutrition remains a major health problem in resource-poor settings. Approximately one-third of children less than fi ve years of age in developing countries are stunted (low height-for-age), and large proportions are also defi cient in one or more micronutrients. That means they require the addition of nutrient dense, high quality foods in suffi cient quantities to their diet along with continued breastfeeding. Table 5.3: Breastfeeding and supplementary feeding Breastfeeding and supplementary feeding status of living children at each age group, Mombasa Informal Settlement Survey, Kenya, 2009 Items Percent Number of children Children age 0-5 months exclusively breastfed1 (7.2) 40 Children age 6-9 months receiving breast-milk and solid/mushy food (94.0) 33 Children age 12-15 months breastfed2 (80.6) 36 Children age 20-23 months breastfed3 (39.4) 39 Children age 6-11 months who received breast-milk and complementary food at least the minimum recommended number of times per day 38.0 54 Children age 0-11 months who were appropriately fed Male Female Total 26.1 (23.4) 24.8 51 43 94 1 MICS indicator 2.6, 2 MICS indicator 2.7, 3 MICS indicator 2.8 Note: Breastfeeding status is based on mother’s or caretaker's reports of children’s consumption in the 24 hours prior to the interview. Exclusive breastfeeding refers to children who receive only breast-milk, or breast-milk and vitamins, mineral supplements, or medicine. ( ) Based on 25-49 un-weighted cases. Nutrition 17 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 suffi cient. 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 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. Table 5.4 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 (a) in Table 5.4 for a defi nition of minimum number of times for different age groups). Overall, more than one-third of the children aged 6-23 months (35 per cent) were receiving solid, semi-solid and soft foods the minimum number of times. A slightly higher proportion of females (39 per cent) were enjoying the minimum meal frequency compared to males (32 per cent). Among currently breastfeeding children aged 6-23 months, nearly one-third (31 per cent) were receiving solid, semi-solid and soft foods the minimum number of times and this proportion was higher among females (37 per cent) compared to males (27 per cent). Among non-breastfeeding children, nearly half of the children were receiving solid, semi-solid and soft foods or milk feeds four times or more. Table 5.4: Minimum meal frequency (NU.7) Percentage of children age 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, Mombasa Informal Settlement Survey, Kenya, 2009 Currently breastfeeding Currently not breastfeeding All 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 feeds1 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 frequency2 Number of children age 6-23 months Sex Male 26.8 65 * * 18 32.4 83 Female 37.1 53 * * 18 38.9 70 Age 6-8 months (38.4) 25 * * 0 (38.4) 25 9-11 months (38.9) 28 * * 1 (40.9) 29 12-17 months (24.5) 43 * * 8 28.7 51 18-23 months * 21 (36.5) (45.5) 27 (37.6) 48 Education Primary 31.3 68 * * 20 31.3 88 Secondary (26.4) 37 * * 13 (39.6) 49 Wealth index Low (30.7) 34 * * 11 (32.4) 46 Medium (34.5) 41 * * 8 (31.0) 49 High (29.1) 42 * * 17 41.4 59 Religion of household head Other Christian 26.4 67 * * 15 32.7 82 Muslim (37.3) 33 * * 15 (36.7) 49 Total 31.4 117 41.4 48.2 36 35.4 153 1 MICS indicator 2.15; 2 MICS indicator 2.13 *Not shown, based on less than 25 un-weighted cases; () Based on 25-49 un-weighted cases. Note: a) Among currently breastfeeding children age 6-8 months, minimum meal frequency is defined as children who also received solid, semi-solid or soft foods 2 times or more. Among currently breastfeeding children age 9-23 months, receipt of solid, semi-solid or soft foods at least 3 times constitutes minimum meal frequency. For non-breastfeeding children age 6-23 months, minimum meal frequency is defined as children receiving solid, semi-solid or soft foods, and milk feeds, at least 4 times during the previous day. b) 16 children with missing information on mother’s/caretaker’s education, 21 children belong to Catholic and 2 children belong to other religion are not shown separately. 18 Nutrition 5.4 Salt Iodization Iodine Defi ciency 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 defi ciency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine defi ciency is most commonly and visibly associated with goitre. IDD results in poor school performance, reduced intellectual ability, and impaired work performance. The international goal is to achieve sustainable elimination of iodine defi ciency by 2005. This is monitored by the indicator “percentage of households consuming adequately iodized salt (>15 parts per million)”. In 87 per cent of households in Mombasa informal settlements, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodide. Table 5.5 shows that 10 per cent of households reported having no salt available, a fi gure that is much higher than expected. In 90 per cent of households, salt was found to be adequately iodized, .i.e., the salt contained 15 parts per million (ppm) or more of iodine. Differentials by wealth index show that, a slightly higher proportion (93 per cent) of households from high wealth index category use adequately iodized salt compared with those from the low wealth index category (86 per cent). 5.5 Vitamin A Supplements 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. However, 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 insuffi cient to meet dietary requirements. Inadequate intake is 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 defi ciency is quite prevalent in the developing world and particularly in countries with a high incidence of under-fi ve deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A defi ciency 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 Table 5.5: Iodized salt consumption (NU.5) Percentage of households consuming adequately iodized salt, Mombasa Informal Settlement Survey, Kenya, 2009 Wealth index Percent of households in which salt was tested Number of households interviewed Percent of households with Number of households in which salt was tested or with no salt No salt Salt test result < 15 PPM 15+ PPM1 Total Low 83.0 367 13.2 0.6 86.2 100.0 351 Medium 88.0 384 8.4 0.3 91.3 100.0 369 High 91.7 265 6.5 0.8 92.7 100.0 260 Total 87.2 1016 9.6 0.5 89.8 100.0 980 1 MICS indicator 2.16 Nutrition 19 immune function also makes control of its defi ciency 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-fi ve mortality by the year 2015”. For countries with vitamin A defi ciency 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 a year is a safe, cost-effective, effi cient strategy for eliminating vitamin A defi ciency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the fi rst 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 defi nition of the indicator is the proportion of children aged 6-59 months receiving at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Ministry of Health, Government of Kenya recommends that children aged 6-11 months be given one high dose Vitamin A capsules and children aged 12-59 months be given a vitamin A capsule every 6 months. In some parts of the country, 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. Table 5.6 shows children’s vitamin A supplementation by selected background characteristics such as sex, and age of child, mother’s education, household’s wealth index and religion of household head. Within the six months prior to the survey, 33 per cent of children aged 6-59 months received a high dose Vitamin A supplement. Forty six per cent received the supplement prior to last 6 months and in about 12 per cent of cases their mother/caretaker was unable to specify when. Only seven per cent of children aged 6-59 months reported to have never received the Vitamin A supplementation at any point in time. The differentials by sex show slightly higher proportion of female children (35 per cent) receiving Vitamin A supplementation within the last six months compared with male children (31 per cent). There is a consistent decline in Vitamin A supplementation with the age of children. For example, supplementation in the last six months preceding the survey declines from 75 per cent among children aged 6-11 months to 14 per cent among children aged 48-59 months. The differentials by household wealth index show a positive association with Vitamin A supplementation coverage. For example, 39 per cent of children from low wealth index households received Vitamin A supplementation compared with 52 per cent among high wealth index households. 20 Nutrition Table 5.7 shows post-partum mother’s vitamin A supplementation by the education level of mother, household wealth index and religion of household head. About 45 per cent mothers with a birth in the previous two years before the survey received a Vitamin A supplement within eight weeks of the birth. As expected, the vitamin A supplementation coverage increases with increaseing levels of the household wealth index. For example, 39 per cent of women who live in a low wealth index household reported receiving vitamin A supplementation compared with 52 per cent among high wealth index category. Table 5.6: Children's vitamin A supplementation (NU.6) Percent distribution of children aged 6-59 months by whether they have received a high dose vitamin A supplement in the last 6 months, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristics Percent of children who received vitamin A: Not sure if received vitamin A Never received vitamin A Total Number of children aged 6-59 months Within last 6 months1 Prior to last 6 months Not sure when Sex Male 31.0 45.7 12.5 2.1 8.6 100.0 224 Female 35.0 46.4 10.9 2.1 5.6 100.0 190 Age 6-11 months 74.8 3.4 3.5 0.0 18.3 100.0 54 12-23 months 49.0 44.9 3.1 1.0 1.9 100.0 100 24-35 months 28.2 45.5 17.1 4.0 5.2 100.0 74 36-47 months 14.2 60.3 19.0 3.6 2.9 100.0 106 48-59 months 13.5 57.6 13.7 1.2 14.1 100.0 80 Mother’s education None (24.8) (43.0) (17.9) (0.0) (14.3) (100.0) 48 Primary 35.1 47.6 9.8 3.6 3.8 100.0 241 Secondary + 31.6 44.1 13.1 0.0 11.2 100.0 124 Wealth index Low 26.6 47.0 12.8 2.2 11.4 100.0 137 Medium 34.9 48.0 9.1 2.2 5.8 100.0 132 High 36.9 43.3 13.2 1.9 4.6 100.0 145 Religion of household head Catholic 39.9 46.5 6.8 0.0 6.8 100.0 58 Other Christian 35.3 45.5 12.0 2.4 4.7 100.0 200 Muslim 27.5 46.4 13.8 2.6 9.7 100.0 150 Total 32.8 46.0 11.8 2.1 7.2 100.0 414 1 MICS indicator 2.17. ( ) Based on 25-49 un-weighted cases. Note: 6 children belong to other religion are not shown separately. Nutrition 21 5.6 Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health, and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who are 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 abilities which affect 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 that have the most impact include the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during 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 signifi cantly 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 fi nish 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 newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Table 5.7: Post-partum mothers' vitamin A supplementation (NU.7) Percentage of women aged 15-49 years with a live birth in the 2 years preceding the survey by whether they received a high dose vitamin A supplement before the infant was 8 weeks old, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristics Received vitamin A supplement Not sure if received vitamin A Number of women aged 15-49 years Education Primary 46.0 4.2 122 Secondary + 42.8 3.0 66 Wealth index Low 38.6 0.0 68 Medium 42.5 2.9 69 High 52.4 7.1 73 Religion of household head Catholic (38.1) (0.0) 31 Other Christian 44.7 5.6 111 Muslim 47.7 1.5 65 Total 44.7 3.4 211 ( ) Based on 25-49 un-weighted cases. Note: 23 women with no education and 4 women belong to other religion are not shown separately. 