Malawi DHS Final Report (2010)

Publication date: 2011

Malawi 2010Demographic and Health Survey M alaw i 2010 D em ographic and H ealth Survey Malawi Demographic and Health Survey 2010 National Statistical Office Zomba, Malawi ICF Macro Calverton, Maryland, USA September 2011 The 2010 Malawi Demographic and Health Survey (2010 MDHS) was implemented by the National Statistical Office (NSO) and the Community Health Sciences Unit (CHSU) from June through November 2010. The funding for the MDHS was provided by the government of Malawi, National AIDS Commission (NAC), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Kingdom Department for International Development (DFID), the Centers for Disease Control and Prevention (CDC), and the United States Agency for International Development (USAID). ICF Macro provided technical assistance as well as funding to the project through the MEASURE DHS programme, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Additional information about the 2010 MDHS may be obtained from the Demography and Social Statistics Division, National Statistical Office, Chimbiya Road, P.O. Box 333, Zomba, Malawi; Telephone: 265-1-524-377, 265-1-524-111; Fax: 265-1-525-130; Email: enquiries@statistics.gov.mw; Internet: www.nso.malawi.net. Information about the MEASURE DHS programme may be obtained from ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@measuredhs.com, Internet: http://www.measuredhs.com. Recommended citation: National Statistical Office (NSO) and ICF Macro. 2011. Malawi Demographic and Health Survey 2010. Zomba, Malawi, and Calverton, Maryland, USA: NSO and ICF Macro. Contents | iii CONTENTS Page TABLES AND FIGURES . ix FOREWORD . xxi MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxiii MAP OF MALAWI . xxiv CHAPTER 1 INTRODUCTION 1.1 Geography, History, and the Economy . 1 1.1.1 Geography . 1 1.1.2 History. 1 1.1.3 Economy . 1 1.2 Population . 2 1.3 Objective of the Survey . 2 1.4 Organisation of the Survey . 3 1.5 Sample Design . 3 1.6 Questionnaires . 4 1.7 HIV and Anaemia Testing . 5 1.8 Pretest . 6 1.9 Training of Field Staff . 6 1.10 Fieldwork . 6 1.11 Data Processing . 6 1.12 Response Rates . 7 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age, Sex, and Residence . 9 2.2 Household Composition . 10 2.3 Education of Household Population . 11 2.3.1 Educational Attainment . 11 2.3.2 School Attendance Rates . 14 2.3.3 Grade Repetition and Dropout Rates . 16 2.4 Household Environment . 17 2.4.1 Improved Drinking Water . 18 2.4.2 Household Sanitation Facilities . 19 2.4.3 Housing Characteristics . 20 2.5 Household Possessions . 21 2.6 Wealth Index . 22 iv | Contents CHAPTER 3 RESPONDENTS’ CHARACTERISTICS 3.1 Characteristics of Survey Respondents . 25 3.2 Educational Attainment by Background Characteristics . 27 3.3 Literacy. 28 3.4 Access to Mass Media . 30 3.5 Employment . 32 3.6 Occupation . 34 3.7 Earnings, Employers, and Continuity of Employment . 36 3.8 Knowledge and Attitudes Regarding Tuberculosis . 37 3.9 Tobacco Use . 39 CHAPTER 4 FERTILITY 4.1 Introduction . 43 4.2 Current Fertility . 43 4.3 Fertility Trends . 45 4.4 Children Ever Born and Living . 46 4.5 Birth Intervals . 47 4.6 Age at First Birth . 49 4.7 Median Age at First Birth . 49 4.8 Teenage Pregnancy and Motherhood . 50 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods . 53 5.2 Ever Use of Contraception . 55 5.3 Current Use of Contraceptive Methods . 57 5.4 Differentials in Contraceptive Use by Background Characteristics . 59 5.5 Trends in Contraceptive Use . 60 5.6 Number of Children at First Use of Contraception . 61 5.7 Brands of Pills and Condoms Used . 61 5.8 Knowledge of the Fertile Period . 63 5.9 Timing of Sterilisation . 64 5.10 Source of Contraception . 64 5.11 Informed Choice . 65 5.12 Future Use of Contraception . 66 5.13 Exposure to Family Planning Messages in the Media . 67 5.13.1 Exposure of Females to Specific Family Planning Messages . 68 5.13.2 Exposure of Males to Specific Family Planning Messages . 69 5.14 Contact of Non-Users with Family Planning Providers . 70 5.15 Husband’s/Partner’s Knowledge of Women’s Contraceptive Use . 71 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status . 73 6.2 Polygyny . 74 6.3 Age at First Marriage . 75 6.4 Median Age at First Marriage . 76 6.5 Age at First Sexual Intercourse . 78 Contents | v 6.6 Median Age at First Sexual Intercourse . 79 6.7 Recent Sexual Activity . 80 6.8 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 82 6.9 Menopause . 84 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 85 7.2 Desire to Limit Childbearing . 86 7.3 Need for Family Planning Services . 88 7.4 Ideal Family Size . 91 7.5 Fertility Planning . 92 7.6 Wanted Fertility Rates . 93 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Background and Assessment of Data Quality . 95 8.2 Infant and Child Mortality Levels and Trends . 96 8.3 Socioeconomic Differentials in Infant and Child Mortality . 97 8.4 Demographic Differentials in Childhood Mortality . 98 8.5 Perinatal Mortality . 100 8.6 High-risk Fertility Behaviour . 101 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 103 9.2 Number of ANC Visits and Timing of First Visit . 105 9.3 Components of Antenatal Care . 106 9.4 Tetanus Toxoid Vaccine Doses . 107 9.5 Place of Delivery . 109 9.6 Assistance during Delivery . 110 9.7 Postnatal Care . 111 9.9 Perceived Problems in Accessing Health Care . 113 CHAPTER 10 CHILD HEALTH 10.1 Child’s Weight at Birth . 117 10.2 Vaccination of Children . 118 10.2.1 Trends in Vaccination Coverage . 120 10.3 Acute Respiratory Infection . 121 10.4 Fever . 122 10.5 Prevalence of Diarrhoea . 124 10.6 Diarrhoea Treatment . 126 10.7 Feeding Practices . 127 10.8 Knowledge of ORS Packets . 128 vi | Contents CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 129 11.1.1 Measurement of Nutritional Status among Young Children . 129 11.1.2 Results of Data Collection . 130 11.1.3 Trends in Malnutrition . 133 11.2 Initiation Of Breastfeeding . 134 11.3 Breastfeeding Status by Age . 136 11.4 Duration of Breastfeeding . 139 11.5 Types of Complementary Foods . 139 11.6 Infant and Young Child Feeding (IYCF) Practices . 140 11.7 Prevalence of Anaemia in Children . 143 11.8 Micronutrient Intake among Children . 144 11.9 Presence of Iodised Salt in Households . 147 11.10 Nutritional Status of Women . 147 11.11 Prevalence of Anaemia among Women . 149 11.12 Micronutrient Intake among Mothers . 150 CHAPTER 12 MALARIA 12.1 Introduction . 153 12.2 Mosquito Nets . 154 12.2.1 Ownership of Mosquito Nets . 154 12.2.2 Use of Mosquito Nets by Persons in the Household . 155 12.2.3 Use of Mosquito Nets by Children Under Five Years . 155 12.2.4 Use of Mosquito Nets by Pregnant Women . 156 12.3 Indoor Residual Spraying . 157 12.4 Use of Intermittent Preventive Treatment of Malaria in Pregnancy . 159 12.5 Prevalence and Prompt Treatment of Fever . 160 12.6 Prevalence of Anaemia in Children . 163 CHAPTER 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 Introduction . 165 13.2 HIV and AIDS Knowledge, Transmission and Prevention Methods . 166 13.2.1 Awareness of AIDS . 166 13.2.2 Knowledge of HIV Prevention . 166 13.2.3 Comprehensive Knowledge and Misconceptions about HIV/AIDS . 168 13.3 Knowledge about Mother-to-Child Transmission . 170 13.4 Attitudes Towards People Living with HIV and AIDS . 172 13.5 Attitudes Towards Negotiating Safer Sexual Relations with Husbands . 174 13.6 Attitudes Towards Condom Education for Youth . 175 13.7 Multiple Sexual Partners . 176 13.8 Concurrent Sexual Partners . 178 13.9 Payment for Sex . 181 13.10 Male Circumcision . 182 13.11 Self-reporting of Sexually Transmitted Infections . 183 13.12 Prevalence of Medical Injections . 184 Contents | vii 13.13 HIV and AIDS-related Knowledge and Behaviour among Youth . 185 13.13.1 Knowledge about HIV and AIDS and Sources for Condoms . 185 13.13.2 Age at First Sexual Intercourse . 187 13.13.3 Premarital Sex . 188 13.13.4 Multiple Sexual Partners among Youth . 190 13.13.5 Age-mixing in Sexual Relationships . 191 CHAPTER 14 HIV PREVALENCE 14.1 Coverage Rates for HIV Testing . 193 14.2 HIV Prevalence . 196 14.2.1 HIV Prevalence by Age and Sex . 196 14.2.2 Trends in HIV Prevalence . 197 14.2.3 HIV Prevalence by Socioeconomic Characteristics . 197 14.2.4 HIV Prevalence by Demographic Characteristics . 199 14.2.5 HIV Prevalence by Sexual Risk Behaviour . 200 14.3 HIV Prevalence Among Youth . 202 14.3.1 HIV Prevalence by Sexual Behaviour among Youth . 204 14.4 HIV Prevalence by Other Characteristics . 205 14.4.1 HIV Prevalence and STIs . 205 14.4.2 HIV Prevalence by Male Circumcision . 205 14.5 HIV Prevalence Among Cohabiting Couples . 208 CHAPTER 15 SELF-REPORTED PRIOR HIV TESTING AND TREATMENT 15.1 Coverage of HIV Testing Services . 209 15.2 HIV Testing among Youth . 211 15.3 Self-reported HIV Status and HIV Status According to the 2010 MDHS . 212 15.4 Self-Reported Use of Antiretroviral Medications (ARVs) . 214 15.5 HIV Testing during Pregnancy . 217 15.6 Self-reported Use of Prevention of Mother-to-Child Transmission (PMTCT) Services . 218 CHAPTER 16 ADULT AND MATERNAL MORTALITY 16.1 Data . 219 16.2 Estimates of Adult Mortality . 220 16.3 Estimates of Maternal Mortality . 221 CHAPTER 17 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES 17.1 Women’s and Men’s Employment . 223 17.1.1 Employment Status . 223 17.2 Women’s Control Over Their Own Earnings and Relative Magnitude of Women’s Earnings . 224 17.3 Women’s Participation in Decision-making . 227 17.4 Attitudes Towards Wife Beating . 231 17.5 Women’s Empowerment Indicators . 234 viii | Contents 17.6 Current Use of Contraception by Woman’s Empowerment Status . 234 17.7 Ideal Family Size and Unmet Need by Women’s Status . 235 17.8 Women’s Status and Reproductive Health Care . 236 CHAPTER 18 DOMESTIC VIOLENCE 18.1 Introduction . 239 18.2 Women Experiencing Physical Violence . 240 18.3 Perpetrators of Physical Violence . 242 18.4 Force at Sexual Initiation . 242 18.5 Experience of Sexual Violence . 243 18.6 Age at First Experience of Sexual Violence . 244 18.7 Perpetrators of Sexual Violence . 245 18.8 Experience of Different Forms of Violence . 246 18.9 Violence during Pregnancy . 246 18.10 Marital Control by Husband. 247 18.11 Forms of Spousal Violence . 249 18.12 Spousal Violence by Background Characteristics . 251 18.13 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 253 18.14 Frequency of Spousal Violence . 254 18.15 Onset of Spousal Violence . 256 18.16 Physical Consequences of Spousal Violence . 257 18.17 Violence by Women Against their Husbands . 257 18.18 Help-Seeking Behaviour by Women Who Experience Violence . 259 CHAPTER 19 ORPHANS AND VULNERABLE CHILDREN 19.1 Orphaned and Vulnerable Children . 261 19.1.1 Children’s Living Arrangements and Orphanhood . 261 19.1.2 Orphaned and Vulnerable Children . 262 19.2 Social and Economic Situation of Orphaned and Vulnerable Children . 264 19.2.1 School Attendance . 264 19.2.2 Basic Material Needs . 265 19.2.3 Nutritional Status . 265 19.2.4 Sex before Age 15 . 266 19.3 Care and Support for OVCs . 267 19.3.1 Property Dispossession and Legal Assistance . 267 19.3.2 External Support for Households with OVCs . 268 REFERENCES . 271 APPENDIX A DISTRICT TABLES . 273 APPENDIX B SAMPLE DESIGN AND IMPLEMENTATION . 409 APPENDIX C ESTIMATES OF SAMPLING ERRORS . 421 APPENDIX D DATA QUALITY TABLES . 431 APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2010 MDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION . 437 APPENDIX F SURVEY PERSONNEL . 439 APPENDIX G QUESTIONNAIRES . 447 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 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 . 9 Table 2.2 Household composition . 11 Table 2.3.1 Educational attainment of the female household population . 13 Table 2.3.2 Educational attainment of the male household population . 13 Table 2.4 School attendance ratios . 15 Table 2.5 Grade repetition and dropout rates . 16 Table 2.6 Household drinking water . 18 Table 2.7 Household sanitation facilities . 19 Table 2.8 Household characteristics . 21 Table 2.9 Household durable goods . 22 Table 2.10 Wealth quintiles . 23 Figure 2.1 Population Pyramid . 10 Figure 2.2 Distribution of Household Population with No Education by Sex . 14 Figure 2.3 Age-specific Attendance Rates . 17 CHAPTER 3 RESPONDENTS’ CHARACTERISTICS Table 3.1 Background characteristics of respondents . 26 Table 3.2.1 Educational attainment: Women . 27 Table 3.2.2 Educational attainment: Men . 28 Table 3.3.1 Literacy: Women . 29 Table 3.3.2 Literacy: Men . 30 Table 3.4.1 Exposure to mass media: Women . 31 Table 3.4.2 Exposure to mass media: Men . 31 Table 3.5.1 Employment status: Women . 32 Table 3.5.2 Employment status: Men . 33 Table 3.6.1 Occupation: Women . 34 Table 3.6.2 Occupation: Men . 35 Table 3.7.1 Type of employment: Women . 36 Table 3.7.2 Type of employment: Men . 37 Table 3.8.1 Knowledge and attitude concerning tuberculosis: Women . 38 Table 3.8.2 Knowledge and attitude concerning tuberculosis: Men . 39 Table 3.9.1 Use of tobacco: Women . 40 Table 3.9.2 Use of tobacco: Men . 41 x | Tables and Figures CHAPTER 4 FERTILITY Table 4.1 Current fertility . 43 Table 4.2 Fertility by background characteristics . 44 Table 4.3.1 Trends in age-specific fertility rates . 45 Table 4.3.2 Trends in age-specific and total fertility rates . 46 Table 4.4 Children ever born and living . 47 Table 4.5 Birth intervals . 48 Table 4.6 Age at first birth . 49 Table 4.7 Median age at first birth . 50 Table 4.8 Teenage pregnancy and motherhood . 51 Figure 4.1 Trends in Age-specific Fertility Rates, Various Sources, 1992-2010 . 46 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 54 Table 5.2 Knowledge of contraceptive methods by background characteristics . 55 Table 5.3.1 Ever use of contraception: Women . 56 Table 5.3.2 Ever use of contraception: Men . 57 Table 5.4.1 Current use of contraception by age: Women . 58 Table 5.4.2 Current use of contraception by age: Men . 59 Table 5.5 Current use of contraception by background characteristics: Women . 60 Table 5.6 Trends in current use of contraception . 60 Table 5.7 Number of children at first use of contraception . 61 Table 5.8.1 Use of social marketing brand pills and condoms . 62 Table 5.8.2 Use of social marketing brand of condoms: Men . 62 Table 5.9.1 Knowledge of fertile period: Women . 63 Table 5.9.2 Knowledge of fertile period: Men . 63 Table 5.10 Timing of sterilisation . 64 Table 5.11 Source of modern contraception methods . 65 Table 5.12 Informed choice . 66 Table 5.13 Future use of contraception . 67 Table 5.14 Exposure to family planning messages . 68 Table 5.15.1 Exposure of respondents to specific family planning or health programmes on the radio: Women . 69 Table 5.15.2 Exposure of respondents to specific family planning or health programmes on the radio: Men . 70 Table 5.16 Contact of non-users with family planning providers . 71 Table 5.17 Husband/partner’s knowledge of women’s use of contraception . 72 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 73 Table 6.2.1 Number of women’s cowives . 74 Table 6.2.2 Number of men’s wives . 75 Table 6.3 Age at first marriage . 76 Table 6.4.1 Median age at first marriage: Women . 77 Table 6.4.2 Median age at first marriage: Men . 77 Table 6.5 Age at first sexual intercourse . 78 Table 6.6.1 Median age at first intercourse: Women . 79 Tables and Figures | xi Table 6.6.2 Median age at first intercourse: Men . 80 Table 6.7.1 Recent sexual activity: Women . 81 Table 6.7.2 Recent sexual activity: Men . 82 Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility . 83 Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility . 84 Table 6.10 Menopause . 84 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 85 Table 7.2.1 Desire to limit childbearing: Women . 87 Table 7.2.2 Desire to limit childbearing: Men . 88 Table 7.3.1 Need and demand for family planning among currently married women . 89 Table 7.3.2 Need and demand for family planning for all women and for women who are not currently married . 90 Table 7.4 Ideal number of children . 91 Table 7.5 Mean ideal number of children. 92 Table 7.6 Fertility planning status . 92 Table 7.7 Wanted fertility rates . 93 Figure 7.1 Percentage of Currently Married Women and Men Who Want No More Children, by Number of Living Children . 86 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 96 Table 8.2 Trends in early childhood mortality . 97 Table 8.3 Early childhood mortality rates by socioeconomic characteristics . 98 Table 8.4 Early childhood mortality rates by demographic characteristics . 99 Table 8.5 Perinatal mortality . 100 Table 8.6 High-risk fertility behaviour . 101 Figure 8.1 Trends in Childhood Mortality, 1992-2010 . 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 vaccine (TTV) . 108 Table 9.5 Place of delivery . 109 Table 9.6 Assistance during delivery . 111 Table 9.7 Timing of first postnatal checkup. 112 Table 9.8 Type of provider of first postnatal checkup . 113 Table 9.9 Problems in accessing health care . 114 Figure 9.1 Problems in Accessing Health Care . 115 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 . 120 Table 10.4 Trends in vaccination coverage . 120 Table 10.5 Vaccinations in first year of life. 121 Table 10.6 Prevalence and treatment of symptoms of ARI . 122 Table 10.7 Prevalence and treatment of fever . 123 Table 10.8 Antimalarial drugs taken by children . 124 Table 10.9 Prevalence of diarrhoea . 125 Table 10.10 Diarrhoea treatment . 126 Table 10.11 Feeding practices during diarrhoea . 127 Table 10.12 Knowledge of ORS packets or pre-packaged liquids . 128 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 131 Table 11.2 Initial breastfeeding . 135 Table 11.3 Breastfeeding status by age . 136 Table 11.4 Median duration of breastfeeding . 139 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 140 Table 11.6 Infant and young child feeding (IYCF) practices . 142 Table 11.7 Prevalence of anaemia in children . 144 Table 11.8 Micronutrient intake among children . 146 Table 11.9 Presence of iodized salt in households . 147 Table 11.10 Nutritional status of women . 148 Table 11.11.1 Prevalence of anaemia in nonpregnant women . 149 Table 11.11.2 Prevalence of anaemia in pregnant women . 150 Table 11.12 Micronutrient intake among mothers . 151 Figure 11.1 Nutritional Status of Children by Age . 133 Figure 11.2 Trends in Nutritional Status of Children Under Five, 2004 MDHS and 2010 MDHS . 134 Figure 11.3 Infant Feeding Practices by Age . 137 Figure 11.4 Trends in Infant Feeding Practices for Children 0-5 Months and 6-9 Months, 2004 MDHS and 2010 MDHS . 138 Figure 11.5 Indicators on Breastfeeding Status, Malawi 2010 . 139 Figure 11.6 IYCF Feeding Practices . 143 CHAPTER 12 MALARIA Table 12.1 Household possession of mosquito nets . 154 Table 12.2 Use of mosquito nets by persons in the household . 155 Table 12.3 Use of mosquito nets by children . 156 Table 12.4 Use of mosquito nets by pregnant women . 157 Table 12.5 Indoor residual spraying against mosquitoes . 158 Table 12.6 Use of mosquito nets or sleeping in a house which received IRS . 159 Table 12.7 Prophylactic use of antimalarial drugs and use of Intermittent Preventive Treatment (IPTp) by women during pregnancy . 160 Tables and Figures | xiii Table 12.8 Prevalence and prompt treatment of fever . 161 Table 12.9 Type and timing of antimalarial drugs taken by children with fever . 162 Table 12.10 Percentage of children with haemoglobin <8.0 g/dl in children . 163 CHAPTER 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS. 166 Table 13.2 Knowledge of HIV prevention methods . 167 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 169 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 170 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 171 Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 172 Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 173 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 174 Table 13.7 Adult support of education about condom use to prevent AIDS . 175 Table 13.8.1 Multiple sexual partners in the past 12 months: Women . 176 Table 13.8.2 Multiple sexual partners in the past 12 months: Men . 177 Table 13.9.1 Point prevalence and cumulative prevalence of concurrent sexual partnerships: Women . 179 Table 13.9.2 Point prevalence and cumulative prevalence of concurrent sexual partnerships: Men . 180 Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men . 181 Table 13.11 Male circumcision . 182 Table 13.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms . 183 Table 13.13 Prevalence of medical injections . 185 Table 13.14 Comprehensive knowledge about AIDS and of a source of condoms among youth . 186 Table 13.15 Age at first sexual intercourse among youth . 187 Table 13.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 189 Table 13.17.1 Multiple sexual partners in the past 12 months among youth: Women . 190 Table 13.17.2 Multiple sexual partners in the past 12 months among youth: Men . 191 Table 13.18 Age-mixing in sexual relationships among women age 15-19 . 192 Figure 13.1 Women and Men Seeking Treatment for STIs . 184 Figure 13.2 Trend in Age at First Sexual Intercourse . 188 CHAPTER 14 HIV PREVALENCE Table 14.1 Coverage of HIV testing by residence and region . 194 Table 14.2 Coverage of HIV testing by selected background characteristics . 195 Table 14.3 HIV prevalence by age . 196 Table 14.4 Trends in HIV prevalence by age . 197 Table 14.5 HIV prevalence by socioeconomic characteristics . 198 Table 14.6 HIV prevalence by demographic characteristics . 200 Table 14.7 HIV prevalence by sexual behaviour . 201 Table 14.8 HIV prevalence among young people by background characteristics . 203 Table 14.9 HIV prevalence among young people by sexual behaviour . 204 Table 14.10 HIV prevalence by sexually transmitted infections . 205 xiv | Tables and Figures Table 14.11 HIV prevalence by male circumcision . 207 Table 14.12 HIV prevalence among cohabiting couples . 208 Figure 14.1 HIV Prevalence by Sex and Age . 196 Figure 14.2 HIV Prevalence by Sex and Age MDHS 2004 and 2010 . 197 CHAPTER 15 SELF-REPORTED PRIOR HIV TESTING AND TREATMENT Table 15.1.1 Coverage of prior HIV testing: Women . 209 Table 15.1.2 Coverage of prior HIV testing: Men . 210 Table 15.2 HIV testing among youth . 211 Table 15.3 HIV prevalence by self-reported prior HIV testing . 213 Table 15.4 Self-reported prior HIV testing by current HIV status . 214 Table 15.5 Self-reported HIV status and ARV use . 215 Table 15.6 Pregnant women counselled and tested for HIV. 217 Table 15.7 PMTCT services . 218 Figure 15.1 Self-reported ARV Use and HIV Status among HIV-positive Women Age 15-49 . 216 Figure 15.2 Self-reported ARV Use and HIV Status among HIV-positive Men Age 15-49 . 216 CHAPTER 16 ADULT AND MATERNAL MORTALITY Table 16.1 Data on siblings . 220 Table 16.2 Adult mortality rates . 221 Table 16.3 Maternal mortality . 222 CHAPTER 17 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 17.1 Employment and cash earnings of currently married women and men . 224 Table 17.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women . 225 Table 17.2.2 Control over men’s cash earnings . 226 Table 17.3 Women’s control over her own earnings and over those of her husband . 227 Table 17.4.1 Women’s participation in decision-making . 228 Table 17.4.2 Women’s participation in decision-making according to men . 228 Table 17.5.1 Women’s participation in decision-making by background characteristics . 229 Table 17.5.2 Men’s attitude toward wives’ participation in decision-making . 231 Table 17.6.1 Attitude toward wife beating: Women . 232 Table 17.6.2 Attitude toward wife beating: Men . 233 Table 17.7 Indicators of women’s empowerment . 234 Table 17.8 Current use of contraception by women’s status . 235 Table 17.9 Women’s empowerment and ideal number of children and unmet need for family planning . 236 Table 17.10 Reproductive health care by women’s empowerment . 237 Figure 17.1 Number of Decisions in which Women Participate . 230 Tables and Figures | xv CHAPTER 18 DOMESTIC VIOLENCE Table 18.1 Experience of physical violence . 241 Table 18.2 Persons committing physical violence . 242 Table 18.3 Force at sexual initiation . 243 Table 18.4 Experience of sexual violence . 244 Table 18.5 Age at first experience of sexual violence . 245 Table 18.6 Persons committing sexual violence . 245 Table 18.7 Experience of different forms of violence . 246 Table 18.8 Violence during pregnancy . 247 Table 18.9 Degree of marital control exercised by husbands . 248 Table 18.10 Forms of spousal violence . 250 Table 18.11 Spousal violence by background characteristics. 252 Table 18.12 Spousal violence by husband’s characteristics and empowerment indicators . 254 Table 18.13 Frequency of spousal violence among those who report violence . 255 Table 18.14 Onset of marital violence . 256 Table 18.15 Injuries to women due to spousal violence . 257 Table 18.16 Violence by women against their spouse . 258 Table 18.17 Help seeking to stop violence . 260 Figure 18.1 Percentage of Ever-married Women Who have Experienced Specific Forms of Physical and Sexual Violence Committed by their Husband/Partner, Ever and During the Past 12 Months . 251 CHAPTER 19 ORPHANS AND VULNERABLE CHILDREN Table 19.1 Children’s living arrangements and orphanhood . 262 Table 19.2 Orphans and vulnerable children (OVC) . 263 Table 19.3 School attendance by survivorship of parents and by OVC status . 264 Table 19.4 Possession of basic material needs by orphans and vulnerable children . 265 Table 19.5 Underweight orphans and vulnerable children . 266 Table 19.6 Sexual intercourse before age 15 of orphans and vulnerable children . 266 Table 19.7 Widows dispossessed of property . 267 Table 19.8 External support for very sick persons . 268 Table 19.9 External support for orphans and vulnerable children. 269 APPENDIX A DISTRICT TABLES Table A-2.3.1 Educational attainment of the female household population . 273 Table A-2.3.2 Educational attainment of the male household population . 274 Table A-2.4 School attendance ratios . 275 Table A-2.6.1 Household drinking water: Regions . 277 Table A-2.6.2 Household drinking water: Districts . 277 Table A-2.7.1 Household sanitation facilities: Regions . 278 Table A-2.7.2 Household sanitation facilities: Districts . 279 Table A-2.8.1 Household access to electricity: Regions . 280 Table A-2.8.2 Household access to electricity: Districts . 281 Table A-3.1 Background characteristics of respondents: Districts . 283 Table A-3.2.1 Educational attainment: Women by district . 284 Table A-3.2.2 Educational attainment: Men by district . 285 Table A-3.3.1 Literacy: Women by district . 286 xvi | Tables and Figures Table A-3.3.2 Literacy: Men by district . 287 Table A-3.4.1 Exposure to mass media: Women by district . 288 Table A-3.4.2 Exposure to mass media: Men by district . 289 Table A-3.5.1 Employment status: Women by district . 290 Table A-3.5.2 Employment status: Men by district . 291 Table A-3.6.1 Occupation: Women by district . 292 Table A-3.6.2 Occupation: Men by district . 293 Table A-3.7.1 Type of earnings: Women by district . 294 Table A-3.7.2 Type of earnings: Men by district . 295 Table A-3.7.3 Type of employer: Women by district . 296 Table A-3.7.4 Type of employer: Men by district . 297 Table A-3.7.5 Continuity of employment: Women by district . 298 Table A-3.7.6 Continuity of employment: Men by district . 299 Table A-3.9.1 Knowledge and attitude concerning tuberculosis: Women by district . 300 Table A-3.9.2 Knowledge and attitude concerning tuberculosis: Men by district . 301 Table A-3.10.1 Use of tobacco: Women by district . 302 Table A-3.10.2 Use of tobacco: Men by district . 303 Table A-4.5 Birth intervals . 305 Table A-4.7 Median age at first birth . 306 Table A-4.8 Teenage pregnancy and motherhood . 307 Table A-5.2 Knowledge of contraceptive methods by district of residence . 308 Table A-5.3.1 Ever use of contraception: Women by district . 309 Table A-5.3.2 Ever use of contraception: Men by district . 310 Table A-5.5.1 Current use of contraception by background characteristics: Women by district . 311 Table A-5.5.2 Current use of contraception by background characteristics: Men by district . 312 Table A-5.7 Number of children at first use of contraception: Districts . 313 Table A-5.14 Exposure to family planning messages: Districts . 314 Table A-5.18.1 Exposure of respondents to specific family planning or health programs on the radio: Women by district . 315 Table A-5.18.2 Exposure of respondents to specific family planning or health programs on the radio: Men by district . 316 Table A-5.19 Contact of nonusers with family planning providers: Districts . 317 Table A-5.20 Husband/partner’s knowledge of women’s use of contraception: Districts . 318 Table A-6.2.2 Number of men’s wives: Districts . 320 Table A-6.6.1 Median age at first intercourse: Women . 321 Table A-6.6.2 Median age at first intercourse: Men by districts . 322 Table A-6.7.1 Recent sexual activity: Women by districts . 323 Table A-6.7.2 Recent sexual activity: Men by districts . 324 Table A-7.3.1 Need and demand for family planning among currently married women: Districts . 326 Table A-7.5 Mean ideal number of children: Districts . 327 Table A-8.3 Early childhood mortality rates by socioeconomic characteristics . 329 Table A-9.1 Antenatal care: Districts . 330 Table A-9.3 Components of antenatal care: Districts . 331 Table A-9.4 Tetanus toxoid vaccine (TTV): Districts . 332 Table A-9.5 Place of delivery: Districts . 333 Table A-9.6 Assistance during delivery: Districts . 334 Table A-9.7 Timing of first postnatal checkup: Districts . 335 Table A-9.8 Type of provider of first postnatal checkup: Districts . 336 Tables and Figures | xvii Table A-9.9 Problems in accessing health care: Districts . 337 Table A-10.1 Child’s weight and size at birth: Districts . 338 Table A-10.3 Vaccinations by background characteristics: Districts . 339 Table A-10.6 Prevalence and treatment of symptoms of ARI: Districts . 340 Table A-10.7 Prevalence and treatment of fever: Districts . 341 Table A-10.8 Antimalarial drugs taken by children: Districts . 342 Table A-10.9 Prevalence of diarrhoea: Districts . 343 Table A-10.10 Diarrhoea treatment: Districts . 344 Table A-10.11 Feeding practices during diarrhoea: Districts . 345 Table A-10.12 Knowledge of ORS packets or pre-packaged liquids: Districts . 346 Table A-11.1 Nutritional status of children: Districts . 347 Table A-11.2 Initial breastfeeding: Districts . 348 Table A-11.4 Median duration of breastfeeding: Districts . 349 Table A-11.6 Infant and young child feeding (IYCF) practices: Districts . 350 Table A-11.7 Prevalence of anaemia in children: Districts . 351 Table A-11.8 Micronutrient intake among children: Districts. 352 Table A-11.9 Presence of iodised salt in households: Districts . 353 Table A-11.10 Nutritional status of women: Districts . 354 Table A-11.11.1 Prevalence of anaemia in nonpregnant women: Districts . 355 Table A-11.12 Micronutrient intake among mothers: Districts . 356 Table A-12.1 Household possession of mosquito nets: Districts . 357 Table A-12.2 Use of mosquito nets by persons in the household: Districts . 358 Table A-12.3 Use of mosquito nets by children: Districts . 359 Table A-12.4 Use of mosquito nets by pregnant women: Districts . 360 Table A-12.5 Indoor residual spraying against mosquitoes: Districts . 361 Table A-12.6 Use of mosquito nets or sleeping in a house which received IRS . 362 Table A-12.7 Prophylactic use of antimalarial drugs and use of Intermittent Preventive Treatment (IPTp) by women during pregnancy: Districts . 363 Table A-12.8 Prevalence and prompt treatment of fever: Districts . 364 Table A-12.9 Type and timing of antimalarial drugs taken by children with fever: Districts 365 Table A-12.10 Percentage of children with haemoglobin <8.0 g/dl in children: Districts . 366 Table A-13.1 Knowledge of AIDS: Districts . 367 Table A-13.2 Knowledge of HIV prevention methods: Districts . 368 Table A-13.3.1 Comprehensive knowledge about AIDS: Women by districts . 369 Table A-13.3.2 Comprehensive knowledge about AIDS: Men by districts . 370 Table A-13.4 Knowledge of prevention of mother to child transmission of HIV: Districts . 371 Table A-13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women by districts . 372 Table A-13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men by districts . 373 Table A-13.6 Attitudes toward negotiating safer sexual relations with husband: Districts . 374 Table A-13.7 Adult support of education about condom use to prevent AIDS: Districts . 375 Table A-13.8.1 Multiple sexual partners in the past 12 months: Women by districts . 376 Table A-13.8.2 Multiple sexual partners in the past 12 months: Men by districts . 377 Table A-13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men by districts . 378 Table A-13.11 Male circumcision: Districts . 379 Table A-13.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms: Districts . 380 Table A-13.13 Prevalence of medical injections: Districts . 381 Table A-13.14 Comprehensive knowledge about AIDS and of a source of condoms among youth: Districts . 382 xviii | Tables and Figures Table A-13.15 Age at first sexual intercourse among youth: Districts . 383 Table A-13.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 384 Table A-13.17.1 Multiple sexual partners in the past 12 months among youth: Women by districts . 385 Table A-13.17.2 Multiple sexual partners in the past 12 months among youth: Men by districts . 386 Table A-13.18 Age-mixing in sexual relationships among women age 15-19: Districts . 387 Table A-17.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women by districts . 389 Table A-17.2.2 Control over men’s cash earnings: Districts . 390 Table A-17.5.1 Women’s participation in decision making by background characteristics: Districts . 391 Table A-17.5.2 Men’s attitude toward wives’ participation in decision making: Districts . 392 Table A-17.6.1 Attitude toward wife beating: Women by district . 