Lesotho - Demographic and Health Survey - 2010

Publication date: 2010

Lesotho Demographic and Health Survey 2009 Lesotho 2009 D em ographic and H ealth Survey Lesotho Demographic and Health Survey 2009 Ministry of Health and Social Welfare Maseru, Lesotho ICF Macro Calverton, Maryland, USA November 2010 This report presents the findings of the 2009 Lesotho Demographic and Health Survey (LDHS) conducted by the Ministry of Health and Social Welfare (MOHS). The LDHS is part of the worldwide MEASURE Demographic and Health Surveys (DHS) project funded by the United States Agency for International Development (USAID), for which ICF Macro is the primary contractor. Funding for the Lesotho DHS was provided by the government of Lesotho, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), Irish Aid, Millennium Challenge Account (MCA), National AIDS Commission (NAC), The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), USAID, and the World Health Organization (WHO). The MEASURE DHS project provided technical assistance during all phases of the survey and arranged for the Global Clinical and Viral Laboratory (GCVL) of South Africa to help with the training and laboratory processing for the HIV testing component of the survey. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID or other funding partners. Additional information about the 2009 LDHS may be obtained from the Ministry of Health and Social Welfare, P.O. Box 514, Maseru 100, Lesotho, Southern Africa; Telephone: +266-2231-7707 or +266-2232-4561, Fax: +266-2231-1014. Additional information about the DHS project may be obtained from ICF Macro, 11785 Beltsville Drive, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@measuredhs.com, Internet: http://www.measuredhs.com. Recommended citation: Ministry of Health and Social Welfare (MOHSW) [Lesotho] and ICF Macro. 2010. Lesotho Demographic and Health Survey 2009. Maseru, Lesotho: MOHSW and ICF Macro. Contents | iii CONTENTS Page TABLES AND FIGURES . ix FOREWORD . xvii SUMMARY OF FINDINGS . xix MAP OF LESOTHO . xiv CHAPTER 1 INTRODUCTION Mahlape Ramoseme 1.1 Geography, History, and Economy . 1 1.1.1 Geography . 1 1.1.2 History . 1 1.1.3 Economy . 1 1.2 Population . 1 1.3 Objectives of the Survey . 2 1.4 Organisation of the Survey . 3 1.5 Sample Design . 3 1.6 Questionnaires . 3 1.7 Anaemia and HIV Testing . 4 1.7.1 Anaemia Testing . 4 1.7.2 HIV Testing . 5 1.8 Pretest . 5 1.9 Training . 6 1.10 Fieldwork . 6 1.11 Data Processing . 7 1.12 Sample Results . 7 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS John Nkonyana 2.1 Household Population by Age and Sex . 9 2.2 Household Composition . 11 2.3 Children’s Living Arrangements and Orphanhood . 11 2.4 Educational Attainment of Household Members . 14 2.4.1 Educational Attainment . 14 2.4.2 School Attendance . 16 2.5 Household Environment . 18 iv │ Contents 2.5.1 Drinking Water . 18 2.5.2 Household Sanitation Facilities . 20 2.5.3 Housing Characteristics . 20 2.6 Household Durable Goods . 22 2.7 Residency Status . 22 2.8 Birth Registration . 24 2.9 Wealth Quintile . 25 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics of Respondents . 27 3.2 Educational Attainment and Literacy . 27 3.3 Access to Mass Media . 32 3.4 Employment . 35 3.4.1 Employment Status . 35 3.4.2 Occupation . 38 3.4.3 Type of Employer, Form of Earnings, and Continuity of Employment . 40 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4.1 Introduction . 43 4.2 Current Fertility . 43 4.3 Fertility Differentials by Background Characteristics . 45 4.4 Fertility Trends . 46 4.5 Children Ever Born and Living . 47 4.6 Birth Intervals . 48 4.7 Age at First Birth . 50 4.8 Teenage Pregnancy and Motherhood . 51 CHAPTER 5 FAMILY PLANNING Mahlape Ramoseme 5.1 Knowledge of Contraceptive Methods . 53 5.2 Current Use of Contraceptive Methods . 54 5.3 Trends in Contraceptive Use . 56 5.4 Differentials in Contraceptive Use by Background Characteristics . 56 5.5 Knowledge of the Fertile Period . 58 5.6 Source of Modern Contraception Methods . 58 5.7 Informed Choice . 60 5.8 Future Use of Contraception . 62 5.9 Exposure to Family Planning Messages . 62 5.10 Contact of Nonusers with Family Planning Providers . 64 5.11 Husband/partner’s Knowledge of Women’s Use of Contraception . 65 5.12 Men’s Attitude about Contraception . 66 Contents | v CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Introduction . 69 6.2 Marital Status . 69 6.3 Polygyny . 70 6.4 Age at First Marriage . 72 6.5 Age at First Sexual Intercourse . 74 6.6 Recent Sexual Activity . 76 6.7 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 79 6.8 Termination of Exposure to Pregnancy . 82 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 83 7.2 Need for Family Planning Services . 85 7.3 Ideal Family Size . 88 7.4 Wanted and Unwanted Fertility . 90 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Levels and Trends in Infant and Child Mortality . 94 8.2 Socioeconomic Differentials in Infant and Child Mortality . 95 8.3 Demographic Differentials in Infant and Child Mortality . 97 8.4 Perinatal Mortality . 99 8.5 High-Risk Fertility Behaviour . 101 CHAPTER 9 MATERNAL HEALTH Mahlape Ramoseme 9.1 Antenatal Care . 103 9.1.1 Antenatal Care Coverage . 103 9.1.2 Number and Timing of Antenatal Care Visits . 105 9.1.3 Components of Antenatal Care . 105 9.1.4 Tetanus Toxoid Immunisation . 107 9.2 Delivery Care . 109 9.2.1 Place of Delivery . 109 9.2.2 Assistance at Delivery . 110 9.2.3 Timing of First Postnatal Checkup . 112 9.2.4 Type of Provider of First Postnatal Checkup . 113 9.2.5 Problems is Accessing Health Care . 115 CHAPTER 10 CHILD HEALTH Mahlape Ramoseme 10.1 Child’s Size at Birth . 117 10.2 Vaccination Coverage of Children . 119 vi │ Contents 10.2.1 Collection of Data . 119 10.2.2 Level and Trends in Vaccination Coverage . 119 10.3 Acute Respiratory Infection and Fever . 122 10.4 Diarrhoeal Disease . 125 10.4.1 Prevalence of Diarrhoea . 125 10.4.2 Diarrhoea Treatment . 125 10.4.3 Feeding Practices during Diarrhoea. 127 10.4.4 Knowledge of ORS . 129 10.4.5 Disposal of Children’s Stools . 129 CHAPTER 11 NUTRITION Mahlape Ramoseme 11.1 Nutritional Status of Children Under Age 5 . 131 11.1.1 Stunting . 132 11.1.2 Wasting . 134 11.1.3 Underweight . 134 11.2 Breastfeeding and Supplementation . 135 11.2.1 Initiation of Breastfeeding . 135 11.2.2 Complementary Feeding . 141 11.2.3 Infant and Young Child Feeding . 142 11.3 Prevalence of Anaemia in Children . 145 11.4 Micronutrient Intake among Children. 147 11.5 Iodisation of Household Salt . 149 11.6 Nutritional Status of Women and Men . 150 11.7 Prevalence of Anaemia in Women and Men . 153 11.8 Micronutrient Intake among Mothers . 155 CHAPTER 12 HIV AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR John Nkonyana 12.1 Knowledge of AIDS . 160 12.2 Knowledge of HIV Prevention Methods . 162 12.3 Beliefs About AIDS . 163 12.4 Knowledge of Prevention of Mother-To-Child Transmission of HIV . 167 12.5 Stigma Associated With AIDS and Attitudes Related To HIV/AIDS . 169 12.6 Attitudes Towards Negotiating Safer Sex . 172 12.7 Adult Support for Education about Condom Use . 174 12.8 Multiple Sexual Partnerships . 176 12.9 Transactional Sex and Condom Use . 179 12.10 Coverage of Prior HIV testing . 180 12.11 Male Circumcision . 183 12.12 Self-Reporting of Sexually Transmitted Infections . 185 12.13 Prevalence of Injections . 187 Contents | vii 12.14 HIV/AIDS-Related Knowledge and Behaviour among Youth . 189 12.14.1 Knowledge of HIV Transmission and Source for Condoms . 189 12.14.2 Age at First Sex among Youth . 190 12.14.3 Higher-Risk Sex among Youth . 194 12.14.4 Age Mixing in Sexual Relationships . 196 12.14.5 Recent HIV Tests among Youth . 197 CHAPTER 13 HIV PREVALENCE AND ASSOCIATED FACTORS John Nkonyana 13.1 Coverage of HIV Testing . 199 13.2 HIV Prevalence . 202 13.2.1 HIV Prevalence by Age and Sex . 202 13.2.2 HIV Prevalence by Socioeconomic Characteristics . 204 13.2.3 HIV Prevalence by Demographic Characteristics . 206 13.2.4 HIV Prevalence by Sexual Behaviour . 207 13.3 HIV Prevalence among Youth. 208 13.4 HIV Prevalence by Other Characteristics . 211 13.4.1 HIV Prevalence by Other Characteristics Related to HIV Risk . 211 13.4.2 HIV Prevalence by Male Circumcision . 212 13.4.3 HIV Prevalence among Cohabiting Couples . 215 13.4.4 HIV Prevalence and Women’s Anaemia . 216 13.4.5 HIV Prevalence and Fertility . 217 13.5 The HIV Burden in Lesotho . 218 CHAPTER 14 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 14.1 Employment . 219 14.2 Control of Earnings . 220 14.2.1 Control over Women’s Earnings and Women’s Contribution to Household Expenditures . 220 14.2.2 Control over Own Earnings and Husband’s Earnings . 223 14.3 Women’s Empowerment . 223 14.3.1 Women’s Participation in Decision-Making . 224 14.3.2 Attitudes towards Wife Beating . 228 14.3.3 Attitudes toward Refusing Sexual Intercourse with Husband . 231 14.4 Women’s Empowerment Indicators . 235 14.5 Current Use of Contraception by Women’s Status . 236 14.6 Ideal Family Size and Unmet Need By Women’s Status . 237 14.7 Women’s Status and Reproductive Health Care . 237 14.8 Early Childhood Mortality Rates by Women’s Status . 238 viii │ Contents CHAPTER 15 TUBERCULOSIS 15.1 Background on Tuberculosis . 241 15.2 Respondents’ Knowledge of Tuberculosis . 242 15.3 Self-reported Diagnosis, Symptoms, and Treatment . 246 15.4 Willingness to Work with Someone Who Has Previously been Treated for Tuberculosis . 253 CHAPTER 16 ADULT AND MATERNAL MORTALITY 16.1 Data . 255 16.2 Estimates of Adult Mortality . 256 16.3 Estimates of Maternal Mortality . 258 CHAPTER 17 ADULT HEALTH ISSUES 17.1 Noncommunicable Diseases . 261 17.1.1 Use of Tobacco . 261 17.1.2 Breast Self-examination . 262 17.1.3 Cervical Cancer Examination . 264 17.1.4 Diabetes . 265 17.2 Hypertension . 265 17.2.1 History of Hypertension . 266 17.2.2 Prevalence of Hypertension . 268 17.3 Health Insurance . 271 17.4 Succession Planning . 273 17.5 Widows Dispossessed of Property . 275 17.6 Father’s Participation in Family Health Care . 276 17.6.1 Advice or Care during Antenatal, Delivery, and Postnatal Periods . 276 17.6.2 Knowledge of Feeding Practices during Diarrhoea . 276 REFERENCES . 279 APPENDIX A SAMPLE DESIGN . 283 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 291 APPENDIX C DATA QUALITY TABLES . 303 APPENDIX D PERSONS INVOLVED IN THE 2009 LESOTHO DEMOGRAPHIC AND HEALTH SURVEY . 309 APPENDIX E QUESTIONNAIRES . 315 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators . 2 Table 1.2 Results of the household and individual interviews . 7 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 10 Table 2.2 Household composition . 11 Table 2.3 Children's living arrangements and orphanhood . 12 Table 2.4 School attendance by survivorship of parents . 13 Table 2.5.1 Educational attainment of the female household population . 14 Table 2.5.2 Educational attainment of the male household population . 15 Table 2.6 School attendance ratios . 17 Table 2.7 Household drinking water . 19 Table 2.8 Household sanitation facilities . 20 Table 2.9 Household characteristics . 21 Table 2.10 Household durable goods . 22 Table 2.11 Residency status . 23 Table 2.12 Birth registration of children under age five . 24 Table 2.13 Wealth quintiles . 26 Figure 2.1 Population Pyramid . 10 Figure 2.2 Percentage of Males and Females Currently Attending School, by Age . 18 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents . 28 Table 3.2.1 Educational attainment by background characteristics: Women . 29 Table 3.2.2 Educational attainment by background characteristics: Men . 30 Table 3.3.1 Literacy: Women . 31 Table 3.3.2 Literacy: Men . 32 Table 3.4.1 Exposure to mass media: Women . 33 Table 3.4.2 Exposure to mass media: Men . 34 Table 3.5.1 Employment status: Women . 36 Table 3.5.2 Employment status: Men. 37 Table 3.6.1 Occupation: Women . 38 Table 3.6.2 Occupation: Men . 39 Table 3.7.1 Type of employment: Women . 40 Table 3.7.2 Type of employment: Men . 41 x | Tables and Figures Figure 3.1 Access to Mass Media . 35 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Table 4.1 Current fertility . 44 Table 4.2 Fertility by background characteristics . 45 Table 4.3 Trends in age-specific fertility rates . 46 Table 4.4 Trends in age-specific fertility rates . 47 Table 4.5 Children ever born and living . 48 Table 4.6 Birth intervals . 49 Table 4.7 Age at first birth . 50 Table 4.8 Median age at first birth . 51 Table 4.9 Teenage pregnancy and motherhood . 52 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence . 44 Figure 4.2 Total Fertility Rates by Background Characteristics . 46 Figure 4.3 Total Fertility Rates, Lesotho 1976-2009 . 47 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 54 Table 5.2 Current use of contraception by age . 55 Table 5.3 Trends in current contraceptive use . 56 Table 5.4 Current use of contraception by background characteristics . 57 Table 5.5 Knowledge of fertile period . 58 Table 5.6 Source of modern contraception methods . 59 Table 5.7 Informed choice . 61 Table 5.8 Future use of contraception . 62 Table 5.9 Exposure to family planning messages . 63 Table 5.10 Contact of nonusers with family planning providers . 64 Table 5.11 Husband/partner's knowledge of women's use of contraception . 65 Table 5.12 Men's attitude about contraception . 66 Figure 5.1 Current Use of Family Planning among Currently Married Women Age 15-49, Selected Countries in East Africa and Southern Africa . 55 Figure 5.2 Current Use of Any Contraceptive Method among Currently Married Women Age 15-49, by Background Characteristics . 58 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 70 Table 6.2 Polygyny: Currently married men . 71 Table 6.3.1 Age at first marriage: Women . 72 Table 6.3.2 Age at first marriage: Men . 73 Table 6.4 Median age at first marriage . 74 Table 6.5 Age at first sexual intercourse . 75 Table 6.6 Median age at first intercourse . 76 Tables and Figures | xi Table 6.7.1 Recent sexual activity: Women . 77 Table 6.7.2 Recent sexual activity: Men . 78 Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility . 80 Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility . 81 Table 6.10 Menopause . 82 Figure 6.1 Percentage of Currently Married Men Who Have More Than One Wife . 72 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 84 Table 7.2 Desire to limit childbearing . 85 Table 7.3 Need and demand for family planning among currently married women . 87 Table 7.4 Ideal number of children . 89 Table 7.5 Mean ideal number of children . 90 Table 7.6 Fertility planning status . 91 Table 7.7 Wanted fertility rates . 92 Figure 7.1 Fertility Preferences among Currently Married Women Age 15-49 . 84 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 94 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 96 Table 8.3 Early childhood mortality rates by demographic characteristics . 98 Table 8.4 Perinatal mortality . 100 Table 8.5 High-risk fertility behaviour . 102 Figure 8.1 Trends in Infant, Child, and Under-5 Mortality, 2001 LDS, 2004 LDHS, and 2009 LDHS . 95 Figure 8.2 Under-5 Mortality by Background Characteristics . ` 97 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 104 Table 9.2 Number of antenatal care visits and timing of first visit . 105 Table 9.3 Components of antenatal care . 106 Table 9.4 Tetanus toxoid injections . 108 Table 9.5 Place of delivery . 109 Table 9.6 Assistance during delivery . 111 Table 9.7 Timing of first postnatal checkup . 113 Table 9.8 Type of provider of first postnatal checkup . 114 Table 9.9 Problems in accessing health care . 115 Figure 9.1 Antenatal Care, Tetanus Vaccinations, Place of Delivery, and Delivery Assistance . 110 xii | Tables and Figures CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth . 118 Table 10.2 Vaccinations by source of information . 119 Table 10.3 Vaccinations by background characteristics . 121 Table 10.4 Vaccinations in first year of life . 122 Table 10.5 Prevalence and treatment of symptoms of ARI . 123 Table 10.6 Prevalence and treatment of fever . 124 Table 10.7 Prevalence of diarrhoea . 125 Table 10.8 Diarrhoea treatment . 126 Table 10.9 Feeding practices during diarrhoea . 128 Table 10.10 Knowledge of ORS packets or pre-packaged liquids . 129 Table 10.11 Disposal of children's stools . 130 Figure 10.1 Percentage of Children Age 12-23 Months with Specific Vaccines, According to Health Card or Mother's Report . 120 Figure 10.2 Trends in Vaccination Coverage, Lesotho 2004 and 2009 . 120 CHAPTER 11 NUTRITION Table 11.1 Nutritional status of children . 133 Table 11.2 Initial breastfeeding . 136 Table 11.3 Breastfeeding status by age . 138 Table 11.4 Median duration and frequency of breastfeeding . 140 Table 11.5 Foods and liquids consumed by children during the day or night preceding the interview . 142 Table 11.6 Infant and young child feeding (IYCF) practices . 144 Table 11.7 Prevalence of anaemia in children . 146 Table 11.8 Micronutrient intake among children . 148 Table 11.9 Presence of iodized salt in household . 150 Table 11.10.1 Nutritional status of women . 151 Table 11.10.2 Nutritional status of men . 152 Table 11.11.1 Prevalence of anaemia in women . 154 Table 11.11.2 Prevalence of anaemia in men . 155 Table 11.12 Micronutrient intake among mothers . 157 Figure 11.1 Nutritional Status of Children by Age . 134 Figure 11.2 Among Last Children Born in the Five Years Preceding the Survey Who Received a Prelacteal Liquid, the Percentage Who Received Specific Liquids . 137 Figure 11.3 Infant Feeding Practices by Age . 139 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 12.1 Knowledge of AIDS . 161 Table 12.2 Knowledge of HIV prevention methods . 163 Table 12.3.1 Comprehensive knowledge about AIDS: Women . 165 Tables and Figures | xiii Table 12.3.2 Comprehensive knowledge about AIDS: Men . 166 Table 12.4 Knowledge of prevention of mother to child transmission of HIV . 168 Table 12.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 170 Table 12.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 171 Table 12.6 Attitudes toward negotiating safer sexual relations with husband . 173 Table 12.7 Adult support of education about condom use to prevent AIDS . 175 Table 12.8.1 Multiple sexual partners in the past 12 months: Women . 177 Table 12.8.2 Multiple sexual partners in the past 12 months: Men . 178 Table 12.9 Payment for sexual intercourse . 179 Table 12.10.1 Coverage of prior HIV testing: Women . 181 Table 12.10.2 Coverage of prior HIV testing: Men . 182 Table 12.11 Male circumcision . 184 Table 12.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 186 Table 12.13 Prevalence of medical injections . 188 Table 12.14 Comprehensive knowledge about AIDS and of a source of condoms among youth . 190 Table 12.15 Age at first sexual intercourse among youth . 191 Table 12.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 193 Table 12.17.1 Multiple sexual partners in the past 12 months among youth: Women . 194 Table 12.17.2 Multiple sexual partners in the past 12 months among youth: Men . 195 Table 12.18 Age-mixing in sexual relationships among women and men age 15-19 . 196 Table 12.19 Recent HIV tests among youth . 197 CHAPTER 13 HIV PREVALENCE AND ASSOCIATED FACTORS Table 13.1 Coverage of HIV testing by sex, residence, and district . 200 Table 13.2 Coverage of HIV testing by selected background characteristics . 201 Table 13.3 HIV prevalence by age and sex . 203 Table 13.4 HIV prevalence by socioeconomic characteristics . 205 Table 13.5 HIV prevalence by demographic characteristics . 206 Table 13.6 HIV prevalence by sexual behaviour . 208 Table 13.7 HIV prevalence among young people by background characteristics . 209 Table 13.8 HIV prevalence among young people by sexual behaviour . 210 Table 13.8 HIV prevalence among young people by sexual behaviour . 210 Table 13.9 HIV prevalence by other characteristics . 211 Table 13.10 Prior HIV testing by current HIV status . 212 Table 13.11 HIV prevalence by male circumcision . 213 Table 13.12 HIV prevalence by age at first sex and age at circumcision . 214 Table 13.13 HIV prevalence among couples . 215 Table 13.14 Fertility and HIV status . 217 Figure 13.1 HIV Prevalence among Women Age 15-49, Lesotho 2004 and 2009 . 203 Figure 13.2 HIV Prevalence among Men 15-49, Lesotho 2004 and 2009 . 204 Figure 13.3 Anaemia among Women by HIV Status . 217 xiv | Tables and Figures CHAPTER 14 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 14.1 Employment and cash earnings of currently married women . 219 Table 14.2.1 Control over women's cash earnings and relative magnitude of women's earnings: Women . 221 Table 14.2.2 Control over men's cash earnings . 222 Table 14.3 Women's control over her own earnings and over those of her husband . 223 Table 14.4.1 Women's participation in decision making . 224 Table 14.4.2 Women's participation in decision-making according to men . 224 Table 14.5.1 Women's participation in decision-making by background characteristics . 225 Table 14.5.2 Men's attitude towards wives' participation in decision-making. 227 Table 14.6.1 Attitude toward wife beating: Women . 229 Table 14.6.2 Attitude toward wife beating: Men . 230 Table 14.7.1 Attitude toward refusing sexual intercourse with husband: Women . 232 Table 14.7.2 Attitude toward refusing sexual intercourse with husband: Men . 233 Table 14.7.3 Men's attitude toward a husband's rights when his wife refuses to have sexual intercourse . 234 Table 14.8 Indicators of women's empowerment . 235 Table 14.9 Current use of contraception by women's status . 236 Table 14.10 Women's empowerment and ideal number of children and unmet need for family planning . 237 Table 14.11 Reproductive health care by women's empowerment . 238 Table 14.12 Early childhood mortality rates by women's status . 239 Figure 14.1 Number of Household Decisions in Which Currently Married Women Participate . 226 CHAPTER 15 TUBERCULOSIS Table 15.1 Knowledge of tuberculosis . 242 Table 15.2 Knowledge of specific symptoms of tuberculosis . 243 Table 15.3.1 Knowledge of TB causes and transmission modes by background characteristics: Women . 244 Table 15.3.2 Knowledge of TB causes and transmission modes by background characteristics: Men . 245 Table 15.4.1 Experience of symptoms of tuberculosis: Women . 247 Table 15.4.2 Experience of symptoms of tuberculosis: Men . 248 Table 15.5.1 Reasons for not seeking treatment for symptoms of tuberculosis: Women . 250 Table 15.5.2 Reasons for not seeking treatment for symptoms of tuberculosis: Men . 251 Table 15.6 Diagnosis of tuberculosis . 252 Table 15.7 Positive attitudes towards those with TB . 254 Figure 15.1 Knowledge of Causes of TB and Modes of Transmission . 246 Figure 15.2 Percentage of Women and Men Who Had Symptoms of Tuberculosis Since Age 15 . 249 Tables and Figures | xv CHAPTER 16 ADULT AND MATERNAL MORTALITY Table 16.1 Data on siblings . 255 Table 16.2 Adult mortality rates . 256 Table 16.3 Maternal mortality . 259 Figure 16.1 Trends in Female Adult Mortality in Lesotho by Age, 2004 and 2009 . 257 Figure 16.2 Trends in Male Adult Mortality in Lesotho by Age, 2004 and 2009 . 258 CHAPTER 17 ADULT HEALTH ISSUES Table 17.1 Use of tobacco: Men . 262 Table 17.2 Breast self examination . 263 Table 17.3 Cervical cancer examination . 264 Table 17.4 History of diabetes . 265 Table 17.5 History of hypertension and actions taken to lower blood pressure . 