22 Nutrition 8 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 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 birth8. Table 5.8 shows the incidence of low birth weight infants by the education level of mother, household wealth index and religion of household head. Overall, 81 per cent of births were weighed at birth and 12 per cent of infants weighed less than 2500 grams at birth. A higher proportion of children born to mothers who have secondary and above level of education were weighed at birth (88 per cent) compared with those born to mothers with primary education (80 per cent). There is a noticeable increasing trend in the proportion of children weighed at birth with increase in the household wealth index. For example, 65 per cent of the children from the low wealth index households were weighed compared to 95 per cent for the high wealth index category. Table 5.8: Low birth weight infants (NU.8) Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, Mombasa Informal Settlement Survey, Kenya, 2009 Percent of live births: Number of live births Below 2500 grams1 Weighed at birth2 Education Primary 11.6 79.9 122 Secondary + 9.4 87.9 66 Wealth index Low 12.8 64.5 68 Medium 11.0 82.6 69 High 11.0 94.6 73 Religion of household head Catholic (8.2) (84.2) 31 Other Christian 9.3 83.1 111 Muslim 16.5 79.2 65 Total 11.6 80.9 211 1 MICS indicator 2.18, 2 MICS indicator 2.19 ( ) Based on 25-49 un-weighted cases. Note: 23 women with no education and 4 women belong to other religion are not shown separately. Child Health 23 Child Health 6 6.1 Immunization The fourth Millennium Development Goal (MDG) is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in the progress towards attainment of this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 per cent nationally, with at least 80 per cent coverage in every district or equivalent administrative unit. The Kenya Expanded Programme on Immunizations (KEPI) and the Malezi Bora (a comprehensive initiative to protect children’s health in Kenya) campaigns are playing key roles in this regard. In Kenya, and in accordance with the Ministry of Health guidelines, a child should receive a BCG vaccination to protect him/her against tuberculosis, three doses of DPT to protect against diphtheria, pertussis and tetanus and three doses of Polio vaccine by the age of 12 months. The measles vaccine should be administered by the age of 9 months. This is in accordance with the UNICEF and WHO guidelines as well as the Kenya Child Survival and Development Strategy, 2009. In the Mombasa Informal Settlement Survey, mothers or care givers of children below fi ve years of age were asked to provide vaccination cards and interviewers copied vaccination information from the cards onto the questionnaire. However, information about children with no immunization cards was obtained using a set of structured direct questions on immunization. The immunization coverage shown in this report includes information from cards as well as mother’s or caretaker’s re-call, unless mentioned other-wise. Table 6.1 shows vaccination coverage rates among children aged 12-23 months who received each of the vaccinations by source of information. The denominator for the table is comprised of children aged 12-23 months so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the bottom panel, only those who were vaccinated before their fi rst birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the fi rst birthday is assumed to be the same as for children with vaccination cards. Ninety four per cent of the children aged 12-23 months received a BCG vaccination by the age of 12 months and the fi rst dose of DPT was given to 96 per cent. The percentage declines marginally for subsequent doses of DPT to 92 per cent for the second dose, and 78 per cent for the third dose (Figure 6.1). Similarly, 96 per cent of children received Polio 1 by age 12 months and this declines to 66 per cent by the third dose. The coverage for measles vaccine by 12 months is higher than the third dose coverage of polio or DPT, at 85 per cent. The percentage of children who had received all the recommended vaccinations by their fi rst birthday is only 49 per cent in Mombasa informal settlements. The low level of full immunization coverage is mainly because of the higher DPT and polio dropout rates. The proportion of children receiving yellow fever vaccination is also quite low in the Mombasa informal settlements at 31 per cent. The proportion of children not receiving any type of vaccination is only two per cent. 24 Child Health Table 6.1: Vaccinations among children (CH.1) Percentage of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, Mombasa Informal Settlement Survey, Kenya, 2009 Vaccinated at any time before the survey Percentage of children who received: Number of children aged 12-23 months BCG1 DPT1 DPT2 DPT32 Polio0 Polio1 Polio2 Polio33 Mea- sles4 All# None Yellow fever5 According to: Vaccination card 60.7 64.7 63.8 61.7 46.5 64.4 63.4 57.2 54.7 48.8 0.0 4.0 100 Mother’s report 33.1 33.1 29.2 20.4 25.4 31.4 25.5 11.0 34.9 6.9 2.2 27.2 100 Either 93.8 97.8 93.1 82.1 71.8 95.8 88.9 68.2 89.6 55.7 2.2 31.2 100 Vaccinated by 12 months of age 93.8 96.2 91.5 78.1 71.8 95.8 87.4 65.9 84.8 48.7 2.2 31.2 100 1 MICS indicator 3.1, 2 MICS indicator 3.2, 3 MICS indicator 3.3, 4 MICS indicator 3.4 and MDG indicator 3.6, 5 MICS indicator 3.6. Total number of 12-23 month olds vaccinated with BCG, OPV3, DPT3 and Measles before 12 months, as validated by card or mother’s recall. To estimate the number of children without a card to have received vaccine before 1st birthday the proportion of vaccinations given during the first year of life is assumed to be the same as for the proportion of children with a card that received the vaccine before 1st birthday. #Children who received ‘all’ vaccinations are those who have received 3 doses of DPT & Polio (excluding Polio 0), BCG, and Measles. Figure 6.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months, Mombasa Informal Settlement Survey, Kenya, 2009 Child Health 25 Table 6.2 shows vaccination coverage rates among children aged 12-23 months by sex of the child. Overall, only 65 per cent of children had health cards. If the child did not have a card, the mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and Polio, how many times. The fi gures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. The coverage of BCG, DPT1 and Polio1 is near universal in Mombasa informal settlements. However, the coverage of DPT3 and Polio3 drops by 16 per cent and 28 percentage points respectively. The measles vaccination was received by 90 per cent of children aged 12-23 months. Overall, 56 per cent of children aged 12-23 months are fully vaccinated. That is, they received BCG, 3 doses of DPT, 3 doses of Polio and measles vaccines. The immunization coverage among girls was higher than that of boys. Table 6.2: Vaccinations by sex of the child (CH.2) Percentage of children aged 12-23 months currently vaccinated against childhood diseases by sex of the child, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of children who received: Percent with health card Number of children aged 12- 23 months BCG DPT 1 DPT 2 DPT 3 Polio 0 Polio 1 Polio 2 Polio 3 Mea- sles All None Yellow fever Male 92.2 96.0 94.3 82.3 70.6 92.2 84.6 60.9 88.1 52.2 4.0 26.6 61.8 54 Female (95.6) (100.0) (91.6) (81.8) (73.2) (100.0) (94.0) (76.9) (91.4) (59.9) (0.0) (36.6) (68.3) 46 Total 93.8 97.8 93.1 82.1 71.8 95.8 88.9 68.2 89.6 55.7 2.2 31.2 64.7 100 Note: The calculation is the same as the top panel of Table 6.1 (i.e., children who are vaccinated at any time before the survey is included in the numerator). ( ) Based on 25-49 un-weighted cases. 6.2 Tetanus Toxoid Goal 5, target 6 of the MDGs is to reduce by three quarters the Maternal Mortality Ratio (MMR), with one strategy being to eliminate maternal tetanus. Another goal (Goal 4) is to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1,000 live births. One of the World Fit for Children goal was to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus requires that all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: • Received at least two doses of tetanus toxoid vaccine, the last within the last 3 years; • Received at least 3 doses, the last within the last 5 years; Table 6.3 shows the protection status from tetanus of women who have had a live birth within the last two years. In Mombasa informal settlements, 78 per cent of women who had a child birth during one year preceding the survey had adequate protection against tetanus. The differentials in the neonatal tetanus protection coverage are also shown in Table 6.3. The women aged 25-34 years are more likely to receive neonatal tetanus protection compared with their younger and older counterparts. The differentials by wealth index of the household show a positive association, with the coverage among high wealth index at 80 per cent compared to 79 per cent and 76 per cent respectively for medium and low wealth index households. The differentials in the reported coverage by religions of the household head show a higher proportion of Muslim mothers receiving adequate neonatal protection (83 per cent) compared with Catholics (69 per cent). 26 Child Health 6.3 Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under fi ve worldwide. Most diarrhoea- related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through Oral Rehydration Salts (ORS) or a Recommended Home Fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fl uid intake and continuing to feed the child are also important strategies for managing diarrhoea. The respective goals are to: 1) reduce by one half the deaths due to diarrhoea among children under fi ve by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under fi ve by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 per cent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • (ORT or increased fl uids) AND continued feeding In the Mombasa Informal Settlement Survey questionnaire, mothers (or caretakers) were asked to report whether their child had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the amount the child usually ate and drank. Table 6.3: Neonatal tetanus protection (CH.3) Percentage of mothers with a birth in the last 12 months protected against neonatal tetanus, Mombasa Informal Settlement Survey, Kenya, 2009 Percent of mothers with a birth in the last 12 months who: Number of mothers Received at least 2 doses during last pregnancy Received at least 2 doses, the last within prior 3 years Received at least 3 doses, the last within 5 years Protected against tetanus1 Age 15-24 73.9 1.1 0.0 75.0 104 25-34 (78.3) (8.5) (2.4) (89.2) 46 30-49 67.2 7.9 0.0 75.1 61 Education Primary 75.3 4.8 0.0 80.1 122 Secondary + 74.1 0.0 1.7 75.7 66 Wealth index Low 66.8 8.8 0.0 75.6 68 Medium 77.1 1.4 0.0 78.5 69 High 74.6 3.9 1.5 80.1 73 Religion of household head Catholic (68.6) (0.0) (0.0) (68.6) 31 Other Christian 72.7 4.4 1.0 78.1 111 Muslim 75.1 7.7 0.0 82.8 65 Total 72.9 4.7 .5 78.1 211 1 MICS indicator 3.7 ( ) Based on 25-49 un-weighted cases. Note: 23 women with no education and 4 women belong to other religion are not shown separately. Child Health 27 Table 6.4 shows ORS treatment by background characteristics. It also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Overall, 19 per cent of under fi ve children had diarrhoea in the two weeks preceding the survey. The peak of diarrhoea prevalence occurs in the weaning period, among children aged 6-35 months. For example, 12 per cent of the children below 6 months of age reportedly had diarrhoea during the two weeks preceding the survey compared with 33 per cent among those aged 6-11 months. As expected, a higher proportion of children who live in low wealth index households had diarrhoea compared with those who live in high wealth index households- 23 and 16 per cent respectively. Of those who had diarrhoea, 24 per cent received fl uids from ORS packets; 14 per cent received pre- packaged ORS fl uids, and about 21 per cent received recommended homemade fl uids. Slightly more than two in fi ve (43 per cent) children with diarrhoea received one or more of the recommended home treatments (i.e., received oral dehydration therapy or ORT), while 57 per cent received no treatment. The differentials in the treatment pattern show mixed results with respect to wealth index of the household. Children who live in a Muslim headed household are less likely to receive treatment for diarrhoea compared with those who live in Christian headed households. Table 6.4: Oral rehydration treatment (CH.4) Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), Mombasa Informal Settlement Survey, Kenya, 2009 Had diarrhoea in last two weeks Number of children aged 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea Fluid from ORS packet Recom- mended homemade fluid Pre-packaged ORS fluid No treatment ORT Use Rate Sex Male 18.8 246 (19.8) (14.8) (10.2) (61.7) (38.3) 46 Female 20.0 208 (28.4) (27.1) (18.1) (52.1) (47.9) 42 Age <6 months (11.8) 40 * * * * * 5 6-11 months 32.6 54 * * * * * 18 12-23 months 22.8 100 * * * * * 23 24-35 months 22.7 74 * * * * * 17 36-47 months 18.1 106 * * * * * 19 48-59 months 8.4 80 * * * * * 7 Mother’s education None 24.0 53 * * * * * 13 Primary 22.6 268 20.4 20.4 11.0 61.5 38.5 61 Secondary + 10.9 133 * * * * * 15 Wealth index Low 23.3 150 (24.9) (19.2) (16.1) (58.6) (41.4) 35 Medium 18.9 146 (18.0) (26.4) (7.0) (59.4) (40.6) 28 High 15.9 157 (28.9) (16.0) (18.5) (52.6) (47.4) 25 Religion of household head Christian 19.1 286 27.8 19.2 15.5 57.4 42.6 55 Muslim 18.2 162 (19.7) (22.4) (12.9) (54.5) (45.5) 29 Other * 7 * * * * * 4 Total 19.3 454 23.9 20.6 13.9 57.1 42.9 88 Note: The percentages receiving various treatments will not add to 100 since some children may have received more than one type of treatment. The ORT use rate includes those who received oral rehydration salts from a packet or any appropriate household solution or pre-packaged ORS fluid. *Not shown, based on less than 25 un-weighted cases. ( ) Based on 25-49 un-weighted cases. 28 Child Health Table 6.5 provides information on home management of diarrhoea by background characteristics such as sex, age of child in months, mother’s education, wealth index and religion of household head. Of those under fi ve children who had diarrhoea during the two weeks preceding the survey, 31 per cent drank more than usual while 69 per cent drank the same or less. Thirty eight per cent ate somewhat less, same or more (continued feeding), but 62 per cent ate much less or ate almost none. The differentials in the home management of diarrhoea by sex of the child shows that a higher proportion of girls (28 per cent) received ORT or increased fl uids and continued feeding compared to boys (15 per cent). As expected, the wealth index of the household and proportion receiving home management of diarrhoea are highly positively correlated. 