Lao PDR - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

Lao PDR Monitoring the situation of children and women Multiple Indicator Cluster Survey 2006 Ministry of Planning and Investment Department of Statistics Ministry of Health Hygiene and Prevention Department United Nations Children’s Fund Multiple Indicator Cluster Survey, 2006 i Ministry of Planning and Investment Department of Statistics Multiple Indicator Cluster Survey 2006 September 2008 FINAL REPORT Ministry of Health Hygiene and Prevention Department ii Multiple Indicator Cluster Survey, 2006 The Lao PDR Multiple Indicator Cluster Survey (MICS) was carried out by the Department of Sta- tistics of Ministry of Planning and Investment in collaboration with the Hygiene and Prevention De- partment of Ministry of Health. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) and by the US Centers for Disease Control and Prevention. The survey was conducted as part of the third round of MICS surveys (MICS3), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MICS surveys that were conducted in 1995 and the year 2000. Survey tools were based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Department of Statistics and UNICEF. 2008. Lao PDR Multiple Indicator Cluster Survey 2006, Final Report. Vientiane, Lao PDR: Department of Statistics and UNICEF. Multiple Indicator Cluster Survey, 2006 iii Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Lao PDR, 2006 1 Differs from the standard MICS indicator, as the Lao PDR MICS only tested the presence/absence of iodine in salt, and did not test whether it was “adequately” iodised by measuring ppms. i Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Lao PDR, 2006 Topic MICS Indicator Number MDG Indicator Number Indicator Value NUTRITION 6 4 Underweight prevalence 37.1 percent 7 Stunting prevalence 40.4 percent Nutritional status 8 Wasting prevalence 6.5 percent 45 Timely initiation of breastfeeding 29.8 percent 15 Exclusive breastfeeding rate 26.4 percent Breastfeeding 16 Continued breastfeeding rate at 12-15 months at 20-23 months 81.7 percent 48.4 percent Salt iodisation 41 Iodised salt consumption (salt with any iodine) 83.81 percent 42 Vitamin A supplementation (under-fives) 18.1 percent Vitamin A 43 Vitamin A supplementation (post-partum mothers) 17.9 percent 9 Low birth weight infants 10.8 percent Low birth weight 10 Infants weighed at birth 22.1 percent CHILD HEALTH 25 Tuberculosis immunization coverage 61.0 percent 26 Polio immunization coverage 32.2 percent 27 DPT immunization coverage 31.8 percent 28 15 Measles immunization coverage 33.0 percent Immunization 31 Fully immunized children 14.2 percent Tetanus toxoid 32 Neonatal tetanus protection 55.5 percent 33 Use of oral rehydration therapy (ORT) 50.5 percent 34 Home management of diarrhoea 34.8 percent 35 Received ORT or increased fluids, and continued feeding 49.2 percent 23 Care seeking for suspected pneumonia 32.3 percent Care of illness 22 Antibiotic treatment of suspected pneumonia 52.1 percent Solid fuel use 24 29 Solid fuels 97.5 percent 36 Household availability of insecticide-treated nets (ITNs) 45.0 percent 37 22 Under-fives sleeping under insecticide-treated nets 40.5 percent 38 Under-fives sleeping under mosquito nets 86.7 percent 39 22 Antimalarial treatment (under-fives) 5.1 percent Malaria 40 Intermittent preventive malaria treatment (pregnant women) 1.0 Percent 1 Differs from the standard MICS indicator, as the Lao PDR MICS only tested the presence/absence of iodine in salt, and did not test whether it was “adequately” iodised by measuring ppms. iv Multiple Indicator Cluster Survey, 2006 2 This figure does not correspond to the standard MICS indicator (Indicator 95) for “slum household” as the durability and tenure of the household are not taken into consideration in Lao PDR MICS. 3 This figure represents the survival rate to grade five. This is different from the standard MICS indicator of the net primary school completion rate (MICS Indicator 57) as this figure does not include children that repeat grades and eventually move up to reach grade five. ii Topic MICS Indicator Number MDG Indicator Number Indicator Value ENVIRONMENT 11 30 Use of improved drinking water sources 51.5 percent 12 31 Use of improved sanitation facilities 44.8 percent 13 Water treatment 65.7 percent Water and Sanitation 14 Disposal of child's faeces 11.4 percent Security of tenure and durability of housing Houses in Poor Condition 45.92 percent REPRODUCTIVE HEALTH 20 Antenatal care 35.1 percent 44 Content of antenatal care Blood sample taken Blood pressure measured Urine specimen taken Weight measured 9.3 percent 23.8 percent 11.4 percent 31.8 percent 4 17 Skilled attendant at delivery 20.3 percent Maternal and newborn health 5 Institutional deliveries 17.1 percent CHILD DEVELOPMENT 46 Support for learning 25.3 percent 47 Father's support for learning 19.8 percent 48 Support for learning: children’s books 2.5 percent 49 Support for learning: non-children’s books 10.7 percent 50 Support for learning: materials for play 30.0 percent Child development 51 Non-adult care 25.5 percent EDUCATION 52 Pre-school attendance 7.4 percent 53 School readiness 30.9 percent 54 Net intake rate in primary education 57.7 percent 55 6 Net primary school attendance rate 79.0 percent 56 Net secondary school attendance rate 35.5 percent 57 7 Children reaching grade five 65.43 percent 58 Transition rate to secondary school 88.2 percent 59 7b Primary completion rate 26.7 percent Education 61 9 Gender parity index primary school secondary school 0.95 ratio 0.81 ratio Literacy 60 8 Adult literacy rate 67.3 Percent 2 This figure does not correspond to the standard MICS indicator (Indicator 95) for “slum household” as the durability and tenure of the household are not taken into consideration in Lao PDR MICS. 3 This figure represents the survival rate to grade five. This is different from the standard MICS indicator of the net primary school completion rate (MICS Indicator 57) as this figure does not include children that repeat grades and eventually move up to reach grade five. Multiple Indicator Cluster Survey, 2006 v iii Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD PROTECTION Birth registration 62 Birth registration 71.5 percent 71 Child labour 11.3 percent 72 Labourer students 72.2 percent Child labour 73 Student labourers 12.0 percent Child discipline 74 Child discipline Any psychological/physical punishment 71.2 percent Domestic violence 100 Attitudes towards domestic violence 81.2 percent Disability 101 Child disability 8.2 percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 90 Counselling coverage for the prevention of mother- to-child transmission of HIV 7.6 percent 91 Testing coverage for the prevention of mother-to- child transmission of HIV 1.1 percent 75 Prevalence of orphans 6.6 percent 77 20 School attendance of orphans versus non-orphans 0.85 ratio Support to orphaned and vulnerable children 78 Children’s living arrangements 3.9 percent vi Multiple Indicator Cluster Survey, 2006 Table of Contents Summary Table of Findings . iii Table of Contents . vi List of Tables . viii List of Figures . x List of Abbreviations . xi Foreword . xii Executive Summary . xiii Chapter 1 Introduction . 3 Background . 3 Survey Objectives . 4 Chapter 2 Sample and Survey Methodology . 7 Sample Design . 7 Questionnaires . 7 Training and Fieldwork . 8 Data Processing . 9 Chapter 3 Sample Coverage and the Characteristics of Households and Respondents .13 Sample Coverage . 13 Characteristics of Households . 13 Characteristics of Respondents .14 Chapter 4 Nutrition . 19 Nutritional Status . 19 Breastfeeding . 21 Salt Iodisation . 24 Vitamin A Supplements . 25 Low Birth Weight . 26 Chapter 5 Child Health . 29 Immunization . 29 Tetanus Toxoid . 31 Oral Rehydration Treatment . 32 Care Seeking and Antibiotic Treatment of Pneumonia . 34 Solid Fuel Use . 34 Malaria . 35 Multiple Indicator Cluster Survey, 2006 vii Chapter 6 Environment . 39 Water and Sanitation . 39 Houses in poor condition . 42 Chapter 7 Reproductive Health . 45 Antenatal Care . 45 Assistance at Delivery . 46 Chapter 8 Child Development . 49 Chapter 9 Education . 53 Pre-School Attendance and School Readiness . 53 Primary and Secondary School Participation . 53 Adult Literacy . 56 Chapter 10 Child Protection . 59 Birth Registration . 59 Child Labour . 59 Child Discipline . 60 Domestic Violence . 60 Child Disability . 61 Chapter 11 HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children . 65 HIV counselling and testing . 65 Orphans and Vulnerable Children . 65 List of Table . 69 Appendix A. Sample Design . 135 Appendix B. List of Personnel Involved in the Survey . 139 Appendix C. Estimates of Sampling Errors . 143 Appendix D. Data Quality Tables . 152 Appendix E. MICS Indicators: Numerators and Denominators . 159 Appendix F. Questionnaires . 166 viii Multiple Indicator Cluster Survey, 2006 List of Tables Table HH.1: Results of household and individual interviews Table HH.2: Household age distribution by sex Table HH.3: Household composition Table HH.4: Women’s background characteristics Table HH.5: Children’s background characteristics Table NU.1: Child malnourishment Table NU.2: Initial breastfeeding Table NU.3: Breastfeeding Table NU.3w: Infant feeding patterns by age Table NU.4: Adequately fed infants Table NU.5: Iodised salt consumption Table NU.6: Children’s vitamin A supplementation Table NU.7: Post-partum mothers’ vitamin A supplementation Table NU.8: Low birth weight infants Table CH.1: Vaccinations in first year of life Table CH.2: Vaccinations by background characteristics Table CH.3: Neonatal tetanus protection Table CH.4: Oral rehydration treatment Table CH.5: Home management of diarrhoea Table CH.6: Care seeking for suspected pneumonia Table CH.7: Antibiotic treatment of pneumonia Table CH.7A: Knowledge of the two danger signs of pneumonia Table CH.8: Solid fuel use Table CH.9: Solid fuel use by type of stove or fire Table CH.10: Availability of insecticide treated nets Table CH.11: Children sleeping under bednets Table CH.12: Treatment of children with anti-malarial drugs Table CH.13: Intermittent preventive treatment for malaria Table EN.1: Use of improved water sources Table EN.2: Household water treatment Table EN.3: Time to source of water Table EN.4: Person collecting water Table EN.5: Use of sanitary means of excreta disposal Table EN.6: Disposal of child’s faeces 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 Multiple Indicator Cluster Survey, 2006 ix Table EN.7: Use of improved water sources and improved sanitation Table EN.8: Houses in poor condition Table RH.1: Antenatal care provider Table RH.2: Antenatal care Table RH.2w: Antenatal care content Table RH.3: Assistance during delivery Table CD.1: Family support for learning Table CD.2: Learning materials Table CD.3: Children left alone or with other children Table ED.1: Early childhood education Table ED.2: Primary school entry Table ED.3: Primary school net attendance ratio Table ED.4: Secondary school net attendance ratio Table ED 4W Secondary school age children attending primary school Table ED.5: Children reaching grade five Table ED.6: Primary school completion and transition to secondary education Table ED.7: Education gender parity Table ED.8: Adult literacy Table CP.1: Birth registration Table CP.2: Child labour Table CP.2w: Child labour (working table) Table CP.3: Labourer students and student labourers Table CP.4: Child discipline Table CP.5: Attitudes toward domestic violence Table CP.6: Child disability Table HA.1: HIV testing and counselling coverage during antenatal care Table HA.2: Children’s living arrangements and orphanhood Table HA.3: School attendance of orphaned children 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 x Multiple Indicator Cluster Survey, 2006 List of Figures Figure HH.1: Age and sex distribution of household population Figure NU.1: Percentage of children under-five who are undernourished Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth Figure NU.3: Infant feeding patterns by age: Percent distribution of children aged under three by feeding pattern by age group Figure NU.4: Percentage of households consuming adequately iodised salt Figure CH.1: Percentage of children aged 12-23 months who received the recom- mended vaccination by 12 months Figure CH.2: Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus Figure CH.3: Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment Figure CH.4: Percentage of children aged 0-59 months with diarrhoea who received ORT or increased fluids, AND continued feeding Figure EN.1: Percentage distribution of household members by source of drinking water 14 20 22 23 24 30 31 32 33 40 Multiple Indicator Cluster Survey, 2006 xi List of Abbreviations AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care BCG Bacillis-Cereus-Geuerin (Tuberculosis) CBAW Child-bearing Age Women CLE Centre for Laboratory and Epidemiology CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization FDQCC Food and Drug Quality Control Centre GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders INMU Institute of Nutrition, Mahidol University, Thailand IPT Intermittent Preventive Treatment ITN Insecticide Treated Net Lao PDR Lao People’s Democratic Republic MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MOH Ministry of Health MPI Ministry of Planning and Investment NCHS U.S. National Centers for Health Statistics NGPES National Growth and Poverty Eradication Strategy NSC National Statistics Centre (New name - Department of Statistics) NSEDP National Socioeconomic Development Plan ORS Oral Re-hydration Salts ORT Oral Re-hydration Treatment ppm Parts Per Million RHF Recommended Home Fluid SPSS Statistical Package for Social Sciences UI International Unit UNAIDS United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund USCDC U.S. Center for Disease Control and Prevention USI Universal Salt Iodisation WFFC World Fit For Children WHO World Health Organization xii Multiple Indicator Cluster Survey, 2006 Foreword The Multiple Indicator Cluster Survey 2006 (MICS 2006) is the third Multiple Indicator Cluster Survey undertaken by the Department of Statistics (Former NSC) of the Ministry of Planning and Investment in close collaboration with the Hygiene and Prevention Department of Ministry of Health. For the pur- poses of MICS3 a number of additional nutrition indicators were included, with the aim of strengthen- ing the planning and management of the national nutrition programme. A separate National Nutrition Survey report has been produced to document the findings from the nutrition component of the survey. MICS3 was carried out by the Department of Statistics, under the Ministry of Planning and Invest- ment, in collaboration with the Hygiene and Prevention Department, under the Ministry of Health. UNICEF and the US Centers for Disease Control and Prevention (US CDC) provided financial and technical support for the survey. The survey was undertaken with the purpose of: • providing up-to-date information to be used to assess the situation of children and women in the Lao PDR; • furnishing data needed for monitoring progress toward goals established in the Millennium Declaration, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals; • providing a basis for future action; and • contributing to the improvement of data and monitoring systems in the Lao PDR and strength- ening technical expertise in the design, implementation, and analysis of such systems. The survey results will serve as the baseline information for government and programming towards improving the health and living conditions of children and women. In addition, we believe that the survey will provide key sources and reference information for researchers and academics to conduct in-depth analysis and research studies in specific areas. We would like to extend our sincere appreciation to all organisations and individuals who have contributed to making this survey a success. Dr. Samaychanh Boupha Director General, Department of Statistics Ministry of Planning and Investment Mr. Douangchan Keoasa Director General, Department of Hygiene and Prevention Ministry of Health Ms. Laila Ismail Khan UNICEF Representative UNICEF Lao PDR Multiple Indicator Cluster Survey, 2006 xiii Executive Summary The Lao PDR Multiple Indicator Survey is a nationally representative sample survey which was con- ducted between March and June 2006. In the 5,894 households successfully interviewed nationally in the survey, 33,100 household members were listed. Of these, 16,467 were males and 16,633 were females. The average household size found in the survey was 5.6. Nutrition Nutritional Status • 37.1 percent of children under age five are moderately or severely underweight and 9.0 per- cent are classified as severely underweight. • 40.4 percent of children are stunted or too short for their age and 6.5 percent are wasted or too thin for their height. • Children are more likely to be underweight and stunted in rural areas than in urban areas. • Children in the South region are more likely to be underweight than other children at 49.5 per- cent. • Children in the poorest quintile households are about 2.4 times more likely to be underweight and more than three times more likely to be stunted than those of the richest quintile. Breastfeeding • 26.4 percent of infants aged 0-5 months are exclusively breastfed. Infants aged 0-5 months in the South region are least likely to be exclusively breastfed at 6.4 percent. • 29.8 percent of women started breastfeeding within one hour of their infant’s birth. The figure was lowest in the South region at 17.5 percent. • Over half of mothers (55.2 percent) started breastfeeding within one day of their infant’s birth. Salt Iodisation • In 83.8 percent of households, salt was found to be iodised. Vitamin A Supplementation • Within the six months prior to the survey, 18.1 percent of children aged 6-59 months had re- ceived a high dose Vitamin A supplement. • 10.6 percent did not receive the supplement in the last six months but did receive one prior to that time. • 11.0 percent of children received a Vitamin A supplement at some time in the past but their mother/ caretaker was unable to specify when. • 58.7 percent of children aged 6-59 months never received a Vitamin A supplement prior to the survey. Children in the North region are most likely to not receive any Vitamin A supplement. • 17.9 percent of mothers with a birth in the previous two years before the survey received a Vitamin A supplement within eight weeks of the birth. Child Health Immunization • 14.2 percent of children receive all eight recommended vaccinations by their first birthday. • Only 11.6 percent of one-year old children from Hmong speaking households are completely vaccinated and nearly 50 percent are not vaccinated against any disease. xiv Multiple Indicator Cluster Survey, 2006 Tetanus Toxoid • 55.5 percent of women are protected. • 69.6 percent of urban women are protected, while the figure declines to 59.1 for women in rural areas with road access and about 40.7 for rural without road access women. • Women with secondary or higher education are most likely to be protected at a rate of about 74.3 percent, while those with no education are least likely at about 39.4 percent. Oral Rehydration Treatment of Diarrhoea • About half (50.5 percent) of children with diarrhoea received one or more of the recommended home treatments, while the other half (49.5 percent) received no treatment. • Children with diarrhoea in the South region are most likely to receive oral re-hydration treat- ment at 60.3 percent, while children from the Central region are least likely at 43.4 percent. Antibiotic Treatment of Pneumonia • 4.8 percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 32.3 percent were taken to an appropriate provider. • Slightly more than half (52.1 percent) of under-5 children with suspected pneumonia had re- ceived an antibiotic during the two weeks prior to the survey. Solid Fuel Use • Most households (97.5 percent) are using solid fuel for cooking. • In the North region, 95.6 percent of households use firewood, while 65.2 percent do so in the Central and the South regions. • In the Central and the South regions, 29.2 percent and 31.4 percent of households use coal/ lignite respectively. • The use of coal/lignite is higher in urban areas as compared with rural areas (44.0 percent in urban, 14.7 percent in rural with road access, and 6.3 percent in rural without road access areas). • Throughout the country, an open stove or fire with no chimney or hood is used by 86.6 percent of households. Malaria • 93.6 percent of households have at least one mosquito net, and 45.0 percent have at least one insecticide treated net (ITN). • 86.7 percent of children under the age of five slept some kind of mosquito net the night prior to the survey and 40.5 percent slept under an ITN. 23.9 percent of children slept under an unidentified mosquito net. • 8.2 percent of children with fever in the two weeks prior to the survey were treated with an “appropriate” anti-malarial drug and 5.1 percent received anti-malarial drugs within 24 hours of onset of symptoms. • The prevalence of medicine to prevent malaria during pregnancy is 6.9 percent, with only 1.0 percent prevalence of intermittent preventive therapy. • The availability of ITN is highest in rural areas with road access at 51.6 percent. Environment Water and Sanitation • About half (51.5 percent) of the population uses an improved source of drinking water – 70.4 percent in urban, 49.6 percent in rural with road access and 35.0 percent in rural without road access areas. In the South region, nearly 30 percent of the water source is surface water. • 65.7 percent of households appropriately treat water for drinking at home (90.2 percent in the North, 73.0 percent in the South, and 45.0 percent in the Central region). Boiling is almost the only method used for appropriate treatment. • For 37.4 percent of households, the drinking water source is on the premises. Excluding those households with water on the premises, the average time to the source of drinking water is 11.7 minutes. Multiple Indicator Cluster Survey, 2006 xv • In 83.4 percent of households, women collect water. Children collect water in less than 10 percent of households. • 44.8 percent of the population is living in households using improved sanitation facilities. The percentage is 83.5 in urban areas, 38.8 in rural with road access, and 15.8 in rural without road access areas. While 98.3 percent of the richest quintile households use improved sanitation facilities, only 7.1 percent of those in the poorest quintile do. Residents of the South region are much less likely than others to use improved facilities at 27.7 percent. • Children’s stools are disposed of safely in 11.4 percent of cases. 