267 Table 17.6.1 Levels of hypertension by socioeconomic characteristics: Women . 268 Table 17.6.2 Levels of hypertension by socioeconomic characteristics: Men . 269 Table 17.7.1 Levels of hypertension by health status measures: Women . 270 Table 17.7.2 Levels of hypertension by health status measures: Men . 271 Table 17.8.1 Health insurance coverage: Women . 272 Table 17.8.2 Health insurance coverage: Men . 273 Table 17.9 Succession planning . 274 Table 17.10 Widows dispossessed of property . 275 Table 17.11 Advice or care received by mother during pregnancy and delivery, and after delivery . 276 Table 17.12 Knowledge of feeding practices during diarrhoea . 277 APPENDIX A SAMPLE DESIGN Table A.1 Sample implementation: Women . 284 Table A.2 Sample implementation: Men . 285 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 294 Table B.2 Sampling errors for National sample . 295 Table B.3 Sampling errors for Urban sample . 296 Table B.4 Sampling errors for Rural sample . 297 Table B.5 Sampling errors for Lowlands sample . 298 Table B.6 Sampling errors for Foothills sample . 299 Table B.7 Sampling errors for Mountains sample. 300 Table B.8 Sampling errors for Senqu River Valley sample . 301 xvi | Tables and Figures APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 303 Table C.2 Age distribution of eligible and interviewed women . 304 Table C.3 Completeness of reporting . 305 Table C.4 Births by calendar years . 305 Table C.5 Reporting of age at death in days . 306 Table C.6 Reporting of age at death in months . 307 Table C.7 Nutritional status of children . 308 Foreword | xvii FOREWORD The 2009 Lesotho Demographic and Health Survey (LDHS) was commissioned by the Ministry of Health and Social Welfare (MOHSW) to provide countrywide, population-based information on maternal and child mortality, nutrition, fertility levels, family planning, sexually transmitted infections (STIs), HIV and AIDS, and tuberculosis (TB). The findings from the survey will provide data to benchmark efforts in ongoing health sector reforms and to provide information needs for defining global targets, such as the Millennium Development Goals (MDGs) and the United Nations General Assembly Special Summit on HIV and AIDS (UNGASS). The mainstay of the survey was a structured interview, which was conducted with a nationally representative sample of residents drawn from about 10,000 households. The survey assessed their health status, knowledge, attitudes, and behaviours. Selected biomarkers for anaemia, blood pressure, and HIV status, as well as a number of anthropometric indices, were also measured. The 2009 LDHS used personal digital assistants (PDAs) instead of paper questionnaires to collect the data. Lesotho is appreciative that it is the first country in Africa to have used PDAs in a DHS. The main findings of the survey include a relative increase in contraceptive prevalence, low fertility levels, high levels of antenatal care attendance, and declining coverage for basic childhood immunisations. An important aspect of the survey was the large amount of information obtained on HIV and AIDS, STIs, and TB knowledge and behaviour. The survey findings indicated a stable HIV prevalence and high levels of infant and maternal mortality. The success of the survey would not have been possible without the additional financial support received from the Global Fund to Fight AIDS, Tuberculosis, and Malaria; Irish Aid; Millennium Challenge Account (MCA); National Institute for Health and Welfare, United States President’s Emergency Fund for AIDS Relief (PEPFAR), National AIDS Commission (NAC), United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), United States Agency for International Development (USAID), and the World Health Organization (WHO). The Ministry of Health and Social Welfare (MOHSW) greatly appreciates their support. Our sincere gratitude also goes to the District Council Secretaries, the Community Councillors, and the chiefs in areas that were selected for the survey; these individuals contributed to the success of the survey in many ways. The Ministry appreciates the dedication shown by the survey coordinators, field coordinators, supervisors, social mobilisation staff, editors, laboratory staff, and logistics officer who all worked tirelessly till the end of the survey. Special thanks and recognition go to the respondents who open- heartedly gave their time to provide the information needed and to undertake a variety of tests. They can rest assured that the information they have provided has added great value to the knowledge of health and demographics in Lesotho and will be treated with the highest level of confidence. xviii | Foreword The MOHSW also wishes to express its appreciation for the professional guidance received from ICF Macro, from preparation to completion of the survey. The staff at MOHSW, who worked closely with ICF Macro for almost two years, benefited from their integrity and work ethics. Mrs. M. M. Khoeli Principal Secretary for Health Ministry of Health and Social Welfare Summary of Findings | xix SUMMARY OF FINDINGS The 2009 Lesotho Demographic and Health Survey (2009 LDHS) is a nationally representa- tive survey of 7,624 women age 15-49 and 3,317 men age 15-59 from 9,391 households covering 400 sample points (enumeration areas) through- out Lesotho. This survey is the second nationally representative population and health survey con- ducted as part of the worldwide Demographic and Health Surveys (DHS) programme. The sur- vey is designed to provide data to monitor the population and health situation in Lesotho. The sample was selected from the 2006 Population Census in two stages and was designed to pro- duce separate estimates for key indicators for (1) the country as a whole, (2) urban and rural areas, (3) the four ecological zones, and (4) each of the ten districts in Lesotho. Data collection took place over a three-month period, from 16 Octo- ber 2009 to 26 January 2010. The survey obtained detailed information on fertility levels and preferences, marriage, sexual activity, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality, maternal and child health, awareness and behaviour regarding HIV/AIDS, other sexu- ally transmitted infections (STIs), and tuberculo- sis. In addition, the 2009 LDHS carried out anaemia testing in adults and in children under age 5 and HIV testing in women age 15-49 and men age 15-59. Blood pressure measurements were also collected from the same adults. The 2009 LDHS was implemented by the Ministry of Health and Social Welfare (MOHSW) with the support of the Bureau of Statistics (BOS). Technical assistance was pro- vided through the MEASURE DHS programme, which is funded by the United States Agency for International Development (USAID). Financial support for the survey was pro- vided by the government of Lesotho; the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); Irish Aid; Millennium Challenge Ac- count (MCA); President's Emergency Plan for AIDS Relief (PEPFAR); National AIDS Commission (NAC); United Nations Population Fund (UNFPA); United Nations Children's Fund (UNICEF), USAID, and World Health Organisation (WHO). FERTILITY Fertility Levels and Trends. The 2009 LDHS adds to the wealth of demographic data on Lesotho. Changes in fertility levels over time can be tracked by examining fertility estimates from various sur- veys and censuses that span the last three decades. Comparing data from the 2009 LDHS with that of previous censuses and surveys indicates that the total fertility rate (TFR) has declined significantly over the last three decades, from 5.4 children per woman in the mid-1970s to 5.3 in the mid-1980s, to 4.1 in the mid-1990s, and to 3.5 children per woman in 2004. With a current TFR of 3.3, Lesotho has one of the lowest fertility rates in sub-Saharan Africa. Fertility Differentials. There are notable differ- entials; rural women have almost twice as many children (4.0 children per woman) as urban women (2.1 children per woman). The total fertility rate is highest in the Mountains zone (4.7 children per woman) and lowest in the Lowlands (2.7 children per woman). As expected, a woman’s education is strongly associated with fertility. For example, the TFR decreases from 4.5 children for women with some primary education to 2.5 children for women with secondary or higher education. Fertility is also very closely related to household economic status. Women who live in households in the lowest wealth quintile have high fertility (5.9 children) while those who live in households in the highest wealth quintile have low fertility (2.0 children). Unplanned Fertility. Despite a steady rise in the level of contraceptive use over the past 15 years, the 2009 LDHS data indicate that more than half of pregnancies are unplanned; 31 percent are mistimed (wanted later), and 21 percent are unwanted. xx | Summary of Findings Fertility Preferences. The majority of cur- rently married women in Lesotho express a de- sire to stop childbearing (59 percent), including the 2 percent who are sterilised. Nationally, around four in ten married women want to have another child—23 percent want a child later and 16 percent want a child soon (within two years). The 2009 LDHS results show that the mean ideal family size among currently married women in Lesotho has declined from 3.5 chil- dren in 2004 to 3.2 children in 2009. FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is almost universal, with 98 percent or more of women and men age 15-49 knowing at least one modern method of family planning. The male condom is the most widely known method of family planning among all women and men, with 97 percent of women and men saying that they have heard of the method. Among women, knowledge of injectables, the pill, and the female condom is 87 percent or higher. A significant proportion of women have also heard about the IUCD (69 percent) and fe- male sterilisation (66 percent). Among men, next to male condom, the most known method is the female condom (78 per- cent), followed by injectables and the pill (72 percent each). Implants are the least known modern method among men (8 percent). Use of Contraception. The contraceptive prevalence rate (CPR) among married women is 47 percent. Almost all currently married women who use contraception use modern methods (46 percent). The most commonly used contracep- tive methods among married women are in- jectables (19 percent), the pill (13 percent), and the male condom (9 percent). Trends in Contraceptive Use. Current use of contraception by married women between the 2004 LDHS and the 2009 LDHS survey in- creased from 37 percent to 47 percent. The most notable increase is in the use of male condoms, from 5 percent in 2004 to 9 percent in 2009. Use of injectables increased substantially in the 5-year period, from 15 percent to 19 percent. Differentials in Contraceptive Use. Use of any contraception among married women in urban areas is higher than in rural areas (58 percent compared with 42 percent). The CPR among married women is highest in the Lowlands zone (54 percent) and low- est in the Senqu River Valley zone (33 percent). Across districts, the CPR is highest among married women in Maseru (56 percent) and lowest in Mok- hotlong (30 percent). Contraceptive use among currently married women increases with increasing level of education and wealth quintile. Source of Modern Methods. The most com- mon source of contraceptive methods in Lesotho is government health centres, which supply almost one third of users of modern methods. A large proportion of pill users and users of injectables obtain the methods from a government source (63 percent and 74 percent, respectively). Government sources sup- ply 56 percent of IUCDs. The most common source for the male condoms is the public sector (45 per- cent), followed by other sources, such as shops (26 percent) and friends or relatives (10 percent). Unmet Need for Family Planning. Twenty- three percent of married women in Lesotho have an unmet need for family planning. Unmet need for limiting births (12 percent) is higher than unmet need for spacing births (11 percent). In 2009, 67 percent of the demand for family planning was being met, implying that the needs of about one in three women in Lesotho are not being met. MATERNAL HEALTH Antenatal Care. A relatively high percentage of women, 92 percent, receive antenatal care from a medical professional, either from doctors (11 per- cent) or nurses or midwives (81 percent). Very few women receive antenatal care from traditional birth attendants, and 8 percent do not receive any antena- tal care. The 2009 LDHS data indicate a slight im- provement since the 2004 LDHS, which reported 90 percent coverage for antenatal care from a health professional. Sixty percent of women received at least two doses of tetanus toxoid for their most recent birth in the five years preceding the survey. Summary of Findings | xxi Delivery Care. Nationally, more than half of births in the five years preceding the survey were delivered in a health facility: 38 percent in public health facilities, 2 percent in private health facilities, and 13 percent in Christian Health Association of Lesotho (CHAL) facili- ties. Forty percent of births occurred at home. The 2009 LDHS data also show that skilled pro- viders assisted with more than 60 percent of de- liveries, community health workers assisted with 11 percent of deliveries, traditional birth assis- tants (TBAs) assisted with 5 percent of deliver- ies, and relatives or friends attended 22 percent of deliveries. In the five years since 2004, the proportion of deliveries by medically trained providers increased from 55 percent to 62 per- cent, and deliveries by TBAs declined from 13 percent to 5 percent. Postnatal Care. Only 3 percent of women received postnatal care within the recommended one hour after delivery. Forty-five percent of women who had a live birth in the five years preceding the survey received postnatal care within two days of delivery, and 6 percent re- ceived postnatal care 3 to 41 days after delivery. The proportion of women who did not receive any postnatal care declined from 72 percent in 2004 to 42 percent in 2009. CHILD HEALTH Childhood Mortality. Data from the 2009 LDHS show a continued upward trend in the early childhood mortality rates over time. Data for the approximate 2005-2009 period suggest that under-5 mortality is 117 deaths per 1,000 live births. About eight in ten of these deaths occur in the first year of life―infant mortality is 91 deaths per 1,000 live births, and child mortal- ity is 28 deaths per 1,000 children at age 1. Neo- natal and postneonatal mortality in the same pe- riod accounted for 47 and 45 deaths per 1,000 live births, respectively. The pattern shows that deaths occurring during the neonatal and post- neonatal periods account for 79 percent of all deaths under age 5. Childhood Vaccination Coverage. The 2009 LDHS data suggest that vaccination cover- age among children age 12-23 months has declined from 68 percent in 2004 to 62 percent in 2009. Ninety-five percent of children have received vac- cine to prevent tuberculosis (BCG). Coverage levels are also very high for the first dose of diphtheria, pertussis, and tetanus (DPT) vaccine (96 percent) and the first polio vaccination (94 percent). While coverage for the first dose of DPT and polio is high, the proportion of children receiving the recom- mended third dose of DPT and polio is lower (84 percent and 75 percent, respectively), as is the pro- portion receiving a measles vaccination (80 percent). Childhood Illnesses and Treatment. Six per- cent of children under age 5 were reported to have had symptoms of acute respiratory illness in the two weeks preceding the survey, and 17 percent were reported to have had fever during the same period. Among children with fever, 60 percent were taken to a health facility or provider for treatment. Eleven percent of children under age 5 had di- arrhoea in the two weeks preceding the survey, and 53 percent were taken to a health provider. More than half of children with diarrhoea were given a solution made from oral rehydration salts (ORS), 55 percent received recommended home fluids (RHFs), and 22 percent were given increased fluids. Overall, three in four children with diarrhoea received ORS, RHF, or increased fluids. NUTRITION Breastfeeding Practices. Overall, 92 percent of children are breastfed at some point, slightly less than the 95 percent reported in the 2004 LDHS. More than half (53 percent) of last-born, ever breast- fed children were given breast milk within one hour of birth, and 93 percent started breastfeeding within one day of birth. Although a large majority (94 percent) of chil- dren under age 6 months are breastfed, just over half (54 percent) are exclusively breastfed, as recom- mended. About one in five breastfeeding children age 4-5 months consumes solid or semi-solid foods (21 percent) or infant formula (19 percent), one in nine (11 percent) receives other milk, and four in ten (40 percent) receive other liquids (excluding plain water). The 2009 LDHS data indicate that supple- mentary feeding of children begins early. Breast- xxii | Summary of Findings feeding practices in Lesotho should improve because giving supplemental foods to children under age 6 months can be detrimental to a child’s health. One in four children (26 percent) under age 6 months in Lesotho is fed using a bottle with a nipple. Iodisation of household salt. Overall, 93 percent of the households interviewed in the 2009 LDHS had their salt tested for iodine, while 7 percent had no salt available in the household. Eighty-three percent of children age 6-59 months live in households with adequately iodised salt (<15 parts per million). Intake of Vitamin A. Ensuring that children age 6-59 months receive enough vitamin A may be the single most effective child survival inter- vention. Deficiencies in this micronutrient can cause blindness and can increase the severity of infections such as measles and diarrhoea. One in three (34 percent) children age 6-59 months were given vitamin A supplement in the six months preceding the survey. Eight in ten of the youngest children age 6-35 months who live with their mothers have consumed fruits and vegetables rich in vitamin A in the past 24 hours. Thirty-nine percent of women receive vita- min A supplementation postpartum (in the first two months after delivery), more than double the proportion reported in the 2004 LDHS (17 per- cent). The level of night blindness among preg- nant women is 1 percent (after adjusting for women who had difficulty with daytime vision). Prevalence of Anaemia. Twenty-six per- cent of women have some level of anaemia. Anaemia prevalence is somewhat higher among pregnant women (30 percent) and those who smoke cigarettes or tobacco (29 percent). Iron-deficiency anaemia is a major threat to maternal health and child health. Overall, 47 percent of children 6-59 months in Lesotho have some level of anaemia, including 25 percent of children who are mildly anaemic, 21 percent who are moderately anaemic, and 1 percent who are severely anaemic. The prevalence of anaemia is less pronounced among men than among women and children. Twelve percent of men age 15-49 in Lesotho have some level of anaemia. Nutritional Status of Children. According to the 2009 LDHS, 39 percent of children under age 5 are stunted, and 15 percent are severely stunted. Four percent of children under age 5 are wasted, and 1 percent are severely wasted. These findings are similar to the 2004 LDHS findings. Weight-for-age results show that 13 percent of children under age 5 are underweight, with 4 percent severely under- weight. Children who do not live in the same household with their biological mothers are more likely to be stunted than other children. Nutritional Status of Women. Only 2 percent of women in Lesotho fall below the 145-centimetres cut-off point, the same percentage as in the 2004 LDHS. The mean BMI for women age 15-49 is 25. Six percent of women were found to be chronically malnourished (BMI less than 18.5), while 42 percent were overweight or obese. Notably, 17 percent of women age 15-49 are obese, with a BMI of 30.0 or higher. Awareness of AIDS. Data show that knowledge of AIDS in Lesotho has been almost universal since 2004. In 2009, 97 percent of women and 95 percent of men age 15-49 indicated that they had heard about AIDS. Knowledge that using condoms can reduce the risk of contracting HIV during sexual intercourse is widespread (87 percent of women and 80 percent of men). Eighty-seven percent of women and 82 per- cent of men said that the chances of getting the AIDS virus (HIV) can be reduced by limiting sex to one faithful, uninfected partner. Knowledge of both of these ways of avoiding HIV transmission is high, with 81 percent of women and 72 percent of men citing both as ways of reducing the risk of contract- ing HIV/AIDS. Summary of Findings | xxiii Knowledge that a healthy-looking person can have HIV is widespread. Overall, 87 percent of women and 78 percent of men are aware that a healthy-looking person can have HIV. A per- son is considered to have a comprehensive knowledge about AIDS when they report that (1) using a condom every time sexual inter- course occurs and having just one uninfected and faithful partner can reduce the chances of contracting HIV/AIDS, (2) a healthy-looking person can have HIV, and (3) they reject the two most common local misconceptions about how HIV/AIDS is transmitted. In Lesotho, only 38 percent of women and 29 percent of men age 15-49 have comprehensive knowledge of HIV/ AIDS transmission and prevention methods. These rates are higher than in the 2004 LDHS (24 percent of women and 19 percent of men). HIV-Related Behavioural Indicators. One of the strategies for reducing the risk of contract- ing a sexually transmitted infection (STI) is for young persons to delay the age at which they become sexually active. Eight percent of women and 22 percent of men age 15-24 have had sex by age 15. Forty-seven percent of women and 63 percent of men reported they had first sexual intercourse by age 18. Sexual intercourse with more than one part- ner is associated with a high risk of exposure to sexually transmitted infections. One in four women (26 percent) and 45 percent of men age 15-49 reported having sexual intercourse with more than one partner in the 12 months preced- ing the survey. Promoting the use of condoms is an impor- tant strategy in the fight against HIV/AIDS transmission. Overall, 38 percent of women and 52 percent of men age 15-49 who had more than one sexual partner used a condom in the 12 months preceding the survey. Circumcision among males is practiced in many communities in Lesotho and often serves as a rite of passage to adulthood. This is con- firmed by the 2009 LDHS, which shows that 52 percent of men age 15-59 in Lesotho are cir- cumcised and only 4 percent were circumcised when younger than age 13. HIV Prevalence. HIV tests were conducted for 94 percent of the 4,112 eligible women and 88 percent of the 3,493 eligible men. Results from the 2009 LDHS indicate that 23 percent of adults age 15-49 in Lesotho are infected with HIV. The prevalence of HIV infection is 27 percent for women age 15-49 and 18 percent for men age 15-49. HIV prevalence has not changed since 2004. For both sexes, rates of infection rise with age, peaking at 42 percent for women age 35-39 and at 40 percent among men age 30-34. Patterns of HIV Prevalence. Urban residents are more likely to be HIV positive than rural resi- dents (27 and 21 percent, respectively). Among the four ecological zones, Lowlands has the highest rate of infection (24 percent) whereas Senqu River Val- ley has the lowest (21 percent). Among the districts, Maseru has the highest infection rate for both women and men, while Butha-Buthe has the lowest rate. For both women and men, education does not seem to have a direct relationship with infection lev- els. Women who have completed primary school have the highest infection levels. One-third of em- ployed women and 22 percent of employed men are HIV positive, compared with 21 percent of unem- ployed women and 9 percent of unemployed men. The relationship between HIV status and wealth quintile is not uniform. However, the lowest HIV rates are found among women and men in the lowest wealth quintile. More than 800 couples were tested for HIV in the 2009 LDHS. Results show that, for 65 percent of cohabiting couples, both partners are HIV negative, while for 19 percent of couples, both partners are HIV positive. In 17 percent of couples, there is dis- cordance in HIV-positive status; that is, one partner is infected and the other is not. Therefore, almost half of couples in which at least one partner is HIV positive have a discordant HIV status. xxiv | Map of Lesotho Introduction | 1 INTRODUCTION 1 Mahlape Ramoseme 1.1 GEOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geography Lesotho is a small, mountainous kingdom situated in the southern part of Africa where it is completely surrounded by the republic of South Africa. The country is divided into 10 administrative districts with a total area of about 30,355 square kilometres. Less than 10 percent of the land is arable. The country has been divided into two residential areas, urban and rural, and further subdivided into four ecological zones: Lowlands, Foothills, Mountains, and Senqu River Valley. In Lesotho, there are four seasons in a year; summer being from December to February, with January the warmest month; autumn from March to May; winter from June to August, (the temperature can drop below zero degrees centigrade, and snowfall is not unexpected, especially in the mountains); and spring from September to November. Rainfall amounts vary from 700 mm to 800 mm in most parts of the Lowlands, and most rain falls between the months of October and April. 