393 Table A-17.6.2 Attitude toward wife beating: Men by districts . 394 Table A-18.1 Experience of physical violence: Districts . 395 Table A-18.4 Experience of sexual violence: Districts . 396 Table A-18.8 Violence during pregnancy: Districts . 397 Table A-18.9 Degree of marital control exercised by husbands: Districts . 398 Table A-18.11 Spousal violence by district . 399 Table A-18.13 Frequency of spousal violence among those who report violence: Districts . 400 Table A-18.17 Help seeking to stop violence: Districts . 401 Table A-19.1 Children’s living arrangements and orphanhood: Districts . 402 Table A-19.2 Orphans and vulnerable children (OVC): Districts . 403 Table A-19.3 School attendance by OVC status: Districts . 404 Table A-19.4 Possession of basic material needs by orphans and vulnerable children: Districts . 405 Table A-19.7 Widows dispossessed of property: Districts . 406 Table A-19.8 External support for very sick persons: Districts . 407 Table A-19.9 External support for orphans and vulnerable children: Districts . 408 APPENDIX B SAMPLE DESIGN AND IMPLEMENTATION Table B.1 Sample allocation of clusters and households . 410 Table B.2 Sample implementation . 414 Table B.3 Sample implementation . 415 Table B.4 Coverage of HIV testing among interviewed women by social and demographic characteristics . 416 Table B.5 Coverage of HIV testing among interviewed men by social and demographic characteristics . 417 Table B.6 Coverage of HIV testing among interviewed women by sexual behaviour characteristics . 418 Table B.7 Coverage of HIV testing among interviewed men by sexual behaviour characteristics . 419 APPENDIX C ESTIMATES OF SAMPLING ERRORS Table C.1 List of selected variables for sampling errors, Malawi DHS 2010 . 423 Table C.2 Sampling errors for national sample, Malawi 2010 . 424 Table C.3 Sampling errors for urban sample, Malawi 2010 . 425 Tables and Figures | xix Table C.4 Sampling errors for rural sample, Malawi 2010 . 426 Table C.5 Sampling errors for Northern Region sample, Malawi 2010 . 427 Table C.6 Sampling errors for Central Region sample, Malawi 2010 . 428 Table C.7 Sampling errors for Southern Region sample, Malawi 2010 . 429 APPENDIX D DATA QUALITY TABLES Table D.1 Household age distribution . 431 Table D.2.1 Age distribution of eligible and interviewed women . 432 Table D.2.2 Age distribution of eligible and interviewed men . 432 Table D.3 Completeness of reporting . 433 Table D.4 Births by calendar years . 433 Table D.5 Reporting of age at death in days . 434 Table D.6 Reporting of age at death in months . 435 Table D.7 Data on siblings . 435 Table D.8 Sibship size and sex ratio of siblings . 436 APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2010 MDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION Table E.1 Nutritional status of children . 437 Foreword | xxi FOREWORD The 2010 Malawi Demographic and Health Survey (2010 MDHS) presents the major findings of a large, nationally representative sample survey conducted by the National Statistical Office (NSO) in partnership with the Ministry of Health Community Sciences Unit (CHSU). It is the fourth survey of its kind to be conducted in Malawi, encompassing a total of 27,000 households and involving 24,000 female and 7,000 male respondents. The survey, which has expanded in sample size over the years, updates the 1992, 2000, and 2004 survey findings. The 2010 report is the second in the series to include results of HIV testing. In addition to presenting national estimates, the report provides estimates of key indicators for rural and urban areas in Malawi, the three regions, and for the first time, the 27 districts. The primary objective of the 2010 MDHS is to provide up-to-date information for policymakers, planners, researchers, and programme managers. Topics include fertility levels, nuptiality, fertility preferences, knowledge and use of family planning methods, breastfeeding practices, nutritional status of mothers and children, childhood illnesses and mortality, use of maternal and child health services, maternal mortality, and domestic violence. The survey also reports on the anaemia status of women age 15-49 and children age 6-59 months. Chapters on infectious processes cover malaria, HIV and AIDS-related knowledge and behaviour, and HIV prevalence. The 2010 MDHS results demonstrate a decline in current fertility, an increase in use of modern methods of contraception, an improvement in child vaccination rates, and expanded coverage of prior HIV testing. The NSO would like to acknowledge the efforts of a number of organizations that made the success of the 2010 survey possible. First, we would like to acknowledge the financial assistance of the government of Malawi, the United States Agency for International Development (USAID/Malawi), the President’s Emergency Plan for AIDS Relief (PEPFAR), the Centers for Disease Control and Prevention (CDC), the United Kingdom Department for International Development (DFID), the United Nations Children’s Fund (UNICEF/Malawi), and the United National Population Fund (UNFPA). We gratefully acknowledge the dedication of the core 2010 MDHS staff at NSO for managing all technical, administrative, and logistical phases of the survey. Similarly, we wish to acknowledge the technical support provided by CHSU, and we especially commend the laboratory team for their work throughout training, data collection, and HIV testing. We would also like to acknowledge ICF Macro for its technical assistance at all stages of the survey. Special mention is given to the Ministry of Health and Population, Ministry of Development Planning and Cooperation, and all members of the steering committee and various technical working groups. Finally, we wish to acknowledge the dedication and professionalism of all team members and others who worked tirelessly to produce this report. Our gratitude also goes to the survey respondents who generously gave of their time to provide the required information. Charles Machinjili Commissioner of Statistics Millennium Development Goal Indicators | xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS Goals and Indicators Value Female Male Total 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under five years of age1 11.7 14.0 12.8 2. Achieve universal primary education 2.1 Net enrollment ratio in primary education2 91.5 89.9 90.7 2.3 Literacy rate of 15-24 year olds3 77.4 81.8 79.6 3. Promote gender equality and empower women 3.1a Ratio of girls to boys in primary education4 na na 1.02 3.1b Ratio of girls to boys in secondary education4 na na 1.08 3.1c Ratio of girls to boys in tertiary education4 na na 0.74 4. Reduce child mortality 4.1 Under-five mortality rate (per 1000 live births)5 99 125 112 4.2 Infant mortality rate (per 1000 live births)5 56 76 66 4.3 Proportion of 1 year-old children immunized against measles 94.3 91.7 93.0 5. Improve maternal health 5.1 Maternal mortality ratio6 675 na na 5.2 Proportion of births attended by skilled health personnel6 na na 71.4 5.3 Contraceptive prevalence rate7 46.1 32.8 na 5.4 Adolescent birth rate8 152 na na 5.5a Antenatal care coverage: at least 1 visit by skilled health professional 97.6 na na 5.5b Antenatal care coverage: at least 4 visits by any provider 45.5 na na 5.6 Unmet need for family planning 26.1 na na 6. Combat HIV/AIDS, malaria and other diseases 6.1 HIV prevalence among population aged 15-24 5.2 1.9 3.6 6.2 Condom use at last high-risk sex: youth 15-24 years9 na 40.5 49.7 6.3 Percentage of population 15-24 years with comprehensive knowledge of HIV/AIDS10 41.8 47.7 42.2 6.4 Ratio of school attendance of orphans to school attendance of non- orphans aged 10-14 years11 0.97 0.95 0.96 6.7 Percentage of children under five sleeping under ITN 40.2 38.6 39.4 6.8 Percentage of children under five with fever who are appropriately treated with anti-malarial drugs11 43.5 43.3 43.4 Value Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved drinking water source12 91.9 76.9 79.3 7.9 Percentage of population with access to improved sanitation13 21.9 6.5 8.8 na = Not applicable 1 Proportion of children age 0-59 months who are below -2 standard deviations (SD) from the median of the WHO Child Growth Standards in weight-for-age. 2 Based on reported attendance, not enrollment. 3 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence. The total estimate is an average of the female and male literacy rate for 15-24 year olds. 4 Based on reported net attendance not gross enrollment 5 Among births in the 5-year period before the survey 6 Based on the 5-year period before survey 7 Use of any contraceptive method among women/men married or in-union aged 15 to 49 8 Age-specific fertility rates for women age 15-19 years corresponding to the 3-year period before the survey 9 Higher-risk sex refers to sexual intercourse with two or more partners in the 12 months preceding the survey 10 A person is considered to have comprehensive knowledge about HIV/AIDS when s/he knows that consistent use of a condom during sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting HIV, knows that a health-looking person can have HIV, and rejects the two most common misconceptions about HIV, i.e., that HIV can be transmitted by mosquito bites and that a person can get HIV by eating from the same plate as someone who has HIV. 11 Malaria treatment is measured as the percentage of children age 0-59 months who were ill with a fever in the two weeks preceding the interview and received anti-malarial drug. 12 Percentage of de-jure population whose main source of drinking water is a household connection (piped), public standpipe, borehole, protected dug well or spring, or rainwater collection. 13 Percentage of de-jure population with access to flush toilet, ventilated improved pit latrine, traditional pit latrine with a slab, or composting toilet. xxiv | Map of Malawi Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY, AND THE ECONOMY 1.1.1 Geography Malawi is a sub-Saharan African country located south of the equator. It is bordered to the north and northeast by the United Republic of Tanzania; to the east, south, and southwest by the People’s Republic of Mozambique; and to the west and northwest by the Republic of Zambia. The country is 901 kilometres long and 80 to 161 kilometres wide. The total area is approximately 118,484 square kilometres of which 94,276 square kilometres is land. The remaining area is mostly composed of Lake Malawi, which is about 475 kilometres long and delineates Malawi’s eastern boundary with Mozambique. Malawi’s most striking topographic feature is the Rift Valley, which runs the entire length of the country, passing through Lake Malawi in the Northern and Central Regions to the Shire Valley in the south. The Shire River drains the water from Lake Malawi into the Zambezi River in Mozambique. To the west and south of Lake Malawi lay fertile plains and mountain ranges whose peaks range from 1,700 to 3,000 metres above sea level. The country is divided into three regions: the Northern, Central, and Southern Regions. There are 28 districts in the country. Six districts are in the Northern Region, nine are in the Central Region, and 13 are in the Southern Region. Administratively, the districts are subdivided into traditional authorities (TAs), presided over by chiefs. Each TA is composed of villages, which are the smallest administrative units, and the villages are presided over by village headmen. Malawi has a tropical continental climate with maritime influences. Rainfall and temperature vary depending on altitude and proximity to the lake. From May to August, the weather is cool and dry. From September to November, the weather becomes hot. The rainy season begins in October or November and continues until April. 1.1.2 History Malawi was ruled by Britain and known as the Nyasaland protectorate from 1891 until July 1964. In 1953, the Federation of Rhodesia and Nyasaland was created, which was composed of three countries, Southern Rhodesia (now Zimbabwe), Northern Rhodesia (now Zambia), and Nyasaland (now Malawi). In July 1964, Nyasaland became the independent state of Malawi, which gained republic status in 1966. 1.1.3 Economy The economy of Malawi is based primarily on agriculture, which accounts for 30 percent of the gross domestic product (GDP). The country’s major exports are tobacco, tea, and sugar. They account for approximately 85 percent of Malawi’s domestic exports. In 2009, the agricultural sector achieved growth of 13.9 percent. Tobacco production was high following favourable prices that were offered at auction in the 2008 marketing season. In 2010, estimated growth slowed to 1.3 percent because of dry spells and heavy rains. Malawi experienced a food surplus during the 2008-2009 growing season due to favourable weather and the benefits of the government’s Farm Input Subsidy Programme (FISP). These events led to the financial growth that occurred during the 2009-2010 fiscal year. 2 | Introduction 1.2 POPULATION The major source of historical demographic data comes from the population census, which took place approximately every ten years from 1891 to 1931. After World War II, the population censuses were conducted in 1945, 1966, 1977, 1987, 1998, and 2008. Other sources of population data include nationwide surveys, such as the 1992 Malawi Demographic and Health Survey (MDHS); the 1996 Malawi Knowledge, Attitudes, and Practices in Health survey (MKAPH); the 2000 MDHS, and the 2004 MDHS. Table 1.1 shows data for demographic indicators for Malawi between 1966 and 2008. Table 1.1 Demographic indicators Selected demographic indicators, Malawi Population and Housing Census, 1966-2008 Indicators Census 1966 Census 1977 Census 1987 Census 1998 Census 2008 Population (millions) 4,039,583 5,547,460 7,988,507 9,933,868 13,077,160 Intercensal growth rate 3.3 2.9 3.7 2.0 2.8 Density (pop/sq.km) 43 59 85 105 139 Percentage of urban population 5.0 8.5 10.7 14.0 15.3 Women of childbearing age as a percentage of female population 47.6 45.1 44.2 47.2 44.4 Sex ratio 90.0 93.0 94.0 96.0 94.7 Crude birth rate na 48.3 41.2 37.9 39.5 Crude death rate na 25.0 14.1 21.1 10.4 Male na 39.2 41.4 40.0 48.3 Female na 42.4 44.6 44.0 51.4 na = Not available The population of Malawi grew from 8.0 million in 1987 to 9.9 million in 1998. The 2008 Population and Housing Census found the population to be 13.1 million, representing an increase of 32 percent, or an intercensal population growth rate of 2.8 percent per year. Population density increased from 105 persons per square kilometre in 1998 to 139 persons per square kilometre in 2008. Malawi adopted in 1994 a National Population Policy, which was designed to reduce population growth to a level compatible with Malawi’s social and economic goals (OPC, 1994). The policy’s objectives are to improve family planning and health care programmes, to increase school enrolment (with emphasis on raising the proportion of female students to half of total enrolment), and to increase employment opportunities, particularly in the private sector. Also in 1994, Malawi adopted a multiparty system and a strategy to eradicate poverty. The Malawi Growth and Development Strategy (MGDS) is a five-year strategy launched in July 2007 to reduce poverty. The MGDS is the overarching development strategy for the country. 1.3 OBJECTIVE OF THE SURVEY The 2010 Malawi Demographic and Health Survey (2010 MDHS) was implemented by the National Statistical Office (NSO) from June through November 2010, with a nationally representative sample of more than 27,000 households. All eligible women age 15-49 in these households and all eligible men age 15-54 in a subsample of one-third of the households were individually interviewed. The survey is a follow-up to the 1992, 2000, and 2004 MDHS surveys, although it expands the content and provides updated estimates of basic demographic and health indicators covered in these earlier surveys. Similar to the 2004 MDHS survey, the 2010 MDHS includes information on violence against women and HIV testing among women age 15-49 and men age 15-54. Although previous surveys collected data at the national, regional, and selected district levels, the 2010 MDHS is the first MDHS survey to collect data on basic demographic and health indicators at the district level. Introduction | 3 The primary objectives of the 2010 MDHS project are to provide up-to-date information on fertility levels; nuptiality; sexual activity; fertility preferences; awareness and use of family planning methods; breastfeeding practices; nutritional status of mothers and young children; early childhood mortality; maternal mortality; maternal and child health; malaria; awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections; and HIV prevalence. 1.4 ORGANISATION OF THE SURVEY The 2010 MDHS survey was a comprehensive survey that involved several agencies. The survey was implemented by the National Statistical Office (NSO) and the Community Health Sciences Unit (CHSU). The funding for the MDHS was provided by the Government of the Republic of Malawi, the National AIDS Commission (NAC), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Kingdom’s Department for International Development (DFID), the Centers for Disease Control and Prevention (CDC), and the United States Agency for International Development (USAID). Technical assistance was provided by ICF Macro through the MEASURE DHS programme, a USAID-funded project. 1.5 SAMPLE DESIGN The sample for the 2010 MDHS was designed to provide population and health indicator estimates at the national, regional, and district levels. The sample design allowed for specific indicators, such as contraceptive use, to be calculated for each of the country’s 3 regions and 27 districts (Nkhata Bay and Likoma are combined). The sampling frame used for the 2010 MDHS was the 2008 Malawi Population and Housing Census (PHC), which was provided by the National Statistical Office. Administratively, Malawi is divided into 28 districts. Each district is subdivided into smaller administrative units. During the 2008 PHC, which was designed and carried out by the National Statistical Office, each of the districts was subdivided into enumeration areas (EAs), also referred to as clusters, where each EA as a whole was classified as urban or rural. The 2010 MDHS sample was selected using a stratified, two-stage cluster design, with EAs being the sampling units for the first stage. The 2010 MDHS sample included 849 clusters: 158 in urban areas and 691 in rural areas.1 The 849 clusters were not allocated among the districts in proportion to their contribution to the national population because this would have left smaller districts and regions with too few clusters to represent them. For example, districts in the Northern Region were oversampled to take into account its smaller population size. In most districts in Malawi, more than 90 percent of the population resides in rural areas, so urban areas were also oversampled. A complete listing of households was done in each of the MDHS clusters from May to June 2009. The list of households served as a sampling frame for selection of households. Households comprised the second stage of sampling. A minimum sample size of 950 households was required per district to provide an acceptable level of precision for the indicators measured in the survey. A representative sample of 27,345 households was selected for the 2010 MDHS survey. A subsample of one-third of the households was selected to conduct HIV testing for eligible women age 15-49 and eligible men age 15-54. In the same subsample of households, anaemia testing was conducted for eligible children age 6-59 months and eligible women age 15-49 years, and anthropometric measures were taken for eligible children age 0-5 years and eligible women age 15- 1 The final survey sample included all of the selected 849 clusters. However, during fieldwork some of these clusters were found to be dramatically smaller than they were at the time of listing. The sample size did not reach the expected number of households for eight clusters, despite selecting every household in these clusters, resulting in a net decrease of 38 households between the sample design and fieldwork. 4 | Introduction 49. Additionally, domestic violence questions were asked of one eligible woman per household in the same subsample of households. 1.6 QUESTIONNAIRES Three questionnaires were used for the 2010 MDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires were adapted to reflect the population and health issues relevant to Malawi. Issues were identified at a series of meetings with various stakeholders from government ministries and agencies, nongovernmental organisations, and development partners. In addition to English, the questionnaires were translated into two major languages, Chichewa and Tumbuka. The Household Questionnaire was used to list all the usual members and visitors of selected households. Basic information was collected on the characteristics of each person listed, including his or her age, sex, education, and relationship to the head of the household. For children under age 18, survival status of the parents was determined. If a child in the household had a parent who was sick for more than three consecutive months in the 12 months preceding the survey or had a parent who had died during the 12 months preceding the survey, additional questions relating to support for orphans and vulnerable children were asked. Further, if an adult in the household was sick for more than three consecutive months in the 12 months preceding the survey or an adult in the household had died in the past 12 months, questions were asked relating to support for sick people or those who have died. The data on the age and sex of household members obtained in the Household Questionnaire was used to identify women and men who were eligible for the individual interview. Additionally, the Household Questionnaire collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, and ownership and use of mosquito nets (to assess the coverage of malaria prevention programmes). The Household Questionnaire was also used to record height and weight measurements for eligible children age 0-59 months and eligible women age 15-49 years. The Woman’s Questionnaire was used to collect information from all eligible women age 15- 49. These women were asked questions on the following main topics: • Background characteristics (education, residential history, media exposure, etc.) • Birth history and childhood mortality • Knowledge and use of family planning methods • Fertility preferences • Antenatal, delivery, and postnatal care • Breastfeeding and infant feeding practices • Women’s and children’s nutritional status • Vaccinations and childhood illnesses • Marriage and sexual activity • Women’s work and husband’s background characteristics • Malaria prevention and treatment • Awareness and behaviour regarding AIDS and other sexually transmitted infections (STIs) • Adult mortality, including maternal mortality • Domestic violence The Man’s Questionnaire was administered to all eligible men age 15-54 in every third household in the 2010 MDHS sample. This questionnaire collected much of the same information found in the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition. Introduction | 5 1.7 HIV AND ANAEMIA TESTING In a subsample of one-third of all households, blood specimens were collected for anaemia testing from children age 6-59 months and women age 15-49 years who voluntarily consented to the testing. Additionally, in every third household, blood specimens were collected for HIV testing from all women age 15-49 and men age 15-54 who consented to the test. The protocol for the blood specimen collection and the testing for HIV was reviewed and approved by the Malawi Health Sciences Research Committee, the Institutional Review Board of ICF Macro, and the Centres for Disease Control and Prevention (CDC) in Atlanta. Women and men who were interviewed in the 2010 MDHS were asked to voluntarily provide five drops of blood for HIV testing. The protocol for the blood specimen collection and analysis was based on the anonymous linked protocol developed for MEASURE DHS. This protocol allows for the merging of the HIV test results with the sociodemographic data collected in the individual questionnaires, provided that information that could potentially identify an individual is destroyed before data linking takes place. Interviewers explained the procedure, the confidentiality of the data, and the fact that the test results would not be made available to the respondent. They also explained the option of dried blood spot (DBS) storage for use in additional testing. If a respondent consented to the HIV testing, five blood spots from the finger prick were collected on a filter paper card to which a bar code label unique to the respondent was affixed. If the respondent did not consent to additional testing using their sample, it was indicated on the questionnaire that the respondent refused additional tests using their specimen, and the words ‘no further testing’ were written on the filter paper card. Each household, whether individuals consented to HIV testing or not, was given an information brochure on HIV/AIDS and a list of fixed sites providing voluntary counselling and testing (VCT) services in surrounding districts within the region. Each DBS sample was given a bar code label, with a duplicate label attached to the Individual Questionnaire. A third copy of the same bar code was affixed to the Blood Sample Transmittal Form to track the blood samples from the field to the laboratory. DBS samples were dried overnight and packaged for storage the following morning. Samples were periodically collected in the field, along with the corresponding completed questionnaires for each completed cluster, and transported to the NSO in Zomba to be logged in, checked, and then transported to the Community Health Sciences Unit (CHSU) in Lilongwe. Upon arrival at CHSU, each DBS sample was logged into the CSPro HIV Test Tracking System (CHTTS) database, given a laboratory number, and stored at -20˚C until tested. According to the HIV testing protocol, testing on all samples could only be conducted after all of the questionnaire data entry was completed, verified, and cleaned, and all unique identifiers were removed from the questionnaire file except the barcode number. HIV testing began in February 2011. The testing protocol was to test all samples on the first assay test, an ELISA, Vironostika® HIV Uni-Form II Plus O, Biomerieux. A negative result was considered negative. All samples with positive results were subjected to a second ELISA test by Enzygnost® Anti-HIV 1/2 Plus, Dade Behring. Positive samples on the second test were considered positive. If the first and second tests were discordant, the sample was retested with tests 1 and 2. If on repetition of tests 1 and 2, both results were negative, the sample was rendered negative. If both results were positive, the sample was rendered positive. If there was still a discrepancy in the results after repeating tests 1 and 2, a third confirmatory test, Western Blot 2.2, Abbott Labs, was administered. The final result was rendered positive if the Western Blot (WB) confirmed the result to be positive and rendered negative if the WB confirmed it to be negative. If the Western Blot results were indeterminate, the sample was rendered indeterminate. Upon finalising HIV testing, the HIV test results for the 2010 MDHS were entered into a spreadsheet with a barcode as the unique identifier to the result. Data from the HIV results and linked demographic and health data are included in this 2010 MDHS Final Report. 6 | Introduction 1.8 PRETEST The training for the pretest took place from January through February 2010. Twelve interviewers (six females and six males) and five supervisors were trained to administer the questionnaires. Two laboratory scientists from CHSU and a biomarker specialist from ICF Macro trained interviewers to take anthropometric measurements and collect blood for anaemia and HIV testing. The pretest training for the interviewers and supervisors focused on survey objectives, techniques of interviewing, field procedures, and all sections of the household and individual questionnaires. Blood specimen collection procedures were demonstrated and practiced, and two days of field practice were held. The trainers/resource persons included professionals from NSO and ICF Macro. The pretest fieldwork was conducted in the Northern, Central, and Southern Regions of Malawi by three teams. The teams were divided according to languages spoken by team members. There was one Tumbuka team in the North and two Chichewa teams, one each in the Central and the Southern Regions. The supervisors and editors were drawn from the NSO core technical team. The teams covered 12 enumeration areas, half in urban areas and half in rural areas. At the end of the fieldwork, a debriefing session was held at NSO among all staff involved in the pretest, and the questionnaires were amended based on the pretest findings. 1.9 TRAINING OF FIELD STAFF NSO recruited and trained 318 people for the fieldwork to serve as supervisors, field editors, female and male interviewers, reserve interviewers, and quality control interviewers. Training of field staff for the main survey was conducted during a four-week period in May through June 2010. Specialists in various areas such as HIV/AIDS, malaria, and family planning were invited as guest lecturers. The training course consisted of instruction regarding interviewing techniques and field procedures, a detailed review of items on the questionnaires, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews with real respondents in areas outside the 2010 MDHS sample points. During this period, field editors, team supervisors, and quality control interviewers were provided with additional training in methods of field editing, data quality control procedures, and fieldwork coordination. Thirty-seven supervisors, 37 editors, 148 female interviewers, and 74 male interviewers were selected to make up 37 data collection teams for the 2010 MDHS. Six people were selected to be quality control interviewers. 1.10 FIELDWORK Thirty-seven interviewing teams carried out data collection for the 2010 MDHS. Each team consisted of one supervisor (team leader), one field editor, four female interviewers, two male interviewers, and one driver. Six senior staff members from NSO, one ICF Macro resident advisor, and one ICF Macro consultant coordinated and supervised fieldwork activities. Data collection took place over a six-month period, from June through November 2010. 1.11 DATA PROCESSING All questionnaires for the 2010 MDHS were returned to the NSO headquarters office in Zomba for data processing, which consisted of office editing, coding of open-ended questions, data entry, and editing computer-identified errors. The data were processed by a team of 38 data entry operators, 6 office editors, and 3 data entry supervisors. Data entry and editing were accomplished using the CSPro software. The processing of data began in June 2010 and was completed in December 2010. Introduction | 7 1.12 RESPONSE RATES The household and individual response rates for the 2010 MDHS are shown in Table 1.2. For the sample, a total of 27,307 households were selected, and of these, 25,311 were occupied. Of the 25,311 households found, 24,825 were successfully interviewed, yielding a response rate of 98 percent. In the interviewed households, a total of 23,748 women were identified to be eligible for the individual interview, of which 97 percent were successfully interviewed. Among men, 7,783 were identified as eligible, and 92 percent were successfully interviewed. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Malawi 2010 Result Residence Total Urban Rural Household interviews Households selected 3,157 24,150 27,307 Households occupied 2,965 22,346 25,311 Households interviewed 2,909 21,916 24,825 Household response rate1 98.1 98.1 98.1 Interviews with women age 15-49 Number of eligible women 3,179 20,569 23,748 Number of eligible women interviewed 3,068 19,952 23,020 Eligible women response rate2 96.5 97.0 96.9 Interviews with men age 15-54 Number of eligible men 1,130 6,653 7,783 Number of eligible men interviewed 1,014 6,161 7,175 Eligible men response rate2 89.7 92.6 92.2 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 9 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter summarises demographic and socioeconomic characteristics of the population in households sampled during the 2010 MDHS. Information on housing characteristics is also provided. For the 2010 MDHS, a household was defined as a person or a group of persons, related or unrelated, who live together and share common cooking and eating arrangements. The Household Questionnaire included a schedule for collecting basic demographic and socioeconomic information (e.g., age, sex, educational attainment, and current school attendance) for all usual residents and visitors who slept in the household the night preceding the interview. This method of data collection allowed for analysis of the results for either the de jure population (usual residents) or the de facto population (persons in the household at the time of the survey). The Household Questionnaire also was used to obtain information on housing facilities, including dwelling characteristics, source of water supply, sanitation facilities, and household assets. The information in this chapter is intended to facilitate interpretation of key demographic, socioeconomic, and health indices presented later in the report. It will also assist in the assessment of the representativeness of the survey sample.1 2.1 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE Age and sex, which are important demographic variables, are the primary basis for demographic classification. They are also important variables in the study of mortality, fertility, and nuptiality. The distribution by five-year age groups of the de facto household population in the 2010 MDHS is shown in Table 2.1, according to sex and residence. The 24,825 households successfully interviewed in the 2010 MDHS consisted of 113,574 persons; 58,414 were women representing 51 percent of the population, and 55,159 were men, representing 49 percent of the population. The distribution shows that the younger age groups make up the higher proportion of the household population in both urban and rural areas. Sixty-seven percent of the total population is under age 25, while 4 percent of the population is age 65 or older. 