63.2 percent of stools are left in the open. Reproductive Health Antenatal Care • 35.1 percent of women nationwide receive antenatal care by skilled personnel. • 39.3 percent of pregnant women receive antenatal care during pregnancy. • 60.7 percent do not receive any antenatal care. • 76.2 percent of women in urban areas receive antenatal care by skilled personnel, while 34.0 percent in rural with road access areas and 14.1 percent in rural without road access areas do. • 75.7 percent of women with secondary or higher education receive skilled antenatal care, while 14.2 percent of those with no education do. • 87.6 percent of women in the richest quintile receive skilled antenatal care, while 16.3 percent of those in the poorest quintile do. Assistance at Delivery • 20.3 percent of births occurring in the year prior to the survey were delivered by skilled person- nel. • 67.8 percent of deliveries in urban areas are assisted by skilled personnel, while 15.2 percent and 3.0 percent of cases are in rural with road access and rural without road access areas respectively. • While only 3.4 percent of mothers who have no education are attended by skilled personnel, 62.8 percent of mothers who have secondary or higher education are attended by skilled per- sonnel. • 17.1 percent of the births in the year prior to the MICS survey were delivered in health facili- ties. • In urban areas, 61.6 percent of births are delivered in health facilities, while only 11.9 percent are in rural with road access areas and 1.9 percent are in rural without road access areas. While the figure is 72.6 percent for the richest quintile, it is only 2.8 percent for the poorest quintile. Child Development • For 25.3 percent of under-five children, an adult had engaged in more than four activities that promote learning and school readiness during the three days preceding the survey. • A larger proportion of adults engage in learning and school readiness activities with children in urban areas (42.7 percent) than in rural areas (23.0 percent in with road-access areas, 19.4 percent in without road access areas). • The households belonging to the richest quintile (45.6 percent) are three times more likely to engage in these activities than those belonging to the poorest quintile (14.9 percent). • 10.7 percent of children under five years old have three or more non-children’s books, and 2.5 percent have three or more children’s books in their households. 30.0 percent have three or more types of playthings. • 25.5 percent of children were left with inadequate care during the week preceding the survey. Children of both rural areas were about twice as likely to be left with inadequate care than those of urban areas. xvi Multiple Indicator Cluster Survey, 2006 Education Pre-School Attendance and School Readiness • 7.4 percent of children aged 36-59 months are attending pre-school. The figure is 33.6 percent in urban areas, but as low as 2.4 and 2.1 percent in rural with and without road access areas respectively. • 30.9 percent of children who are currently aged six and attending the first grade of primary school were attending pre-school the previous year. • Almost two-thirds of children in urban areas (63.1 percent) had attended pre-school the previ- ous year while about one-fifth among those living in rural with road access areas (20.2 per- cent) and one-fourth among those in rural without road access areas (27.4 percent) had. Primary School Participation • 57.5 percent of children of primary school entry age attend grade one. • 79.0 percent of children of primary school age attend school. • 93.0 percent of children attend school in urban areas, while in rural with road access and with- out road access areas, 79.9 and 65.6 percent attend respectively. • 98.2 percent of children from richest quintile households attend primary school, as compared with only 59.0 percent of those from the poorest quintile. • At the time of the survey, 26.7 percent of the children of primary completion age (11 years) were attending the last grade of primary education. This value should be distinguished from the gross primary completion ratio which includes children of any age attending the last grade of primary. • Gender parity for primary school is 0.95. The number of girls facing disadvantage is particu- larly pronounced in the North region, as well as among children from the poorest households, of mothers with no education, rural areas, and in households where the head speaks Khmou or Hmong. Secondary School Participation • 35.5 percent of secondary school age children attend secondary school nationwide (29.3 per- cent of secondary school age children attend primary school). The figure of 8.1 percent for the poorest quintile children rises along the quintiles, up to 69.9 percent of the richest quintile. • 63.8 percent of secondary school age children in urban areas attend secondary school, while only 29.4 percent of those in rural with road access areas and 16.5 percent in rural without road access areas do. • The gender parity index is 0.81 for secondary education. Adult Literacy • 67.3 percent of females aged 15-24 years are literate. • The percentage is highest in the Central region at 76.2 percent and lowest in the North region at 57.3 percent. • In urban areas 93.1 percent are literate, while about 61.7 percent are in rural with road access areas and 40.0 percent are in rural without road access areas. • While 100 percent of females aged 15-24 with at least secondary education are automatically assumed to be literate in the questionnaire, only 65.1 percent of those with primary education and 0.3 percent of those with no education are literate. • The literacy rate is positively correlated to the socioeconomic status of the women, ranging from 95.7 percent in the richest quintile females to 24.2 percent in the poorest quintile fe- males. Child Protection Birth Registration • The births of 71.5 percent of children under five years have been registered. • Children in the North are least likely to have their births registered at 59.0 percent. The reg- Multiple Indicator Cluster Survey, 2006 xvii istration rate gradually rises with the age of children, from 61.0 percent of those aged 0-11 months old to 72.5 percent of those aged 12-23 months old and almost stays the same there- after. • Mother’s education and the socioeconomic status of the household are positively correlated to the registration rate. Child Labour • 11.3 percent of children aged 5-14 years are involved in child labour. The figures are 10.2 percent for boys and 12.5 percent for girls. • Child labour is most common in the North region at 15.1 percent. • 7.6 percent of children in urban areas are involved in child labour, while 11.6 percent in rural with road access and 13.8 percent in rural without road access areas are. • Of the 68.1 percent of the children 5-14 years of age attending school, 12.0 percent are also involved in child labour activities. On the other hand, out of the 11.3 percent of the children classified as child labourers, 72.2 percent are attending school. Child Discipline • 71.2 percent of children aged 2-14 years are subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members. • 7.5 percent are subjected to severe physical punishment. • 18.4 percent of mothers/caretakers believe that children should be physically punished. • Rural without road access children are most likely to receive psychological or physical punish- ment. Children of mothers with less education and of poorer households are more likely to receive psychological and physical punishment. Domestic Violence • 81.2 percent of women believe that a husband is justified in beating his wife/partner. • About two-thirds of women believe that a husband’s violence is justified when his wife/partner neglects the children. Child Disability • 8.2 percent of children aged 2-9 years have at least one reported disability. • 3.0 percent of children aged 2-9 are not learning to do things like other children his/her age. HIV/AIDS and Orphaned and Vulnerable Children HIV Counselling and Testing • 7.6 percent of child-bearing age women who gave birth in the two years preceding the survey were offered HIV counselling, and 1.5 percent were tested for HIV at antenatal care visits. 1.1 received HIV test results. Orphans and Vulnerable Children • 87.9 percent of children aged 0-17 years are living with both parents. • 3.9 percent of children aged 0-17 years are not living with a biological parent. • 6.6 percent of children aged 0-17 years have lost one or more parents. • 0.7 percent of children aged 10-14 have lost both parents. xviii Multiple Indicator Cluster Survey, 2006 Multiple Indicator Cluster Survey, 2006 1 Photo: Jacky Knowles 2 Multiple Indicator Cluster Survey, 2006 1 Multiple Indicator Cluster Survey, 2006 3 Introduction CHAPTER 1 1 Background This report is based on the Lao PDR Multiple Indicator Cluster Survey, conducted in 2006 by the Department of Statistics of the Ministry of Planning and Investment in close collaboration with the Hygiene and Diseases Prevention Department of Ministry of Public Health. The survey provides valuable information on the situation of children and women in the Lao PDR, and was largely based on the need to monitor progress towards goals and targets emanating from recent international agreements, such as the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving condi- tions for their children and to monitoring progress towards that end. UNICEF was assigned a sup- porting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity- building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialised agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” 1 Introduction 4 Multiple Indicator Cluster Survey, 2006 The Lao PDR is one of the least developed countries in the world, with about 73 percent of the popu- lation living in rural areas. Although the economic situation has improved, In 2005 estimated GDP per capita was still only US$511 per year and, according to the Population and Housing Census 2005, 33.6% of villages do not have road access. Such a population structure and economic condition impose a heavy burden on government systems, especially for the provision of health care, as well as education. The Government of the Lao PDR gives highest priority to upgrading conditions and providing op- portunities for the full development of the country’s children. In 1979, the Action Committee for the International Year of Child was established and played an active role in promoting the well being of children. The Lao PDR participated in the World Summit For Children in 1990. The Summit Declara- tion and Plan of Action were signed by Lao representatives on 4 July 1991 and the Lao PDR acceded to the Convention of the Rights of the Child and in 1996 submitted its first report to the UN Committee of Child Rights. The National Commission for Mothers and Children was established in March 1992 to prepare and oversee the implementation of the Lao PDR Programme of Action for Children. The country has had experience in conducting MICS1 and 2, which were originally developed in re- sponse to the World Summit for Children to measure progress towards an internationally agreed set of mid-decade goals and end-decade goals respectively. MICS1 and 2 were conducted in 1996 and 2000 respectively, allowing Lao PDR to report to the General Assembly of the United Nations with recent data on the progress made. The third round of MICS “MICS3” focuses on providing data for indicators used to monitor progress towards A World Fit for Children, the Millennium Development Goals (MDGs), as well as for other major international commitments and the National Priorities Goals, particularly for the Lao Govern- ment’s National Growth and Poverty Eradication Strategy (NGPES). MICS3 was combined with a National Nutrition Survey, which involved collection of additional information on food taboos, con- sumption of specific foods and collection of biological samples from a subset of households included in the MICS sampling frame. This final report presents the results of the indicators and topics covered in the MICS survey, how- ever, data for the additional nutrition modules are presented in a separate, National Nutrition Survey report. Survey Objectives The 2006 Lao PDR Multiple Indicator Cluster Survey has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in the Lao PDR; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action; • To contribute to the improvement of data and monitoring systems in the Lao PDR and to strengthen technical expertise in the design, implementation, and analysis of such systems. 1 In tr od uc tio n Multiple Indicator Cluster Survey, 2006 5 Photo: Jacky Knowles 6 Multiple Indicator Cluster Survey, 20062 Multiple Indicator Cluster Survey, 2006 7 Sample and Survey Methodology CHAPTER 2 2 Sample Design The sample for the Lao PDR Multiple Indicator Cluster Survey (MICS) was designed to provide esti- mates on a large number of indicators conerning the situation of children and women at the national level, for urban and rural areas, and for three regions: North, Central and South. Regions were identi- fied as the main sampling domains and the sample was selected in two stages. Within each region, 100 census enumeration areas were selected with probability proportional to size. After a household listing was carried out within the selected enumeration areas, a systematic sample of 20 households was drawn. Although the sample was designed to collect information from 6,000 households, it was known in advance that one village only had 15 households, therefore the total expected number of households was 5,995. Of the selected enumeration areas, all but two were visited during the field- work period. The two missing enumeration areas were replaced in the field with villages of similar area type. The sample was stratified by region and is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which 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 five living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: o Extended household listing o Education 1 o Water and Sanitation o Household Characteristics o Insecticide Treated Nets o Child Labour o Child Discipline o Disability o Salt Iodisation and Consumption of Fortifiable Centrally-processed Foods The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules: 1 Differing from the MICS standard questionnaire, the code for “higher education” was removed from the Lao PDR MICS questionnaire. All respondents who answered university as their highest level of education were coded similarly to the respondents who answered the highest grade in secondary school as their highest level of education. Together, they are classified as “Secondary +”. 2 Sam ple and Survey M ethodology 8 Multiple Indicator Cluster Survey, 2006 2 The terms “children under five”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 3 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. 4 When the respondents did not speak Lao, enumerators and volunteers from village committees translated the questions into local languages verbally (as most languages do not have scripts). o Pregnancy o Tetanus Toxoid o Maternal and Newborn Health o Attitudes Towards Domestic Violence o Anthropometry assessments on women of reproductive age o Collection of blood and urine from women of reproductive age The Questionnaire for Children Under Five was administered to mothers or caretakers of children under five years of age2 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster or was not home, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Birth Registration and Early Learning o Child Development o Vitamin A o Breastfeeding o Care of Child Illness o Malaria among Under Five o Immunization o Anthropometry o Collection of blood and stool samples (In the subset of nutrition clusters only - results of bio- chemical analyses of these samples can be found in the nutrition report) The questionnaires are based on the MICS3 model questionnaire2. From the MICS3 model English version, the questionnaires were translated into Lao and were pre-tested in four villages of Vientiane Capital during January 2006. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Lao PDR MICS questionnaires is pro- vided in Appendix F3. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of children aged under five years. Details and findings of these measurements are provided in the respective sections of the report. Moreover in the subset of clusters selected for the nutrition component, there was collection of: o salt (for quantitative assessment of iodine content); o blood from women of reproductive age (15-49 years) and children 6-59 months old (for as- sessment of hemoglobin, serum ferritin, transferrin receptor, C-reactive protein and alpha1- glycoprotein); o urine from women of reproductive age (for assessment of iodine content); and o stool samples from children aged 24-59 months (for assessment of intestinal and liver parasite infection). Training and Fieldwork Training for the fieldwork was conducted over 14 days in February 2006. Training included lectures on interviewing techniques and the contents of the questionnaires. In addition, a group of labora- tory technicians were trained in collection of biochemical samples for the nutrition component of the survey and were also trained and standardised in anthropometry measurement techniques. Towards the end of the training period, all trainees spent three days in practice interviewing, anthropometry 2 Sa m pl e an d Su rv ey M et ho do lo gy Multiple Indicator Cluster Survey, 2006 9 5 Against the MICS standard guidelines, male interviewers were used in the Lao PDR MICS. It has been the norm in the country to use male interviewers in national household surveys conducted by the Department of Statistics of the Ministry of Planning and Investment. and sample collection in nine villages (one village per team). The pilot villages were all in rural areas with road access. The data were collected by nine teams; each comprised four interviewers, one driver, one labora- tory technician (who was responsible for anthropometry and also collection of additional samples for the additional nutrition component of the survey), one editor/measurer and a supervisor5. Fieldwork began in March 2006 and concluded in June 2006. Data Processing Data were entered using the CSPro software. The data were entered on 14 microcomputers and car- ried out by 14 data entry operators and four data entry supervisors. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. However due to unfamiliarity in using the CSPro software, the final consistency checks and the correction in data files were performed using the Statistical Package for Social Sciences (SPSS) software instead. Procedures and standard programmes developed under the global MICS3 project and adapted to the Lao PDR questionnaire were used throughout, except for the final step in consistency checks. Data processing began in May 2006 and was completed in August 2006. Data were analysed using the SPSS software program, Version 14, and the model syntax and tabulation plans developed by UNICEF for this purpose with alterations for the Lao context. 