1.1.2 History Lesotho gained its independence on 4 October 1966 after having been a British protectorate for almost 100 years (1868-1966). The three largest religious organizations are the Roman Catholic Church, the Lesotho Evangelical Church, and the Anglican Church. Lesotho has two official languages, Sesotho and English. 1.1.3 Economy Lesotho is primarily a country of subsistence farming. Most of the farming is done between August and April, and harvesting takes place in June and July. The major agricultural products are wheat, corn, sorghum, and livestock. Lesotho’s gross domestic product (GDP) is Maluti 9,013 million, with an annual growth rate of 4.4 percent. The inflation rate is estimated at 4.5 percent (BOS, 2010), and the unemployment rate is 22.7 percent (BOS, 2008). Agriculture contributes about 7 percent of the GDP, and manufacturing accounts for 17 percent of the GDP (BOS, 2009). Other industries include mining, electricity, water, and construction. In 2004, diamond mining and quarrying constituted 9 percent of the GDP, and the contribution of the service industries varied between 55 and 60 percent. The average growth rate of imports has remained at 2.0 percent since 1998 (BOS, 2009). 1.2 POPULATION According to the 2006 Population and Housing Census, the population of Lesotho is 1,876,633, of which 23 percent live in the urban areas. The urban population was 17 percent of the total population in 1996 (BOS, 2009a). Table 1.1 shows that Lesotho’s population has not increased much since then. The annual population growth rate was 0.08 percent between 1996 and 2006. 2 | Introduction The 2006 population census shows that the crude birth rate for Lesotho is 33 births per 1,000 population compared with 30 births per 1,000 population estimated in the 1996 census. Between 1996 and 2006, the crude death rate increased more than two fold—from 12.8 deaths to 26.5 deaths per 1,000 population. The infant mortality rate (IMR) in 2006 was 94 deaths per 1,000 live births. For the first time since 1986, the IMR increased after it had declined from 113 deaths per 1,000 live births in 1976 to 85 deaths per 1,000 live births in 1986. Table 1.1 shows that the total fertility rate in Lesotho declined from 4.1 to 3.5 births per woman between 1996 and 2006. In the same inter-censal period, life expectancy at birth decreased from 59 years to 41 years. Data from population censuses show that the population of Lesotho is predominantly rural. However, there is an observed increase of population in the urban areas. Table 1.1 Basic demographic indicators Selected demographic indicators for Lesotho, 1976, 1986, 1996, and 2006 Indicator 1976 1986 1996 2006 Population (millions) 1.2 1.6 1.9 1.9 Inter-censal growth rate (percent) 2.3 2.6 1.5 0.08 Density (pop./km2) 40 53 61 61 Percent urban 11 12 17 23 Crude birth rate 38-40 37 30.0 32.83 Crude death rate 16-18 11.6 12.8 26.5 Total fertility rate 5.4 5.3 4.1 3.5 Infant mortality rate (per 1,000 births) 113 85 74 94 Life expectancy (years) 51 55 59 41 Male 49.3 49.3 58.6 39.7 Female 52.7 56.7 60.2 42.9 Source: BOS, 1976; BOS, 1986; BOS, 1996; BOS, 2006 (census reports) 1.3 OBJECTIVES OF THE SURVEY The Ministry of Health and Social Welfare (MOHSW) conducted the 2009 Lesotho Demographic and Health Survey (LDHS) to collect population-based data to inform the Health Sector Reform Programme (2000-2009), evaluate the strides made since the first LDHS was conducted in 2004, set a baseline for new programmes, and provide information for policy and strategic planning. The 2009 LDHS was conducted using a representative sample of women and men of reproductive age. The specific objectives were to: • Provide national data on key demographic indicators, particularly fertility and child and adult mortality rates • Analyze the direct and indirect factors that determine the level of and trends in fertility • Measure the level of contraceptive knowledge and practice of women and men by method, urban-rural residence, and region • Provide data on family health, including immunization coverage among children, prevalence and treatment of diarrhoea and other diseases among children under age 5, maternity care indicators including antenatal visits, and assistance at delivery Introduction | 3 • Provide data on child feeding practices, including breastfeeding, the nutritional status of women and children, and the prevalence of anaemia among children under age 5, women age 15-49, and men age 15-59 • Provide data on knowledge and attitudes of women and men about sexually-transmitted diseases and HIV/AIDS, and evaluate patterns of recent behaviour regarding condom use • Provide information on the prevalence of HIV among women age 15-49 and men age 15-59 • Provide biomarker data on blood pressure among women age 15-49 and men age 15-59 1.4 ORGANISATION OF THE SURVEY The 2009 LDHS was implemented by MOHSW with the support of the Bureau of Statistics (BOS). Technical assistance was provided through the MEASURE DHS programme of ICF Macro, which is funded by the United States Agency for International Development (USAID). Financial support for the survey was provided by the government of Lesotho; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund); Irish Aid; the Millennium Challenge Account (MCA); the President's Emergency Plan for AIDS Relief (PEPFAR); the National AIDS Commission (NAC); the United Nations Population Fund (UNFPA); the United Nations Children's Fund (UNICEF); USAID; and the World Health Organisation (WHO). 1.5 SAMPLE DESIGN The 2009 LDHS was designed to provide estimates of health and demographic indicators at the national level, for urban-rural areas, and for each of the ten districts of Butha-Buthe, Leribe, Berea, Maseru, Mafeteng, Mohale’s Hoek, Quthing, Qacha’s Nek, Mokhotlong, and Thaba-Tseka. The 2009 LDHS sample points (clusters) were selected from a list of enumeration areas (EAs) defined for the 2006 Lesotho Population and Housing Census. A total of 400 clusters were drawn from the census sample frame, 94 in the urban areas and 306 in the rural areas. The clusters were selected with probability proportional to size (PPS). Bureau of Statistics (BOS) staff conducted an exhaustive listing of households in each of the LDHS clusters from July through December 2009. From these lists, a systematic sample of households was drawn for a total of 10,000 households, about 25 households on average per cluster. All women age 15-49 identified in the entire sample of households were eligible for individual interview. In addition, half of these households (5,000 households) were selected randomly, and in these households, all men age 15- 59 were eligible for individual interview. In the LDHS households where men were interviewed, all children under age 6 were eligible for height, weight, and mid-upper arm circumference measurements as well as anaemia testing. In the same households, women and men who were eligible for individual interview were also eligible for height, weight, and blood pressure measurements in addition to anaemia and HIV testing. 1.6 QUESTIONNAIRES Three types of questionnaires were used for the LDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. The contents of the questionnaires were based on questionnaires developed for the MEASURE DHS programme. The LDHS questionnaires were developed in collaboration with a wide range of stakeholders. After the LDHS survey instruments were drafted, they were translated into and printed in the local language, Sesotho, for pre-testing. 4 | Introduction The Household Questionnaire was used to list all the usual members and visitors to the selected households. Basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. The Household Questionnaire was also used to identify persons eligible for the individual interview. In addition, information was collected about the dwelling, such as the source of water, type of toilet facilities, materials used to construct the house, and ownership of various consumer goods. The results of anthropometric measurement and anaemia testing were recorded in the Household Questionnaire, as was the information on the consent of eligible household members for the HIV testing. The Woman’s Questionnaire was used to collect information on the following topics: • Background characteristics (age, education, employment, religion, etc.) • Birth history and childhood mortality • Knowledge and use of family planning methods • Antenatal, delivery, and postnatal care • Infant feeding practices, including patterns of breastfeeding • Childhood vaccinations • Episodes of childhood illness and responses to illness • Marriage and sexual activity • Fertility preferences • Husband’s background and the woman’s work status • Adult mortality, including maternal mortality • HIV/AIDS-related knowledge, attitudes, and behaviour • Knowledge, attitudes, and behaviour related to other health issues The Man’s Questionnaire was shorter than the Woman’s Questionnaire but covered many of the same topics, excluding the reproductive history and sections dealing with maternal and child health and maternal mortality. In this survey, instead of paper questionnaires, personal data assistants (PDAs) were used to record responses during interviews. Bluetooth wireless technology was used for electronic transfer of files, such as transfer of the assignment sheet from the team supervisor to the interviewers, transfer of household questionnaires among survey team members, and transfer of completed questionnaires to team and central office supervisors. The PDA interview applications were implemented using the mobile version of CSPro, which was developed by the MEASURE DHS project in collaboration with the U.S. Census Bureau. 1.7 ANAEMIA AND HIV TESTING In addition to the collection of information during the survey interview, the LDHS also included anaemia and HIV testing. The protocol for the anaemia and HIV testing was based on the standard protocols employed in the MEASURE DHS programme and adapted to achieve the objectives of the LDHS. It was reviewed and approved by the Research and Ethics Committee at the Ministry of Health and Social Welfare and by the ICF Macro Institutional Review Board (IRB). 1.7.1 Anaemia Testing Haemoglobin testing is the primary method of anaemia diagnosis. In the LDHS, haemoglobin measurement was performed in the field by the survey field staff. Prior to collecting the blood specimen, participants age 18 and older and married youth age 15-17 were asked to give informed consent to the Introduction | 5 testing. For unmarried youth age 15-17, consent was asked from the parent or guardian and the respondent. For children age 6 months to 5 years, consent was asked only from the parent or guardian. The consent statement explained the purpose of the test, informed the prospective subjects and/or their caretakers how the test would be done, advised them that the results would be available as soon as the test was completed, and requested permission for the test to be carried out. For the haemoglobin measurement, capillary blood was generally taken from one finger of each individual using sterile, single-use lancets that allowed a relatively painless puncture. The concentration of haemoglobin in the blood was measured in the field using the HemoCue system. The results of the anaemia test were immediately provided for all eligible individuals who were tested. Levels of anaemia were classified as severe, moderate, or mild according to criteria developed by WHO. Respondents were provided with a brochure on anaemia, which included suggested changes to diet to treat anaemia. Individuals who were found to be severely anaemic were referred to health facilities for further evaluation. 1.7.2 HIV Testing The LDHS testing protocol for HIV involved the collection of at least three blood spots from a finger prick (generally the same prick used to obtain the blood drop for anaemia testing) on a special filter paper card. The HIV testing in the LDHS was anonymous; that is, it was conducted in such fashion that the results could not be linked to individual respondents. A unique random identification number (bar code) was assigned to each eligible respondent consenting to the testing, and labels containing that code were affixed to the filter paper card, the questionnaire, and a field tracking form at the time of the collection of the sample. No other identifiers were attached to the sample of dried blood spots (DBS). Because of the anonymous nature of the testing approach in the LDHS, it was not possible to provide information on the results from the HIV testing conducted during the LDHS. In lieu of providing the LDHS test results, written and verbal information was provided on counselling and testing (VCT) sites where free confidential counselling and HIV testing was available. In addition, any person (whether or not they participated in the LDHS) who approached an LDHS team with a request about VCT was provided with information on the sites in an effort to increase VCT usage in Lesotho. The procedures that LDHS field staff followed to obtain informed consent from eligible individuals and to collect DBS samples for the HIV test were similar to those used for obtaining consent for the anaemia testing. The HIV consent statement explained the objective of the test and how the DBS sample would be collected, informed prospective subjects and/or their caretakers that the testing process was anonymous and, that, therefore, their result would not be available to them, advised them of the availability of free voluntary counselling and testing services, and requested permission for the test to be carried out. After the survey team completed a cluster, all questionnaires, the dried blood spot samples, and the sample transmittal forms for the cluster were sent to the MOHSW for logging and checking prior to data entry. Blood samples were checked against the transmittal form and then forwarded to the Lesotho Blood Transfusion Service (LBTS) laboratory for testing. No identifying information other than the unique barcode label affixed at the time of the collection of the DBS sample accompanied the specimen to the laboratory. 1.8 PRETEST The pre-test training took place in July 2009 at the MOHSW Headquarters. The training was conducted following the DHS training procedures, including class presentations and mock interviews, 6 | Introduction using paper questionnaires as well as PDAs. The participants were also trained to take biomarker measurements and tests. Fourteen people were trained, including two IT officers. They were drawn from staff of the MOHSW, the Christian Health Association of Lesotho (CHAL), the Lesotho Planned Parenthood Association (LPPA), the Food and Nutrition Coordinating Office (FNCO), and the Lesotho Red Cross Society (LRCS). Four female trainees participated in the 2004 LDHS. The pre-test fieldwork was conducted in Leribe and Butha-Buthe districts in both urban and rural clusters to help gauge how the respondents’ reception of the LDHS teams might vary by locality. On average, the Household Questionnaire took 30 minutes to complete, the Woman’s Questionnaire took 90 minutes, and the Man’s Questionnaire, 80 minutes. 1.9 TRAINING A total of 109 persons, 34 males and 75 females, were trained to be the 2009 LDHS field staff. The training followed the standard DHS training procedures, including instructions on how to conduct interviews and how to fill in all three questionnaires, classroom demonstration and practice in administer- ing the questionnaires using both paper questionnaires and PDAs, and tests. The participants also prac- ticed interviewing in actual households. Their field experiences were discussed in class. The first two weeks of the 2009 LDHS training were spent building the participants’ familiarity with the survey instruments, enhancing knowledge and skills in conducting interviews, and practicing how to record responses in paper questionnaires. The PDAs were introduced in the third week of training. Participants were also trained to use the case-management system on the PDA to accomplish such tasks as selecting assigned interviews and receiving electronic case assignments from their supervisor. The fourth week was used to practice skills—interviewing in Sesotho, taking measurements of height, weight, and mid-upper arm circumference, testing for anaemia, and taking blood samples for HIV testing in the field; also during this week, supervisors and editors were selected. The training continued through the fifth week with a general overview of biomarkers and the PDA. The supervisors and editors were given instructions on how to perform their tasks during the fieldwork. All participants received extensive classroom training plus additional field practice on biomarker data collection. They learned how to use informed consent procedures; how to take height, weight, and blood pressure measurements, how to collect finger prick blood spot samples for anaemia and HIV testing, and how to handle and package the dried blood spots. All staff received training in universal precautions and the disposal of hazardous waste. 1.10 FIELDWORK Fieldwork for the 2009 LDHS commenced on 16 October 2009 and was completed on 26 January 2010. Data collection was carried out by 15 interviewing teams, each consisting of one supervisor, one field editor, three to four female interviewers, and one or two male interviewers. After Christmas break, due to drop out and iteration, the field staff was regrouped into 13 teams. Three Field Coordinator (FC) teams were formed; two consisted of one senior MOHSW staff and one data processing supervisor, and one team consisted of two senior MOHSW staff. The FC teams supervised the data collection teams throughout the fieldwork period. Collected data were transferred from the interviewer’s PDA to the team supervisor’s at the end of the day. During visits by the FC teams, data files were transferred from the team supervisors’ PDAs to the Introduction | 7 FCs’ PDAs. Blood samples were also collected during these visits and transferred to the Lesotho Blood Transfusion Service (BLTS) laboratory. 1.11 DATA PROCESSING All data files for the LDHS were stored in a computer at the MOHSW Headquarters. The data processing operation included secondary editing, which involved checking for inconsistencies. The LDHS data entry and editing programmes used CSPro, a computer software package specifically de- signed for processing survey data such as that pro- duced by DHS surveys. Data processing commenced in November 2009 and was completed in February 2010. 1.12 SAMPLE RESULTS Table 1.2 shows household and individual response rates for the 2009 LDHS. A total of 9,994 households were selected for the sample, of which 9,619 were found occupied during data collection. Of the existing households, 9,391 were successfully in- terviewed, yielding a household response rate of 98 percent. In these households, 7,786 women were identified as eligible for the individual interview. Interviews were completed with 98 percent of these women. Of the 3,493 eligible men identified in the sub-sample of households selected, 95 percent were successfully interviewed. Overall, response rates were higher in rural areas than in urban areas. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Lesotho 2009 Residence Result Urban Rural Total Household interviews Households selected 2,347 7,647 9,994 Households occupied 2,247 7,372 9,619 Households interviewed 2,141 7,250 9,391 Household response rate1 95.3 98.3 97.6 Interviews with women age 15-49 Number of eligible women 2,043 5,743 7,786 Number of eligible women interviewed 1,977 5,647 7,624 Eligible woman response rate2 96.8 98.3 97.9 Household interviews for men Households selected 1,222 3,972 5,194 Households occupied 1,167 3,826 4,993 Households interviewed 1,105 3,768 4,873 Household response rate1 94.7 98.5 97.6 Interviews with men age 15-59 Number of eligible men 791 2,702 3,493 Number of eligible men interviewed 736 2,581 3,317 Eligible men response rate2 93.0 95.5 95.0 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 9 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 John Nkonyana This chapter presents information on the social, economic, and demographic characteristics of the household population, focusing mainly on background characteristics such as age, sex, educational attendance and attainment, place of residence, and socioeconomic conditions. The information provided is intended to facilitate interpretation of the key demographic, socioeconomic, and health indices. It is further intended to assist in assessment of the representativeness of the survey. One of the background characteristics used throughout this report is an index of socioeconomic status. The economic index used here was developed and tested in a large number of countries in relation to inequities in household income, use of health services, and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The economic index was constructed using household asset data with principal components analysis. The asset information was collected through the Household Questionnaire of the 2009 LDHS. Included is information on household ownership of a number of consumer items, ranging from a television to a bicycle to a car. Also provided is information on dwelling characteristics, for example, the source of drinking water, sanitation facilities, and type of material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and a standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles ranging from one (lowest) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural populations. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX The 2009 LDHS Household Questionnaire solicited information on key demographic and socioeconomic characteristics; parental survivorship and residence status for people age 17 years and under; educational attendance and attainment; and housing characteristics. A household was defined as a person or group of people, related or unrelated to each other, who live together in the same dwelling unit and share a common source of food. Table 2.1 presents the distribution of the 2009 LDHS household population by five-year age groups, according to sex and urban-rural residence. The household population constitutes 33,719 persons, of which 46 percent are male and 54 percent are female. There are more persons in the young age groups than in the old age groups for both sexes. For instance, half of the population is under 20 years old. Figure 2.1 shows the age-sex structure of the Lesotho population. The household population age structure has a wide base, indicating that most of Lesotho’s population is still young. Forty percent of the population in Lesotho is under age 15, and 7 percent is age 65 or older. The recent decline in fertility is also apparent in the narrow base of the pyramid. The large proportion of women age 50-54 is most likely a result of a deliberate attempt by interviewers to reduce their workload by placing respondents outside of the age range of eligibility for the interview. 10 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Lesotho 2009 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 10.9 9.2 9.9 14.4 12.7 13.5 13.6 11.8 12.6 5-9 12.5 8.9 10.4 14.9 13.1 14.0 14.4 12.0 13.1 10-14 12.8 11.5 12.0 16.7 14.3 15.5 15.8 13.6 14.6 15-19 11.6 11.0 11.3 12.1 10.2 11.1 12.0 10.4 11.1 20-24 9.6 11.6 10.7 8.8 8.1 8.5 9.0 9.0 9.0 25-29 9.4 11.3 10.5 6.6 5.8 6.2 7.2 7.3 7.2 30-34 8.9 8.8 8.8 4.4 4.8 4.6 5.4 5.8 5.6 35-39 6.1 6.7 6.4 3.3 3.9 3.6 3.9 4.6 4.3 40-44 4.5 4.6 4.5 2.6 3.5 3.1 3.0 3.8 3.4 45-49 3.8 4.4 4.2 2.7 3.4 3.1 3.0 3.7 3.4 50-54 3.1 4.1 3.7 2.4 4.1 3.3 2.6 4.1 3.4 55-59 2.2 2.6 2.5 2.5 3.5 3.0 2.4 3.3 2.9 60-64 1.7 1.9 1.8 2.4 2.8 2.6 2.2 2.6 2.4 65-69 0.9 0.8 0.8 1.9 2.2 2.1 1.7 1.8 1.8 70-74 1.0 0.9 1.0 1.5 2.5 2.1 1.4 2.1 1.8 75-79 0.8 0.9 0.8 1.5 2.4 2.0 1.3 2.0 1.7 80 + 0.3 0.8 0.6 1.2 2.5 1.9 1.0 2.1 1.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,485 4,698 8,183 11,999 13,535 25,536 15,484 18,233 33,719 Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 LDHS 2009 Male Percent Female Age Household Population and Housing Characteristics | 11 2.2 HOUSEHOLD COMPOSITION Table 2.2 shows the distribution of households by sex of the head of household and by size of the household, according to rural-urban residence. Accord- ing to the 2009 LDHS, women head 36 percent of the households, a finding similar to that of the 2006 Popu- lation and Housing Census (35 percent) (BOS, 2006). There are modest differences in female-headed house- holds between urban and rural areas (37 percent and 36 percent, respectively). This may be partly attributed to rural to urban migration, exacerbated by the prolifera- tion of textile industries in the cities whose employees are predominantly women. Table 2.2 shows that the mean size of a Lesotho household is 3.6 persons, which is 0.3 persons lower than the mean household size of 3.9 persons found in the 2004 LDHS (MOHSW, BOS, and ORC Macro, 2005). As expected, urban households have on average a much smaller household size (2.9 persons) than rural households (3.9 persons). Table 2.2 also provides information on the pro- portion of households with foster children (that is, chil- dren who live in households with neither biological parent present), double orphans (children with both parents dead), and single orphans (children with one parent dead). Overall, 42 percent of the households con- tain foster children or orphans. Most of these house- holds have foster children (36 percent). More than 21 percent of households have single orphans, and 8 percent have double orphans. Rural households have a higher proportion of foster children and orphans than urban households (47 percent compared with 29 per- cent). 2.3 CHILDREN’S LIVING ARRANGEMENTS AND ORPHANHOOD Living arrangements and parental survival status of children under age 18 who were usual residents of households in the LDHS sample were collected in the Household Questionnaire. The results indicate that only 24 percent of children under age 18 are living in a household with both of their parents; 34 percent are not living with either parent. Children who are living with a single parent are much more likely to live with their mother (33 percent) than with their father (5 percent). Orphanhood is common; 20 percent of children under age 18 have lost one of their parents, and 7 percent have lost both. Among single orphans, children are four times as likely to have lost their father as their mother (16 percent and 4 percent, respectively). Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under age 18, according to residence, Lesotho 2009 Residence Characteristic Urban Rural Total Household headship Male 62.9 64.0 63.7 Female 37.1 36.0 36.3 Total 100.0 100.0 100.0 Number of usual members 0 0.5 0.5 0.5 1 26.9 15.1 18.6 2 20.5 14.8 16.5 3 19.2 18.1 18.4 4 15.2 17.3 16.6 5 9.1 13.5 12.2 6 4.5 8.6 7.4 7 2.3 5.4 4.5 8 1.1 3.1 2.6 9+ 0.7 3.6 2.7 Total 100.0 100.0 100.0 Mean size of households 2.9 3.9 3.6 Percentage of households with orphans and foster children under age 18 Foster children1 22.8 40.9 35.6 Double orphans 5.1 9.8 8.4 Single orphans2 16.2 23.5 21.3 Foster and/or orphan children 29.1 47.1 41.8 Number of households 2,778 6,613 9,391 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those children under age 18 living in households where neither their mother nor their father is a de jure member of the household. 2 Includes children with one dead parent and an unknown survival status of the other parent. 12 | Household Population and Housing Characteristics Table 2.3 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Lesotho 2009 Living with both parents Living with mother but not father Living with father but not mother Not living with either parent Missing infor- mation on father or mother Percent- age not living with a biological parent Percent- age with one or both parents dead1 Background characteristic Both alive Only father alive Only mother alive Both dead Total Number of children Father alive Father dead Mother alive Mother dead Age 0-4 31.8 36.0 4.7 3.4 0.3 14.4 0.9 2.8 1.0 4.8 100.0 19.1 10.1 4,174 <2 37.1 43.9 3.9 1.6 0.3 7.5 0.4 1.4 0.4 3.6 100.0 9.6 6.6 1,649 2-4 28.4 30.8 5.2 4.6 0.3 18.9 1.2 3.8 1.3 5.5 100.0 25.3 12.3 2,525 5-9 23.5 25.5 6.9 4.3 1.1 19.3 2.5 7.4 4.1 5.4 100.0 33.3 22.9 4,418 10-14 19.4 18.8 10.4 4.6 2.0 15.0 3.9 10.9 10.2 4.9 100.0 40.1 38.9 4,961 15-17 18.3 15.1 11.1 3.8 1.5 15.1 4.5 12.0 15.2 3.2 100.0 46.9 45.4 2,250 Sex Male 24.2 24.5 8.2 4.4 1.3 15.7 2.6 7.5 6.7 4.8 100.0 32.6 27.3 7,926 Female 23.0 24.8 7.9 3.8 1.1 16.4 3.0 8.4 6.9 4.7 100.0 34.6 28.2 7,877 Residence Urban 29.1 24.1 9.5 3.3 1.3 12.0 2.2 7.5 6.1 5.0 100.0 27.7 27.5 3,138 Rural 22.3 24.8 7.6 4.3 1.2 17.1 3.0 8.1 7.0 4.7 100.0 35.1 27.8 12,665 Ecological zone Lowlands 23.0 25.8 7.9 4.0 1.1 15.0 2.8 7.8 7.2 5.4 100.0 32.8 27.8 8,200 Foothills 19.3 27.4 6.1 2.8 0.9 20.2 3.2 8.5 6.5 5.0 100.0 38.4 26.2 1,865 Mountains 28.4 20.7 9.0 5.0 1.5 16.0 2.6 7.5 5.8 3.4 100.0 32.0 27.2 4,307 Senqu River Valley 18.7 26.6 8.2 3.3 1.4 16.8 3.0 9.5 7.7 4.8 100.0 37.0 30.9 1,431 District Butha-Buthe 25.2 21.8 7.8 4.8 1.4 16.7 2.5 8.2 6.6 4.9 100.0 34.0 27.8 845 Leribe 23.0 28.3 7.7 3.9 1.3 15.3 3.4 7.4 5.2 4.4 100.0 31.3 25.7 2,606 Berea 24.8 24.1 6.3 3.7 1.1 18.8 2.8 7.8 5.4 5.1 100.0 34.9 24.5 2,065 Maseru 25.1 24.7 8.3 4.1 1.1 13.7 2.7 7.5 8.4 4.4 100.0 32.3 28.8 3,354 Mafeteng 16.0 29.4 7.6 2.8 1.5 16.2 2.6 9.2 8.6 6.2 100.0 36.5 31.0 1,468 Mohale's Hoek 22.8 24.4 7.3 3.6 1.1 16.6 2.9 8.3 7.1 5.8 100.0 35.0 27.9 1,428 Quthing 17.4 25.6 10.0 2.9 2.0 16.4 3.4 9.5 7.3 5.5 100.0 36.6 33.5 984 Qacha’s Nek 20.3 20.9 9.0 4.6 1.1 18.8 3.7 8.8 7.9 4.8 100.0 39.2 31.4 587 Mokhotlong 27.5 21.0 8.5 5.0 0.5 17.2 1.0 8.3 5.9 5.1 100.0 32.4 25.1 973 Thaba-Tseka 30.3 19.2 9.5 6.1 1.2 15.8 2.9 6.8 5.5 2.6 100.0 31.0 26.4 1,492 Wealth quintile Lowest 31.3 18.0 8.3 4.7 2.0 15.3 2.4 7.8 6.7 3.5 100.0 32.2 27.9 3,591 Second 22.7 21.0 7.1 4.7 0.5 19.0 2.9 8.8 7.4 6.0 100.0 38.1 27.8 3,321 Middle 17.9 25.3 8.5 4.0 1.0 17.7 3.5 8.5 7.9 5.7 100.0 37.6 30.6 3,296 Fourth 18.4 33.0 9.2 3.8 1.2 14.9 2.6 6.7 6.2 4.1 100.0 30.3 26.8 3,000 Highest 27.7 28.1 6.8 2.9 1.4 12.6 2.7 7.9 5.4 4.6 100.0 28.5 24.8 2,595 Total <15 24.5 26.2 7.5 4.1 1.2 16.2 2.5 7.3 5.4 5.0 100.0 31.4 24.8 13,552 Total <18 23.6 24.7 8.0 4.1 1.2 16.1 2.8 8.0 6.8 4.8 100.0 33.6 27.7 15,803 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead, and one parent dead but missing information on survival status of the other parent. Household Population and Housing Characteristics | 13 Children’s living arrangements vary by their background characteristics. As expected, the percentage of children who do not live with either parent increases with age. Fifteen percent of children age 15-17 are double orphans. Table 2.3 shows that the children’s living arrangements do not vary by gender; boys and girls are equally likely to be living apart from their parents. Children from rural areas are less likely to live with both parents than children from urban areas (22 percent and 29 percent, respectively). The percentage of children who do not live with either or both parents ranges from 31 percent in Leribe and Thabe-Tseka to 39 percent in Qacha’s Nek. Orphaned children may be at greater risk of dropping out of school because of lack of funds to pay school fees or the need to stay at home to care for a sick parent or sibling. Table 2.4 shows that school attendance rates among de jure children age 10-14 years vary somewhat by whether they have lost one or both parents. Ninety-three percent of children whose mother and father are dead are currently attending school compared with 95 of children whose parents are both alive and who are living with at least one parent. The rate of school attendance among children who are orphaned is virtually identical to the rate of attendance among non-orphaned children (93 percent compared with 95 percent). Table 2.4 School attendance by survivorship of parents For de jure children 10-14 years of age, the percentage attending school by parental survival and the ratio of the percentage attending, by parental survival, according to background characteristics, Lesotho 2009 Percentage attending school by survivorship of parents Background characteristic Both parents dead Number Both parents alive and living with at least one parent Number Ratio1 Sex Male 86.2 233 91.8 1,081 0.94 Female 98.5 274 97.3 1,039 1.01 Residence Urban 100.0 84 99.4 451 1.01 Rural 91.4 423 93.1 1,669 0.98 Ecological zone Lowlands 94.8 281 96.8 1,129 0.98 Foothills 96.8 53 94.9 231 1.02 Mountains 85.8 124 89.9 591 0.95 Senqu River Valley 95.3 48 94.5 167 1.01 District Butha-Buthe 93.3 31 94.3 106 0.99 Leribe 97.5 64 97.1 406 1.00 Berea 90.3 44 98.5 258 0.92 Maseru 90.4 129 95.3 467 0.95 Mafeteng 93.4 70 93.7 178 1.00 Mohale's Hoek 96.4 47 90.6 180 1.06 Quthing 97.0 34 94.9 116 1.02 Qacha’s Nek 93.4 22 94.1 74 0.99 Mokhotlong 91.0 27 90.1 128 1.01 Thaba-Tseka 87.7 38 89.2 207 0.98 Wealth quintile Lowest 86.7 113 87.5 474 0.99 Second 91.6 115 95.2 404 0.96 Middle 92.5 123 94.5 406 0.98 Fourth 97.4 94 96.8 431 1.01 Highest 100.0 61 99.4 404 1.01 Total 92.8 506 94.5 2,120 0.98 Note: Table is based only on children who usually live in the household. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent 14 | Household Population and Housing Characteristics 2.4 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS 2.4.1 Educational Attainment Tables 2.5.1 and 2.5.2 show that women are more likely than men to attend school. For instance, 5 percent of the women and 15 percent of the men age 6 and older who were found in the selected households the night before the survey (de facto) have no education. Less than half of women and 54 percent of men have some primary education, and 15 percent of women and 8 percent of men have completed primary education. Data in the tables also show that 31 percent of women and 22 percent of men have attended secondary school.1 Progress in providing education is taking place in Lesotho because these figures are higher than those recorded in the 2004 LDHS (22 percent of women and 16 percent of men). Additionally, the median number of years of schooling is higher among women (5.6 years) than among men (3.4 years). Table 2.5.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Lesotho 2009 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 12.9 87.1 0.0 0.0 0.0 0.0 0.0 100.0 1,748 0.3 10-14 0.6 85.6 5.4 8.4 0.0 0.0 0.0 100.0 2,478 3.9 15-19 0.9 24.4 16.4 54.7 3.0 0.5 0.1 100.0 1,896 7.0 20-24 0.8 18.9 20.4 39.8 13.6 5.4 1.0 100.0 1,648 7.9 25-29 1.6 21.7 21.6 35.6 12.5 6.0 0.9 100.0 1,322 7.5 30-34 1.9 23.2 25.5 29.7 10.3 8.5 0.9 100.0 1,066 6.9 35-39 1.7 21.0 32.0 30.1 7.0 7.3 0.9 100.0 840 6.8 40-44 2.2 29.2 25.6 30.3 5.7 6.5 0.4 100.0 691 6.7 45-49 3.0 39.4 24.9 19.2 4.1 7.3 2.0 100.0 672 6.3 50-54 6.3 47.5 19.0 17.2 1.6 6.3 2.0 100.0 747 5.7 55-59 5.0 65.7 12.6 8.9 1.6 4.6 1.7 100.0 598 4.6 60-64 7.3 70.8 8.9 6.1 1.1 3.8 2.0 100.0 472 3.9 65+ 16.2 71.7 5.0 2.3 0.2 1.5 3.1 100.0 1,465 2.8 Residence Urban 1.8 30.8 14.0 33.2 10.1 9.0 1.1 100.0 4,168 7.1 Rural 5.6 56.1 14.8 18.7 2.5 1.4 0.9 100.0 11,474 5.0 Ecological zone Lowlands 2.6 42.5 14.5 27.8 6.3 5.1 1.1 100.0 9,131 6.3 Foothills 4.5 57.9 16.4 17.9 1.4 1.1 0.8 100.0 1,614 4.9 Mountains 7.9 60.1 14.7 13.6 2.2 1.0 0.5 100.0 3,613 4.4 Senqu River Valley 9.0 57.5 12.6 15.8 2.8 1.6 0.8 100.0 1,285 4.6 District Butha-Buthe 4.2 51.8 13.6 21.6 5.3 2.9 0.6 100.0 790 5.4 Leribe 3.8 45.4 16.9 25.5 5.0 2.4 0.9 100.0 2,727 6.0 Berea 2.6 43.6 14.4 27.2 5.2 5.7 1.3 100.0 2,134 6.2 Maseru 2.8 42.4 14.4 27.6 6.2 5.6 1.0 100.0 3,753 6.3 Mafeteng 2.7 52.5 14.5 22.0 4.2 3.0 1.1 100.0 1,444 5.6 Mohale's Hoek 6.5 56.3 12.5 18.9 3.1 2.1 0.4 100.0 1,322 5.0 Quthing 10.5 57.3 11.3 15.0 2.9 2.1 0.9 100.0 892 4.3 Qacha’s Nek 9.0 56.2 11.1 17.2 3.7 2.1 0.8 100.0 533 4.5 Mokhotlong 6.8 59.2 16.5 14.1 2.1 0.9 0.5 100.0 822 4.5 Thaba-Tseka 7.4 61.9 16.1 10.7 2.1 0.9 0.9 100.0 1,224 4.2 Wealth quintile Lowest 10.2 68.6 12.8 7.3 0.3 0.0 0.7 100.0 2,890 3.5 Second 6.2 63.1 15.9 12.9 1.0 0.1 0.7 100.0 2,972 4.4 Middle 3.7 54.4 17.4 20.5 2.4 0.7 1.0 100.0 2,990 5.4 Fourth 2.3 38.7 17.0 33.0 6.0 1.9 1.1 100.0 3,253 6.4 Highest 1.3 27.8 10.4 35.2 11.5 12.8 1.1 100.0 3,538 8.2 Total 4.5 49.4 14.6 22.5 4.5 3.5 0.9 100.0 15,642 5.6 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level 1 Includes women and men who have some secondary education, have completed secondary education, and have more than secondary education Household Population and Housing Characteristics | 15 Table 2.5.1 shows that education is becoming more common among younger women, another indication of improvement in education in Lesotho over the years. Urban women and men are more likely to be educated than rural women. For example, 2 percent of urban women have no education compared with 6 percent of rural women. The proportion of urban women who complete secondary education (19 percent) is almost five times as high as that of rural women (4 percent). Educational opportunities go up with wealth; the median number of years completed ranges from 3.5 years for women in the poorest households to 8.2 years for women in the richest households. Table 2.5.2 shows that 17 percent of men in rural areas have no education compared with 7 percent of men in urban areas. There is a marked urban-rural differential in higher education; 46 percent of men in urban areas have attended secondary school compared with only 15 percent in rural areas. Table 2.5.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Lesotho 2009 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 15.5 84.2 0.1 0.0 0.0 0.0 0.1 100.0 1,808 0.0 10-14 2.5 90.7 2.7 3.8 0.0 0.0 0.2 100.0 2,454 2.9 15-19 4.4 45.6 9.8 37.4 1.7 0.6 0.5 100.0 1,853 6.0 20-24 11.0 34.4 11.7 29.6 7.1 5.9 0.5 100.0 1,391 6.4 25-29 14.1 33.0 14.9 18.9 9.9 8.2 1.0 100.0 1,115 6.2 30-34 18.0 29.7 13.1 20.4 10.6 7.6 0.6 100.0 838 6.2 35-39 19.2 35.2 11.9 18.5 5.8 8.4 1.0 100.0 611 5.2 40-44 18.2 33.5 13.8 15.9 9.8 7.5 1.2 100.0 468 5.7 45-49 27.7 33.8 10.7 12.8 4.6 8.8 1.6 100.0 462 4.1 50-54 26.0 38.3 11.2 12.0 4.0 7.0 1.5 100.0 399 3.4 55-59 29.6 44.0 10.9 7.4 2.0 4.5 1.6 100.0 372 2.4 60-64 37.6 45.4 3.3 7.4 0.9 3.6 1.9 100.0 343 1.3 65+ 42.9 43.4 3.2 2.8 1.1 4.1 2.6 100.0 841 0.5 Don't know/missing 36.1 0.0 0.0 63.9 0.0 0.0 0.0 100.0 4 8.5 Residence Urban 6.7 37.6 8.8 26.4 8.9 10.7 0.9 100.0 3,026 6.5 Rural 17.3 59.6 7.4 11.6 2.0 1.4 0.7 100.0 9,934 2.8 Lesotho Ecological Zone Lowlands 8.4 50.8 9.0 20.1 5.1 5.8 0.8 100.0 7,237 4.8 Foothills 15.7 62.8 8.1 10.2 1.1 0.8 1.2 100.0 1,461 2.8 Mountains 26.7 58.0 5.3 6.9 1.9 0.7 0.5 100.0 3,158 1.4 Senqu River Valley 21.6 56.9 5.5 11.7 2.5 1.2 0.7 100.0 1,104 2.3 District Butha-Buthe 13.1 55.0 7.3 18.2 3.6 2.5 0.3 100.0 715 3.8 Leribe 12.1 53.8 10.0 16.4 3.7 3.1 0.9 100.0 1,995 3.8 Berea 8.1 52.5 9.4 18.5 4.7 5.9 0.9 100.0 1,777 4.5 Maseru 10.4 50.0 8.2 19.6 4.7 6.1 1.0 100.0 3,104 4.7 Mafeteng 12.5 58.2 7.6 14.0 3.8 3.1 0.7 100.0 1,243 3.4 Mohale's Hoek 23.0 55.7 6.7 9.9 2.4 2.0 0.3 100.0 1,136 2.3 Quthing 22.2 56.7 4.6 11.4 3.0 1.6 0.5 100.0 742 2.4 Qacha’s Nek 18.9 58.3 4.7 12.4 2.9 1.4 1.4 100.0 443 2.5 Mokhotlong 22.2 60.1 6.3 8.2 1.7 1.1 0.2 100.0 694 1.7 Thaba-Tseka 26.9 58.3 5.2 6.9 1.5 0.6 0.6 100.0 1,110 1.3 Wealth quintile Lowest 30.6 60.9 4.0 3.7 0.1 0.1 0.5 100.0 2,567 0.9 Second 19.4 64.1 7.2 7.8 0.8 0.0 0.6 100.0 2,608 2.2 Middle 11.3 60.4 10.5 13.9 2.2 0.9 0.8 100.0 2,682 3.6 Fourth 8.8 52.2 9.4 22.3 4.2 2.3 0.9 100.0 2,614 4.7 Highest 3.8 33.5 7.4 28.1 11.1 15.2 0.9 100.0 2,489 7.5 Total 14.8 54.4 7.7 15.1 3.6 3.6 0.7 100.0 12,960 3.4 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level 16 | Household Population and Housing Characteristics Men in the Mountains and in the Senqu River Valley zones are most disadvantaged in educational opportunities. Across all districts, Thaba-Tseka has the highest proportion of men who never went to school (27 percent), and Berea has the lowest (8 percent). The variation in education among men according to wealth quintile is similar to that among women. As expected, wealthy men are more likely than poor men to be educated. The median number of years of schooling for men in the highest wealth quintile is 7.5 years compared with 0.9 years for men in the lowest quintile. 2.4.2 School Attendance Table 2.6 presents net attendance ratios (NARs) and gross attendance ratios (GARs) for the de jure household population by level of schooling and sex. The NAR for primary school measures the proportion of children of primary school age who attend primary school, and the GAR represents the total number of primary school students age 5-24 as a percentage of children of primary school age. In the Lesotho context, the levels refer to age 6-12 years for primary school and age 13-17 years for secondary school. The GAR is usually higher than the NAR because the GAR includes participation of those who may be older or younger than the official age range for that level. Students who are over the official age for a given level of school may have started school late, may have repeated one or more grades in school, or may have dropped out of school and later returned. Table 2.6 shows that 94 percent of children of primary school age (age 6-12) attend primary school. The NAR is 92 percent for males and 97 percent for females. The total NAR in urban areas is higher than in rural areas (97 and 94 percent, respectively). Among districts, the NAR is highest in Leribe and Berea (97 percent) and lowest in Thaba-Tseka and Mohale’s Hoek (89 percent). The GAR indicates that there are children in primary school who are not of primary school age, with ratios of 170 for both males and females. This is probably a result of the introduction of free primary education about six years ago. As expected, both the NAR and the GAR are low at the secondary school level. The NAR indicates that only 34 percent of the secondary-school-age population (age 13-17) is attending secondary school. Net secondary school attendance is higher for females (NAR of 40) than for males (NAR of 28). The GAR shows that there are many secondary school students who are not of secondary school age. School attendance ratios at the secondary level are much lower in rural than in urban areas. For instance, the NAR at the secondary school level in rural areas is 28 percent compared with 57 percent in urban areas. Similarly, the GAR at secondary school is 38 percent in rural areas compared with 78 percent in urban areas. There is a strong relationship between household economic status and school attendance that can be seen at both the primary and secondary levels and among both the males and the females. The primary school NAR increases from 87 percent for males from the poorest households to 98 percent for males from the richest households. The Gender Parity Index (GPI) represents the ratio of the NAR or GAR for females to the NAR or GAR for males. It is presented at both the primary and secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI less than 1 indicates that a smaller proportion of females than males attends school. In Lesotho, the GPI is slightly more than 1.01 for primary school attendance, indicating that the gender gap is relatively small, while for secondary school attendance it is greater than 1.30, indicating that females are much more advantaged at this educational level. There are marked differences in GPI in secondary school by residence. For example, the GPI is 1.48 in rural areas compared with 0.94 in urban areas. Household Population and Housing Characteristics | 17 Table 2.6 School attendance ratios Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Lesotho 2009 Net attendance ratio 1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index (GPI)3 Male Female Total Gender Parity Index (GPI) 3 PRIMARY SCHOOL Residence Urban 97.4 96.8 97.1 0.99 173.8 159.5 166.3 0.92 Rural 91.1 96.4 93.7 1.06 168.3 173.2 170.7 1.03 Ecological zone Lowlands 95.3 96.7 96.0 1.01 177.6 166.7 172.1 0.94 Foothills 97.0 99.4 98.1 1.02 166.5 176.3 171.0 1.06 Mountains 85.2 95.2 90.1 1.12 152.8 172.3 162.4 1.13 Senqu River Valley 90.8 96.2 93.4 1.06 181.6 178.7 180.2 0.98 District Butha-Buthe 92.8 98.8 95.7 1.06 164.8 168.6 166.6 1.02 Leribe 96.0 97.3 96.7 1.01 168.5 168.1 168.3 1.00 Berea 97.5 96.8 97.2 0.99 182.3 166.9 174.4 0.92 Maseru 93.0 98.0 95.4 1.05 172.8 165.8 169.5 0.96 Mafeteng 93.9 97.2 95.5 1.04 171.7 174.9 173.2 1.02 Mohale's Hoek 86.3 92.6 89.3 1.07 164.4 164.3 164.3 1.00 Quthing 91.6 97.9 94.7 1.07 177.0 182.8 179.8 1.03 Qacha’s Nek 94.8 97.1 96.0 1.02 207.8 185.5 196.6 0.89 Mokhotlong 87.6 94.4 90.9 1.08 155.7 171.8 163.7 1.10 Thaba-Tseka 84.6 93.7 88.9 1.11 144.9 177.3 160.1 1.22 Wealth quintile Lowest 87.0 94.3 90.5 1.08 146.2 170.2 157.6 1.16 Second 90.4 97.2 93.8 1.07 177.8 177.9 177.9 1.00 Middle 94.2 96.7 95.4 1.03 172.6 175.2 173.8 1.02 Fourth 94.5 98.0 96.2 1.04 183.7 170.6 177.5 0.93 Highest 97.8 97.0 97.4 0.99 174.4 156.2 164.5 0.90 Total 92.2 96.5 94.3 1.05 169.3 170.4 169.9 1.01 SECONDARY SCHOOL Residence Urban 59.1 55.7 57.2 0.94 80.8 75.8 77.9 0.94 Rural 20.6 34.9 27.6 1.70 30.4 44.9 37.5 1.48 Ecological zone Lowlands 38.5 48.4 43.6 1.26 53.8 63.4 58.8 1.18 Foothills 18.0 35.7 26.4 1.99 27.5 45.1 35.8 1.64 Mountains 12.6 24.6 18.7 1.96 20.0 33.0 26.6 1.65 Senqu River Valley 20.4 33.5 26.8 1.64 29.2 45.3 37.1 1.55 District Butha-Buthe 39.5 47.0 42.9 1.19 52.8 62.9 57.4 1.19 Leribe 29.9 41.7 36.4 1.39 42.4 52.9 48.2 1.25 Berea 38.7 52.8 46.0 1.37 49.6 69.3 59.9 1.40 Maseru 34.3 46.2 40.3 1.35 55.3 60.4 57.9 1.09 Mafeteng 25.8 35.1 30.1 1.36 32.4 44.8 38.2 1.38 Mohale's Hoek 21.3 34.4 27.9 1.62 26.3 46.6 36.5 1.77 Quthing 19.6 34.1 27.0 1.74 29.7 44.7 37.4 1.50 Qacha’s Nek 20.8 32.6 26.3 1.57 32.8 49.6 40.7 1.51 Mokhotlong 12.2 29.4 20.8 2.41 23.5 43.7 33.6 1.86 Thaba-Tseka 14.1 19.5 16.8 1.39 19.3 23.9 21.6 1.24 Wealth quintile Lowest 6.7 14.8 10.7 2.22 11.0 19.1 15.0 1.73 Second 15.3 27.1 21.0 1.77 23.2 33.6 28.3 1.45 Middle 24.9 38.1 31.2 1.53 33.7 46.3 39.7 1.38 Fourth 37.0 51.6 44.4 1.39 53.7 70.9 62.5 1.32 Highest 59.9 61.8 61.0 1.03 84.2 83.6 83.9 0.99 Total 28.3 40.1 34.3 1.42 40.5 52.7 46.7 1.30 1 The NAR for primary school is the percentage of the primary-school age (6-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (13-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. 