6.4 Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to Acute Respiratory Infections (ARI). Table 6.5: Home management of diarrhoea (CH.5) Percentage of children aged 0-59 months with diarrhoea in the last two weeks who took increased fluids and continued to feed during the episode, Mombasa Informal Settlement Survey, Kenya, 2009 Had diarrhoea in last two weeks Number of children aged 0- 59 months Children with diarrhoea who: Home manage- ment of diarrhea Received ORT or increased fluids AND continued feeding1 Number of children aged 0-59 months with diarrhoea Drank more Drank the same or less Ate somewhat less, same or more Ate much less or none Sex Male 18.8 246 (38.7) (61.3) (31.4) (68.6) (10.6) (14.8) 46 Female 20.0 208 (23.3) (76.7) (46.2) (53.8) (9.3) (27.5) 42 Age 0-11 months 23.7 94 * * * * * * 22 12-23 months 22.8 100 * * * * * * 23 24-35 months 22.7 74 * * * * * * 17 36-47 months 18.1 106 * * * * * * 19 48-59 months 8.4 80 * * * * * * 7 Mother’s education None 24.0 53 * * * * * * 13 Primary 22.6 268 32.8 67.2 39.8 60.2 9.6 17.5 61 Secondary + 10.9 133 * * * * * * 15 Wealth index Low 23.3 150 (25.3) (74.7) (35.6) (64.4) (2.8) (16.3) 35 Medium 18.9 146 (45.7) (54.3) (34.6) (65.4) (13.6) (17.2) 28 High 15.9 157 (24.3) (75.7) (46.5) (53.5) (16.1) (30.9) 25 Religion of household head Christian 19.1 286 37.7 62.3 39.0 61.0 14.4 24.9 55 Muslim 18.2 162 (23.9) (76.1) (32.8) (67.2) (3.1) (15.9) 29 Total 19.3 454 31.4 68.6 38.4 61.6 10.0 20.8 88 1 MICS indicator 3.8 *Not shown, based on less than 25 un-weighted cases. ( ) Based on 25-49 un-weighted cases. Note: 7 children belong to other religion is not shown separately. Child Health 29 Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or diffi cult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia Table 6.6 presents prevalence of acute respiratory infection (ARI or suspected pneumonia) among children aged 0-59 months during the two weeks preceding the survey by selected characteristics. Overall, 10 per cent of the children under fi ve years of age reportedly had ARI during the two weeks prior to the survey. The differentials in the prevalence by selected characteristics show that level of mothers education and household wealth index are negatively associated with ARI prevalence among children. For example, 15 per cent of the children to mothers with no education had ARI compared with nine per cent among those educated up to secondary or higher. The care seeking and treatment of children aged 0-59 months with suspected pneumonia (or ARI) are presented in Table 6.7. Overall, 76 per cent of the children with suspected pneumonia during the Table 6.6: Suspected pneumonia (CH.6) Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks, Mombasa Informal Settlement Survey, Kenya, 2009 Had acute respiratory infection Number of children aged 0-59 months Sex Male 9.7 246 Female 10.2 208 Age 0-11 months 7.1 94 12-23 months 9.3 100 24-35 months 16.8 74 36-47 months 8.1 106 48-59 months 10.0 80 Mother’s education None 14.5 53 Primary 9.2 268 Secondary + 9.4 133 Wealth index Low 14.8 150 Medium 7.4 146 High 7.6 157 Religion of household head Catholic 4.4 64 Other Christian 5.8 222 Muslim 18.2 162 Total 9.9 454 Note: 7 children belong to other religion is not shown separately. two weeks prior to the survey received treatment from any provider. Twenty-two per cent received treatment from government hospital, 17 per cent from government dispensary, four per cent from government health centre, 32 per cent from private hospital/clinic, fi ve per cent from pharmacy and another two per cent from a relative/friend. Further, all mothers/caretakers of children who had suspected pneumonia in Mombasa informal settlement survey were asked on ‘whether the child has received any medicine to treat the illness?’ and ‘what medicine was given to the child?’ Twenty nine per cent of the mothers/caretakers reported that the child was given an antibiotic drug to treat the suspected pneumonia or ARI. 30 Child Health 6.5 Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including carbon monoxide (CO), polyaromatic hydrocarbons, sulphur dioxide (SO2), and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Information regarding solid fuel use by background characteristics such as education level of the household head, wealth index and religion of the household head are shown in Table 6.8. Forty four per cent of the households in Mombasa informal settlements use solid fuels for cooking. Forty fi ve per cent of the households use kerosene for cooking followed by charcoal (38 per cent), wood (6 per cent) and liquefi ed petroleum gas (LPG, 5 per cent). Differentials with respect to household wealth index show that 13 per cent of the high wealth index households use LPG for cooking compared with less than one per cent among low wealth index households. The use of LPG also increases with increasing educational level of the household head. Table 6.7: Care seeking for pneumonia Percentage of children aged 0-59 months with suspected pneumonia who received treatment, received antibiotic treatment, Mombasa Informal Settlement Survey, Kenya, 2009 Percent Percent of children who received treatment for pneumonia from: Government hospital (22.4) Government health centre (4.2) Government dispensary (16.9) Private hospital/clinic (32.4) Pharmacy (4.7) Relative/friend (2.1) Any provider1 (75.8) Percent of children who received antibiotic treatment for suspected pneumonia2 (28.5) Number of children age 0-50 months with suspected pneumonia during the 2 weeks preceding the survey 45 1 MICS indicator 3.9; 2 MICS indicator 3.10 ( ) Based on 25-49 un-weighted cases. Child Health 31 6.6 Malaria Malaria contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of mosquito nets treated with insecticide (ITNs) can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food and younger children should continue breastfeeding. The Mombasa informal settlement survey incorporated questions on the availability and use of bed nets, both at household level and among children under fi ve years of age, as well as anti-malarial treatment, and intermittent preventive therapy for malaria. Availability of Insecticide Treated Nets (ITN) by education level of the household head, wealth index and religion of household head are shown in Table 6.9. The results indicate that 73 per cent of households in Mombasa informal settlements have at least one insecticide treated net. Thirty per cent of the households reported to have two or more mosquito nets and the mean number of nets per households in Mombasa informal settlements is 1.2. As shown in Figure 6.2, the differentials by household characteristics indicate that possession of insecticide treated mosquito nets increases with increasing educational level of the head of the household and the wealth index of the household. For example, 64 per cent of the households headed by an illiterate member have a mosquito net compared with 78 per cent in case of households headed by a member who is educated up to secondary level or above. Table 6.8: Solid fuel use (CH.8) Percent distribution of households according to type of cooking fuel, and percentage of households using solid fuels for cooking, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristic Percent of households using (….) fuel for cooking Total Solid fuels for cooking1 Number of households Liquefied petroleum gas (LPG) Natural/ bio gas Kero- sene Coal/ lignite Charc oal Wood Missing Education of household head None 1.4 0.0 24.4 0.0 42.7 21.3 10.3 100.0 64.0 79 Primary 2.5 0.0 48.2 0.2 36.8 7.0 5.2 100.0 44.1 466 Secondary + 6.9 1.0 45.3 0.0 38.9 1.6 6.3 100.0 40.4 461 Wealth index Low 0.0 0.3 44.5 0.3 32.3 14.9 7.7 100.0 47.5 367 Medium 2.9 0.0 50.7 0.0 38.6 0.5 7.3 100.0 39.1 384 High 13.0 1.6 36.8 0.0 46.1 0.4 2.2 100.0 46.5 265 Religion of household head Catholic 4.3 0.5 55.4 0.0 28.6 2.7 8.5 100.0 31.3 211 Other Christian 5.9 0.6 48.9 0.0 37.4 2.6 4.7 100.0 39.9 502 Muslim 2.6 0.3 28.9 0.4 47.4 13.7 7.2 100.0 61.5 278 Other (0.0) (0.0) (56.2) (0.0) (36.0) (4.1) (3.8) (100.0) (40.1) 25 Total 4.5 0.5 44.8 0.1 38.3 5.7 6.1 100.0 44.0 1,016 1 MICS indicator 3.11 ( ) Based on 25-49 un-weighted cases. Note: 10 households with missing information on education of household head is not shown separately. 32 Child Health Table 6.9: Household possession of mosquito nets (TN01) Percentage of households with at least one and more than one mosquito net (treated or untreated), Mombasa Informal Settlement Survey, Kenya, 2009 Percent of households having any type of mosquito net Average number of nets per household Percent of households having ever treated mosquito nets Average number of ever treated nets per household Percent of households having insecticide treated mosquito nets (ITNs) Average number of ITNs per house-hold Number of households At least one More than one At least one More than one At least one1 More than one Education of household head None 64.3 30.8 1.2 64.3 30.8 1.2 57.8 30.8 1.1 79 Primary 68.2 23.4 1.0 67.1 23.0 1.0 60.7 23.0 0.9 466 Secondary + 78.0 34.8 1.3 77.1 34.8 1.3 69.2 34.8 1.2 461 Wealth index Low 65.6 20.5 0.9 65.6 20.2 0.9 57.8 20.2 0.8 367 Medium 70.6 26.2 1.1 69.3 26.0 1.1 63.9 26.0 1.0 384 High 84.9 46.7 1.7 83.0 46.4 1.7 74.4 46.4 1.5 265 Religion of household head Catholic 73.5 26.8 1.1 73.0 26.3 1.1 66.5 26.3 1.0 211 Other Christian 72.6 28.2 1.2 71.8 28.0 1.1 64.0 28.0 1.0 502 Muslim 72.8 35.5 1.3 71.3 35.1 1.3 65.1 35.1 1.2 278 Other (60.2) (12.2) (0.8) (56.2) (12.2) (0.7) (48.5) (12.2) (0.6) 25 Total 72.5 29.5 1.2 71.5 29.2 1.2 64.4 29.2 1.1 1,016 1 MICS indicator 3.12 ( ) Based on 25-49 un-weighted cases. Note: 10 households with missing information on education of household head is not shown separately. 58 61 69 58 64 74 64 Education of … None Primary Secondary Wealth Index Low Medium High Total Percent Figure 6.2 Percentage of households having an insecticide treated net (ITN), Mombasa Informal Settlement Survey, Kenya, 2009 Child Health 33 As shown in Table 6.10, 64 per cent of children under the age of fi ve slept under any mosquito net the night prior to the survey while 58 per cent slept under an insecticide treated net. There are no signifi cant gender disparities in ITN use among children under fi ve. However, a positive relation is observed with respect to proportion of children sleeping under a mosquito net, and mother’s education and household wealth index. Table 6.11 shows information on women aged 15-49 years who slept under a mosquito net the previous night by selected characteristics. Little more than half (52 per cent) of the women reportedly slept under a mosquito net and 47 per cent slept under an insecticide treated net. As expected the proportion of women sleeping under mosquito nets increases with women’s level of education and household wealth index. Surprisingly, there are no signifi cant differentials noticed with respect to proportion of pregnant and non-pregnant women sleeping under a mosquito net. Table 6.10: Children sleeping under bednets (TN02) Percentage of children aged 0-59 months who slept under an insecticide treated net during the previous night, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of children who: Number of children aged 0-59 months Slept under a bednet1 Slept under an ever treated net Slept under an insecticide treated net (ITN)2 Sex Male 62.3 61.5 57.0 246 Female 65.2 64.3 58.1 208 Age 0-11 months 68.0 68.0 66.9 94 12-23 months 67.9 66.9 60.8 100 24-35 months 62.0 59.3 50.1 74 36-47 months 61.6 61.6 58.9 106 48-59 months 57.4 56.2 47.5 80 Mothers education None 44.6 41.0 31.7 53 Primary 60.1 59.7 53.7 268 Secondary + 78.3 77.6 75.4 133 Wealth index Low 59.3 59.3 53.3 150 Medium 61.7 61.0 54.3 146 High 69.6 67.8 64.5 157 Religion of household head Catholic 70.1 70.1 67.1 64 Other Christian 68.6 68.2 64.6 222 Muslim 55.1 53.3 44.7 162 Total 63.6 62.8 57.5 454 1 MICS indicator 3.14, 2 MICS indicator 3.15 Note: 7 households belong to other religion is not shown separately. 34 Child Health Table 6.12 shows information on treatment of children with anti-malarial drugs. More than one in four (27 per cent) of under fi ve children were ill with fever in the two weeks prior to the survey. Fever prevalence declined with age but peaks at 12-23 months (35 per cent). However, contrary to the expectation, the differentials by mother’s education and wealth index appear to be showing an inconsistent pattern. Further, all mothers with a child below fi ve years who had fever during the two weeks prior to the survey and sought treatment were asked ‘was child given any medicine for fever or malaria?’ and ‘what medicine was given to the child?’ to treat the fever. This includes both medicines given at home and medicines given or prescribed at a health facility. Only 30 per cent of children with fever in the last two weeks preceding the survey were treated with an appropriate anti-malarial drug and 20 per cent received anti- malarial drugs within 24 hours of onset of symptoms in Mombasa informal settlements. Children of mothers having education up to secondary or higher and those from households from the high wealth index were more likely to receive an appropriate anti-malarial drug. For example, only 17 per cent of children who had fever and belonged to low wealth index households received any appropriate anti-malarial drug compared with 31 per cent for those who belonged to high wealth index households. Table 6.11: Women sleeping under bednets (TN03) Percentage of women aged 15-49 years who slept under an insecticide treated net during the previous night, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of women aged 15-49 who: Number of women aged 15-49 Slept under a bednet Slept under an ever treated net Slept under an insecticide treated net (ITN) 1 Age 15-19 38.6 38.6 35.2 118 20-24 48.7 48.3 46.6 242 25-29 58.8 57.3 54.2 186 30-34 57.4 56.5 47.8 121 35-39 51.7 51.7 44.7 74 40-44 (54.2) (54.2) (54.2) 44 45-49 (56.6) (56.6) (48.1) 36 Currently pregnant Yes 52.1 52.1 48.2 53 No 51.7 51.1 47.0 761 Education None 45.8 42.9 40.2 65 Primary 46.9 46.7 42.6 457 Secondary + 60.8 60.1 56.0 295 Wealth index Low 44.1 44.1 39.8 248 Medium 53.7 52.7 49.4 275 High 56.3 55.7 51.3 298 Religion of household head Catholic 60.9 60.9 57.5 140 Other Christian 52.8 52.4 48.1 418 Muslim 45.5 44.7 41.0 248 Total 51.7 51.2 47.2 821 1 MICS indicator 3.19 ( ) Based on 25-49 un-weighted cases. Note: 15 women belong to other religions is not shown separately. Child Health 35 Ta bl e 6. 