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, Malawi 2010 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 14.5 15.0 14.8 17.8 17.4 17.6 17.3 17.0 17.2 5-9 14.4 15.2 14.8 18.0 17.1 17.5 17.4 16.8 17.1 10-14 11.9 12.9 12.4 15.7 14.5 15.1 15.1 14.3 14.7 15-19 12.3 11.2 11.7 10.3 8.6 9.4 10.6 9.0 9.8 20-24 10.8 10.9 10.9 6.9 7.6 7.3 7.6 8.1 7.8 25-29 10.7 11.0 10.8 6.1 7.2 6.6 6.8 7.7 7.3 30-34 8.3 7.3 7.8 5.2 5.5 5.4 5.7 5.8 5.8 35-39 5.7 4.4 5.1 4.7 4.4 4.5 4.8 4.4 4.6 40-44 3.2 3.0 3.1 3.1 3.1 3.1 3.1 3.1 3.1 45-49 2.4 2.7 2.6 2.7 2.7 2.7 2.6 2.7 2.7 50-54 1.9 2.2 2.1 2.2 2.8 2.5 2.2 2.7 2.5 55-59 1.4 1.2 1.3 1.9 2.2 2.1 1.8 2.1 1.9 60-64 1.2 1.1 1.1 1.8 2.0 1.9 1.7 1.9 1.8 65-69 0.5 0.8 0.7 1.2 1.5 1.3 1.1 1.4 1.2 70-74 0.4 0.4 0.4 0.9 1.2 1.1 0.8 1.1 1.0 75-79 0.3 0.2 0.2 0.7 1.0 0.9 0.6 0.9 0.8 80+ 0.2 0.3 0.3 0.7 1.2 0.9 0.6 1.0 0.8 Don’t know/ missing 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 9,079 8,817 17,896 46,080 49,597 95,677 55,159 58,414 113,574 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 10 | Household Population and Housing Characteristics Figure 2.1 illustrates the age structure of the Malawi household population in a population pyramid. A feature of population pyramids is their strength in illustrating whether a population is young or old. The broad base of the pyramid indicates that Malawi’s population is young. This scenario is typical of countries with high fertility rates. Figure 2.1 Population Pyramid MDHS 2010 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 <5 Ag e g r ou p 0246810 0 2 4 6 8 10 Percent MaleFemale 2.2 HOUSEHOLD COMPOSITION Information on key aspects of household composition, including sex of the household head and size of the household, is presented in Table 2.2. These characteristics are important because they are associated with household welfare. Female-headed households are, for example, typically poorer than male-headed households. Economic resources are often more limited in larger households. Moreover, where the size of the household is large, crowding also can lead to health problems. Table 2.2 shows that households in Malawi are predominantly headed by men (72 percent). This figure has remained relatively constant through all of the DHS surveys in Malawi: it was 75 percent in 1992, 73 percent in 2000, and 75 percent in 2004. Households headed by women are more common in rural areas (30 percent) than in urban areas (21 percent). The 2010 MDHS results indicate that the average household size is 4.6 persons, with rural households (4.7 persons) having slightly more members than urban households (4.4 persons). This shows that a modest increase in household size has occurred in the five years since the 2004 MDHS when households averaged 4.4 household members. Table 2.2 further provides information on the proportion of households with foster children (that is, children 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, 33 percent of households contain foster children or orphans. The proportion of households with foster children (28 percent) is higher than the proportion with double orphans (4 percent) or the proportion with single orphans (15 percent). There are no differences across urban and rural areas in the proportion of households with foster children and orphans. Household Population and Housing Characteristics | 11 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 18, according to residence, Malawi 2010 Characteristic Residence Total Urban Rural Household headship Male 79.3 70.5 71.9 Female 20.7 29.5 28.1 Total 100.0 100.0 100.0 Number of usual members 0 0.1 0.1 0.1 1 8.8 6.4 6.8 2 11.3 9.6 9.9 3 17.7 15.7 16.1 4 17.5 18.3 18.2 5 16.6 16.7 16.7 6 11.1 13.8 13.4 7 7.0 9.2 8.9 8 5.3 5.1 5.1 9+ 4.5 5.0 5.0 Total 100.0 100.0 100.0 Mean size of households 4.4 4.7 4.6 Percentage of households with orphans and foster children under 18 Foster children1 27.8 27.9 27.9 Double orphans 5.1 4.3 4.4 Single orphans2 14.5 14.7 14.7 Foster and/or orphan children 32.6 33.3 33.2 Number of households 4,116 20,709 24,825 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households where neither their mother nor their father is a de jure resident. 2 Includes children with one dead parent and an unknown survival status of the other parent. 2.3 EDUCATION OF HOUSEHOLD POPULATION Education is a key determinant of the lifestyle and societal status an individual enjoys. Studies have consistently shown that educational attainment is strongly associated with health-related behaviours and attitudes. In the 2010 MDHS, information on education, including school attendance and educational attainment, was collected for every household member. In Malawi, official primary school age is age 6-13; students enter primary school at age 6. They stay in primary school for eight years, and at the end they sit for a Primary School Leaving Certificate (PSLCE). Students who receive the certificate qualify to start secondary education; the official age for the secondary school level is age 14-17. Secondary school lasts four years and is divided into two sets of two-year courses. At the end of the first two years, students sit for the Junior Certificate of Education (JCE). At the end of the second set of courses, they sit for the Malawi School Certificate of Education (MSCE) and the General School Certificate of Education (GCSE). Tertiary education consists of public and private universities and technical colleges. 2.3.1 Educational Attainment Tables 2.3.1 and 2.3.2 present data on educational attainment for female and male household members age 6 and older. Results from both tables indicate that, overall, more females than males have never attended school (19 percent compared with 11 percent). Figure 2.2 shows the percentage of males and females who have never attended school by age group. The proportion that has never attended school is higher for females than for males across all age groups except for those under age 14. The proportion of respondents with some primary education is about the same among men (65 percent) and women (64 percent), as is the proportion of men and women completing the primary 12 | Household Population and Housing Characteristics level of education (7 percent each). However, more men than women have attended or completed secondary education (17 percent compared to 11 percent). There are some urban-rural differences in educational attainment. More than 20 percent of the women in rural areas (21 percent) have no education at all; in comparison, 9 percent of women in urban areas lack education. The trend is the same for men; 13 percent in rural areas have no education, which compares with 5 percent in urban areas. With the exception of the youngest age group, some of whom will begin to attend school in the future, the proportion with no education increases steadily with age for both men and women. For example, the proportion of women who have never attended any formal schooling increases from 11 percent among those age 25-29 to 60 percent among those age 65 and older. For men, the proportion increases from 7 percent for those age 25-29 to 31 percent for those age 65 and older. The proportion of the population that has attained education varies greatly by region. The Southern and Central Regions have higher proportions of women without education, 21 percent and 20 percent respectively, compared with 9 percent in the Northern Region. Among men, 12 and 13 percent in the Southern and Central Regions, respectively, have never attended school while 5 percent in the Northern Region have no education. As expected, the proportion with no education consistently declines as wealth quintile level increases. The median number of years of schooling completed is 2.5 years for women and 3.5 years for men. This number is much higher in urban areas than in rural areas: 5.3 years compared with 2.1 for women, and 6.9 years compared with 3.0 for men. Median years of schooling completed increases steadily with increasing wealth quintile index for both men and women. Median years completed also varies across the regions of Malawi, with the Northern Region having the highest figures (4.3 for women and 4.9 for men), followed by the Southern Region (2.3 for women and 3.3 for men), and finally the Central Region (2.2 for women and 3.2 for men). Overall there has been progress in educational attainment since the 2004 MDHS: the proportion with no education has decreased, and the proportion with primary education has increased. In the 2004 MDHS, 30 percent of women and 20 percent of men had no education at all; these proportions have decreased to 19 percent and 11 percent. The median number of school years completed has increased from 3.1 to 3.5 for men and from 1.8 to 2.5 for women. Household Population and Housing Characteristics | 13 Table 2.3.1 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, Malawi 2010 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 18.6 80.7 0.1 0.0 0.0 0.0 0.6 100.0 7,790 0.4 10-14 2.7 88.0 7.7 1.2 0.0 0.0 0.3 100.0 8,343 2.8 15-19 3.5 59.6 14.0 19.2 3.1 0.5 0.2 100.0 5,267 5.7 20-24 7.8 54.7 10.0 15.8 8.7 2.6 0.4 100.0 4,724 5.7 25-29 10.7 55.9 8.9 13.4 8.3 2.5 0.1 100.0 4,518 5.5 30-34 18.1 55.1 7.7 9.5 7.9 1.6 0.1 100.0 3,371 3.9 35-39 30.6 53.3 6.2 4.8 3.3 1.8 0.1 100.0 2,567 2.4 40-44 34.5 50.8 6.3 4.5 1.5 2.2 0.2 100.0 1,791 2.2 45-49 37.7 52.0 5.9 2.1 1.3 0.8 0.2 100.0 1,599 1.5 50-54 44.7 46.7 3.8 2.2 1.0 0.8 0.8 100.0 1,605 0.5 55-59 49.2 43.9 3.1 1.5 0.2 1.2 1.0 100.0 1,207 0.0 60-64 52.6 42.0 2.7 0.7 0.0 0.9 1.1 100.0 1,092 0.0 65+ 59.6 36.8 1.0 0.3 0.1 0.1 2.2 100.0 2,565 0.0 Residence Urban 8.5 54.2 7.1 15.6 9.6 4.9 0.2 100.0 7,155 5.3 Rural 20.7 65.3 6.5 5.0 1.7 0.3 0.5 100.0 39,310 2.1 Region Northern 9.1 69.0 9.1 8.8 3.1 0.5 0.4 100.0 5,491 4.3 Central 19.8 64.0 6.4 6.0 2.6 0.8 0.4 100.0 20,060 2.2 Southern 20.5 61.7 6.0 6.7 3.2 1.3 0.5 100.0 20,913 2.3 Wealth quintile Lowest 29.8 63.4 4.6 1.5 0.2 0.0 0.5 100.0 9,692 1.0 Second 24.6 65.4 6.3 2.8 0.4 0.0 0.5 100.0 9,217 1.6 Middle 18.7 67.8 7.6 4.5 0.9 0.0 0.5 100.0 9,063 2.3 Fourth 14.8 67.4 7.4 7.6 2.2 0.2 0.5 100.0 9,176 3.0 Highest 5.9 54.1 7.0 17.0 11.0 4.7 0.3 100.0 9,317 5.9 Total 18.9 63.6 6.5 6.7 2.9 1.0 0.5 100.0 46,465 2.5 Note: Total includes 28 unweighted cases with information missing on educational attainment. 1 Completed 8th grade at the primary level 2 Completed 4th grade at the secondary level Table 2.3.2 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, Malawi 2010 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 20.5 78.8 0.1 0.0 0.0 0.0 0.6 100.0 7,652 0.4 10-14 4.1 88.8 6.3 0.4 0.0 0.0 0.3 100.0 8,331 2.6 15-19 4.4 62.3 13.4 17.4 2.0 0.2 0.2 100.0 5,842 5.4 20-24 5.3 45.5 6.9 23.7 14.8 3.5 0.3 100.0 4,170 7.2 25-29 7.4 46.5 8.2 16.8 16.3 4.7 0.1 100.0 3,773 6.9 30-34 9.3 46.8 6.4 15.6 18.0 3.7 0.2 100.0 3,161 6.9 35-39 12.3 52.8 7.1 10.6 13.1 3.9 0.2 100.0 2,673 5.8 40-44 13.5 57.3 7.0 8.9 8.2 4.9 0.2 100.0 1,709 5.9 45-49 15.1 61.8 6.9 7.3 4.9 3.8 0.3 100.0 1,460 4.9 50-54 17.2 59.2 8.0 6.9 5.2 3.0 0.5 100.0 1,189 5.0 55-59 21.2 56.6 7.4 6.0 5.3 3.0 0.6 100.0 997 4.0 60-64 29.2 52.4 6.4 5.9 4.0 1.3 0.9 100.0 955 2.8 65+ 30.9 55.9 6.0 4.0 1.2 0.8 1.2 100.0 1,736 1.8 Residence Urban 4.7 49.4 5.7 17.1 16.3 6.5 0.2 100.0 7,459 6.9 Rural 12.8 67.8 6.7 7.5 4.0 0.8 0.4 100.0 36,209 3.0 Region Northern 5.2 68.2 8.0 11.3 5.8 1.2 0.3 100.0 5,230 4.9 Central 12.5 65.1 6.8 8.3 5.6 1.4 0.3 100.0 19,158 3.2 Southern 12.0 63.3 5.8 9.4 6.6 2.3 0.5 100.0 19,279 3.3 Wealth quintile Lowest 20.2 69.6 5.5 3.5 0.8 0.0 0.4 100.0 7,742 1.8 Second 16.5 70.0 6.6 5.0 1.4 0.0 0.5 100.0 8,486 2.4 Middle 10.7 71.0 7.5 7.5 3.0 0.1 0.4 100.0 8,653 3.1 Fourth 8.6 66.2 7.2 11.1 6.0 0.5 0.5 100.0 9,153 4.0 Highest 3.2 48.9 5.9 16.9 17.3 7.5 0.2 100.0 9,634 7.1 Total 11.4 64.7 6.5 9.1 6.1 1.8 0.4 100.0 43,668 3.5 Note: Total includes 21 unweighted cases with information missing on educational attainment. 1 Completed 8th grade at the primary level 2 Completed 4th grade at the secondary level 14 | Household Population and Housing Characteristics Figure 2.2 Distribution of Household Population with No Education by Sex MDHS 2010 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Age 0 20 40 60 80 Percent Female Male 2.3.2 School Attendance Rates The 2010 MDHS collected information that allows the calculation of net attendance ratios (NARs) and gross attendance ratios (GARs). The NAR for primary school is the percentage of the primary-school-age population (age 6-13) that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age population (age 14-17) that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR for primary school is the total number of primary school students, of any age, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, of any age, 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. Youth are considered to be attending school currently if they attended formal academic school at any point during the given school year. The gender parity index (GPI) assesses sex-related differences in school attendance rates and is calculated by dividing the GAR for females by the GAR for males. A GPI that is less than one indicates a gender disparity in favor of males (i.e., a higher proportion of males than females attends that level of schooling). A GPI that exceeds one indicates a gender disparity in favor of females. A GPI of one indicates parity or equality between the rates of participation for males and females. Table 2.4 shows the NARs and GARs for the de facto household population by sex, level of schooling, and GPI, according to background characteristics. Results show that the overall NAR for primary schools is 91 percent, while the GAR is 152 percent. This is an improvement from the 2004 MDHS figures, which indicated an overall primary NAR of 82 percent and a GAR of 106 percent. The primary NAR is slightly higher for female children (92 percent) than for male children (90 percent), and the GAR is higher for males than for females. This might indicate that there are more underage or overage male students attending primary school as compared with females. The primary gender parity index for GAR of 0.95 indicates that there are more male students than female students attending primary school. The same trend was observed in the 2004 MDHS where the GPI was 0.94. There are variations in primary NAR, GAR, and GPI between urban and rural households. Overall, the NAR is higher for urban populations (95 percent) than for rural populations (90 percent). Household Population and Housing Characteristics | 15 The GAR is also slightly higher in urban areas than in rural areas (154 and 152 percent, respectively). Across the regions, the primary school NAR is higher in the Northern Region (97 percent) and lower in the Central and Southern Regions (90 percent in both). Similarly, the primary school GAR is higher in the Northern Region (165 percent) than in the Southern and Central Regions (150 percent in both). There is a consistent increase in the primary NAR and GAR as the wealth quintile index increases. Results for the 2010 MDHS show that the secondary school NAR has increased from 11 percent in the 2004 MDHS to 12 percent, while the GAR has decreased from 30 percent in the 2004 MDHS to 20 percent. The secondary NAR is slightly higher for females than males (13 and 12 percent, respectively), while there is a more pronounced difference between males and females for secondary GAR (22 and 17 percent, respectively). The overall secondary school GPI for GAR of 0.77 indicates that there are more males than females attending secondary school. Table 2.4 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Malawi 2010 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index PRIMARY SCHOOL Residence Urban 96.3 94.6 95.4 0.98 160.8 146.7 153.6 0.91 Rural 88.9 91.0 90.0 1.02 155.4 147.9 151.7 0.95 Region Northern 96.6 96.8 96.7 1.00 170.8 158.3 164.7 0.93 Central 88.8 90.6 89.7 1.02 154.1 146.3 150.1 0.95 Southern 89.1 91.0 90.0 1.02 154.0 146.3 150.1 0.95 Wealth quintile Lowest 82.4 84.0 83.2 1.02 138.6 131.8 135.2 0.95 Second 87.1 89.7 88.5 1.03 153.3 143.6 148.3 0.94 Middle 90.8 92.3 91.6 1.02 159.0 149.6 154.4 0.94 Fourth 92.4 95.0 93.7 1.03 165.3 155.4 160.3 0.94 Highest 97.4 97.7 97.5 1.00 166.0 160.7 163.4 0.97 Total 89.9 91.5 90.7 1.02 156.1 147.8 151.9 0.95 SECONDARY SCHOOL Residence Urban 28.1 30.3 29.2 1.08 47.5 40.8 44.2 0.86 Rural 8.6 9.1 8.8 1.06 17.3 12.4 14.9 0.72 Region Northern 13.3 16.6 15.0 1.25 25.4 20.9 23.2 0.82 Central 8.8 10.4 9.6 1.18 18.5 14.3 16.4 0.77 Southern 14.2 13.8 14.0 0.97 25.0 19.0 22.1 0.76 Wealth quintile Lowest 3.4 3.0 3.2 0.88 7.6 4.0 5.9 0.52 Second 3.7 5.1 4.4 1.37 9.2 6.8 8.0 0.75 Middle 6.6 7.2 6.9 1.10 14.1 9.5 12.0 0.67 Fourth 12.5 12.2 12.3 0.98 23.8 16.8 20.5 0.71 Highest 29.0 30.5 29.8 1.05 50.4 41.5 45.9 0.82 Total 11.8 12.7 12.2 1.08 22.2 17.2 19.8 0.77 1 The NAR for primary school is the percentage of the primary-school age (6-13 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (14-17 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. 16 | Household Population and Housing Characteristics There are differentials between urban and rural populations regarding secondary NAR. A much higher proportion of urban students of appropriate ages are attending secondary school (29 percent) than are rural students (9 percent). The GAR similarly indicates that the urban population is more likely to attend secondary school than their rural counterparts (44 percent and 15 percent, respectively). There are considerable differences in secondary NAR across the regions, with the Central Region having the lowest NAR at 10 percent and the Northern and Southern Regions having NARs of 15 and 14 percent, respectively. The GAR is also lowest in the Central Region (16 percent) while the Southern and Northern Regions stand at 22 and 23 percent, respectively. Secondary NAR and secondary GAR vary consistently across the wealth quintile index, with populations living in higher wealth quintile households more likely to attend secondary school than their counterparts in lower wealth quintile households. 2.3.3 Grade Repetition and Dropout Rates Repetition rates and dropout rates shown in Table 2.5 describe the flow of pupils at the primary level through the educational system in Malawi. The repetition rates and dropout rates were computed from information about the grade or standard that children were attending during the previous school year. The table shows that repetition rates are high in Standard 1 (45 percent); no improvement has occurred since the same figure was reported in the 2004 MDHS. After Standard 1, there is a decline in repetition rates until Standard 8, where they increase sharply. This is a trend similar to that reported in the 2004 MDHS. There are no consistent differences in repetition rates between the sexes and across the grades, although at Standard 8 the rate is slightly higher for females than for males (26 and 24 percent, respectively). Repetition rates according to place of residence show no consistent pattern; however, for Standard 8, rural students are more likely to repeat the year than their urban counterparts. The second panel of Table 2.5 shows the expected pattern of increasing dropout rates with increasing years in school. Three percent of children drop out of school after attending Standard 1, but 17 percent drop out at Standard 8, up from 10 percent in the 2004 MDHS. There are no substantial differences in dropout rates between males and females. Rural children are more likely than urban children to drop out at all grades. Table 2.5 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Malawi 2010 Background characteristic School grade 1 2 3 4 5 6 7 8 REPETITION RATE1 Sex Male 45.1 22.0 25.2 18.5 16.3 19.3 14.0 23.8 Female 45.0 21.6 22.9 19.2 16.7 14.5 11.7 26.0 Residence Urban 39.2 14.8 24.0 15.0 19.9 20.3 12.4 11.2 Rural 45.8 22.7 24.1 19.5 15.9 16.1 13.0 28.9 Region Northern 37.4 18.8 22.3 18.3 14.0 17.7 19.1 42.5 Central 45.4 20.6 24.1 19.3 17.2 16.6 8.2 20.8 Southern 46.5 23.8 24.5 18.6 16.8 16.9 14.8 19.9 Wealth quintile Lowest 47.8 24.1 26.1 23.3 17.1 18.2 13.3 34.3 Second 49.7 25.3 27.1 19.5 15.8 15.7 15.1 31.2 Middle 43.0 22.6 23.6 20.1 18.1 16.7 12.3 24.4 Fourth 44.6 19.4 26.0 18.6 15.3 16.8 10.2 23.9 Highest 37.0 16.4 17.3 14.7 16.4 17.2 14.3 20.8 Total 45.1 21.8 24.0 18.8 16.5 16.9 12.9 24.7 Continued… Household Population and Housing Characteristics | 17 Table 2.5—Continued Background characteristic School grade 1 2 3 4 5 6 7 8 DROPOUT RATE2 Sex Male 2.4 2.1 3.0 4.7 4.0 6.2 8.4 16.6 Female 2.8 1.7 3.1 4.0 5.7 6.9 12.0 17.0 Residence Urban 1.3 0.9 2.9 3.9 2.7 2.5 7.2 11.6 Rural 2.7 2.0 3.1 4.4 5.3 7.6 11.0 18.3 Region Northern 0.4 0.4 1.3 2.2 2.0 7.2 5.3 13.2 Central 2.8 2.1 4.6 5.6 7.1 6.4 12.7 21.0 Southern 2.9 2.0 2.2 3.9 3.8 6.5 9.7 14.7 Wealth quintile Lowest 4.1 3.3 5.6 8.2 6.9 11.5 16.9 21.2 Second 3.0 3.2 2.9 4.4 7.4 6.2 17.1 25.4 Middle 2.2 1.6 2.6 4.9 6.0 7.8 9.7 21.2 Fourth 2.1 0.9 2.4 4.0 3.3 8.9 12.3 15.8 Highest 0.9 0.1 2.0 1.6 2.6 2.1 3.1 11.5 Total 2.6 1.9 3.1 4.4 4.8 6.6 10.1 16.7 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school. Figure 2.3 shows the age-specific attendance rates for the male and female de facto population age 5-24. There are no marked differences in attendance rates between males and females age 5 to 15; however, attendance rates for males older than age 15 are much higher than rates for females. Figure 2.3 Age-specific Attendance Rates MDHS 2010 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age (years) 0 20 40 60 80 100 Percent Female Male 2.4 HOUSEHOLD ENVIRONMENT The 2010 MDHS provides indicators of physical characteristics of household dwelling units and of access to drinking water and sanitation facilities. These indicators are important for socioeconomic planning and monitoring of programmes aimed at the improvement of health status of individuals. Respondents were asked a number of questions about their housing environment, 18 | Household Population and Housing Characteristics including their source of drinking water; type of sanitation facility; type of dwelling construction materials; number of rooms in the dwelling; access to electricity; usage of solid fuels; and possession of durable goods. The results are presented both for households and for the de jure population. 2.4.1 Improved Drinking Water One of the Millennium Development Goals (MDGs) that Malawi and other countries have adopted is to increase the percentage of the population with sustainable access to an improved water source in both urban and rural areas. Improved water sources refer to a household connection (piped), public standpipe, tube well or borehole, protected dug well, and protected spring or rainwater. However, water that must be fetched from an improved source that is not immediately accessible to the household may be contaminated during transport or storage. Long distances to an improved source of water and a disproportionate burden on female members of the household to collect water may limit the quantity of suitable drinking water available to a household. Home water treatment can improve the quality of household drinking water. Table 2.6 includes a number of indicators that are useful in monitoring household access to improved drinking water. Table 2.6 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, Malawi 2010 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 92.6 77.1 79.7 91.9 76.9 79.3 Piped water into dwelling/yard/plot 31.0 1.8 6.6 32.2 1.8 6.6 Public tap/standpipe 45.3 10.1 15.9 43.7 9.8 15.1 Tube well or borehole 12.8 58.8 51.2 12.8 59.1 51.8 Protected dug well 3.4 6.0 5.5 3.1 5.9 5.5 Protected spring 0.1 0.4 0.4 0.1 0.4 0.4 Rainwater 0.0 0.0 0.0 0.0 0.0 0.0 Non-improved source 7.4 22.6 20.1 8.0 22.8 20.5 Unprotected dug well 6.2 17.1 15.3 6.4 17.1 15.5 Unprotected spring 0.8 2.3 2.0 1.0 2.3 2.1 Tanker truck/cart with small tank 0.1 0.1 0.1 0.2 0.1 0.1 Surface water 0.3 3.1 2.7 0.4 3.2 2.8 Other sources 0.0 0.3 0.3 0.0 0.3 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 92.6 77.1 79.7 91.9 76.9 79.3 Time to obtain drinking water (round trip) Water on premises 34.4 5.7 10.5 36.1 5.8 10.6 Less than 30 minutes 41.0 48.0 46.9 39.9 47.8 46.5 30 minutes or longer 24.3 45.6 42.1 23.8 45.7 42.3 Don’t know/missing 0.2 0.7 0.6 0.2 0.7 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 50.8 80.0 75.1 52.2 81.4 76.8 Adult male 15+ 7.7 4.3 4.9 3.6 1.9 2.2 Female child under age 15 5.9 8.6 8.1 6.8 9.4 9.0 Male child under age 15 1.0 1.0 1.0 1.1 1.1 1.1 Other 0.1 0.2 0.2 0.1 0.1 0.1 Water on premises 34.4 5.7 10.5 36.1 5.8 10.6 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 Water treatment prior to drinking1 Boiled 6.8 11.3 10.5 6.1 11.4 10.6 Bleach/chlorine 26.1 24.4 24.7 26.1 25.0 25.2 Strained through cloth 1.1 1.7 1.6 1.2 1.8 1.7 Ceramic, sand or other filter 0.2 0.1 0.1 0.2 0.1 0.1 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 Other 3.4 4.1 4.0 3.5 4.3 4.2 No treatment 66.5 64.7 65.0 66.8 64.2 64.6 Percentage using an appropriate treatment method2 31.2 32.5 32.3 30.8 33.0 32.6 Number 4,116 20,709 24,825 18,165 96,935 115,100 1 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Household Population and Housing Characteristics | 19 The table shows that 80 percent of the households and 79 percent of the population have access to improved sources of water. In urban areas, 93 percent of the households have access to improved sources of water compared with 77 percent of households in rural areas. Piped water (to the dwelling or to a public tap) is the main source of drinking water for households in urban areas (76 percent), whereas in rural areas the main source of drinking water is a tube well or borehole (59 percent). Overall, 51 percent of households draw water from a borehole. The most commonly used non-improved source of water is an unprotected dug well (15 percent). Eleven percent of households have a source of drinking water on the premises. The availability of a source of drinking water on the premises is higher in urban areas (34 percent) than in rural areas (6 percent). Forty-two percent of the households take 30 or more minutes to obtain water, including 24 percent of households in urban areas and 46 percent of households in rural areas. Adult females collect drinking water more often than female children (75 percent and 8 percent, respectively). Five percent of adult males and one percent of male children collect water. While most households (65 percent) do not treat their water, about 32 percent of households use an appropriate treatment method. Bleach or chlorine is most commonly used by households for water treatment (25 percent). Eleven percent of households boil their water. 2.4.2 Household Sanitation Facilities Increasing the percentage of the population with access to improved sanitation in both urban and rural areas is another indicator of the MDGs. For MDG monitoring, improved sanitation technologies are defined as follows: connection to a public sewer, connection to a septic system, pour- flush latrine, simple pit latrine with a slab, or ventilated, improved pit latrine. According to the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation of 2004, 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 with other households) and if the facility used by the household separates the waste from human contact. Table 2.7 shows that 8 percent of households use an improved latrine facility, and 92 percent use a non-improved facility. Use of improved and not shared facilities is slightly higher among households in urban areas (19 percent) as compared with 6 percent in rural areas. A pit latrine with slab is the toilet facility most commonly used (5 percent) among households using an improved and not shared facility. Eight percent of households in urban areas and 4 percent of households in rural areas use this type of facility. Only 2 percent of households use a facility that flushes to a piped sewer system and is not shared. This proportion is higher among urban households (9 percent) compared with less than 1 percent in rural households. Table 2.7 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Malawi 2010 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 9.4 0.4 1.9 10.1 0.4 1.9 Ventilated improved pit (VIP) latrine 1.5 1.6 1.6 2.0 1.7 1.7 Pit latrine with slab 8.3 4.0 4.7 9.8 4.4 5.2 Non-improved facility Any facility shared with other households 16.2 3.3 5.5 13.9 3.2 4.9 Pit latrine without slab/open pit 61.9 77.5 74.9 61.4 78.5 75.8 No facility/bush/field 2.4 12.5 10.8 2.5 11.3 9.9 Other 0.1 0.6 0.5 0.0 0.5 0.5 Missing 0.3 0.0 0.1 0.3 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,116 20,709 24,825 18,165 96,935 115,100 20 | Household Population and Housing Characteristics Sharing of a toilet facility is more common in urban areas, where 16 percent of households do so, than in rural areas (3 percent). The majority of the Malawian population uses a pit latrine without a slab (75 percent), which is not an improved sanitation facility. Eleven percent have no facility and use the bush. Usage of the bush as a toilet is more common among households in rural areas (13 percent) than in urban areas (2 percent). 2.4.3 Housing Characteristics Table 2.8 presents information on a number of household dwelling characteristics and the proportion of households using various types of fuel for cooking. These characteristics reflect the household’s socioeconomic situation. They also may influence environmental conditions that have a direct bearing on household members’ health and welfare. For example, the use of biomass fuels for cooking increases exposure to indoor air pollution. In Malawi, 9 percent of households have electricity. The proportion is higher among households in urban areas (35 percent) than in rural areas (4 percent). Earth or sand is the most common material used for flooring (74 percent). Rural households are more likely to have floors made of earth or sand (83 percent) than urban households (32 percent). On the other hand, use of cement floors is more common among households in urban areas than in rural areas (66 percent compared with 14 percent). Overall, 23 percent of the households have floors made of cement. About 42 percent of the dwelling units have two rooms for sleeping, while 36 percent have a single room. There is little difference in the number of rooms used for sleeping in urban and rural areas. Nine percent of the households cook inside the house, while 32 percent cook outdoors and 59 percent cook in a separate building. The percentage of households that cook within the dwelling is higher among households in urban areas (25 percent) than in rural areas (6 percent). Additionally, 48 percent of urban households cook outdoors compared with 28 percent of rural households. The proportion of households cooking in a separate building is higher in rural areas (66 percent) than in urban areas (27 percent). Wood is the fuel most commonly used for cooking, reported by 85 percent of households. Use of wood is more common in rural areas (94 percent) than in urban areas (37 percent). Twelve percent of all households interviewed use charcoal for cooking, including 53 percent in urban areas and 4 percent in rural areas. Among all households interviewed, 98 percent use solid fuel for cooking. Almost all households in rural areas and 90 percent in urban areas use solid fuel. Ninety-eight percent of households using solid fuel for cooking reported usage of an open fire or stove without a chimney. Household Population and Housing Characteristics | 21 Table 2.8 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, Malawi 2010 Housing characteristic Households Population Urban Rural Total Urban Rural Total Electricity Yes 34.7 3.5 8.7 36.8 3.8 9.1 No 65.3 96.4 91.2 63.1 96.0 90.8 Missing 0.0 0.1 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 32.2 82.5 74.1 30.6 82.0 73.9 Dung 0.6 3.0 2.6 0.5 2.9 2.5 Parquet or polished wood 0.0 0.2 0.1 0.0 0.2 0.2 Ceramic tiles 0.4 0.0 0.1 0.4 0.0 0.1 Cement 65.9 14.1 22.7 67.6 14.6 23.0 Carpet 0.5 0.0 0.1 0.5 0.0 0.1 Other 0.1 0.0 0.0 0.1 0.0 0.0 Missing 0.1 0.0 0.0 0.1 0.0 0.0 Total 99.8 99.9 99.9 99.7 99.9 99.9 Rooms used for sleeping One 33.6 36.2 35.7 21.2 25.1 24.5 Two 40.9 42.2 41.9 42.3 44.8 44.4 Three or more 25.4 21.3 22.0 36.4 29.9 30.9 Missing 0.2 0.4 0.3 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 24.5 6.0 9.1 22.5 4.5 7.4 In a separate building 27.0 65.5 59.1 30.7 69.0 63.0 Outdoors 48.2 28.3 31.6 46.6 26.4 29.6 Other 0.1 0.1 0.1 0.1 0.0 0.0 Missing 0.2 0.1 0.1 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 9.2 0.2 1.7 8.9 0.2 1.6 Kerosene 0.2 0.0 0.0 0.1 0.0 0.0 Coal/lignite 0.2 0.0 0.0 0.1 0.0 0.0 Charcoal 52.8 3.7 11.8 49.4 3.0 10.4 Wood 36.7 94.1 84.6 40.7 95.0 86.4 Straw/shrubs/grass 0.7 1.9 1.7 0.5 1.7 1.5 No food cooked in household 0.2 0.1 0.1 0.1 0.0 0.0 Other 0.1 0.0 0.0 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 90.3 99.6 98.1 90.9 99.8 98.3 Number of households 4,116 20,709 24,825 18,165 96,935 115,100 Type of fire/stove among households using solid fuel Closed stove with chimney 0.2 0.2 0.2 0.2 0.1 0.1 Open fire/stove with chimney 0.6 1.0 0.9 0.5 0.9 0.8 Open fire/stove with hood 1.2 0.2 0.4 1.2 0.2 0.4 Open fire/stove without chimney or hood 98.0 98.5 98.4 98.0 98.7 98.6 Missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/ population using solid fuel 3,716 20,632 24,348 16,503 96,696 113,199 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, and agricultural crops. 