18 | Household Population and Housing Characteristics Figure 2.2 shows that attendance rates for both males and females are 95 percent or higher for females at ages 8-14, and only 82 to 94 percent for males in the same age range. Both boys and girls tend to drop out of school after a certain age, so that at age 15, only 79 percent of boys and 85 percent of girls are still in school. At age 20, boys are as likely to be in school as girls (33 and 31 percent, respectively) and at age 24, 10 percent of males and 13 percent of females are attending school. 2.5 HOUSEHOLD ENVIRONMENT The physical characteristics of the dwelling in which a household lives are important determi- nants of the health status of household members, especially children. They can also be used as indicators of the socioeconomic status of households. The 2009 LDHS respondents were asked a number of ques- tions about their household environment, including questions on the source of drinking water; type of sanitation facility; type of flooring, walls, and roof; and number of rooms in the dwelling. The results are presented both in terms of households and of their usual members. 2.5.1 Drinking Water Increasing access to improved drinking water is one of the Millennium Development Goals that Lesotho, along with other nations worldwide, has adopted (United Nations General Assembly, 2001). Table 2.6 includes a number of indicators that are useful in monitoring household access to improved drinking water (WHO and UNICEF, 2005). The source of drinking water is an indicator of whether it is suitable for drinking. Table 2.7 presents the sources that are likely to provide water suitable for drinking. These improved sources include a piped source within the dwelling or plot, public tap, tube well or borehole, protected well or spring, and rainwater.2 Lack of ready access to a water source may limit the quantity of suitable drinking water that is available to a household. Even if the water is obtained from an improved source, water that must be fetched from a source that is not immediately accessible to the household may be contaminated during transport or storage. Another factor in considering the accessibility of water sources is that the burden of going for water often falls disproportionately on female 2 The categorisation of improved and non-improved sources follows that proposed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (WHO and UNICEF, 2004). Figure 2.2 Percentage of Males and Females Currently Attending School, by Age LDHS 2009 , , , , , , , , , , , , , , , , , , , # # # # # # # # # # # # # # # # # # # 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age in years 0 20 40 60 80 100 120 Male Female# , Percent Household Population and Housing Characteristics | 19 members of the household. Finally, home water treatment can be effective in improving the quality of household drinking water. Eight in ten households in Lesotho obtain water from improved sources. There is wide variation in usage between urban and rural households (91 percent and 74 percent, respectively). The time taken to obtain water varies among households, with water available on the premises for only 23 percent of all households (63 percent in the urban areas and 6 percent in the rural areas). Overall, one in four households takes 30 minutes or more to obtain water (9 percent in the urban areas compared with 32 percent in the rural areas). Table 2.7 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and the de jure population by treatment of drinking water, according to residence, Lesotho 2009 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 91.1 73.7 78.9 90.1 72.5 76.7 Piped water into dwelling/yard/plot 58.9 3.1 19.6 58.0 2.7 16.1 Public tap/standpipe 24.3 52.7 44.3 23.9 51.6 44.9 Tube well or borehole 5.2 9.2 8.0 5.4 8.9 8.1 Protected dug well 0.8 4.5 3.4 0.9 4.9 3.9 Protected spring 1.8 4.1 3.4 2.0 4.3 3.7 Rainwater 0.1 0.1 0.1 0.0 0.1 0.1 Non-improved source 4.1 25.6 19.2 4.8 26.9 21.6 Unprotected dug well 2.3 14.9 11.1 2.7 15.7 12.5 Unprotected spring 1.2 9.6 7.1 1.6 10.1 8.0 Tanker truck/cart with small tank 0.4 0.5 0.5 0.3 0.5 0.4 Surface water 0.1 0.6 0.5 0.2 0.7 0.6 Bottled water, improved source for cooking/washing1 0.1 0.0 0.0 0.1 0.0 0.0 Other 4.7 0.5 1.8 5.0 0.4 1.5 Missing 0.0 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 91.2 73.7 78.9 90.2 72.5 76.8 Time to obtain drinking water (round trip) Water on premises 63.4 5.5 22.6 61.6 5.2 18.8 Less than 30 minutes 27.6 61.9 51.8 27.6 61.6 53.4 30 minutes or longer 8.9 31.5 24.8 10.6 32.3 27.1 Don't know/missing 0.2 1.1 0.8 0.2 0.9 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 24.6 67.9 55.1 25.9 73.7 62.2 Adult male 15+ 8.8 17.4 14.9 8.1 10.9 10.2 Female child under age 15 1.7 6.6 5.2 2.3 7.7 6.4 Male child under age 15 1.2 2.1 1.9 1.6 2.0 1.9 Other 0.3 0.3 0.3 0.4 0.3 0.3 Water on premises 63.4 5.5 22.6 61.6 5.2 18.8 Missing 0.0 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 14.5 5.4 8.1 15.0 5.3 7.6 Bleach/chlorine 0.6 0.3 0.4 0.7 0.3 0.4 Strained through cloth 0.2 1.4 1.0 0.2 1.4 1.1 Ceramic, sand or other filter 0.1 0.1 0.1 0.1 0.0 0.1 Other 0.1 0.6 0.5 0.1 0.7 0.5 No treatment 85.0 92.5 90.3 84.5 92.7 90.7 Percentage using an appropriate treatment method3 14.9 6.7 9.2 15.5 6.5 8.7 Number 2,778 6,613 9,391 8,091 25,470 33,561 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 3 Appropriate water-treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 20 | Household Population and Housing Characteristics Getting water is a chore predominantly done by women. Water is collected by women for more than half of the households surveyed, with 55 percent collected by women age 15 or older and 5 percent collected by female children under age 15. This is particularly true in the rural areas where 68 percent of the household’s water is collected by women age 15 or older and 87 percent is collected by female children under age 15. Households were further asked if they treat the water before drinking it. Nine in 10 households do not treat the water in any way. The most common form of treatment is boiling the water, a step taken by 8 percent (15 percent of households in urban areas and 5 percent of households in rural areas). 2.5.2 Household Sanitation Facilities Ensuring adequate sanitation facilities is another of the Millennium Development Goals that Lesotho shares with other countries. A household is classified as having an improved toilet if the toilet is used only by members of one household (i.e., it is not shared) and if the facility used by the household separates the waste from human contact (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004). Proper sanitation facilities lead to improved hygiene practices, and ultimately low infant mortality rates. Overall, 24 percent of households in Lesotho have improved (not shared) sanitation facilities, and 43 percent have non-improved facilities. Urban households have a higher proportion of improved facilities than rural households (26 and 22 percent, respectively) (Table 2.8). One in 3 households has no toilet facility (4 percent in the urban areas and 45 percent in the rural areas). Table 2.8 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Lesotho 2009 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility 26.3 22.1 23.5 30.4 23.4 25.1 Flush/pour flush to piped sewer system 2.7 0.1 0.9 2.6 0.1 0.7 Flush/pour flush to septic tank 2.9 0.2 1.0 3.1 0.1 0.8 Flush/pour flush to pit latrine 0.2 0.0 0.1 0.2 0.0 0.1 Ventilated improved pit (VIP) latrine 7.5 8.0 7.8 8.9 8.6 8.6 Pit latrine with slab 11.9 11.8 11.9 14.4 12.4 12.9 Composting toilet 1.1 2.0 1.8 1.2 2.2 2.0 Non-improved facility 68.7 32.3 43.1 64.2 30.6 38.8 Any facility shared with other households 34.5 5.6 14.2 28.8 4.7 10.5 Flush/pour flush not to sewer/septic tank/pit latrine 0.6 0.0 0.2 0.7 0.0 0.2 Pit latrine without slab/open pit 33.5 26.7 28.7 34.6 25.9 28.0 Bucket 0.1 0.0 0.0 0.1 0.0 0.1 No facility/bush/field 4.4 44.9 32.9 4.9 45.4 35.6 Other 0.5 0.5 0.5 0.4 0.4 0.4 Missing 0.0 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,778 6,613 9,391 8,091 25,470 3,561 2.5.3 Housing Characteristics Given that there is a strong relationship between household economic conditions and exposure to diseases, information on housing characteristics, such as access to electricity, source of drinking water, sanitary facilities, and flooring and roofing materials is key to explaining the interrelationships among the Household Population and Housing Characteristics | 21 social and economic conditions of the household and the likely exposure to and prevalence of diseases. Table 2.9 shows the percent distribution of households by housing characteristics. Table 2.9 shows that only 17 percent of Lesotho households have electricity, which is, however, an increase of 143 percent from the percentage recorded in the 2004 LDHS (7 percent). Urban households are much more likely to have electricity than rural households (43 percent compared with 6 percent). Table 2.9 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Lesotho 2009 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 43.2 6.0 17.0 48.3 5.8 16.1 No 56.8 93.8 82.9 51.7 94.0 83.8 Missing 0.0 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Natural floor mud/earth 3.6 45.4 33.0 3.7 46.4 36.1 Rudimentary floor wood planks 0.3 0.1 0.2 0.3 0.1 0.1 Finished floor parquet or polished wood 0.7 0.3 0.4 0.6 0.3 0.4 Vinyl or asphalt strips 18.2 15.9 16.6 18.0 15.5 16.1 Ceramic tiles 10.4 3.2 5.3 12.7 3.6 5.8 Brick tiles 1.9 1.0 1.3 2.1 1.0 1.2 Cement 50.3 23.6 31.5 48.0 23.0 29.1 Carpet 14.0 9.5 10.8 14.1 9.2 10.3 Other 0.6 0.9 0.8 0.6 0.8 0.8 Missing 0.0 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 46.4 39.2 41.3 41.7 33.3 35.4 Two 19.5 33.0 29.0 24.4 36.3 33.4 Three or more 14.3 14.3 14.3 19.4 18.9 19.1 Missing 19.8 13.5 15.4 14.5 11.4 12.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 92.3 36.2 52.8 90.1 33.9 47.4 In a separate building 1.7 8.2 6.2 2.1 8.8 7.1 Outdoors 5.8 55.4 40.7 7.7 57.2 45.2 Other 0.1 0.0 0.0 0.0 0.0 0.0 Missing 0.2 0.2 0.2 0.1 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 19.7 2.0 7.3 20.1 1.7 6.1 LPG 53.1 11.9 24.1 53.1 10.2 20.5 Kerosene 20.3 6.2 10.4 17.7 4.1 7.4 Coal, lignite 0.1 0.2 0.2 0.1 0.2 0.2 Wood 5.2 60.4 44.1 7.0 62.9 49.4 Straw / shrubs / grass 0.8 8.9 6.5 0.8 9.5 7.4 Agricultural crop 0.0 1.0 0.7 0.0 1.1 0.8 Animal dung 0.6 8.9 6.5 1.1 10.1 7.9 No food cooked in household 0.1 0.1 0.1 0.0 0.0 0.0 Other 0.1 0.1 0.1 0.1 0.1 0.1 Missing 0.0 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 6.8 79.5 58.0 8.9 83.8 65.7 Number of households 2,778 6,613 9,391 8,091 25,470 33,561 Type of fire/stove among households using solid fuels1 Closed stove with chimney 1.6 0.4 0.4 1.2 0.3 0.4 Open fire/stove with chimney 2.2 0.7 0.7 2.3 0.8 0.8 Open fire/stove with hood 0.0 0.5 0.4 0.0 0.4 0.4 Open fire/stove without chimney or hood 96.2 98.0 97.9 96.6 98.0 98.0 Other 0.0 0.5 0.5 0.0 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population using solid fuel 189 5,258 5,447 724 21,338 22,062 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 22 | Household Population and Housing Characteristics The type of flooring material used in dwellings is a proxy indicator of the socioeconomic status of the household as well as its likely exposure to disease-causing agents. The predominant flooring materials used by Lesotho households are mud, earth, or dung (33 percent), followed closely by cement (32 percent). Half of urban households have cement floors, while 45 percent of rural households have mud, earth, or dung floors. The most common source of cooking fuel in Lesotho is firewood (44 percent), followed by LPG or natural gas (24 percent). In urban households, the most commonly used source is LPG or natural gas (53 percent). In rural areas, 7 in 10 households use firewood or straw for cooking. 2.6 HOUSEHOLD DURABLE GOODS Table 2.10 shows the percentage of households possessing various durable goods by urban-rural residence. This indicator also provides a rough measure of the socioeconomic status of households. Ninety-two percent of households in Lesotho have a bed and mattress, 65 percent have a mobile telephone, and 62 percent have a radio. Information technology is starting to be used in households; 3 percent of households have a computer, and 1 percent has access to the Internet. These items are more often found in urban households than in rural households. Households are more likely to own animal-drawn carts (9 percent) than cars or trucks (7 percent). One percent of households have none of the selected durable goods. As expected, the selected goods are more likely to be available in urban households than in rural households. Table 2.10 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Lesotho 2009 Households Population Possession Urban Rural Total Urban Rural Total Radio 77.5 54.9 61.6 78.4 56.3 61.6 Television 40.1 10.2 19.0 46.0 10.8 19.3 Mobile telephone 87.2 55.6 64.9 89.3 59.8 66.9 Non-mobile telephone 14.0 1.4 5.1 17.6 1.4 5.3 Refrigerator 31.9 7.5 14.7 38.1 7.6 14.9 Bicycle 3.3 1.6 2.1 4.2 1.8 2.4 Animal drawn cart 1.5 11.7 8.7 1.9 13.9 11.0 Motorcycle/scooter 0.4 0.2 0.3 0.4 0.2 0.3 Car/truck 14.3 3.6 6.7 17.1 4.0 7.1 Bed/mattress 98.3 89.4 92.0 98.7 89.2 91.5 Battery or generator 10.7 18.5 16.2 11.6 20.6 18.4 Computer 8.5 1.0 3.2 9.4 0.9 3.0 Internet access 3.3 0.4 1.3 3.4 0.4 1.1 Ownership of agricultural land 15.2 67.2 51.8 15.4 70.6 57.3 Ownership of farm animals1 22.4 64.1 51.8 26.8 70.7 60.1 None of the above 0.3 1.2 0.9 0.3 1.2 1.0 Number 2,778 6,613 9,391 8,091 25,470 33,561 1 Cattle, cows, bulls, horses, donkeys, goats, sheep or chickens, pigs, and rabbits 2.7 RESIDENCY STATUS Table 2.11 shows the residency status of the household population in Lesotho. Three in 4 men who are usual residents were found in their households during the survey compared with 80 percent of women. Fifteen percent of men and women live elsewhere in Lesotho. Ten percent of men and 5 percent of women were reported to live in the Republic of South Africa (RSA). Household Population and Housing Characteristics | 23 The proportion of the male household population that lives in their usual residence varies across districts, ranging from 68 percent in Qacha’s Nek to 79 percent in Berea. Twelve percent or more of men in Butha-Buthe, Leribe, Mafeteng, Mohale’s Hoek, Quthing, and Qacha’s Nek live in RSA. Respondents with more than secondary education are more likely to live elsewhere in Lesotho, while respondents with primary or higher education are more likely than other respondents to live in RSA. The residency status does not have a uniform variation by wealth quintile. Table 2.11 Residency status Percentage of household population by residency status, according to background characteristics, Lesotho 2009 Males Females Percentage usually living: Percentage usually living: Background characteristic In the household Elsewhere in Lesotho In RSA Total Number of males In the household Elsewhere in Lesotho In RSA Total Number of females Age 0-9 90.4 8.7 1.0 100.0 4,773 88.7 10.1 1.1 100.0 4,823 10-19 81.9 16.4 1.7 100.0 5,310 79.7 18.3 2.0 100.0 5,392 20-29 61.3 23.7 15.0 100.0 4,139 68.8 24.4 6.8 100.0 4,202 30-39 58.4 19.1 22.3 100.0 2,457 73.8 17.4 8.7 100.0 2,543 40-49 60.1 13.5 26.4 100.0 1,513 76.2 12.6 11.0 100.0 1,775 50-59 66.8 11.7 21.4 100.0 1,154 85.3 7.6 7.0 100.0 1,596 60+ 90.0 4.8 5.1 100.0 1,350 92.4 5.4 2.2 100.0 2,128 Residence Urban 77.4 14.4 8.0 100.0 4,500 82.9 13.2 3.7 100.0 5,556 Rural 74.4 15.4 10.2 100.0 16,201 79.4 15.8 4.8 100.0 16,902 Ecological zone Lowlands 75.5 14.2 10.1 100.0 11,249 81.2 14.0 4.7 100.0 12,768 Foothills 73.9 14.9 11.2 100.0 2,421 77.6 16.9 5.5 100.0 2,415 Mountains 75.4 18.1 6.5 100.0 5,191 80.2 17.2 2.6 100.0 5,296 Senqu River Valley 72.5 12.7 14.7 100.0 1,840 77.4 15.3 7.3 100.0 1,979 District Butha-Buthe 73.1 15.2 11.7 100.0 1,157 80.1 12.5 7.5 100.0 1,161 Leribe 72.5 15.9 11.6 100.0 3,312 81.3 13.7 5.0 100.0 3,784 Berea 78.9 12.2 8.7 100.0 2,677 82.3 13.1 4.3 100.0 2,961 Maseru 77.1 16.3 6.5 100.0 4,706 80.1 16.5 3.3 100.0 5,320 Mafeteng 73.9 13.0 13.1 100.0 2,008 80.2 15.1 4.7 100.0 2,088 Mohale's Hoek 71.0 14.4 14.6 100.0 1,952 76.3 16.8 6.9 100.0 2,035 Quthing 78.0 9.7 12.3 100.0 1,144 83.1 11.4 5.5 100.0 1,253 Qacha’s Nek 68.1 15.9 15.8 100.0 788 76.3 14.0 9.7 100.0 811 Mokhotlong 77.6 17.1 5.4 100.0 1,130 82.1 15.8 2.1 100.0 1,183 Thaba-Tseka 74.9 20.3 4.7 100.0 1,828 78.5 19.9 1.6 100.0 1,863 Education No education 77.3 12.8 9.9 100.0 3,063 87.8 9.6 2.6 100.0 1,311 Some primary 77.9 13.3 8.7 100.0 9,142 86.7 10.4 2.9 100.0 8,920 Completed primary 61.6 18.8 19.5 100.0 1,634 75.4 17.6 6.9 100.0 2,977 Some secondary 67.1 20.0 12.7 100.0 2,906 71.0 21.8 7.1 100.0 4,835 Completed secondary 64.5 22.6 12.7 100.0 718 72.2 21.5 6.2 100.0 957 More than secondary 61.7 28.9 9.2 100.0 720 64.6 29.1 5.5 100.0 810 Wealth quintile Lowest 78.5 15.7 5.8 100.0 4,168 81.9 15.2 2.9 100.0 4,210 Second 75.3 16.4 8.4 100.0 4,201 79.3 15.8 4.8 100.0 4,466 Middle 74.6 14.5 10.9 100.0 4,319 78.0 16.2 5.8 100.0 4,467 Fourth 71.9 14.9 13.1 100.0 4,177 80.1 15.0 4.8 100.0 4,630 Highest 75.0 14.3 10.6 100.0 3,835 81.9 13.6 4.3 100.0 4,686 Total 75.0 15.2 9.8 100.0 20,701 80.3 15.2 4.5 100.0 22,458 Note: Total includes 4 males with missing information on current residency status. RSA = Republic of South Africa 24 | Household Population and Housing Characteristics 2.8 BIRTH REGISTRATION Lesotho is a signatory to the International Convention of the Rights of the Child (United Nations, 1989), which in part states that every child has the right to a name and a nationality and the right to protection from loss of his or her identity. To assess the coverage of birth registration in the 2009 LDHS for all children born in the five years before the survey, a household member was asked if the child had a registered birth certificate. In the 2009 LHDS, a birth is considered to be registered if the child has a birth certificate or if the birth has been reported to the civil authority for the purpose of initiating the registration process. Table 2.12 shows that 45 percent of the births in the past five years in Lesotho are registered, which is an improvement from the 26 percent reported in the 2004 LDHS. Children under age 2 are less likely than children age 2-4 to have a birth certificate (13 percent compared with 21 percent, respectively). There are small differences by the child’s sex. Urban children have a certificate more often than rural children, but births in the rural areas are more often reported to local authorities than are births to urban children. Overall, there is a small urban-rural difference in the coverage of births that are registered. Table 2.12 Birth registration of children under age five Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Lesotho 2009 Percentage of children whose births are registered Background characteristic Had a birth certificate Did not have a birth certificate Total registered Number of children Age <2 12.9 26.4 39.3 1,649 2-4 21.4 27.5 48.9 2,525 Sex Male 19.2 26.5 45.7 2,035 Female 16.9 27.7 44.6 2,139 Residence Urban 21.8 21.6 43.4 802 Rural 17.1 28.4 45.5 3,372 District Butha-Buthe 25.9 29.5 55.4 225 Leribe 13.4 26.0 39.3 677 Berea 23.3 30.2 53.6 552 Maseru 19.3 19.8 39.1 885 Mafeteng 18.8 23.8 42.6 394 Mohale's Hoek 14.5 36.2 50.7 384 Quthing 17.6 30.8 48.4 219 Qacha’s Nek 11.8 39.9 51.7 143 Mokhotlong 22.6 20.4 43.0 281 Thaba-Tseka 13.4 31.9 45.4 414 Mother’s education No education 17.8 39.4 57.2 64 Some primary 12.1 28.9 41.0 981 Completed primary 16.5 27.0 43.5 948 Some secondary 18.0 28.5 46.5 1,066 Completed secondary 26.0 26.8 52.7 208 More than secondary 43.3 25.6 68.9 117 Mother not in household 21.7 22.5 44.2 762 Wealth quintile Lowest 8.6 33.0 41.6 1,005 Second 14.9 28.0 43.0 893 Middle 19.9 26.4 46.3 858 Fourth 22.8 24.5 47.3 775 Highest 28.8 20.6 49.4 643 Total 18.0 27.1 45.1 4,174 Household Population and Housing Characteristics | 25 Differentials by district indicate that Butha-Buthe has the highest proportion of children with a birth certificate (26 percent) and Qacha’s Nek has the lowest (12 percent). Births to mothers with no education are more likely than other births to be reported, but less likely to have a certificate. The likelihood that a birth is registered and has a birth certificate increases with the mother’s education. Seven in 10 births to mothers with more than secondary education are registered; 43 percent have a birth certificate, and 26 percent are registered but have no birth certificate. Birth registration is positively associated with wealth quintile; 9 percent of children in the poorest households have birth certificates compared with 29 percent of children in the richest households. On the other hand, children in the poorest households are more likely to be reported to local authorities without receiving a certificate than children in the richest households. Overall, coverage of birth registration (with or without a birth certificate) increases with wealth quintile, reaching 49 percent among children in the highest wealth quintile. 