2 Sam ple and Survey M ethodology 10 Multiple Indicator Cluster Survey, 2006 Multiple Indicator Cluster Survey, 2006 11 Photo: Jacky Knowles 12 Multiple Indicator Cluster Survey, 20063 Multiple Indicator Cluster Survey, 2006 13 3 Sample Coverage and the Characteristics of Households and Respondents CHAPTER 3 Sample Coverage Of the 5,995 households selected for the sample, 5,991 were found to be occupied. Of these, 5,894 were successfully interviewed for a household response rate of 98.4 percent. In the interviewed households, 7,703 women (age 15-49) were identified. Of these, 7,387 were successfully inter- viewed, yielding a response rate of 95.9 percent. In addition, 4,204 children under five were listed in the household questionnaire. Questionnaires were completed for 4,136 of these children, which cor- responds to a response rate of 98.4 percent. Overall response rates of 94.3 and 96.8 are calculated for the women’s and under-5’s interviews respectively (Table HH.1). Response rates were similar across all regions and areas. Characteristics of Households The age and sex distribution of survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 5,894 households successfully in- terviewed in the survey, 33,100 household members were listed. Of these, 16,467 were males, and 16,633 were females. These figures also indicate that the survey estimated the average household size at 5.6. Children aged 0-17 years make up 47.6 percent of the household members identified in the survey and also comprise 48.8 percent of males and 46.3 percent of females surveyed. Children under 15 years of age make up 40.6 percent of the total household members and represent 41.2 percent of males, 40.0 percent of females surveyed. Household populations aged between 15-64 make up 55.4 percent of the total household population surveyed, and comprise 54.9 percent of males, 55.9 percent of females surveyed. All these figures are very close to and are within the acceptable range of the relevant figures found in the 2005 National Census of the Lao PDR; however a few minor ir- regularities are observed as the figure for males aged 20-24 drops by 4.1 percentage points from the age group 15-19, and that of females aged 15-19 drops by 4.4 percentage points from the age group 10-14. These sudden drops in the population distribution seem somewhat abnormal, as the respective drops occur only by 2.5 and 2.2 percentage points in the Census. It suggests possible bias among the interviewers when determining women’s ages around the cut off point for inclusion for further interviews. Another irregularity observed in the population pyramid of the survey is that the female population aged 50-54 exceeds its population aged 45-49 by about 25 percent. This trend is not observed in the census. The raw data shows that the number of women aged exactly 50 was about seven times greater than the number of women aged 49, and twice the number of women aged 51. It could be assumed that a considerable proportion of women aged around 50 do not know their exact ages and tend to round them to 50. However, this trend was not found among men of same age. Also, as more women aged under 50 rounded up their age to 50 than women aged over 50 rounded their age down to 50, it seems likely that a degree of bias was introduced by the interviewers to avoid inclusion of women for further interviews. In the survey, 0.1 percent of males, females, and total household members’ ages were missing. 3 Sam ple C overage and the C haracteristics of H ouseholds and R espondents 14 Multiple Indicator Cluster Survey, 2006 Table HH.3 provides basic background information on the households. Within households, the sex of the household head, region, urban/rural status, number of household members, and mother tongue6 of the household head are shown in the table. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, since sample weights were nor- malised (See Appendix A). The table also shows the proportions of households where at least one child under 18, at least one child under five, and at least one eligible woman age 15-49 were found. In the survey, 89.9 percent of household heads were male. 37.8 percent of households had four to five members and 27.9 percent had six to seven members. About 90 percent of households had at least one child aged under 18 and a similar percentage of households had at least one woman aged 15-49. About half of all households (48.3 percent) had at least one child aged under five. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under five. In both tables, the total numbers of weighted and un- weighted observations are equal, since sample weights have been normalised (standardised). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents 15-49 years of age. The Figure HH.1: Age and Sex Distribution of Household Population, Lao PDR, 2006 6 This was determined by asking “what is the household head’s mother tongue (speaking language)?” Based on the Popula- tion and Housing Census 2005, there are 49 ethnic groups in the country, and Lao (54.6 percent), Hmong (8.0 percent), and Khmou (10.9 percent) were identified as the three major ethnic groups. According to the Lao National Front for Recon- struction, each ethnic group has its own language, meaning there are as many as 49 ethnic languages in the country. 15 13 11 9 7 5 3 1 1 3 5 7 9 11 13 15 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 Males Females 3 Sa m pl e C ov er ag e an d th e C ha ra ct er is tic s of H ou se ho ld s an d R es po nd en ts Multiple Indicator Cluster Survey, 2006 15 7 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 8 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 as- sets used in these calculations were as follows: electricity, clock, radio, electric fan, mattress, black and white television, colour television, CD/VCD player, water pump, bed, DVD player, satellite, mobile telephone, telephone, refrigerator, air conditioner, cloth washing machine, sofa, watch, bicycle, oxcart, motorbike, tractor, tuk-tuk, car/truck, engine boat, type of sanitation facility, type of cooking fuel, type of materials used for floor, roof, and wall). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the par- ticular 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. table includes information on the distribution of women according to region, urban-rural areas, age, education7, wealth index quintiles8, and ethnicity. While the population of the Lao PDR is concen- trated in the Central region, the raw sample was taken equally from all three regions. Consequently, the weighted number of women for the Central region is about 1.5 times greater than that of the unweighted number, and the number for the South region is 0.58 of the unweighted number. The number stayed more or less the same for the North region. The weight applied to the sample did not yield any significant changes for the distribution of females in other attributes. The weighted sample shows that 72.7 percent of females between age 15 and 49 have primary or higher education. This figure is very close to the figure that can be derived from the most recent national census of the Lao PDR which was conducted in 2005 and recorded a figure of 72.1 percent. In the weighted sample, 25.3 percent of females belong to the households from the richest wealth index quintile, while those who belong to each of the other quintiles represent between 17.5 and 21.1 percent of the total. This may be due to the fact that many females reside away from their nuclear families to live in the households belonging to the richest quintile, mostly located in urban areas, for such purposes as to 1) attend school, 2) live with their relatives, or 3) work as housekeepers. Some background characteristics of children under five are presented in Table HH.5. These include distribution of children by several attributes: sex, region and area of residence, age in months, moth- er’s or caretaker’s education, wealth, and ethnicity. Similar to the figures found in Table HH.4, since the national population of the Lao PDR is concentrated in the Central region and is most scarce in the South region, the weighted number of under-5 children is about 1.5 times greater than the unweighted number in the Central region, while the number falls by about 40 percent for the South region. The number remains almost the same for the North region. According to Table HH.5, 39.9 percent of children under five were born to mothers who have no edu- cation. As the proportion of females aged 15-49 who do not have any education is 26.1 percent, this shows that females without any education tend to have more births than those with education. The weighted number of children under five is most represented in the poorest quintile at 29.8 percent, followed by the second quintile at 23.8 percent. The proportion continues to decline along the wealth quintiles to 12.1 percent for the richest quintile. Comparing these figures with those of Table HH.4, it can be derived that while more females tend to reside in households belonging to the richest quintile, they have fewer children than those of the poorest quintile. 3 Sam ple C overage and the C haracteristics of H ouseholds and R espondents 16 Multiple Indicator Cluster Survey, 2006 Multiple Indicator Cluster Survey, 2006 17 Photo: Jacky Knowles 18 Multiple Indicator Cluster Survey, 20064 Multiple Indicator Cluster Survey, 2006 19 Nutrition CHAPTER 4 For the MICS3 survey in the Lao PDR, additional modules were included and conducted for a sub- sample of the overall survey in order to assess in more detail nutritional status and factors potentially influencing nutritional status so that effective interventions can be designed and evaluated in the fu- ture. These included assessment of: haemoglobin and iron status among children aged 6-59 months and among non-pregnant women aged 15-49 years; iodine nutrition and adherence to postpartum food taboos among non-pregnant women aged 15-49 years; parasite infection rates among children aged 24-59 months; quantitative assessment of iodine in salt using the WYD checker; and, obtain- ing information about the frequency of consumption of potential food fortification vehicles, such as cooking oil, sugar, MSG etc. Full details of these nutrition modules, methodology, results and recom- mendations can be found in the separate National Nutrition Survey report. Results below include only information about standard MICS nutrition modules. Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential 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 if they survive, they are more likely to have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target 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 five by at least one-third (between 2000 and 2010), with special attention to children under two. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/USCDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Analysis of the same nutrition data using the WHO standards (2005) can be found in the separate national nutrition survey report. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two stan- dard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three 4 4 N utrition 20 Multiple Indicator Cluster Survey, 2006 standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recur- rent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In MICS, weights and heights of all children under five were measured using anthropometric equip- ment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above two standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (approximately 1.7 percent of children) and those whose measurements are outside a plausible range are excluded. In addition, a small number of children whose birth dates are not known are excluded. Almost two in every five children under five in the Lao PDR are moderately or severely underweight (37.1 percent) and 9.0 percent are classified as severely underweight (Table NU.1). 40.4 percent of children are stunted or too short for their age and 6.5 percent are wasted or too thin for their height. Children in the South region are more likely to be underweight than other children, at 49.5 percent. Mother’s education is strongly correlated to the weight and height of children. While around 40 per- cent of children of mothers who have no education (42.2 percent) or primary education (37.2 percent) are underweight, 25.0 percent of those whose mothers have secondary or higher education are 0 10 20 30 40 50 60 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) P er ce nt Underweight Stunted Wasted Figure NU.1: Percentage of children under-5 who are undernour- ished, Lao PDR, 2006 4 N ut rit io n Multiple Indicator Cluster Survey, 2006 21 underweight. Similarly, while about half of children whose mothers have no education are stunted, about a quarter of those whose mothers have secondary or higher education are also stunted. Chil- dren are least likely to be stunted in the Central region at 34.9 percent. The pattern of malnutrition with age indicates a large increase in both underweight and stunting be- tween the ages of 6-8 months (Figure NU.1). This may be due to poor sanitation, low access to clean water and low knowledge of appropriate young child feeding practices, since many children of these ages are introduced to complementary foods and are exposed to contamination in water, food and in the environment. Children are more likely to be underweight and stunted in rural areas than in urban areas. Children in the households belonging to the poorest quintile are about 2.4 times as likely to be underweight and more than three times as likely to be stunted than those of the richest quintile. Underweight is significantly lower among children from households where the head speaks Hmong (28.2 percent) when compared with children from households where the head speaks Lao (33.8 percent), Khmou (37.3 percent), or “other” languages (54.3 percent). The prevalence of child stunt- ing is significantly lower among children from households where the household head speaks Lao (31.9 percent) compared with 47.2 to 53.8 percent among children in the other three groups. The prevalence of wasting is highest among children from households where the household head speaks “other” languages at 9.7 percent. Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, as soon as other liquids and foods are introduced into the diet there is an increased risk of infection, subsequent growth faltering and micronutrient malnutrition, especially in areas where clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for six months and continue to be breastfed with safe, appropriate and adequate complementary feeding up to two years of age and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at six months • Frequency of complementary feeding: twice per day for 6-8 month olds; three times per day for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. 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 one hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.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). Overall, less than one in every three women (29.8 percent) in the Lao PDR started breastfeeding within one hour of their infant’s birth. The figure was lowest in the South region at 17.5 percent. Mothers living in urban areas or who have at least secondary education were about twice as likely to start breastfeeding within one hour than those living in rural areas or with no more than primary education. The figures increase from 21.7 percent of the mothers in the poorest quintile to 56.2 percent of those in the richest quintile. Mothers of households where “other” languages are spoken are least likely to start breastfeeding within one hour of birth at 19.4 percent. Nationally, over half of mothers (55.2 percent) started breastfeeding within one day of their infant’s birth. The percentage was lower in the South and Central regions at 45.9 percent and 52.8 percent 4 N utrition 22 Multiple Indicator Cluster Survey, 2006 respectively, compared with 64.1 percent in the North Region. While 74.2 percent of mothers who have at least secondary education started breastfeeding within one day, only about 50 percent of those with primary (50.1 percent) or no education (51.5 percent) did. Urban mothers were most likely to start breastfeeding within one day at 73.4 percent, as compared with those in rural areas with road access at 55.1 percent and of rural areas without road access at 44.9 percent. Across the wealth quintiles, around 48-54 percent of mothers belonging to the poorest four quintiles started breastfeed- ing within one day, while 79.0 percent of those of the richest quintile did. Mothers of households where the household head speaks “other” languages are least likely to start breastfeeding within one day of birth at 45.7 percent. In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s con- sumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breast- feeding of children at 12-15 and 20-23 months. Approximately one-fourth (26.4 percent) of children aged less than six months are exclusively breast- fed. At age 6-9 months, 70.3 percent of children are receiving breast milk and soft/mushy, semi solid or solid foods. By age 12-15 months, 81.7 percent of children are still being breastfed and by age 20-23 months, 48.4 percent are still breastfed. No major disparities are found between the feeding pattern for boys and girls. Children aged 0-5 months living in households where the household head speaks Khmou or Hmong are exclusively breastfed more commonly (46.8 percent and 57.0 percent respectively) than those of households where the head speaks Lao (18.1 percent) or “other” languages (7.3 percent). Only 6.4 percent of children aged 0-5 months from the South region are exclusively breastfed, while 43.6 percent of those in the North are exclusively breastfed. 64.1 52.8 45.9 73.4 55.1 44.9 55.2 33.9 33.5 17.5 52.8 27.2 21.8 29.8 0 10 20 30 40 50 60 70 80 North Centre South Urban Rural with road Rural without road Total P er ce nt Within one day Within one hour Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Lao PDR, 2006 4 N ut rit io n Multiple Indicator Cluster Survey, 2006 23 Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. The adequacy of infant feeding in children under 12 months is provided in Table NU.4. According to the standard MICS definition, adequate infant feeding for infants aged between 6-12 months is breastfeeding with solid or semi-solid (mushy) food (at least two times a day for infants aged 6-9 months, and at least three times for infants aged 9-11 months). However, in the Lao PDR MICS, some types of semi-solid (mushy) food were not categorised under the semi-solid food (as they should be), and instead were categorised together with “any other liquid” as inadequate food9. Therefore, some children who are fed with breast milk and the types of semi-solid (mushy) food that are not categorised correctly as adequate food were not counted towards those adequately-fed. This means the prevalence of children aged 6-11 months fed with complementary food found in the Table NU.4 and described below does not include all infants fed adequately with complementary foods and is an underestimation of the prevalence of adequately-fed infants. For infants aged 0-5 months, 26.4 percent are appropriately fed exclusively with breast milk. No significant disparity was found between males and females. Infants in the North region are most likely to be exclusively breastfed at 43.6 percent. Those in the South region have the lowest figure at 6.4 percent. For the age group 6-8 months, at least 34.7 percent nationwide are fed with breast milk and comple- mentary food at least twice in 24 hours. As a result of these feeding patterns, at least 44.5 percent of children aged 6-11 months are being fed with breast milk and complementary food for the minimum recommended times per day. Figure NU.3 Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Lao PDR, 2006 0 10 20 30 40 50 60 70 80 90 100 0- 1 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 24 -2 5 26 -2 7 28 -2 9 30 -3 1 32 -3 3 34 -3 5 Age (in Months) P er ce nt Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk/ formula Breastfed and complementary foods 9 This occurred due to the difficulties in precisely translating the difference between other liquid and mushy food (some mushy foods were considered liquid as opposed to solid). Figure NU.3 Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Lao PDR, 2006 4 N utrition 24 Multiple Indicator Cluster Survey, 2006 Salt Iodisation Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodised salt (>15 parts per million). However, the Lao PDR MICS only tested the presence/absence of iodine in salt using a field rapid test kit10. In the Lao PDR, the Government has established an IDD control programme using increased iodine intake through Universal Salt Iodisation (USI) as its main strategy. In May 1995, the Prime Minister issued a decree requiring all salt, locally produced or sold on the market, to be iodised. In over 99 percent of households, salt was tested for iodine content by using salt test kits and testing for the presence of potassium iodate. Table NU.5 shows that in a very small proportion of house- holds (0.4 percent), there was no salt available. In 83.8 percent of households, salt was found to be iodised. For more detailed discussion of iodised salt use throughout the country please refer to the National Nutrition Survey Report. 