2.5 HOUSEHOLD POSSESSIONS The availability of durable consumer goods is a good indicator of a household’s socioeconomic status. Moreover, particular goods have specific benefits. For instance, having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs food storage; and a means of transport allows greater access to many services away from the local area. 22 | Household Population and Housing Characteristics Table 2.9 shows the presence of selected consumer goods by residence; 53 percent of households own a radio. In urban areas, 70 percent own a radio as compared with half of the households (50 percent) in rural areas. A mobile telephone is owned by 39 percent of households (73 percent in urban areas and 32 percent in rural areas). Eleven percent of the households have a television: 34 percent in urban areas and 6 percent in rural areas. Four percent have a refrigerator, and the proportion is higher among households in urban areas (16 percent) than in rural areas (1 percent). Table 2.9 also shows the proportion of households owning various means of transport. Forty- four percent of the households own a bicycle (30 percent in urban areas and 47 percent in rural areas), while 2 percent own a car or truck and a similar percentage own an animal-drawn cart. Among the means of transport listed, the bicycle and animal drawn cart are more common in rural areas while ownership of a car or truck is more common in urban areas. Agricultural land is owned by 79 percent of households (87 percent in rural areas and 39 percent in urban areas), whereas farm animals are owned by 60 percent of households (66 percent in rural areas and 27 percent in urban areas). Table 2.9 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, Malawi 2010 Possession Households Population Urban Rural Total Urban Rural Total Household effects Radio 70.3 49.8 53.2 73.3 52.4 55.7 Television 34.2 6.1 10.8 38.4 6.8 11.8 Mobile telephone 72.7 32.3 39.0 75.6 35.0 41.4 Non-mobile telephone 6.8 1.0 2.0 8.6 1.2 2.3 Refrigerator 15.7 1.3 3.7 18.5 1.6 4.3 Means of transport Bicycle 29.9 46.5 43.8 34.5 50.7 48.1 Animal drawn cart 0.9 2.5 2.2 1.2 3.1 2.8 Motorcycle/scooter 1.2 1.2 1.2 1.5 1.4 1.4 Car/truck 6.5 0.7 1.7 8.0 1.0 2.1 Ownership of agricultural land 38.6 87.4 79.3 40.5 88.4 80.8 Ownership of farm animals1 26.5 66.4 59.8 30.8 70.6 64.3 Number 4,116 20,709 24,825 18,165 96,935 115,100 1 Cattle, cows, bulls, horses, donkeys, goats, sheep or chickens 2.6 WEALTH INDEX The wealth index is used throughout the report as a background characteristic. It serves as a proxy for measuring the long-term standard of living. It is based on data from the household’s ownership of consumer goods; dwelling characteristics; type of drinking water source; toilet facilities; and other characteristics that are related to a household’s socioeconomic status. To construct the index, each of these assets was assigned a weight (factor score) generated through principal component analysis, and the resulting asset scores were standardised in relation to a standard normal distribution with a mean of zero and 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 from one (lowest) to five (highest). A single asset index was developed on the basis of data from the entire country sample, and this index is used in all the tabulations presented. Table 2.10 shows the percent distribution of the de jure household population by wealth quintile, according to residence and region. The distributions indicate the degree to which wealth is evenly (or unevenly) distributed geographically. The table shows that urban areas have a higher proportion of people in the highest quintile (66 percent) compared with rural areas (11 percent). On the other hand, rural areas have a higher proportion of the population in the lowest, second, and third quintiles than urban areas. The fourth quintile contains an equal percentage of households for both urban and rural areas (20 percent). Household Population and Housing Characteristics | 23 The Northern Region has the highest proportion of persons in the fourth and highest quintiles while the Central Region has the lowest proportion of the population in these quintiles. The proportion of households in the lowest and second quintiles is highest in the Central Region followed by the Southern Region, while the Northern Region contributes the lowest proportion of households. Table 2.10 Wealth quintiles Percent distribution of the de jure population by wealth quintiles and the Gini Coefficient, according to residence and region, Malawi 2010 Residence/region Wealth quintile Total Number of population Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 2.9 3.4 7.5 19.9 66.3 100.0 18,165 27.7 Rural 23.2 23.1 22.3 20.0 11.3 100.0 96,935 35.1 Region Northern 12.2 14.5 22.3 26.6 24.5 100.0 13,564 33.1 Central 23.8 21.3 20.0 17.6 17.2 100.0 49,988 42.0 Southern 18.3 20.1 19.4 20.6 21.5 100.0 51,548 42.9 Total 20.0 20.0 20.0 20.0 20.0 100.0 115,100 41.8 Respondents’ Characteristics | 25 RESPONDENTS’ CHARACTERISTICS 3 The purpose of this chapter is to create a demographic and socioeconomic profile of individual female and male respondents. This information helps in interpretation of findings presented later in the report and provides an indication of the representativeness of the survey. The chapter begins by describing basic background characteristics, including age, marital status, residence, education, religion, ethnicity, and economic status of respondents’ households. The chapter then covers more detailed information on education, media exposure, employment, and indicators of women’s status. Information on knowledge and attitudes concerning tuberculosis is presented, and findings on tobacco use are provided as a lifestyle measure.1 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 shows the distribution of women and men age 15-49 by background characteristics. The table shows declining proportions of women and men with advancing age indicating that Malawi’s age structure is broad based, i.e., a young age structure. This is a trend similar to that observed in the 2004 MDHS. Women who are in union (i.e., currently married or living with a man) constitute two-thirds of all interviewed women (67 percent). In comparison, more than half of men are currently in union (57 percent). The proportion of men who have never been married is almost double that of women who have never been married, 39 percent compared with 20 percent. Table 3.1 also shows that the majority of women (81 percent) and men (79 percent) live in rural areas. By region, the majority of women and men live in the Central and Southern Regions, while 12 percent of women and 11 percent of men live in the Northern Region. Although the majority of respondents have had some education, the level of educational attainment varies by sex: 85 percent of women and 94 percent of men ever attended school. Among all the levels of educational attainment, the majority of women and men have attained some primary level education; however, a higher proportion of men (31 percent) have attended secondary school or higher compared with 20 percent of women. The distribution of respondents by religion shows that a majority of the respondents are Christians (86 percent of women and 84 percent of men), while 13 percent of women and 12 percent of men are Muslims. Less than 1 percent of women and 3 percent of men reported no religious affiliation. Regarding ethnic self-identification, Chewa is the largest ethnic group, making up one- third of female and male respondents, followed by the Lomwe, who constitute 16 percent of women and 18 percent of men. The Yao and Ngoni both constitute 13 percent of the respondents for both women and men. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 26 | Respondents’ Characteristics Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Malawi 2010 Background characteristic Women Men Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 21.7 5,005 5,040 25.6 1,748 1,757 20-24 19.8 4,555 4,392 18.2 1,239 1,217 25-29 19.1 4,400 4,313 16.1 1,099 1,064 30-34 14.1 3,250 3,290 13.9 948 942 35-39 11.0 2,522 2,575 11.7 798 777 40-44 7.5 1,730 1,777 7.8 529 552 45-49 6.8 1,558 1,633 6.7 458 496 Marital status Never married 19.7 4,538 4,526 39.4 2,689 2,703 Married 58.7 13,520 13,493 47.8 3,257 3,293 Living together 8.7 2,008 1,952 9.4 638 580 Divorced/separated 9.3 2,135 2,189 3.0 206 204 Widowed 3.6 819 860 0.4 28 25 Residence Urban 18.7 4,302 3,068 21.1 1,440 973 Rural 81.3 18,718 19,952 78.9 5,379 5,832 Region Northern 11.6 2,677 4,189 10.9 744 1,215 Central 42.8 9,857 7,862 45.1 3,074 2,464 Southern 45.5 10,485 10,969 44.0 3,001 3,126 Education No education 15.2 3,505 3,390 6.2 422 398 Primary 64.8 14,916 15,339 62.6 4,270 4,359 Secondary 18.1 4,177 3,970 27.9 1,904 1,854 More than secondary 1.8 422 321 3.3 223 194 Wealth quintile Lowest 18.5 4,268 4,539 14.6 997 1,092 Second 18.8 4,332 4,506 19.2 1,309 1,380 Middle 19.6 4,517 4,721 20.0 1,367 1,401 Fourth 19.6 4,515 4,699 20.2 1,376 1,452 Highest 23.4 5,388 4,555 26.0 1,770 1,480 Religion Anglican 2.3 541 718 2.5 168 221 Catholic 20.6 4,754 4,670 22.3 1,519 1,466 CCAP1 16.6 3,823 3,684 16.8 1,143 1,112 Muslim 13.0 2,993 2,530 12.2 833 695 Seventh Day Advent/Baptist 6.7 1,541 1,653 7.1 482 500 Other Christian 39.5 9,087 9,559 35.2 2,400 2,565 No religion 0.8 173 137 2.6 177 174 Missing 0.1 15 14 0.0 1 1 Ethnicity Chewa 34.1 7,855 6,780 33.3 2,274 1,994 Lambya 0.4 84 170 0.4 26 56 Lomwe 16.3 3,743 3,731 17.8 1,211 1,197 Mang’anja 3.0 701 698 2.8 191 186 Ndali 0.4 89 188 0.3 23 54 Ngoni 12.9 2,969 3,145 12.9 877 889 Nkhonde 1.0 238 377 0.9 65 110 Nyanja 1.3 307 312 1.6 109 87 Sena 4.6 1,061 1,288 4.4 300 384 Tonga 1.9 434 751 1.8 123 234 Tumbuka 9.2 2,109 2,497 8.7 590 690 Yao 13.1 3,005 2,424 13.2 897 714 Other 1.8 418 650 1.9 133 209 Missing 0.0 7 9 0.0 1 1 Total 15-49 100.0 23,020 23,020 100.0 6,818 6,805 50-54 na na na na 357 370 Total men 15-54 na na na na 7,175 7,175 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable 1Church of Central Africa, Presbyterian Respondents’ Characteristics | 27 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Table 3.2.1 provides an overview of the relationship between women’s level of education and various background characteristics. In Malawi, 15 percent of women have never attended school, 56 percent have some primary education, and 9 percent have completed primary school. At the secondary level, 13 percent have some secondary education, while 6 percent have completed secondary school. Two percent of women have more than a secondary education. The results show that older women are less likely than younger women to have some education. Thirty-eight percent of women age 45-49 reported that they have no education compared with 5 percent of women age 15-24. Place of residence is also associated with women’s level of education because women in rural areas are far less likely to have ever attended school than their urban counterparts: 17 percent of rural women have never attended school compared with 7 percent of urban women. Women in the Central and Southern Regions (17 percent each) are four times as likely as women in the Northern Region (4 percent) to have no schooling. Wealth is highly associated with having ever been to school, as more than a quarter of women in the lowest wealth quintile (26 percent) have never been to school compared with only 4 percent of women in the highest quintile. Nationally, women have completed a median number of 4.9 years of school. The median number of years of school completed for rural women is 4.3 years compared with 7.5 years for women from urban areas. Similarly, differences in the level of education attained are observed among the regions. The median number of years of school completed is highest for women from the Northern Region at 6.8 years, followed by 4.7 years in the Southern Region, and 4.3 years in the Central Region. Educational attainment increases as household wealth increases. One-quarter of women in the highest wealth quintile have completed secondary or higher education compared with less than 1 percent of women in the lowest wealth quintile. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median grade completed, according to background characteristics, Malawi 2010 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 5.3 56.9 12.0 18.2 6.0 1.6 100.0 5.9 9,559 15-19 2.9 59.6 13.7 19.7 3.4 0.7 100.0 5.9 5,005 20-24 7.9 53.8 10.1 16.6 8.9 2.7 100.0 5.8 4,555 25-29 10.0 56.6 9.0 13.8 7.8 2.8 100.0 5.5 4,400 30-34 18.2 55.1 7.8 9.6 7.6 1.8 100.0 4.0 3,250 35-39 30.8 53.2 6.3 4.6 3.4 1.8 100.0 2.4 2,522 40-44 34.3 52.5 5.4 4.5 1.3 1.9 100.0 2.1 1,730 45-49 38.3 51.8 6.1 2.0 1.2 0.7 100.0 1.4 1,558 Residence Urban 7.0 40.1 7.2 23.5 14.8 7.3 100.0 7.5 4,302 Rural 17.1 59.0 9.8 10.0 3.5 0.6 100.0 4.3 18,718 Region Northern 3.9 60.9 11.0 16.8 6.5 1.0 100.0 6.8 2,677 Central 16.7 56.1 9.5 11.2 5.0 1.5 100.0 4.3 9,857 Southern 16.7 53.6 8.7 12.7 5.9 2.4 100.0 4.7 10,485 Wealth quintile Lowest 26.3 61.6 8.1 3.5 0.5 0.0 100.0 2.5 4,268 Second 21.2 61.7 10.7 5.4 0.9 0.0 100.0 3.4 4,332 Middle 16.1 60.9 12.3 8.8 1.9 0.0 100.0 4.5 4,517 Fourth 11.8 60.0 9.2 14.5 4.1 0.4 100.0 5.4 4,515 Highest 3.8 37.3 6.7 26.9 17.8 7.4 100.0 8.2 5,388 Total 15.2 55.5 9.3 12.5 5.6 1.8 100.0 4.9 23,020 1 Completed 8 years at the primary level 2 Completed 4 years at the secondary level 28 | Respondents’ Characteristics Table 3.2.2 shows the relationship between men’s level of education and other background characteristics. Nationally, 6 percent of men age 15-49 have no education compared with more than twice as many women of the same age (15 percent). Men from urban areas have higher levels of educational attainment than their rural counterparts. Two percent of urban males compared with 7 percent of their rural counterparts have no formal education. While 31 percent of urban males have completed secondary or higher education, 9 percent of their rural counterparts have done so. Overall, the median years of school completed for men age 15-49 is 6.1 years. For men, the level of educational attainment varies by region, but similar to the trend among women, men in the Northern Region attend school longer compared with men from the Central and Southern Regions. Two percent of men in the Northern Region had no education compared with 7 percent of men with no education in both the Central and Southern Regions. For men, as for women, educational attainment increases as household wealth increases. The median years of education completed increases with each wealth quintile, from 3.8 years among men in the lowest quintile to 7.6 years among men in the highest quintile. Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median grade completed, according to background characteristics, Malawi 2010 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 2.6 55.2 10.9 21.6 7.5 2.1 100.0 6.1 2,987 15-19 1.9 62.1 13.1 20.0 2.4 0.5 100.0 5.7 1,748 20-24 3.7 45.6 7.8 23.8 14.7 4.4 100.0 6.6 1,239 25-29 5.1 45.5 10.7 18.3 15.8 4.6 100.0 6.6 1,099 30-34 7.0 46.0 7.0 18.0 18.0 4.0 100.0 6.6 948 35-39 12.2 55.4 7.7 9.5 13.0 2.0 100.0 5.3 798 40-44 11.3 60.1 6.6 8.1 7.3 6.5 100.0 5.6 529 45-49 13.8 63.4 5.7 8.8 3.8 4.4 100.0 4.7 458 Residence Urban 1.7 31.8 6.8 28.4 22.1 9.2 100.0 7.5 1,440 Rural 7.4 59.1 9.9 14.2 7.6 1.7 100.0 5.6 5,379 Region Northern 1.7 50.7 10.2 22.7 11.8 3.0 100.0 7.0 744 Central 6.5 56.3 9.1 14.6 10.7 2.7 100.0 5.8 3,074 Southern 7.0 51.0 9.2 18.5 10.4 3.9 100.0 6.0 3,001 Wealth quintile Lowest 14.7 67.5 9.3 7.2 1.3 0.0 100.0 3.8 997 Second 8.8 64.5 11.4 12.2 3.1 0.0 100.0 4.8 1,309 Middle 6.9 62.3 11.0 13.2 6.4 0.2 100.0 5.5 1,367 Fourth 3.6 52.9 9.7 20.2 12.1 1.6 100.0 6.5 1,376 Highest 1.0 30.6 6.1 27.4 23.8 11.2 100.0 7.6 1,770 Total 15-49 6.2 53.3 9.3 17.2 10.7 3.3 100.0 6.1 6,818 50-54 15.4 65.5 6.6 6.4 3.9 2.2 100.0 4.7 357 Total men 15-54 6.6 53.9 9.2 16.7 10.4 3.2 100.0 6.1 7,175 1 Completed 8 years at the primary level 2 Completed 4 years at the secondary level 3.3 LITERACY The ability to read is crucial for exploring social and economic opportunities during a person’s lifetime. Program planners use literacy statistics to determine the best ways to get health and other messages to women and men in different subgroups. The literacy status of respondents in the 2010 MDHS was determined by assessing their ability to read all or part of a simple sentence in any of the four languages; English, Chichewa, Yao, or Tumbuka. The literacy test was administered only to respondents who had less than a secondary school education because those with a secondary education or higher were assumed to be literate. Tables 3.3.1 and 3.3.2 present literacy data for women and men age 15-49. Respondents’ Characteristics | 29 Table 3.3.1 shows the percent distribution of women by the level of schooling attended, level of literacy, and percentage literate, according to background characteristics. More than three in five (68 percent) women are literate. The level of literacy is much higher for women age 15-19, compared with women age 45-49 (81 and 45 percent, respectively). Eighty-three percent of women in urban areas are literate compared with 64 percent of their rural counterparts. Literacy varies by region, ranging from a high of 80 percent in the Northern Region to a low of 65 percent in the Central Region. Women in the highest wealth quintile are nearly twice as likely to be literate as women in the lowest wealth quintile (89 and 48 percent, respectively). 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, Malawi 2010 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 23.8 48.5 8.6 18.9 0.0 0.0 0.2 100.0 80.9 5,005 20-24 28.1 37.5 7.8 26.2 0.0 0.1 0.1 100.0 73.5 4,555 25-29 24.4 40.1 8.1 27.2 0.1 0.0 0.1 100.0 72.7 4,400 30-34 18.9 37.9 7.8 35.0 0.0 0.2 0.1 100.0 64.6 3,250 35-39 9.7 32.5 8.4 49.2 0.0 0.1 0.1 100.0 50.6 2,522 40-44 7.8 34.2 9.6 47.5 0.0 0.6 0.3 100.0 51.5 1,730 45-49 3.9 33.0 8.4 53.6 0.0 0.9 0.2 100.0 45.3 1,558 Residence Urban 45.7 32.7 4.5 16.6 0.0 0.2 0.2 100.0 82.9 4,302 Rural 14.1 40.9 9.1 35.6 0.0 0.2 0.1 100.0 64.1 18,718 Region Northern 24.3 44.0 11.4 20.0 0.1 0.1 0.1 100.0 79.7 2,677 Central 17.7 38.9 7.8 35.2 0.0 0.2 0.1 100.0 64.5 9,857 Southern 21.0 38.6 7.9 32.1 0.0 0.2 0.2 100.0 67.5 10,485 Wealth quintile Lowest 4.0 34.3 9.3 52.1 0.0 0.1 0.1 100.0 47.7 4,268 Second 6.3 40.9 9.3 43.2 0.1 0.2 0.1 100.0 56.5 4,332 Middle 10.7 45.5 9.6 33.8 0.0 0.3 0.1 100.0 65.8 4,517 Fourth 19.0 45.6 8.5 26.6 0.0 0.1 0.2 100.0 73.1 4,515 Highest 52.2 31.8 5.3 10.3 0.0 0.2 0.3 100.0 89.3 5,388 Total 20.0 39.4 8.3 32.0 0.0 0.2 0.2 100.0 67.6 23,020 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence. Table 3.3.2 shows that 81 percent of men are literate. The patterns of men’s literacy are similar to those among women. However, there are marked differences between the sexes in the literacy levels across the age groups. Eighty percent of men age 45-49 are literate compared with 45 percent of women in the same age group. Similarly, marked disparities are observed between women and men across the wealth quintiles, as 64 percent of men in the poorest households are literate compared with 48 percent of women in the same wealth quintile. 30 | Respondents’ Characteristics 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, Malawi 2010 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 22.9 49.0 10.2 17.4 0.0 0.0 0.5 100.0 82.2 1,748 20-24 42.9 31.1 7.3 18.4 0.1 0.0 0.2 100.0 81.3 1,239 25-29 38.7 38.4 6.3 16.2 0.0 0.2 0.2 100.0 83.4 1,099 30-34 40.0 36.5 7.4 16.1 0.0 0.0 0.0 100.0 83.9 948 35-39 24.6 43.4 7.8 24.0 0.0 0.2 0.0 100.0 75.8 798 40-44 21.9 46.7 10.0 21.4 0.0 0.0 0.0 100.0 78.6 529 45-49 17.1 53.6 8.9 20.2 0.3 0.0 0.0 100.0 79.6 458 Residence Urban 59.7 27.8 4.6 7.7 0.0 0.0 0.2 100.0 92.1 1,440 Rural 23.6 45.5 9.3 21.4 0.0 0.1 0.2 100.0 78.4 5,379 Region Northern 37.5 35.9 8.9 17.6 0.0 0.0 0.0 100.0 82.3 744 Central 28.1 42.8 10.0 18.6 0.0 0.1 0.3 100.0 80.9 3,074 Southern 32.8 42.2 6.3 18.5 0.0 0.0 0.1 100.0 81.3 3,001 Wealth quintile Lowest 8.5 46.6 9.3 35.5 0.0 0.0 0.1 100.0 64.4 997 Second 15.3 49.6 9.7 25.1 0.1 0.1 0.1 100.0 74.6 1,309 Middle 19.8 47.5 11.2 21.2 0.1 0.0 0.2 100.0 78.5 1,367 Fourth 33.9 44.7 8.0 13.1 0.0 0.2 0.2 100.0 86.5 1,376 Highest 62.4 26.7 4.7 6.0 0.0 0.0 0.2 100.0 93.8 1,770 Total 15-49 31.2 41.8 8.3 18.5 0.0 0.1 0.2 100.0 81.3 6,818 50-54 12.6 56.1 7.6 23.4 0.0 0.3 0.0 100.0 76.3 357 Total men 15-54 30.3 42.5 8.3 18.7 0.0 0.1 0.2 100.0 81.0 7,175 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence. 3.4 ACCESS TO MASS MEDIA The 2010 MDHS collected information on the respondents’ exposure to common print and electronic media. Respondents were asked how often they read a newspaper, listened to the radio, or watched television. This information is important because it indicates the extent to which Malawians are regularly exposed to mass media, often used to convey messages on family planning and other health topics. Data on exposure to mass media for both women and men age 15-49 are presented in Tables 3.4.1 and 3.4.2. There are disparities in the exposure to mass media between the sexes. Twelve percent of women read the newspaper at least once a week compared with 26 percent of men. More than twice as many men (34 percent) watch the television at least once a week compared with women (16 percent). Although more than half of female respondents (57 percent) listen to the radio at least once a week, more than three-quarters of men (76 percent) do so. The percentage of men who are exposed to all three forms of media (newspaper, television, and radio) is about three times that of women (14 percent compared with 5 percent). Similarly, wealth status is positively related to exposure to mass media. For instance, 66 percent of women in the lowest quintile have no weekly exposure to any media source; while 15 percent of those in the highest quintile have no exposure. For men, 31 percent in the lowest wealth quintile have no weekly exposure to any media source compared with 6 percent of men in the highest wealth quintiles. Respondents’ Characteristics | 31 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, Malawi 2010 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the 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 17.0 20.5 58.4 6.5 34.7 5,005 20-24 14.1 15.6 60.0 5.4 35.8 4,555 25-29 11.1 16.0 56.8 4.8 38.9 4,400 30-34 9.7 15.9 57.5 4.1 38.6 3,250 35-39 7.7 13.1 55.1 3.0 41.2 2,522 40-44 7.5 12.3 53.1 2.4 43.1 1,730 45-49 6.1 10.4 55.0 2.7 43.2 1,558 Residence Urban 22.9 41.3 65.7 13.3 24.2 4,302 Rural 9.2 10.1 55.3 2.7 41.4 18,718 Region Northern 15.7 19.0 64.9 5.0 29.8 2,677 Central 10.4 13.1 54.5 4.1 41.6 9,857 Southern 12.1 17.8 57.9 5.2 37.2 10,485 Education No education 0.3 4.3 43.2 0.0 55.3 3,505 Primary 7.8 10.9 56.0 1.6 40.5 14,916 Secondary 30.1 38.0 71.7 15.7 19.0 4,177 More than secondary 66.4 70.5 75.4 42.4 3.5 422 Wealth quintile Lowest 5.1 3.3 30.9 0.5 65.8 4,268 Second 5.7 4.1 47.4 0.8 49.9 4,332 Middle 7.7 6.2 60.4 1.0 36.7 4,517 Fourth 9.5 10.2 66.6 1.8 30.6 4,515 Highest 27.3 48.3 75.7 16.5 14.5 5,388 Total 11.8 15.9 57.3 4.7 38.2 23,020 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, Malawi 2010 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the 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 24.4 41.1 73.1 13.7 17.9 1,748 20-24 30.2 39.0 76.2 17.7 16.4 1,239 25-29 26.3 33.7 78.4 13.6 15.0 1,099 30-34 23.7 29.8 76.1 13.5 19.9 948 35-39 24.3 27.7 76.4 11.9 17.4 798 40-44 25.9 28.0 84.3 12.4 11.6 529 45-49 21.7 24.8 76.3 11.5 18.6 458 Residence Urban 44.9 55.3 75.6 27.3 11.3 1,440 Rural 20.4 28.6 76.6 10.3 18.5 5,379 Region Northern 27.1 40.2 78.9 16.1 15.7 744 Central 22.4 31.5 76.8 11.7 17.3 3,074 Southern 28.5 35.7 75.4 15.7 16.9 3,001 Education No education 0.7 17.9 68.9 0.2 28.0 422 Primary 15.8 28.1 74.7 7.6 19.8 4,270 Secondary 46.3 46.4 80.9 25.5 9.7 1,904 More than secondary 83.8 78.9 84.8 63.0 3.2 223 Wealth quintile Lowest 11.6 20.6 64.0 4.7 30.7 997 Second 14.9 20.6 71.1 5.2 23.9 1,309 Middle 18.0 27.1 76.4 8.4 17.6 1,367 Fourth 24.6 30.1 81.4 11.9 14.2 1,376 Highest 48.0 60.8 83.5 31.4 5.7 1,770 Total 15-49 25.6 34.3 76.4 13.9 16.9 6,818 50-54 20.7 17.7 79.6 6.2 17.7 357 Total men 15-54 25.3 33.4 76.6 13.5 17.0 7,175 32 | Respondents’ Characteristics 3.5 EMPLOYMENT Employment is one source of empowerment for women, given that they exercise control over their own income. It is, however, difficult to measure employment status because even though some women work, it is on family farms, in family businesses, or in the informal sector, and such work is often not perceived as employment by the women and men themselves. As a result, it is difficult to capture this type of activity, which is rarely reported as work. The 2010 MDHS asked women and men detailed questions about their employment status in order to ensure complete coverage of employment in any sector, formal or informal. Women and men who reported that they were currently working and those who reported that they worked at some time during the 12 months preceding the survey are considered to have been employed. Additional information was collected on the type of work women and men were doing, whether they worked continuously throughout the year or not, for whom they worked, and the form in which they received their earnings. Tables 3.5.1 and 3.5.2 show the percent distribution of women and men age 15-49 by employment status, according to background characteristics. Fifty-six percent of women are currently employed. Seventeen percent of women reported that they worked at some point during the past Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Malawi 2010 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of women Currently employed1 Not currently employed Age 15-19 36.5 19.0 44.4 0.1 100.0 5,005 20-24 51.0 18.5 30.5 0.0 100.0 4,555 25-29 59.7 17.5 22.8 0.1 100.0 4,400 30-34 63.8 17.3 18.8 0.0 100.0 3,250 35-39 67.3 16.0 16.7 0.1 100.0 2,522 40-44 66.6 15.9 17.6 0.0 100.0 1,730 45-49 68.8 13.5 17.7 0.0 100.0 1,558 Marital status Never married 37.4 16.8 45.7 0.1 100.0 4,538 Married or living together 58.1 18.1 23.7 0.0 100.0 15,528 Divorced/separated/widowed 69.4 15.0 15.7 0.0 100.0 2,954 Number of living children 0 39.3 17.3 43.3 0.0 100.0 5,344 1-2 55.7 17.8 26.5 0.1 100.0 7,079 3-4 62.2 18.1 19.6 0.1 100.0 6,006 5+ 65.2 16.1 18.7 0.0 100.0 4,592 Residence Urban 49.5 12.3 38.2 0.0 100.0 4,302 Rural 56.9 18.6 24.4 0.1 100.0 18,718 Region Northern 52.7 19.4 27.8 0.1 100.0 2,677 Central 56.6 20.1 23.2 0.0 100.0 9,857 Southern 55.1 14.4 30.4 0.0 100.0 10,485 Education No education 56.2 17.8 25.9 0.1 100.0 3,505 Primary 56.4 18.4 25.2 0.0 100.0 14,916 Secondary 50.3 14.9 34.8 0.0 100.0 4,177 More than secondary 69.8 7.0 23.2 0.0 100.0 422 Wealth quintile Lowest 56.9 20.4 22.7 0.0 100.0 4,268 Second 56.3 18.9 24.6 0.1 100.0 4,332 Middle 56.7 18.4 24.7 0.1 100.0 4,517 Fourth 55.7 17.4 26.9 0.0 100.0 4,515 Highest 52.5 13.1 34.4 0.0 100.0 5,388 Total 55.5 17.4 27.0 0.0 100.0 23,020 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. Respondents’ Characteristics | 33 12 months, but were not working at the time of the survey; while 27 percent of women reported not having worked at all in the 12 months preceding the survey. Older women are more likely to be currently employed when compared with their younger counterparts. While 37 percent of women age 15-19 are currently employed, 69 percent of women age 45-49 are employed. More rural women are currently employed than their urban counterparts (57 and 50 percent, respectively). Women who are divorced, separated, or widowed (69 percent), those with five or more children (65 percent), and women with more than a secondary education (70 percent) are more likely to be currently employed than their counterparts. Women in the highest wealth quintile were the least likely to be currently employed and the most likely to have been unemployed during the 12 months preceding the survey (53 and 34 percent, respectively). A similar pattern is observed in men’s employment status. Overall, 82 percent of men age 15- 49 are currently employed, 7 percent worked in the 12 months prior to the survey but are not currently working, and 11 percent have not been employed for the 12 months preceding the survey. Men age Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Malawi 2010 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of men Currently employed1 Not currently employed Age 15-19 60.3 10.8 28.9 0.0 100.0 1,748 20-24 79.4 7.5 13.1 0.0 100.0 1,239 25-29 91.1 4.9 4.1 0.0 100.0 1,099 30-34 93.9 3.6 2.4 0.1 100.0 948 35-39 92.8 5.8 1.4 0.0 100.0 798 40-44 95.0 3.8 1.1 0.1 100.0 529 45-49 91.9 6.0 2.1 0.0 100.0 458 Marital status Never married 64.9 9.9 25.2 0.0 100.0 2,689 Married or living together 93.3 4.7 1.9 0.0 100.0 3,895 Divorced/separated/widowed 90.7 5.4 3.9 0.0 100.0 234 Number of living children 0 66.9 9.6 23.6 0.0 100.0 2,918 1-2 93.3 4.2 2.4 0.0 100.0 1,485 3-4 92.6 5.5 1.8 0.1 100.0 1,269 5+ 94.2 4.4 1.4 0.0 100.0 1,146 Residence Urban 76.3 5.2 18.6 0.0 100.0 1,440 Rural 83.6 7.2 9.2 0.0 100.0 5,379 Region Northern 78.3 4.9 16.8 0.0 100.0 744 Central 85.3 6.4 8.2 0.0 100.0 3,074 Southern 79.6 7.6 12.8 0.0 100.0 3,001 Education No education 85.5 9.4 5.0 0.1 100.0 422 Primary 83.7 6.9 9.3 0.0 100.0 4,270 Secondary 77.5 6.0 16.4 0.0 100.0 1,904 More than secondary 82.3 4.6 13.2 0.0 100.0 223 Wealth quintile Lowest 82.2 10.6 7.2 0.1 100.0 997 Second 84.3 6.9 8.7 0.1 100.0 1,309 Middle 86.4 5.3 8.3 0.0 100.0 1,367 Fourth 83.3 7.3 9.4 0.0 100.0 1,376 Highest 75.9 5.2 18.8 0.0 100.0 1,770 Total 15-49 82.0 6.8 11.2 0.0 100.0 6,818 50-54 90.2 5.5 4.2 0.0 100.0 357 Total men 15-54 82.4 6.7 10.8 0.0 100.0 7,175 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. 34 | Respondents’ Characteristics 40-44 are more likely to be currently employed (95 percent) than men in other age groups. Men who are divorced, separated, or widowed (91 percent) are more likely to be currently employed than those who have never married (65 percent). Similar to the pattern seen among women, employment status is associated with the number of living children that the man has. Sixty-seven percent of men with no living children were currently working compared with 93 percent of men with one to two children. As observed with women, men in rural areas are more likely to be currently employed than men in urban areas (84 and 76 percent, respectively). Likewise, women and men in the Central Region are more likely to be currently employed than their counterparts in other regions: 57 percent for women and 85 percent for men. 3.6 OCCUPATION Respondents who reported that they are currently employed or that they worked in the 12 months preceding the survey were asked what type of work they normally do. Tables 3.6.1 and 3.6.2 show the distribution of women and men by occupation, according to background characteristics. 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, Malawi 2010 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual1 Domestic service Agriculture Total Number of women Age 15-19 0.3 0.2 16.3 5.4 7.9 2.1 67.8 100.0 2,780 20-24 1.7 0.8 26.0 5.5 6.1 1.7 58.2 100.0 3,168 25-29 2.1 1.1 29.4 6.7 6.4 1.7 52.6 100.0 3,396 30-34 2.6 1.4 28.0 6.8 6.1 1.5 53.6 100.0 2,637 35-39 3.5 0.7 25.2 7.2 5.5 1.5 56.4 100.0 2,101 40-44 3.7 1.3 23.0 7.4 5.9 1.0 57.7 100.0 1,426 45-49 1.3 0.6 21.1 8.3 7.6 1.0 60.0 100.0 1,283 Marital status Never married 2.1 1.6 19.3 5.5 8.8 3.0 59.7 100.0 2,460 Married or living together 2.0 0.6 25.1 6.4 5.5 0.9 59.4 100.0 11,838 Divorced/separated/widowed 2.1 1.5 28.0 7.9 8.6 3.6 48.4 100.0 2,491 Number of living children 0 2.1 1.4 20.2 5.5 7.5 2.9 60.4 100.0 3,028 1-2 2.9 1.4 27.7 6.1 6.0 1.9 54.0 100.0 5,202 3-4 1.8 0.6 26.1 7.0 6.3 1.0 57.2 100.0 4,826 5+ 1.2 0.1 22.1 7.3 6.6 0.9 61.8 100.0 3,734 Residence Urban 6.1 3.9 53.1 7.5 6.7 6.6 16.1 100.0 2,657 Rural 1.3 0.3 19.3 6.3 6.4 0.6 65.6 100.0 14,133 Region Northern 2.2 0.3 29.6 7.3 4.0 0.5 56.1 100.0 1,930 Central 1.6 0.7 22.4 6.7 8.2 1.3 59.0 100.0 7,565 Southern 2.4 1.3 25.7 6.1 5.3 2.2 57.0 100.0 7,294 Education No education 0.0 0.1 16.4 6.6 7.2 0.9 68.8 100.0 2,596 Primary 0.4 0.1 22.4 6.6 6.5 1.7 62.2 100.0 11,149 Secondary 6.1 2.9 41.4 6.3 5.7 2.0 35.6 100.0 2,722 More than secondary 42.0 16.4 27.3 3.7 6.1 1.1 3.5 100.0 324 Wealth quintile Lowest 0.3 0.1 14.2 5.0 8.9 0.5 71.0 100.0 3,299 Second 0.2 0.0 16.7 6.0 7.6 0.5 68.9 100.0 3,260 Middle 0.7 0.0 19.2 7.4 5.9 0.8 66.0 100.0 3,396 Fourth 0.9 0.5 26.7 6.4 5.6 2.0 57.9 100.0 3,299 Highest 7.7 3.7 45.1 7.8 4.6 4.0 27.2 100.0 3,536 Total 2.0 0.9 24.7 6.5 6.5 1.6 57.8 100.0 16,790 1 Unskilled manual labour includes cases for occupations for unskilled labour and cases for which occupation information was missing for respondents who worked in the past 12 months, but did not provide information on their occupation. Respondents’ Characteristics | 35 Among women, more than half of women are employed in the agricultural sector, and a quarter of women are employed in sales and services (58 and 25 percent, respectively). Seven percent of women are engaged in both skilled and unskilled manual jobs. Forty-two percent of women with more than secondary school education are in professional, technical, or managerial occupations representing the majority in that educational group. On the other hand, 69 percent of women with no education and 62 percent of women with a primary school education are employed in the agricultural sector. Findings for men are similar to those for women: Table 3.6.2 shows that the highest proportion of men age 15-49 work in agriculture (49 percent). Eighteen percent of men work as skilled labourers, followed by 16 percent of men in sales and services. The trends in occupation type by the level of education are very similar to those for women. The majority of men with more than a secondary education (45 percent) are in the professional, technical, or managerial occupations, while 65 percent of men with no education have agricultural occupations. 