2.9 WEALTH QUINTILE Table 2.13 shows the distribution of the de jure household population into five wealth levels (quintiles) based on the wealth index by residence. This distribution indicates the degree to which wealth is distributed by geographic area. Six in 10 persons residing in urban areas are from the richest quintile. On the other hand, more than half of the rural residents are in the two poorest quintiles. In terms of households, 61 percent of households in the urban areas are in the highest quintile compared with only 7 percent of households in the rural areas. Among the four ecological zones, close to one in three households in the Lowlands zone fall in the highest wealth quintile. In contrast, 50 percent of households in the Mountains zone are in the lowest quintile. Across districts, 30 percent or more of households in Berea and Maseru are in the highest quintile, while 50 percent or more of households in Mokhotlong and Thaba-Tseka are in the lowest quintile. Also included in Table 2.13 is the Gini Coefficient, which indicates the level of concentration of wealth, with 0 being an equal distribution and 100 being a totally unequal distribution. Wealth is more evenly distributed in urban areas (7 percent) than in rural areas (21 percent). The results also show that wealth is most evenly distributed in the Foothills (13 percent) and least evenly distributed in the Mountains zone (26 percent). Across districts, the population of Mafeteng has the most equal wealth distribution (18 percent) and that in Qacha’s Nek has the least (30 percent). 26 | Household Population and Housing Characteristics Table 2.13 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini coefficient according to residence and region, Lesotho 2009 Wealth quintile Number of population Gini coefficient Residence/region Lowest Second Middle Fourth Highest Total Residence Urban 0.4 2.4 6.9 29.5 60.8 100.0 8,091 6.9 Rural 26.3 25.6 24.2 17.0 7.0 100.0 25,470 21.4 Ecological zone Lowlands 4.4 14.6 21.9 27.2 31.8 100.0 18,873 19.4 Foothills 22.4 30.6 28.7 14.7 3.6 100.0 3,664 13.0 Mountains 50.0 25.8 12.4 7.8 4.1 100.0 8,158 25.9 Senqu River Valley 34.4 25.5 17.5 14.2 8.5 100.0 2,866 24.9 District Butha-Buthe 20.4 26.8 21.3 19.0 12.6 100.0 1,7752 23.7 Leribe 14.9 18.5 25.1 22.0 19.5 100.0 5,478 25.0 Berea 8.8 14.9 26.2 19.8 30.3 100.0 4,551 22.2 Maseru 7.7 13.1 14.4 30.7 34.1 100.0 7,890 20.1 Mafeteng 7.2 22.2 31.7 22.8 16.2 100.0 3,158 18.4 Mohale's Hoek 25.2 26.5 20.9 15.1 12.2 100.0 2,939 28.1 Quthing 34.5 26.7 15.2 13.9 9.8 100.0 1,934 25.5 Qacha’s Nek 39.8 22.7 14.7 11.7 11.1 100.0 1,156 30.2 Mokhotlong 49.7 26.9 12.3 7.7 3.4 100.0 1,848 25.1 Thaba-Tseka 53.7 26.5 11.3 4.9 3.6 100.0 2,832 21.7 Total 20.0 20.0 20.0 20.0 20.0 100.0 33,561 26.6 Characteristics of Survey Respondents | 27 CHARACTERISTICS OF SURVEY RESPONDENTS 3 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Information on the basic characteristics of women and men interviewed in the 2009 LDHS survey increases understanding of the findings subsequently presented in the final report. Background character- istics of the 7,624 women and 3,317 men age 15-59 are presented in Table 3.1. For both sexes, the proportion of respondents in each age group declines as age increases, reflecting the comparatively young age structure of the population. More than half of the women are currently married compared with 38 percent of the men. Almost all respondents in current marital unions reported themselves as married, with less than 1 percent of the women and men living together in an informal union. Five percent of the women are divorced or separated compared with 3 percent of the men. Eight percent of the women and 2 percent of the men are widowed. One in three women and 56 percent of the men have never married. Slightly more than two in three women and men live in rural areas. More than 60 percent of the respondents live in the Lowlands zone, 2 in 10 live in the Mountains zone, and 1 in 10 lives in the Foothills zone. By district, the proportion of respondents ranges from around 3 percent in Qacha’s Nek to about 27 percent in Maseru. Women are much less likely than men to have never attended school (1 and 11 percent, respectively). Women are more likely than men to complete primary school (23 percent versus 12 percent). They also are more likely to attend secondary school. More than half of women but only about 40 percent of the men, have attended secondary school or obtained higher education. Women diverge in wealth more widely than men. About 14 percent in the lowest wealth quintile, and 28 percent are in the highest quintile. The corresponding proportions for men are 15 and 23 percent, respectively. More than 4 in 10 of the survey respondents are Roman Catholic, and another one in five each belongs to the Lesotho Evangelical Church and the Pentecostal Church. Only 2 percent of women and 7 percent of men belong to other religions (Table 3.1) 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 3.2.1 and 3.2.2 reveal that younger persons attain higher levels of education than older people do. This is demonstrated by the higher proportion of young persons who attend secondary school and higher; younger persons also have completed more median years of schooling than older persons. The differential in educational attainment between women and men is evident in every age group but is much greater among older compared with younger respondents. Urban residents have attained a better education than rural residents. For example, 69 percent of women in urban areas have attended at least some secondary school compared with 44 percent of rural residents. The corresponding figures for men are 69 and 29 percent, respectively.1 1 These figures were attained by adding together three education categories: some secondary, completed secondary, and more than secondary. 28 | Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Lesotho 2009 Women Men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 23.4 1,785 1,840 27.8 835 838 20-24 20.4 1,552 1,556 21.1 634 631 25-29 16.3 1,244 1,203 15.4 463 462 30-34 12.9 983 960 13.2 396 370 35-39 10.0 763 755 9.7 290 282 40-44 8.6 656 664 6.5 196 204 45-49 8.4 641 646 6.4 193 202 Marital status Never married 34.3 2,618 2,554 56.2 1,691 1,682 Married 52.3 3,990 4,071 38.1 1,147 1,129 Living together 0.8 58 58 0.7 22 18 Divorced/separated 5.0 385 349 2.8 84 96 Widowed 7.5 573 592 2.1 64 64 Residence Urban 33.7 2,573 1,977 28.1 845 676 Rural 66.3 5,051 5,647 71.9 2,162 2,313 Ecological zone Lowlands 62.9 4,798 3,610 61.5 1,850 1,419 Foothills 9.5 725 718 10.6 319 320 Mountains 20.3 1,544 2,336 20.7 621 901 Senqu River Valley 7.3 556 960 7.2 217 349 District Butha-Buthe 4.7 357 648 5.6 168 297 Leribe 17.8 1,359 845 16.6 498 312 Berea 14.7 1,122 819 15.0 451 342 Maseru 26.7 2,036 1,211 25.7 773 450 Mafeteng 8.9 682 711 9.8 295 302 Mohale's Hoek 7.9 599 667 8.3 250 271 Quthing 5.0 379 669 5.0 150 257 Qacha’s Nek 2.9 219 605 2.6 79 214 Mokhotlong 4.7 356 695 4.6 137 250 Thaba-Tseka 6.8 515 754 6.8 206 294 Education No education 1.2 93 114 11.2 336 393 Primary incomplete 23.7 1,810 2,053 36.4 1,095 1,144 Primary complete 22.8 1,741 1,812 12.4 372 350 Secondary+ 52.2 3,979 3,645 40.1 1,205 1,102 Religion Roman Catholic 42.9 3,270 3,218 42.4 1,276 1,217 Lesotho Evangelical 18.6 1,417 1,400 19.6 590 582 Anglican 8.1 619 585 8.7 261 265 Pentecostal 23.5 1,789 1,838 19.1 575 577 Other Christian 4.9 372 412 3.2 97 114 Other religion 2.0 158 171 6.9 209 234 Wealth quintile Lowest 14.1 1,073 1,518 14.7 443 584 Second 15.6 1,190 1,421 19.1 575 635 Middle 17.4 1,325 1,376 22.1 666 647 Fourth 24.9 1,900 1,615 21.3 640 560 Highest 28.0 2,136 1,694 22.7 684 563 Total 15-49 100.0 7,624 7,624 100.0 3,008 2,989 50-59 na na na - 309 328 Total men 15-59 na na na - 3,317 3,317 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Survey Respondents | 29 Respondents living in the Lowlands zone are in general better educated than respondents living in the other zones. Across districts, the proportion of women with at least some secondary education ranges from a low of 29 percent in Thaba-Tseka to a high of 61 percent in Berea. For men, the corresponding range, from low to high, is 21 percent in Thaba-Tseka to 50 percent in Maseru. As expected, the level of education increases with the wealth index. For example, only 18 percent of women in the lowest wealth quintile have at least some secondary education compared with 78 percent of women in the highest quintile. Table 3.2.1 Educational attainment by background characteristics: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Lesotho 2009 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Median years completed Number of women Age 15-24 0.5 20.1 18.9 48.8 8.4 3.3 100.0 7.5 3,337 .15-19 0.3 21.6 17.6 56.2 3.7 0.6 100.0 7.2 1,785 .20-24 0.7 18.5 20.4 40.4 13.7 6.3 100.0 8.0 1,552 25-29 1.6 22.2 23.2 34.4 11.8 6.9 100.0 7.2 1,244 30-34 1.4 23.2 26.6 30.2 9.1 9.4 100.0 6.9 983 35-39 1.5 22.7 30.7 31.8 5.5 7.8 100.0 6.8 763 40-44 1.1 31.9 25.2 30.9 4.5 6.4 100.0 6.6 656 45-49 3.6 39.4 25.1 20.0 3.8 8.1 100.0 6.3 641 Residence Urban 0.7 12.3 17.7 43.9 13.6 11.8 100.0 8.6 2,573 Rural 1.5 29.6 25.5 35.6 5.2 2.7 100.0 6.7 5,051 Ecological zone Lowlands 0.7 17.3 20.4 43.7 9.8 8.0 100.0 7.9 4,798 Foothills 0.9 31.2 28.6 34.1 3.5 1.7 100.0 6.6 725 Mountains 2.3 35.6 28.1 27.1 5.0 1.9 100.0 6.4 1,544 Senqu River Valley 3.0 36.9 21.6 29.5 6.5 2.4 100.0 6.4 556 District Butha-Buthe 1.2 21.6 22.4 37.5 12.1 5.1 100.0 7.4 357 Leribe 0.7 18.1 26.6 41.8 8.0 4.9 100.0 7.4 1,359 Berea 0.3 19.7 19.1 45.2 8.0 7.8 100.0 7.7 1,122 Maseru 1.2 18.3 20.3 41.8 9.8 8.7 100.0 7.8 2,036 Mafeteng 0.1 23.3 24.1 40.1 7.7 4.6 100.0 6.9 682 Mohale's Hoek 2.3 35.3 19.4 34.2 5.5 3.4 100.0 6.6 599 Quthing 4.0 36.6 21.5 28.2 6.8 2.8 100.0 6.4 379 Qacha’s Nek 2.2 30.6 20.1 33.3 9.0 4.9 100.0 6.8 219 Mokhotlong 2.4 34.4 30.3 27.3 4.3 1.3 100.0 6.4 356 Thaba-Tseka 1.8 38.1 30.8 22.1 4.6 2.5 100.0 6.3 515 Wealth quintile Lowest 3.1 50.6 27.8 17.4 0.9 0.1 100.0 5.8 1,073 Second 2.5 35.7 31.5 27.8 2.2 0.3 100.0 6.3 1,190 Middle 0.8 27.1 27.8 38.0 5.1 1.1 100.0 6.7 1,325 Fourth 0.9 16.2 21.8 48.7 9.3 3.1 100.0 7.7 1,900 Highest 0.1 8.2 13.4 46.0 15.5 16.9 100.0 9.2 2,136 Total 1.2 23.7 22.8 38.4 8.0 5.8 100.0 7.0 7,624 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level 30 | Characteristics of Survey Respondents Table 3.2.2 Educational attainment by background characteristics: Men Percent distribution of men age 15-9 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Lesotho 2009 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Median years completed Number of men Age 15-24 4.8 38.5 11.0 37.8 4.8 3.1 100.0 6.4 1,470 .15-19 2.4 42.6 9.9 42.3 1.6 1.1 100.0 6.3 835 .20-24 8.0 33.1 12.3 31.7 9.1 5.8 100.0 6.7 634 25-29 12.5 37.5 13.2 17.5 11.5 7.8 100.0 6.0 463 30-34 15.5 28.9 16.4 23.8 6.3 9.0 100.0 6.3 396 35-39 18.5 40.6 8.9 17.9 4.4 9.7 100.0 4.7 290 40-44 19.1 29.8 15.6 16.1 13.7 5.8 100.0 6.1 196 45-49 28.2 33.5 14.7 8.3 3.9 11.5 100.0 4.0 193 Residence Urban 3.8 16.1 10.7 40.3 13.2 15.9 100.0 8.7 845 Rural 14.0 44.4 13.0 22.6 3.9 2.1 100.0 5.2 2,162 Ecological zone Lowlands 4.8 31.1 13.2 33.9 8.2 8.8 100.0 6.9 1,850 Foothills 11.8 51.8 16.7 17.3 1.9 0.5 100.0 4.9 319 Mountains 27.6 42.9 8.7 14.9 4.4 1.5 100.0 3.4 621 Senqu River Valley 17.7 40.1 9.4 25.3 5.6 2.0 100.0 5.2 217 District Butha-Buthe 7.7 38.3 12.0 27.8 9.6 4.5 100.0 6.3 168 Leribe 6.6 34.0 15.9 32.1 6.2 5.1 100.0 6.5 498 Berea 3.9 37.2 13.1 29.6 8.5 7.7 100.0 6.5 451 Maseru 8.7 28.7 12.7 33.2 6.7 10.0 100.0 6.8 773 Mafeteng 8.0 42.8 12.3 24.9 6.6 5.3 100.0 5.9 295 Mohale's Hoek 19.1 45.2 11.4 18.2 3.4 2.7 100.0 4.6 250 Quthing 15.8 40.1 8.1 25.4 8.0 2.5 100.0 5.4 150 Qacha’s Nek 15.2 43.3 9.5 22.5 5.6 3.8 100.0 5.4 79 Mokhotlong 23.3 41.7 10.0 18.9 4.3 1.9 100.0 4.2 137 Thaba-Tseka 31.8 39.3 8.2 15.5 4.0 1.3 100.0 3.0 206 Wealth quintile Lowest 33.6 49.0 8.8 8.4 0.3 0.0 100.0 2.1 443 Second 15.3 55.1 13.0 14.7 1.7 0.2 100.0 4.5 575 Middle 8.1 44.3 16.1 25.9 4.3 1.3 100.0 5.8 666 Fourth 5.4 29.4 14.7 40.1 7.3 3.1 100.0 6.9 640 Highest 1.5 11.4 8.4 40.7 16.0 21.9 100.0 9.4 684 Total 15-49 11.2 36.4 12.4 27.6 6.5 6.0 100.0 6.2 3,008 50-59 30.3 41.3 9.3 10.1 3.3 5.6 100.0 3.0 309 Total men 15-59 12.9 36.9 12.1 26.0 6.2 5.9 100.0 6.0 3,317 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level The 2009 LDHS respondents who have not attended secondary or high school were asked to read a simple, short sentence to establish literacy. The sentences were written in Sesotho and English (for those who were interviewed in English). Tables 3.3.1 and 3.3.2 show that the literacy rate is higher for women (97 percent) than for men (81 percent). This pattern is not unexpected in view of the generally higher educational attainment of women than men in Lesotho. The literacy rate decreases with increasing age, particularly among men. Among women, there are relatively minor differences in literacy rates by residence, with urban women only slightly more likely to be able to read than rural women (99 and 96 percent, respectively). Among men, the residential differential is much more pronounced; 94 percent for urban men compared with 76 percent for rural men. Literacy rates rise with increasing wealth, with variations being more significant for men than for women. Among men, the literacy rate across districts ranges from a low of 59 percent in Thaba-Tseka to a high of 90 percent in Berea. Characteristics of Survey Respondents | 31 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Lesotho 2009 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Total Percentage literate1 Number Age 15-19 60.5 32.4 5.8 1.1 0.1 100.0 98.8 1,785 20-24 60.4 30.6 6.5 2.4 0.0 100.0 97.5 1,552 25-29 53.0 36.8 6.8 3.2 0.2 100.0 96.6 1,244 30-34 48.7 39.0 9.1 2.9 0.2 100.0 96.8 983 35-39 45.1 43.0 8.4 3.4 0.1 100.0 96.5 763 40-44 41.8 44.4 10.5 3.1 0.2 100.0 96.6 656 45-49 31.9 48.3 11.9 8.0 0.0 100.0 92.0 641 Residence Urban 69.3 24.6 4.8 1.1 0.1 100.0 98.8 2,573 Rural 43.5 43.4 9.2 3.8 0.1 100.0 96.0 5,051 Ecological zone Lowlands 61.6 31.0 5.8 1.6 0.0 100.0 98.4 4,798 Foothills 39.4 46.4 10.0 4.2 0.0 100.0 95.8 725 Mountains 34.0 49.6 11.0 5.1 0.3 100.0 94.5 1,544 Senqu River Valley 38.5 42.3 11.8 6.7 0.5 100.0 92.7 556 District Butha-Buthe 54.7 29.9 12.4 3.0 0.0 100.0 97.0 357 Leribe 54.7 35.0 8.4 1.9 0.0 100.0 98.1 1,359 Berea 61.0 32.1 5.3 1.6 0.0 100.0 98.4 1,122 Maseru 60.3 31.2 6.5 1.9 0.1 100.0 98.0 2,036 Mafeteng 52.4 43.3 2.6 1.7 0.0 100.0 98.3 682 Mohale's Hoek 43.1 42.2 9.4 5.3 0.0 100.0 94.7 599 Quthing 37.9 37.5 14.6 8.5 1.4 100.0 90.0 379 Qacha’s Nek 47.1 37.4 9.8 5.3 0.4 100.0 94.3 219 Mokhotlong 32.9 51.4 10.2 5.5 0.0 100.0 94.5 356 Thaba-Tseka 29.3 56.2 9.7 4.4 0.2 100.0 95.2 515 Wealth quintile Lowest 18.4 58.1 15.0 8.1 0.2 100.0 91.6 1,073 Second 30.3 51.5 12.3 5.7 0.2 100.0 94.1 1,190 Middle 44.2 45.0 7.9 2.8 0.0 100.0 97.2 1,325 Fourth 61.1 32.1 5.3 1.5 0.1 100.0 98.5 1,900 Highest 78.3 17.9 3.5 0.2 0.1 100.0 99.7 2,136 Total 52.2 37.0 7.7 2.9 0.1 100.0 96.9 7,624 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 32 | Characteristics of Survey Respondents Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Lesotho 2009 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Total Percentage literate1 Number Age 15-19 45.0 34.1 10.7 10.0 0.2 0.0 100.0 89.8 835 20-24 46.6 26.0 11.7 15.3 0.1 0.3 100.0 84.3 634 25-29 36.7 27.7 12.6 23.0 0.0 0.0 100.0 77.0 463 30-34 39.1 27.6 11.8 21.5 0.0 0.0 100.0 78.5 396 35-39 32.0 25.9 12.5 29.2 0.0 0.4 100.0 70.4 290 40-44 35.5 26.1 11.3 26.6 0.0 0.5 100.0 72.9 196 45-49 23.7 33.0 11.8 31.6 0.0 0.0 100.0 68.4 193 Residence Urban 69.4 19.8 4.6 6.2 0.0 0.0 100.0 93.8 845 Rural 28.6 32.8 14.4 23.9 0.1 0.2 100.0 75.8 2,162 Ecological zone Lowlands 50.9 28.8 9.3 10.9 0.0 0.1 100.0 89.0 1,850 Foothills 19.7 38.6 19.1 22.2 0.0 0.4 100.0 77.4 319 Mountains 20.8 26.0 14.2 38.7 0.4 0.0 100.0 61.0 621 Senqu River Valley 32.9 27.3 12.9 26.2 0.3 0.5 100.0 73.1 217 District Butha-Buthe 41.9 24.2 15.5 18.3 0.0 0.0 100.0 81.7 168 Leribe 43.4 25.7 14.7 15.8 0.0 0.3 100.0 83.8 498 Berea 45.8 35.1 9.0 10.1 0.0 0.0 100.0 89.9 451 Maseru 49.9 27.0 9.9 13.2 0.0 0.0 100.0 86.8 773 Mafeteng 36.9 36.1 10.1 16.5 0.0 0.4 100.0 83.1 295 Mohale's Hoek 24.3 32.6 10.6 32.5 0.0 0.0 100.0 67.5 250 Quthing 35.9 20.5 17.2 23.8 1.9 0.7 100.0 73.7 150 Qacha’s Nek 32.0 38.0 12.0 18.0 0.0 0.0 100.0 82.0 79 Mokhotlong 25.1 27.1 13.4 34.4 0.0 0.0 100.0 65.6 137 Thaba-Tseka 20.8 26.6 11.3 41.3 0.0 0.0 100.0 58.7 206 Wealth quintile Lowest 8.6 29.6 12.9 48.6 0.0 0.3 100.0 51.1 443 Second 16.6 36.4 19.2 27.6 0.1 0.0 100.0 72.3 575 Middle 31.5 37.6 13.8 16.8 0.2 0.1 100.0 82.8 666 Fourth 50.6 28.9 10.4 9.7 0.1 0.3 100.0 89.9 640 Highest 78.6 14.8 3.6 3.1 0.0 0.0 100.0 96.9 684 Total 15-49 40.1 29.2 11.6 18.9 0.1 0.1 100.0 80.9 3,008 50-59 19.1 39.9 10.3 28.7 0.0 2.0 100.0 69.2 309 Total men 15-59 38.1 30.2 11.5 19.8 0.1 0.3 100.0 79.8 3,317 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 3.3 ACCESS TO MASS MEDIA Mass media access is essential for increasing people’s knowledge and awareness of what takes place around them, which in turn affects their perceptions and behaviour. Exposure to media was assessed by asking survey respondents how often they read newspapers, watched television, or listened to a radio. The answers helped to identify population groups accessible by mass media. Development programs will be able to spread information more efficiently as they work to improve health, alleviate poverty, and slow or eliminate the spread of HIV/AIDS. Characteristics of Survey Respondents | 33 Tables 3.4.1 and 3.4.2 show that radio has the widest audience, with 66 percent of women and 62 percent of men listening to the radio at least once a week (also see Figure 3.1). Twenty-five percent of women and 27 percent of men watch television at least once a week, and 18-19 percent of women and men read a newspaper or a magazine weekly. Twenty-nine percent of women and 33 percent of men are not exposed to any of these media sources weekly. In contrast, 9 percent of women and 11 percent of men were exposed to all types of media on a regular basis. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Lesotho 2009 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week All three media at least once a week No media at least once a week Number Age 15-19 20.1 24.3 61.2 8.2 31.5 1,785 20-24 19.8 24.0 65.6 8.8 28.6 1,552 25-29 17.8 26.0 70.1 8.2 25.4 1,244 30-34 17.6 26.6 65.1 8.2 28.0 983 35-39 17.1 28.3 69.9 10.6 25.9 763 40-44 14.2 24.7 67.0 7.3 28.4 656 45-49 14.9 22.1 63.7 8.6 32.6 641 Residence Urban 30.3 49.7 78.2 18.8 13.2 2,573 Rural 11.9 12.6 59.2 3.3 36.7 5,051 Ecological zone Lowlands 23.9 34.7 73.1 12.3 20.0 4,798 Foothills 9.0 9.8 57.5 2.1 38.9 725 Mountains 7.4 7.3 50.6 1.8 46.6 1,544 Senqu River Valley 9.9 11.4 53.6 2.6 41.5 556 District Butha-Buthe 15.2 13.7 58.1 3.6 36.2 357 Leribe 22.0 26.9 70.2 12.2 26.6 1,359 Berea 22.5 37.4 72.8 11.6 19.1 1,122 Maseru 24.2 34.5 70.9 11.7 21.6 2,036 Mafeteng 13.9 18.3 65.9 5.4 28.1 682 Mohale's Hoek 9.7 19.0 58.8 5.0 35.9 599 Quthing 11.9 11.6 49.8 3.0 45.0 379 Qacha’s Nek 12.2 13.2 43.8 3.9 50.8 219 Mokhotlong 7.2 7.6 54.2 1.9 42.6 356 Thaba-Tseka 6.1 6.9 58.4 1.6 40.0 515 Education No education 0.0 4.7 45.0 0.0 54.0 93 Primary incomplete 4.8 9.0 50.8 1.1 46.3 1,810 Primary complete 8.0 15.4 61.9 2.6 34.2 1,741 Secondary+ 29.0 37.1 74.5 14.7 17.8 3,979 Wealth quintile Lowest 3.8 1.8 35.0 0.2 62.8 1,073 Second 6.8 4.6 49.7 1.3 47.5 1,190 Middle 10.3 7.1 62.9 1.7 33.9 1,325 Fourth 19.3 16.8 73.1 4.2 21.2 1,900 Highest 35.2 66.7 85.0 24.8 4.7 2,136 Total 18.1 25.1 65.6 8.5 28.7 7,624 34 | Characteristics of Survey Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Lesotho 2009 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week All three media at least once a week No media at least once a week Number Age 15-19 18.1 27.6 57.0 9.8 36.5 835 20-24 19.0 25.0 54.9 10.2 39.0 634 25-29 18.5 28.0 62.2 11.0 32.3 463 30-34 19.4 31.8 70.7 12.8 25.1 396 35-39 22.3 31.8 70.7 15.1 24.7 290 40-44 20.6 30.4 67.6 11.9 26.3 196 45-49 18.2 24.4 60.3 12.5 37.0 193 Residence Urban 38.7 60.3 79.3 28.0 11.3 845 Rural 11.4 15.4 54.4 4.7 41.6 2,162 Ecological zone Lowlands 25.5 36.5 67.9 16.1 25.8 1,850 Foothills 7.7 17.6 46.8 3.2 49.1 319 Mountains 8.3 11.4 50.7 2.9 45.3 621 Senqu River Valley 11.8 18.6 57.9 6.3 37.0 217 District Butha-Buthe 16.3 17.4 51.2 7.5 42.0 168 Leribe 22.3 30.0 64.0 13.1 31.8 498 Berea 21.3 35.6 68.1 15.2 27.3 451 Maseru 26.9 41.8 69.1 17.1 24.5 773 Mafeteng 15.6 14.5 48.8 6.4 44.4 295 Mohale's Hoek 10.8 19.5 55.9 6.0 38.9 250 Quthing 12.3 18.1 51.7 6.3 43.7 150 Qacha’s Nek 16.8 18.1 48.3 6.1 43.0 79 Mokhotlong 8.7 13.1 62.4 4.3 34.7 137 Thaba-Tseka 7.3 14.6 55.9 3.4 38.3 206 Education No education 1.5 6.6 44.0 0.5 54.3 336 Primary incomplete 4.6 13.2 51.6 1.4 45.5 1,095 Primary complete 10.8 26.9 61.3 7.1 34.3 372 Secondary+ 39.7 47.8 75.1 24.5 15.5 1,205 Wealth quintile Lowest 4.6 5.4 39.0 0.9 57.8 443 Second 6.0 9.2 50.9 2.1 46.7 575 Middle 8.2 11.7 54.6 2.4 42.0 666 Fourth 20.1 30.7 71.6 10.4 24.5 640 Highest 49.1 71.8 81.7 35.2 5.2 684 Total 15-49 19.1 28.0 61.4 11.3 33.1 3,008 50-59 13.7 19.5 62.4 7.8 34.7 309 Total men 15-59 18.6 27.2 61.5 11.0 33.3 3,317 Characteristics of Survey Respondents | 35 There are relatively large differentials by residence in the proportions of respondents with access to media. For example, 19 percent of urban women are exposed to all forms of media once a week compared with only 3 percent of rural women. Among female respondents from the various ecological zones, the residents from the Lowlands zone are the most exposed to the three media sources, and those from the Mountains and Foothills zones are the least exposed (12 and 2 percent, respectively). Across districts, the Leribe, Berea, and Maseru districts have the highest proportion of respondents who are exposed to all three media, while Thaba-Tseka district has the lowest proportion. The proportion of respondents with access to the media increases with increasing education level and wealth status. 3.4 EMPLOYMENT 3.4.1 Employment Status The 2009 LDHS respondents were asked whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. Tables 3.5.1 and 3.5.2 show that 39 percent of women and 63 percent of men age 15-59 are currently employed. Eight percent of women and 7 percent of men were not working at the time of the survey but had been employed at some point in the 12 months preceding the survey. Up to age 35-39, the proportion of women currently employed increases with age. For men, the proportion increases up to age 40-44 before declining somewhat at age 45-49. Women who have never married are the least likely to be employed (27 percent). On the other hand, divorced, separated, or widowed women are the most likely to be employed (60 percent). In contrast, married men are somewhat more likely to be employed than divorced, separated, or widowed men. The employment rate among women and men who have no children is lower than among those who have children. Urban residents are more likely to be currently employed than rural residents. The percentage of women and men who are currently employed is highest in Thaba-Tseka (47 and 80 percent, respectively). In contrast, the lowest employment rate for women is 22 percent in Qacha’s Nek and for men is 52 percent in Quthing. 