10 This was due to the field test kit not being able to measure the ppm level precisely. Some of the salt samples collected for MICS were further tested in a laboratory for ppm measurements, and these results are found in the National Nutrition Survey Report. 84.2 81 89.7 90.7 82.4 77.6 83.8 0 20 40 60 80 100 North Centre South Urban Rural with road Rural without road Total Pe rc en t Figure NU.4 Percentage of households consuming iodized salt, Lao PDR, 2006 4 N ut rit io n Multiple Indicator Cluster Survey, 2006 25 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, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-5 deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly’s Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child sur- vival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high- dose vitamin A supplementation every four to six months, targeted at all children between the ages of 6-59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother’s stores of vitamin A, which are de- pleted during pregnancy and lactation. For countries with vitamin A supplementation programmes, the definition of the indicator is the percentage of children 6-59 months of age receiving at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Lao PDR Ministry of Health recommends that children aged 6-11 months be given one capsule of 100,000 international units (UI) of Vitamin A and children aged 12-59 months be given a 200,000 UI capsule of vitamin A at least every six months. Vitamin A cap- sule distribution is linked to immunization services nationwide and capsules 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 six weeks of giving birth due to increased vitamin A requirements during pregnancy and lactation. Within the six months prior to the MICS, 18.1 percent of children aged 6-59 months had received a high dose vitamin A supplement (Table NU.6). 10.6 percent did not receive the supplement in the last six months, but did receive one prior to that time. 11.0 percent of children received a vitamin A supplement at some time in the past, but their mother/caretaker was unable to specify when. While about 20 percent of children living in households where the head speaks Lao or Khmou receive vi- tamin A supplement at least every six months, only 10.4 percent of those of households where the head speaks Hmong do. The figure was 17.1 percent for those living in households where “other” languages are spoken. Nationally, 58.7 percent of children aged 6-59 months never received a vitamin A supplement prior to the survey. Children in the North region are most likely not to receive any vitamin A supplement at 66.2 percent. The mother’s level of education is also related to the likelihood of vitamin A supplemen- tation. While about half of children aged 6-59 whose mothers have secondary or higher education receive vitamin A supplements at some time, only about one-third of those whose mothers who have no education do. The percentage of children who have never received vitamin A is the highest for the poorest quintile at 64.6 percent, and is the lowest for the richest quintile at 49.3 percent. 65.8 percent of children from rural areas without road access never receive vitamin A supplements while about 55 percent of those from urban (54.1 percent) and rural areas with road access (56.4 percent) areas also never receive them. 4 N utrition 26 Multiple Indicator Cluster Survey, 2006 17.9 percent of mothers who had a birth in the previous two years before the MICS received a vitamin A supplement within eight weeks of the birth (Table NU.7). This percentage is highest in urban areas at 31.9 percent and lowest in rural areas without road access at 11.4 percent. Vitamin A coverage increases with the education of the mother, but it is still only 28.4 percent among women with sec- ondary or higher education. While 38.6 percent of mothers of households belonging to the richest quintile receive a vitamin A supplement within eight weeks of the birth, only 11.3 percent of those of households belonging to the poorest quintile do. 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 were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job oppor- tunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, the mother’s short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it ac- counts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In addition, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these esti- mates are biased for most developing countries because the majority of newborns are not delivered in these facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is esti- mated 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 birth11. Only 22.1 percent of births are weighed at birth and 10.8 percent of them weighed less than 2,500 grams at birth (Table NU.8). 11 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 4 N ut rit io n Multiple Indicator Cluster Survey, 2006 27 Photo: Jim Holmes 28 Multiple Indicator Cluster Survey, 20065 Multiple Indicator Cluster Survey, 2006 29 5 Child Health CHAPTER 5 Immunization The Millennium Development Goal 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a re- sult, vaccine-preventable diseases cause more than two million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT+HepB to protect against diphtheria, pertussis, tetanus and Hepatatis B, three doses of polio vaccine, and a measles vaccination by the age of 12 months. Moth- ers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. Overall, 48.9 percent of children have 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+HepB and Polio, how many times. The percentage of children aged 12 to 23 months who received each of the vaccinations is shown in Table CH.1. 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 first birthday, as recommended are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. 61.0 percent of children aged 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 60.1 percent. The percentage declines for subsequent doses of DPT to 45.3 percent for the second dose, and 31.8 percent for the third dose (Figure CH.1). Simi- larly, 63.0 percent of children received Polio 1 by age 12 months and this declines to 32.2 percent by the third dose. The coverage for measles vaccine by 12 months is 33.0 percent. As a result, the percentage of children who had all eight recommended vaccinations by their first birthday is 14.2 percent (Figure CH.1). 5 C hild H ealth 30 Multiple Indicator Cluster Survey, 2006 61 60.1 45.3 31.8 15.8 63 48.1 32.2 33 14.2 0 10 20 30 40 50 60 70 BCG DPT1 DPT2 DPT3 Polio0Polio1Polio2Polio3 Measles All P er ce nt Table CH.2 shows vaccination coverage rates among children 12-23 months by background char- acteristics. The figures 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’ reports12. Urban children have the highest vaccination completion rates for all recommended vaccines except measles and rural without road access children have the lowest. While in urgan areas 40.3 percent of children are completely vaccinated, the figure is only 24.8 percent in rural areas with road access and 24.3 percent are in rural areas without road access. While 26.7 percent of children in urban areas are not vaccinated against any disease, the figure rises to 36.4 percent in rural areas without road access. Children from the South region tend to be vaccinated most commonly with any of the recommended vaccines, while children from the Central region tend to be vaccinated at the lowest rate for all diseases except for measles and the third dose of polio and DPT. While around 30 percent of children from the Central (29.1 percent) and South (32.5 percent) regions are completely vacci- nated, only 20.4 percent are in the North region. 39.3 percent of children in the Central region are not vaccinated against any diseases, while 29.5 percent in the North and 20.4 percent in the South region are not vaccinated against any diseases either. Children of mothers who have no education are least likely to be vaccinated for any of the diseases. 18.8 percent of children of mothers who have no education are completely vaccinated, while 39.3 percent of those of mothers who have secondary or higher education are completely vaccinated. 40.4 percent of children of mothers who have no education are not vaccinated against any diseases, while 26.0 percent of those of mothers who have at least primary education are not either. Children of households where the head speaks Hmong are less likely to be vaccinated for any of the diseases as compared with those of other households; only 11.6 percent of them are completely vaccinated and 48.0 percent are not vaccinated against any disease. 12 The results of this MICS differ from the routine data used by the WHO/UNICEF Review of National Immunization Cover- age 1980-2006. The routine data is based on an estimated number of children under age one and an estimated number of births, whereas MICS data is based on the sample population. Figure CH.1 Percentage of children aged 12-23 months who re- ceived the recommended vaccinations by 12 months, Lao PDR, 2006 5 C hi ld H ea lth Multiple Indicator Cluster Survey, 2006 31 Tetanus Toxoid One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1000 live births in every district. A World Fit for Children goal is to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: • Received at least two doses of tetanus toxoid vaccine, the last within the prior three years; • Received at least three doses, the last within the prior five years; • Received at least four doses, the last within 10 years; • Received at least five doses during lifetime. Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 24 months. Figure CH.2 shows the protection of women against neonatal tetanus by major back- ground characteristics. Overall, 55.5 percent of women in the Lao PDR are protected against teta- nus. Women from the South region had the highest protection rate of 63.5 percent, when compared with those from the Central region (54.2 percent) and the North region (51.6 percent). 69.6 percent of urban women are protected, while the figure declines to 59.1 and 40.7 percent for those of rural areas with road access and of rural areas without road access, respectively. Education of women is also very closely correlated to their protection rate as women with secondary or higher education are most likely to be protected, at a rate of 74.3 percent, while those with no education are least likely at 39.4 percent. 74.0 percent of women from the richest quintile and 72.4 percent of women from the fourth quintile groups are protected, while only 60.3 percent of those from the middle quintile and 45.7 percent of those from the poorest and second quintile groups are protected. 63.1 percent of women of households where the head speaks Lao and 57.7 percent of women of households where the head speaks Khmou are protected, while 49.6 percent of those of households where the head speaks “other” languages and 34.2 percent of those of households where the head speaks Hmong are protected. 51.6 54.2 63.5 69.6 59.1 40.7 39.4 62.1 74.3 55.5 0 20 40 60 80 100 Regions North Centre South Area Urban Rural with road Rural without road Mother's Education No education Primary Secondary + Total Percent Figure CH.2 Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus Lao PDR, 2006 5 C hild H ealth 32 Multiple Indicator Cluster Survey, 2006 Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diar- rhoea-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 rehydra- tion salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Prevent- ing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared with 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared with 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • ORT or increased fluids AND continued feeding In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had 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 child usually ate and drank. Overall, 12.4 percent of under-5 children had diarrhoea in the two weeks preceding the survey (Table CH.4). The peak of diarrhoea prevalence occurs in the weaning period, among children aged 6-23 months. Table CH.4 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. 30.7 percent received fluids from ORS packages, 19.6 percent from pre-packaged ORS fluids, and 29.8 percent received recommended homemade fluids. About half (50.5 percent) of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or RHF), while the other half (49.5 percent) received no treatment. Children with diarrhoea in the South region are most likely to receive oral re-hydration treatment at 60.3 percent, while children from the Central region are least likely at 43.4 percent. Although the sample sizes were small (less than 50 for urban areas), the results indicate that the prevalence of oral rehydration treatment was 84.7 percent in urban areas, 50.3 percent in rural areas with road ac- cess, and 40.8 percent in rural areas without road access. 50.1 43.4 60.3 41.9 53.9 73.6 50.5 0 10 20 30 40 50 60 70 80 North Centre South None Primary Secondary + Total Pe rc en t Figure CH.3 Percentage of children aged 0-59 months with diar- rhoea who received oral rehydration treatment, Lao PDR, 2006 5 C hi ld H ea lth Multiple Indicator Cluster Survey, 2006 33 Little more than half (53.0 percent) of under-5 children with diarrhoea drank more than usual while 45.0 percent drank the same or less (Table CH.5). 70.2 percent ate somewhat less, the same or more (continued feeding), but 28.9 percent ate much less or ate almost nothing. Combining the information in Table CH.5 with those in Table CH.4 on oral rehydration therapy, it is observed that 49.2 percent of children either receive ORT or increased fluid intake, and at the same time, feeding is continued, as is the recommendation. Different attributes affect home management of diarrhoea. 53.1 percent of boys’ diarrhoea cases are treated with ORT or increased fluids AND continued feeding, while 44.1 percent of girls cases are). Although the sample size may have been too small to show patterns with statistical confidence, these types of home management of diarrhoea are most common for children from urban areas at 73.1 percent, as compared with children from rural areas with road access and from rural areas without road access of which 44.3 and 51.3 percent are treated in such ways respectively. The prevalence of the home management system which consists of ORT or increased fluids AND continued feed- ing is higher for children whose mothers have higher education. It is less prevalent for children of households where the head speaks Hmong at 40.5 percent and those of households where the head speaks “other” languages at 43.4 percent, as compared with those of other households that have 52.9-53.9 percent of prevalence. Figure CH.4 Percentage of children aged 0-59 months with diarrhoea who received ORT or increased fluids, AND continued feeding Lao PDR, 2006 52.4 44.9 51.4 73.1 44.3 51.3 43.9 52 60.8 49.2 0 10 20 30 40 50 60 70 80 Regions North Centre South Area Urban Rural with road Rural without road Mother's Education No education Primary Secondary + Total Percent Figure CH.4 Percentage of children aged 0-59 months with diar- rhoea who received ORT or increased fluids, AND continued feeding, Lao PDR, 2006 5 C hild H ealth 34 Multiple Indicator Cluster Survey, 2006 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 sus- pected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were 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 CH.6 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. 4.8 percent of children aged 0-59 months were reported to have had symp- toms of pneumonia during the two weeks preceding the survey. Of these children, 32.3 percent were taken to an appropriate provider. 10.9 percent were taken to Government hospitals, 9.6 percent to private hospitals or clinics, 9.1 percent to government regional health centres, and 3.1 percent to village health centres. Table CH.7 presents the use of antibiotics for the treatment of suspected pneumonia in under-5s by sex, age, region, residence, and socioeconomic factors. In the Lao PDR, slightly more than half (52.1 percent) of under-5 children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Obvi- ously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behav- iour. Overall, 6.4 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is fever. 12.1 percent of mothers identified fast breathing and 19.6 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Solid Fuel Use More than three billion people around the world rely on solid fuel (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuel leads to high lev- els of indoor smoke and a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is in the form of 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 pro- portion of the population using solid fuels as the primary source of domestic energy for cooking. Overall, most households (97.5 percent) in the Lao PDR are using solid fuels for cooking. In the North region, 95.6 percent of households use firewood, while 65.2 percent do so in the Central and the South regions. In the Central and the South regions, about 30 percent of households use coal/ lignite (29.2 percent in the central and 31.4 percent in the south region). The use of coal/lignite is higher in urban areas as compared with rural areas (44.0 percent in urban, 14.7 percent in rural ar- eas with road access, and 6.3 percent in rural areas without road access). While only 30.6 percent of households belonging to the richest quintile use firewood, 67.3 percent of fourth quintile households, 86.1 percent of middle quintiles, and almost all of poorest (99.9 percent) and second quintile (97.6 percent) households do. Solid fuel use alone is a poor guide to levels of indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimises indoor pollution, while use of an open stove or fire with no chimney or hood 5 C hi ld H ea lth Multiple Indicator Cluster Survey, 2006 35 means that there is no protection from the harmful effects of solid fuels. The type of stove used with solid fuel is depicted in Table CH.9. Throughout the Lao PDR, open stoves or fires with no chimneys or hoods are used by 86.6 percent of households. In the North and the Central regions, 87.0 and 98.5 percent of households use these types of stove, while the figure is significantly lower at 57.9 percent in the South region. In the South region, 41.7 percent of households use open stoves or fires with chimneys or hoods. Overall, there are few disparities among different areas, education of household heads, wealth quintiles or languages. Malaria Malaria is a leading cause of death of children under age five in the Lao PDR. It also contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of mosquito nets treated with insecticide (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or con- vulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food and, for younger children, should continue breastfeeding. The questionnaire incorporates questions on the availability and use of bed nets, both at household level and among children under five years of age, as well as anti-malarial treatment, and intermit- tent preventive therapy for malaria. In the Lao PDR the survey results indicate that 45.0 percent of households have at least one ITN. 93.6 percent of households have at least one mosquito net that is not necessarily treated with insecticide. (Table CH.10). In the South region, 60.4 percent of house- holds have at least one ITN, while 50.7 percent in the North region and 35.0 percent in the Central region do. The availability of ITNs is highest in rural areas with road access at 51.6 percent, when compared with 41.6 percent of rural areas without road access and 35.1 percent of urban areas. Results indicate that 86.7 percent of children under the age of five slept under any mosquito net on the night prior to the survey and 40.5 percent slept under an ITN. 23.9 percent of children slept under an unidentified mosquito net (Table CH.11). ITN use among children under five is constant among different age groups and there are no significant gender disparities among children under five. While 45.5 percent of children in rural areas with road access slept under an ITN, 33.4 percent of those in rural areas without road access did. Children in the South region are most likely to sleep under an ITN at 54.3 percent. Questions on the prevalence and treatment of fever were asked for all children under five. Slightly more than one in every seven (15.2 percent) children under five years of age were ill with fever in the two weeks prior to the MICS3 (Table CH.12). Fever prevalence peaked at 12-23 months (20.1 percent) and declined with age. The level of mothers’ education was not a significant factor in the prevalence of ill children in the two weeks prior to the survey. Regional differences in fever preva- lence are not large, ranging from 11.6 to 17.9 percent across the three regions. Mothers were asked to report all of the medicines given to a child to treat the fever, including medi- cines given at home and medicines given or prescribed at a health facility. Overall, 8.2 percent of children with fever in the two weeks prior to the survey were treated with an “appropriate” anti-malar- ial drug and 5.1 percent received anti-malarial drugs within 24 hours of onset of symptoms. “Appropriate” antimalarial drugs include chloroquin, Sulfamethoxazol and Pyrimetamine (SP), ar- temisine combination drugs, etc. In the Lao PDR, 4.0 percent of children with fever were given chlo- roquin, and 0.7 percent were given SP. Only 0.1 percent received artemisine combination therapy. A large percentage (52.7 percent) of children were given other types of medicines that are not anti- malarials, including antipyretics such as paracetamol, panadol or acetaminophen. Overall, children with fever in the Central region are least likely to receive an appropriate anti-malarial drug within 24 hours of onset of symptoms at 0.5 percent. Pregnant women living in places where malaria is highly prevalent are four times more likely than 5 C hild H ealth 36 Multiple Indicator Cluster Survey, 2006 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 first year of life. For this reason, steps are taken to protect preg- nant women by distributing insecticide-treated mosquito nets and treatment during antenatal check- ups with drugs that prevent malaria infection (intermittent preventive treatment). In the Lao PDR MICS, women were asked of the medicines they had received in their last pregnancy during the two years preceding the survey. Women are considered to have received intermittent preventive therapy if they have received at least two doses of SP/Fansidar during the pregnancy. Intermittent preventive treatment for malaria in pregnant women who gave birth in the two years preceding the survey is presented in Table CH.13. In the Lao PDR, the prevalence of medicine to prevent malaria during pregnancy is 6.9 percent, with only 1.0 percent prevalence of intermittent preventive therapy. 