12 : Tr ea tm en t of c hi ld re n w it h an ti -m al ar ia l d ru gs ( C H .1 2) Pe rc en ta ge o f ch ild re n ag ed 0 -5 9 m on th s w ho w er e ill w ith f ev er in t he la st t w o w ee ks w ho r ec ei ve d an ti- m al ar ia l d ru gs , M om ba sa I nf or m al S et tle m en t Su rv ey , K en ya , 2 00 9 H ad a fe ve r in la st tw o w ee ks N um be r of ch ild re n ag ed 0- 59 m on th s Ch ild re n w ith a f ev er in t he la st t w o w ee ks w ho w er e tr ea te d w ith : N um be r of ch ild re n w ith fe ve r in la st tw o w ee ks An ti- m al ar ia ls : O th er m ed ic at io ns : An y ap pr op ria te an ti- m al ar ia l d ru g w ith in 2 4 ho ur s of o ns et o f sy m pt om s1 SP / Fa ns id ar Ch lo ro - qu in e Am od ia - qu in e Ar te m is in in ba se d co m bi n- at io ns O th er an ti- m al ar ia l An y ap pr op - ria te An ti- m al ar ia l dr ug Pa ra ce t- am ol / Pa na do l/ Ac et am in - op he n As pi rin Ib u- pr of en O th er D on 't kn ow Se x M al e 26 .8 24 6 1. 5 0. 0 1. 5 13 .8 5. 8 21 .0 49 .8 2. 9 4. 3 50 .3 3. 1 15 .0 66 Fe m al e 26 .4 20 8 1. 9 1. 9 1. 7 10 .4 24 .8 40 .6 42 .0 1. 7 1. 7 37 .3 5. 1 26 .4 55 A ge 0- 11 m on th s 34 .6 94 (0 .0 ) (0 .0 ) (2 .8 ) (1 4. 8) (1 7. 9) (3 5. 6) (3 8. 1) (0 .0 ) (2 .8 ) (6 0. 2) (2 .8 ) (2 6. 8) 33 12 -3 5 m on th s 24 .3 17 3 (0 .0 ) (2 .4 ) (2 .3 ) (7 .0 ) (1 1. 4) (2 3. 0) (5 8. 4) (2 .2 ) (2 .2 ) (4 3. 7) (0 .0 ) (1 6. 0) 42 36 -5 9 m on th s 24 .8 18 6 (4 .4 ) (0 .0 ) (0 .0 ) (1 5. 3) (1 4. 7) (3 2. 1) (4 0. 9) (4 .2 ) (4 .2 ) (3 3. 8) (8 .5 ) (1 9. 3) 46 M ot he r’ s ed uc at io n N on e 27 .3 53 * * * * * * * * * * * * 15 Pr im ar y 28 .1 26 8 2. 7 1. 4 0. 0 5. 3 10 .3 18 .3 44 .7 1. 3 2. 6 45 .5 2. 6 10 .4 75 Se co nd ar y + 23 .5 13 3 (0 .0 ) (0 .0 ) (6 .1 ) (1 9. 4) (2 4. 9) (5 0. 3) (5 0. 0) (3 .0 ) (0 .0 ) (4 3. 2) (6 .3 ) (3 7. 9) 31 W ea lt h in de x Lo w 26 .1 15 0 (2 .6 ) (2 .6 ) (0 .0 ) (9 .7 ) (2 .5 ) (1 7. 3) (4 2. 2) (7 .3 ) (7 .3 ) (3 2. 8) (7 .4 ) (9 .7 ) 39 M ed iu m 27 .2 14 6 (2 .5 ) (0 .0 ) (2 .4 ) (1 7. 0) (2 1. 9) (4 1. 4) (4 6. 5) (0 .0 ) (0 .0 ) (6 0. 8) (2 .5 ) (2 9. 1) 40 H ig h 26 .7 15 7 (0 .0 ) (0 .0 ) (2 .2 ) (1 0. 1) (1 8. 4) (3 0. 8) (4 9. 8) (0 .0 ) (2 .2 ) (3 9. 6) (2 .2 ) (2 1. 7) 42 R el ig io n of h ou se ho ld h ea d Ch ris tia n 27 .7 28 6 2. 6 0. 0 1. 2 12 .7 14 .8 29 .9 43 .5 2. 5 1. 2 45 .9 6. 1 21 .2 79 M us lim 24 .8 16 2 (0 .0 ) (2 .5 ) (2 .4 ) (1 1. 9) (1 4. 4) (3 1. 3) (5 1. 5) (2 .3 ) (7 .1 ) (4 1. 1) (0 .0 ) (1 9. 2) 40 To ta l 26 .6 45 4 1. 7 0. 8 1. 6 12 .3 14 .4 29 .9 46 .3 2. 4 3. 1 44 .4 4. 0 20 .2 12 1 1 M IC S in di ca to r 3 .1 8 *N ot s ho w n, b as ed o n le ss t ha n 25 u n- w ei gh te d ca se s. ( ) B as ed o n 25 -4 9 un -w ei gh te d ca se s. N ot e: T he p er ce nt ag es g iv en v ar io us d ru gs w ill n ot a dd t o 10 0 si nc e so m e ch ild re n m ay h av e be en g iv en m or e th an o ne t yp e of d ru g. S ev en c hi ld re n be lo ng t o ot he r re lig io n ar e no t sh ow n se pa ra te ly . 36 Child Health Appropriate anti-malarial drugs include chloroquine, SP/fansidar, artemisinin combination drugs, etc. In Mombasa informal settlements, the most commonly administered anti-malarial drug is Artemisinin based combinations (12 per cent), however majority could not specify the type of anti- malarial drug given to the child (14 per cent). Other types of commonly administered medicines that are not anti-malarials include anti-pyretics such as paracetemol (46 per cent), aspirin (2 per cent), ibuprofen (3 per cent) and other (44 per cent). The sex differentials in treatment pattern are clearly evident. For example, 26 per cent of girls with fever in the last two weeks preceding the survey were treated with an “appropriate” anti-malarial drug within 24 hours of onset of symptoms compared with only 15 per cent of boys. Pregnant women living in places where malaria is highly prevalent are four times more likely than other adults to get malaria and twice as likely to die of the disease. Once infected, pregnant women risk anemia, premature delivery and stillbirth. Their babies are likely to be of low birth weight, which makes them unlikely to survive their fi rst year of life. For this reason, steps are taken to protect pregnant women by distributing insecticide-treated mosquito nets and treatment during antenatal check-ups with drugs that prevent malaria infection (Intermittent Preventive Treatment or IPT). In the Mombasa Informal Settlement Survey, women were asked of the medicines they had received in their last pregnancy during the 2 years preceding the survey. Women are considered to have received intermittent preventive therapy if they received at least 2 doses of SP/Fansidar during the pregnancy. The IPT for malaria in pregnant women who gave birth in the two years preceding the survey by background characteristics are presented in Table 6.13. Seventy two per cent of mothers who delivered a child during the two year period preceding the survey received medicine to prevent malaria during pregnancy. Seventeen per cent received SP/Fansidar only once while 23 per cent received the same two or more times. The differentials by wealth index of the household show a positive correlation with the use of medicine to prevent malaria during pregnancy. For example, 60 per cent of mothers who live in low wealth index households used medicine to prevent malaria during pregnancy compared with 83 per cent among those from high wealth index households. Table 6.13: Intermittent preventive treatment for malaria (CH.13) Percentage of women aged 15-49 years who gave birth during the two years preceding the survey who received intermittent preventive therapy (IPT) for malaria during pregnancy, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of pregnant women who took: Number of women who gave birth in prior two years Medicine to prevent malaria during pregnancy SP/ Fansidar only one time SP/Fansidar two or more times1 SP/ Fansidar, but number of times not known Chloro- quine Other medi- cines Don't know Education Primary 71.3 15.7 23.7 0.0 3.0 10.4 18.5 122 Secondary + 74.5 18.5 21.0 1.6 0.0 10.5 22.9 66 Wealth index Low 60.0 13.3 12.9 0.0 2.8 9.8 22.7 68 Medium 72.0 16.6 30.5 1.5 2.7 5.8 14.8 69 High 83.1 21.2 25.9 0.0 1.2 12.2 22.6 73 Religion of household head Catholic (68.7) (16.5) (21.2) (0.0) (0.0) (9.1) (21.9) 31 Other Christian 72.4 16.3 21.6 1.0 4.2 12.5 17.8 111 Muslim 75.7 20.0 28.2 0.0 0.0 4.5 22.9 65 Total 72.0 17.1 23.2 0.5 2.2 9.3 20.1 211 1 MICS indicator 3.20 ( ) Based on 25-49 un-weighted cases. Note: 23 women with no education and 4 women belong to other religion are not shown separately. Environment 37 Environment 7 7.1 Water Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a signifi cant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis (or snail fever). Drinking water can also be polluted by chemical, physical, and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility of carrying water, often over long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in Mombasa Informal Settlement Survey is as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces 38 Environment The distribution of the population by source of drinking water is shown in Figure 7.1. The same is shown by background characteristics in Table 7.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot), public tap/ standpipe, piped water from neighbour, water kiosk, protected well, tube/bore well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. Overall, 87 per cent of the population in Mombasa informal settlement are using an improved source of drinking water. The differentials by level of education of the household head and wealth index of the household are not in the expected direction with respect to the proportion of population using an improved source of drinking water. This is mainly because of a higher proportion of households headed by highly educated members and those from the high wealth index households use water from ‘cart with tank/drum’, which is categorized under un-improved sources as per international classifi cation of water sources. For example, only fi ve per cent of the population who live in low wealth index households use water from ‘cart with tank/drum’ compared with 16 per cent of the population living in high wealth index households. Other im 2% Figure Momb proved % e 7.1 Percent basa Informa Wa Cart w tage distribu al Settlemen ter kiosk 56% with tank/drum 12% Other ution of hous nt Survey, Ke dwe r unimproved 1% sehold mem enya, 2009 Piped into elling, yard or p 13% bers by sour lot Public t rce of drinkin tap/standpipe 11% Piped from nei 5% ng water, water ighbour % Environment 39 Ta bl e 7. 1: U se o f im pr ov ed w at er s ou rc es ( EN .1 ) Pe rc en t di st rib ut io n of h ou se ho ld p op ul at io n ac co rd in g to m ai n so ur ce o f dr in ki ng w at er a nd p er ce nt ag e of h ou se ho ld p op ul at io n us in g im pr ov ed d rin ki ng w at er s ou rc es , M om ba sa I nf or m al S et tle m en t Su rv ey , K en ya , 2 00 9 M ai n so ur ce o f dr in ki ng w at er To ta l Im pr ov ed so ur ce o f dr in ki ng w at er 1 N um be r of ho us eh ol d m em be rs Im pr ov ed s ou rc es U ni m pr ov ed s ou rc es Pi pe d in to dw el lin g Pi pe d in to ya rd / pl ot Pu bl ic t ap / st an d- pi pe Pi pe d w at er f ro m ne ig hb ou r W at er ki os k Pr ot ec te d w el l O th er im pr ov ed # U np ro te ct ed w el l Ca rt w ith ta nk / dr um O th er un im pr ov ed $ Ed uc at io n of h ou se ho ld h ea d N on e 4. 4 4. 7 11 .9 0. 0 64 .3 6. 9 0. 0 2. 4 5. 1 0. 3 10 0. 0 92 .2 34 7 Pr im ar y 4. 1 3. 9 13 .0 6. 0 58 .3 1. 6 0. 3 0. 2 12 .0 0. 6 10 0. 0 87 .2 1, 38 8 Se co nd ar y + 10 .0 8. 8 9. 5 4. 5 51 .4 0. 1 1. 4 0. 0 13 .5 0. 8 10 0. 0 85 .7 1, 44 1 N on -s ta nd ar d/ D K (2 0. 0) (0 .0 ) (4 .6 ) (0 .0 ) (3 8. 2) (0 .0 ) (2 .2 ) (0 .0 ) (3 5. 1) (0 .0 ) (1 00 .0 ) (6 4. 9) 43 W ea lt h in de x Lo w 0. 0 2. 0 11 .6 3. 9 71 .9 3. 8 0. 3 1. 1 5. 2 0. 3 10 0. 0 93 .4 1, 07 3 M ed iu m 1. 1 3. 8 14 .8 4. 2 58 .4 0. 6 0. 7 0. 0 15 .1 1. 2 10 0. 0 83 .7 1, 07 8 H ig h 20 .0 12 .7 7. 2 5. 7 36 .3 0. 0 1. 4 0. 0 16 .4 0. 5 10 0. 0 83 .2 1, 06 7 R el ig io n of h ou se ho ld h ea d Ca th ol ic 6. 1 6. 2 8. 9 4. 8 56 .6 .2 0. 4 0. 7 14 .8 1. 3 10 0. 0 83 .2 51 6 O th er C hr is tia n 6. 1 5. 8 13 .0 4. 5 55 .8 1. 1 1. 4 0. 6 11 .2 0. 5 10 0. 0 87 .7 1, 49 4 M us lim 8. 7 6. 9 9. 3 4. 2 54 .9 2. 2 .3 0. 0 13 .0 0. 5 10 0. 0 86 .5 1, 14 0 N o re lig io n 3. 0 0. 0 15 .4 11 .2 58 .3 7. 8 0. 0 0. 0 2. 9 1. 4 10 0. 0 95 .7 66 To ta l 7. 0 6. 1 11 .2 4. 6 55 .6 1. 5 0. 8 0. 4 12 .2 0. 6 10 0. 0 86 .8 3, 21 9 1 M IC S in di ca to r 4 .1 # In cl ud es t ub e w el l, bo re ho le a nd b ot tle d w at er ; $I nc lu de s ta nk er /t ru ck a nd b ot tle d w at er . ( ) Ba se d on 2 5- 49 u n- w ei gh te d ca se s. N ot e: 3 p er so ns b el on g to o th er r el ig io n is n ot s ho w n se pa ra te ly . 40 Environment Table 7.2 presents use of in-house water treatment by selected characteristics in Mombasa informal settlements. It shows the percentages of household members using appropriate water treatment methods, separately for all households, for those using improved and unimproved drinking water sources. Households were asked of ways they may be treating water at home to make it safer to drink such as boiling, adding bleach or chlorine, using a water fi lter, and using solar disinfection which are considered as proper treatment of drinking water. Roughly, one out of two households in Mombasa informal settlements drink appropriately treated water. The proportion of households treating the water is nearly the same for those households drawing water from improved (49%) and un-improved sources (50%). Adding bleach chlorine is the most common water treatment method reported at 36 per cent and another 19 per cent of the households boil the water. The proportion of households using appropriate water treatment is positively correlated with the wealth index and level of education of the head of the household. For example, 27 per cent of the low wealth index households appropriately treated drinking water compared with 67 per cent of the high wealth index households (see Figure 7.2). The amount of time it takes to obtain water is presented in Table 7.3. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. The majority (64 per cent) of households in Mombasa informal settlements spend less than 15 minutes for water collection. Excluding those households with water on the premises, the average time to the source to bring drinking water is 13 minutes. Among those households which fetch water from outside the household premises, the differentials by household characteristics and time taken to fetch water show a mixed pattern. However, as expected, the proportion of households having water on premises is positively associated with education of the household head and wealth index of the household. Table 7.2: Household water treatment (EN.2) Percent distribution of household population according to drinking water treatment method used in the household, and percentage of household population that applied an appropriate water treatment method, Mombasa Informal Settlement Survey, Kenya, 2009 Water treatment method used in the household Percent of household members using appropriate water treatment method None Boil Add bleach/ chlorine Other All water sources1 Number of house- hold members Imp- roved sources Number of house- hold members Un-imp- roved sources Number of house- hold members Education of household head None 68.8 16.3 19.5 0.3 31.2 347 31.4 321 (28.4) 26 Primary 56.9 18.3 29.2 0.4 43.0 1,388 42.2 1209 48.3 178 Secondary + 40.7 20.7 47.5 0.4 59.0 1,441 60.2 1238 51.5 203 Non-standard/ DK (62.5) (19.1) (18.4) (0.0) (37.5) 43 (3.7) 28 * 15 Wealth index Low 72.4 13.4 16.4 1.1 27.1 1,073 26.9 1004 29.6 69 Medium 47.4 19.9 39.5 0.1 52.6 1,078 53.8 905 46.4 174 High 33.3 24.2 52.8 0.0 66.7 1,067 67.6 888 62.3 180 Religion of household head Catholic 48.3 18.4 39.5 0.0 51.7 516 51.3 432 53.8 85 Other Christian 46.4 19.9 42.1 0.7 53.2 1,494 54.9 1312 40.9 181 Muslim 57.8 18.6 27.8 0.0 42.2 1,140 39.3 986 60.7 154 Other 63.6 18.7 24.2 0.0 36.4 66 38.0 63 * 3 Total 51.0 19.2 36.2 0.3 48.8 3,219 48.5 2796 50.4 422 1 MICS indicator 4.2 Note: Multiple response categories may be used and hence total may add to more than 100 percent. *Not shown, based on less than 25 un-weighted cases. ( ) Based on 25-49 un-weighted cases. Environment 41 Details on the person who usually collected the water are presented in Table 7.4. In most households, an adult male is likely to be the person collecting the water, accounting for 54 per cent of the households. The differentials by religion of household head show similar pattern. For instance, 55 per cent of adult males in the Muslim households usually collect water compared with 51 per cent or 62 per cent in Catholic or other Christian households respectively in Mombasa informal settlements. This is a unique observation in Table 7.3: Time to source of water (EN.3) Percent distribution of households according to time to go to source of drinking water, get water and return, and mean time to source of drinking water, Mombasa Informal Settlement Survey, Kenya, 2009 Time to source of drinking water Mean time to source of drinking water# Number of house- holds Water on premises Less than 15 minutes 15 minutes to less than 30 minutes 30 minutes to less than 1 hour 1 hour or more Don't know Total Education of household head None 6.4 72.1 0.0 12.7 7.6 1.2 100.0 15.2 79 Primary 12.1 63.7 12.7 8.2 2.8 0.4 100.0 12.4 466 Secondary + 22.6 63.6 6.4 3.8 3.4 0.2 100.0 12.2 461 Wealth index Low 5.8 67.2 11.6 10.6 4.2 0.6 100.0 13.5 367 Medium 10.1 73.1 9.1 4.1 3.2 0.5 100.0 11.1 384 High 41.4 46.6 4.5 4.8 2.8 0.0 100.0 13.7 265 Religion of household head Catholic 3.0 13.1 2.3 1.5 0.7 0.1 20.7 13.0 211 Other Christian 8.8 32.3 3.9 2.7 1.7 0.1 49.6 12.7 502 Muslim 4.5 17.2 2.3 2.4 1.0 0.1 27.5 12.3 278 Other (0.3) (1.4) (0.3) (0.0) (0.0) (0.1) (2.1) (8.5) 25 Total 16.5 64.2 8.8 6.6 3.4 0.4 100.0 12.6 1016 #The mean time to source of drinking water is calculated based on those households that do not have water on the premises. ( ) Based on 25-49 un-weighted cases. Note: 10 households with missing or other category of education of household head is not shown separately. 31 43 59 27 53 67 49 Education of … None Primary Secondary Wealth Index Low Medium High Total Percent Figure 7.2: Percentage of household members using appropriate water treatment method, Mombasa Informal Settlement Survey, Kenya, 2009 42 Environment Mombassa slum settlements, especially since results elsewhere in Kenya show that water collection activities have traditionally remained an activity for women and young children. Adult females usually collect water in 44 per cent of cases, and in less than two per cent of the cases a child under age 15 years. 7.2 Sanitation Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include: fl ush or pour fl ush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine, pit latrine with slab, and composting toilet. Information regarding sanitation by education of the household head, wealth index and religion of household head is shown in Table 7.5. Slightly more than two in three persons (67 per cent) living in households in Mombasa informal settlements use improved sanitation facilities. Use of improved sanitation facilities is strongly correlated with educational level of household head and household wealth index. For example, 46 per cent of the population living in low wealth index households use improved sanitation compared with 82 per cent in case of high wealth index households. Pit latrines with fl ush or slab are the most commonly used facility with 50 per cent of the population in Mombasa informal settlements using the same and another 24 per cent using pit latrines without slab or an open pit. The pour/fl ush to piped sewer system or septic tank is used by 18 per cent. Table 7.4: Person collecting water (EN.4) Percent distribution of households according to the person collecting drinking water used in the household, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristic Person collecting drinking water Number of households Adult woman Adult man Female child under age 15 Male child under age 15 Don't know Total Education of household head None 50.3 45.5 0.0 2.8 1.5 100.0 74 Primary 43.8 54.2 1.8 0.2 0.0 100.0 391 Secondary + 43.0 56.1 0.6 0.3 0.0 100.0 338 Wealth index Low 46.3 50.7 2.1 0.6 0.3 100.0 332 Medium 41.7 57.4 0.6 0.3 0.0 100.0 332 High 44.5 54.7 0.0 0.7 0.0 100.0 146 Religion of household head Catholic 35.6 62.0 1.7 0.0 0.6 100.0 172 Other Christian 48.5 50.8 0.7 0.0 0.0 100.0 396 Muslim 42.1 55.2 0.9 1.8 0.0 100.0 223 Total 44.1 54.2 1.1 0.5 0.1 100.0 810 Note: 7 households from ‘missing or other ’ category of education of household head and 19 households belong to other religion are not shown separately. Environment 43 Ta bl e 7. 5: U se o f sa ni ta ry m ea ns o f ex cr et a di sp os al ( EN .5 ) Pe rc en t di st rib ut io n of h ou se ho ld p op ul at io n ac co rd in g to t yp e of t oi le t fa ci lit y us ed b y th e ho us eh ol d, a nd t he p er ce nt ag e of h ou se ho ld p op ul at io n us in g sa ni ta ry m ea ns of e xc re ta d is po sa l, M om ba sa I nf or m al S et tle m en t Su rv ey , K en ya , 2 00 9 Ty pe o f to ile t fa ci lit y us ed b y ho us eh ol d To ta l Pe rc en ta ge of p op ul at io n us in g sa ni ta ry m ea ns o f ex cr et a di sp os al 1 N um be r of ho us eh ol d m em be rs Im pr ov ed s an ita tio n fa ci lit y U ni m pr ov ed s an ita tio n fa ci lit y Fl us h/ po ur f lu sh t o: Ve nt ila te d im pr ov ed pi t la tr in e Pi t la tr in e w ith s la b Fl us h/ po ur f lu sh to s om e- w he re e ls e Fl us h/ p ou r flu sh t o un kn ow n pl ac e/ n ot su re / do n' t kn ow Pi t la tr in e w ith ou t sl ab / op en p it O th er / m is si ng N o fa ci lit ie s / bu sh / fie ld Pi pe d se w er sy st em Se pt ic ta nk Pi t la tr in e Ed uc at io n of h ou se ho ld h ea d N on e 4. 7 0. 9 6. 5 0. 0 22 .7 0. 0 0. 0 42 .7 0. 0 22 .6 10 0. 0 34 .7 34 7 Pr im ar y 6. 3 8. 2 12 .1 0. 3 40 .2 0. 4 2. 0 24 .3 0. 5 5. 6 10 0. 0 67 .1 1, 38 8 Se co nd ar y + 14 .8 8. 2 11 .8 1. 2 38 .8 0. 4 5. 2 18 .9 0. 2 0. 6 10 0. 0 74 .7 1, 44 1 N on -s ta nd ar d/ D K (0 .0 ) (2 6. 3) (3 3. 6) (0 .0 ) (3 5. 6) (0 .0 ) (0 .0 ) (4 .6 ) (0 .0 ) (0 .0 ) (1 00 .0 ) (9 5. 4) 43 W ea lt h in de x Lo w 0. 3 1. 1 3. 2 0. 0 41 .2 0. 4 0. 8 37 .0 0. 6 15 .4 10 0. 0 45 .8 1, 07 3 M ed iu m 4. 6 6. 5 12 .3 0. 8 50 .7 0. 2 1. 7 23 .1 0. 2 0. 0 10 0. 0 74 .8 1, 07 8 H ig h 24 .8 15 .3 19 .6 1. 2 20 .8 0. 5 7. 0 10 .5 0. 3 0. 0 10 0. 0 81 .7 1, 06 7 R el ig io n of h ou se ho ld h ea d Ca th ol ic 11 .3 9. 3 6. 5 0. 4 44 .5 0. 4 6. 6 18 .8 0. 5 1. 7 10 0. 0 72 .0 51 6 O th er C hr is tia n 11 .1 8. 7 10 .3 0. 9 38 .1 0. 5 3. 3 23 .9 0. 5 2. 8 10 0. 0 69 .0 1, 49 4 M us lim 7. 6 6. 0 15 .9 0. 5 33 .2 0. 2 1. 4 25 .6 0. 0 9. 5 10 0. 0 63 .3 1, 14 0 N o re lig io n 8. 9 0. 0 10 .6 0. 0 46 .5 0. 0 2. 9 20 .5 0. 0 10 .6 10 0. 0 66 .0 66 To ta l 9. 8 7. 7 11 .7 0. 6 37 .6 0. 4 3. 2 23 .6 0. 4 5. 1 10 0. 0 67 .4 3, 21 9 1 M IC S in di ca to r 4 .3 ( ) Ba se d on 2 5- 49 u n- w ei gh te d ca se s. N ot e: 3 p er so ns b el on g to o th er r el ig io n is n ot s ho w n se pa ra te ly . 44 Environment Information on disposal of faeces of children aged 0-2 years of age is presented in Table 7.6. Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet or by rinsing the stool into a toilet or latrine. In 89 per cent of the cases, the stool of children age 0-2 years are disposed safely and almost all of them reported putting the stool in the toilet/latrine as the mode of disposal. As expected, the proportion of households practising safe disposal of children waste increases with mother’s education and household wealth index. Table 7.6: Disposal of child's faeces (EN.6) Percent distribution of children aged 0-2 years according to place of disposal of child's faeces, and the percentage of children aged 0-2 years whose stools are disposed of safely, Mombasa Informal Settlement Survey, Kenya, 2009 Place of disposal of child's faeces Proportion of children whose stools are disposed of safely1 Number of children aged 0- 2 years Child used toilet Put/rinsed into toilet or latrine Put/rinsed into drain or ditch Thrown into garbage Buried Left in the open Other Don't know/ missing Total Mother’s education None (0.0) (78.7) (0.0) (6.2) (0.0) (12.1) (0.0) (3.0) (100.0) (78.7) 31 Primary 1.1 88.6 1.8 2.4 1.2 1.7 1.1 2.1 100.0 89.7 164 Secondary + 3.7 87.7 0.0 4.0 0.0 0.0 1.2 3.5 100.0 91.4 80 Wealth index Low 0.0 79.2 1.0 4.2 2.1 7.3 3.1 3.1 100.0 79.2 90 Medium 3.1 93.2 0.0 0.0 0.0 0.0 0.0 3.7 100.0 96.3 90 High 2.1 89.2 2.2 5.4 0.0 0.0 0.0 1.0 100.0 91.4 94 Religion of household head Catholic (2.5) (94.5) (0.0) (2.9) (0.0) (0.0) (0.0) (0.0) (100.0) (97.1) 37 Other Christian 1.4 86.8 1.4 3.6 1.4 2.7 2.0 0.7 100.0 88.2 140 Muslim 2.0 84.5 1.0 3.0 0.0 3.0 0.0 6.6 100.0 86.4 94 Total 1.7 87.2 1.1 3.3 0.7 2.4 1.0 2.6 100.0 89.0 275 1 MICS indicator 4.4 ( ) Based on 25-49 un-weighted cases. Note: 4 children belong to other religion is not shown separately. As shown in Table 7.7, the percentage share of households using improved sources of drinking water and sanitary means of excreta disposal is 58 per cent. This proportion increases with the education of household head and household wealth index. For example, about 30 per cent of household population living in households whose head has no education are using improved sources of drinking water and sanitary means of excreta disposal in contrast to 64 per cent among members whose household head is educated up to secondary or higher levels. A similar pattern is observed in case of household wealth index. Environment 45 Table 7.7: Use of improved water sources and improved sanitation (EN.7) Percentage of household population using both improved drinking water sources and sanitary means of excreta disposal, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of household population: Using improved sources of drinking water Using sanitary means of excreta disposal Using improved sources of drinking water and using sanitary means of excreta disposal Number of household members Education of household head None 92.2 34.7 29.6 347 Primary 87.2 67.1 57.6 1,388 Secondary + 85.7 74.7 64.1 1,441 Non-standard/DK (64.9) (95.4) (60.4) 43 Wealth index Low 93.4 45.8 42.0 1,073 Medium 83.7 74.8 61.9 1,078 High 83.2 81.7 68.6 1,067 Religion of household head Catholic 83.2 72.0 59.9 516 Other Christian 87.7 69.0 61.1 1,494 Muslim 86.5 63.3 51.2 1,140 No religion 95.7 66.0 64.6 66 Total 86.8 67.4 57.5 3,219 ( ) Based on 25-49 un-weighted cases. Note: 3 persons belong to other religion is not shown separately. 7.3 Hand Washing Practices Hand washing is a critical hygiene intervention to interrupt the transmission of diseases such as diarrhoea and respiratory infections. It is most effective when done using water and soap after visiting a toilet or cleaning a child, before eating or handling food and, before feeding a child. Monitoring correct hand washing behaviour at these critical times is challenging. A reliable alternative to observations or self- reported behaviour is assessing the likelihood that correct hand washing behaviour takes place by observing if a household has a specifi c place where people most often wash their hands and observing if water and soap (or other local cleansing materials) are present at a specifi c place for hand washing. In Mombasa, only six per cent of the households had a specifi c place for hand washing observed leaving 94 per cent of households who could not indicate a specifi c place where household members usually wash their hands (Table 7.8). Among those with a specifi c hand washing place, almost two-thirds (63 per cent) had both water and soap present at the designated place. In 18 per cent of the households only water was available at the designated place, while in 17 per cent of the households the place only had soap but no water. The remaining two per cent of households had neither water nor soap available at the designated place for hand washing. Twenty four per cent of the households were not able to show any soap present in the household and in the remaining 76 per cent either the soap was observed or shown to the interviewer (Table 7.9). 