18 25 66 9 19 28 61 11 Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week All three media at least once a week 0 20 40 60 80 Percent Women 15-49 Men 15-49 Figure 3.1 Access to Mass Media LDHS 2009 36 | Characteristics of Survey Respondents Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Lesotho 2009 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Total Number of women Age 15-19 13.6 4.9 81.5 100.0 1,785 20-24 32.0 9.0 59.0 100.0 1,552 25-29 48.5 10.1 41.4 100.0 1,244 30-34 51.9 7.7 40.4 100.0 983 35-39 55.8 6.0 38.2 100.0 763 40-44 50.8 8.2 40.9 100.0 656 45-49 55.5 7.7 36.8 100.0 641 Marital status Never married 26.9 6.8 66.2 100.0 2,618 Married or living together 41.8 7.9 50.3 100.0 4,049 Divorced/separated/widowed 59.5 8.5 32.0 100.0 957 Number of living children 0 26.0 6.5 67.5 100.0 2,627 1-2 45.3 8.4 46.3 100.0 3,063 3-4 46.9 7.5 45.5 100.0 1,347 5+ 45.3 8.2 46.5 100.0 587 Residence Urban 53.2 6.6 40.3 100.0 2,573 Rural 31.7 8.1 60.2 100.0 5,051 Ecological zone Lowlands 41.5 7.5 51.0 100.0 4,798 Foothills 27.4 6.8 65.8 100.0 725 Mountains 39.8 8.1 52.1 100.0 1,544 Senqu River Valley 29.9 8.1 62.1 100.0 556 District Butha-Buthe 35.7 10.5 53.7 100.0 357 Leribe 37.9 6.3 55.8 100.0 1,359 Berea 38.9 4.7 56.3 100.0 1,122 Maseru 45.5 7.6 46.9 100.0 2,036 Mafeteng 28.5 8.6 62.9 100.0 682 Mohale's Hoek 37.2 10.5 52.2 100.0 599 Quthing 26.1 5.2 68.7 100.0 379 Qacha’s Nek 22.2 6.9 71.0 100.0 219 Mokhotlong 44.1 10.4 45.5 100.0 356 Thaba-Tseka 46.7 10.2 43.1 100.0 515 Education No education 31.5 10.4 58.1 100.0 93 Primary incomplete 36.7 8.4 54.9 100.0 1,810 Primary complete 39.9 8.4 51.7 100.0 1,741 Secondary+ 39.7 6.8 53.5 100.0 3,979 Wealth quintile Lowest 35.1 8.4 56.5 100.0 1,073 Second 29.8 9.8 60.3 100.0 1,190 Middle 26.6 8.7 64.6 100.0 1,325 Fourth 41.3 7.6 51.1 100.0 1,900 Highest 51.5 5.2 43.3 100.0 2,136 Total 38.9 7.6 53.5 100.0 7,624 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. The proportion of men currently employed is highest among men with no education (78 percent). For women, the employment rate is highest among those who have completed primary school or attended secondary school or higher (40 percent). The proportion of women and men currently employed is lowest for those in the middle wealth quintile. Characteristics of Survey Respondents | 37 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Lesotho 2009 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Total Number of men Age 15-19 38.1 5.3 56.5 100.0 835 20-24 59.4 8.6 32.0 100.0 634 25-29 72.3 7.8 19.9 100.0 463 30-34 76.8 9.5 13.7 100.0 396 35-39 80.1 7.2 12.7 100.0 290 40-44 79.6 9.1 11.3 100.0 196 45-49 74.6 4.9 20.2 100.0 193 Marital status Never married 50.1 7.1 42.8 100.0 1,691 Married or living together 77.7 7.5 14.7 100.0 1,169 Divorced/separated/widowed 75.4 9.0 15.6 100.0 148 Number of living children 0 52.5 7.3 40.2 100.0 1,864 1-2 78.5 7.3 14.2 100.0 737 3-4 74.8 9.1 15.8 100.0 297 5+ 79.3 4.2 16.5 100.0 110 Residence Urban 64.2 7.1 28.6 100.0 845 Rural 61.2 7.4 31.3 100.0 2,162 Ecological zone Lowlands 58.6 8.2 33.2 100.0 1,850 Foothills 63.5 7.7 28.8 100.0 319 Mountains 72.9 4.1 23.0 100.0 621 Senqu River Valley 58.8 8.5 32.7 100.0 217 District Butha-Buthe 66.0 4.3 29.7 100.0 168 Leribe 54.1 8.3 37.6 100.0 498 Berea 56.2 7.8 36.0 100.0 451 Maseru 63.6 8.2 28.3 100.0 773 Mafeteng 60.2 6.7 32.8 100.0 295 Mohale's Hoek 70.8 10.7 18.4 100.0 250 Quthing 52.0 8.5 39.5 100.0 150 Qacha’s Nek 53.1 4.7 42.2 100.0 79 Mokhotlong 75.1 2.2 22.7 100.0 137 Thaba-Tseka 79.6 3.8 16.6 100.0 206 Education No education 78.0 7.3 14.7 100.0 336 Primary incomplete 63.9 5.5 30.6 100.0 1,095 Primary complete 64.0 10.7 25.4 100.0 372 Secondary+ 55.4 7.9 36.6 100.0 1,205 Wealth quintile Lowest 69.4 5.8 24.8 100.0 443 Second 62.5 9.0 28.4 100.0 575 Middle 58.0 7.6 34.4 100.0 666 Fourth 58.4 8.4 33.2 100.0 640 Highest 64.3 5.7 29.9 100.0 684 Total 15-49 62.1 7.3 30.6 100.0 3,008 50-59 73.7 5.5 20.8 100.0 309 Total men 15-59 63.2 7.2 29.6 100.0 3,317 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 38 | Characteristics of Survey Respondents 3.4.2 Occupation The occupations of women and men employed in the 12 months preceding the survey are shown in Tables 3.6.1 and 3.6.2. One in five women and half of all men are engaged in agricultural occupations. For women, the other common occupation is sales and service (21 percent). About 12 percent of women are engaged in each of three occupations: skilled manual labour, unskilled manual labour, and domestic service. Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Lesotho 2009 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of women Age 15-19 2.2 7.9 12.9 2.1 8.2 21.9 36.1 8.8 100.0 330 20-24 7.7 9.6 20.2 12.4 12.3 13.4 21.9 2.5 100.0 637 25-29 7.3 10.2 19.8 17.3 15.3 10.9 15.9 3.3 100.0 729 30-34 11.9 7.5 23.2 12.0 16.1 9.0 17.8 2.5 100.0 586 35-39 13.4 4.7 21.2 16.9 13.9 9.2 18.2 2.5 100.0 472 40-44 14.1 5.8 28.0 10.7 6.3 12.2 20.7 2.1 100.0 387 45-49 17.0 5.5 24.4 10.4 5.3 8.8 27.0 1.5 100.0 405 Marital status Never married 8.9 11.3 20.7 9.5 13.5 16.3 15.3 4.5 100.0 884 Married or living together 11.3 6.3 20.4 13.4 12.0 8.0 26.1 2.5 100.0 2,011 Divorced/separated/widowed 9.3 7.2 25.3 14.2 9.5 17.0 14.5 3.1 100.0 651 Number of living children 0 8.6 12.1 18.8 9.6 9.9 16.9 18.6 5.5 100.0 853 1-2 10.9 7.7 21.8 16.2 14.2 10.2 16.7 2.3 100.0 1,646 3-4 12.2 5.1 22.7 12.0 11.3 11.1 23.4 2.2 100.0 733 5+ 7.7 1.6 23.1 2.8 6.7 7.6 47.6 2.9 100.0 314 Residence Urban 12.5 9.7 25.9 18.7 15.0 11.7 2.8 3.7 100.0 1,537 Rural 8.6 6.1 17.9 7.9 9.5 11.8 35.4 2.7 100.0 2,010 Ecological zone Lowlands 11.4 9.0 23.3 16.7 15.2 13.8 7.3 3.4 100.0 2,348 Foothills 8.3 6.1 18.5 6.0 8.0 10.3 40.1 2.7 100.0 247 Mountains 8.2 4.4 16.6 3.8 4.6 6.2 53.5 2.7 100.0 739 Senqu River Valley 8.7 6.6 20.5 4.6 5.3 10.1 42.5 1.6 100.0 211 District Butha-Buthe 17.3 13.6 26.3 6.4 5.6 12.9 14.0 4.1 100.0 165 Leribe 9.9 8.5 15.7 20.5 16.0 8.6 15.5 5.3 100.0 601 Berea 15.1 11.2 27.2 11.0 9.8 15.3 9.5 0.9 100.0 490 Maseru 8.9 7.5 24.0 17.3 17.1 12.7 8.7 3.7 100.0 1,082 Mafeteng 11.7 6.8 22.9 10.3 14.6 19.7 12.0 1.9 100.0 253 Mohale's Hoek 6.7 3.8 22.4 5.8 5.9 11.5 43.8 0.0 100.0 286 Quthing 10.2 7.2 25.8 8.6 6.4 11.2 28.0 2.6 100.0 119 Qacha’s Nek 13.7 7.4 28.9 5.9 8.4 10.2 23.5 2.0 100.0 64 Mokhotlong 7.6 3.9 11.4 3.1 3.5 6.3 58.6 5.6 100.0 194 Thaba-Tseka 7.9 4.4 12.1 2.9 3.6 5.5 61.4 2.1 100.0 293 Education No education 0.0 0.0 20.5 13.0 1.7 11.8 50.8 2.2 100.0 39 Primary incomplete 2.3 1.2 20.7 8.3 11.4 15.6 36.9 3.6 100.0 817 Primary complete 2.6 4.8 16.6 15.2 13.7 17.7 26.1 3.3 100.0 841 Secondary+ 17.6 12.0 23.9 13.3 11.5 7.3 11.6 2.8 100.0 1,849 Wealth quintile Lowest 2.6 1.1 13.7 1.9 5.4 9.3 63.2 2.8 100.0 467 Second 5.3 3.0 17.6 4.8 10.8 14.4 42.0 2.1 100.0 471 Middle 6.1 5.8 21.1 7.9 12.9 14.8 26.7 4.6 100.0 469 Fourth 6.7 9.0 22.7 20.5 18.8 8.6 10.7 2.9 100.0 929 Highest 19.7 11.7 25.0 15.4 9.2 12.8 3.1 3.1 100.0 1,211 Total 10.3 7.7 21.4 12.6 11.9 11.7 21.3 3.1 100.0 3,546 Characteristics of Survey Respondents | 39 Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Lesotho 2009 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of men Age 15-19 0.5 1.9 6.3 6.8 5.2 0.6 75.6 3.1 100.0 363 20-24 4.2 2.3 10.3 16.3 8.5 0.2 57.7 0.5 100.0 431 25-29 4.2 3.9 12.9 20.4 6.6 0.9 49.6 1.4 100.0 371 30-34 9.5 3.1 18.5 20.3 13.6 0.9 32.3 1.8 100.0 341 35-39 8.5 1.7 12.6 22.8 16.8 0.3 36.4 1.1 100.0 253 40-44 7.9 3.5 12.2 20.3 10.4 0.0 40.4 5.4 100.0 174 45-49 16.3 1.5 9.0 20.5 9.8 0.0 43.0 0.0 100.0 153 Marital status Never married 3.5 2.9 8.3 14.0 6.8 0.3 62.6 1.7 100.0 967 Married or living together 9.2 2.4 15.7 19.8 12.7 0.7 37.5 1.9 100.0 996 Divorced/separated/widowed 2.4 2.1 6.5 25.6 8.0 0.6 53.9 0.9 100.0 125 Number of living children 0 4.2 2.7 9.1 14.4 7.5 0.4 59.4 2.4 100.0 1,115 1-2 9.3 2.4 17.3 21.2 12.7 0.8 36.0 0.4 100.0 632 3-4 7.8 2.6 12.1 21.6 11.7 0.0 42.5 1.8 100.0 249 5+ 3.5 3.5 4.2 17.8 11.0 0.8 55.4 4.0 100.0 92 Residence Urban 14.5 4.4 23.6 25.2 15.1 0.7 12.3 4.1 100.0 603 Rural 2.8 1.9 6.9 14.3 7.5 0.4 65.4 0.8 100.0 1,485 Ecological zone Lowlands 8.2 3.6 16.5 21.9 12.4 0.5 34.1 2.7 100.0 1,236 Foothills 1.7 1.2 4.9 11.0 7.5 0.0 73.6 0.0 100.0 227 Mountains 3.0 1.1 4.6 10.6 4.2 0.2 75.5 0.8 100.0 478 Senqu River Valley 5.5 1.2 5.3 12.0 8.5 1.8 65.5 0.3 100.0 146 District Butha-Buthe 4.8 3.8 12.3 16.1 10.0 0.6 51.7 0.8 100.0 118 Leribe 6.6 3.6 12.9 17.8 12.5 1.0 43.5 2.0 100.0 311 Berea 12.3 3.5 15.5 17.5 11.5 0.0 37.9 1.8 100.0 288 Maseru 6.3 2.9 17.0 23.3 11.1 0.5 35.5 3.3 100.0 555 Mafeteng 1.8 2.8 9.1 14.3 7.0 0.0 64.0 1.0 100.0 197 Mohale's Hoek 3.9 2.1 4.4 14.0 8.4 0.4 66.6 0.0 100.0 204 Quthing 6.6 1.1 9.5 14.7 8.7 1.8 57.6 0.0 100.0 91 Qacha’s Nek 9.7 1.7 8.8 25.8 12.6 0.0 39.7 1.7 100.0 46 Mokhotlong 4.1 0.3 4.9 12.1 4.2 0.0 72.0 2.5 100.0 106 Thaba-Tseka 3.0 0.4 3.9 8.8 4.7 0.4 78.3 0.4 100.0 172 Education No education 0.6 1.7 6.3 9.6 4.2 0.0 77.3 0.3 100.0 286 Primary incomplete 1.8 0.6 6.4 16.6 7.7 0.1 66.4 0.3 100.0 760 Primary complete 2.6 1.3 14.7 20.4 13.2 0.8 43.8 3.1 100.0 278 Secondary+ 13.9 5.4 18.0 20.2 12.4 0.9 25.9 3.3 100.0 763 Wealth quintile Lowest 0.5 0.5 3.0 10.3 3.4 0.2 81.7 0.4 100.0 333 Second 1.6 0.9 5.4 14.6 8.1 0.0 69.3 0.1 100.0 411 Middle 2.6 1.1 7.3 15.9 8.8 0.8 62.5 1.0 100.0 437 Fourth 4.3 4.9 19.5 21.6 12.4 0.8 35.3 1.1 100.0 427 Highest 18.8 4.9 20.5 22.6 13.9 0.4 13.4 5.4 100.0 479 Total 15-49 6.1 2.6 11.8 17.4 9.7 0.5 50.1 1.8 100.0 2,088 50-59 7.2 2.8 9.7 23.2 6.7 2.4 47.6 0.4 100.0 245 Total men 15-59 6.3 2.6 11.5 18.0 9.4 0.7 49.8 1.6 100.0 2,333 The respondents’ occupation varies according to their age, residence and socioeconomic status. As expected, rural women (35 percent) and men (65 percent) are employed in agriculture, while urban women and men are most often found working in non-agricultural jobs such as sales and services (26 percent for women and 24 percent for men). 40 | Characteristics of Survey Respondents 3.4.3 Type of Employer, Form of Earnings, and Continuity of Employment Table 3.7.1 shows that 70 percent of employed women receive cash payment for their work, small percentages receive payment in kind, and almost one in four work without pay. Women are most likely to be paid in kind or not paid at all if they are employed in agricultural activities. For example, 14 percent of women who work in agriculture were paid in cash compared with 86 percent of women who work in the non-agricultural sector. Fifty-seven percent of women are employed by a non-family member, 28 percent are self- employed, and 16 percent are employed by a family member. Women are less likely to be employed by a non-family member if they are doing agricultural work than if they are engaged in non-agricultural work (20 percent compared with 67 percent). Women also more often work seasonally if they are employed in agricultural activities (77 percent) than if they work in non-agricultural occupations (12 percent). Conversely, women who engage in non-agricultural work are more likely to work all year than are women who work in the agricultural sector (74 percent and 10 percent, respectively). Table 3.7.1 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Lesotho 2009 Employment characteristic Agricultural work Non-agricultural work Total Type of earnings Cash only 13.5 86.0 69.8 Cash and in-kind 3.7 2.1 2.4 In-kind only 11.7 1.3 3.5 Not paid 71.0 10.6 24.2 Total 100.0 100.0 100.0 Type of employer Employed by family member 43.8 7.6 15.5 Employed by non-family member 20.1 66.9 56.7 Self-employed 36.2 25.5 27.8 Total 100.0 100.0 100.0 Continuity of employment All year 10.0 73.5 60.2 Seasonal 77.4 11.5 25.5 Occasional 12.6 15.0 14.3 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 755 2,682 3,546 Note: Total includes women with information missing on type of employment who are not shown separately. Table 3.7.2 shows that, overall, men are less likely than women to be paid for their work; 39 percent of employed men work without pay and about half (51 percent) receive cash payment for their work. These proportions change when the type of employment is considered. Men who are employed in non-agricultural activities are more likely than those who work in agriculture to be paid in cash. For example, 18 percent of men who work in agriculture are paid in cash compared with 86 percent of men who work in non-agriculture sector. Two in three men who work in agriculture are not paid, compared with 11 percent of men who are employed in non-agricultural activities. Characteristics of Survey Respondents | 41 Forty-seven percent of men are employed by a non-family member, 29 percent are employed by a family member, and 24 percent are self-employed. Men are much more likely to be employed by a non- family member if they are doing non-agricultural work than if they are engaged in agricultural work (67 percent compared with 27 percent). Less than half of men work all year. Men less often work all year if they are employed in agricultural activities (34 percent) than if they are in non-agricultural occupations (64 percent). Likewise, men who are engaged in non-agricultural work are less likely to work seasonally than men who work in the agricultural sector (14 percent and 56 percent, respectively). Table 3.7.2 Type of employment: Men Percent distribution of men age 15-59 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Lesotho 2009-10 Employment characteristic Agricultural work Non-agricultural work Total Type of earnings Cash only 17.7 85.5 51.4 Cash and in-kind 3.0 2.3 2.6 In-kind only 13.0 0.8 6.9 Not paid 66.3 11.4 39.2 Total 100.0 100.0 100.0 Type of employer Employed by family member 50.2 8.2 29.0 Employed by non-family member 26.7 67.2 46.6 Self-employed 23.2 24.5 24.3 Total 100.0 100.0 100.0 Continuity of employment All year 34.2 63.5 49.0 Seasonal 56.3 14.0 35.0 Occasional 9.5 22.4 16.0 Total 100.0 100.0 100.0 Number of men employed during the past 12 months 1,163 1,132 2,333 Note: Total includes men with information missing on type of employment who are not shown separately. Fertility Levels, Trends, and Differentials | 43 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 4.1 INTRODUCTION The 2009 Lesotho Demographic and Health Survey (LDHS) collected information on current, past, and cumulative fertility. This chapter presents the results of the survey on levels, trends, and differentials in fertility based on the analysis of the birth histories collected from women age 15-49. Women were first asked a series of questions to determine the total number of live births that occurred in their lifetime. For each live birth, information was collected on the age, sex, and survival status of the child. For dead children, age at death was recorded. Information from the birth history was used to estimate current fertility (age-specific and total fertility) and completed fertility (number of children ever born alive to the woman), as well as to look at other fertility-related factors, such as age at first birth, birth intervals, and teenage childbearing. The accuracy of fertility estimates is affected by the quality of reporting of births, the total number of births, and the dates of each birth. Underreporting of the number of births affects the estimates of fertility levels, while misreporting of the dates of births can distort estimates of fertility trends. If these errors vary by socioeconomic characteristics of the women, the differentials in fertility will also be affected. 4.2 CURRENT FERTILITY The level of current fertility is one of the most important topics in this report because of its direct relevance to population policies and programs. Current fertility can be measured using the age-specific fertility rate (ASFR), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). The ASFR provides the age pattern of fertility, while the TFR refers to the number of live births that a woman would have had if she were subject to the current ASFRs throughout the reproductive ages (15-49 years). The GFR is expressed as the number of live births per 1,000 women of reproductive age, and the CBR is defined as the number of live births per 1,000 population. The measures of fertility presented in this chapter refer to the period three years prior to the survey, corresponding approximately to the period from late 2007 to late 2009. Current estimates of fertility levels are presented in Table 4.1 by urban-rural residence. Table 4.1 shows that, on average, a woman in Lesotho has 3.3 children. Rural women have almost twice as many children as urban women (4.0 children and 2.1 children per woman, respectively), which is reflected in each ASFR. Fertility declines with age more rapidly among urban women than among rural women, with the greatest absolute urban-rural difference in ASFR (80 births per 1,000 women) occurring among women age 20-24 (Figure 4.1). 44 | Fertility Levels, Trends, and Differentials Table 4.1 Current fertility Age-specific fertility rate, total fertility rate, general fertility rate, and crude birth rate for the three years preceding the survey, by residence, Lesotho 2009 Residence Age group Urban Rural Total 15-19 64 110 96 20-24 120 200 171 25-29 108 186 155 30-34 73 146 117 35-39 31 97 74 40-44 20 49 40 45-49 3 8 7 TFR 15-49 2.1 4.0 3.3 GFR 80 139 119 CBR 24.5 27.1 26.4 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population # # # # # # # ( ( ( ( ( ( ( ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 250 Births per 1,000 women Urban Rural Total) ( # LDHS 2009 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence Fertility Levels, Trends, and Differentials | 45 4.3 FERTILITY DIFFERENTIALS BY BACKGROUND CHARACTERISTICS Fertility is known to vary by a woman’s resi- dence, educational background, and other character- istics. Table 4.2 indicates that there are large varia- tions in the TFR by residence, education, and wealth quintile. Women in the Lowlands zone and in the Maseru district have on average the fewest children in the country, while women in the Mountains zone and in the Thaba-Tseka district have the most chil- dren. Fertility is inversely associated with the woman’s education and wealth quintile: fertility de- creases as they increase. For example, the TFR for women in the lowest (poorest) quintile is 5.9 children per woman compared with 2.0 children for women in the highest quintile. The percentage of women who are pregnant provides a useful additional measure of current fer- tility, although it may be an underestimate because many women may not recognise in themselves the earliest signs of pregnancy. Table 4.2 shows that 4 percent of women said that they were pregnant at the time of the survey. This proportion was higher in rural areas (5 percent) than in urban areas (3 per- cent). The proportion pregnant by wealth quintile does not show a clear pattern. However, women in the second quintile are more than twice as likely to be pregnant as women in the highest quintile. The last column in Table 4.2 presents a crude assessment of trends in fertility by comparing current fertility with a measure of completed fertility: the mean number of children ever born to women age 40-49. The mean number of children ever born to older women who are nearing the end of their reproductive years is an indicator of average com- pleted fertility among women who began childbearing during the three decades preceding the survey. If fertility remained constant over time, and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born for women age 40-49 are expected to be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born. The 2009 LDHS data show that the mean number of children ever born for women age 40-49 is much higher than the TFR for the three years preceding the survey (4.1 compared with 3.3 children per woman), indicating a recent substantial reduction in fertility. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Lesotho 2009 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 2.1 3.2 3.2 Rural 4.0 4.7 4.5 Ecological zone Lowlands 2.7 4.0 3.6 Foothills 4.0 4.3 4.3 Mountains 4.7 5.0 5.1 Senqu River Valley 3.9 3.5 4.5 District Butha-Buthe 3.6 3.7 4.0 Leribe 3.1 4.8 4.2 Berea 3.0 3.9 3.6 Maseru 2.7 4.0 3.6 Mafeteng 3.4 4.0 3.7 Mohale's Hoek 3.9 2.0 4.2 Quthing 3.8 3.7 4.5 Qacha’s Nek 3.5 5.0 4.4 Mokhotlong 4.4 7.0 5.1 Thaba-Tseka 4.9 5.5 5.7 Education No education * 4.1 4.5 Primary incomplete 4.5 4.0 4.8 Primary complete 3.9 4.7 4.4 Secondary+ 2.5 4.1 3.1 Wealth quintile Lowest 5.9 5.4 5.5 Second 4.3 5.7 4.8 Middle 3.8 4.2 4.5 Fourth 2.5 4.5 3.7 Highest 2.0 2.6 3.0 Total 3.3 4.2 4.1 Note: Total fertility rates are for the period 1-36 months prior to interview. An asterisk indicates that an estimate is based on fewer than 125 person-years exposure. 46 | Fertility Levels, Trends, and Differentials 4.4 FERTILITY TRENDS Table 4.3 uses information from the retrospective birth histories obtained from 2009 LDHS respondents to examine trends in age-specific fertility rates for successive five-year periods before the survey. To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of birth. Because birth histories were not collected for women over age 50, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years or more prior to the survey, because women in that age group would have been age 50 or older at the time of the survey. The results in Table 4.3 confirm that fertility has fallen substantially among all age groups, except among women age 15-19. The most rapid decline is shown by women in their early 30s. Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates (per 1,000 women) and total fertility rates, Lesotho 1976-2009 Mother's age at birth 1976 Census 1986 Census 1996 Census 2001 LDS 2004 LDHS 2006 Census 2009 LDHS 15-19 65 70 37 81 91 112 96 20-24 239 246 145 196 177 171 171 25-29 259 256 153 204 160 148 155 30-34 222 223 131 122 122 121 117 35-39 165 178 106 148 101 90 74 40-44 96 95 66 60 46 47 40 45-49 39 30 27 28 9 7 TFR 5.4 5.3 4.1 4.2 3.5 3.4 3.3 Note: Estimates based on the 1976, 1986, 1996, and 2006 censuses are for five-year periods preceding the census. Sources: BOS 1976, BOS 1986, BOS 1996, BOS 2001, MOHSW, BOS, and ORC Macro, 2005, BOS 2008, MOHSW and ICF Macro, 2010 2.1 4.0 2.7 4.0 4.7 3.9 3.6 3.1 3.0 2.7 3.4 3.9 3.8 3.5 4.4 4.9 4.5 3.9 2.5 RESIDENCE Urban Rural ECOLOGICAL ZONE Lowlands Foothills Mountains Senqu River Valley DISTRICT Butha-Buthe Leribe Berea Maseru Mafeteng Mohale's Hoek Quthing Qacha's Nek Mokhotlong Thaba-Tseka EDUCATION Primary incomplete Primary complete Secondary+ 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Total fertility rate LDHS 2009 Figure 4.2 Total Fertility Rates by Background Characteristics Fertility Levels, Trends, and Differentials | 47 Another way to examine fertility trends is to compare current estimates with earlier data sources. Table 4.4 and Figure 4.3 show the ASFRs for the 1976, 1986, 1996, and 2006 censuses, the 2001 LDS, and the 2004 and 2009 LDHS surveys. Data indicate that the TFR in Lesotho has declined significantly since 1976, from 5.4 children per woman in the mid-1970s to 3.3 children in 2007-2009. Table 4.4 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Lesotho 2009 Mother's age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 92 76 83 85 20-24 175 169 206 211 25-29 147 155 177 202 30-34 117 131 150 (157) 35-39 81 102 (110) - 40-44 42 (52) - - 45-49 (6) - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 4.5 CHILDREN EVER BORN AND LIVING Table 4.5 presents the distribution of all women and currently married women by number of children ever born, according to five-year age groups. The table also shows the mean number of children ever born. Data on the number of children ever born reflect the accumulation of births to women over the course of their reproductive years and therefore have limited reference to current fertility levels, particularly when a country has experienced a decline in fertility. However, the information on children ever born is useful for observing how average family size varies across age groups and also for observing the level of primary infertility. 