5 C hi ld H ea lth Multiple Indicator Cluster Survey, 2006 37 Photo: Jim Holmes 38 Multiple Indicator Cluster Survey, 20066 Multiple Indicator Cluster Survey, 2006 39 6 Environment CHAPTER 6 Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with 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 impor- tant for women and children, especially in rural areas, as it is they who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustain- able 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 afford- able and safe drinking water by at least one-third. The list of indicators used in MICS are 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 The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.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, tubewell/borehole, protected well, protected spring or 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 handwashing and cooking. 6 Environm ent 40 Multiple Indicator Cluster Survey, 2006 Other unimproved 6.2% Surface water 15.3% Unprotected well or spring 27.0% Bottled water 11.2% Protected well or spring 10.0% Tubewell/borehole 11.7% Public tap/standpipe 9.6% Piped into dwelling, yard or plot 8.9% Overall, about half (51.5 percent) of the population uses an improved source of drinking water – 70.4 percent in urban areas, 49.6 percent in rural areas with road access and 35.0 percent in rural areas without road access. Across regions, the coverage ranges from 56.7 percent of the North region to 47.0 percent of the Central region. 72.4 percent of households in the richest quintile use an improved source of water, while only 40.4 percent of those in the poorest quintile do. The most common improved sources of water are tubewell/borehole (11.7 percent), bottled water (11.2 percent) and public tap/standpipe (9.6 percent). The most common unimproved sources of water are unprotected wells (21.1 percent), surface water (15.3 percent), unprotected spring water (5.9 percent). 5.9 percent of people use bottled water for drinking, but use unimproved sources for other purposes. In the Central region unprotected wells form more than one fourth of the source of drinking water. In the South region, 29.0 percent of the water source is surface water. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all households, for households using improved and unimproved drinking water sourc- es. Overall, about two-thirds (65.7 percent) of households appropriately treat water for drinking at home (90.2 percent in the North, 73.0 percent in the South, and 45.0 percent in the Central region). While only half (50.7 percent) of urban households treat water appropriately at home, 69.2 percent and 74.2 percent of households do in rural areas with road access and without road access areas respectively. While 90.5 percent of households where the head speaks Khmou and 86.6 percent of households where the head speaks Hmong appropriately treat water, only 59.5 percent of house- holds where the head speaks “other” languages and 58.8 percent of households where the head speaks Lao do so. Boiling is by far the most common method used for appropriate treatment. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. 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. Table EN.3 shows that for 37.4 percent of households, the drinking water source is on the premises. For 93.1 percent of all households, it takes less than 30 minutes to get to the water source and bring water, while 1.7 percent of households spend more than one hour. Excluding those households with water on the premises, the average time to the source of drinking water is 11.7 minutes. Table EN.4 shows that for the majority of households, an adult female (83.4 percent) is usually the person collecting the water, when the source of drinking water is not on the premises. Adult men collect water in only 8.3 percent of cases, as female (6.3 percent) or male (1.5 percent) children Figure EN.1 Percentage distribution of household members by source of drinking water Lao PDR, 2006 6 En vi ro nm en t Multiple Indicator Cluster Survey, 2006 41 under age 15 collect water in the rest of cases. While adult women collect water in 84.3 percent of the poorest wealth quintile households, this figure drops to 64.8 percent for the households belong- ing to the richest quintile. Contrarily, while adult men collect water in 7.2 percent of the households belonging to the poorest quintile, the figure rises to 26.7 percent for the households belonging to the richest quintile. 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: flush or pour flush toilets connected to a piped sewer system, septic tank, or latrine; ventilated im- proved pit latrines; pit latrines with slabs; and composting toilets. 44.8 percent of the population of the Lao PDR is living in households using improved sanitation facilities (Table EN.5). The percentage is 83.5 in urban areas, 38.8 in rural areas with road access, and 15.8 in rural areas without road access. While 98.3 percent of the households belonging to the richest quintile use improved sanitation facilities, only 7.1 percent of those in the poorest quintile do. Education level of the household head is strongly correlated with the use of improved sanitation facilities, ranging from 27.3 percent where the household head has no education to 68.7 percent where they have secondary or higher education. Residents of the South region are much less likely than others to use improved facilities at 27.7 percent. The most common improved facilities are flush toilets with connection to pit (26.9 percent) and septic tank (15.0 percent). While 56.1 percent of households where the head speaks Lao use improved facilities, only 33.7 percent of those where the head speaks Khmou, 29.5 percent of those where the head speaks Hmong, and 13.8 percent of those where the head speaks “other” languages do. 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. Disposal of faeces of children 0-2 years of age is presented in Table EN.6. In the Lao PDR, children’s stools are disposed of safely in 11.4 percent of cases. In urban areas, they are safely disposed in 41.2 percent of cases, but in rural areas with road access and rural areas without road access, they are done so in only 7.5 and 1.0 percent of cases respectively. Mother’s education is strongly correlated with safe disposal, ranging from 2.5 percent safe disposal by mothers who have no education to 38.5 percent of mothers who have secondary or higher educa- tion. While no significant disparities are found among the poorest three quintiles of the population, whose proportion of safe disposal does not surpass 5.2 percent, the pattern improves significantly to 18.3 percent for the fourth quintile and drastically to 51.1 percent for the richest quintile. While 18.3 percent of households where the head speaks Lao dispose of stools safely, 7.0 percent of those where the head speaks Khmou, 3.6 percent of those where the head speaks Hmong, and 0.9 percent of those where the head speaks “other” languages do so. Nationally, 63.2 percent of stools are left in the open. An overview of the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. The table indicates that 29.1 per- cent of households in the Lao PDR are using both improved sources of drinking water and sanitary means for excreta disposal. The figure for the households in the South region is considerably lower than those of other regions at 19.3 percent. While about two out of every three urban households are using improved water sources and sanitary means for excreta disposal, only about one in five households in rural areas with road access and one in10 in rural areas without road access are using them. The use of improved sources and sanitary means are strongly correlated with the education level of household heads and wealth of households, ranging from 17.2 percent use where household heads have no education to 45.3 percent in households where the head has secondary or higher education, and from 5.1 percent of the poorest quintile to 71.5 percent of the richest quintile. The use of improved water sources and sanitary means is lower among households where the head speaks “other” languages, at 11.3 percent, and in Hmong speaking households at 18.3 percent, as compared with the figures for households where Lao or Khmou are spoken (34.8 percent among Lao speaking households, 28.7 percent among Khmou speaking households). 6 Environm ent 42 Multiple Indicator Cluster Survey, 2006 Houses in Poor Condition Target 11 of the MDGs is on the achievement of significant improvements in the lives of at least 100 million slum dwellers, and the related indicator is the proportion of urban household members living in slum housing. In MICS, three indicators were introduced to measure issues related to houses in poor condition: security of tenure, durability of housing, and proportion living in slum households. An urban household is considered a slum in MICS if it fulfils one of the following conditions: improved drinking water sources are not used, improved sanitation facilities are not used, living area is not sufficient, housing is not durable, or security of tenure is lacking. For MICS in Lao PDR, information on only three of these conditions was collected: living area is not sufficient, improved drinking water source are not secured, and improved sanitation facilities are not used. Therefore, the findings of this survey do not show the proportion of urban household members living in slum households; it shows the proportion of urban household members living in houses in poor condition (not a standard MICS indicator). Table EN.8 brings together these three components of houses in poor condition (see above). Overall, 45.9 percent of households are considered to be living in houses in poor condition. This coincides with 47.2 percent of household members. 30.6 percent of the households belonging to the richest quintile still live in houses in poor condition. 6 En vi ro nm en t Multiple Indicator Cluster Survey, 2006 43 Photo: Jim Holmes 44 Multiple Indicator Cluster Survey, 20067 Multiple Indicator Cluster Survey, 2006 45 7 Reproductive Health CHAPTER 7 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 infants. Better under- standing 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 supply information on birth spacing, which is recognised as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of ma- laria among pregnant women, management of anaemia during pregnancy and treatment of sexually transmitted infections (STIs) can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women’s nutritional status and prevent infections (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 dif- ferent models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anemia • Weight/height measurement (optional) In the Lao PDR 39.3 percent of women receive antenatal care at least once during the pregnancy. The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding is presented in Table RH.1. Overall, only 35.1 percent of women nationwide receive antenatal care by skilled personnel (23.3 percent by medical doctor, 9.7 percent by nurse/midwife, and 2.1 percent by auxiliary midwife). 60.7 percent do not receive any antenatal care. In the Central region 44.4 percent of women receive antenatal care by skilled personnel, in the South region the fig- ure is 30.1 percent, while it is 27.9 percent in the North region. 76.2 percent of women in urban areas receive antenatal care by skilled personnel, while 34.0 percent in rural areas with road access and 14.1 percent in rural areas without road access do. Skilled antenatal care coverage is strongly corre- lated to women’s education and wealth. 75.7 percent of women with secondary or higher education receive skilled antenatal care, while only 14.2 percent of those with no education do. 87.6 percent of women in the richest quintile receive skilled antenatal care, compared with 16.3 percent of those in the poorest quintile. Between 35-39 percent of women aged 15-39 years are attended by skilled personnel, while only 14.1 percent of women aged 40-44 years are. While 49.1 percent of women of households where the head speaks Lao receive antenatal care, this figure drops to 31.5 percent of those in households where the head speaks Khmou, to18.0 percent in households where the head 7 R eproductive H ealth 46 Multiple Indicator Cluster Survey, 2006 speaks “other” languages, and to 10.3 percent in households where the head speaks Hmong. The types of services pregnant women receive are shown in Table RH.2. Overall, among pregnant women aged 15-49 years who gave birth in the two years preceding the survey in the Lao PDR, 39.3 percent received at least instance of one antenatal care during pregnancy, 9.3 percent had a blood sample taken, 23.8 percent had blood pressure measured, 11.4 percent had urine specimen taken and 31.8 percent were weighed. While 48.3 percent of pregnant women in the Central region received antenatal care, only 33.9 percent in the South and 32.7 percent in the North region did. In urban areas, 81.1 percent women received antenatal care, whereas only 37.8 percent in rural with road access areas and 18.8 percent in rural areas without road access did. 79.8 percent of women with at least secondary education received antenatal care, but only 42.4 percent of those with pri- mary education and 18.3 percent of those with no education did. While 91.5 percent of women from the richest quintile received antenatal care, only 20.4 percent of those from the poorest quintile did. Access to antenatal care is most common among women of households where the head speaks Lao (at 54.2 percent), less common among those in households where the head speaks Khmou (35.9 percent) and those in households where the head speaks “other” languages (21.0 percent) and least common among those from households where the head speaks Hmong (13.0 percent). 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 skilled attendant at delivery indicator is also used to track progress toward the Millennium Development Goal target of reducing the mater- nal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. About one in every five births that occurred in the year prior to the MICS survey was delivered by skilled personnel (20.3 percent) (Table RH.3). 67.8 percent of deliveries are assisted by skilled per- sonnel in urban areas, while 15.2 percent and 3.0 percent of cases are assisted by skilled personnel in rural areas with road access and rural areas without road access respectively. While only 3.4 per- cent of mothers who have no education are attended by skilled personnel, 62.8 percent of mothers who have secondary or higher education are attended by skilled personnel. The percentage of de- livery assisted by skilled personnel is strongly correlated with the wealth quintiles of mothers as well; ranging from 3.0 percent for mothers of the poorest quintile to 81.2 percent for mother of the richest quintile. While 31.8 percent of women from households where the head speaks Lao give birth with assistance of skilled personnel, only 10.4 percent of those from households where the head speaks Khmou, 7.1 percent of those from households where the head speaks Hmong, and 5.3 percent of those from households where the head speaks “other” languages do so. 17.1 percent of the births in the two years prior to the MICS survey were delivered in health facilities. Compared with the other two regions, in the Central region, it is almost three times more common to have the delivery in a health facility. In urban areas, 61.6 percent of births are delivered in health facilities, while only 11.9 percent are in rural areas with road access and 1.9 percent are in rural areas without road access. The more educated a mother is, the more likely she is to deliver her child at a health facility. While the figure is 72.6 percent for the richest quintile, it is only 2.8 percent for the poorest quintile. While 27.3 percent of women of households where the head speaks Lao give birth in a health facility, only 7.8 percent of those of households where the head speaks Khmou, 5.9 per- cent of those of households where the head speaks Hmong, and 4.1 percent of those of households where the head speaks “other” languages do. Only 3.5 percent of the births in the year prior to the MICS survey were delivered with assistance by a nurse or midwife. Doctors assisted 15.4 percent of deliveries and auxiliary midwives assisted 1.4 percent. In the South region, 45.0 percent of births were delivered by traditional birth attendants. 7 R ep ro du ct iv e H ea lth Multiple Indicator Cluster Survey, 2006 47 Photo: Jim Holmes 48 Multiple Indicator Cluster Survey, 20068 Multiple Indicator Cluster Survey, 2006 49 8 Child Development CHAPTER 8 It is well recognised that a period of rapid brain development occurs in the first three to four years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, involvement of adults in children’s activities, presence of books in the home, for the child, and the conditions of care are important indicators of quality of home 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 was collected in the 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. For just one-fourth (25.3 percent) of under-five children, an adult engaged in more than four activities that promote learning and school readiness during the three days preceding the survey (Table CD.1). The average number of activities that adults engaged with children was 2.7. The table also indicates that the father’s involvement in such activities was somewhat limited. Fathers’ involvement with one or more activities was only 19.8 percent. 6.9 percent of children were living in a household without their natural father. There are no gender differentials in terms of involvement of adults in children’s activities. A larger proportion of adults engage in learning and school readiness activities with children in urban areas (42.7 percent) than in rural areas (23.0 percent in with road-access areas, 19.4 percent in without road access areas). Adult engagement in activities with children is greatest in the South region at 31.9 percent as compared with around 23 percent in other regions. The households belonging to the richest quintile (45.6 percent) are three times more likely to engage in these activities than those belonging to the poorest quintile (14.9 percent). Mothers and fathers with higher education tend to engage themselves in activities with children more commonly than those with less education. While household members are engaged in four or more activities to promote learning and school readiness in 33.1 percent of households where the head speaks Lao, it is done in only 17.2 percent of house- holds where the head speaks Khmou, 17.0 percent of those where the head speaks Hmong, and 15.2 percent of those where the head speaks “other” languages. Exposure to books in early years not only provides the child with greater understanding of the nature of print, but may also give the child opportunities to see others reading, such as older siblings doing school work. Presence of books is important for later school performance and IQ scores. In the Lao PDR, only 10.7 percent of children are living in households where at least three non-chil- dren’s books are present (Table CD.2). Even worse, only 2.5 percent of children aged 0-59 months have three or more children’s books. Both the median number of non-children’s books and children’s books are very low (0.0 and 0.3 books). While no gender differentials are observed, urban children appear to have more access to both types of books than those living in rural households. 