46 Environment Table 7.9: Availability of soap (CH.18) Percent distribution of households by availability of soap in the dwelling, Mombasa Informal Settlement Survey, Kenya, 2009 Place for handwashing observed Place for handwashing not observed Total Percentage of households with soap anywhere in the dwelling1 Number of house- holds Soap observed Soap not observed at place for handwashing Soap shown No soap in house- hold Not able/ Does not want to show soap Soap shown No soap in house- hold Education of household head None 1.3 0.0 0.0 54.4 44.3 0.0 100.0 55.7 79 Primary 1.8 1.3 0.0 71.5 25.0 0.4 100.0 74.6 466 Secondary + 7.8 0.4 0.7 72.5 17.9 0.7 100.0 80.8 461 Wealth index Low 0.3 0.0 0.0 67.8 31.5 0.5 100.0 68.0 367 Medium 1.9 0.8 0.0 76.1 20.7 0.5 100.0 78.8 384 High 14.4 1.9 1.2 65.9 16.2 0.4 100.0 82.2 265 Religion of household head Catholic 4.2 1.0 1.0 75.4 17.4 1.0 100.0 80.6 211 Other Christian 4.2 0.6 0.2 73.9 20.7 0.4 100.0 78.7 502 Muslim 5.5 1.1 0.0 61.3 32.1 0.0 100.0 67.9 278 No religion/other (3.9) (0.0) (0.0) (60.9) (31.4) (3.8) (100.0) (64.8) 25 Total 4.6 0.8 0.3 70.4 23.4 0.5 100.0 75.8 1016 1 MICS indicator 3.22 ( ) Based on 25-49 un-weighted cases. Note: 10 cases with ‘missing or other’ category on education of household head is not shown separately. Table 7.8: Water and soap at place for handwashing (CH.17) Percentage of households where place for handwashing was observed and percent distribution of households by availability of water and soap at place for handwashing, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of households where place for hand-washing was observed Number of house- holds Percent distribution of households where place for handwashing was observed, where: Total Number of house-holds where place for hand- washing was observed Water and soap are available1 Water is available, soap is not available Water is not available, soap is available Water and soap are not available Education of household head None 1.3 79 * * * * * 1 Primary 3.1 466 * * * * * 14 Secondary + 9.0 461 (65.5) (12.6) (21.9) (0.0) (100.0) 41 Wealth index Low 0.3 367 * * * * * 1 Medium 2.7 384 * * * * * 10 High 17.5 265 (67.3) (17.7) (15.0) (0.0) (100.0) 46 Religion of household head Catholic 6.2 211 * * * * * 13 Other Christian 5.0 502 (68.4) (12.2) (15.5) (3.9) (100.0) 25 Muslim 6.6 278 * * * * * 18 No religion/other (3.9) 25 * * * * * 1 Total 5.7 1016 63.1 17.8 17.4 1.7 100.0 58 1 MICS indicator 3.21 *Not shown, based on less than 25 un-weighted cases. () Based on 25-49 un-weighted cases. Note: 10 cases with ‘missing or other’ category of education of household head is not shown separately. Reproductive Health 47 Reproductive Health 8 8.1 Fertility Achieving national development goals is directly linked to the fertility and resources available to support the country’s population. Studies have shown that in most developing countries the resources are meagre to support their populations and hence it is very important to balance the population growth with resources available. To develop programs to target the fertility reduction, information about prevailing fertility levels become a crucial component. In Mombasa Informal Settlement Survey, birth histories of women age 15-49 years from the sampled households were collected to measure the fertility level. Birth histories include details of all children ever born alive to a woman, such as child’s name, sex, month and year of birth, survival status and if dead, the age at death. Table 8.1 presents current fertility levels in Mombasa informal settlements for the three-year period preceding the survey. This corresponds to the period from fi rst quarter of 2006 to fi rst quarter of 2009. Current fertility measures include Age-Specifi c Fertility Rates (ASFRs) and Total Fertility Rate (TFR). ASFRs are calculated by dividing the number of births to women in a specifi c age group by the number of women years lived during a given period. TFR is defi ned as the average number of children a woman would have if she went through her entire reproductive period (15-49 years) reproducing at the prevailing ASFR. The total fertility rate in Mombasa informal settlements is 3.4 children per woman for the three year period preceding the survey. This is higher than the replacement level of fertility. As expected, the ASFR is higher in the age groups of 20-24, 25-29 and 30-34 years, and the contribution of these ages to the total fertility rate is 72 per cent. It is also important to note that the contribution of the youngest age group 15-19 years to the total TFR is almost 12 per cent. The percentage distribution of all women and married women based on the number of children ever born and living are shown in Table 8.2. The mean number of children ever born to all women aged 15-49 years is 1.9 and that of surviving is 1.7. In the case of currently married/in-union women aged 15-49 years, the mean number of children ever born is 2.5 and that of surviving is 2.3. Eleven per cent of the currently married/in-union women aged 15-49 years have not had any live births, which indicates a high level of infertility in Mombasa informal settlements compared to the national average of fi ve per cent (KDHS, 2008- 09). Little more than one in three (34 per cent) currently married/in union women aged 45-49 years reported seven or more children ever born, and this is more than one in fi ve (22 per cent) in case of women aged 40-44 years. Table 8.1: Current fertility Age specific fertility rates (ASFR) and total fertility rate (TFR) for the 3-year period preceding the survey, Mombasa Informal Settlement Survey, Kenya, 2009 Age group ASFR 15-19 0.0821 20-24 0.170 25-29 0.149 30-34 0.173 35-39 0.098 40-44 0.016 45-49 0.000 Total fertility rate 3.4 1 MICS indicator 5.1 TFR: Total fertility rate for women age 15-49 years expressed per woman. 48 Reproductive Health 8.2 Teenage Pregnancy and Motherhood Reducing pregnancy among adolescents is one of the fl agship programs of the Government of Kenya. The proportion of women aged 15-19 years who have had a live birth or are currently pregnant by selected characteristics are shown in Table 8.3. Twenty per cent of women aged 15-19 years have begun child bearing. Of those who begun child bearing, 84 per cent had a live birth. The proportion of women who begun child bearing is higher (25 per cent) among women who live in low wealth index households compared with 15 per cent among those from high wealth index households. Table 8.2: Children ever born and living (RH.11) Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born and living, according to age groups, Mombasa Informal Settlement Survey, Kenya, 2009 Age group Number of children ever born Total Number of women Mean number of children 0 1 2 3 4 5 6 7 + Ever born Living All women 15-19 83.2 15.1 0.0 1.0 0.8 0.0 0.0 0.0 100.0 118 0.2 0.2 20-24 37.8 34.4 16.1 8.3 2.9 0.4 0.0 0.0 100.0 242 1.1 0.9 25-29 24.0 25.8 25.9 14.0 5.9 3.1 1.3 0.0 100.0 186 1.7 1.5 30-34 6.5 13.2 24.5 18.3 22.5 6.5 4.2 4.3 100.0 121 3.0 2.7 35-39 3.7 12.5 13.6 14.4 20.3 17.5 8.5 9.5 100.0 74 3.8 3.4 40-44 (2.4) (15.7) (12.9) (4.7) (25.4) (12.0) (10.7) (16.2) (100.0) 44 (4.1) (3.7) 45-49 (3.0) (9.2) (8.1) (13.0) (14.1) (17.2) (8.1) (27.2) (100.0) 36 (5.1) (4.3) Total 30.1 22.5 16.5 10.6 9.4 4.8 2.6 3.6 100.0 821 1.9 1.7 Currently Married/In-union Women 15-19 41.5 49.7 0.0 4.7 4.1 0.0 0.0 0.0 100.0 24 0.8 0.7 20-24 16.1 44.5 22.9 12.0 4.5 0.0 0.0 0.0 100.0 135 1.4 1.3 25-29 12.4 27.5 29.7 16.1 8.6 3.8 1.9 0.0 100.0 127 2.0 1.8 30-34 3.2 13.8 22.1 18.2 25.7 8.3 4.4 4.3 100.0 94 3.2 2.9 35-39 1.8 11.6 7.6 13.1 22.7 21.4 12.1 9.8 100.0 52 4.1 3.7 40-44 (3.8) (6.9) (13.3) (7.4) (25.6) (11.0) (10.4) (21.5) (100.0) 28 (4.5) (4.1) 45-49 (0.0) (14.5) (4.0) (15.8) (8.7) (18.0) (4.6) (34.3) (100.0) 23 (5.3) (4.6) Total 10.8 27.1 20.3 14.0 13.1 6.4 3.5 4.8 100.0 482 2.5 2.3 ( ) Based on 25-49 un-weighted cases. Table 8.3: Teenage pregnancy and motherhood (RH.12) Percentage of women age 15-19 years who are mothers or pregnant with their first child and percentage who have begun child bearing, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristic Percentage who Percentage who have began child bearing Number of women Have had a live birth Are pregnant with first child Age 15-17 years 6.5 0.0 6.5 65 18-19 years 29.5 7.1 36.5 53 Education Primary 19.1 3.6 22.7 77 Secondary + (8.5) (0.0) (8.5) 36 Wealth index Low (22.3) (2.1) (24.5) 43 Medium (17.3) (2.7) (20.0) 34 High (10.5) (4.7) (15.3) 40 Total 16.8 3.2 20.0 118 Reproductive Health 49 8.3 Contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) spacing the period between births; and 3) limiting the number of children. A World Fit for Children goal is to ensure access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many i.e., unwanted pregnancies. Details on current use of contraception are shown in Table 8.5. Results from the Mombasa informal settlement survey indicate that 40 per cent of married/in union women aged 15-49 years are currently using any contraceptive method. The modern methods were used by 35 per cent while fi ve per cent reported using traditional methods. The most popular method is injections, which is used by 23 per cent followed by pills (7 per cent). All other methods were used by less than two per cent of the married/in-union women aged 15-49 years in Mombasa informal settlements. As expected, the contraceptive use increases with increasing educational levels and household wealth index. For example, only 12 per cent of women with no education reported using any contraceptive method vis-a-vis 51 per cent among those educated up to secondary or higher. 8.4 Unmet Need Unmet need9 for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth or who wish to stop childbearing altogether. Unmet need is identifi ed in MICS by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity, and fertility preferences. Women with an unmet need for spacing includes women who are currently married (or in union), fecund (are currently pregnant or think that they are physically able to become pregnant), currently not using contraception, and want to space their births. Pregnant women are considered to want to space their births when they did not want the child at the time they got pregnant. Women who are not pregnant are classifi ed in this category if they want to have a(another) child, but want to have the child at least two years later, or after marriage. Women with an unmet need for limiting are those women who are currently married (or in union), fecund (are currently pregnant or think that they are physically able to become pregnant), currently not using contraception, and want to limit their births. The latter group includes women who are currently pregnant but had not wanted the pregnancy at all, and women who are not currently pregnant but do not want to have a (another) child. Total unmet need for contraception is simply the sum of unmet need for spacing and unmet need for limiting. Using information on contraception and unmet need, the percentage of demand for contraception satisfi ed is also estimated from the MICS data. Percentage of demand for contraception satisfi ed is defi ned as the proportion of women currently married or in union who are currently using contraception, out of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. 9 Unmet need measurement in MICS is somewhat different than that used in other household surveys, such as the Demographic and Health Surveys (DHS). In DHS, more detailed information is collected on postpartum amenorrhoea, and sexual activity. Results from the two types of surveys are strictly not comparable. 50 Reproductive Health Ta bl e 8. 4: U se o f co n tr ac ep ti on ( R H .1 ) Pe rc en ta ge o f w om en a ge d 15 -4 9 ye ar s cu rr en tly m ar rie d or in u ni on w ho a re u si ng ( or w ho se p ar tn er is u si ng ) a co nt ra ce pt iv e m et ho d, M om ba sa I nf or m al S et tle m en t Su rv ey , K en ya , 2 00 9 Pe rc en t of w om en ( cu rr en tly m ar rie d or in u ni on ) w ho a re u si ng : To ta l An y m od er n m et ho d An y tr ad iti on al m et ho d An y m et ho d1 N um be r of w om en N ot u si ng an y m et ho d Fe m al e st er ili za tio n Pi ll IU D In je ct io ns Im pl an ts Co nd om LA M Pe rio di c ab st in en ce W ith dr aw al A ge 15 -2 4 65 .3 0. 0 3. 5 0. 0 25 .2 0. 6 0. 6 1. 8 3. 0 0. 0 10 0. 0 29 .9 4. 8 34 .7 15 8 25 -3 4 55 .9 0. 5 9. 9 0. 9 24 .6 1. 8 0. 8 1. 8 3. 3 0. 4 10 0. 0 38 .6 5. 5 44 .1 22 1 35 -4 9 63 .2 4. 0 6. 0 2. 0 16 .0 2. 2 2. 8 1. 0 2. 9 0. 0 10 0. 0 33 .0 3. 8 36 .8 10 3 N um be r of li vi ng c hi ld re n 0 89 .9 0. 0 3. 3 0. 0 3. 6 0. 0 1. 7 0. 0 1. 5 0. 0 10 0. 0 8. 7 1. 5 10 .1 60 1 61 .7 0. 0 6. 3 0. 7 22 .6 1. 4 0. 6 2. 0 4. 7 0. 0 10 0. 0 31 .6 6. 7 38 .3 14 1 2 49 .4 0. 0 8. 7 0. 9 35 .0 2. 0 0. 0 1. 0 3. 0 0. 0 10 0. 0 46 .6 4. 0 50 .6 97 3 57 .0 1. 4 9. 0 0. 0 26 .5 1. 3 1. 2 1. 3 2. 3 0. 0 10 0. 0 39 .3 3. 6 43 .0 77 4+ 55 .2 3. 9 6. 9 1. 9 20 .9 2. 1 2. 7 2. 7 2. 8 0. 9 10 0. 0 38 .4 6. 3 44 .8 10 7 Ed uc at io n N on e (8 8. 1) (2 .6 ) (2 .4 ) (0 .0 ) (6 .9 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (1 00 .0 ) (1 1. 9) (0 .0 ) (1 1. 9) 42 Pr im ar y 62 .6 1. 2 5. 8 0. 3 23 .5 1. 1 0. 3 2. 4 2. 4 0. 3 10 0. 0 32 .2 5. 2 37 .4 27 9 Se co nd ar y + 49 .2 0. 6 10 .3 1. 9 26 .5 2. 6 3. 0 0. 6 5. 2 0. 0 10 0. 0 44 .9 5. 8 50 .8 16 0 W ea lt h in de x Lo w 75 .4 0. 8 2. 0 0. 6 15 .9 .7 1. 3 1. 4 2. 0 0. 0 10 0. 0 21 .2 3. 4 24 .6 14 2 M ed iu m 56 .1 0. 6 4. 3 0. 0 28 .9 1. 8 1. 8 3. 0 3. 5 0. 0 10 0. 0 37 .4 6. 5 43 .9 16 1 H ig h 52 .8 1. 8 13 .3 1. 7 23 .3 1. 8 0. 5 0. 6 3. 6 0. 5 10 0. 0 42 .4 4. 7 47 .2 17 9 R el ig io n of h ou se ho ld h ea d Ca th ol ic 61 .7 2. 5 7. 6 0. 0 17 .1 3. 6 1. 3 1. 2 5. 0 0. 0 10 0. 0 32 .1 6. 2 38 .3 80 O th er C hr is tia n 53 .8 0. 5 6. 8 1. 2 29 .4 1. 4 1. 2 2. 0 3. 8 0. 0 10 0. 0 40 .4 5. 8 46 .2 24 0 M us lim 72 .2 1. 4 6. 1 0. 6 14 .4 0. 7 1. 2 1. 4 1. 3 0. 6 10 0. 0 24 .5 3. 3 27 .8 15 1 To ta l 60 .5 1. 1 7. 0 0. 8 23 .0 1. 5 1. 2 1. 6 3. 1 0. 2 10 0. 0 34 .5 4. 9 39 .5 48 2 1 M IC S in di ca to r 5 .3 a nd M D G in di ca to r 5 .3 ( ) Ba se d on 2 5- 49 u n- w ei gh te d ca se s. N ot e: 2 w om en w ith in fo rm at io n on e du ca tio n m is si ng a nd 1 1 w om en b el on g to o th er r el ig io n ar e no t sh ow n se pa ra te ly . Reproductive Health 51 Table 8.5 shows the results of the unmet need and the demand for contraception satisfi ed among currently married or in union women aged 15-49 years in Mombasa informal settlements. The total unmet need for contraception is 24 per cent, of which 14 per cent is for spacing and the remaining 10 per cent is for limiting. As expected, unmet need for contraception decreases with increase in age of women. Overall, among those wanting to use contraception in Mombasa informal settlements, 62 per cent are currently using them or their demands are met. The proportion with demand for contraception satisfi ed increases with increasing educational level and household wealth index. As seen in case of unmet need, the proportion with contraceptive demand satisfi ed (47 per cent) is lower among Muslims compared with other religions (around 68 per cent). 