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, Malawi 2010 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual1 Domestic service Agriculture Total Number of men Age 15-19 0.5 0.2 9.8 10.6 13.2 2.0 63.8 100.0 1,243 20-24 3.0 1.1 14.6 21.8 10.5 1.5 47.5 100.0 1,076 25-29 3.4 1.7 18.5 22.9 13.0 1.3 39.2 100.0 1,054 30-34 5.0 2.4 19.7 20.1 7.8 1.0 44.0 100.0 924 35-39 4.5 1.7 18.6 19.2 7.8 0.8 47.4 100.0 787 40-44 9.1 2.9 14.7 19.7 5.3 2.0 46.4 100.0 522 45-49 5.2 1.1 14.7 14.4 8.0 0.4 56.2 100.0 448 Marital status Never married 2.7 0.9 11.7 14.9 12.6 1.9 55.2 100.0 2,011 Married or living together 4.4 1.7 17.8 19.8 8.5 1.1 46.7 100.0 3,818 Divorced/separated/widowed 2.3 1.1 12.8 24.5 15.0 1.4 43.0 100.0 225 Number of living children 0 3.0 0.8 12.1 15.3 12.4 1.9 54.5 100.0 2,230 1-2 4.5 1.9 17.5 20.6 11.1 1.4 43.0 100.0 1,449 3-4 3.8 2.3 20.4 19.8 8.0 0.9 45.0 100.0 1,245 5+ 4.4 1.2 14.9 19.9 6.7 0.7 52.3 100.0 1,130 Residence Urban 9.7 4.0 28.5 31.1 12.1 4.0 10.6 100.0 1,172 Rural 2.3 0.8 12.5 15.3 9.6 0.7 58.7 100.0 4,882 Region Northern 3.7 1.1 11.4 15.2 13.9 0.5 54.2 100.0 619 Central 3.4 1.2 14.3 17.0 8.9 1.2 54.0 100.0 2,821 Southern 4.1 1.8 18.0 20.6 10.5 1.7 43.3 100.0 2,615 Education No education 0.0 0.4 11.0 16.6 7.3 0.2 64.5 100.0 400 Primary 0.4 0.7 14.0 17.1 10.5 1.1 56.2 100.0 3,870 Secondary 7.8 3.0 21.1 21.6 10.3 2.4 33.9 100.0 1,591 More than secondary 45.0 5.8 11.0 20.6 7.0 0.1 10.5 100.0 193 Wealth quintile Lowest 0.4 0.0 8.3 12.7 10.4 0.3 68.0 100.0 925 Second 0.2 0.3 12.0 14.3 11.0 0.4 61.8 100.0 1,194 Middle 0.9 0.6 12.7 17.0 12.4 0.6 55.7 100.0 1,253 Fourth 2.2 1.7 16.0 19.8 9.2 1.8 49.3 100.0 1,246 Highest 12.7 3.8 25.4 25.2 8.0 3.2 21.7 100.0 1,436 Total 15-49 3.7 1.4 15.6 18.3 10.1 1.4 49.4 100.0 6,054 50-54 5.5 0.5 15.8 15.3 7.2 0.3 55.5 100.0 342 Total men 15-54 3.8 1.4 15.6 18.2 10.0 1.3 49.7 100.0 6,396 1 Unskilled manual labour includes cases for occupations for unskilled labour and cases for which occupation information was missing for respondents who worked in the past 12 months, but did not provide information on their occupation. 36 | Respondents’ Characteristics 3.7 EARNINGS, EMPLOYERS, AND CONTINUITY OF EMPLOYMENT Tables 3.7.1 and 3.7.2 show the distribution of women and men by type of earnings, type of employer, and continuity of employment. Table 3.7.1 separately presents information on women engaged in agricultural or nonagricultural work. The two sectors influence the type of earnings women receive, the type of employer they work for, and the continuity of their employment. Over half of women (58 percent) employed in agricultural work are not paid; this compares with one in five women (21 percent) who are employed in nonagricultural work and are not paid. More than two- thirds of the women employed in the agricultural sector are self-employed and work seasonally (67 and 70 percent, respectively). About a quarter of women in agricultural work are employed by a family member (26 percent) compared with 11 percent of women employed in nonagricultural work. Among women employed in the nonagricultural sector, 72 percent earn cash only, 67 percent are self- employed, and 47 percent work all year. 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 nonagricultural), Malawi 2010 Employment characteristic Agricultural work Nonagricultural work Missing Total Type of earnings Cash only 25.9 71.8 2.3 45.1 Cash and in-kind 11.2 6.0 4.3 9.0 In-kind only 5.0 1.2 0.0 3.4 Not paid 57.7 20.7 91.2 42.3 Missing 0.2 0.3 2.1 0.3 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 25.9 10.7 2.7 19.5 Employed by nonfamily member 6.6 22.3 0.0 13.2 Self-employed 67.3 66.7 95.1 67.1 Missing 0.1 0.3 2.1 0.2 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 23.8 47.4 78.7 33.8 Seasonal 69.8 29.6 13.0 52.8 Occasional 6.2 22.6 6.2 13.1 Missing 0.2 0.3 2.1 0.3 Total 100.0 100.0 100.0 100.0 Number of women employed during the last 12 months 9,705 7,040 45 16,790 Note: Total includes women with missing information on type of employment who are not shown separately. Table 3.7.2 shows that half of the men (50 percent) employed in agricultural work are not paid. Fifty-six percent of men in agricultural work are self-employed, and 61 percent work seasonally. Among men employed in the nonagricultural sector, 82 percent are paid in cash only, 46 percent are self-employed, and 59 percent work all year. Respondents’ Characteristics | 37 Table 3.7.2 Type of employment: Men Percent distribution of men 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 nonagricultural), Malawi 2010 Employment characteristic Agricultural work Nonagricultural work Missing Total Type of earnings Cash only 35.0 81.7 59.5 56.4 Cash and in-kind 11.2 4.3 2.2 7.5 In-kind only 3.4 0.6 0.3 2.0 Not paid 50.4 13.4 37.8 34.1 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 33.4 9.2 16.7 21.9 Employed by nonfamily member 10.9 45.0 44.4 28.1 Self-employed 55.7 45.7 38.7 49.9 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 35.1 58.8 22.9 43.5 Seasonal 61.4 27.6 42.3 45.8 Occasional 3.2 13.5 34.6 10.5 Total 100.0 100.0 100.0 100.0 Number of men employed during the last 12 months 2,990 2,452 612 6,054 Note: Total includes men with missing information on type of employment who are not shown separately. 3.8 KNOWLEDGE AND ATTITUDES REGARDING TUBERCULOSIS The 2010 MDHS collected information on knowledge and attitudes towards tuberculosis (TB), a major public health concern worldwide. Respondents were asked if they had ever heard of TB and how it is spread, whether the disease is curable and through what methods, and several other TB- related questions. Additionally, respondents were asked whether or not they would want other people to know if a family member had TB. Tables 3.8.1 and 3.8.2 present information on knowledge and attitudes concerning TB for women and men age 15-49, by background characteristics. Almost all women and men are knowledgeable about TB: 98 percent of women and 99 percent of men. Among all respondents who report having heard of TB, 78 percent of women and 86 percent of men reported that TB is spread through the air by coughing. The greatest differentials regarding knowledge of the spread of TB and attitudes on whether it can be cured are observed by respondents’ educational levels. Eighty-nine percent of women and 92 percent of men with at least a secondary school education correctly reported that TB is spread through the air by coughing compared with 74 percent of women and 80 percent of men with no education. Ninety-two percent of women with at least a secondary school education believe that TB can be cured compared with 73 percent of women with no education. For men, 96 percent with at least a secondary school education believe TB can be cured compared with 75 percent with no education. 38 | Respondents’ Characteristics Table 3.8.1 Knowledge and attitude concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Malawi 2010 Background characteristic Among all respondents Among respondents who have heard of TB Percentage who have heard of TB Number Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number Age 15-19 96.0 5,005 73.1 67.7 52.5 4,803 20-24 97.6 4,555 76.2 79.1 51.1 4,446 25-29 98.5 4,400 80.8 83.3 50.5 4,335 30-34 98.7 3,250 82.7 85.1 51.3 3,209 35-39 97.7 2,522 78.9 81.9 49.1 2,463 40-44 98.1 1,730 81.7 82.0 49.0 1,697 45-49 98.5 1,558 80.9 80.9 47.8 1,534 Residence Urban 99.5 4,302 87.1 90.5 48.3 4,280 Rural 97.3 18,718 76.3 76.3 51.3 18,208 Region Northern 98.3 2,677 65.6 70.8 53.5 2,633 Central 97.2 9,857 77.5 73.3 45.2 9,581 Southern 98.0 10,485 82.5 86.4 55.1 10,273 Education No education 95.6 3,505 73.7 72.7 54.0 3,350 Primary 97.6 14,916 75.8 76.2 51.6 14,552 Secondary 99.7 4,177 89.3 91.8 46.9 4,164 More than secondary 100.0 422 97.8 99.3 30.4 422 Wealth quintile Lowest 95.6 4,268 71.8 69.9 49.2 4,081 Second 96.4 4,332 73.8 72.8 53.3 4,176 Middle 97.6 4,517 76.9 76.3 51.9 4,411 Fourth 98.6 4,515 79.7 81.6 52.1 4,454 Highest 99.6 5,388 87.0 90.8 47.7 5,366 Total 97.7 23,020 78.4 79.0 50.7 22,487 Women in the highest wealth quintile are more likely to believe that TB can be cured (91 percent) compared with those from the lowest quintile (70 percent). A similar pattern is observed among men (94 percent and 81 percent, respectively). Overall, women are more likely than men to want to conceal the fact that a family member has TB (51 and 34 percent, respectively). Data on both sexes show that attitudes on whether they would want others to know that their family member had TB are associated with the level of education. Fifty-four percent of females and 44 percent of males with no education would want knowledge of their family member’s TB kept a secret compared with 30 percent of women and 17 percent of men with more than a secondary school education. Respondents’ Characteristics | 39 Table 3.8.2 Knowledge and attitude concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Malawi 2010 Background characteristic Among all respondents Among respondents who have heard of TB Percentage who have heard of TB Number Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number Age 15-19 96.3 1,748 82.5 78.4 38.2 1,683 20-24 98.7 1,239 85.0 88.4 35.4 1,223 25-29 99.3 1,099 85.3 90.9 32.0 1,091 30-34 99.8 948 88.3 93.5 33.5 947 35-39 99.6 798 87.5 90.9 31.3 795 40-44 99.5 529 90.4 92.3 27.5 527 45-49 99.1 458 86.8 92.0 26.4 453 Residence Urban 99.2 1,440 88.2 94.5 28.9 1,428 Rural 98.3 5,379 85.1 86.1 34.8 5,289 Region Northern 98.5 744 80.4 82.5 45.0 733 Central 98.7 3,074 89.0 85.5 29.3 3,035 Southern 98.3 3,001 83.7 91.6 35.2 2,950 Education No education 95.0 422 80.4 75.4 43.8 401 Primary 98.2 4,270 83.0 84.7 35.8 4,195 Secondary 99.9 1,904 92.0 96.3 28.4 1,902 More than secondary 99.2 223 93.8 98.9 16.9 221 Wealth quintile Lowest 97.0 997 81.7 80.9 35.7 967 Second 98.4 1,309 83.5 84.6 35.1 1,288 Middle 98.4 1,367 86.2 87.5 35.3 1,345 Fourth 98.5 1,376 86.0 88.3 36.3 1,354 Highest 99.6 1,770 89.1 94.1 27.8 1,762 Total 15-49 98.5 6,818 85.7 87.9 33.6 6,718 50-54 99.4 357 88.0 91.2 24.0 354 Total men 15-54 98.6 7,175 85.9 88.0 33.1 7,072 3.9 TOBACCO USE Tobacco is used in various ways. It is dried and rolled into cigarettes and cigars for smoking, shredded and inserted into pipes (also for smoking), and finely pulverised for inhalation as snuff. Smoking has been shown to have significant adverse health effects, including increased risk of respiratory and cardiovascular illnesses both for the individual smoker and for other people exposed to second-hand or environmental tobacco smoke (WHO, 2002). Information on women’s and men’s tobacco use was collected during the 2010 MDHS. Tables 3.9.1 and 3.9.2 show the percentages of women and men age 15-49 who smoke cigarettes or a pipe or use other forms of tobacco. Additionally, both tables show the percent distribution of cigarette smokers age 15-49 by the number of cigarettes smoked in the past 24 hours, according to background characteristics. The majority of women (99 percent) and men (83 percent) reported that they do not use tobacco. Only one percent of women reported using tobacco. Two percent of women in the Northern Region reported using tobacco, compared with one percent each for women in the Central and Southern Regions. Women with no education are more likely to use tobacco products (4 percent) than their counterparts who have been to school. Among men age 15-49, 17 percent reported they use tobacco products, of which almost all smoke cigarettes. Men in rural areas are more likely to smoke cigarettes (19 percent) compared with their urban counterparts (10 percent). Cigarette smoking among 40 | Respondents’ Characteristics men is also highest among men with no education and among those in the lowest wealth quintile (34 percent and 29 percent, respectively). Men from the Central Region are most likely to smoke cigarettes (20 percent) compared with men from the Northern Region and the Southern Region (both 14 percent). By age, tobacco use is highest among men age 45-49 (32 percent). Among men who use tobacco, 63 percent report smoking one to five cigarettes in the last 24 hours. Sixteen percent of men report smoking 6-9 cigarettes in the last 24 hours and 14 percent reported smoking 10 or more cigarettes in the last 24 hours. Half of women that report using tobacco smoked one to five cigarettes in the last 24 hours. Table 3.9.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics and maternity status, Malawi 2010 Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of women Number of cigarettes in the last 24 hours Total Number of cigarette smokers 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 0.1 0.0 0.0 99.8 5,005 * * * * * 100.0 4 20-24 0.2 0.0 0.1 99.7 4,555 * * * * * 100.0 10 25-29 0.3 0.0 0.4 99.4 4,400 * * * * * 100.0 14 30-34 0.6 0.1 0.3 99.2 3,250 * * * * * 100.0 19 35-39 0.4 0.0 1.3 98.4 2,522 * * * * * 100.0 9 40-44 1.1 0.0 3.4 95.9 1,730 * * * * * 100.0 19 45-49 1.0 0.0 4.5 94.8 1,558 * * * * * 100.0 15 Residence Urban 0.5 0.1 0.2 99.4 4,302 * * * * * 100.0 21 Rural 0.4 0.0 1.0 98.7 18,718 14.0 34.5 4.6 4.3 42.7 100.0 70 Region Northern 0.3 0.0 1.5 98.3 2,677 * * * * * 100.0 7 Central 0.3 0.0 0.8 98.9 9,857 * * * * * 100.0 34 Southern 0.5 0.0 0.7 98.9 10,485 26.7 24.0 5.9 6.0 37.4 100.0 50 Education No education 1.0 0.0 2.5 96.8 3,505 (22.8) (53.2) (8.1) (8.9) (7.0) 100.0 33 Primary 0.3 0.0 0.7 99.1 14,916 (17.9) (16.4) (1.1) (4.8) (59.9) 100.0 45 Secondary 0.3 0.0 0.2 99.7 4,177 * * * * * 100.0 11 More than secondary 0.3 0.0 0.0 99.7 422 * * * * * 100.0 1 Maternity status Pregnant 0.2 0.0 0.4 99.4 2,072 * * * * * 100.0 3 Breastfeeding (not pregnant) 0.3 0.0 0.5 99.2 7,403 (5.1) (14.4) (0.0) (3.7) (76.8) 100.0 23 Neither 0.5 0.0 1.1 98.5 13,544 26.4 33.1 5.0 6.7 28.8 100.0 64 Wealth quintile Lowest 0.5 0.0 1.2 98.4 4,268 * * * * * 100.0 20 Second 0.5 0.0 1.3 98.3 4,332 * * * * * 100.0 23 Middle 0.3 0.0 1.0 98.8 4,517 * * * * * 100.0 11 Fourth 0.5 0.0 0.6 98.9 4,515 (4.8) (43.9) (4.8) (9.0) (37.5) 100.0 23 Highest 0.3 0.0 0.2 99.6 5,388 * * * * * 14 Total 0.4 0.0 0.8 98.8 23,020 20.0 30.3 3.5 5.7 40.6 100.0 91 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Respondents’ Characteristics | 41 Table 3.9.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Malawi 2010 Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of men Number of cigarettes in the last 24 hours Total Number of cigarette smokers 0 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 2.5 0.0 0.4 97.2 1,748 (9.9) (30.7) (29.2) (3.1) (12.6) 14.5 100.0 44 20-24 12.8 0.0 1.0 87.0 1,239 4.1 33.4 38.5 9.9 12.5 1.6 100.0 159 25-29 21.2 0.1 1.3 78.5 1,099 5.4 32.5 32.3 21.1 8.0 0.7 100.0 233 30-34 22.8 0.1 1.3 77.0 948 6.5 20.2 44.7 11.2 15.4 2.0 100.0 216 35-39 27.4 0.5 1.7 71.9 798 1.8 24.8 33.4 22.1 14.5 3.3 100.0 219 40-44 25.5 0.0 1.2 74.2 529 6.1 21.4 41.6 14.4 15.0 1.6 100.0 135 45-49 31.6 0.0 3.2 66.4 458 2.3 17.6 40.6 19.4 19.5 0.7 100.0 144 Residence Urban 10.0 0.0 0.5 89.9 1,440 10.2 23.4 42.3 7.9 15.5 0.7 100.0 144 Rural 18.7 0.1 1.4 80.8 5,379 3.8 25.9 37.0 17.4 13.4 2.4 100.0 1,006 Region Northern 14.2 0.1 1.1 85.1 744 3.0 25.3 35.6 16.4 16.1 3.6 100.0 105 Central 20.0 0.2 1.3 79.6 3,074 4.3 24.4 41.2 17.5 11.7 0.8 100.0 615 Southern 14.3 0.0 1.1 85.3 3,001 5.4 27.4 33.2 14.3 15.9 3.8 100.0 429 Education No education 33.5 0.7 3.3 65.8 422 2.9 27.2 29.3 20.3 18.2 2.0 100.0 141 Primary 19.2 0.1 1.4 80.3 4,270 3.7 25.5 38.7 16.5 13.9 1.8 100.0 819 Secondary 9.7 0.1 0.3 90.3 1,904 10.3 25.0 40.5 12.1 8.3 3.8 100.0 184 More than secondary 2.5 0.0 0.0 97.5 223 * * * * * * 100.0 6 Wealth quintile Lowest 29.2 0.4 2.5 69.9 997 4.8 25.2 37.6 15.5 16.3 0.6 100.0 291 Second 21.4 0.1 2.0 77.9 1,309 2.5 23.5 35.4 21.7 14.1 2.8 100.0 281 Middle 18.4 0.1 0.9 81.3 1,367 4.2 30.6 33.0 17.5 12.2 2.5 100.0 252 Fourth 13.9 0.0 1.0 85.7 1,376 5.0 26.1 42.8 12.2 11.4 2.3 100.0 191 Highest 7.6 0.0 0.2 92.3 1,770 8.9 20.8 44.2 9.4 13.2 3.5 100.0 134 Total 15-49 16.9 0.1 1.2 82.7 6,818 4.6 25.6 37.7 16.2 13.7 2.2 100.0 1,150 50-54 31.4 0.2 1.7 67.4 357 6.7 14.2 50.4 9.3 17.9 1.4 100.0 112 Total men 15-54 17.6 0.1 1.2 82.0 7,175 4.8 24.6 38.8 15.6 14.1 2.1 100.0 1,262 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Fertility | 43 FERTILITY 4 4.1 INTRODUCTION This chapter focuses on a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women begin childbearing. Information on current and cumulative fertility is essential for monitoring population growth. Birth intervals are important because short intervals are associated with high childhood mortality. The age at which childbearing begins can also have a major impact on the health and wellbeing of both the mother and the child. To generate data on fertility, a birth history was collected from each woman interviewed in the 2010 MDHS. Women were asked to report the total number of sons and daughters to whom they had given birth in their lifetime. To ensure all information was reported, women were asked separately about children still living at home, those living elsewhere, and those who had died. Sex, date of birth, and survival status of each child was obtained, and age at death for dead children was recorded.1 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 programmes. Measures of current fertility presented in this chapter include age-specific fertility rates (ASFR), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). The rates are presented for the period 1 to 36 months preceding the survey, which was determined from the date of interview and a child’s birth date. A three-year period is chosen for calculating these rates to provide the most current information, to reduce sampling error, and to avoid problems from the displacement of births. Age-specific fertility rates show the age pattern of fertility. Numerators for the ASFRs are calculated by identifying live births that occurred in the three-year period preceding the survey and classifying them by the age of the mother (in five-year age groups) at the time of the child’s birth. The denominators of the rates represent the number of woman-years lived by the survey respondents in each of the five-year age groups during the specified period. The TFR refers to the number of live births a woman would have if she were subject to the current age-specific fertility rates throughout her reproductive years (15-49 years). The GFR represents the number of live births per 1,000 women of reproductive age. The CBR is the number of live births per 1,000 population. The latter two measures are based on birth history data for the three-year period before the survey and the age-sex distribution of the household population. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. Table 4.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Malawi 2010 Age group Residence Total Urban Rural 15-19 109 162 152 20-24 206 285 269 25-29 200 248 238 30-34 133 222 206 35-39 125 169 162 40-44 32 91 82 45-49 3 38 33 TFR (15-49) 4.0 6.1 5.7 GFR 154 213 202 CBR 36.0 39.8 39.2 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 44 | Fertility Table 4.1 shows age-specific fertility rates for women by five-year age groups; it also shows the current fertility for the three-year period preceding the 2010 MDHS. Age-specific and total fertility rates were calculated directly from the birth history data. The sum of age-specific fertility rates (known as the total fertility rate, or TFR) is a summary measure of the level of fertility. If fertility were to remain constant at current levels, a Malawian woman would bear an average of 5.7 children in her lifetime. The phenomenon of rural-urban variation in fertility also holds true, as the table indicates that rural women will give birth to two more children during their reproductive years than urban women (6.1 and 4.0, respectively). This rural-urban difference in the TFR is similar to that observed in the 2004 MDHS. The TFR measured in the 2010 MDHS (5.7) is slightly lower than the TFR measured in the 2004 MDHS (6.0). Examination of the age pattern of fertility rates show that the peak of childbearing in Malawi is during age 20-24. The same age pattern was observed in the 2004 MDHS. Table 4.1 further shows a general fertility rate of 202 live births per 1,000 women age 15-44 years and a crude birth rate of 39.2 births per 1,000 population. This section examines associations between a woman’s background characteristics and her fertility. Table 4.2 shows fertility differentials by residence, region, education, and wealth quintile. The analysis of the fertility differentials in this report is conducted by presenting the TFR, percentage of currently pregnant women, and completed fertility in terms of the mean number of births to women age 40-49 by these characteristics. 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, Malawi 2010 Background characteristic Total fertility rate Percentage women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 4.0 5.8 5.8 Rural 6.1 9.7 6.7 Region Northern 5.7 9.4 6.5 Central 5.8 8.6 7.0 Southern 5.6 9.3 6.1 Education No education 6.9 8.7 7.1 Primary 5.9 9.8 6.5 Secondary 3.8 6.8 4.2 More than secondary 2.1 6.0 3.6 Wealth quintile Lowest 6.8 9.7 7.0 Second 6.8 11.0 7.2 Middle 6.3 10.5 6.8 Fourth 5.3 8.1 6.4 Highest 3.7 6.3 5.5 Total 5.7 9.0 6.6 Note: Total fertility rates are for the period 1-36 months prior to interview. Table 4.2 shows that the TFR in the Northern Region is 5.7 births per woman, while in the Central and Southern Regions it is 5.8 and 5.6 births per woman, respectively. Education consistently appears as an important variable in the analysis of fertility-related behaviour. Generally, the TFR declines as educational level increases. Women with more than a secondary education have a TFR of 2.1, compared with women with no education who have a TFR of 6.9. A similar relationship is reflected in the association between fertility rates and the wealth index, which shows that women have Fertility | 45 fewer children as wealth increases. Women in the highest wealth quintile have an average of three children fewer than women in the lowest quintile (3.7 and 6.8 births per woman, respectively). Nine percent of interviewed women reported that they were pregnant at the time of the survey. The percentage of women who are currently pregnant provides another measure of current fertility, although it is recognised that the survey may not capture all pregnancies because some women may not know that they are pregnant or may be reluctant to report early-stage pregnancies. The last column in Table 4.2 shows the mean number of children ever born (CEB) to women age 40-49. This is an indicator of cumulative fertility; it reflects the fertility performance of older women who are nearing the end of their reproductive period and thus represents completed fertility. The findings show that the mean number of children ever born to women age 40-49 (6.6 children per woman) is slightly higher than the TFR for the 3 years preceding the survey (5.7 children per woman), suggesting a slight recent reduction in fertility. 4.3 FERTILITY TRENDS Table 4.3.1 uses information from the retrospective birth histories obtained from the 2010 MDHS respondents to examine trends in age-specific fertility rates for successive five-year periods before the survey. To calculate these rates, births are classified according to the period of time in which the birth occurred and the mother’s age at the time of the birth. Because birth histories were not collected for women age 50 and older, 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 five to nine years or more preceding the survey because women in that age group would have been 50 years or older at the time of the survey. The results in Table 4.3.1 show age-specific fertility rates decreased between the two five- year periods prior to the survey for all age groups. A constant decrease is also observed for the last three periods before the survey for the 20-24, 25-29, 30-34, and 35-39 age groups. Table 4.3.1 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, Malawi 2010 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 157 180 171 166 20-24 270 297 316 303 25-29 241 281 288 289 30-34 208 240 253 [297] 35-39 159 172 [207] - 40-44 82 [119] - - 45-49 [35] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Another way to examine fertility trends is to compare current estimates with earlier surveys and censuses. The results shown in Table 4.3.2 and Figure 4.1 confirm the earlier conclusion that fertility has declined in Malawi in the past two decades and continues to decline. The TFR has substantially declined from 6.7 children per woman in the 1992 MDHS to 6.3 children per woman in the 2000 MDHS, to 6.0 children per woman in the 2004 MDHS, and to 5.7 children per woman in the 2010 MDHS. 46 | Fertility Table 4.3.2 Trends in age-specific and total fertility rates Age-specific and total fertility rates (TFR), Malawi DHS 1992- 2010 Mother’s age at birth 1992 MDHS1 2000 MDHS2 2004 MDHS3 2010 MDHS 15-19 161 172 162 152 20-24 287 305 293 269 25-29 269 272 254 238 30-34 254 219 222 206 35-39 197 167 163 162 40-44 120 94 80 82 45-49 58 41 35 33 TFR 15-49 6.7 6.3 6.0 5.7 Note: Age-specific fertility rates are per 1,000 women. 1 NSO and Macro International, 1994 2 NSO and ORC Macro, 2001 3 NSO and ORC Macro, 2005 Figure 4.1 Trends in Age-specific Fertility Rates, Various Sources, 1992-2010 MDHS 2010 # # # # # # # & & & & & & & , , , , , , , ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 50 100 150 200 250 300 350 Bi rt h s pe r 1 , 0 00 w om en MDHS 1992 MDHS 2000 MDHS 2004 MDHS 2010) , & # 4.4 CHILDREN EVER BORN AND LIVING Table 4.4 shows the distribution of all women and currently married women by the number of children ever born, according to five-year age groups. The table also shows the mean number of children ever born and the mean number of living children. Information on the number of children ever born reflects the accumulation of births over a woman’s entire reproductive period (parity) and therefore has limited reference to current fertility levels, particularly when the country has experienced a decline in fertility. However, as an indicator, the number of children ever born to all women is useful for observing how average family size varies across age groups, and for observing the level of primary infertility. Comparison of the mean number of children ever born to all women and the mean number of living children shows the cumulative effects of mortality during the childbearing period. Four-fifths of all women age 15-19 (80 percent) have never given birth. However, this proportion declines to 2 percent or less for women age 30 and older; indicating that childbearing among Malawian women is nearly universal. The percentage of women who are childless at the end Fertility | 47 of the reproductive period is an indirect measure of primary infertility (the proportion of women who are unable to bear children at all). Voluntary childlessness is rare in Malawi; therefore, it is likely that married women with no births are unable to have children. The data show that less than two percent of married women remain childless by their 40s. The same pattern is seen for currently married women, except that the mean number of children ever born is higher (3.8 children) among currently married women compared with all women (3.1 children). The difference in the mean number of children ever born to all women and to currently married women can be attributed to a substantial proportion of young and unmarried women in the former category who exhibit lower fertility. In addition to giving a description of average family size, information on children ever born and number of living children also gives some indication of the extent of childhood mortality. The 2010 MDHS results indicate that on average, all women have more than 2.6 surviving children, and currently married women have 3.2 children who survive. The difference between the mean number of children ever born and mean number of children still living for the two groups of women increases with a woman’s age. Table 4.4 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Malawi 2010 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 79.9 17.6 2.3 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.00 5,005 0.23 0.21 20-24 15.4 31.7 34.1 14.5 3.6 0.6 0.1 0.0 0.0 0.0 0.0 100.00 4,555 1.61 1.44 25-29 3.8 8.8 22.6 30.5 23.2 8.0 2.6 0.4 0.1 0.0 0.0 100.00 4,400 2.98 2.64 30-34 1.9 4.3 8.4 18.0 22.7 22.7 13.2 6.1 1.9 0.4 0.3 100.00 3,250 4.23 3.59 35-39 2.1 2.3 4.3 7.4 13.3 20.3 19.8 15.6 8.5 4.2 2.3 100.00 2,522 5.45 4.50 40-44 1.3 2.4 4.0 6.1 9.1 12.8 13.9 21.6 12.1 8.3 8.4 100.00 1,730 6.26 5.04 45-49 1.6 2.9 3.6 4.7 6.6 9.2 12.4 13.6 13.8 14.0 17.5 100.00 1,558 6.91 5.29 Total 21.8 13.0 13.8 12.9 10.9 8.7 6.4 5.2 3.1 2.1 2.1 100.00 23,020 3.07 2.57 CURRENTLY MARRIED WOMEN 15-19 37.0 53.6 8.6 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.00 1,171 0.73 0.65 20-24 4.9 33.6 39.9 16.8 4.2 0.6 0.1 0.0 0.0 0.0 0.0 100.00 3,469 1.84 1.65 25-29 2.0 7.5 22.5 31.8 24.1 8.7 2.8 0.5 0.1 0.0 0.0 100.00 3,718 3.09 2.74 30-34 1.2 3.5 7.6 17.4 22.5 24.1 13.9 6.8 2.2 0.5 0.3 100.00 2,636 4.37 3.74 35-39 1.5 1.5 3.5 5.5 11.9 20.8 21.3 16.8 9.9 4.5 2.8 100.00 2,040 5.70 4.73 40-44 1.2 2.1 3.6 4.6 7.8 12.0 14.3 22.8 12.4 9.2 9.8 100.00 1,339 6.48 5.21 45-49 1.3 2.2 2.8 4.0 5.2 7.8 12.5 13.5 14.1 16.3 20.2 100.00 1,155 7.26 5.62 Total 5.0 14.5 17.2 15.8 13.2 10.6 8.0 6.4 3.8 2.7 2.8 100.00 15,528 3.80 3.20 4.5 BIRTH INTERVALS A birth interval is defined as the period of time between two successive live births. Information about birth intervals is important in understanding the health status of young children. Research has shown that short birth intervals (<24 months) are associated with poor health outcomes, especially during infancy. Children born too soon after a previous birth, especially if the interval between the births is less than two years, have an increased risk of sickness and death at an early age. Longer birth intervals (more than two years), on the other hand, contribute to improved health status for both the mother and child. Table 4.5 presents the percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, according to selected demographic and socioeconomic variables. The median length of birth interval in Malawi is 36 months, which is the same as the median birth interval in the 2004 MDHS. The table further shows that 5 percent of non- first births are born after an interval of less than 18 months, and 10 percent are born after an interval of 18 to 23 months. One in three births (35 percent) are born 24 to 35 months after the previous birth, and 25 percent are born 36 to 47 months after the previous birth. 48 | Fertility The median number of months since the preceding birth increases markedly with age, from 26 months among mothers age 15-19 to 41 months among mothers age 40-49. The median birth interval does not vary much by birth order or sex of the preceding birth. However, there are notable variations in the median birth interval according to survival of the preceding birth, residence, and educational level. The median birth interval is higher (36.7 months) if the preceding birth’s survival status is living rather than dead (28.4 months). Variation by residence shows that the median birth interval for urban mothers is higher (39.8 months) than for rural mothers (35.7 mothers). By level of education, the median birth interval ranges from 35.9 months among women with no education to 55.3 months among women with more than secondary education. Table 4.5 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, Malawi 2010 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 15.3 18.2 44.6 16.6 2.5 2.8 100.0 125 26.1 20-29 5.4 10.9 39.4 25.8 11.1 7.4 100.0 8,165 34.2 30-39 3.8 9.3 30.2 25.0 14.4 17.4 100.0 5,871 38.4 40-49 6.0 7.6 27.2 20.2 13.0 26.0 100.0 1,466 41.2 Birth order 2-3 5.0 10.2 36.2 25.1 12.0 11.4 100.0 7,160 35.6 4-6 4.2 9.4 33.7 25.0 13.3 14.4 100.0 6,173 36.8 7+ 6.5 11.3 33.5 23.6 11.7 13.3 100.0 2,294 35.4 Sex of preceding birth Male 5.0 9.4 34.6 23.8 13.3 13.9 100.0 7,853 36.3 Female 4.8 10.7 35.1 26.0 11.6 11.8 100.0 7,773 35.8 Survival of preceding birth Living 2.8 9.3 35.6 26.1 13.0 13.2 100.0 13,855 36.7 Dead 21.0 16.1 28.9 15.5 8.1 10.4 100.0 1,772 28.4 Residence Urban 5.2 8.1 29.5 23.5 15.2 18.4 100.0 2,064 39.8 Rural 4.8 10.4 35.6 25.1 12.0 12.0 100.0 13,562 35.7 Region Northern 4.2 7.7 38.1 27.1 12.0 10.9 100.0 1,805 36.0 Central 5.4 10.3 35.0 24.3 12.6 12.4 100.0 6,659 35.7 Southern 4.6 10.4 33.9 24.9 12.4 13.8 100.0 7,163 36.4 Education No education 5.3 11.2 33.8 23.4 12.4 13.9 100.0 3,170 35.9 Primary 4.8 10.2 36.1 25.5 11.9 11.5 100.0 10,616 35.6 Secondary 5.0 7.3 29.8 24.1 15.4 18.4 100.0 1,759 39.6 More than secondary 2.2 9.1 14.6 13.4 22.2 38.5 100.0 81 55.3 Wealth quintile Lowest 5.4 11.7 35.3 25.8 10.8 10.9 100.0 3,483 35.1 Second 5.8 10.7 36.9 24.3 11.6 10.7 100.0 3,472 35.1 Middle 4.6 9.9 36.7 26.0 11.3 11.5 100.0 3,396 35.6 Fourth 4.1 9.8 34.8 24.4 13.9 12.9 100.0 2,912 36.5 Highest 4.1 7.4 28.3 23.3 16.0 20.8 100.0 2,363 41.4 Total 4.9 10.1 34.8 24.9 12.5 12.9 100.0 15,627 36.1 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Fertility | 49 4.6 AGE AT FIRST BIRTH The age at which childbearing commences is an important determinant of overall fertility as well as the health and welfare of the mother and child. In some societies, the delay of first births as a result of an increase in the age at marriage has contributed to a decrease in fertility. However, in Malawi, it is not uncommon for women to have children before getting married. Table 4.6 shows the percentage of women who have given birth by specific ages, according to their age at the time of the survey. Overall, the median age at first birth for women age 20-49 in Malawi is 18.9 years. The median age at first birth varies little by age group. In Malawi, 7 percent of women age 25-49 have given birth by age 15, and 65 percent have become mothers by age 20. Comparing the proportions of women who have given birth by age 15 across age groups provides another way to view trends in age at first birth over time. The results indicate a decrease in early childbearing over time. The percentage of women who gave birth by exact age 15 is 7 percent or higher among women age 35-49, around 5 percent among women age 20-34, and less than two percent among women age 15-19.This reduction in the percentage of women giving birth early supports the findings that age at first childbirth has been increasing slowly. Table 4.6 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, Malawi 2010 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 1.3 na na na na 79.9 5,005 a 20-24 4.8 34.7 66.7 na na 15.4 4,555 18.9 25-29 5.1 35.2 66.3 84.8 94.0 3.8 4,400 18.9 30-34 5.4 34.4 65.1 83.8 94.4 1.9 3,250 19.0 35-39 6.9 34.2 60.6 79.0 92.6 2.1 2,522 19.2 40-44 10.8 40.9 65.4 82.2 91.5 1.3 1,730 18.7 45-49 7.1 38.3 63.8 80.6 90.0 1.6 1,558 18.9 20-49 6.1 35.6 65.1 na na 5.7 18,015 18.9 25-49 6.5 35.9 64.5 82.6 93.0 2.4 13,461 18.9 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 4.7 MEDIAN AGE AT FIRST BIRTH Age at first birth varies by the demographic and socioeconomic characteristics of the woman. Table 4.7 shows the median age at first birth across age cohorts for key sub-groups of women. The measures are presented for women age 25-49 to ensure that half of the women have already had a birth by the start of the age group. Urban women age 25-49 have a higher median age at first birth (19.4 years) than their rural counterparts (18.8 years). A comparison across regions shows that the median age at first birth for women age 25-49 ranges from 19.2 years in the Central Region to 18.7 years in the Southern Region. The median age at first birth increases with level of education. Women with no education have their first birth at a median age of 18.4 years, while women who have attended more than secondary education have a median age at first birth of 24.4 years, a difference of six years. On the other hand, there is no correlation between age at first birth and wealth quintile. 