22 per- cent of under-5 children living in urban areas live in households with more than three non-children’s books, while the figure is 9.3 percent in rural areas with road access and 6.8 percent in rural areas without road access. The proportion of under-5 children who have three or more children’s books is 8 C hild D evelopm ent 50 Multiple Indicator Cluster Survey, 2006 9.0 percent in urban areas, 1.5 percent in rural areas with road access and 0.8 percent in rural areas without road access. The presence of both non-children’s and children’s books is positively corre- lated with the mother’s education and the household’s wealth status. In 21.4 percent of households where mothers have secondary or higher education, there are three or more non-children’s books, while the figure is 6.3 percent for households where mothers have no education. About a quarter (24.0 percent) of households belonging to the richest quintile have three or more non-children books, while only 4.0 percent of those in the poorest quintile do. Similar differences are observed for chil- dren’s books. Table CD.2 also shows that 30.0 percent of children aged 0-59 months had three or more playthings to play with in their homes, while 18.9 percent had none of the playthings mentioned in the ques- tions presented to the mothers/caretakers (Table CD.2). The playthings in MICS included household objects, homemade toys, toys that came from a store, and objects and materials found outside the home. Among the lowest four quintile groups, the existence of three or more playing things is posi- tively related to the socioeconomic status of households; however, the richest quintile (22.2 percent) has lower percentage than the second quintile group (29.9 percent). Only 10.9 percent of house- holds in the North region have three or more toys, while 44.8 percent do in the Central region and 31.4 percent do in the South region. 40.7 percent of households where the head speaks Lao have three or more types of playthings, while only 29.3 percent of households where the head speaks “other” languages, 12.2 percent of households where the head speaks Khmou, and 9.6 percent of households where the head speaks Hmong do. While female children are more likely to play with household objects than male children, male chil- dren are more likely to play with toys that came from a store than female children. 60.4 percent of children in the Central region play with toys that came from a store, while only 31.3 percent of those in the South region and 15.7 percent of those in the North region do. The higher the education of mother is the less their children play with household objects or objects and materials found outside the home; the more their children play with toys that came from a store. 64.0 percent of children from the households belong to the richest quintile play with toys that came from a store, while only 21.2 percent of those from the households belonging to the poorest quintile do. While 54.5 percent of chil- dren of households where the head speaks Lao play with toys from a store, 27.4 percent of those of households where the head speaks “other” languages, and approximately 15 percent of those from Khmou-speaking and Hmong-speaking households do. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In MICS, two questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the interview, and whether children were left in the care of other children under 10 years of age. Table CD.3 shows that 24.0 percent of children aged 0-59 months were left in the care of other chil- dren, while 5.9 percent were left alone during the week preceding the interview. Combining the two care indicators, it is calculated that 25.5 percent of children were left with inadequate care during the week preceding the survey. No differences were observed by the sex of the child. Inadequate care was most prevalent among children whose mothers had no education (29.9 percent), while it was least prevalent among children whose mothers had at least secondary education (14.6 percent). Children aged 24-59 months were left with inadequate care more commonly (32.0 percent) than those who were aged 0-23 months (15.6 percent). Children of both rural areas with road access and without road access areas (27.8 percent and 27.6 percent respectively) were about twice as likely to be left with inadequate care than those of urban areas (14.6 percent). While 33.3 percent of the households belonging to the poorest quintile left their children with inadequate care, the percentage dropped to 27.4 percent for the second quintile, to 24.3 percent for the middle, and 15.5 percent for the fourth quintile households. The figure slightly bounced up again for the richest quintile to 17.0 percent. 8 C hi ld D ev el op m en t Multiple Indicator Cluster Survey, 2006 51 Photo: Jim Holmes 52 Multiple Indicator Cluster Survey, 20069 Multiple Indicator Cluster Survey, 2006 53 9 Education CHAPTER 9 Pre-School Attendance and School Readiness Pre-school education and attendance at an organised learning or child education programme is important for the readiness of children to go to school. One of the World Fit for Children goals is the promotion of early childhood education. Only 7.4 percent of children aged 36-59 months are attending pre-school (Table ED.1). Urban-rural differentials are significant – the figure is as high as 33.6 percent in urban areas, compared with 2.4 and 2.1 percent in rural with and without road access areas respectively. While 11.5 percent of chil- dren in the Central region attend pre-school, 5.1 percent in the North region and 3.3 percent in the South region do. No significant disparities between genders exist, but disparities among wealth quin- tiles are considerable. 43.7 percent of children living in households belonging to the richest quintile attend pre-school, while the figure drops to 7.9 percent for fourth quintile households and continues to drop to 1.4 percent for households belonging to the poorest quintile. While 35.1 percent of children of mothers who have at least secondary education attend pre-school, only 3.3 percent of those of mothers who have primary education and 1.0 of those of mothers who have no education attend. The table also shows the proportion of children in the first grade of primary school who attended pre- school the previous year (Table ED.1), an important indicator of school readiness. Overall, 30.9 per- cent of children who are currently six years old and attending the first grade of primary school were attending pre-school the previous year. Almost two-thirds of children in urban areas (63.1 percent) had attended pre-school the previous year compared with about one-fifth among those living in rural areas with road access (20.2 percent). Regional variations are also very significant; first graders in the South region had attended pre-school about three times as much (45.3 percent) as their coun- terparts in the North region (16.3 percent). Among children of mothers who have at least secondary education, 54.0 percent of those that are attending first grade have attended preschool. The figure drops to 31.2 percent for children of mothers who have primary education and to 11.6 percent for those whose mothers who have no education. While the figure for the households belonging to the richest quintile is over 70 percent, it drops to about 30 percent for the fourth quintile, and under 20 percent for the rest of quintiles. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s chil- dren is one of the most important of the Millennium Development and A World Fit for Children goals. 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 influencing 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 9 Education 54 Multiple Indicator Cluster Survey, 2006 • 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 five • Transition rate to secondary school • Net primary completion rate Of children who are of primary school entry age (age six) in the Lao PDR, 57.7 percent are attending the first grade of primary school (ED.2). Table ED.3 provides the percentage of children of primary school age attending primary or secondary school13. About four out of five children of primary school age are attending school (79.0 percent). Boys’ attendance rate is about four percentage points higher than that of girls at the national level. In urban areas, boys and girls have almost similar attendance rates, but in rural areas without road access boys’ attendance rate is more than seven percentage points higher than girls’. Overall, 93.0 percent of children attend school in urban areas, while in rural areas with road access and without road access areas, 79.9 and 65.6 percent attend respectively. Strong positive correlations exist with regard to mother’s education and the socioeconomic status of households. While 96.6 percent of children of mothers who have secondary or higher education attend primary school, the figure drops to 86.0 percent for those of mothers who have primary education and further to 65.5 percent for those of mothers who have no education. 98.2 percent of children from households belonging to the richest quintile attend primary school, as compared with only 59.0 percent of those from the poorest quintile. While the net attendance ratio is 88.7 percent for the children of households where the head speaks Lao, it is 79.2 percent for those of households where the head speaks Khmou, 68.6 percent for those of the households where the head speaks Hmong, and 52.4 percent for those of households where the head speaks “other” languages. The secondary school net attendance ratio is presented in Table ED.4. Only 35.5 percent of second- ary school age children attend secondary school nationwide. 29.3 percent of secondary school age children attend primary school in the Lao PDR. The secondary school attendance rate is highest in the Central region at 42.3 percent, as compared with approximately 30 percent in the North and South regions. The percentage of children attending secondary school rises from 20.1 percent at 11 years old to 42.6 percent at14 years old, and then drops to 35.0 percent for 16-year-olds. Very strong positive correlations exist with regards to mother’s education and the household’s socioeconomic status. While 18.0 percent of children of mothers who have no education attend secondary school, 72.3 percent of those of mothers who have secondary or higher education attend. The figure of 8.1 percent for the poorest quintile children rises along the quintiles, up to 69.9 percent in the richest quintile. 63.8 percent of children in urban areas attend secondary school, while only 29.4 percent of those in rural areas with road access and 16.5 percent in rural areas without road access do. The secondary school net attendance ratio is 45.6 percent for households where the head speaks Lao, 21.8 percent for those where the head speaks Hmong, 20.4 percent for those where the head speaks Khmou, and 10.0 percent for those where the head speaks “other” languages. It is 39.0 percent for male and 31.8 percent for female. The primary school net attendance ratio of children of secondary school age is presented in Table ED.4W. Three out of 10 (29.3 percent) children of secondary school age are attending primary school when they should be attending secondary school. The remaining 35.2 percent are not at- tending school at all. They are children out of school since it has already been indicated that 35.5 13 The percentage for not attending school, especially for ages 17-24 may be slightly higher than the reality. As the code for “higher education” was removed from the Lao PDR MICS questionnaire, all respondents who answered university as their highest level of education were coded similarly to the respondents who answered the highest grade in secondary school as their highest level of education. Together, they are classified as “Secondary +”. In this process, some of the respon- dents attending university might have been omitted from the data. However, the omission may only affect the data slightly as the Population Census 2005 indicates that only 0.7 percent of the population in the age group 15-19 and 6.4 percent of the population in the age group 20-24 complete higher education. 9 Ed uc at io n Multiple Indicator Cluster Survey, 2006 55 14 This is different from the standard MICS indicator of the net primary school completion rate (MICS Indicator 57) percent of them are attending secondary school. Only 16.5 percent of secondary school age children living in urban areas attend primary school, while only 32.8 percent of those in rural areas with road access and 36.0 percent of those in rural areas without road access do. While only 15.0 percent of secondary school age children of mothers who have at least secondary education still attend primary school, 30.2 percent of children whose mothers who have primary education and 37.6 percent of those whose mothers who have no education do. The percentage of children aged 11 who are still attending primary school is 63.6 percent, but the figure gradually declines with age to 2.7 percent for those aged 16. The percentage of children in first grade who reach grade five without repeating grades is presented in Table ED.514. Of all children in grade one, about two-thirds of them (65.4 percent) will reach grade five without repeating any grade. This number does not include children that repeat grades and who eventually move up to reach grade 5. Girls are more likely to reach grade 5 without repeating grades than boys by a difference of about 3 percent. Nearly three-quarters (73.9 percent) of children in grade one reach grade five without repetition in urban areas while about two-thirds (66.1 percent) do in rural areas with road access and 56.1 percent do in rural areas without road access. While 58.7 percent of children of mothers who have no education in grade one reach grade five without repeat- ing grades, 69.1 percent of those of mothers who have primary education and 76.7 percent of those of mothers who have secondary education do. Children of households belonging to the poorest quintile are least likely to reach grade five at 56.4 percent while children of the households belonging to the richest quintile are most likely at 78.6 percent. The net primary school completion rate and transition rate to secondary education are presented in Table ED.6. At the time of the survey, 26.7 percent of the children of primary completion age (11 years) were attending the last grade of primary education. This value should be distinguished from the gross primary completion ratio which includes children of any age attending the last grade of primary. Girls’ completion rate is about seven percentage points higher than that of boys’. While the figure is 52.3 percent in urban areas, it is 22.1 percent in rural areas with road access and 9.4 percent in rural areas without road access. The completion rate is lowest in the North region at 17.6 percent, when compared with 33.9 percent in the Central region and 26.1 percent in the South re- gion. Mother’s education is strongly correlated to the completion rate, as while 6.7 percent of children whose mothers have no education complete primary school, 58.0 percent of those whose mothers have secondary or higher education do. While only one in 20 children of households belonging to the poorest quintile completes primary school, two out of three children of the richest quintile do. The completion rate is highest among households where the head speaks Lao at 39.6 percent, as compared with 7.1 percent of those where the head speaks Khmou, 6.9 percent of those where the head speaks Hmong, and 4.8 percent of those where the head speaks “other” languages. 88.2 percent of the children that successfully completed the last grade of primary school were found at the time of the survey to be attending the first grade of secondary school. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). Notice that the ratios included here are obtained from net attendance ratios rather than gross attendance ratios. The latter ratios provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary education tend to be boys. The table shows that gender parity for primary school is 0.95. The indicator drops to 0.81 for secondary education. The disadvantage of girls is par- ticularly pronounced in the North region, as well as among children from the poorest households, of mothers who have no education, rural areas, and of households where the head speaks Khmou or Hmong. The school attendance of girls is more affected by the level of mother’s education and the wealth of household than that of boys. The location of households (urban, rural areas with road ac- cess, or rural areas without road access) also has greater implications for girls than for boys. 9 Education 56 Multiple Indicator Cluster Survey, 2006 Adult Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. In MICS, since only a women’s questionnaire was admin- istered, the results are based only on females aged 15-24. Literacy was assessed on the ability of women to read a short simple statement or on school attendance. The percentage of literate women is presented in Table ED.8. Overall, about two out of three (67.3 percent) females are literate in the Lao PDR. The percentage is highest in the Central region at 76.2 percent and lowest in the North region at 57.3 percent. 93.1 percent are literate in urban areas, while about 61.7 percent are in rural areas with road access and 40.8 percent are in rural areas without road access. While 100 percent of females aged 15-24 with at least secondary education are automatically assumed to be literate in the questionnaire, only 65.1 percent of those with primary education and 0.3 percent of those with no education are literate. The literacy rate is positively correlated to the socioeconomic status of these females, ranging from 95.7 percent of the richest quintile females to 24.2 percent of the poorest quin- tile females. While 81.5 percent of females of households where the head speaks Lao are literate, only 48.3 percent of those from households where the head speaks Khmou are and this drops to 31.7 percent of those from households where the head speaks “other” languages, and 30.3 percent of those from households where the head speaks Hmong. 9 Ed uc at io n Multiple Indicator Cluster Survey, 2006 57 Photo: Jim Holmes 58 Multiple Indicator Cluster Survey, 200610 Multiple Indicator Cluster Survey, 2006 59 10 Child Protection CHAPTER 10 Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a na- tionality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under five whose birth is registered. The births of 71.5 percent of children under five years in the Lao PDR have been registered (Table CP.1)15. There are no significant variations in birth registration between boys and girls. Children in the North are least likely to have their births registered at 59.0 percent, as compared with those in the South region at 83.7 percent and those in the Central region at 74.7 percent. The registration rate gradually rises along the age of children, from 61.0 percent of those aged 0-11 months old to 72.5 percent of those 12-23 months old and almost stays the same after, reaching 75.4 percent of those aged 48-59 months. Mother’s education and the socioeconomic status of the household are positively correlated to the registration rate. While 62.9 percent of children of mothers who have no education are registered, the figure rises to 84.3 percent for those of mothers who have at least sec- ondary education. The registration rate is 62.0 percent for children belonging to the poorest quintile, which rises to 84.7 percent for those of the richest quintile. Child Labour Article 32 of the Convention on the Rights of the Child states: “States Parties recognise the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or social development.” The World Fit for Children mentions nine strategies to combat child labour and the MDGs call for the protection of children against exploitation. In the MICS questionnaire, a number of questions addressed the issue of child labour, that is, children 5-14 years of age involved in labour activities. A child is considered to be involved in child labour activities at the moment of the survey if during the week preceding the survey: • At age 5-11 they engaged in at least one hour of economic work or 28 hours of domestic work per week. • At age 12-14 they engaged in at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows differentiation between child labour and child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of 15 Although further analysis and more data are needed to draw any conclusions, a possible explanation for the significant increase in birth registration since the previous MICS may be that the Government has strengthened the birth registration process and system throughout the country through the conduct of the Population Census in 2005. 