8.5 Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their unborn child. Better understanding of foetal growth and development and its relationship to the mother’s health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to provide information on birth spacing, which is recognized as an important factor Table 8.5: Unmet need for contraception (RH.2) Percentage of women aged 15-49 years currently married or in union with an unmet need for family planning and percentage of demand for contraception satisfied, Mombasa Informal Settlement Survey, Kenya, 2009 Current use of contraception Unmet need for contraception Number of women currently married or in union Percentage of demand for contraception satisfied€ Number of women currently married or in union with need for contraception For spacing@ For limiting# Total1 Age 15-24 34.7 24.2 5.6 29.8 158 53.8 102 25-34 44.1 10.5 10.9 21.5 221 67.3 145 35-49 36.8 3.9 16.0 19.9 103 65.0 58 Education Primary 37.4 13.8 9.9 23.7 279 61.2 170 Secondary + 50.8 10.8 8.7 19.6 160 72.2 112 Wealth index Low 24.6 18.2 13.9 32.2 142 43.4 80 Medium 43.9 12.1 5.7 17.9 161 71.1 100 High 47.2 11.2 11.4 22.6 179 67.6 125 Religion of household head Catholic 38.3 7.1 11.5 18.5 80 (67.4) 45 Other Christian 46.2 14.5 7.2 21.7 240 68.0 163 Muslim 27.8 15.8 15.1 31.0 151 47.3 89 Total 39.5 13.6 10.2 23.8 482 62.3 305 1 MICS indicator 5.4 and MDG indicator 5.6 @Unmet need for spacing is defined as women who are fecund and not currently using contraception and want to space their births. #Unmet need to limit is defined as women who are fecund and not currently using contraception and want to limit their births. €Proportion of demand satisfied is defined as the proportion of currently married or in union women who are currently using contraception of the total demand for contraception. *Not shown, based on less than 25 un-weighted cases. ( ) Based on 25-49 un-weighted cases. Note: 23 women belong to no education or missing information on education and 8 women belong to other religion are not shown separately. 52 Reproductive Health in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of STIs can signifi cantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women’s nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specifi c on the content of antenatal care visits, which include: • Blood pressure measurement • Urine testing for bacteriuria and proteinuria • Blood testing to detect syphilis and severe anemia • Weight/height measurement (optional) The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two preceding years by selected characteristics is presented in Table 8.6. Coverage of antenatal care by any skilled personnel (a doctor, nurse, or midwife) is relatively high in Mombasa informal settlements with 94 per cent of women receiving antenatal care at least once during the pregnancy. No substantial differences were noticed between age, education levels, wealth index and religion with respect to receiving any antenatal care from any skilled personnel. However, in line with other indicators, the proportion of women receiving antenatal care from a medical doctor was higher among women from wealthier households (40 per cent) than those from low wealth index (26 per cent). Table 8.6: Antenatal care provider (RH.3) Percent distribution of women aged 15-49 who gave birth in the two years preceding the survey by type of personnel providing antenatal care, Mombasa Informal Settlement Survey, Kenya, 2009 Person providing antenatal care# No antenatal care Total Antenatal care by any skilled personnel@ Number of women who gave birth in the preceding two years Medical doctor Nurse/ midwife Clinical Officer Relative/ friend Age 15-24 32.9 53.7 7.7 1.0 4.7 100.0 94.3 104 25-34 38.4 50.9 3.3 0.0 7.4 100.0 92.6 83 Education Primary 35.6 52.9 4.1 0.9 6.5 100.0 92.6 122 Secondary + 39.1 52.0 5.9 0.0 3.0 100.0 97.0 66 Wealth index Low 25.9 59.8 7.0 0.0 7.4 100.0 92.6 68 Medium 39.2 49.2 4.4 1.5 5.7 100.0 92.8 69 High 40.4 50.0 5.4 0.0 4.2 100.0 95.8 73 Religion of household head Catholic (25.0) (65.4) (3.3) (0.0) (6.4) (100.0) (93.6) 31 Other Christian 36.8 49.9 7.9 1.0 4.5 100.0 94.5 111 Muslim 36.8 55.4 1.6 0.0 6.2 100.0 93.8 65 Total 35.3 52.9 5.6 0.5 5.7 100.0 93.8 211 1 MICS indicator 5.5a and MDG indicator 5.5 - includes doctors, nurses, midwives, and auxiliary midwives. #If the respondent mentioned more than one provider, only the most qualified provider is considered. ( ) Based on 25-49 un-weighted cases. Note: 24 women age 35-49 years, 23 women with no education and 4 women belong to other religion are not shown separately. Reproductive Health 53 The types of ANC services provided to pregnant women by selected characteristics are shown in Table 8.7. Among those women who have given birth to a child during the two years preceding the survey, 89 per cent reported that a blood sample was taken during antenatal care visits, 90 per cent reported that their blood pressure was checked, 87 per cent reported that urine specimen was taken and in 92 per cent of cases weights were measured. The differentials by selected characteristics are not very substantial. UNICEF and WHO recommend a minimum of at least four antenatal care visits during pregnancy. Table 8.8 shows number of antenatal care visits during the last pregnancy in the two years preceding the survey, regardless of provider by selected characteristics. Almost nine in ten mothers (87 per cent) receive antenatal care more than once and over half of mothers received antenatal care at least four times (57 per cent). Mothers from the poorest households and those with primary education are less likely to receive ANC four or more times than wealthier and highly educated mothers. For example, 44 per cent of the women belonging to low wealth index reported four or more antenatal care visits compared with 64 per cent for those from high wealth index category. 8.6 Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The indicator for skilled attendant at delivery is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 Table 8.7: Antenatal care (RH.4) Percentage of pregnant women receiving antenatal care among women aged 15-49 years who gave birth in two years preceding the survey and percentage of pregnant women receiving specific care as part of the antenatal care received, Mombasa Informal Settlement Survey, Kenya, 2009 Percent of pregnant women receiving ANC one or more times during pregnancy Percent of pregnant women who had@: Number of women who gave birth in two years preceding survey Blood test taken Blood pressure measured Urine specimen taken Weight measured Age 15-24 95.3 88.1 89.4 86.6 92.4 104 25-34 92.6 89.3 87.8 84.4 90.2 83 Education Primary 93.5 85.9 88.4 84.5 92.6 122 Secondary + 97.0 94.2 94.0 92.4 92.4 66 Wealth index Low 92.6 85.8 86.9 82.7 92.6 68 Medium 94.3 91.1 91.1 86.9 89.9 69 High 95.8 90.1 90.4 90.4 93.2 73 Religion of household head Catholic (93.6) (93.6) (90.5) (87.3) (90.5) 31 Other Christian 95.5 88.4 90.1 86.7 92.7 111 Muslim 93.8 90.5 92.0 90.5 92.3 65 Total 94.3 89.0 89.5 86.8 91.9 211 @Proportions are calculated separately: Total number of women weighed, blood pressure measured, gave urine sample, gave blood sample. ( ) Based on 25-49 un-weighted cases. Note: 24 women age 35-49 years, 23 women with no education and 4 women belong to other religion are not shown separately. 54 Reproductive Health Table 8.8: Number of antenatal care visits (RH.7) Percent distribution of women who had a live birth during the two years preceding the survey by number of antenatal care visits by any provider, Mombasa Informal Settlement Survey, Kenya, 2009 Percent distribution of women who had: Number of women who had a live birth in the preceding two years No antenetal care visits One visit Two visits Three visits 4 or more visits1 DK/ missing Total Mother's age at birth Less than 20 (11.4) (12.0) (4.1) (12.6) (59.9) (0.0) (100.0) 25 20-29 3.8 6.1 11.3 20.7 58.2 0.0 100.0 133 30-49 7.7 3.9 9.5 24.5 50.5 3.9 100.0 53 Education Primary 6.5 7.4 12.4 21.6 52.1 0.0 100.0 122 Secondary 3.0 4.7 4.7 17.0 69.1 1.5 100.0 66 Wealth index Low 7.4 7.2 14.2 27.8 43.5 0.0 100.0 68 Medium 5.7 6.1 10.7 14.5 61.4 1.6 100.0 69 High 4.2 5.4 5.3 20.0 63.8 1.3 100.0 73 Religion of household head Catholic (6.4) (12.9) (15.2) (18.5) (47.0) (0.0) (100.0) 31 Other Christian 4.5 4.5 9.6 20.6 60.0 0.9 100.0 111 Muslim 6.2 6.4 7.2 20.0 58.4 1.7 100.0 65 Total 5.7 6.2 10.0 20.7 56.5 1.0 100.0 211 1 MICS indicator 5.5b; MDG indicator 5.5 ( ) Based on 25-49 un-weighted cases. Note: 23 cases with no education and 4 cases from other religion are not shown separately. and 2015. The Mombasa Informal Settlement Survey (MICS4) included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. Table 8.9 shows the type of personnel available at delivery by selected characteristics. Sixty seven per cent of births that occurred during the two years preceding the survey were delivered by skilled personnel. Educated women are more likely to deliver the baby with the assistance of a skilled attendant and a similar trend is observed with the level of household wealth index. For example, 42 per cent of women from low wealth index households were assisted by a skilled health personnel during delivery compared with 89 per cent among those from the high wealth index. The proportion delivering their baby in a health facility shows a similar pattern. A signifi cant proportion (18 per cent) of deliveries to women who live in Mombasa informal settlements were assisted by traditional birth attendants and nine per cent were assisted by either a relative or friend. The differentials by religion of household head show that Muslim women are less likely to deliver their babies with the assistance of any skilled health personnel or deliver their babies in a health facility compared with Catholic or other Christian women who live in Mombasa informal settlements. Reproductive Health 55 T ab le 8 .9 : A ss is ta n ce d u ri n g de liv er y (R H .5 ) Pe rc en t di st rib ut io n of w om en a ge d 15 -4 9 w ith a b irt h in t w o ye ar s pr ec ed in g th e su rv ey b y ty pe o f pe rs on ne l a ss is tin g at d el iv er y, M om ba sa I nf or m al S et tle m en t Su rv ey , K en ya , 20 09 Pe rs on a ss is tin g at d el iv er y N o at te nd an t To ta l An y sk ill ed pe rs on ne l1 D el iv er ed in he al th f ac ili ty 2 N um be r of w om en w ho g av e bi rt h in pr ec ed in g tw o ye ar s M ed ic al do ct or Cl in ic al of fic er N ur se / m id w ife Tr ad iti on al b irt h at te nd an t Co m m un ity he al th w or ke r R el at iv e / fr ie nd O th er / m is si ng A ge 15 -2 4 30 .6 6. 6 31 .8 14 .0 0. 9 11 .3 4. 0 0. 9 10 0. 0 68 .9 66 .9 10 4 25 -3 4 31 .5 4. 8 31 .3 19 .7 0. 0 5. 7 1. 1 5. 9 10 0. 0 67 .6 66 .4 83 Ed uc at io n Pr im ar y 28 .0 6. 3 28 .0 21 .7 0. 0 10 .4 2. 4 3. 2 10 0. 0 62 .3 59 .8 12 2 Se co nd ar y + 41 .0 4. 7 41 .0 6. 1 1. 5 2. 7 1. 5 1. 5 10 0. 0 86 .7 86 .7 66 W ea lt h in de x Lo w 19 .7 3. 0 18 .9 32 .8 0. 0 18 .1 4. 6 2. 9 10 0. 0 41 .6 38 .6 68 M ed iu m 34 .1 4. 2 29 .6 16 .3 1. 4 7. 7 4. 1 2. 7 10 0. 0 67 .9 67 .9 69 H ig h 36 .7 9. 4 43 .2 5. 5 1. 2 1. 2 0. 0 2. 8 10 0. 0 89 .3 87 .9 73 R el ig io n of h ou se ho ld h ea d Ca th ol ic (3 4. 3) (3 .6 ) (3 4. 2) (9 .4 ) (3 .1 ) (1 2. 5) (0 .0 ) (3 .0 ) (1 00 .0 ) (7 2. 1) (6 8. 9) 31 O th er C hr is tia n 31 .2 8. 0 34 .6 12 .2 0. 0 8. 8 3. 5 1. 8 10 0. 0 73 .8 73 .8 11 1 M us lim 28 .9 3. 0 23 .3 29 .6 1. 4 6. 1 3. 2 4. 5 10 0. 0 55 .2 53 .5 65 To ta l 30 .4 5. 6 30 .9 17 .9 0. 9 8. 8 2. 8 2. 8 10 0. 0 66 .9 65 .4 21 1 1 M IC S in di ca to r 5. 7 an d M D G in di ca to r 5. 2 - do ct or s, c lin ic al o ff ic er , nu rs es , m id w iv es a nd c om m un ity h ea lth w or ke r. 2 M IC S in di ca to r 5. 8 ( ) Ba se d on 2 5- 49 u n- w ei gh te d ca se s. N ot e: 2 4 w om en a ge 3 5- 49 , 23 w om en w ith n o ed uc at io n an d 4 w om en b el on g to o th er r el ig io n ar e no t sh ow n se pa ra te ly . 56 Child Development Child Development 9 It is well recognized that a period of rapid brain development occurs in the fi rst 3-4 years of life, and the quality of home care is a major determinant of the child’s development during this period. In this context, adult activities with children, presence of books at home, for the child, and the conditions of care are important indicators of quality of child care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning and development was collected in the Mombasa Informal Settlement Survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting or drawing things. 9.1 Adult Participation in Childhood Development Table 9.1 shows the family support for learning disaggregated by selected characteristics. In slightly more than one in four (26 percent) children under-fi ve, an adult is engaged in four or more activities that promote learning and school readiness during the 3 days preceding the survey. The average number of activities that household members engaged with children was only 2.3. Father’s involvement with one or more activities was in 39 percent cases, with an average of less than one activity during the three days preceding the survey. The differentials by selected characteristics show that, the involvement of parents in childhood development activities is positively associated with parent’s educational level and household wealth index. 9.2 Availability of Learning Materials The mother/caretaker of all children under fi ve years were asked about ‘number of children’s books or picture books you have for the child’, ‘household objects or outside objects’, ‘home made toys’ or ‘toys that came from a shop’ that are available for the child to play with at home, and the results are presented in Table 9.2. Less than seven per cent of the children under fi ve reported to have three or more children’s book. The availability of learning materials at home increased with increasing educational levels of parents. Overall, 33 per cent of the children reported to have three or more types of playing things at home. Seventy three per cent have household objects or outside objects, 46 percent have homemade toys and 72 per cent have toys that came from a shop. The availability of playing things at home increased with parent’s educational level and household wealth index. For example, 33 per cent of the children to mothers with no education reported to have three or more playing things compared with 38 per cent among those with mothers educated up to secondary or higher. Child Development 57 9.3 Child Care Presence of an adult member is an important factor in a child’s growth and development. In Mombasa Informal Settlement Survey, questions were addressed to mother/caretaker of all children below fi ve years of age to understand the extent to which young children are left alone at home, and the results are presented in Table 9.3. The specifi c questions asked were ‘On how many days in the past week the child was - left alone?’ and ‘left in the care of another child (below 10 years old)?’ In Mombasa informal settlements, about one in fi ve children were left with inadequate care during the one week preceding the survey. Ten per cent reported that the child was left in the care of another child and 13 per cent reported that the child was left alone at home. The differentials by selected characteristics show that, the proportion of children left in inadequate care decreases with household wealth. The sex differentials show that a higher proportion of male children were left in inadequate care compared with female children during the week preceding the survey. Table 9.1: Family support for learning (CD.1) Percentage of children aged 0-59 months for whom household members are engaged in activities that promote learning and school readiness, Mombasa Informal Settlement Survey, Kenya, 2009 Percent of children under 5 Mean number of activities Living in a household without their natural father Number of children aged 0-59 months With whom adult household members engaged in four or more activities1 For whom the father engaged in one or more activities2 An adult household member engage in with the child The father engaged in with the child Sex Male 24.6 38.1 2.3 0.7 23.1 246 Female 26.8 39.5 2.4 0.7 17.6 208 Age 0-23 months 10.9 35.8 1.8 0.6 16.3 194 24-59 months 36.6 40.9 2.7 0.9 23.7 260 Mother's education None 23.4 30.8 2.3 0.4 20.4 53 Primary 21.4 43.6 2.2 0.8 19.4 268 Secondary + 35.1 32.1 2.6 0.7 23.0 133 Father's education Primary 21.5 47.4 2.2 0.8 NA 174 Secondary + 30.3 50.6 2.5 1.1 NA 171 Father not in HH 23.6 4.1 2.3 0.1 100.0 93 Wealth index Low 20.8 30.4 2.1 0.5 26.6 150 Medium 24.1 40.2 2.3 0.8 17.6 146 High 31.6 45.4 2.6 0.9 17.6 157 Religion of household head Catholic 22.9 33.5 2.3 0.7 26.9 64 Other Christian 25.3 42.0 2.3 0.8 19.5 222 Muslim 28.2 36.8 2.4 0.7 19.8 162 Total 25.6 38.7 2.3 0.7 20.6 454 1 MICS indicator 6.1 – engaged in activities to promote learning and school readiness during past 3 days. 2 MICS indicator 6.2 – Father engaged in activities that promote learning and school readiness. Note: 15 children with father’s education none or other and 7 children belong to other religion are not shown separately. 58 Child Development Table 9.2: Learning materials for children (CD.2) Percentage of children aged 0-59 months living in households containing learning materials, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristic Percent of children having 3 or more books1 Child play with Percent of children having 3 or more types of playing things Number of children aged 0-59 months Household objects or outside objects Home- made toys Toys that came from shop No playthings mentioned Sex Male 7.8 69.9 45.1 70.2 13.2 33.8 246 Female 5.4 76.4 46.9 73.4 9.6 32.2 208 Age 0-23 months 1.6 58.6 39.0 63.9 22.8 28.0 194 24-59 months 10.5 83.5 51.0 77.5 3.1 36.8 260 Mother's education None 4.0 81.8 59.6 53.2 14.7 33.4 53 Primary 5.6 72.0 41.2 69.2 12.9 30.5 268 Secondary + 10.0 71.0 49.8 84.0 7.5 38.1 133 Father's education Primary 3.7 75.8 44.9 67.5 14.5 32.9 174 Secondary + 11.7 71.1 49.4 78.8 9.3 37.3 171 Father not in HH 4.4 71.6 39.2 72.5 7.5 26.5 93 Wealth index Low 2.1 75.8 43.3 55.4 14.2 22.8 150 Medium 9.5 72.5 47.4 75.3 10.7 39.2 146 High 8.6 70.4 46.9 83.8 9.8 37.1 157 Religion of household head Catholic 7.6 69.9 41.5 71.5 9.7 27.6 64 Other Christian 6.4 69.5 41.7 73.9 12.3 31.1 222 Muslim 6.4 79.3 54.7 71.6 10.5 39.3 162 Total 6.7 72.9 45.9 71.7 11.5 33.1 454 1 MICS indicator 6.3. Note: 15 children with father’s education none or other and 7 children belong to other religion are not shown separately. Child Development 59 9.4 Child Development Index Early child development is defi ned as an orderly, predictable process along a continuous path, in which a child learns to handle more complicated levels of moving, thinking, speaking, feeling and relating to others. Physical growth, literacy and numeracy skills, socio-emotional development and readiness to learn are vital domains of a child’s overall development, which is a basis for overall human development. In Mombasa Informal Settlement Survey a 10-item questionnaire was developed and used to calculate the Early Child Development Index (ECDI). The question specifi es some benchmarks that children would be expected to have if they are developing as the majority of children in that age group. The primary purpose of the ECDI is to inform public policy regarding the developmental status of surveyed Mombasa children. The results are presented in Table 9.4. In Mombasa informal settlements, 40 per cent of children aged 36-59 months are developmentally on track. ECDI is higher among boys (43 per cent) than girls (37 per cent). As expected, ECDI is much higher in older age group (49 per cent among 48-59 months old compared to 33 per cent among 36-47 months old), since children gain more skills with increase in age. Higher ECDI is seen in children attending pre-school (55 per cent compared to 17 per cent for those who are not attending Table 9.3: Children left alone or with other children (CD.3) Percentage of children age 0-59 months left in the care of other children under the age of 10 years or left alone in the past week, Mombasa Informal Settlement Survey, Kenya, 2009 Characteristic Percentage of children age 0-59 months Number of children aged 0-59 months Left in the care children under the age of 10 years in past week Left alone in the past week Left with inadequate care in past week1 Sex Male 12.5 13.4 21.5 246 Female 7.7 12.5 16.5 208 Age 0-23 months 8.2 10.3 13.9 194 24-59 months 11.9 15.0 23.1 260 Mother's education None 7.4 17.9 21.6 53 Primary 9.6 13.7 17.8 268 Secondary + 12.9 9.7 21.1 133 Father's education Primary 13.1 16.0 23.4 174 Secondary + 10.0 7.6 14.7 171 Father not in HH 7.5 17.3 20.6 93 Wealth index Low 12.6 18.5 26.5 150 Medium 11.1 11.6 17.9 146 High 7.4 9.0 13.4 157 Religion of household head Catholic 22.0 15.5 31.3 64 Other Christian 9.4 11.2 17.5 222 Muslim 7.4 15.1 17.6 162 Total 10.3 13.0 19.2 454 1 MICS indicator 6.5 - inadequate care is defined as children left in the care of other children under the age of 10 years or left alone in the past week. Note: 15 children with father’s education none or other and 7 children belong to other religion are not shown separately. 60 Child Development preschool) – a somewhat expected pattern, but not of this magnitude. Children living in low wealth index households have lower ECDI (34 per cent) compared to children living in high wealth index households (47 per cent of children developmentally on track). The analysis of four domains of child development shows that 76 per cent of Mombasa children living in informal settlements are on track in the learning domain, but much less on track (53 per cent) in physical, literacy-numeracy (46 per cent) and social-emotional (43 per cent) domain. The pattern is similar as the one presented above – in each individual domain the higher score is associated with high wealth index households, with children attending preschool, older children, and among boys. Table 9.4: Child development outcomes (CD5 – MICS4) Percentage of children age 36-59 months who are developmentally on target in language-cognitive, physical, social-emotional, and approaches to learning domains, and the child development index score, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of children age 36-59 months who are developmentally on target for indicated domains Child development index score1 Number of children age 36-59 months Language- Cognitive Physical Social- Emotional Approaches to learning Sex Male 48.8 60.7 45.7 81.4 43.3 99 Female 44.0 44.7 40.2 69.3 36.8 88 Age 36-47 months 33.0 57.7 45.0 69.6 33.3 106 48-59 months 64.4 47.3 40.6 83.8 49.4 80 Preschool attendance Attending 62.9 55.9 49.9 79.3 54.6 116 Not attending 20.2 53.3 36.1 77.2 17.0 62 Mother’s education Primary 44.3 56.9 43.3 78.2 41.1 108 Secondary + 59.3 48.2 44.8 75.7 41.1 56 Wealth index Low 30.9 56.5 38.4 69.9 34.1 63 Medium 44.0 49.0 44.6 77.2 39.2 60 High 64.4 53.8 46.6 80.1 47.3 63 Religion of household head Catholic (48.0) (42.3) (41.0) (76.1) (33.9) 29 Other Christian 49.0 50.7 38.9 79.9 40.7 87 Muslim 44.7 61.9 48.4 70.5 44.0 68 Total 46.5 53.2 43.1 75.7 40.2 186 1 MICS indicator 6.6 - child development index is calculated as the percentage of children who are developmentally on target in at least three of the four component domains (language-cognitive, physical, social-emotional, and approaches to learning). ( ) Based on 25-49 un-weighted cases. Note: 8 children with missing information on pre-school attendance, 23 children with illiterate mother/caretaker and 3 children belong to other religion are not shown separately. Administrator Sticky Note An updated Table 9.4 with the corrected ECDI values has been appended at the end of the report. MICS Team - 17 March 2016 Education 61 Education 10 10.1 Pre-School Attendance and School Readiness Attendance to pre-school education in an organized learning or child education program is important for the readiness of children to school. One of the World Fit for Children goals is the promotion of early childhood education. Details on Early Childhood Education (ECD) by background characteristics such as sex and age of child in months, mother’s education, wealth index and religion of household head are presented in Table 10.1. Sixty two per cent of children aged 36-59 months are currently attending an early childhood education centre (or pre-school). The proportion of children attending an ECD centre increases with mother’s education and wealth index. For example, 51 per cent of children of mothers with no education currently attend an ECD centre while attendance is 74 per cent among children with mothers educated up to secondary and above. Similarly, 45 per cent of children living in low wealth index households attend pre-school compared with 80 per cent among those who live in high wealth index households. As expected, children of young age group 36-47 months are less likely (54 per cent) to attend pre-school in comparison to 48-59 months old (73 per cent). Table 10.1: Early childhood education (ED.1) Percentage of children aged 36-59 months who are attending some form of organized early childhood education programme, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of children currently attending early childhood education1 Number of children aged 36-59 months Sex Male 63.2 99 Female 61.6 88 Age of child 36-47 months 54.1 106 48-59 months 73.4 80 Mother's education Primary 58.8 108 Secondary + 73.9 56 Wealth index Low 44.5 63 Medium 62.3 60 High 80.4 63 Religion of household head Catholic (57.8) 29 Other Christian 67.6 87 Muslim 60.4 68 Total 62.4 186 1 MICS indicator 6.7 ( ) Based on 25-49 un-weighted cases. Note: 23 children with no education on mother and 2 children belong to other religion are not shown separately. 62 Education 10.2 Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and infl uencing population growth. The indicators for primary and secondary school attendance include: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of children of secondary school age • Female to male education ratio (or gender parity index - GPI) The indicators of school progression include: • Survival rate to grade fi ve • Transition rate to secondary school • Net primary completion rate Information on Primary school entry by sex of the child is presented in Table 10.2. Among children who are of primary school entry age (6 years) in Mombasa informal settlements, 57 per cent are attending the fi rst grade of primary school. More male children of primary school entry age are attending the fi rst grade (62 per cent) compared with female children (52 per cent). Table 10.2: Primary school entry (ED.2) Percentage of children of primary school entry age (6 years old) attending grade 1, Mombasa Informal Settlement Survey, Kenya, 2009 Percentage of children currently attending grade 11 Number of children of primary school entry age Male (62.2) 35 Female (52.0) 32 Total 57.4 67 1 MICS indicator 7.3 ( ) Based on 25-49 un-weighted cases. Table 10.3 provides the percentage of children of primary school age attending primary school by selected characteristics. Ninety-one per cent of children of primary school age are attending school. Primary school attendance among female children is slightly higher than that of male children, 92 per cent against 90 per cent. As expected, primary school attendance increases with increasing education of the mother and household wealth index. For example, 86 per cent of the primary school age children from low wealth index are currently attending primary school compared with 97 per cent from high wealth index households. Education 63 Table 10.3: Primary school net attendance ratio (ED.3) Percentage of children of primary school age (6 – 13 years) attending primary or secondary school (NAR), Mombasa Informal Settlement Survey, Kenya, 2009 Net attendance ratio1 Number of children Male Female Total Male Female Total Age 6 (67.5) (80.8) 73.8 35 32 67 7 (85.1) (83.7) 84.5 40 25 65 8 (100.0) (95.3) 97.2 27 40 67

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