50 | Fertility Table 4.7 Median age at first birth Median age at first birth among women age 20-49 (25-49) years, according to background characteristics, Malawi 2010 Background characteristic Age Women age 20-49 Women age 25-49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban 19.8 19.7 19.6 19.5 18.7 18.4 19.5 19.4 Rural 18.8 18.7 18.9 19.1 18.7 19.0 18.8 18.8 Region Northern 19.1 18.7 19.3 19.0 19.2 18.7 19.0 18.9 Central 19.2 19.4 19.2 19.3 18.8 19.2 19.2 19.2 Southern 18.5 18.6 18.7 19.0 18.4 18.6 18.6 18.7 Education No education 18.3 17.8 18.2 18.8 18.1 19.2 18.4 18.4 Primary 18.4 18.5 18.8 19.0 18.7 18.7 18.6 18.7 Secondary a 20.5 21.2 21.2 20.4 20.1 a 20.8 More than secondary a a 26.4 23.7 23.2 22.5 a 24.4 Wealth quintile Lowest 18.5 18.6 18.7 19.5 18.9 19.4 18.8 18.9 Second 18.5 18.6 18.9 18.8 18.6 18.7 18.7 18.7 Middle 18.7 18.7 18.7 19.2 18.1 18.6 18.7 18.7 Fourth 18.8 18.6 19.0 18.7 18.4 18.7 18.7 18.7 Highest a 19.8 19.9 19.8 19.3 19.1 19.9 19.7 Total 18.9 18.9 19.0 19.2 18.7 18.9 18.9 18.9 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 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. In addition, childbearing during the teenage years frequently has adverse social consequences, particularly regarding educational attainment, because women who become mothers in their teens are more likely to curtail their education. Table 4.8 shows the percentage of women age 15-19 who have either had a live birth or who are pregnant with their first child. Overall, one in every four teenagers (26 percent) age 15-19 has begun childbearing; 20 percent have had a live birth and 6 percent are pregnant with their first child. A higher proportion of teenagers in rural areas (27 percent) has begun childbearing compared with teenagers in urban areas (21 percent). At the regional level, the proportion of teenagers who have started childbearing is highest in the Southern Region (29 percent) and the Northern Region (28 percent) compared with the Central Region (22 percent). The percentage of teenagers who have started childbearing decreases with increasing level of education. Forty-five percent of teenagers with no education have already begun childbearing as compared with only 4 percent of those with more than secondary education. Teenagers in the lowest wealth quintile are more than twice as likely to have started childbearing as those in the highest wealth quintile (31 and 16 percent, respectively). Fertility | 51 Table 4.8 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, Malawi 2010 Background characteristic Percentage who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 1.6 2.0 3.5 1,234 16 7.5 5.1 12.6 1,152 17 15.0 6.7 21.7 927 18 34.4 9.0 43.4 907 19 57.2 6.3 63.5 784 Residence Urban 16.0 4.5 20.5 947 Rural 21.0 5.8 26.8 4,058 Region Northern 20.7 7.5 28.1 618 Central 16.6 5.1 21.7 2,179 Southern 23.3 5.4 28.7 2,208 Education No education 32.9 11.6 44.6 146 Primary 22.0 6.1 28.1 3,669 Secondary 13.0 2.9 15.9 1,156 More than secondary 0.0 4.0 4.0 34 Wealth quintile Lowest 24.7 6.4 31.1 891 Second 24.9 6.2 31.1 890 Middle 23.2 7.0 30.2 985 Fourth 18.1 5.7 23.8 985 Highest 12.5 3.2 15.6 1,254 Total 20.1 5.5 25.6 5,005 Family Planning | 53 FAMILY PLANNING 5 Family planning refers to a conscious effort by a couple to limit or space the number of children they want to have through the use of contraceptive methods. This chapter presents results from the 2010 MDHS on a number of aspects of contraception: knowledge of specific contraceptive methods, attitudes and behaviour towards contraceptive use, ever use and current use, sources of contraceptive methods, and costs of methods. The focus of this chapter is on sexually active women, as these women have the greatest risk of exposure to pregnancy and the greatest need to regulate their fertility. The results of interviews with men are presented alongside those with women, as men play an equally important role in the realisation of reproductive health and family planning decisions and behaviour. Comparisons are also made, where feasible, with findings from previous surveys to evaluate changes in contraceptive measures over time in Malawi.1 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Information on knowledge and use of family planning methods was obtained from female and male respondents by asking them to mention ways or methods by which a couple can delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent had heard of it. For each method known, respondents were asked if they had ever used the method. Respondents who reported they used the method were asked whether they or their partners were using a method at the time of the survey. Contraceptive methods are classified as modern or traditional methods. Modern methods include female sterilisation, male sterilisation, the pill, the intrauterine device (IUD), injectables, implants, the male condom, the female condom, and emergency contraception. Methods such as rhythm (periodic abstinence) and withdrawal are grouped as traditional methods. Provision was also made in the questionnaire to record any other methods mentioned by the respondent, including folk methods. Table 5.1 shows that knowledge of any contraceptive method is universal in Malawi, with 98 percent of all women and 99 percent of all men knowing at least one method of contraception. Modern methods are more widely known than traditional methods; 98 percent of all women know of a modern method while 74 percent know of a traditional method. Among modern methods for women, injectables and male condoms are the most commonly known methods (95 percent each), and emergency contraception is the least known modern method (35 percent). Knowledge of a modern method of family planning among currently married women (100 percent) and sexually active unmarried women (99 percent) is universal. Among traditional methods, withdrawal and the rhythm method are the most commonly known among all women (60 and 53 percent, respectively). Overall, women know a mean number of 8.5 contraceptive methods while men know 7.8 methods. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 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, Malawi 2010 Method Women Men All women Currently married women Sexually active unmarried woman1 All men Currently married men Sexually active unmarried men1 Any method 97.9 99.7 99.2 98.6 99.7 98.9 Any modern method 97.9 99.7 99.2 98.5 99.7 98.5 Female sterilisation 88.6 93.0 88.4 83.9 91.9 83.3 Male sterilisation 67.7 73.3 67.0 69.9 78.9 62.3 Pill 91.1 96.6 89.2 82.9 92.3 79.4 IUD 73.8 81.7 71.9 62.1 73.9 48.4 Injectables 95.3 99.0 95.2 90.0 97.5 88.5 Implants 77.6 85.9 75.4 53.5 66.9 38.8 Male condom 94.7 96.8 97.5 97.6 98.9 98.4 Female condom 86.0 89.6 89.0 84.8 89.4 85.0 Emergency contraception 35.1 38.8 35.8 34.2 40.6 38.7 Any traditional method 74.4 82.3 75.5 70.3 81.4 73.8 Rhythm 53.4 57.7 58.2 53.0 61.7 53.9 Withdrawal 59.6 67.8 63.6 57.4 68.1 62.1 Folk method 22.5 26.6 19.0 9.9 14.4 7.7 Mean number of methods known by respondents 15-49 8.5 9.1 8.5 7.8 8.7 7.5 Number of respondents 23,020 15,528 523 6,818 3,895 469 Mean number of methods known by respondents 15-54 na na na 7.8 8.7 7.5 Number of respondents na na na 7,175 4,218 474 na = Not applicable 1 Had last sexual intercourse within 30 days preceding the survey Table 5.2 shows knowledge of contraceptive methods among women and men by background characteristics. There is no variation in contraceptive knowledge by background characteristics between women and men. In general, all currently married women and men have heard of at least one contraceptive method and at least one modern contraceptive method. Family Planning | 55 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method by background characteristics, Malawi 2010 Background characteristic Women Men Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Age 15-19 98.0 98.0 1,171 (100.0) (100.0) 40 20-24 99.9 99.9 3,469 99.2 99.2 466 25-29 99.9 99.9 3,718 99.8 99.8 868 30-34 99.9 99.8 2,636 99.8 99.7 862 35-39 99.7 99.7 2,040 100.0 100.0 737 40-44 99.6 99.6 1,339 99.8 99.8 495 45-49 99.6 99.6 1,155 99.5 99.5 428 Residence Urban 100.0 100.0 2,686 99.3 99.3 686 Rural 99.6 99.6 12,841 99.8 99.8 3,209 Region Northern 99.6 99.6 1,871 100.0 100.0 428 Central 99.7 99.7 6,678 99.9 99.9 1,792 Southern 99.7 99.7 6,979 99.4 99.4 1,676 Education No education 99.5 99.4 2,826 98.5 98.5 333 Primary 99.7 99.7 10,231 99.8 99.8 2,460 Secondary 100.0 100.0 2,275 100.0 100.0 980 More than secondary 100.0 100.0 195 99.0 99.0 122 Wealth quintile Lowest 99.2 99.2 2,639 99.5 99.5 603 Second 99.9 99.8 3,120 99.9 99.9 826 Middle 99.5 99.5 3,303 99.9 99.9 850 Fourth 99.8 99.8 3,197 99.8 99.8 783 Highest 99.9 99.9 3,268 99.4 99.4 833 Total 15-49 99.7 99.7 15,528 99.7 99.7 3,895 50-54 na na na 99.8 99.5 323 Total men 15-54 na na na 99.7 99.7 4,218 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, and emergency contraception 5.2 EVER USE OF CONTRACEPTION Ever use of contraception provides a measure of the cumulative experience of a population with family planning. Ever use of family planning methods in the 2010 MDHS thus refers to use of a method at any time, with no distinction between past and current use. The 2010 MDHS collected data on the level of ever use of family planning methods from respondents. All women interviewed in the 2010 MDHS who said that they had heard of a method of family planning were asked whether they had ever used that method. Men were only asked about ever use of male sterilisation, the male condom, the female condom, the rhythm method, and withdrawal. Table 5.3.1 shows the percentage of all women, currently married women, and sexually active unmarried women who have ever used specific methods of family planning, by age. Table 5.3.2 presents comparable information for men. Overall, 65 percent of all women reported ever using a method of contraception at some time; 62 percent used a modern method and 18 percent used any traditional method. Among currently married women, 79 percent have used any method in the past and 75 percent have ever used a modern method. The most widely used modern methods among currently married women are: injectables (61 percent), male condoms (20 percent), the pill (15 percent), and female sterilisation (10 percent). 56 | Family Planning Seventy-two percent of sexually active unmarried women have ever used a family planning method at some time. Half (50 percent) have used a male condom; 43 percent have used injectables; 14 percent have used pills; 4 percent have used female sterilisation; 1 percent has used the pill; and 1 percent has used the IUD. Twenty percent of sexually active unmarried women have used a traditional method at some point in time. Table 5.3.1 Ever use of contraception: Women Percentage of all women, currently married women, and sexually active unmarried women age 15-49 who have ever used any contraceptive method by method, according to age, Malawi 2010 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Number of women Female sterili- sation Male sterili- sation Pill IUD Inject- ables Implants Male condom Female condom Emer- gency contra- ception Rhythm With- drawal Folk method ALL WOMEN 15-19 20.5 19.5 0.0 0.0 1.0 0.1 9.2 0.2 12.5 0.7 0.2 4.1 1.7 3.1 0.4 5,005 20-24 70.7 67.1 0.5 0.1 8.1 0.5 54.2 1.4 24.7 1.3 0.6 16.5 5.3 11.7 2.2 4,555 25-29 83.5 80.2 2.6 0.1 16.1 0.8 69.1 2.9 23.1 1.6 1.1 20.4 6.4 14.5 3.6 4,400 30-34 84.4 81.1 9.5 0.1 19.7 1.1 68.0 3.6 20.5 1.6 1.4 22.9 8.4 14.3 5.3 3,250 35-39 81.5 77.2 17.6 0.3 22.3 0.8 63.2 2.0 18.3 1.5 0.6 25.5 7.8 14.7 8.3 2,522 40-44 73.8 68.1 25.4 0.3 19.0 1.7 50.2 0.8 13.5 1.1 0.5 24.5 7.5 13.4 8.7 1,730 45-49 65.4 57.7 25.8 0.2 15.5 2.0 37.6 0.9 9.4 0.8 0.9 24.2 6.6 12.7 10.6 1,558 Total 65.2 61.8 7.5 0.1 12.6 0.8 48.8 1.7 18.6 1.2 0.7 17.6 5.7 11.3 4.2 23,020 CURRENTLY MARRIED WOMEN 15-19 47.9 45.6 0.0 0.0 3.3 0.2 30.8 0.4 22.2 1.5 0.3 12.1 3.8 10.1 1.2 1,171 20-24 77.2 72.8 0.6 0.1 8.6 0.5 62.3 1.7 23.6 1.3 0.6 18.5 5.9 13.0 2.6 3,469 25-29 85.4 81.9 2.8 0.1 16.0 1.0 71.4 2.9 21.9 1.4 0.8 21.3 6.5 15.1 3.9 3,718 30-34 85.9 82.4 10.0 0.2 20.3 1.2 70.4 3.9 19.3 1.4 1.6 23.9 8.3 15.0 5.9 2,636 35-39 83.5 79.0 19.7 0.4 21.9 0.7 65.0 2.2 18.0 1.5 0.5 26.7 7.9 15.6 8.9 2,040 40-44 76.7 70.8 28.5 0.3 18.7 1.8 51.8 0.9 12.7 1.0 0.6 26.1 8.4 13.6 10.1 1,339 45-49 70.4 62.8 29.1 0.2 15.8 2.0 40.6 0.7 9.6 0.8 1.1 25.4 6.2 13.6 11.8 1,155 Total 78.7 74.5 9.7 0.2 15.1 0.9 61.3 2.2 19.6 1.3 0.8 21.8 6.8 14.1 5.5 15,528 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 50.2 49.8 0.0 0.0 1.4 0.0 9.4 0.0 44.8 1.1 0.0 11.0 3.4 9.1 0.0 180 20-24 80.8 80.8 2.4 0.0 10.2 3.2 48.6 0.1 55.1 2.7 0.5 19.1 6.4 14.1 0.9 122 25-29 84.9 84.9 3.0 0.0 22.9 0.0 68.2 3.8 60.2 5.0 5.9 23.8 7.3 16.3 2.0 88 30-34 91.7 91.7 6.9 0.0 26.5 0.0 69.8 2.1 56.2 5.6 3.3 34.1 19.5 17.6 3.7 63 35-39 (77.5) (77.0) (12.7) (0.0) (40.2) (0.4) (66.0) (6.1) (39.0) (2.8) (2.0) (27.4) (1.5) (27.4) (3.1) 37 40-44 * * * * * * * * * * * * * * * 22 45-49 * * * * * * * * * * * * * * * 12 Total 71.8 71.1 4.3 0.0 14.4 1.1 42.5 1.3 49.8 3.2 1.7 19.8 6.5 14.5 1.5 523 Note: Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Women who had sexual intercourse within the 30 days preceding the survey Table 5.3.2 shows that 58 percent of all men age 15-49 reported having used any method of contraception at some time; 49 percent used a modern method, and 29 percent used a traditional method. The male condom is the most commonly used method (49 percent) for men, while male sterilisation is the least commonly used method (1 percent). The male condom is reported as the most commonly used method among currently married men (56 percent). Similarly, male condoms are the most common method ever used by sexually active unmarried men (70 percent). Family Planning | 57 Table 5.3.2 Ever use of contraception: Men Percentage of all men, currently married men, and sexually active unmarried men age 15-49 who have ever used any contraceptive method by method, according to age, Malawi 2010 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Number of men Male sterili- sation Male condom Female condom Rhythm With- drawal ALL MEN 15-19 27.7 26.1 0.0 25.7 1.4 7.6 5.4 4.2 1,748 20-24 64.2 58.5 0.8 57.6 4.9 26.2 17.0 15.9 1,239 25-29 71.6 62.2 1.0 61.8 4.5 34.5 22.2 21.6 1,099 30-34 71.3 59.7 0.5 59.1 4.6 41.6 28.4 24.5 948 35-39 68.4 53.6 1.3 52.6 4.4 40.1 26.8 24.5 798 40-44 70.5 53.8 1.6 51.7 5.2 42.9 27.7 25.8 529 45-49 62.7 46.9 1.5 46.5 5.5 37.7 23.0 23.5 458 Total 15-49 57.9 49.2 0.8 48.5 3.9 28.6 18.8 17.3 6,818 50-54 57.7 35.0 1.2 34.4 1.1 38.7 24.6 23.9 357 Total men 15-54 57.9 48.5 0.8 47.8 3.8 29.1 19.1 17.6 7,175 CURRENTLY MARRIED MEN 15-19 (57.4) (52.7) (1.4) (51.3) (1.8) (13.8) (10.2) (11.4) 40 20-24 73.5 64.5 0.7 63.9 5.4 37.6 25.4 22.8 466 25-29 70.5 59.4 1.2 58.9 4.2 38.2 24.4 24.3 868 30-34 70.6 58.1 0.5 57.5 4.6 43.8 30.0 25.8 862 35-39 68.6 53.1 1.0 52.2 3.8 39.9 27.5 23.5 737 40-44 70.2 52.3 1.7 50.7 4.8 43.8 27.9 27.0 495 45-49 63.0 47.9 1.6 47.5 5.6 38.4 23.4 24.4 428 Total 15-49 69.5 56.3 1.1 55.6 4.5 40.2 26.5 24.5 3,895 50-54 57.0 32.9 1.1 32.7 0.6 39.6 25.7 24.4 323 Total men 15-54 68.6 54.5 1.1 53.8 4.2 40.1 26.5 24.5 4,218 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 66.5 61.7 0.1 61.0 5.8 25.3 16.0 15.9 221 20-24 82.8 77.5 0.3 74.4 11.0 27.1 14.1 20.4 158 25-29 90.6 86.1 0.0 86.1 14.0 25.9 22.5 14.9 60 30-34 * * * * * * * * 13 35-39 * * * * * * * * 11 40-44 * * * * * * * * 2 45-49 * * * * * * * * 4 Total 15-49 76.3 71.6 0.2 70.2 9.1 27.7 16.7 18.9 469 50-54 * * * * * * * * 5 Total men 15-54 75.8 71.2 0.2 69.8 9.0 27.6 16.5 18.8 474 Note: Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who had sexual intercourse within 30 days preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS This section presents information on the prevalence of current contraceptive use among women age 15-49. The level of current use is a measure of actual contraceptive practice at the time of the survey. It is also the most widely used and valuable measure of the success of family planning programmes. Furthermore, it can be used to estimate the reduction in fertility attributable to contraception. The contraceptive prevalence rate (CPR) is usually defined as the percentage of currently married women who are currently using a method of contraception. This section focuses on the levels and differentials in current use of contraception in Malawi. Table 5.4.1 shows by age the percent distribution of all women, currently married women, and sexually active unmarried women who are currently using specific family planning methods. The contraceptive prevalence rate (CPR) among all women using any method is 35 percent, any modern method is 33 percent, and any traditional method is 3 percent. The CPR is 46 percent among currently married women using any method of contraception, an increase from 33 percent in the 2004 MDHS. Among currently married women using contraception, 42 percent use a modern method of contraception and 4 percent use traditional methods. With respect to specific modern methods, injectables (26 percent), female sterilisation (10 percent), pills (3 percent), and male condoms (2 58 | Family Planning percent) are the most widely used methods. The CPR increases with age, rising from 29 percent for women age 15-19, peaking at 54 percent for women age 35-39, and thereafter declining. As expected, the use of modern family planning methods is higher for sexually active unmarried women than for currently married women (46 percent versus 42 percent). The most notable difference between these two groups of women is that 23 percent of sexually active unmarried women use male condoms compared with 2 percent of married women. Table 5.4.1 Current use of contraception by age: Women Percent distribution of all women, currently married women, and sexually active unmarried women age 15-49 by contraceptive method currently used, according to age, Malawi 2010 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Not currently using Total Number of women Female sterili- sation Male sterili- sation Pill IUD Inject- ables Implants Male condom Female condom Rhythm With- drawal Folk method ALL WOMEN 15-19 9.8 9.0 0.0 0.0 0.4 0.0 6.0 0.1 2.5 0.1 0.8 0.2 0.5 0.1 90.2 100.0 5,005 20-24 36.1 33.1 0.5 0.0 1.5 0.2 26.5 0.9 3.4 0.1 3.0 0.8 1.5 0.7 63.9 100.0 4,555 25-29 44.5 42.1 2.6 0.0 3.1 0.3 30.9 2.1 2.9 0.1 2.4 0.6 1.5 0.4 55.5 100.0 4,400 30-34 46.1 42.4 9.5 0.0 3.3 0.3 24.0 2.1 3.1 0.1 3.7 0.9 1.6 1.2 53.9 100.0 3,250 35-39 48.2 44.3 17.6 0.3 3.0 0.3 19.6 1.1 2.2 0.1 4.0 0.7 1.9 1.3 51.8 100.0 2,522 40-44 44.1 39.7 25.4 0.0 1.3 0.0 11.0 0.3 1.7 0.0 4.4 1.1 0.9 2.4 55.9 100.0 1,730 45-49 37.2 33.0 25.8 0.0 0.5 0.2 5.1 0.1 1.3 0.1 4.2 0.6 1.0 2.6 62.8 100.0 1,558 Total 35.4 32.6 7.5 0.0 1.9 0.2 19.2 1.1 2.7 0.1 2.8 0.6 1.2 0.9 64.6 100.0 23,020 CURRENTLY MARRIED WOMEN 15-19 28.8 26.4 0.0 0.0 1.6 0.0 21.4 0.4 2.8 0.2 2.4 0.0 2.0 0.4 71.2 100.0 1,171 20-24 41.8 38.0 0.6 0.0 1.8 0.2 31.8 1.0 2.6 0.1 3.8 1.0 1.9 0.9 58.2 100.0 3,469 25-29 47.8 45.0 2.8 0.0 3.2 0.4 33.7 2.1 2.7 0.1 2.8 0.6 1.7 0.4 52.2 100.0 3,718 30-34 50.4 46.0 10.0 0.1 3.8 0.4 27.0 2.2 2.6 0.1 4.3 0.9 1.9 1.5 49.6 100.0 2,636 35-39 53.5 49.1 19.7 0.3 3.3 0.2 22.0 1.2 2.1 0.2 4.4 0.8 2.3 1.3 46.5 100.0 2,040 40-44 50.4 45.0 28.5 0.0 1.5 0.0 12.8 0.4 1.7 0.1 5.4 1.4 1.1 2.9 49.6 100.0 1,339 45-49 43.4 38.2 29.1 0.0 0.6 0.3 6.4 0.1 1.5 0.2 5.2 0.9 1.4 3.0 56.6 100.0 1,155 Total 46.1 42.2 9.7 0.1 2.5 0.3 25.8 1.3 2.4 0.1 3.9 0.8 1.8 1.2 53.9 100.0 15,528 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 31.1 30.0 0.0 0.0 0.0 0.0 3.2 0.0 26.9 0.0 1.0 0.4 0.6 0.0 68.9 100.0 180 20-24 50.7 50.7 2.4 0.0 0.0 0.0 24.2 0.1 24.1 0.0 0.0 0.0 0.0 0.0 49.3 100.0 122 25-29 55.7 55.7 3.0 0.0 4.6 0.0 26.9 2.5 17.9 1.0 0.0 0.0 0.0 0.0 44.3 100.0 88 30-34 70.9 64.7 6.9 0.0 8.3 0.0 20.8 0.5 28.2 0.0 6.2 6.2 0.0 0.0 29.1 100.0 63 35-39 (63.6) (63.6) (12.7) (0.0) (9.4) (0.0) (15.3) (6.1) (20.1) (0.0) (0.0) (0.0) (0.0) (0.0) (36.4) 100.0 37 40-44 * * * * * * * * * * * * * * * 100.0 22 45-49 * * * * * * * * * * * * * * * 100.0 12 Total 47.4 46.3 4.3 0.0 2.4 0.0 15.4 0.9 23.0 0.2 1.1 0.9 0.2 0.0 52.6 100.0 523 Note: If more than one method is used, only the most effective method is considered in this tabulation. Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Women who have had sexual intercourse within 30 days preceding the survey Table 5.4.2 shows the percentage of men age 15-49 who used contraception at last sexual intercourse. Thirty-four percent of all men used any method of contraception at last sex: 32 percent used a modern method, and 2 percent used a traditional method. The most commonly used method among all men is the male condom (13 percent) followed by injectables (12 percent). The most commonly used method among currently married men is injectables (21 percent). Among sexually active unmarried men, on the other hand, the male condom is by far the most commonly used method (50 percent). Family Planning | 59 Table 5.4.2 Use of contraception at last sex by age: Men Percent distribution of all men, currently married men, and sexually active unmarried men age 15-49 by contraceptive method used at last sexual intercourse, according to age, Malawi 2010 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Not current- ly using Total Number of men Female sterili- sation Male sterili- sation Pill IUD Inject- ables Implants Male condom Female condom Rhythm With- drawal Folk method ALL MEN 15-19 14.5 14.2 0.2 0.0 0.1 0.0 0.3 0.0 13.5 0.0 0.3 0.1 0.1 0.1 85.5 100.0 1,748 20-24 32.4 29.7 0.3 0.8 0.8 0.1 5.9 0.3 21.5 0.1 2.6 0.7 1.7 0.2 67.6 100.0 1,239 25-29 42.2 40.4 0.3 1.0 2.9 0.2 19.9 0.8 15.1 0.1 1.8 0.2 1.0 0.7 57.8 100.0 1,099 30-34 44.4 41.1 1.7 0.5 3.9 0.3 23.2 1.7 9.7 0.2 3.3 0.8 2.0 0.5 55.6 100.0 948 35-39 43.4 39.5 3.5 1.3 5.5 0.1 21.5 0.6 6.8 0.3 3.9 0.9 1.7 1.3 56.6 100.0 798 40-44 42.4 38.3 8.0 1.6 2.3 0.6 18.9 0.0 6.6 0.3 4.1 0.4 2.9 0.8 57.6 100.0 529 45-49 43.9 39.1 12.8 1.5 3.5 0.0 11.7 0.6 8.8 0.2 4.7 0.3 3.4 1.1 56.1 100.0 458 Total 33.9 31.5 2.3 0.8 2.2 0.2 12.3 0.5 13.0 0.1 2.4 0.5 1.4 0.5 66.1 100.0 6,818 CURRENTLY MARRIED MEN 15-19 (12.3) (9.9) (0.0) (1.4) (0.0) (0.0) (3.1) (0.0) (5.4) (0.0) (2.4) (2.4) (0.0) (0.0) (87.7) 100.0 40 20-24 32.6 29.9 0.7 0.7 0.5 0.2 14.4 0.7 12.4 0.2 2.7 0.2 2.4 0.1 67.4 100.0 466 25-29 41.2 39.2 0.4 1.2 3.3 0.2 24.1 0.9 8.9 0.2 2.0 0.3 1.1 0.7 58.8 100.0 868 30-34 44.8 41.3 1.8 0.5 3.8 0.4 25.2 1.5 7.9 0.1 3.5 0.8 2.1 0.6 55.2 100.0 862 35-39 44.0 40.4 3.4 1.0 5.6 0.1 23.2 0.6 6.1 0.3 3.6 1.0 1.4 1.2 56.0 100.0 737 40-44 43.7 39.3 8.3 1.7 2.5 0.6 19.7 0.0 6.2 0.3 4.4 0.4 3.1 0.9 56.3 100.0 495 45-49 45.6 40.5 13.7 1.6 3.1 0.0 12.6 0.6 8.7 0.2 5.1 0.3 3.6 1.2 54.4 100.0 428 Total 42.0 38.6 3.8 1.1 3.4 0.3 21.0 0.8 8.2 0.2 3.4 0.6 2.0 0.8 58.0 100.0 3,895 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 41.8 41.8 0.0 0.1 0.0 0.0 1.2 0.0 40.4 0.0 0.0 0.0 0.0 0.0 58.2 100.0 221 20-24 64.0 61.3 0.0 0.3 0.3 0.0 1.7 0.0 59.1 0.0 2.6 0.0 2.6 0.0 36.0 100.0 158 25-29 71.7 69.7 0.0 0.0 0.6 0.0 7.7 2.0 59.3 0.0 2.0 0.0 2.0 0.0 28.3 100.0 60 30-34 * * * * * * * * * * * * * * * 100.0 13 35-39 * * * * * * * * * * * * * * * 100.0 11 40-44 * * * * * * * * * * * * * * * 100.0 2 45-49 * * * * * * * * * * * * * * * 100.0 4 Total 54.6 53.4 0.0 0.2 0.2 0.0 2.8 0.6 49.6 0.0 1.2 0.0 1.1 0.1 45.4 100.0 469 Note: If more than one method is used, only the most effective method is considered in this tabulation. Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who have had sexual intercourse within 30 days preceding the survey 5.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS Table 5.5 presents information on current use of contraception among married women age 15- 49 by background characteristics. Current use of contraception varies by residence, region, education, number of living children, and wealth quintile. More than half of urban women use any method of contraception compared with 45 percent of their rural counterparts. Half of women (50 percent) in urban areas use a modern method compared with 41 percent in the rural areas. At the regional level, 48 percent of currently married women in the Central Region use any contraceptive method compared with 47 percent in the Northern Region, and 44 percent in the Southern Region. Contraceptive use increases with educational attainment. Fifty-seven percent of women with more than a secondary level education use a contraceptive method compared with 40 percent of women with no education. In general, women do not begin using contraception until after they have had at least one child, and contraceptive use increases with an increase in the number of living children. By wealth quintile, women in the lowest quintile are least likely to use a contraceptive method (39 percent) compared with women in the highest quintile (53 percent). 60 | Family Planning Table 5.5 Current use of contraception by background characteristics: Women Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Malawi 2010 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not current- ly using Total Number of women Female sterili- sation Male sterili- sation Pill IUD Inject- ables Implants Male condom Female condom Rhythm With- drawal Folk method Residence Urban 53.7 49.6 12.4 0.0 3.9 0.4 27.2 2.3 3.3 0.0 4.1 1.7 1.8 0.6 46.3 100.0 2,686 Rural 44.5 40.7 9.1 0.1 2.2 0.2 25.5 1.1 2.2 0.1 3.8 0.6 1.8 1.4 55.5 100.0 12,841 Region Northern 47.1 39.0 10.4 0.1 3.2 0.1 16.6 1.9 6.7 0.0 8.1 0.5 6.5 1.1 52.9 100.0 1,871 Central 48.0 44.6 12.0 0.1 2.4 0.2 26.7 1.4 1.6 0.1 3.4 0.8 1.5 1.0 52.0 100.0 6,678 Southern 44.0 40.8 7.3 0.0 2.5 0.3 27.5 1.1 2.0 0.1 3.2 0.9 0.8 1.5 56.0 100.0 6,979 Education No education 40.3 37.1 13.5 0.0 2.1 0.2 19.8 0.4 1.1 0.0 3.1 0.5 1.1 1.5 59.7 100.0 2,826 Primary 46.0 42.1 9.4 0.1 2.2 0.2 26.5 1.2 2.4 0.1 3.9 0.6 2.0 1.3 54.0 100.0 10,231 Secondary 52.8 48.4 5.8 0.0 4.3 0.5 31.4 3.1 3.5 0.0 4.4 1.7 2.2 0.5 47.2 100.0 2,275 More than secondary 57.3 49.0 13.8 0.7 9.2 0.7 12.0 2.9 8.6 1.1 8.2 6.5 1.1 0.6 42.7 100.0 195 Number of living children 0 5.8 4.9 0.6 0.0 1.0 0.0 1.4 0.0 1.9 0.0 0.9 0.4 0.5 0.0 94.2 100.0 1,000 1-2 41.4 37.9 1.5 0.0 2.3 0.2 29.2 1.3 3.3 0.1 3.5 1.0 1.9 0.6 58.6 100.0 5,643 3-4 51.4 48.0 8.7 0.1 3.1 0.2 31.5 1.9 2.2 0.2 3.4 0.7 1.8 0.9 48.6 100.0 4,942 5+ 56.4 50.7 25.0 0.1 2.5 0.3 20.2 0.9 1.5 0.0 5.7 0.8 2.1 2.8 43.6 100.0 3,943 Wealth quintile Lowest 38.7 34.9 6.4 0.1 2.1 0.4 23.9 0.6 1.4 0.1 3.8 0.4 1.8 1.6 61.3 100.0 2,639 Second 44.0 39.8 8.0 0.0 2.2 0.1 26.9 0.6 1.9 0.1 4.2 0.8 1.7 1.7 56.0 100.0 3,120 Middle 45.0 41.4 9.0 0.1 1.9 0.2 26.4 1.0 2.6 0.1 3.6 0.4 2.2 1.0 55.0 100.0 3,303 Fourth 48.4 45.2 11.3 0.0 2.5 0.1 27.0 1.4 2.8 0.2 3.1 0.5 1.5 1.1 51.6 100.0 3,197 Highest 53.0 48.4 13.2 0.1 3.9 0.4 24.7 2.9 3.1 0.1 4.6 1.9 2.0 0.8 47.0 100.0 3,268 Total 46.1 42.2 9.7 0.1 2.5 0.3 25.8 1.3 2.4 0.1 3.9 0.8 1.8 1.2 53.9 100.0 15,528 Note: If more than one method is used, only the most effective method is considered in this tabulation. 5.5 TRENDS IN CONTRACEPTIVE USE Table 5.6 presents trends in current use of specific contraceptive methods among currently married women between 1992 and 2010. Over the 18-year period, contraceptive prevalence has increased from 13 percent to 46 percent. The largest increase is in the use of injectables, which increased from 2 percent in 1992 to 26 percent in 2010. Female sterilisation has increased steadily from 2 percent in 1992 to 10 percent in 2010. Male condom use has remained at a constant 2 percent among currently married women over the last two decades. Table 5.6 Trends in current use of contraception Percent distribution of currently married women age 15-49 by contraceptive method currently used, by specific method, Malawi 1992-2010 Method 1992 MDHS1 2000 MDHS2 2004 MDHS3 2010 MDHS Any method 13.0 30.6 32.5 46.1 Any modern method 7.4 26.1 28.1 42.2 Female sterilisation 1.7 4.7 5.8 9.7 Male sterilisation 0.0 0.1 0.0 0.1 Pill 2.2 2.7 2.0 2.5 IUD 0.3 0.1 0.1 0.3 Injectables 1.5 16.4 18.0 25.8 Implants na 0.1 0.5 1.3 Male condom 1.6 1.6 1.8 2.4 Any traditional method 5.6 4.5 4.3 3.9 Rhythm/periodic abstinence 2.2 0.9 0.5 0.8 Withdrawal 1.5 1.5 2.1 1.8 Other traditional methods 2.0 2.1 1.7 1.2 Number of women 3,492 9,452 8,312 15,528 na = Not applicable 1 NSO and Macro International, 1994 2 NSO and ORC Macro, 2001 3 NSO and ORC Macro, 2005 Family Planning | 61 5.6 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION Couples use family planning methods either to limit family size or to delay the next birth. To control family size (i.e., to stop having children) many couples adopt contraception when they have already had the number of children they want. When contraception is used to space births, couples may start to use family planning earlier, with the intention of delaying a pregnancy. Women interviewed in the 2010 MDHS were asked how many children they had at the time they first used a method of family planning. Table 5.7 shows the percent distribution of women by the number of living children at the time of first contraceptive use, according to current age. The table shows that 35 percent of women have never used a contraceptive method. Five percent started using contraceptives before they had their first child. Twenty-five percent of women initiated use after they had their first child, while 11 percent did not begin using contraceptives until they had four or more children. The highest proportion of women starting use when they had their first child is observed among women age 20-24 (43 percent). Table 5.7 Number of children at first use of contraception Percent distribution of women age 15-49 by number of living children at the time of first use of contraception, according to current age, Malawi 2010 Current age Never used Number of living children at time of first use of contraception Total Number of women 0 1 2 3 4+ Missing 15-19 79.5 9.9 9.5 0.5 0.0 0.0 0.6 100.0 5,005 20-24 29.3 8.9 43.3 15.2 2.6 0.3 0.4 100.0 4,555 25-29 16.5 3.1 40.2 25.0 10.4 4.8 0.2 100.0 4,400 30-34 15.6 1.9 28.2 24.1 16.6 13.4 0.1 100.0 3,250 35-39 18.5 1.7 15.1 20.9 17.5 26.2 0.1 100.0 2,522 40-44 26.2 0.7 9.0 13.7 14.0 36.0 0.3 100.0 1,730 45-49 34.6 1.0 6.8 7.8 10.1 39.1 0.6 100.0 1,558 Total 34.8 5.1 25.1 15.1 8.5 11.1 0.3 100.0 23,020 5.7 BRANDS OF PILLS AND CONDOMS USED Women age 15-49 who are currently using oral contraceptives and condoms were asked for the brand name of the pills and condoms they last used. Information on women’s use of social marketing brand contraceptives is useful for monitoring the success of social marketing programmes. Table 5.8.1 shows the percent distribution of women age 15-49 using pills and condoms by social marketing brand, according to background characteristics. Among pill users, the brands most commonly used are Lofeminol (62 percent), Microgynon (19 percent), and Ovrette (7 percent). Lofeminol is the brand most commonly used by all women regardless of their background characteristics. The most common brand of condom used among women age 15-49 is Chishango (56 percent). Nineteen percent of women use Manyuchi, and less than one percent use Care, a female condom. 