10 C hild Protection 60 Multiple Indicator Cluster Survey, 2006 child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained above. Table CP.2 presents the results of child labour by the type of work. Percentages do not add up to the total child labour as children may be involved in more than one type of work. Overall, 11.3 percent of children aged 5-14 years are involved in child labour in the Lao PDR. The figures are 10.2 percent for boys and 12.5 percent for girls. Child labour is most common in the North region at 15.1 percent. The rate is lowest in urban areas at 7.6 percent. Mother’s educa- tion and the socioeconomic status of households are negatively correlated to the prevalence of child labour. While12.2 percent of children of mothers who have no education are engaged in child labour, the prevalence declines to 8.8 percent for those of mothers who have at least secondary education. While 13.1 percent of children in the households belonging to the poorest quintile are engaged in child labour, the figure drops to 6.6 percent for those belonging to the richest quintile. Table CP.3 presents the percentage of children classified as student labourers or as labourer stu- dents. Student labourers are the children attending school that were involved in child labour activities at the moment of the surveys. More specifically, of the 68.1 percent of the children 5-14 years of age attending school, 12.0 percent are also involved in child labour activities. On the other hand, out of the 11.3 percent of the children classified as child labourers, 72.2 percent are also attending school. Children of rural areas, of mothers who have no education, or of poorest quintiles tend to be involved in child labour more commonly than those of urban areas, mothers who have higher education, or higher index quintiles. Child Discipline As stated in A World Fit for Children, “children must be protected against any acts of violence …” and the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In the Lao PDR MICS survey, mothers/caretakers of children age 2-14 years were asked a series of questions on the ways parents tend to discipline their children when they misbehave. Note that for the child discipline module, one child aged 2-14 per household was selected randomly during fieldwork. Out of these questions, the two indicators used to describe aspects of child discipline are: 1) the number of children 2-14 years that experience psychological aggression as punishment or minor physical punishment or severe physical punishment; and 2) the number of parents/caretakers of children 2-14 years of age that believe that in order to raise their children properly, they need to physically punish them. In the Lao PDR, 71.2 percent of children aged 2-14 years are subjected to at least one form of psy- chological or physical punishment by their mothers/caretakers or other household members (Table CP.4). More importantly, 7.5 percent of children are subjected to severe physical punishment. 18.4 percent of mothers/caretakers believe that children should be physically punished. Male children are subjected more to minor physical discipline (47.0) than female children (39.8). Even though children of the North region are least likely to receive minor physical punishment at 41 percent, they are most likely to receive severe physical punishment at 8.8 percent. Urban children are most likely to be disciplined only by non-violent ways and least likely to receive psychological or physical punishment. Children from rural areas without road access are least likely to be disciplined only by non-violent ways and most likely to receive psychological or physical punishment. Children of mothers who have higher education and of richer households are more likely to receive only non- violent discipline and less likely to receive psychological and physical punishment than those of mothers who have less education and of poorer households. Domestic Violence A number of questions were asked of women aged 15-49 years to assess their attitudes on whether husbands are justified in hitting or beating their wives/partners for a variety of reasons. These questions were asked to gain an indication of cultural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that 10 C hi ld P ro te ct io n Multiple Indicator Cluster Survey, 2006 61 women who agree with the statements indicating that husbands/partners are justified in beating their wives/partners under the situations described, in reality, tend to be abused by their own husbands/ partners. The responses to these questions can be found in Table CP.5. Nationally, 81.2 percent of women believe that a husband is justified in beating his wife/partner for one of following reasons: 1) when she goes out without telling him, 2) when she neglects the children, 3) when she argues with him, 4) when she refuses sex with him, or 5) when she burns the food. Compared with other regions, a greater proportion of women from the South region (85.2 percent) believe that a husband beating his wife/partner for one of these reasons is justified. 84.3 percent of women from rural areas with road access and 82.7 percent of those from rural areas without road access also believe these reasons provide justification for beating and 75.0 percent of those from urban areas agree with them. 81.9 percent of women with no education and 84.7 percent of women with primary education believe that beatings are justifiable, whereas among those with at least secondary education 75.8 percent believe so. Between 82.7 percent and 84.1 percent of women of the poorest four quintile groups believe that these reasons justify beatings, while 74.7 percent of women of the richest quintile group believe so. Nationally, about two-thirds of women believe that a husband’s violence is justified when his wife/partner neglects the children. Child Disability One of the World Fit for Children goals is to protect children against abuse, exploitation, and vio- lence, including the elimination of discrimination against children with disabilities. For children age 2-9 years, a series of questions were asked to assess a number of disabilities/impairments, such as sight impairment, deafness, and difficulties with speech. This approach rests in the concept of functional disability developed by WHO and aims to identify the implications of any impairment or disability for the development of the child (e.g. health, nutrition, education ,etc.). Table CP.6 presents the results of these questions. In the Lao PDR, 8.2 percent of children aged 2-9 years have at least one reported disability. Disability is most common among children of the North region at 9.5 percent. Prevalence of children with disabilities is 6.5 percent in urban areas, whereas in rural with road areas the rate is 8.4 percent and in rural without road areas it is 9.1 percent. It is highest among children of mothers who have no education at 9.1 percent and lowest among those of mothers who have secondary or higher education at 5.2 percent. While 9.8 percent of children of households belonging to the poorest quintile have at least one disability, 5.9 percent of those of the richest quintile do. Chil- dren of households where the head speaks Khmou have the highest disability rate at 11.5 percent. 3.0 percent of children aged 2-9 are not learning to do things like other children his/her age. 10 C hild Protection 62 Multiple Indicator Cluster Survey, 2006 Multiple Indicator Cluster Survey, 2006 63 Photo: Jacky Knowles 64 Multiple Indicator Cluster Survey, 200611 Multiple Indicator Cluster Survey, 2006 65 11 HIV/AIDS and Orphaned and Vulnerable Children CHAPTER 11 HIV Counselling and Testing The UN General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to im- prove the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal, as well as the MDG of reducing HIV infections by half include improving the level of knowledge of HIV and its prevention, and changing behaviours to prevent further spread of the disease. The partial HIV module was administered to women 15-49 years of age. Among women who had given birth within the two years preceding the survey, the percentage who received counselling and HIV testing during antenatal care is presented in Table HA.1. Overall, only 7.6 percent of mothers were offered HIV counselling, and 1.5 percent were tested for HIV at antena- tal care visits. Figures remain very low across all categories at one-digit for HIV Testing. Women in urban areas are most likely to receive HIV counselling at 21.7 percent. While 18.6 percent of women who have at least secondary education receive HIV counselling, 8.9 percent of those who have primary education and 1.3 percent of those who have no education do. Women in the richest (22.3 percent) and fourth (16.0 percent) quintiles are more likely to receive HIV counselling than those of the other quintiles. Orphans and Vulnerable Children As the HIV epidemic progresses, more and more children are becoming orphaned and vulnerable because of AIDS. Children who are orphaned or in vulnerable households may be at increased risk of neglect or exploitation if the parents are not available to assist them. Monitoring the variations in different outcomes for orphans and vulnerable children and comparing them to their peers gives us a measure of how well communities and governments are responding to their needs. To monitor these variations, a measurable definition of orphaned and vulnerable children needed to be created. The UNAIDS Monitoring and Evaluation Reference Group developed proxy definition of children who have been affected by adult morbidity and mortality. This should capture many of the children affected by AIDS in countries where a significant proportion of the adults are HIV infected. This definition classifies children as orphaned and vulnerable if they have experienced the death of either parent, if either parent is chronically ill, or if an adult (aged 18-59) in the household either died (after being chronically ill) or was chronically ill in the year prior to the survey. The frequency of children living with neither parent, mother only, and father only is presented in Table HA.2. In the Lao PDR, 87.9 percent of children aged 0-17 years are living with both parents. 6.6 percent of children have lost one or more parents. The figures are similar across all categories, except for those aged 15-17 years, 76.3 percent of whom live with both parents, and 15.6 percent of whom have lost one or more parents. One of the measures developed for the assessment of the status of orphaned and vulnerable chil- dren relative to their peers looks at the school attendance of children 10-14 for children who have lost both parents (double orphans) versus children whose parents are alive (and who live with at least 11 H IV/A ID S and O rphaned and Vulnerable C hildren 66 Multiple Indicator Cluster Survey, 2006 one of these parents). If children whose parents have died do not have the same access to school as their peers, then families and schools are not ensuring that these children’s rights are being met. In the Lao PDR, 0.7 percent of children aged 10-14 have lost both parents (Table HA.3). Although the sample size of children that have lost both parents was very small in the survey, the survey indicates that 70.1 per cent of them are currently attending school. Among the children ages 10-14 who have not lost a parent and who live with at least one parent, 81.3 percent are attending school. 11 H IV /A ID S an d O rp ha ne d an d Vu ln er ab le C hi ld re n Multiple Indicator Cluster Survey, 2006 67 Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16. Blanc, A. and Wardlaw, T. 2005. “Monitoring Low Birth Weight: An Evaluation of International Esti- mates and an Updated Estimation Procedure”. WHO Bulletin, 83 (3), 178-185. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. Government of Lao People’s Democratic Republic (Steering Committee for Census of Population and Housing), 2006. Results from the Population and Housing Census 2005, Vientiane. UNICEF, 2006. Monitoring the Situation of Children and Women. Multiple Indicator Cluster Survey Manual, New York. www.Childinfo.org. List of References 68 Multiple Indicator Cluster Survey, 2006 Multiple Indicator Cluster Survey, 2006 69 Tables 70 Multiple Indicator Cluster Survey, 2006 Ta bl e Multiple Indicator Cluster Survey, 2006 71 Table Table HH.1: Results of household and individual interviews Numbers of households, women and children under 5 by results of the household, women’s and under-five’s interviews, and household, women’s and under-five’s response rates, Lao PDR, 2006 Table HH.1: Results of household and individual interviews Numbers of households. women and children under 5 by results of the household. women's and under-five's interviews. and household. women's and under-five's response rates. Lao PDR. 2006 Area Region Total Background characteristics Urban Rural with road Rural without road North Centre South Urban Sampled households 1480 3420 1095 1995 2000 2000 5995 Occupied households 1480 3416 1095 1995 1996 2000 5991 Interviewed households 1427 3380 1087 1979 1926 1989 5894 Household response rate 96.4 98.9 99.3 99.2 96.5 99.5 98.4 Eligible women 2010 4280 1413 2644 2528 2531 7703 Interviewed women 1921 4104 1362 2538 2413 2436 7387 Women response rate 95.6 95.9 96.4 96.0 95.5 96.2 95.9 Women's overall response rate 92.1 94.9 95.7 95.2 92.1 95.7 94.3 Eligible children under 5 633 2538 1033 1468 1134 1602 4204 Mother/Caretaker Interviewed 616 2502 1018 1430 1116 1590 4136 Child response rate 97.3 98.6 98.5 97.4 98.4 99.3 98.4 Children's overall response rate 93.8 97.5 97.8 96.6 95.0 98.7 96.8 72 Multiple Indicator Cluster Survey, 2006 Ta bl e Table HH.2: Household age distribution by sex 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, Lao PDR, 2006 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Note: DK= Doesn’t know Table HH.3: Household composition Percent distribution of households by selected characteristics. Lao PDR. 2006 Weighted percent Number of households weighted Number of households unweighted Male 89.9 5297 5322 Sex of household head Female 10.1 597 572 North 31.2 1842 1979 Centre 48.9 2881 1926Region South 19.9 1172 1989 Urban 28.0 1653 1427 Rural with road 51.5 3036 3380Area Rural without road 20.4 1205 1087 1 (0.9) 51 42 2-3 15.1 893 854 4-5 37.8 2231 2182 6-7 27.9 1644 1685 8-9 12.1 713 750 Number of household members 10+ 6.2 363 381 Lao 67.6 3986 3839 Khmou 11.4 673 702 Hmong 8.9 526 494 Other Language 12.0 708 857 Mother tongue of head Missing (*) 2 2 Total 100.0 5894 5894 At least one child aged < 18 years 90.6 5894 5894 At least one child aged < 5 years 48.3 5894 5894 At least one woman aged 15-49 years 91.8 5894 5894 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Figures in parenthesis are based on 25-49 unweighted cases. Table HH.2: Household age distribution by sex 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. Lao PDR. 2006 Sex Total Male Female Number Percent Number Percent Number Percent Number Percent 0-4 2064 12.5 1966 11.8 4030 12.2 5-9 2399 14.6 2296 13.8 4695 14.2 10-14 2323 14.1 2399 14.4 4722 14.3 15-19 1865 11.3 1655 10.0 3520 10.6 20-24 1187 7.2 1314 7.9 2501 7.6 25-29 1053 6.4 1158 7.0 2210 6.7 30-34 972 5.9 1141 6.9 2113 6.4 35-39 1013 6.2 1009 6.1 2022 6.1 40-44 853 5.2 830 5.0 1683 5.1 45-49 764 4.6 642 3.9 1406 4.2 50-54 605 3.7 793 4.8 1398 4.2 55-59 415 2.5 405 2.4 820 2.5 60-64 317 1.9 345 2.1 662 2.0 65-69 241 1.5 242 1.5 483 1.5 70+ 385 2.3 416 2.5 800 2.4 Age Missing/DK 12 (*) 23 (*) 35 (0.1) <15 6786 41.2 6661 40.0 13447 40.6 15-64 9044 54.9 9291 55.9 18335 55.4 65+ 625 3.8 658 4.0 1283 3.9 Dependency age groups Missing/DK 12 (*) 23 (*) 35 (0.1) Children aged 0-17 8037 48.8 7708 46.3 15746 47.6 Age Adults 18+/Missing/DK 8429 51.2 8925 53.7 17354 52.4 Total 16467 100.0 16633 100.0 33100 100.0 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Note: DK= Doesn’t know Multiple Indicator Cluster Survey, 2006 73 Table Table HH.3: Household composition Percent distribution of households by selected characteristics, Lao PDR, 2006 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Figures in parenthesis are based on 25-49 unweighted cases. Table HH.3: Household composition Percent distribution of households by selected characteristics. Lao PDR. 2006 Weighted percent Number of households weighted Number of households unweighted Male 89.9 5297 5322 Sex of household head Female 10.1 597 572 North 31.2 1842 1979 Centre 48.9 2881 1926Region South 19.9 1172 1989 Urban 28.0 1653 1427 Rural with road 51.5 3036 3380Area Rural without road 20.4 1205 1087 1 (0.9) 51 42 2-3 15.1 893 854 4-5 37.8 2231 2182 6-7 27.9 1644 1685 8-9 12.1 713 750 Number of household members 10+ 6.2 363 381 Lao 67.6 3986 3839 Khmou 11.4 673 702 Hmong 8.9 526 494 Other Language 12.0 708 857 Mother tongue of head Missing (*) 2 2 Total 100.0 5894 5894 At least one child aged < 18 years 90.6 5894 5894 At least one child aged < 5 years 48.3 5894 5894 At least one woman aged 15-49 years 91.8 5894 5894 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Figures in parenthesis are based on 25-49 unweighted cases. 74 Multiple Indicator Cluster Survey, 2006 Ta bl e Table HH.4: Women’s background characteristics Percent distribution of women aged 15-49 years by background characteristics, Lao PDR, 2006 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Table HH.4: Women's background characteristics Percent distribution of women aged 15-49 years by background characteristics. Lao PDR. 2006 Weighted percent Number of women weighted Number of women unweighted North 31.8 2347 2538 Centre 49.0 3622 2413Region South 19.2 1418 2436 Urban 30.2 2231 1921 Rural with road 49.5 3653 4104Area Rural without road 20.3 1503 1362 15-19 20.8 1539 1546 20-24 16.7 1235 1231 25-29 15.0 1112 1116 30-34 14.9 1104 1096 35-39 13.2 974 982 40-44 10.9 805 806 Age 45-49 8.4 618 610 None 26.1 1929 1996 Primary 41.8 3090 3261 Secondary + 30.9 2286 2054 Education Non-standard curriculum 1.1 82 76 Poorest 17.6 1299 1380 Second 17.5 1290 1367 Middle 18.6 1375 1526 Fourth 21.1 1558 1598 Wealth index quintiles Richest 25.3 1865 1516 Lao 68.1 5033 4818 Khmou 11.8 873 914 Hmong 8.1 598 570 Other Language 11.9 880 1083 Mother tongue of head Missing (*) 2 2 Total 100.0 7387 7387 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Table HH.5: Children's background characteristics Percent distribution of children under five years of age by background characteristics. Lao PDR. 2006 Multiple Indicator Cluster Survey, 2006 75 Table Table HH.4: Women's background characteristics Percent distribution of women aged 15-49 years by background characteristics. Lao PDR. 2006 Weighted percent Number of women weighted Number of women unweighted North 31.8 2347 2538 Centre 49.0 3622 2413Region South 19.2 1418 2436 Urban 30.2 2231 1921 Rural with road 49.5 3653 4104Area Rural without road 20.3 1503 1362 15-19 20.8 1539 1546 20-24 16.7 1235 1231 25-29 15.0 1112 1116 30-34 14.9 1104 1096 35-39 13.2 974 982 40-44 10.9 805 806 Age 45-49 8.4 618 610 None 26.1 1929 1996 Primary 41.8 3090 3261 Secondary + 30.9 2286 2054 Education Non-standard curriculum 1.1 82 76 Poorest 17.6 1299 1380 Second 17.5 1290 1367 Middle 18.6 1375 1526 Fourth 21.1 1558 1598 Wealth index quintiles Richest 25.3 1865 1516 Lao 68.1 5033 4818 Khmou 11.8 873 914 Hmong 8.1 598 570 Other Language 11.9 880 1083 Mother tongue of head Missing (*) 2 2 Total 100.0 7387 7387 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Table HH.5: Children's background characteristics Percent distribution of children under five years of age by background characteristics. Lao PDR. 2006 Table HH.5: Children’s background characteristics Percent distribution of children under five years of age by background characteristics, Lao PDR, 2006 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Figures in parenthesis are based on 25-49 unweighted cases. Weighted percent Number of under-5 children weighted Number of under-5 children unweighted Male 51.0 2109 2119 Sex Female 49.0 2027 2017 North 34.2 1413 1430 Centre 42.3 1749 1116Region South 23.6 975 1590 Urban 16.8 694 616 Rural with road 54.3 2247 2502Area Rural without road 28.9 1195 1018 < 6 months 10.9 451 445 6-11 months 8.5 353 362 12-23 months 20.0 828 839 24-35 months 20.5 847 828 36-47 months 22.7 937 938 Age 48-59 months 17.4 720 724 None 39.9 1649 1627 Primary 42.3 1749 1838 Secondary 16.4 677 622 Mother's education Non-standard curriculum (1.5) 61 49 Poorest 