5.4 5.3 4.1 4.2 3.5 3.4 3.3 1976 Census 1986 Census 1996 Census 2001 LDS 2004 LDHS 2006 Census 2009 LDHS 0 1 2 3 4 5 6 Figure 4.3 Total Fertility Rates, Lesotho 1976-2009 Births per woman 48 | Fertility Levels, Trends, and Differentials Table 4.5 shows that, on average, women have given birth to fewer than one child by their mid- 20s, more than two children by their mid-30s, and about 3.5 children by their mid-40s. Differences in the mean number of children ever born between all women and currently married women are large among the younger age groups, after which they narrow. Table 4.5 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born and mean number of living children, according to age group, Lesotho 2009 Mean number of children ever born Mean number of living children Number of women Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total ALL WOMEN 15-19 84.2 14.3 1.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,785 0.17 0.16 20-24 37.4 41.0 17.8 3.4 0.4 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,552 0.89 0.81 25-29 17.9 31.9 28.6 14.5 5.7 1.1 0.2 0.2 0.0 0.0 0.0 100.0 1,244 1.63 1.44 30-34 9.6 18.7 26.9 24.0 12.7 5.2 2.1 0.6 0.1 0.0 0.0 100.0 983 2.39 2.18 35-39 5.7 12.2 21.9 21.9 18.0 9.8 6.4 2.8 1.0 0.2 0.1 100.0 763 3.12 2.81 40-44 3.9 9.4 13.4 20.0 18.0 14.5 10.5 4.4 3.1 1.3 1.5 100.0 656 3.86 3.49 45-49 3.9 7.2 13.2 15.4 17.6 14.0 11.5 7.5 4.0 3.0 2.6 100.0 641 4.29 3.81 Total 32.7 22.0 16.5 11.4 7.5 4.3 2.8 1.4 0.7 0.4 0.4 100.0 7,624 1.80 1.62 CURRENTLY MARRIED WOMEN 15-19 37.3 54.7 7.7 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 292 0.71 0.66 20-24 15.7 51.4 26.7 5.4 0.7 0.1 0.0 0.0 0.0 0.0 0.0 100.0 860 1.24 1.12 25-29 8.1 31.6 32.8 17.8 7.7 1.6 0.3 0.2 0.0 0.0 0.0 100.0 857 1.92 1.70 30-34 4.4 17.0 27.9 27.0 14.0 5.8 2.9 0.8 0.1 0.0 0.0 100.0 704 2.63 2.44 35-39 3.9 8.4 19.9 23.2 20.2 12.0 7.8 3.1 1.2 0.1 0.2 100.0 522 3.40 3.08 40-44 2.2 8.7 13.0 18.2 15.5 17.2 11.9 5.6 4.0 1.7 1.9 100.0 429 4.15 3.75 45-49 1.7 5.6 12.4 13.3 20.0 14.8 11.5 8.3 5.5 3.8 3.0 100.0 386 4.62 4.10 Total 9.4 27.0 23.2 15.8 10.4 6.2 3.9 2.0 1.1 0.6 0.5 100.0 4,049 2.50 2.25 4.6 BIRTH INTERVALS A birth interval is defined as the length of time between two live births. The study of birth intervals is important in understanding the health status of young children. Research has shown that short birth intervals are closely associated with poor health of children, especially during infancy. Children born too close to a previous birth, especially if the interval between the births is less than two years, are at increased risk of health problems and death at an early age. Longer birth intervals, on the other hand, contribute to the improved health status of both mother and child. The study of birth intervals is done using two measures, namely, median birth interval and proportion of non-first births that occur with an interval of 24 months or more after the previous birth. Table 4.6 presents the distribution of second and higher-order births in the five years preceding the survey by the number of months since the previous birth, according to background characteristics. The table also presents the median number of months since the preceding birth. Results of the 2009 LDHS indicate that the overall median birth interval is 44 months. Twelve percent of births in Lesotho occur fewer than 24 months after the birth of a previous child, and 43 percent take place four or more years after a previous birth. The median birth interval is longest for women who give birth at age 30-39. There are differences in birth intervals by residence; non-first births in the urban areas, in the Lowlands zone, and in Mafeteng have the longest birth intervals. Fertility Levels, Trends, and Differentials | 49 Table 4.6 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Lesotho 2009 Median number of months since preceding birth Number of non-first births Background characteristic Months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Total Age 15-19 * * * * * * 100.0 25 * 20-29 7.0 11.2 28.0 26.5 11.9 15.4 100.0 1,054 37.3 30-39 1.3 4.1 18.2 18.6 15.6 42.1 100.0 920 53.3 40-49 5.1 4.4 12.8 21.4 18.8 37.6 100.0 270 50.7 Birth order 2-3 5.0 8.4 21.1 22.1 13.2 30.2 100.0 1,445 43.7 4-6 3.1 6.0 23.6 22.3 16.8 28.2 100.0 665 45.0 7+ 8.3 8.3 26.3 27.0 12.3 17.8 100.0 160 37.9 Sex of preceding birth Male 4.5 7.5 23.5 22.3 15.1 27.1 100.0 1,181 43.3 Female 4.9 7.8 20.8 22.6 13.2 30.6 100.0 1,088 44.2 Survival of preceding birth Living 2.3 6.6 22.5 22.9 15.2 30.4 100.0 2,000 45.2 Dead 22.2 15.2 20.0 19.2 6.7 16.7 100.0 269 29.5 Residence Urban 4.5 4.8 12.8 20.1 13.5 44.3 100.0 435 54.9 Rural 4.7 8.3 24.5 23.0 14.4 25.1 100.0 1,834 41.9 Ecological zone Lowlands 4.3 7.1 16.9 20.9 14.1 36.7 100.0 1,123 48.5 Foothills 5.5 6.9 19.4 25.1 14.9 28.2 100.0 255 44.4 Mountains 4.5 9.0 31.1 24.0 14.8 16.8 100.0 703 37.9 Senqu River Valley 6.5 7.4 24.4 23.1 11.7 26.8 100.0 188 42.0 District Butha-Buthe 1.6 5.9 24.5 21.8 19.1 27.1 100.0 118 45.7 Leribe 6.5 8.7 18.7 21.2 14.6 30.3 100.0 401 45.3 Berea 4.5 7.3 20.9 21.5 13.2 32.7 100.0 285 44.0 Maseru 3.6 7.3 16.2 25.1 14.8 32.9 100.0 480 46.5 Mafeteng 4.9 5.3 16.7 18.8 13.1 41.2 100.0 188 51.5 Mohale's Hoek 2.8 6.6 23.9 26.3 13.7 26.7 100.0 209 43.4 Quthing 7.7 11.6 25.7 17.7 12.4 24.9 100.0 113 40.2 Qacha’s Nek 4.7 5.8 30.6 20.1 18.2 20.6 100.0 75 41.6 Mokhotlong 5.3 7.5 31.7 25.0 14.6 16.0 100.0 167 37.7 Thaba-Tseka 5.1 9.4 33.1 21.7 11.4 19.2 100.0 233 36.8 Education No education 7.8 5.4 29.9 24.6 9.9 22.5 100.0 54 38.1 Primary incomplete 7.3 9.5 24.8 22.0 14.3 22.2 100.0 796 39.8 Primary complete 3.2 7.1 22.1 24.4 13.0 30.3 100.0 695 44.0 Secondary+ 3.0 6.4 18.9 21.1 15.6 35.0 100.0 724 48.4 Wealth quintile Lowest 6.4 10.1 31.2 23.5 13.1 15.7 100.0 627 36.6 Second 5.6 7.9 25.2 24.9 15.5 20.9 100.0 454 41.7 Middle 3.2 8.6 21.4 20.7 16.6 29.5 100.0 444 45.1 Fourth 3.9 4.6 14.5 23.0 14.1 39.9 100.0 427 51.4 Highest 3.2 5.3 11.8 18.8 11.2 49.8 100.0 317 59.9 Total 4.7 7.7 22.2 22.5 14.2 28.8 100.0 2,269 43.7 Note: The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. First-order births are excluded. 50 | Fertility Levels, Trends, and Differentials The interval between births is much lower for births in which a preceding sibling did not survive. This relationship is largely a result of replacement fertility, whereby a mother will get pregnant again soon after the death of a child. In Lesotho, the median birth interval length is shortened by 16 months when the preceding sibling dies. 4.7 AGE AT FIRST BIRTH One of the factors that determines the fertility in a population is the average age at first birth. Women who marry early are typically exposed to pregnancy for a longer period. Thus, early childbearing generally leads to a large family size and is often associated with increased health risks for the mother and child. A rise in the median age at first birth is typically a sign of transition to lower fertility levels. Table 4.7 indicates that women are delaying first childbirth. The distribution is similar to that in the 2004 LDHS and shows that the prevalence of early childbearing has declined over time. While 44 percent of women age 45-49 had their first child by age 20, the proportion of women age 20-24 who had their first child by age 20 is 37 percent. The increase in the median age at first birth among Basotho women can also be observed in the last column of Table 4.7—20.4 years for women age 45-49 compared with 21.2 years for women age 25-29. Table 4.7 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Lesotho 2009 Percentage who have never given birth Number of women Median age at first birth Percentage who gave birth by exact age Current age 15 18 20 22 25 15-19 0.9 na na na na 84.2 1,785 a 20-24 0.8 13.2 37.3 na na 37.4 1,552 a 25-29 0.8 13.6 35.0 57.1 76.2 17.9 1,244 21.2 30-34 0.9 13.1 37.3 61.7 77.9 9.6 983 20.9 35-39 1.0 16.1 40.3 60.4 79.8 5.7 763 20.9 40-44 1.1 13.2 38.7 63.6 84.1 3.9 656 20.9 45-49 0.9 16.4 44.2 66.2 82.9 3.9 641 20.4 20-49 0.9 14.0 38.1 na na 17.0 5,839 a 25-49 0.9 14.3 38.4 61.1 79.5 9.6 4,287 20.9 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.8 presents trends in the median age at first birth across age cohorts for key sub-groups. The measures are presented for women age 25-49 to ensure that half of the women have already had a birth. There are differences in the age at which women have their first child. Urban women start childbearing 1.4 years later than their rural counterparts (21.9 years compared with 20.5 years). A positive association is noted between educational level and wealth status and median age at first birth. For example, women with secondary or higher education start childbearing about 2.7 years later (median age 22.3 years) than women who do not complete primary education (median age 19.6 years). This relationship holds true for all age groups. Fertility Levels, Trends, and Differentials | 51 Table 4.8 Median age at first birth Median age at first birth among women age 25-49 years, by current age and background characteristics, Lesotho 2009 Women age 25-49 Background characteristic Age 25-29 30-34 35-39 40-44 45-49 Residence Urban 22.7 22.0 21.8 21.2 21.5 21.9 Rural 20.7 20.5 20.6 20.7 20.0 20.5 Ecological zone Lowlands 21.6 21.3 21.4 21.2 20.6 21.3 Foothills 21.0 20.6 20.2 20.4 20.8 20.6 Mountains 20.5 20.4 20.6 20.4 20.0 20.4 Senqu River Valley 21.6 20.4 20.3 20.6 19.7 20.5 District Butha-Buthe 20.9 21.3 21.1 20.7 21.5 21.1 Leribe 21.6 20.5 20.1 20.8 20.3 20.7 Berea 22.0 22.1 20.8 21.2 20.7 21.4 Maseru 21.4 21.1 21.9 21.2 20.7 21.3 Mafeteng 21.2 20.6 20.4 21.0 20.9 20.9 Mohale's Hoek 20.3 21.1 20.6 20.2 19.9 20.5 Quthing 22.1 20.3 19.9 20.3 20.1 20.5 Qacha’s Nek 20.7 20.5 20.1 19.8 21.1 20.4 Mokhotlong 20.4 21.4 21.2 20.8 20.1 20.7 Thaba-Tseka 20.5 19.9 20.8 20.8 19.5 20.3 Education No education * * * * * * Primary incomplete 19.8 19.7 20.0 19.3 19.6 19.6 Primary complete 20.6 20.0 20.2 20.7 20.3 20.4 Secondary+ 22.7 22.3 22.0 22.0 22.3 22.3 Wealth quintile Lowest 19.8 20.1 20.4 20.1 19.8 20.0 Second 20.7 20.5 20.1 20.3 19.5 20.3 Middle 20.4 20.4 20.8 20.8 19.9 20.4 Fourth 21.7 20.6 20.3 20.9 20.8 20.9 Highest 23.1 22.8 22.4 21.7 21.6 22.4 Total 21.2 20.9 20.9 20.9 20.4 20.9 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 4.8 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality for both the mother and child. Childbearing during the teenage years also frequently has adverse social consequences, particularly on female educational attainment. Women who become mothers in their teens are more likely to curtail education and have limited access to job opportunities. Using information from the 2009 LDHS, Table 4.9 shows the percentage of women age 15-19 who are mothers or who are pregnant with their first child. Table 4.9 shows that 2 in 10 teenagers have started childbearing: 16 percent are already mothers and 4 percent are currently pregnant with their first child. These figures are similar to those reported in the 2004 LDHS. The proportion of teenagers who have started childbearing rises very rapidly with age. Although only 3 percent of women age 15 have started childbearing, 41 percent of women have had a baby or are pregnant with their first child by age 19. 52 | Fertility Levels, Trends, and Differentials There is a substantial difference in fertility among urban and rural teenagers. Rural women are almost twice as likely as urban women to have started childbearing (22 and 12 percent, respectively). A woman’s educational attainment is inversely related to the initiation of childbearing; women with less education are more likely to have begun childbearing during adolescence than women with higher education. Twenty-eight percent of women with completed primary education have become mothers compared with 15 percent of women with secondary or higher education. Table 4.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Lesotho 2009 Percentage who: Percentage who have begun childbearing Number of women Background characteristic Have had a live birth Are pregnant with first child Age 15 2.2 0.8 3.0 353 16 5.1 2.8 7.9 343 17 15.5 3.8 19.2 396 18 22.9 4.9 27.9 368 19 34.3 6.7 41.0 325 Residence Urban 9.4 2.9 12.4 485 Rural 18.2 4.1 22.3 1,300 Ecological zone Lowlands 13.6 3.7 17.3 1,056 Foothills 24.2 3.8 28.0 186 Mountains 16.5 3.8 20.3 385 Senqu River Valley 19.2 3.9 23.1 158 District Butha-Buthe 17.8 2.9 20.8 80 Leribe 16.2 3.2 19.4 334 Berea 10.0 5.1 15.0 280 Maseru 14.7 3.2 17.9 383 Mafeteng 17.8 4.6 22.4 177 Mohale's Hoek 24.0 3.7 27.7 155 Quthing 13.9 1.3 15.2 113 Qacha’s Nek 12.6 6.0 18.5 56 Mokhotlong 15.6 3.7 19.3 80 Thaba-Tseka 20.5 5.1 25.6 127 Education No education * * * 6 Primary incomplete 20.6 4.7 25.4 385 Primary complete 23.1 5.0 28.1 314 Secondary+ 11.8 3.1 14.9 1,080 Wealth quintile Lowest 23.8 3.5 27.3 270 Second 20.7 4.4 25.2 307 Middle 18.1 4.9 23.0 359 Fourth 12.2 4.3 16.6 433 Highest 8.8 1.9 10.7 416 Total 15.8 3.8 19.6 1,785 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Family Planning | 53 FAMILY PLANNING 5 Mahlape Ramoseme This chapter presents 2009 LDHS findings about contraceptive knowledge, attitudes, and behaviour. Data are presented for men as well as women because men play an important role in the realisation of a couple’s reproductive goals. Wherever possible, the responses of men are compared with those of women to determine the level of interspousal communication and agreement. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Knowledge about methods of contraception and their availability helps people to make informed choices when planning their families. One of the major objectives of the 2009 LDHS is to assess knowledge of family planning methods among reproductive-age women and men. This information was collected during the survey by asking the respondents to name ways or methods by which a couple can delay or avoid pregnancy. If any respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent recognised it. In this way, information was collected about approximately nine modern methods: female sterilisation, male sterilisation, the pill, the intrauterine contraceptive device (IUCD), injectables, implants, male condoms, female condoms, emergency contraception, and two traditional methods (periodic abstinence or rhythm and withdrawal). Table 5.1 shows that knowledge of contraceptive methods among women and men in Lesotho is nearly universal; 98 percent of women age 15-49 and men age 15-49 know at least one method of family planning. Modern methods are more widely known than traditional methods. For example, 98 percent of women and men have heard of at least one modern method, and 73 percent of women and 72 percent of men know of a traditional method. The male condom is the most widely known method of family planning among women and men, with 97 percent of women and men saying that they have heard of the method. Among women, knowledge of injectables, the pill, and the female condom is 87 percent or higher. A significant proportion of women have also heard about the IUCD (69 percent) and female sterilisation (66 percent). Other modern methods are less well known among women. Table 5.1 shows that, after the male condom, the method most familiar to men is the female condom (78 percent), followed by injectables and the pill (72 percent each). Implants are the least known modern method among men (8 percent). Differences in knowledge of contraceptive methods between women and men are not substantial. Overall, contraceptive knowledge is higher among women than among men. The average number of methods known is 6.8 for women and 5.7 for men. 54 | Family Planning Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who know any contraceptive method, by specific method, Lesotho 2009 Women Men Method All women Currently married women Sexually active unmarried woman1 All men Currently married men Sexually active unmarried men1 Any method 98.3 99.2 99.5 98.2 99.2 99.4 Any modern method 98.2 99.1 99.5 98.0 99.0 99.4 Female sterilisation 66.2 72.1 73.2 54.3 68.9 58.1 Male sterilisation 18.0 18.0 22.7 23.2 25.5 30.4 Pill 88.9 94.9 94.3 71.6 86.6 74.1 IUCD 68.6 76.9 76.2 40.8 52.3 41.1 Injectables 89.6 95.6 95.8 72.1 88.4 76.0 Implants 25.9 31.8 29.3 8.4 11.2 9.0 Male condom 96.8 97.8 99.2 96.6 97.6 98.6 Female condom 86.6 89.6 92.6 77.5 83.1 85.9 Emergency contraception 31.5 32.8 38.4 25.7 29.0 32.2 Any traditional method 73.3 81.4 84.4 72.3 87.8 75.9 Rhythm 36.9 38.2 40.4 28.7 34.1 28.8 Withdrawal 68.3 77.7 80.4 69.5 85.9 73.3 Mean number of methods known by respondents 15-49 6.8 7.3 7.4 5.7 6.6 6.1 Number of respondents 7,624 4,049 466 3,008 1,169 471 Mean number of methods known by men 15-59 na na na 5.8 6.6 6.1 Number of respondents na na na 3,317 1,416 479 1 Had last sexual intercourse within 30 days preceding the survey na = Not applicable 5.2 CURRENT USE OF CONTRACEPTIVE METHODS The percentage of currently married women age 15-49 who use any method of family planning is known as the contraceptive prevalence rate (CPR). Table 5.2 shows that the CPR for Lesotho in 2009 is 47 percent, an increase of 10 percentage points from the percentage of 37 percent recorded in the 2004 LDHS. Almost all currently married women who use contraception use modern methods (46 percent). Current contraceptive use is higher among sexually active unmarried women than among married women (58 percent and 47 percent, respectively), primarily because 31 percent of sexually active unmarried women report using male condoms. The most commonly used contraceptive methods among married women are injectables (19 percent), the pill (13 percent), and the male condom (9 percent). Use of any contraceptive method increases with age, from a low of 28 percent among married women age 15-19 to a peak of 57 percent among married women age 30-34. Use then steadily declines to 32 percent at age 45-49. Use of the pill and injectables is most common among women in the prime childbearing years (age 20-39). As expected, use of female sterilisation as a method increases with age to a high of 9 percent at age 40-44. At 47 percent, the CPR in Lesotho is lower only than in Zimbabwe, Namibia, and Swaziland and higher than in other countries in eastern or southern Africa with comparable data (Figure 5.1). Family Planning | 55 Table 5.2 Current use of contraception by age Percent distribution of all women, currently married women, and sexually active unmarried women age 15-49 by contraceptive method currently used, according to age, Lesotho 2009 Modern method Traditional method Age Any method Any modern method Female sterili- sation Pill IUCD Inject- ables Implants Male condom Female condom Any tradi- tional method Rhythm With- drawal Folk method Not currently using Total Number of women ALL WOMEN 15-19 10.9 10.4 0.0 1.2 0.0 3.1 0.0 6.0 0.1 0.5 0.1 0.2 0.2 89.1 100.0 1,785 20-24 37.3 36.8 0.1 6.8 0.1 15.8 0.1 13.7 0.2 0.6 0.0 0.4 0.2 62.7 100.0 1,552 25-29 48.5 47.8 0.7 12.3 0.8 20.9 0.1 13.0 0.1 0.7 0.1 0.4 0.3 51.5 100.0 1,244 30-34 54.7 52.8 1.1 14.5 2.0 23.8 0.1 11.2 0.0 1.9 0.3 1.1 0.6 45.3 100.0 983 35-39 50.4 48.7 3.3 12.1 2.9 19.0 0.0 11.1 0.3 1.6 0.0 0.7 0.9 49.6 100.0 763 40-44 41.2 38.8 7.7 7.7 2.6 10.5 0.1 10.0 0.2 2.4 0.0 0.5 1.9 58.8 100.0 656 45-49 26.5 25.2 5.4 4.4 4.1 2.7 0.0 8.4 0.3 1.3 0.4 0.7 0.1 73.5 100.0 641 Total 35.9 34.9 1.7 7.8 1.3 13.4 0.1 10.4 0.2 1.1 0.1 0.5 0.5 64.1 100.0 7,624 CURRENTLY MARRIED WOMEN 15-19 28.2 26.8 0.0 6.8 0.0 13.8 0.0 5.8 0.4 1.4 0.2 0.5 0.7 71.8 100.0 292 20-24 43.9 43.1 0.1 11.0 0.2 23.5 0.1 7.8 0.2 0.8 0.0 0.7 0.2 56.1 100.0 860 25-29 52.2 51.2 0.6 14.7 1.1 24.4 0.1 10.2 0.1 1.0 0.1 0.6 0.4 47.8 100.0 857 30-34 57.4 55.5 0.9 17.6 2.5 24.6 0.2 9.8 0.0 1.8 0.2 1.2 0.4 42.6 100.0 704 35-39 52.7 51.1 3.2 14.5 3.5 18.8 0.0 10.7 0.3 1.7 0.0 1.1 0.6 47.3 100.0 522 40-44 45.3 42.6 9.4 9.2 2.6 9.9 0.2 11.3 0.1 2.7 0.0 0.6 2.1 54.7 100.0 429 45-49 32.0 31.0 6.5 6.7 5.2 3.6 0.0 8.9 0.0 1.0 0.4 0.4 0.2 68.0 100.0 386 Total 47.0 45.6 2.4 12.5 1.9 19.3 0.1 9.4 0.1 1.4 0.1 0.7 0.6 53.0 100.0 4,049 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 44.6 41.4 0.0 0.0 0.0 3.7 0.0 37.6 0.0 3.2 0.0 3.2 0.0 55.4 100.0 67 20-24 53.9 53.9 0.0 5.2 0.0 11.3 0.0 37.4 0.0 0.0 0.0 0.0 0.0 46.1 100.0 97 25-29 66.8 66.8 0.0 17.2 0.0 22.9 0.0 26.7 0.0 0.0 0.0 0.0 0.0 33.2 100.0 70 30-34 71.1 67.7 2.7 14.4 0.0 26.0 0.0 24.6 0.0 3.4 0.0 0.0 3.4 28.9 100.0 73 35-39 65.1 64.5 1.4 13.5 1.0 12.0 0.0 36.6 0.0 0.7 0.0 0.0 0.7 34.9 100.0 56 40-44 55.5 55.5 2.8 5.5 7.4 17.9 0.0 22.0 0.0 0.0 0.0 0.0 0.0 44.5 100.0 63 45-49 43.6 40.0 5.1 0.0 3.1 1.7 0.0 30.2 0.0 3.6 3.6 0.0 0.0 56.4 100.0 41 Total 57.8 56.5 1.4 8.3 1.4 14.4 0.0 31.0 0.0 1.4 0.3 0.5 0.6 42.2 100.0 466 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Women who have had sexual intercourse within 30 days preceding the survey 60 55 51 47 46 41 40 36 26 26 24 15 Zimbabwe 2005-06 Namibia 2006-07 Swaziland 2006-07 Lesotho 2009 Kenya 2008-09 Zambia 2007 Madagascar 2008-09 Rwanda 2007-08 Mozambique 2003 Tanzania 2004-05 Uganda 2006 Ethiopia 2005 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 Percent Any modern method Traditional method Figure 5.1 Current Use of Family Planning among Currently Married Women Age 15-49, Selected Countries in East Africa and Southern Africa Source: Macro International Inc, 2010. MEASURE DHS STATcompiler. http://www.measuredhs.com, August 9, 2010 56 | Family Planning 5.3 TRENDS IN CONTRACEPTIVE USE Table 5.3 shows that the contraceptive prevalence rate for currently married women age 15-49 has increased considerably from 37 percent in the 2004 LDHS to 47 percent in the 2009 LDHS. The most notable increase is in the use of male condoms, from 5 percent in 2004 to 9 percent in 2009. Another method that increased substantially in use during the 5-year period is injectables, which grew from 15 percent to 19 percent. Table 5.3 Trends in current contraceptive use Percent distribution of currently married women by contraceptive method currently used, Lesotho 2001-2010 Contraceptive method LDS 20011 LDHS 2004 LDHS 2009-10 Any method 40.6 37.3 47.0 Any modern method 36.1 35.2 45.6 Pill 11.5 10.9 12.5 IUCD 2.9 2.1 1.9 Injectables 14.7 14.7 19.3 Female sterilisation 0.3 2.7 2.4 Implants 0.1 0.0 0.1 Male condom 6.5 4.8 9.4 Other modern2 0.1 0.0 0.1 Any traditional method 4.5 2.1 1.4 Rhythm or periodic abstinence (calendar) 0.5 0.5 0.1 Withdrawal 0.4 0.9 0.7 Natural family planning 3.5 na na Local tradi

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