62 | Family Planning Men were also asked to report the brand of condom they used if they used a condom the last time they had sexual intercourse. Table 5.8.2 shows that 36 percent of men used Manyuchi and 35 percent of men reported that they used Chishango. More than one-quarter of men did not know which condom brand they used. Table 5.8.2 Use of social marketing brand of condoms: Men Percent distribution condom users age 15-49 by brand of condom used, according to background characteristics, Malawi 2010 Background characteristic Chishango Manyuchi Care (female condom) Other Don’t know/ missing Total Number of condoms users Residence Urban 34.1 46.1 0.0 1.6 18.2 100.0 248 Rural 34.6 32.6 0.9 2.3 29.5 100.0 752 Region Northern 36.5 32.0 0.0 2.9 28.6 100.0 160 Central 28.3 40.6 0.7 2.8 27.5 100.0 424 Southern 40.0 32.8 0.9 1.1 25.2 100.0 416 Education No education (27.1) (23.8) (3.9) (3.8) (41.5) 100.0 37 Primary 35.3 33.2 0.9 1.3 29.4 100.0 512 Secondary 32.1 40.5 0.1 3.2 24.2 100.0 407 More than secondary (54.4) (37.7) (0.7) (0.8) (6.5) 100.0 44 Wealth quintile Lowest 34.8 26.3 0.2 1.3 37.5 100.0 108 Second 28.5 41.4 0.7 3.3 26.1 100.0 165 Middle 30.3 33.1 1.3 3.5 31.7 100.0 175 Fourth 37.6 32.0 0.8 1.2 28.4 100.0 239 Highest 37.5 41.1 0.4 1.7 19.4 100.0 314 Total 34.5 36.0 0.7 2.1 26.7 100.0 1,001 Note: Figures in parentheses are based on 25 to 49 unweighted cases. Table 5.8.1 Use of social marketing brand pills and condoms: Women Percent distribution of pill and condom users age 15-49 by brand of pills or condoms used, according to background characteristics, Malawi 2010 Background characteristic Among pill users Number of women using the pill Among condom users Number of condoms users Lofemi- nol Micro- gynon Ovrette Other Don’t know/ missing Total Chi- shango Manyu- chi Care (female condom) Other Don’t know/ missing1 Total Residence Urban 59.2 19.5 10.1 0.0 11.2 100.0 117 57.0 26.2 0.0 0.7 16.1 100.0 231 Rural 63.4 18.5 5.8 0.1 12.2 100.0 320 55.1 15.4 1.0 1.2 27.3 100.0 404 Region Northern 74.7 13.3 2.2 0.7 9.1 100.0 66 56.2 15.0 2.1 1.8 24.9 100.0 155 Central 52.1 25.1 10.3 0.0 12.5 100.0 180 50.7 23.8 0.3 0.9 24.2 100.0 220 Southern 67.5 14.8 5.4 0.0 12.3 100.0 192 59.8 18.1 0.0 0.7 21.4 100.0 260 Education No education 54.5 22.0 16.4 0.7 6.4 100.0 65 (59.5) (13.9) (0.0) (5.0) (21.6) 100.0 40 Primary 60.4 21.0 6.0 0.0 12.7 100.0 247 57.5 14.5 0.8 0.6 26.6 100.0 344 Secondary 73.1 11.3 1.9 0.0 13.8 100.0 106 55.3 28.9 0.6 0.4 14.7 100.0 198 More than secondary * * * * * 100.0 18 (43.5) (18.8) (0.0) (3.2) (34.5) 100.0 54 Wealth quintile Lowest 69.2 19.2 3.9 0.0 7.7 100.0 63 65.4 9.7 0.0 1.5 23.3 100.0 53 Second 55.8 27.8 9.9 0.0 6.5 100.0 75 49.7 23.4 0.9 0.7 25.3 100.0 81 Middle 68.7 6.6 4.0 0.7 20.0 100.0 71 51.5 8.5 0.5 1.9 37.7 100.0 108 Fourth 61.4 21.3 3.7 0.0 13.6 100.0 88 58.0 18.4 1.3 1.1 21.3 100.0 137 Highest 59.9 18.4 10.2 0.0 11.5 100.0 139 56.3 25.1 0.4 0.7 17.5 100.0 257 Total 62.3 18.8 6.9 0.1 11.9 100.0 437 55.8 19.3 0.6 1.0 23.2 100.0 636 Note: Condom use is based on women’s reports. Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes condom users who do not know the brand of condoms they use and those who are also using contraceptive pills, for whom information on condom brand was not collected. Family Planning | 63 5.8 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for the successful practice of coitus-associated methods such as withdrawal and condoms. Such knowledge is particularly critical in the use of the rhythm method. The 2010 MDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during her menstrual cycle. Respondents were asked, ‘From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?’ If the reply was ‘yes,’ the respondent was further asked whether that time was just before a woman’s period begins, during her period, right after her period has ended, or halfway between two periods. Tables 5.9.1 and 5.9.2 show the percent distributions for women and men by knowledge of the fertile period during the ovulatory cycle. Table 5.9.1 shows that knowledge of the fertile period is generally low among women. Among all women, only 16 percent correctly reported when the fertile period occurs, i.e., a woman is most likely to conceive halfway between two periods. Users of natural family planning methods are more knowledgeable about the fertile period than non-users; 28 percent of users of the rhythm method correctly identified the middle of the cycle as the fertile time, compared with 16 percent of non-users of the method. The table further shows that 12 percent of women reported that they do not know when a woman’s fertile period occurs. Fifteen percent reported that there is no specific time. Table 5.9.1 Knowledge of fertile period: Women Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Malawi 2010 Perceived fertile period Users of rhythm method Non-users of rhythm method All respondents Just before her menstrual period begins 17.0 17.2 17.2 During her menstrual period 0.5 2.8 2.8 Right after her menstrual period has ended 42.7 35.9 36.0 Halfway between two menstrual periods 28.2 15.9 15.9 Other 0.0 0.1 0.1 No specific time 9.0 15.5 15.4 Don’t know 2.6 12.5 12.4 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women 145 22,875 23,020 Table 5.9.2 shows men’s knowledge of a woman’s fertile period. Only 6 percent of men correctly reported that the most likely time for a woman to conceive is halfway between two periods; 13 percent said they did not know, and 15 percent reported that there was no specific time. Table 5.9.2 Knowledge of fertile period: Men Percent distribution of men age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Malawi 2010 Perceived fertile period Users of rhythm method Non-users of rhythm method All respondents Just before her menstrual period begins (64.1) 37.0 37.1 During her menstrual period (0.0) 5.1 5.1 Right after her menstrual period has ended (30.7) 23.3 23.3 Halfway between two menstrual periods (3.0) 6.4 6.4 Other (0.0) 0.1 0.1 No specific time (1.4) 14.6 14.6 Don’t know (0.8) 13.3 13.3 Missing (0.0) 0.1 0.1 Total 100.0 100.0 100.0 Number of men 31 6,788 6,818 Figures in parentheses are based on 25-49 unweighted cases. 64 | Family Planning These findings indicate that the use of periodic abstinence is not a reliable method of contraception among the couples using this method, because knowledge of the fertile period is very limited among both men and women in Malawi. 5.9 TIMING OF STERILISATION Women who reported that they use female sterilisation as a contraceptive method were asked additional questions about how old they were when the procedure was performed. The results in Table 5.10 indicate that one-third of women had the tubal ligation procedure when they were age 30-34, and 29 percent were age 35-39 at the time of sterilisation. It is interesting to note that 16 percent of women were age 25-29. The median age at the time of sterilisation is 33.3 years. Table 5.10 Timing of sterilisation Percent distribution of sterilised women age 15-49 by age at the time of sterilisation and median age at sterilisation, according to the number of years since the operation, Malawi 2010 Years since operation Age at time of sterilisation Total Number of women Median age1 <25 25-29 30-34 35-39 40-44 45-49 <2 4.3 16.6 32.9 28.6 14.1 3.6 100.0 520 33.1 2-3 3.6 14.4 31.1 28.1 18.1 4.8 100.0 341 33.6 4-5 7.5 13.3 25.0 30.7 22.1 1.5 100.0 278 33.8 6-7 4.1 12.5 34.2 31.4 17.8 0.0 100.0 243 33.8 8-9 5.6 11.4 36.9 41.6 4.5 0.0 100.0 100 34.2 10+ 9.3 26.2 40.1 24.4 0.0 0.0 100.0 249 a Total 5.4 16.1 32.7 29.4 14.1 2.3 100.0 1,731 33.3 a = Not calculated due to censoring 1 Median age at sterilisation is calculated only for women sterilised before age 40 to avoid problems of censoring. 5.10 SOURCE OF CONTRACEPTION The information on where women obtain their contraceptive methods is useful for family planning programme managers and implementers for logistic planning. In the 2010 MDHS, all women who reported that they were currently using any modern contraceptive method at the time of the survey were asked where they obtained the method the last time they acquired it. Since women may not know exactly in which category the source falls (e.g., government or private, health centre, or clinic), the interviewers were instructed to note the full name of the source or facility. Furthermore, supervisors and field editors were trained to verify that the name and type of source to maintain the consistency and improve the accuracy of the source, for instance, by asking informants in the clusters for the names of local family planning outlets. Table 5.11 indicates that for users of modern contraceptive methods, the public sector is the most common source (74 percent). Notably, about half (46 percent) of current users of modern methods obtain their method from government health centres compared with 2 percent of users that obtain contraceptives from mobile clinics. In contrast, 3 percent of users reported private hospitals or clinics as their source of modern methods. Family Planning | 65 Table 5.11 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Malawi 2010 Source Female sterilisation Pill IUD Injectables Implants Male condom Total Public sector 54.4 81.6 (72.6) 84.1 83.2 45.8 73.8 Government hospital 31.2 11.8 (27.4) 17.7 47.3 13.2 21.1 Government health centre 23.1 50.1 (44.4) 58.7 35.0 22.6 46.2 Government health post/outreach 0.0 3.1 (0.9) 4.2 0.7 2.2 2.8 Mobile clinic 0.0 2.1 (0.0) 3.0 0.2 1.4 2.0 Health surveillance assistant (HSA) 0.0 12.8 (0.0) 0.3 0.0 5.5 1.4 Community based distribution agents (CBDA)/door-to-door 0.0 1.7 (0.0) 0.0 0.0 0.7 0.2 Other public 0.1 0.0 (0.0) 0.2 0.0 0.2 0.1 Christian Health Association of Malawi (CHAM)/Mission 10.3 9.6 (6.3) 9.3 5.8 3.3 8.9 CHAM/Mission hospital 7.5 2.2 (4.8) 3.5 4.1 1.3 4.2 CHAM/Mission health centre 2.8 6.2 (1.5) 4.7 1.7 0.9 3.9 CHAM/Mission mobile clinic 0.0 0.8 (0.0) 1.0 0.0 1.0 0.7 CHAM/Mission door to door 0.0 0.5 (0.0) 0.0 0.0 0.1 0.0 Private sector 4.3 3.0 (0.6) 4.8 1.8 2.2 3.5 Private hospital/clinic 1.3 2.2 (0.6) 4.5 1.6 1.5 3.2 Private pharmacy 0.0 0.4 (0.0) 0.0 0.0 0.2 0.0 Private mobile clinic 0.0 0.0 (0.0) 0.2 0.2 0.0 0.1 Private CBDA/door-to-door 0.0 0.4 (0.0) 0.0 0.0 0.0 0.0 Other 0.0 0.0 (0.0) 0.1 0.0 0.5 0.1 Banja La Mtsogolo (BLM) 33.0 4.7 (20.5) 1.5 9.0 2.1 9.3 Other source 0.7 1.0 (0.0) 0.1 0.0 46.0 4.0 Shop 0.0 0.0 (0.0) 0.0 0.0 38.0 3.1 Other1 0.7 1.0 (0.0) 0.1 0.0 8.0 0.9 Don’t know 0.0 0.0 (0.0) 0.0 0.0 0.0 0.0 Missing 0.4 0.2 (0.0) 0.3 0.3 0.6 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,731 437 43 4,412 242 618 7,510 Note: Total includes other modern methods. The total number of women includes 26 unweighted cases that are not shown in the table (9 male sterilisation and 17 female condom). Figures in parentheses are based on 25-49 unweighted cases. 1Other includes Malawi AIDS Counselling and Resource Organisation (MACRO), Youth Drop-In Centre, church, friend/relative and other sources. 5.11 INFORMED CHOICE Informed choice is an important tool for assessing and monitoring the quality of family planning services offered to users. Current users of modern methods of contraception were asked whether they were informed about side effects or problems they might have with a method, what to do if they experienced side effects, and other methods they could use. This information assists users in coping with side effects and also decreases unnecessary discontinuations. Obtaining this type of information is also a measure of the quality of family planning service provision. Table 5.12 presents the results by method type and source of the method. Three-quarters (75 percent) of contraceptive users were informed about side effects of the method they use. Equally, 75 percent were informed about what to do if they experienced side effects. Eighty percent of users were informed of other available methods of contraception by a health or family planning worker. Seventy-seven percent of women who obtained their current family planning method from public sector facilities were informed about side effects or method-related problems, and 77 percent of users were also told what to do if they experienced side effects. Similar percentages of contraceptive users who obtained their method from the private medical sector were informed of effects or method-related problems and how to deal with them. 66 | Family Planning Table 5.12 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods that could use, by method and source; and among sterilised women, the percentage who were informed that the method is permanent, by initial source of method, Malawi 2010 Method/source Among women who started last episode of modern contraceptive method within five years preceding the survey: Among women who were sterilised: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Percentage who were informed that sterilisation is permanent Number of women Method Female sterilisation1 60.3 60.2 59.3 997 94.0 997 Pill 76.2 73.7 84.6 408 na na IUD (62.6) (62.6) (73.4) 37 na na Injectables 77.0 77.9 84.5 4,252 na na Implants 87.5 87.6 85.2 232 na na Other * * * 18 na na Initial source of method2 Public sector 77.1 77.4 83.0 4,685 93.2 597 Government hospital 78.9 79.4 81.0 1,200 93.3 275 Government health centre 77.4 77.4 84.1 3,062 93.1 323 Family planning clinic 70.5 74.1 86.8 167 na na Mobile clinic 60.0 66.0 78.3 111 na na Fieldworker 75.7 74.9 74.7 145 na na Private medical sector 74.3 74.5 80.1 523 98.4 101 Private doctor 71.8 72.5 81.6 231 98.1 66 Private hospital or clinic 77.0 76.7 78.8 268 98.9 35 Pharmacy * * * 23 na na Other private sector 76.1 74.4 73.4 164 95.8 14 Shop 76.6 74.8 74.4 161 95.8 14 Church * * * 2 na na Friends relatives * * * 2 na na Other (83.9) (80.4) (81.3) 48 100.0 2 Total 74.5 74.9 80.2 5,944 94.0 997 Note: Table includes users of only the methods listed individually. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Among women who were sterilised in the five years preceding the survey 2 Source at start of current episode of use 5.12 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which non-users plan to use contraceptive methods in the future. In the 2010 MDHS, women age 15-49 who were not using any contraceptive method at the time of the survey were asked about their intention to use family planning in the future. Table 5.13 shows that 74 percent of currently married non-users intend to use a method of contraception in the future, 2 percent are unsure of their intentions, and 23 percent have no intention of using any method in the future. Notably, the proportions of women and their intention for future use of a contraceptive method do not vary much with the number of living children they have, except for childless women and those with four or more children. For instance, the proportion of currently married women that are unsure of future use of contraception is almost 2 percent for all the categories of women, except three percent for women with no children. Family Planning | 67 Table 5.13 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Malawi 2010 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 72.8 78.5 77.9 77.2 67.2 73.7 Unsure 2.9 2.2 2.1 2.4 2.1 2.2 Does not intend to use 23.6 18.0 19.0 19.9 29.8 23.2 Missing 0.7 1.2 1.1 0.6 0.9 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 541 1,610 1,706 1,473 3,038 8,368 1 Includes current pregnancy 5.13 EXPOSURE TO FAMILY PLANNING MESSAGES IN THE MEDIA The exposure to family planning messages is a vital component in delivering family planning services to both urban and rural masses. Information on the level of public exposure to a particular type of media allows policymakers to use the most effective media for various target groups in the population. In the 2010 MDHS, all respondents were asked whether they had heard or seen family planning messages on the radio, on television, or in a newspaper or magazine in the few months before the survey to assess the effectiveness of such media on the dissemination of family planning information. Table 5.14 shows the percent distribution of women and men by their exposure to family planning message through media. Radio is the most frequent source of family planning messages for both women (58 percent) and men (76 percent) age 15-49 years. One in three men (34 percent) reported seeing a family planning message in a newspaper or magazine in the past few months compared with 14 percent of women. Television is the least common source of family planning messages for both men and women (20 and 14 percent, respectively). Women are twice as likely as men to have no exposure to any of the three media family planning message sources (40 and 19 percent, respectively). As expected, the effect of place of residence and wealth quintile on family planning media exposure among respondents is reflected in both men and women. Exposure to family planning messages is more common among men than women and is more common in urban areas than rural areas. Among the regions, women and men in the Northern Region have the highest exposure to family planning messages through any media. The table also shows that the more education a respondent has, the greater the likelihood that he or she has been exposed to family planning messages through each of the three types of mass media. Media exposure also increases with increasing wealth quintile for both women and men. 68 | Family Planning Table 5.14 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on the radio, television, or in a newspaper or magazine in the past few months, according to background characteristics, Malawi 2010 Background characteristic Women Men Radio Television News- paper/ magazine None of these three media sources Number Radio Television News- paper/ magazine None of these three media sources Number Age 15-19 48.4 10.1 16.9 47.6 5,005 68.2 17.8 28.7 26.0 1,748 20-24 59.7 10.3 15.7 37.9 4,555 76.1 21.7 37.4 18.0 1,239 25-29 59.6 11.3 14.4 38.6 4,400 81.2 18.5 36.0 14.6 1,099 30-34 61.6 10.9 12.6 36.9 3,250 78.3 20.9 36.4 16.1 948 35-39 59.8 9.7 10.8 38.9 2,522 77.6 19.2 35.7 16.9 798 40-44 61.1 9.8 10.7 38.1 1,730 81.6 23.3 36.7 14.8 529 45-49 57.1 8.6 9.7 41.6 1,558 82.7 15.9 31.2 15.2 458 Residence Urban 57.7 25.9 27.1 35.9 4,302 69.1 37.9 55.4 18.5 1,440 Rural 57.4 6.7 10.9 41.4 18,718 78.1 14.6 28.4 18.7 5,379 Region Northern 68.9 12.0 16.7 30.3 2,677 81.1 20.3 38.0 15.8 744 Central 55.7 9.2 12.7 42.3 9,857 79.1 17.6 33.2 17.4 3,074 Southern 56.1 10.9 14.4 41.2 10,485 72.2 21.2 34.0 20.8 3,001 Education No education 44.4 2.5 1.4 55.3 3,505 67.8 7.6 5.1 30.9 422 Primary 56.5 6.9 10.0 42.0 14,916 75.0 13.5 23.9 21.5 4,270 Secondary 70.8 25.5 34.2 24.0 4,177 81.7 31.7 58.1 10.8 1,904 More than secondary 66.7 45.1 57.3 22.2 422 69.2 52.3 80.1 9.4 223 Wealth quintile Lowest 38.2 2.2 4.3 61.0 4,268 72.8 11.1 19.0 24.1 997 Second 50.9 2.7 6.6 48.5 4,332 75.8 7.6 23.2 22.0 1,309 Middle 60.3 4.1 9.7 38.7 4,517 78.3 12.8 28.9 19.0 1,367 Fourth 64.5 6.9 12.6 34.1 4,515 78.7 16.5 34.7 16.8 1,376 Highest 69.8 31.0 32.2 24.2 5,388 75.0 40.5 54.2 14.4 1,770 Total 15-49 57.5 10.3 14.0 40.4 23,020 76.2 19.5 34.1 18.7 6,818 50-54 na na na na na 84.8 13.2 30.7 12.8 357 Total men 15-54 na na na na na 76.7 19.2 33.9 18.4 7,175 na = Not applicable 5.13.1 Exposure of Females to Specific Family Planning Messages In the 2010 MDHS, female respondents were asked if they had listened to specific family planning or health programmes on the radio within the past few months. Table 5.15.1 shows the percent distribution of women age 15-49 who listened to specific radio programmes, by background characteristics. Fifty-seven percent of women listened to ‘Safe Motherhood’, 51 percent heard ‘Radio Doctor/Doctor Wapawailesi’, and 59 percent heard or saw ‘Tikuferanji’. More than half of women in all three regions heard or saw these family planning messages. There is a positive relationship between exposure to family planning messages and education and wealth. Family Planning | 69 Table 5.15.1 Exposure of respondents to specific family planning or health programmes on the radio: Women Percentage of women 15-49 who heard specific programme series about family planning or health on the radio in the past few months, by background characteristic, Malawi 2010 Background characteristic Safe Motherhood Phukusi la Moyo Radio Doctor/ Doctor Wapawailesi Umoyo m’Malawi Tikuferanji Chitukuko m’Malawi Uku Ndiko Kudya Other Total Age 15-19 46.7 42.4 40.8 39.8 54.3 45.1 31.3 15.5 5,005 20-24 59.1 50.5 51.1 46.6 59.1 49.6 41.9 19.1 4,555 25-29 61.1 53.2 54.9 50.2 59.7 51.0 44.2 19.9 4,400 30-34 61.5 56.6 57.3 53.1 62.7 55.5 48.2 22.1 3,250 35-39 59.4 56.0 55.3 52.6 60.4 53.9 47.2 20.9 2,522 40-44 58.2 55.1 55.1 51.9 59.8 53.0 44.8 21.1 1,730 45-49 55.4 48.7 52.2 48.0 55.8 50.0 42.8 20.5 1,558 Residence Urban 63.1 57.3 58.8 53.5 69.2 53.1 43.1 22.0 4,302 Rural 55.4 49.5 49.6 46.6 56.2 49.9 41.5 18.7 18,718 Region Northern 65.2 59.0 56.4 56.8 65.3 61.2 49.6 17.0 2,677 Central 54.6 48.2 49.1 44.7 56.0 47.7 39.1 18.8 9,857 Southern 56.9 51.5 52.1 48.7 59.5 50.3 42.3 20.4 10,485 Education No education 42.8 38.7 39.5 37.0 44.3 37.4 33.4 15.7 3,505 Primary 55.5 49.6 49.7 46.4 56.3 50.4 41.3 18.1 14,916 Secondary 72.8 65.2 66.1 62.4 77.2 62.4 51.4 26.3 4,177 More than secondary 64.3 57.4 59.7 49.2 77.4 45.8 35.5 22.1 422 Wealth quintile Lowest 36.4 30.9 30.5 28.7 35.9 31.9 25.1 11.6 4,268 Second 48.6 43.5 43.3 39.6 49.7 43.4 35.9 16.2 4,332 Middle 59.0 52.1 53.1 49.3 59.8 53.4 44.8 19.7 4,517 Fourth 64.1 57.8 58.5 54.8 64.5 57.4 48.5 21.0 4,515 Highest 71.8 66.1 66.8 62.8 78.0 62.7 51.6 26.2 5,388 Total 56.9 50.9 51.3 47.9 58.7 50.5 41.8 19.3 23,020 5.13.2 Exposure of Males to Specific Family Planning Messages Use of family planning methods is facilitated when husbands and wives discuss the issue and their views. As with women, male respondents age 15-49 were asked if they listened to specific family planning or health programmes on the radio within the past few months. Table 5.15.2 shows that 83 percent of men heard ‘Tikuferanji’, 73 percent of men listened to ‘Safe Motherhood’, 72 percent heard ‘Phukusi la Moyo’, and 65 percent constitute the audience for ‘Umoyo m’Malawi’. Six in ten men with no education heard Safe Motherhood compared with eight in ten men with a secondary education. Overall, more men in the rural areas are exposed to family planning or health programmes on the radio than their colleagues in urban areas. 70 | Family Planning Table 5.15.2 Exposure of respondents to specific family planning or health programmes on the radio: Men Percentage of women 15-49 who heard specific programme series about family planning or health on the radio, by background characteristic, Malawi 2010 Background characteristic Safe Motherhood Phukusi la Moyo Radio Doctor/ Doctor Wapawailesi Umoyo m’Malawi Tikuferanji Chitukuko m’Malawi Uku Ndiko Kudya Other Total Age 15-19 58.9 59.3 51.7 48.8 75.3 52.5 36.8 9.0 1,748 20-24 73.0 71.3 67.5 61.6 83.5 63.0 49.7 10.9 1,239 25-29 80.3 79.6 79.1 70.0 86.3 74.2 61.3 14.3 1,099 30-34 79.6 76.7 79.2 72.0 84.9 73.4 65.3 13.8 948 35-39 76.8 76.4 78.0 72.7 85.7 72.8 67.8 14.9 798 40-44 83.7 81.9 81.2 77.7 88.3 77.3 69.9 15.1 529 45-49 80.9 78.8 78.1 75.7 84.7 74.5 68.9 11.4 458 Residence Urban 71.5 68.3 70.6 59.8 84.8 60.3 43.7 12.6 1,440 Rural 73.7 73.3 69.8 65.9 82.2 68.3 58.5 12.1 5,379 Region Northern 75.4 73.2 69.2 65.9 80.8 70.8 60.7 4.9 744 Central 73.8 73.5 71.4 66.1 82.0 69.1 58.6 17.5 3,074 Southern 72.2 70.7 68.6 62.8 84.0 63.0 50.7 8.5 3,001 Education No education 64.6 62.3 62.4 58.9 73.0 57.6 51.6 12.0 422 Primary 71.1 71.6 67.4 64.1 81.1 67.5 56.3 11.6 4,270 Secondary 80.4 76.8 77.4 68.7 88.7 68.1 55.5 12.9 1,904 More than secondary 70.5 64.3 68.9 50.1 81.2 52.5 45.2 17.4 223 Wealth quintile Lowest 64.4 62.7 58.8 59.3 73.4 64.6 52.2 10.7 997 Second 71.0 73.7 67.3 62.7 79.5 65.1 57.5 12.9 1,309 Middle 75.0 76.8 73.8 68.0 84.7 72.2 62.4 11.0 1,367 Fourth 78.5 75.5 75.4 69.5 85.7 69.4 56.6 11.7 1,376 Highest 74.6 70.5 70.9 62.5 86.6 62.2 49.4 13.7 1,770 Total 15-49 73.3 72.2 69.9 64.6 82.7 66.6 55.4 12.2 6,818 Total 73.7 72.8 70.5 65.2 83.0 67.3 56.2 12.3 7,175 5.14 CONTACT OF NON-USERS WITH FAMILY PLANNING PROVIDERS In the 2010 MDHS, women who were not using any family planning method were asked whether they had been visited by a health worker who talked with them about family planning in the 12 months preceding the survey. This information is especially useful for determining whether family planning outreach programmes are reaching non-users. Non-users were also asked if they had visited a health facility in the past 12 months for any reason other than family planning, and if so, whether any health worker at the facility had spoken to them about family planning. These questions help to assess the level of so-called missed opportunities to inform women about contraception. The results shown in Table 5.16 indicate that 12 percent of non-users reported discussing family planning when a fieldworker visited them. Thirty-six percent of non-users reported that they had visited a health facility and discussed family planning, while 30 percent of the non-users visited a health facility but did not discuss family planning. Staff at health facilities are more likely to discuss family planning with women age 25-34 than with younger women or older women. Overall, the majority of non-users (59 percent) did not discuss family planning with a fieldworker or at a health facility during the 12 months prior to the survey. The proportion of women who were visited by a fieldworker is three times higher in rural areas than in urban areas (14 versus 5 percent, respectively). Similarly, women in rural areas are more likely than women in urban areas to visit a health facility and discuss family planning (38 versus 27 percent, respectively). The proportion of non-users who visited a health facility and discussed family planning is slightly higher in the Northern and Southern Regions (37 percent for each) than in the Central Region (35 percent). Women with less education and those in lower wealth quintiles are more likely to visit a health facility and discuss family planning with a provider than women with more education and women in higher wealth quintiles. Family Planning | 71 Table 5.16 Contact of non-users with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor at a health facility, by background characteristics, Malawi 2010 Background characteristic Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who neither discussed family planning with fieldworker nor at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 6.5 11.6 33.4 83.8 4,515 20-24 15.2 46.1 30.6 47.9 2,910 25-29 14.7 52.6 26.7 43.2 2,442 30-34 16.2 53.0 26.7 42.4 1,751 35-39 13.5 47.4 26.8 47.1 1,306 40-44 14.4 37.7 29.3 55.5 967 45-49 14.2 29.5 30.5 62.4 978 Residence Urban 5.1 27.0 38.3 70.5 2,593 Rural 13.9 37.9 28.1 56.3 12,275 Region Northern 9.0 36.6 27.7 60.5 1,703 Central 11.5 34.6 32.4 60.0 6,299 Southern 13.9 37.1 28.2 57.1 6,867 Education No education 16.1 38.0 26.3 54.3 2,242 Primary 12.2 37.2 28.6 57.9 9,626 Secondary 10.6 30.0 37.5 65.0 2,733 More than secondary 4.7 34.7 29.7 63.5 266 Wealth quintile Lowest 14.8 39.7 26.6 53.4 3,038 Second 14.4 38.1 27.1 55.6 2,799 Middle 14.4 39.2 28.1 55.7 2,882 Fourth 11.6 35.5 30.0 59.3 2,783 Highest 7.2 28.4 36.7 68.3 3,366 Total 12.3 36.0 29.9 58.7 14,868 5.15 HUSBAND’S/PARTNER’S KNOWLEDGE OF WOMEN’S CONTRACEPTIVE USE The 2010 MDHS asked married women whether their husband or partner knew that they were using a method of family planning. Table 5.17 shows that 93 percent of currently married women age 15-49 who are using a method reported that their husband or partner knows about their use of contraception, 5 percent reported that their husband or partner does not know, and 2 percent reported that they were unsure whether their husband or partner knows about their use of contraception. Women with the highest educational attainment (99 percent) are most likely to share information about their method choice with their husband or partner. 72 | Family Planning Table 5.17 Husband/partner’s knowledge of women’s use of contraception Among currently married women age 15-49 who are using a method, percent distribution by whether they report that their husbands/partners know about their use, according to background characteristics, Malawi 2010 Background characteristic Knows1 Does not know Unsure whether knows/ missing Total Number of women Age 15-19 90.4 6.4 3.2 100.0 337 20-24 93.1 4.7 2.3 100.0 1,451 25-29 93.6 4.6 1.9 100.0 1,777 30-34 92.9 5.2 1.9 100.0 1,327 35-39 92.7 4.8 2.6 100.0 1,091 40-44 93.5 4.5 2.0 100.0 675 45-49 92.6 3.9 3.5 100.0 501 Residence Urban 93.8 4.9 1.3 100.0 1,443 Rural 92.8 4.7 2.5 100.0 5,717 Region Northern 92.4 6.1 1.6 100.0 882 Central 94.4 3.5 2.0 100.0 3,206 Southern 91.7 5.7 2.7 100.0 3,072 Education No education 90.1 6.2 3.7 100.0 1,138 Primary 93.0 5.0 2.0 100.0 4,709 Secondary 95.0 2.9 2.1 100.0 1,202 More than secondary 99.4 0.0 0.6 100.0 112 Wealth quintile Lowest 91.7 5.1 3.2 100.0 1,022 Second 91.7 5.8 2.5 100.0 1,372 Middle 92.8 4.9 2.3 100.0 1,485 Fourth 93.7 4.1 2.2 100.0 1,547 Highest 94.3 4.2 1.6 100.0 1,733 Total 93.0 4.8 2.2 100.0 7,160 1 Includes women who report use of male sterilisation, male condoms, or withdrawal Other Proximate Determinants of Fertility | 73 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter focuses on the principal factors other than contraception that affect a woman’s risk of becoming pregnant. These factors, referred to as other proximate determinants of fertility, include marriage, sexual activity, postpartum amenorrhoea, abstinence from sexual activity, and onset of menopause. Marriage is a primary indication of the exposure of women to the risk of pregnancy and, therefore, is important for understanding fertility. Postpartum amenorrhoea and postpartum abstinence determine the length of time a woman is protected from the risk of becoming pregnant after childbirth, affecting birth intervals and thus fertility levels. Menopause is important because it marks the end of a woman’s period of exposure to the risk of pregnancy. This chapter also includes information on more direct measures of the beginning of exposure to pregnancy and the level of exposure, for example, the age at first sexual intercourse and the frequency of intercourse.1 6.1 CURRENT MARITAL STATUS Table 6.1 presents data on current marital status by age and sex. Populations in which age at first marriage is young tend to have early childbearing and high fertility rates. However, because a union is not a prerequisite to childbearing, some women have children before entering a formal union. In this context, the term married refers to legal or formal marriage, while living together refers to an informal union in which a man and a woman live together, even if a formal civil, religious, or traditional ceremony has not been contracted. Currently married refers to both formal and informal unions. Table 6.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Malawi 2010 Age Marital status Total Percentage of respon- dents currently in union Number of respon- dents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 73.8 19.5 3.9 1.1 1.5 0.2 100.0 23.4 5,005 20-24 14.2 65.3 10.9 4.3 4.6 0.7 100.0 76.2 4,555 25-29 3.1 74.1 10.4 5.8 5.1 1.5 100.0 84.5 4,400 30-34 1.3 71.3 9.8 7.3 5.9 4.4 100.0 81.1 3,250 35-39 0.7 71.2 9.7 6.5 4.9 7.0 100.0 80.9 2,522 40-44 0.1 68.7 8.7 5.7 6.4 10.4 100.0 77.4 1,730 45-49 0.1 65.0 9.2 7.7 4.6 13.5 100.0 74.1 1,558 Total 15-49 19.7 58.7 8.7 4.9 4.4 3.6 100.0 67.5 23,020 MEN 15-19 97.5 1.9 0.3 0.2 0.1 0.0 100.0 2.3 1,748 20-24 59.0 29.6 8.0 1.7 1.7 0.1 100.0 37.6 1,239 25-29 16.6 67.4 11.5 2.3 1.8 0.3 100.0 79.0 1,099 30-34 4.8 75.2 15.7 2.3 1.4 0.5 100.0 90.9 948 35-39 2.6 75.9 16.5 2.6 1.4 1.0 100.0 92.4 798 40-44 0.6 81.6 12.0 2.9 2.0 0.9 100.0 93.6 529 45-49 0.6 79.7 13.8 3.3 1.4 1.3 100.0 93.5 458 Total 15-49 39.4 47.8 9.4 1.8 1.2 0.4 100.0 57.1 6,818 50-54 0.7 80.7 9.7 5.8 2.2 0.9 100.0 90.5 357 Total men 15-54 37.5 49.4 9.4 2.0 1.3 0.4 100.0 58.8 7,175 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 74 | Other Proximate Determinants of Fertility The results show that 59 percent of women and 48 percent of men age 15-49 are married, and 9 percent of each sex are living together. Overall, 68 percent of women and 57 percent of men are currently in union. The never married proportion is higher among men (39 percent) compared with women (20 percent). Divorce, separation, and widowhood combined is four times higher among women than men (13 percent and 3 percent, respectively). The results further show that one of every five teenage girls (20 percent) age 15-19 is in a formal marriage, and another 4 percent are in an informal union. Teenage boys are less likely to be married (2 percent). The proportion of married women currently in union increases rapidly, from 23 percent among teenage women age 15-19 to a high of 85 percent among all women age 25-29. For men, the percentage increases steadily, from 2 percent among men age 15-19 to a high of 94 percent among men age 40 and older. 