29.8 1234 1238 Second 23.8 984 1004 Middle 19.1 789 855 Fourth 15.2 629 633 Wealth index quintiles Richest 12.1 501 406 Lao 53.2 2200 2143 Khamu 13.6 562 548 Hmong 15.3 631 570 Other Language 17.9 740 873 Mother tongue of head Missing (*) 3 2 Total 100.0 4136 4136 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Figures in parenthesis are based on 25-49 unweighted cases. Table NU.1: Child malnourishment Percentage of children aged 0-59 months who are severely or moderately malnourished. Lao PDR. 2006 76 Multiple Indicator Cluster Survey, 2006 Ta bl e Table NU.1: Child malnourishment Percentage of children aged 0-59 months who are severely or moderately malnourished, Lao PDR, 2006 (NCHS/WHO Reference Population) * MICS indicator 6; MDG indicator 4 ** MICS indicator 7 *** MICS indicator 8 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. % below % below % below % below % below % below % above - 2 SD* - 3 SD* - 2 SD** - 3 SD** - 2 SD*** - 3 SD*** + 2 SD Male 36.6 8.7 40.4 15.4 7.0 0.6 0.7 2,019 Female 37.6 9.3 40.5 16.2 5.8 0.5 0.8 1,921 North 33.5 7.1 43.1 18.0 3.9 0.5 1.1 1,348 Centre 32.9 7.1 34.9 11.9 6.4 0.7 0.8 1,643 South 49.5 14.8 46.2 19.3 10.1 0.4 0.3 949 Urban 25.7 4.0 25.7 6.9 6.0 1.4 1.1 635 Rural with road 37.8 8.9 42.0 16.4 6.3 0.4 0.9 2,161 Rural without road 42.0 11.9 45.7 19.6 7.0 0.4 0.5 1,145 < 6 months 2.7 0.6 9.2 1.9 3.2 0.3 3.5 403 6-11 months 23.1 6.2 24.2 6.2 5.1 - 2.0 344 12-23 months 45.7 12.5 43.8 15.3 13.0 0.6 0.5 796 24-35 months 45.1 12.1 42.0 16.7 7.7 1.1 0.3 814 36-47 months 41.8 9.0 47.7 21.7 3.2 0.5 0.4 898 48-59 months 38.7 7.4 51.6 20.5 4.4 0.4 0.1 686 None 42.2 11.5 48.4 23.1 5.8 0.5 0.6 1,577 Primary 37.2 8.9 38.3 13.1 7.3 0.3 0.7 1,675 Secondary 25.0 3.4 24.5 4.9 6.2 1.3 1.6 630 Non-standard curriculum 25.6 4.2 56.7 11.9 2.4 0.0 0.0 59 Poorest 43.9 12.6 52.6 25.0 5.7 0.4 0.9 1,183 Second 38.0 9.8 44.1 17.0 6.2 0.3 0.4 940 Middle 39.9 8.0 37.4 13.8 8.0 0.7 0.4 771 Fourth 32.7 5.8 32.2 7.5 6.5 0.4 1.0 605 Richest 18.2 3.4 16.8 3.4 6.2 1.5 1.4 442 Lao 33.8 7.3 31.9 10.4 7.4 0.7 0.6 2,096 Kammu 37.3 8.8 48.5 19.7 3.2 0.5 0.9 535 Hmong 28.2 4.1 47.2 18.5 2.3 0.2 2.2 604 Other Language 54.3 18.3 53.8 26.5 9.7 0.5 0.1 702 Missing (*) (*) (*) (*) (*) (*) (*) 3 Total 37.1 9.0 40.4 15.8 6.5 0.5 0.8 3,941 * MICS indicator 6; MDG indicator 4 ** MICS indicator 7 *** MICS indicator 8 Wealth index quintiles Sex Residence Age Mother’s education Number of children aged 0-59 months Weight for age Height for age Weight for height Ethnicity/Language/Religion Region (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Multiple Indicator Cluster Survey, 2006 77 Table Table NU.2: Initial breastfeeding Percentage of women aged 15-49 years with a birth in the 2 years preceding the survey who breast- fed their baby within one hour of birth and within one day of birth, Lao PDR, 2006 * MICS indicator 45 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Table NU.2: Initial breastfeeding Percentage of women aged 15-49 years with a birth in the 2 years preceding the survey who breastfed their baby within one hour of birth and within one day of birth. Lao PDR. 2006 Percentage who started breastfeeding within one hour of birth* Percentage who started breastfeeding within one day of birth Number of women with live birth in the two years preceding the survey North 33.9 64.1 542 Centre 33.5 52.8 625Region South 17.5 45.9 366 Urban 52.8 73.4 250 Rural with road 27.2 55.1 840Area Rural without road 21.8 44.9 442 < 6 months 29.3 50.7 438 6-11 months 30.7 55.2 349Months since last birth 12-23 months 29.7 57.8 745 None 24.4 51.5 593 Primary 25.4 50.1 654 Secondary + 51.3 74.2 266 Education Non-standard curriculum (*) (*) 19 Poorest 21.7 54.1 485 Second 25.4 48.4 370 Middle 29.5 50.1 279 Fourth 32.7 54.3 205 Wealth index quintiles Richest 56.2 79.0 193 Lao 32.6 55.1 807 Khmou 31.4 63.1 216 Hmong 31.0 59.1 236 Mother tongue of head Other Language 19.4 45.7 273 Total 29.8 55.2 1532 * MICS indicator 45 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. 78 Multiple Indicator Cluster Survey, 2006 Ta bl e Ta bl e N U .3 : B re as tfe ed in g P er ce nt o f l iv in g ch ild re n ac co rd in g to b re as tfe ed in g st at us a t e ac h ag e gr ou p, L ao P D R , 2 00 6 * M IC S in di ca to r 1 5, ** M IC S in di ca to r 1 6 (* ) A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up re ss ed . Fi gu re s in p ar en th es is a re b as ed o n 25 -4 9 un w ei gh te d ca se s. T ab le N U .3 : B re as tf ee d in g P e rc e n t o f liv in g c h ild re n a cc o rd in g t o b re a st fe e d in g s ta tu s a t e a ch a g e g ro u p . L a o P D R . 2 0 0 6 C h ild re n 0 -3 m o n th s C h ild re n 0 -5 m o n th s C h ild re n 6 -9 m o n th s C h ild re n 1 2- 15 m o n th s C h ild re n 2 0- 23 m o n th s P er ce n t ex cl u si ve ly b re as tf ed N u m b er o f ch ild re n P er ce n t ex cl u si ve ly b re as tf ed * N u m b er o f ch ild re n P er ce n t re ce iv in g b re as tm ilk a n d so ft /m u sh y o r se m i so lid o r so lid f o o d N u m b er o f ch ild re n P er ce n t b re as tf ed ** N u m b er o f ch ild re n P er ce n t b re as tf ed ** N u m b er o f ch ild re n M a le 3 6 .4 1 4 8 2 6 .9 2 2 2 7 0 .6 1 3 5 8 1 .9 1 6 4 4 4 .9 1 3 0 S ex F e m a le 2 9 .8 1 4 4 2 6 .0 2 2 9 6 9 .8 1 1 0 8 1 .4 1 5 2 5 1 .9 1 2 9 N o rt h 5 1 .7 1 0 7 4 3 .6 1 6 6 6 7 .4 9 2 8 4 .7 1 1 3 5 7 .4 7 9 C e n tr e 2 8 .8 1 2 6 2 1 .9 1 8 5 7 0 .9 9 0 7 4 .3 1 2 5 3 9 .7 1 1 2 R eg io n S o u th 8 .9 5 9 6 .4 1 0 0 7 3 .5 6 2 8 9 .0 7 9 5 2 .2 6 9 U rb a n (2 7 .8 ) 5 5 2 0 .1 7 6 (6 3 .0 ) 4 0 (6 2 .5 ) 5 3 (2 2 .8 ) 4 0 R u ra l w ith ro a d 3 6 .4 1 4 0 2 9 .1 2 2 2 7 2 .5 1 3 3 8 4 .8 1 8 4 5 0 .9 1 5 4 A re a R u ra l w ith o u t ro a d 3 1 .5 9 8 2 5 .7 1 5 3 7 0 .1 7 1 8 7 .1 8 0 5 8 .2 6 5 N o n e 3 4 .8 1 0 8 2 9 .7 1 7 5 7 6 .7 9 9 8 4 .2 1 3 4 6 5 .4 9 5 P ri m a ry 3 1 .0 1 1 7 2 3 .6 1 7 9 6 6 .5 9 7 8 7 .6 1 2 6 4 3 .2 1 2 0 S e co n d a ry 3 4 .1 6 4 2 5 .7 9 3 (6 2 .1 ) 4 6 6 0 .3 5 1 (1 8 .7 ) 4 1 M o th er 's ed u ca ti o n N o n - st a n d a rd cu rr ic u lu m (* ) (* ) (* ) 3 (* ) 3 (* ) 6 (* ) 4 P o o re st 3 7 .4 8 6 3 0 .5 1 3 6 6 7 .0 8 4 8 4 .8 1 0 6 6 2 .0 7 3 S e co n d 3 5 .1 7 3 2 9 .6 1 1 2 7 5 .9 5 3 8 9 .4 7 3 5 5 .0 6 4 M id d le (3 1 .2 ) 3 8 2 2 .0 7 3 (7 5 .6 ) 4 3 8 8 .1 6 1 5 5 .3 6 0 F o u rt h (2 0 .3 ) 3 8 1 6 .7 5 5 (7 1 .8 ) 4 0 7 9 .7 4 3 (2 2 .1 ) 2 6 W ea lt h in d ex q u in ti le s R ic h e st 3 4 .2 5 6 2 5 .8 7 5 (* ) 2 4 (4 5 .4 ) 3 3 (1 7 .7 ) 3 7 L a o 2 5 .0 1 4 7 1 8 .1 2 2 2 7 4 .8 1 2 2 7 5 .9 1 7 0 3 9 .3 1 5 1 K h m o u (5 6 .5 ) 4 0 4 6 .8 5 6 (7 0 .8 ) 4 4 (8 8 .7 ) 4 1 (6 9 .7 ) 2 6 H m o n g (6 1 .1 ) 5 1 5 7 .0 8 0 (4 8 .3 ) 3 8 (8 1 .8 ) 4 7 (5 5 .7 ) 4 4 M o th er to n g u e o f h ea d O th e r L a n g u a g e 1 2 .2 5 5 7 .3 9 2 (7 6 .6 ) 4 1 9 3 .4 5 8 6 1 .4 3 9 T o ta l 33 .1 29 2 26 .4 45 1 70 .3 24 5 81 .7 31 7 48 .4 26 0 Multiple Indicator Cluster Survey, 2006 79 Table Ta bl e N U .3 w : I nf an t f ee di ng p at te rn s by a ge P er ce nt d is tri bu tio n of c hi ld re n ag ed u nd er 3 y ea rs b y fe ed in g pa tte rn b y ag e gr ou p, L ao P D R , 2 00 6 * M IC S in di ca to r 4 5 (* ) A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up re ss ed . M IC S in di ca to r 15 . * * M IC S in di ca to r 16 (* ) A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th a n 25 u n w ei gh te d ca se s an d ha s be en s u pr es se d. F ig ur es in p ar en th es is a re b as ed o n 25 -4 9 un w ei g ht ed c as es . Ta bl e N U .3 w : I nf an t f ee di ng p at te rn s by a ge P er ce nt d is tr ib ut io n of c hi ld re n ag ed u nd er 3 y ea rs b y fe ed in g pa tte rn b y ag e gr ou p. L ao P D R . 2 00 6 In fa nt fe ed in g pa tt er n E xc lu si ve ly br ea st fe d B re as tf ed a nd pl ai n w at er on ly B re as tf ed a nd no n- m ilk li qu id s B re as tf ed a nd ot he r m ilk / fo rm ul a B re as tf ed a nd co m pl em en ta ry fo od s W ea ne d (n ot br ea st fe d) To ta l N um be r of ch ild re n 0- 1 40 .2 20 .0 .0 7. 7 28 .8 3. 2 10 0. 0 13 3 2- 3 27 .2 25 .2 2. 0 8. 6 32 .4 4. 6 10 0. 0 15 9 4- 5 14 .1 19 .4 .6 5. 7 53 .6 6. 6 10 0. 0 15 9 6- 7 9. 8 19 .4 .5 3. 1 60 .3 7. 0 10 0. 0 11 8 8- 9 .8 8. 6 1. 4 1. 7 79 .4 8. 0 10 0. 0 12 7 10 -1 1 .0 2. 2 1. 3 1. 0 87 .4 8. 0 10 0. 0 10 9 12 -1 3 .6 3. 6 .0 1. 3 77 .9 16 .5 10 0. 0 17 7 14 -1 5 .7 3. 2 .0 .6 74 .9 20 .6 10 0. 0 14 0 16 -1 7 .0 1. 8 .0 .0 70 .4 27 .8 10 0. 0 13 3 18 -1 9 .0 .0 .8 .0 56 .3 42 .9 10 0. 0 11 9 20 -2 1 .0 .8 .0 .0 50 .5 48 .7 10 0. 0 14 2 22 -2 3 .0 .0 .0 .5 44 .4 55 .1 10 0. 0 11 8 24 -2 5 .0 .6 .0 .0 35 .3 64 .1 10 0. 0 18 3 26 -2 7 .0 .7 .0 .0 34 .3 64 .9 10 0. 0 14 8 28 -2 9 .0 .0 .0 .0 24 .1 75 .9 10 0. 0 12 7 30 -3 1 .0 .0 .0 .0 19 .6 80 .4 10 0. 0 12 2 32 -3 3 .0 .8 .0 .0 15 .3 83 .9 10 0. 0 13 3 A ge 34 -3 5 .0 .0 .0 .0 12 .2 87 .8 10 0. 0 13 4 To ta l 5. 4 6. 1 .4 1. 8 47 .4 39 .0 10 0. 0 24 79 80 Multiple Indicator Cluster Survey, 2006 Ta bl e Table NU.4: Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6-11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, Lao PDR, 2006 * MICS indicator 18 ** MICS indicator 19 In the Lao PDR MICS, some types of semi-solid (mushy) food was not categorized under the semi-solid food as they should be, and instead categorized together with “any other liquid” as inadequate food ; therefore, some children who are fed with breast milk and the types of semi-solid (mush) food that are not categorized correctly as adequate food were not counted towards those adequately-fed. This means the prevalence of children aged 6-11 months fed with complementary food found in the above Table NU.4 do not include all infants fed adequately with complementary foods and is an underestimation of the prevalence of adequately-fed infants. This occurred due to the difficulties in precisely translating the difference between other liquid and mushy food (some mushy food were considered liquid as opposed to solid). (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. Table NU.4: Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed. percentage of infants 6-11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed. Lao PDR. 2006 0-5 months exclusively breastfed 6-8 months who received breastmilk and complementary food at least 2 times in prior 24 hours 9-11 months who received breastmilk and complementary food at least 3 times in prior 24 hours 6-11 months who received breastmilk and complementary food at least the minimum recommended number of times per day* 0-11 months who were appropriately fed** Number of infants aged 0- 11 months Male 26.9 34.2 57.7 45.3 35.4 412 Sex Female 26.0 35.3 51.9 43.7 33.3 392 North 43.6 27.1 50.0 37.9 41.1 296 Centre 21.9 33.9 48.3 41.6 30.2 320Region South 6.4 46.2 74.9 58.8 31.0 188 Urban 20.1 18.5 46.4 31.0 24.8 133 Rural with road 29.1 41.2 58.1 49.2 38.3 409Area Rural without road 25.7 32.1 53.7 43.7 33.1 261 None 29.7 38.7 53.3 46.2 37.1 320 Primary 23.6 36.6 61.6 48.7 34.7 321 Secondary 25.7 20.7 39.5 28.7 26.9 157 Mother's education Non- standard curriculum (*) (*) (*) (*) (*) 6 Poorest 30.5 27.8 50.7 39.2 34.5 253 Second 29.6 47.0 54.6 51.2 38.7 194 Middle 22.0 42.7 66.0 53.8 36.7 136 Fourth 16.7 39.9 69.2 50.6 33.6 110 Wealth index quintiles Richest 25.8 6.3 35.3 21.2 24.3 110 Lao 18.1 36.9 58.1 47.7 31.2 398 Khmou 46.8 20.3 43.2 32.8 39.3 120 Hmong 57.0 26.5 58.6 39.5 49.9 136 Mother tongue of head Other Language 7.3 50.0 56.5 52.9 25.0 150 Total 26.4 34.7 54.9 44.5 34.4 804 * MICS indicator 18/ ** MICS indicator 19 - In the Lao PDR MICS. some types of semi-solid (mushy) food was not categorized under the semi-solid food as they should be. and instead categorized together with “any other liquid” as inadequate food1; therefore. some children who are fed with breast milk and the types of semi-solid (mush) food that are not categorized correctly as adequate food were not counted towards those adequately-fed. This means the prevalence of children aged 6-11 months fed with complementary food found in the above Table NU.4 do not include all infants fed adequately with complementary foods and is an underestimation of the prevalence of adequately-fed infants. (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed. 1 This occurred due to the difficulties in precisely translating the difference between other liquid and mushy food (some mushy food were considered liquid as opposed to solid). Multiple Indicator Cluster Survey, 2006 81 Table Table NU.5: Iodized salt consumption Percentage of households consuming adequately iodized salt, Lao PDR, 2006 *The Lao PDR MICS only tested the presence/absence of iodine in salt using a field rapid test kit. This was due to the field test kit not being able to measure the ppm level precisely. Some of the salt samples collected for MICS were further tested in a laboratory for ppm measurements, and these results are found in the National Nutrition Survey Report. (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supresse Table NU.5: Iodized salt consumption Percentage of households consuming adequately iodized salt, Lao PDR, 2006 Percent of households with salt test resultPercent of households in which salt was tested Number of households interviewed Percent of households with no salt No colour Colour* Total Number of households in which salt was tested or with no salt North 99,6 1842 0,2 15,6 84,2 100,0 1838 Centre 99,2 2881 0,5 18,3 81,2 100,0 2872 Region South 99,7 1172 0,3 10,0 89,7 100,0 1170 Urban 99,1 1653 0,7 8,5 90,8 100,0 1649 Rural with road 99,5 3036 0,2 17,3 82,5 100,0 3028 Area Rural without road 99,6 1205 0,2 22,2 77,6 100,0 1203 Poorest 99,5 1127 0,5 15,5 84,0 100,0 1127 Second 99,4 1080 0,2 23,1 76,8 100,0 1075 Middle 99,8 1143 0,2 21,4 78,4 100,0 1143 Fourth 99,2 1252 0,4 14,6 85,0 100,0 1247 Wealth index quintiles Richest 99,3 1292 0,5 6,3 93,2 100,0 1289 Lao 99,4 3986 0,4 14,7 84,9 100,0 3979 Khmou 99,7 673 0,0 9,9 90,1 100,0 671 Hmong 99,1 526 0,6 30,1 69,3 100,0 524 Other Language 99,3 708 0,3 17,1 82,6 100,0 704 Mother tongue of head Missing (*) 2 (*) (*) (*) (*) 2 Total 99,4 5894 ,4 15,8 83,8 100,0 5880 *The Lao PDR MICS only tested the presence/absence of iodine in salt using a field rapid test kit. This was due to the field test kit not being able to measure the ppm level precisely. Some of the salt samples collected for MICS were further tested in a laboratory for ppm measurements, and these results are found in the National Nutrition Survey Report. (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supresse 82 Multiple Indicator Cluster Survey, 2006 Ta bl e Table NU.6: Children’s vitamin A supplementation Percent distribution of children aged 6-59 months by whether they received a high dose Vitamin A supplement in the last 6 months, Lao PDR, 2006 * MICS indicator 42 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed Table NU.6: Children's vitamin A supplementation Percent distribution of children aged 6-59 months by whether they received a high dose Vitamin A supplement in the last 6 months. Lao PDR. 2006 Percent of children who received Vitamin A: Total Within last 6 months* Prior to last 6 months Not sure when Not sure if received Never received Vitamin A Total Number of children aged 6-59 months Male 18.4 10.9 10.6 1.3 58.8 100.0 1888 Sex Female 17.8 10.4 11.5 1.8 58.5 100.0 1798 North 16.5 11.0 5.0 1.3 66.2 100.0 1246 Centre 16.1 9.0 14.1 2.4 58.4 100.0 1564Region South 24.1 13.1 14.1 .4 48.3 100.0 875 Urban 17.6 13.5 14.0 .8 54.1 100.0 619 Rural with road 20.3 10.2 11.1 1.9 56.4 100.0 2025Area Rural without road 14.1 9.7 9.1 1.2 65.8 100.0 1041 6-11 months 21.1 2.5 3.5 .4 72.5 100.0 353 12-23 months 23.7 8.9 8.6 1.6 57.2 100.0 828 24-35 months 17.8 12.4 12.0 1.8 56.0 100.0 847 36-47 months 14.8 12.5 12.1 1.7 58.9 100.0 937 Age 48-59 months 15.0 12.0 15.0 1.5 56.5 100.0 720 None 15.2 6.4 10.0 2.2 66.2 100.0 1473 Primary 19.2 12.7 11.5 1.0 55.6 100.0 1570 Secondary 22.2 15.9 13.1 1.3 47.5 100.0 584 Mother's education Non-standard curriculum 21.7 6.7 5.9 4.2 61.5 100.0 58 Poorest 16.8 7.8 9.2 1.7 64.6 100.0 1098 Second 15.7 10.7 10.8 .8 62.0 100.0 871 Middle 19.8 10.8 12.2 2.2 55.1 100.0 716 Fourth 19.2 13.9 11.1 2.0 53.8 100.0 574 Wealth index quintiles Richest 22.1 12.9 14.5 1.2 49.3 100.0 426 Lao 20.1 12.9 13.3 1.4 52.2 100.0 1977 Khamu 20.0 10.7 4.5 1.0 63.8 100.0 506 Hmong 10.4 6.9 3.7 1.0 78.0 100.0 551 Other Language 17.1 6.7 15.5 2.9 57.8 100.0 649 Mother tongue of head Missing (*) (*) (*) (*) (*) (*) 3 Total 18.1 10.6 11.0 1.5 58.7 100.0 3685 * MICS indicator 42 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been supressed Multiple Indicator Cluster Survey, 2006 83 Table Table NU.7: Post-partum mother’s Vitamin A supplementation Percentage of women aged 15-49 years with a birth in the 2 last years preceding the survey whether they received a high dose Vitamin A supplement before the infant was 8 weeks old, Lao PDR, 2006 * MICS indicator 43 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed Table NU.7: Post-partum mother's Vitamin A supplementation Percentage of women aged 15-49 years with a birth in the 2 last years preceding the survey whether they received a high dose Vitamin A supplement before the infant was 8 weeks old. Lao PDR. 2006 Received Vitamin A supplement* Not sure if received Vitamin A Number of women aged 15-49 years North 16.9 3.7 542 Centre 20.6 1.9 625Region South 14.8 1.2 366 Urban 31.9 2.4 250 Rural with road 17.2 1.9 840Area Rural without road 11.4 3.3 442 None 11.5 3.8 593 Primary 19.6 1.6 654 Secondary + 28.7 1.3 266 Education Non-standard curriculum (*) (*) 19 Poorest 11.3 3.9 485 Second 12.7 1.8 370 Middle 18.5 1.6 279 Fourth 22.8 1.3 205 Wealth index quintiles Richest 38.6 1.8 193 Lao 22.3 2.2 807 Khamu 17.6 2.7 216 Hmong 10.2 2.7 236 Mother tongue of head Other Language 12.1 2.1 273 Total 17.9 2.4 1532 * MICS indicator 43 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed 84 Multiple Indicator Cluster Survey, 2006 Ta bl e Table NU.8 : Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, Lao PDR, 2006 Low birth weight estimation * MICS Indicator 9 ** MICS Indicator 10 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed Low birth weight estimation Number of weighed births Number of births weighing < 2500 g Number of births weighing exactly 2500 g Proportion of births weighing < 2500 g Total number of births Estimated number < 2500 g Very large 17.6 .0 .0 .000 33.2 .0 Larger than average 74.0 .5 1.8 .013 194.9 2.6 Average 210.0 9.6 15.3 .064 1094.1 70.1 Smaller than average 33.8 15.0 5.4 .485 145.6 70.6 Very small 3.2 1.6 .0 .500 23.5 11.8 Size of child at birth DK/Missing .5 .0 .5 .250 40.9 10.2 Total 339.0 26.8 23.0 1.312 1532.2 165.3 Table NU.8 : Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth. Lao PDR. 2006 Percent of live births below 2500 grams * Percent of live births weighed at birth ** Number of live births North 10.5 17.9 542 Centre 11.5 32.4 625Region South 10.1 10.9 366 Urban 10.0 70.2 250 Rural with road 11.0 18.0 840Area Rural without road 10.9 2.8 442 None 11.7 2.7 593 Primary 9.8 22.3 654 Secondary + 11.0 64.9 266 Education Non-standard curriculum (*) (*) 19 Poorest 11.1 4.0 485 Second 10.6 7.9 370 Middle 12.0 15.1 279 Fourth 9.7 42.6 205 Wealth index quintiles Richest 9.6 83.2 193 Lao 10.6 34.8 807 Khamu 11.6 13.8 216 Hmong 10.0 7.5 236 Mother tongue of head Other Language 11.5 4.0 273 Total 10.8 22.1 1532 * MICS Indicator 9 ** MICS Indicator 10 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed Low birth weight estimation Number of weighed births Number of births weighing < 2500 g Number of births weighing exactly 2500 g Proportion of births weighing < 2500 g Total number of births Estimated number < 2500 g Very large 17.6 .0 .0 .000 33.2 .0 Larger than average 74.0 .5 1.8 .013 194.9 2.6 Average 210.0 9.6 15.3 .064 1094.1 70.1 Smaller than average 33.8 15.0 5.4 .485 145.6 70.6 Very small 3.2 1.6 .0 .500 23.5 11.8 Size of child at birth DK/Missing .5 .0 .5 .250 40.9 10.2 Total 339.0 26.8 23.0 1.312 1532.2 165.3 Table NU.8 : Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth. Lao PDR. 2006 Percent of live births below 2500 grams * Percent of live births weighed at birth ** Number of live births North 10.5 17.9 542 Centre 11.5 32.4 625Region South 10.1 10.9 366 Urban 10.0 70.2 250 Rural with road 11.0 18.0 840Area Rural without road 10.9 2.8 442 None 11.7 2.7 593 Primary 9.8 22.3 654 Secondary + 11.0 64.9 266 Education Non-standard curriculum (*) (*) 19 Poorest 11.1 4.0 485 Second 10.6 7.9 370 Middle 12.0 15.1 279 Fourth 9.7 42.6 205 Wealth index quintiles Richest 9.6 83.2 193 Lao 10.6 34.8 807 Khamu 11.6 13.8 216 Hmong 10.0 7.5 236 Mother tongue of head Other Language 11.5 4.0 273 Total 10.8 22.1 1532 * MICS Indicator 9 ** MICS Indicator 10 (*) An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed Multiple Indicator Cluster Survey, 2006 85 Table Ta bl e C H .1 : V ac ci na tio ns in fi rs t y ea r of li fe P er ce nt ag e of c hi ld re n ag ed 1 2- 23 m on th s im m un iz ed a ga in st c hi ld ho od d is ea se s at a ny ti m e be fo re th e su rv ey a nd b ef or e th e fir st b irt hd ay , L ao P D R , 2 00 6 * M IC S In di ca to r 2 5 ** M

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