6.2 POLYGYNY Polygyny has implications for the frequency of sexual intercourse, and thus, may have an effect on fertility. The extent of polygyny was measured in the 2010 MDHS by asking all currently married female respondents whether their husband or partner had other wives (co-wives), and if so, how many. Married men were asked whether they had one or more wives or partners with whom they were living. Table 6.2.1 shows the percent distribution of currently married women by number of co- wives. The percent distribution of currently married men by number of wives is shown in Table 6.2.2. Table 6.2.1 shows that in Malawi, 14 percent of married women are in polygynous unions. Thirteen percent of women reported having one co-wife, while only 1 percent has two or more cowives. The level of polygyny increases with age, from 3 percent among women age 15-19 to 23 percent among women age 40-44. Polygynous unions are more prevalent among women in rural areas (16 percent) than in urban areas (6 percent). At the regional level, the Northern Region (21 percent) has the highest percentage of women in polygynous unions, and the Southern Region has the lowest (11 percent). In the Central Region, 16 percent of women report being in a polygynous union. Table 6.2.1 Number of women’s cowives Percent distribution of currently married women age 15-49 by number of cowives, according to background characteristics, Malawi 2010 Background characteristic Number of co-wives Total Number of women 0 1 2+ Missing Age 15-19 95.8 3.1 0.1 1.0 100.0 1,171 20-24 91.6 7.0 0.4 1.0 100.0 3,469 25-29 85.8 12.6 0.9 0.7 100.0 3,718 30-34 82.7 15.2 1.4 0.6 100.0 2,636 35-39 77.8 18.2 3.2 0.8 100.0 2,040 40-44 75.8 21.1 2.1 1.0 100.0 1,339 45-49 78.4 18.2 3.0 0.4 100.0 1,155 Residence Urban 93.5 5.6 0.4 0.6 100.0 2,686 Rural 83.1 14.5 1.6 0.8 100.0 12,841 Region Northern 78.1 18.2 3.2 0.4 100.0 1,871 Central 84.2 13.9 1.6 0.4 100.0 6,678 Southern 87.4 10.7 0.7 1.2 100.0 6,979 Education No education 78.1 18.6 2.8 0.5 100.0 2,826 Primary 85.1 13.0 1.1 0.8 100.0 10,231 Secondary 91.6 6.8 0.8 0.8 100.0 2,275 More than secondary 95.5 2.9 0.2 1.4 100.0 195 Wealth quintile Lowest 79.2 17.9 2.3 0.6 100.0 2,639 Second 84.4 13.6 1.0 1.0 100.0 3,120 Middle 83.4 14.7 1.3 0.5 100.0 3,303 Fourth 84.5 12.8 1.4 1.3 100.0 3,197 Highest 91.8 6.8 1.0 0.5 100.0 3,268 Total 84.9 13.0 1.4 0.8 100.0 15,528 Other Proximate Determinants of Fertility | 75 Polygyny declines with level of education. One in five women with no education (21 percent) are in polygynous unions, compared with 3 percent of women with more than a secondary education. Women in the lower wealth quintiles are more likely to have polygynous unions than those in the higher wealth quintiles. Eight percent of men age 15-49 reported that they practice polygyny (see Table 6.2.2). The level of polygyny increases with age, from 3 percent among men age 20-24 to 16 percent among men age 45-49. The trend of polygyny by place of residence, region, education, and wealth is the same as that observed among women. Table 6.2.2 Number of men’s wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Malawi 2010 Background characteristic Number of wives Total Number of men 1 2+ Missing Age 15-19 (100.0) (0.0) (0.0) 100.0 40 20-24 97.3 2.6 0.0 100.0 466 25-29 96.0 3.4 0.6 100.0 868 30-34 94.1 5.8 0.1 100.0 862 35-39 91.5 8.4 0.0 100.0 737 40-44 85.4 14.6 0.0 100.0 495 45-49 83.6 16.1 0.4 100.0 428 Residence Urban 96.6 3.1 0.3 100.0 686 Rural 91.3 8.5 0.2 100.0 3,209 Region Northern 85.8 13.8 0.4 100.0 428 Central 92.6 7.2 0.2 100.0 1,792 Southern 93.4 6.4 0.1 100.0 1,676 Education No education 87.6 12.4 0.0 100.0 333 Primary 91.1 8.7 0.2 100.0 2,460 Secondary 96.0 3.8 0.2 100.0 980 More than secondary 97.7 2.2 0.1 100.0 122 Wealth quintile Lowest 90.3 9.6 0.1 100.0 603 Second 92.2 7.8 0.0 100.0 826 Middle 91.8 7.8 0.4 100.0 850 Fourth 91.8 8.0 0.2 100.0 783 Highest 94.5 5.2 0.3 100.0 833 Total 15-49 92.2 7.6 0.2 100.0 3,895 50-54 86.8 13.2 0.0 100.0 323 Total men 15-54 91.8 8.0 0.2 100.0 4,218 Note: Figures in parentheses are based on 25-49 unweighted cases. 6.3 AGE AT FIRST MARRIAGE Whether or not the start of marriage coincides with the initiation of sexual intercourse, and thus, the beginning of exposure to the risk of pregnancy, first marriage is an important social and demographic indicator and, in most societies, represents the point in a person’s life when childbearing first becomes welcome. The duration of exposure to the risk of pregnancy depends primarily on the age at which women first marry. Women who marry earlier, on average, are more likely to have their first child earlier and give birth to more children overall, contributing to higher fertility rates. In Table 6.3, the age at first marriage is defined as the age at which the respondent begins living with his or her first spouse or partner. Note that in this table ‘married’ includes ‘living with a woman/man’. The majority of women age 20-49 (75 percent) were married by age 20, while the majority of men age 25-49 (70 percent) were married by age 25. The proportion of women getting married by age 15 declines from 21 percent among women currently age 40-44 to 4 percent among women currently 76 | Other Proximate Determinants of Fertility age 15-19. A comparison with results from the 2004 MDHS survey indicates that the proportion of women age 15-19 who were married by age 15 declined from 6 percent in 2004 to 4 percent in 2010. These findings provide evidence of an increase in age at marriage in Malawi. Men marry considerably later than women. Twenty-five percent of men age 25-29 were married by age 20, compared with 76 percent of women in the similar age group. Only 6 percent of men age 20-24 had married by age 18, compared with 50 percent of women in the same age group. By age 25, 66 percent of men age 45-49 were married compared with 94 percent of women. Table 6.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Malawi 2010 Current age Percentage first married by exact age: Percentage never married Number Median age at first marriage 15 18 20 22 25 WOMEN 15-19 3.6 na na na na 73.8 5,005 a 20-24 11.7 49.6 73.3 na na 14.2 4,555 18.0 25-29 11.5 51.5 76.4 88.2 94.9 3.1 4,400 17.9 30-34 12.5 50.3 74.8 87.2 95.0 1.3 3,250 18.0 35-39 13.8 51.3 73.7 85.1 94.1 0.7 2,522 17.9 40-44 20.6 56.0 77.1 87.3 93.5 0.1 1,730 17.6 45-49 18.0 55.4 76.4 87.2 93.9 0.1 1,558 17.6 20-49 13.5 51.6 75.0 na na 4.7 18,015 17.9 25-49 14.1 52.2 75.6 87.1 94.5 1.5 13,461 17.8 MEN 15-19 0.1 na na na na 97.5 1,748 a 20-24 1.2 6.4 18.0 na na 59.0 1,239 a 25-29 0.8 10.0 25.2 46.8 72.2 16.6 1,099 22.3 30-34 1.1 7.9 22.7 45.8 70.8 4.8 948 22.4 35-39 1.5 6.7 19.8 43.7 69.7 2.6 798 22.6 40-44 2.5 7.3 16.3 43.0 67.6 0.6 529 22.7 45-49 1.0 7.7 21.2 41.8 65.5 0.6 458 22.8 20-49 1.3 7.7 20.8 na na 19.4 5,070 a 25-49 1.3 8.1 21.7 44.8 69.9 6.6 3,831 22.5 20-54 1.4 7.8 20.7 na na 18.2 5,427 a 25-54 1.4 8.2 21.5 44.2 69.5 6.1 4,188 22.6 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group 6.4 MEDIAN AGE AT FIRST MARRIAGE Table 6.4.1 shows median age at first marriage for women age 15-49 by current age and background characteristics. Median age at first marriage for women age 20-49 is 17.9 years. In urban areas, median age at first marriage increases with age: 17 years for women age 45-49 compared with 19.5 years for women age 20-24. In rural areas, the median age at first marriage is similar for all age groups. Among women with no education, the median age at first marriage declines with age: from 17.3 years for women age 45-49 to 16.9 years for women age 20-24. Median age at first marriage for women age 20-49 is higher among women in the highest wealth quintile (19.2 years) than in other quintiles. Other Proximate Determinants of Fertility | 77 Table 6.4.1 Median age at first marriage: Women Median age at first marriage among women by five-year age groups, age 20-49 and age 25-49, according to background characteristics, Malawi 2010 Background characteristic Current age Women age 20- 49 Women age 25- 49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban 19.5 19.0 19.0 18.3 17.9 17.0 18.8 18.6 Rural 17.7 17.7 17.8 17.8 17.5 17.6 17.7 17.7 Region Northern 18.0 17.8 18.1 17.4 18.1 17.3 17.8 17.7 Central 18.3 18.3 18.1 18.2 17.7 17.9 18.2 18.1 Southern 17.6 17.6 17.8 17.7 17.3 17.4 17.6 17.6 Education No education 16.9 16.7 16.9 17.4 17.1 17.3 17.1 17.1 Primary 17.4 17.4 17.6 17.8 17.5 17.5 17.5 17.5 Secondary a 19.8 21.1 21.0 20.5 19.8 a 20.4 More than secondary a a 25.0 23.3 22.4 21.7 a 24.5 Wealth quintile Lowest 17.5 17.5 17.6 18.0 17.8 17.6 17.6 17.6 Second 17.4 17.5 17.6 17.6 17.6 17.3 17.5 17.5 Middle 17.6 17.6 17.6 17.9 17.1 17.4 17.6 17.6 Fourth 18.1 17.8 18.0 17.5 17.2 17.5 17.8 17.7 Highest a 19.2 19.4 18.5 18.3 17.9 19.2 18.8 Total 18.0 17.9 18.0 17.9 17.6 17.6 17.9 17.8 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Table 6.4.2 shows results on median age at first marriage for men age 15-54 by current age and background characteristics. Median age at first marriage for men age 25-54 is 22.6 years. There is little variation in median age at first marriage by age group. Median age at first marriage is slightly higher for men in urban areas (23.6 years), those with secondary education (24.2 years), and men in the highest wealth quintile (24.0 years) than for their counterparts. Table 6.4.2 Median age at first marriage: Men Median age at first marriage among men by five-year age groups, age 20-54 and age 25-54, according to background characteristics, Malawi 2010 Background characteristic Current age Men age 25-54 25-29 30-34 35-39 40-44 45-49 50-54 Residence Urban 24.0 24.9 23.0 23.2 22.5 23.0 23.6 Rural 21.9 22.0 22.5 22.6 22.9 23.1 22.3 Region Northern 22.3 23.1 22.3 23.1 23.0 23.7 22.8 Central 22.4 22.5 22.4 22.6 22.5 23.2 22.5 Southern 22.1 22.1 22.9 22.7 23.2 22.6 22.5 Education No education 21.0 22.6 23.5 21.8 25.3 23.8 22.9 Primary 21.4 21.3 21.9 21.9 22.2 22.7 21.8 Secondary 23.9 24.1 23.9 25.7 23.8 24.9 24.2 More than secondary a 25.7 24.7 27.1 23.9 22.8 a Wealth quintile Lowest 21.4 22.2 22.5 23.3 22.8 25.2 22.4 Second 21.8 21.8 22.4 22.1 22.3 22.8 22.1 Middle 21.7 21.5 22.6 21.8 21.7 24.2 21.9 Fourth 22.4 22.1 22.3 23.2 23.0 22.1 22.5 Highest a 24.8 23.2 23.3 23.6 22.6 24.0 Total 22.3 22.4 22.6 22.7 22.8 23.1 22.6 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner a = Omitted because less than 50 percent of the men married for the first time before reaching the beginning of the age group 78 | Other Proximate Determinants of Fertility 6.5 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is often used as a proxy for the onset of women’s exposure to the risk of pregnancy. However, because some women are sexually active before marriage, the age at which women initiate sexual intercourse more precisely marks the beginning of their exposure to reproductive risk. Table 6.5 shows the percentage of women and men who had first sexual intercourse by exact ages. The information in this table allows an assessment of the age at which women and men start having sexual intercourse and the trend in this indicator across age cohorts. In Malawi the median age at first sexual intercourse is 17.3 years for women age 20-49 and 18.5 years for men age 20-49. There is no major variation in median age at first intercourse by age group for women and men; however, men initiate sexual intercourse later than women in all age groups. The proportion of both women and men age 20-49 who had sexual intercourse by an exact age increases with age. Eighteen percent of women and 14 percent of men initiated sexual intercourse by age 15 compared with 80 percent of women and 65 percent of men who initiated sexual intercourse by age 20. More than half (60 percent) of these women and 43 percent of the men in the same age group initiated sexual intercourse by age 18. Table 6.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Malawi 2010 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse 15 18 20 22 25 WOMEN 15-19 12.1 na na na na 56.0 5,005 a 20-24 16.7 59.5 81.7 na na 6.1 4,555 17.4 25-29 16.8 59.8 80.1 88.3 92.1 0.7 4,400 17.3 30-34 17.5 58.7 80.2 88.5 91.7 0.2 3,250 17.3 35-39 18.1 60.0 79.7 87.4 91.0 0.2 2,522 17.2 40-44 22.2 61.6 78.5 86.9 90.0 0.0 1,730 17.0 45-49 22.0 61.2 79.5 87.2 90.7 0.0 1,558 17.0 20-49 18.1 59.8 80.3 na na 1.8 18,015 17.3 25-49 18.5 59.9 79.8 87.9 91.4 0.3 13,461 17.2 15-24 14.3 na na na na 32.2 9,559 a MEN 15-19 26.4 na na na na 45.6 1,748 a 20-24 16.0 49.5 69.8 na na 13.0 1,239 18.0 25-29 15.3 44.4 65.4 82.7 93.9 2.3 1,099 18.5 30-34 12.3 41.3 64.8 79.0 90.0 0.7 948 18.6 35-39 10.3 39.1 62.4 79.6 90.8 0.8 798 18.7 40-44 14.2 40.1 60.7 76.4 89.2 0.1 529 18.8 45-49 10.3 36.6 57.7 74.0 84.3 0.4 458 19.0 20-49 13.5 43.1 64.7 na na 4.0 5,070 18.5 25-49 12.8 41.0 63.1 79.2 90.5 1.0 3,831 18.7 15-24 22.1 na na na na 32.1 2,987 a 20-54 13.1 42.3 64.0 na na 3.7 5,427 18.6 25-54 12.3 40.1 62.3 78.8 90.1 1.0 4,188 18.7 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group The results further show that the percentage of women who initiated first sexual intercourse by age 15 is lower among women who are of younger ages compared with women in the older cohort. For men, a higher percentage of the younger generation has initiated first sexual intercourse at younger ages compared with the older age cohorts. Twelve percent of women age 15-19 initiated Other Proximate Determinants of Fertility | 79 sexual intercourse by age 15 compared with 22 percent among those age 45-49. Twenty-six percent of men age 15-19 initiated sex at age 15 compared with 10 percent of men age 45-49 who initiated sexual intercourse at the same age. Men are more likely to become sexually active during their teenage years, but they then delay the age at which they marry compared with women, as shown in previous tables. 6.6 MEDIAN AGE AT FIRST SEXUAL INTERCOURSE Table 6.6.1 presents differentials in median age at first sexual intercourse by background characteristics for women. There is no significant difference in the median age at first intercourse for women age 25-49 by place of residence. In this age group, women with secondary and higher education have a higher median age at first intercourse (18.7 and 20.8 years, respectively) than their counterparts with no education (16.6 years) and with primary education (17.0 years). Very little variation is observed among women age 25-49 by wealth. Table 6.6.1 Median age at first intercourse: Women Median age at first sexual intercourse among women by five-year age groups, age 20-49 and age 25-49, according to background characteristics, Malawi 2010 Background characteristic Current age Women age 20- 49 Women age 25- 49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban 18.1 17.9 17.4 17.9 17.3 16.7 17.8 17.6 Rural 17.2 17.1 17.3 17.0 17.0 17.1 17.1 17.1 Region Northern 17.4 17.0 17.1 16.7 17.1 16.7 17.1 16.9 Central 17.9 17.8 17.8 17.7 17.5 17.7 17.8 17.7 Southern 16.8 16.9 16.9 16.8 16.3 16.4 16.8 16.8 Education No education 16.4 16.3 16.4 16.7 16.4 16.9 16.5 16.6 Primary 16.8 16.9 17.1 17.1 17.1 16.9 16.9 17.0 Secondary 18.8 18.7 18.9 18.7 18.7 18.6 18.8 18.7 More than secondary a 20.7 19.8 21.2 21.0 21.6 a 20.8 Wealth quintile Lowest 17.1 16.9 16.9 17.4 17.2 17.5 17.1 17.1 Second 16.9 17.1 17.4 16.7 17.2 16.5 17.0 17.1 Middle 17.0 17.1 17.1 17.2 16.5 16.8 17.0 17.0 Fourth 17.3 17.0 17.2 16.8 16.9 16.8 17.0 17.0 Highest 18.5 18.0 17.9 17.7 17.4 17.6 18.0 17.8 Total 17.4 17.3 17.3 17.2 17.0 17.0 17.3 17.2 a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group Table 6.6.2 presents differentials in median age at first sexual intercourse by background characteristics for men. Among men age 25-54, differences in the median age at first sexual intercourse by background characteristics are generally small. There is a small variation by education in median age at first intercourse for men: men with no education and with primary education tend to have a lower median age at first intercourse (18.9 years and 18.5 years, respectively) than their counterparts with secondary and higher education (19.0 years and 20.1 years, respectively). Greater variation is observed by wealth quintiles for men than for women. 80 | Other Proximate Determinants of Fertility Table 6.6.2 Median age at first intercourse: Men Median age at first sexual intercourse among men by five-year age groups, age 20-54 and age 25-54, according to background characteristics, Malawi 2010 Background characteristic Current age Men age 20-54 Men age 25-54 20-24 25-29 30-34 35-39 40-44 45-49 50-54 Residence Urban 18.3 18.5 18.8 19.0 18.4 19.4 19.0 18.7 18.8 Rural 17.9 18.5 18.6 18.6 18.9 19.0 19.7 18.6 18.7 Region Northern 18.4 18.2 18.8 20.0 20.1 19.9 19.9 18.9 19.1 Central 18.5 18.7 19.1 19.1 18.9 19.2 20.1 18.9 19.0 Southern 17.2 18.4 18.1 18.3 18.4 18.7 18.8 18.2 18.4 Education No education 17.1 18.5 18.6 19.1 18.7 19.4 19.7 18.8 18.9 Primary 17.5 18.2 18.4 18.4 18.7 18.8 19.7 18.4 18.5 Secondary 18.5 19.0 19.0 19.3 18.8 20.2 18.9 18.9 19.0 More than secondary a 20.2 20.7 19.6 20.2 19.7 19.1 a 20.1 Wealth quintile Lowest 17.4 18.3 18.8 19.3 19.3 20.7 20.1 18.6 19.1 Second 18.2 18.8 18.4 18.6 18.9 18.4 20.1 18.6 18.7 Middle 17.6 18.3 18.1 18.1 18.6 18.7 20.4 18.3 18.4 Fourth 18.0 18.2 18.8 18.6 18.8 19.1 19.5 18.6 18.7 Highest 18.6 18.7 19.3 19.5 18.6 19.6 18.7 18.8 18.9 Total 18.0 18.5 18.6 18.7 18.8 19.0 19.5 18.6 18.7 a = Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group 6.7 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the regularity of sexual intercourse. Thus, information on intercourse is important for refining the measurement of exposure to pregnancy. Women and men who have had sexual intercourse were asked how long ago their last sexual contact occurred. Tables 6.7.1 and 6.7.2 show the percent distribution of women and men age 15-49 by the timing of their last sexual intercourse, according to background characteristics. More than half (55 percent) of women age 15-49 were sexually active during the four weeks preceding the interview. Twenty percent had been sexually active in the 12 months preceding the survey, but not in the past month; and 12 percent had not been sexually active for one or more years. About 14 percent reported that they had never had sex. The percentage of women age 15-19 who reported never having had sexual intercourse increased from 48 percent in the 2004 MDHS to 56 percent in the 2010 MDHS. The proportion of women who were sexually active in the four weeks preceding the survey does not vary much by age except for women age 15-19, which is to be expected as the majority of women in this age group have never had sexual intercourse. As expected, the majority of never married women have never had sexual intercourse (69 percent). Five percent of never-married women, 10 percent of widowed women, and 78 percent of married women were sexually active in the four weeks preceding the survey. The results show that there is no significant variation in sexual activity within the last four weeks by place of residence. Women with no education (61 percent) are more likely to have been sexually active in the past four weeks than those with primary education (56 percent). Women with secondary and higher education are least likely to have been sexually active in the past four weeks (45 and 46 percent, respectively). Women in the lowest wealth quintile are least likely to have reported having sexual intercourse in the last 4 weeks (48 percent). Other Proximate Determinants of Fertility | 81 Table 6.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Malawi 2010 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the last 4 weeks Within 1 year1 One or more years Missing Age 15-19 20.5 15.4 7.9 0.2 56.0 100.0 5,005 20-24 59.6 25.0 9.1 0.2 6.1 100.0 4,555 25-29 68.2 20.8 10.1 0.1 0.7 100.0 4,400 30-34 66.0 19.6 13.9 0.3 0.2 100.0 3,250 35-39 67.5 17.5 14.4 0.3 0.2 100.0 2,522 40-44 60.9 17.9 20.9 0.3 0.0 100.0 1,730 45-49 58.2 16.8 24.8 0.1 0.0 100.0 1,558 Marital status Never married 5.3 13.9 11.8 0.2 68.8 100.0 4,538 Married or living together 77.5 18.5 3.9 0.2 0.0 100.0 15,528 Divorced/separated/widowed 9.5 33.3 56.9 0.3 0.0 100.0 2,954 Marital duration2 0-4 years 74.4 22.0 3.4 0.2 0.0 100.0 3,107 5-9 years 75.9 18.7 5.2 0.2 0.0 100.0 3,036 10-14 years 79.4 16.8 3.6 0.2 0.0 100.0 2,347 15-19 years 79.9 15.4 4.3 0.4 0.0 100.0 1,502 20-24 years 79.1 15.5 5.0 0.4 0.0 100.0 1,067 25+ years 76.2 19.5 4.2 0.0 0.0 100.0 1,025 Married more than once 79.2 18.1 2.8 0.0 0.0 100.0 3,444 Residence Urban 53.6 17.8 12.2 0.4 15.9 100.0 4,302 Rural 54.8 19.8 12.3 0.1 13.0 100.0 18,718 Region Northern 52.6 19.3 14.1 0.5 13.6 100.0 2,677 Central 58.6 15.2 10.7 0.1 15.4 100.0 9,857 Southern 51.2 23.5 13.3 0.2 11.8 100.0 10,485 Education No education 61.4 21.1 15.2 0.3 2.0 100.0 3,505 Primary 55.7 19.1 11.0 0.2 14.1 100.0 14,916 Secondary 45.4 19.4 14.0 0.1 21.2 100.0 4,177 More than secondary 46.1 20.6 16.1 0.9 16.2 100.0 422 Wealth quintile Lowest 47.5 23.9 16.7 0.2 11.6 100.0 4,268 Second 57.4 19.6 12.0 0.1 10.9 100.0 4,332 Middle 58.2 19.1 10.0 0.1 12.6 100.0 4,517 Fourth 57.6 18.2 10.6 0.3 13.3 100.0 4,515 Highest 52.1 17.1 12.2 0.3 18.4 100.0 5,388 Total 54.5 19.5 12.3 0.2 13.6 100.0 23,020 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married More than half (54 percent) of men age 15-49 were sexually active in the four weeks preceding the survey, 20 percent had sexual intercourse in the past year but not in the past four weeks, and 12 percent had not been sexually active for one or more years. Similar to women, 15 percent of men had never had sex. Fifteen percent of never married men and 24 percent of divorced, separated, or widowed men were sexually active within the last four weeks prior to the survey. Men in urban areas (42 percent), those with secondary education (49 percent), and those in the highest wealth quintile (45 percent) were the least likely to have been sexually active in the four weeks prior to the survey. 82 | Other Proximate Determinants of Fertility Table 6.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Malawi 2010 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the last 4 weeks Within 1 year1 One or more years Missing Age 15-19 14.4 18.0 21.9 0.2 45.6 100.0 1,748 20-24 43.2 24.6 18.9 0.3 13.0 100.0 1,239 25-29 70.1 21.0 6.3 0.3 2.3 100.0 1,099 30-34 75.5 19.6 4.1 0.2 0.7 100.0 948 35-39 78.7 15.5 4.7 0.3 0.8 100.0 798 40-44 77.3 19.0 3.5 0.1 0.1 100.0 529 45-49 76.7 18.2 4.2 0.6 0.4 100.0 458 Marital status Never married 15.3 22.3 25.0 0.2 37.1 100.0 2,689 Married or living together 82.0 16.8 0.9 0.3 0.0 100.0 3,895 Divorced/separated/widowed 23.9 37.1 38.7 0.2 0.0 100.0 234 Marital duration2 0-4 years 81.9 17.1 0.9 0.0 0.0 100.0 825 5-9 years 81.6 17.1 1.1 0.1 0.0 100.0 793 10-14 years 79.6 19.5 0.4 0.4 0.0 100.0 600 15-19 years 87.2 10.3 1.8 0.7 0.0 100.0 349 20-24 years 77.1 21.3 0.8 0.8 0.0 100.0 234 25+ years 81.7 17.1 0.3 0.9 0.0 100.0 137 Married more than once 83.1 15.8 0.9 0.1 0.0 100.0 958 Residence Urban 41.9 25.7 15.2 0.7 16.5 100.0 1,440 Rural 56.8 18.1 10.8 0.1 14.2 100.0 5,379 Region Northern 50.6 19.2 10.7 0.3 19.2 100.0 744 Central 56.7 17.1 11.5 0.1 14.6 100.0 3,074 Southern 51.4 22.4 12.2 0.4 13.6 100.0 3,001 Education No education 69.0 18.3 7.2 0.0 5.4 100.0 422 Primary 54.1 18.1 11.4 0.2 16.3 100.0 4,270 Secondary 49.3 23.5 13.6 0.3 13.3 100.0 1,904 More than secondary 54.8 21.3 11.2 1.1 11.6 100.0 223 Wealth quintile Lowest 56.1 19.9 10.1 0.1 13.9 100.0 997 Second 58.6 18.7 10.3 0.1 12.3 100.0 1,309 Middle 58.2 18.5 11.1 0.3 12.0 100.0 1,367 Fourth 53.6 19.0 12.4 0.0 14.9 100.0 1,376 Highest 45.3 21.7 13.7 0.6 18.7 100.0 1,770 Total 15-49 53.7 19.7 11.7 0.2 14.7 100.0 6,818 50-54 75.9 16.5 6.2 1.2 0.2 100.0 357 Total men 15-54 54.8 19.5 11.5 0.3 13.9 100.0 7,175 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married 6.8 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Among women who are not using contraception, exposure to the risk of pregnancy in the period after a birth is influenced primarily by two factors: breastfeeding and sexual abstinence. Breastfeeding prolongs postpartum protection from conception through its effect on the length of the amenorrhoea period (the interval between childbirth and the return of menstruation) after a birth. More frequent breastfeeding for longer durations is associated with longer periods of postpartum amenorrhoea. Delaying the resumption of sexual relations after a birth also prolongs the period of postpartum protection. This is referred to as postpartum abstinence. Women are considered insusceptible to pregnancy if they are not at risk of conception, either because they are amenorrhoeic or abstain from sexual activity after a birth. Other Proximate Determinants of Fertility | 83 Table 6.8 shows the percentages of births for which mothers are postpartum amenorrhoeic and abstaining along with the percentage of births for which mothers are defined as still postpartum insusceptible. The latter category includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth and, thus, not exposed (i.e., insusceptible) to the risk of pregnancy. The results presented in the table are based on cross-sectional analysis, representing the experience of mothers of all births at a single point in time rather than the experience of a cohort of mothers over time. The data are grouped in two-month intervals to minimise the fluctuations in the estimates. The median- and mean-duration estimates shown at the bottom of Table 6.8 are calculated from the current status distributions presented in the table. At the time of the survey, 40 percent of the mothers who had given birth during the three years preceding the survey were insusceptible because they were either amenorrhoeic or still abstaining (or both). The median duration of postpartum insusceptibility to pregnancy is 12.4 months. The median duration of amenorrhoea is 10.5 months; while the median duration of postpartum abstinence is much lower (4.6 months). By 10 to 11 months after the birth, 57 percent of mothers are insusceptible to pregnancy, 51 percent are amenorrhoeic, and only 17 percent are abstaining from sexual relations. Abstinence declines rapidly as the months since birth increase compared with amenorrhoea and insusceptibility, which decline at a slower rate. Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Malawi 2010 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 <2 92.1 96.0 99.4 484 2-3 85.1 71.8 93.0 667 4-5 70.9 53.7 80.1 572 6-7 64.4 30.5 71.0 787 8-9 57.9 26.4 65.5 685 10-11 51.3 16.7 56.5 679 12-13 40.2 13.0 46.0 626 14-15 38.6 18.6 46.3 619 16-17 28.3 11.9 34.7 582 18-19 24.7 8.7 30.4 754 20-21 21.3 8.6 27.9 758 22-23 13.0 8.5 19.3 643 24-25 12.5 7.3 18.0 658 26-27 8.8 4.7 12.5 657 28-29 5.6 5.1 10.3 620 30-31 3.1 5.7 8.5 680 32-33 1.9 3.7 5.6 687 34-35 3.0 4.5 7.2 645 Total 33.7 20.7 39.8 11,803 Median 10.5 4.6 12.4 na Mean 12.7 8.2 14.9 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth In some populations differentials across subgroups in the duration of postpartum amenorrhoea and abstinence may indicate incipient changes in traditional postpartum practices. Table 6.9 shows the median durations of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics. The duration of postpartum amenorrhoea is shorter among younger women age 15-29 (9.6 months), compared with older women age 30-49 (12.2 months). The duration of amenorrhoea for women in urban areas is shorter than the duration among rural women (8.5 months compared with 10.8 months). Postpartum amenorrhoea is also shorter among women in the Northern Region (9.8 months), women with more than a secondary education (5.1 months), and those in the highest wealth 84 | Other Proximate Determinants of Fertility quintile (7.2 months). The length of postpartum amenorrhoea declines with an increase in the level of the mother’s education. Differences in the median duration of postpartum abstinence are not notable, except by regions. The duration of postpartum abstinence is 6.5 months for mothers in the Southern Region, compared with 4.9 months for the Northern Region, and 3.1 months for mothers in the Central Region. The length of postpartum insusceptibility is higher among women in rural areas (12.8 months), women with no education (13.7 months), and mothers in the lowest wealth quintile (14.0 months). Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Malawi 2010 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 9.6 4.6 11.9 30-49 12.2 4.6 13.2 Residence Urban 8.5 4.1 9.9 Rural 10.8 4.8 12.8 Region Northern 9.8 4.9 12.7 Central 11.0 3.1 12.4 Southern 10.4 6.5 12.4 Education No education 12.3 5.1 13.7 Primary 10.7 4.5 12.8 Secondary 8.4 4.6 9.8 More than secondary 5.1 4.2 6.1 Wealth quintile Lowest 11.8 4.9 14.0 Second 10.5 4.3 12.8 Middle 11.9 4.5 13.5 Fourth 10.7 5.2 12.4 Highest 7.2 4.2 9.0 Total 10.5 4.6 12.4 Note: Medians are based on the status at the time of the survey (current status). 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth 6.9 MENOPAUSE Above age 30, exposure to the risk of pregnancy declines with age. Table 6.10 presents an important indicator concerning fecundity as measured by evidence of menopause. A woman is considered menopausal, and therefore infecund, if she is neither pregnant nor amenorrhoeic and has not had her menses for six or more months. Table 6.10 shows that 11 percent of women age 30-49 are menopausal. The proportion of women who are menopausal increases with age, from 5 percent among women age 30-34 to 40 percent among women age 48-49. These findings indicate that the onset of menopause increases with age for women age 30 and older. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Malawi 2010 Age Percentage menopausal1 Number of women 30-34 4.5 3,250 35-39 5.7 2,522 40-41 7.0 793 42-43 11.6 646 44-45 21.0 599 46-47 27.4 687 48-49 40.3 563 Total 10.6 9,060 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 85 FERTILITY PREFERENCES 7 Information on fertility preferences is used to assess potential demand for family planning services. The intent of such services is to space or limit future births. To elicit information on fertility preferences, several questions were asked of women (pregnant or not) about whether they would like to have another child, and if so, how soon.1 7.1 DESIRE FOR MORE CHILDREN Information about the desire for more children is important to understanding future reproductive behaviour. The provision of adequate and accessible family planning services depends on the availability of such information. Women and men surveyed in the 2010 MDHS were asked questions to determine their desire to have a/another child. Sterilised women and men, who had undergone tubal ligation or vasectomy operations, were considered to want no more children, and therefore they were not asked questions about their desire for more children. Table 7.1 shows the distribution of currently married women and men age 15-49 by desire for more children, according to the number of living children. Table 7.1 shows that 12 percent of women and 15 percent of men want to have another child soon, and more than one-third of women and men (36 percent and 37 percent, respectively) want to have another child later (in two or more years). Forty-seven percent of women and 42 percent of men want no more children or are sterilised. Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Malawi 2010 Desire for children Number of living children1 Total 15-49 50-54 Total men 15-54 0 1 2 3 4 5 6+ WOMEN Have another soon2 74.3 22.1 14.1 9.1 5.5 2.9 1.9 12.4 na na Have another later3 12.5 63.8 54.5 43.9 26.2 14.0 6.2 36.3 na na Have another, undecided when 2.6 1.6 0.8 0.6 0.6 0.6 0.5 0.9 na na Undecided 0.6 1.2 2.1 2.6 3.8 1.4 1.7 2.1 na na Want no more 4.0 9.2 25.6 36.4 51.4 58.6 61.9 37.1 na na Sterilised4 1.0 1.2 1.8 6.2 11.4 20.9 26.0 9.8 na na Declared infecund 4.8 0.8 1.0 1.0 0.9 1.6 1.6 1.3 na na Missing 0.1 0.2 0.1 0.2 0.2 0.0 0.3 0.2 na na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na na Number 599 2,595 3,059 2,847 2,275 1,766 2,387 15,528 na na MEN5 Have another soon2 51.6 25.6 17.9 13.4 11.9 6.0 6.4 15.0 4.5 14.2 Have another later3 20.5 61.4 53.8 39.1 25.0 24.2 17.6 36.8 4.6 34.4 Have another, undecided when 10.9 2.7 0.9 2.8 1.4 1.5 0.6 1.9 1.4 1.9 Undecided 3.4 2.4 2.3 3.8 2.5 3.4 4.2 3.1 0.6 2.9 Want no more 5.1 6.8 24.3 39.2 56.5 60.7 66.9 40.5 82.3 43.7 Sterilised4 3.8 0.7 0.5 1.5 1.7 2.7 3.7 1.9 4.7 2.1 Declared infecund 2.9 0.4 0.4 0.1 0.9 1.4 0.2 0.6 1.6 0.6 Missing 1.7 0.0 0.0 0.1 0.0 0.2 0.4 0.2 0.3 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 127 623 713 672 545 459 756 3,895 323 4,218 na = Not applicable 1 The number of living children includes current pregnancy for women 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation 5 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 86 | Fertility Preferences Fertility preference relates closely to the number of living children. Almost three-quarters of women with no living children (74 percent) want to have a child soon compared with 2 percent of women with six or more children. Among men without children, 52 percent want to have a child soon compared with 6 percent of men with six or more children. The more children that a woman has, the more likely she is to not want another child. Figure 7.1 shows the differences between women and men who want no more children (or who are sterilised) by the number of living children. Figure 7.1 Percentage of Currently Married Women and Men Who Want No More Children, by Number of Living Children MDHS 2010 5 10 27 43 63 80 88 9 8 25 41 58 63 71 0 1 2 3 4 5 6+ Number of living children 0 20 40 60 80 100 Percent Women Men 7.2 DESIRE TO LIMIT CHILDBEARING Tables 7.2.1 and 7.2.2 show, by number of living children, the percentages of currently married women and men age 15-49 who want no more children, according to background characteristics. The results provide information on variations in the potential demand for fertility control. Women who have been sterilised are considered to want no more children. Men who have been sterilised, or who report that their wife or partner has been sterilised, are considered to want no more children. Overall, nearly half (47 percent) of women age 15-49 indicate no desire for more children. Four in every five (80 percent) women with five living children want to limit childbearing compared with one in every ten (10 percent) women with one living child. Women in urban areas are more likely to want to limit childbearing (51 percent) than women in rural areas (46 percent). The percentage of women who want to limit childbearing increases with the number of living children. Comparing the three regions, the Central Region (50 percent) has the highest proportion of women who want no more children, followed by the Southern Region (46 percent) and then the Northern region (41 percent). Fertility Preferences | 87 Table 7.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Malawi 2010 Background characteristic Number of living children Total 0 1 2 3 4 5 6+ Residence Urban 3.9 14.6 41.2 57.6 84.7 89.7 91.4 51.0 Rural 5.3 9.2 23.6 38.8 59.6 78.1 87.5 46.0 Region Northern 2.1 4.7 15.0 32.1 58.0 72.8 86.3 41.1 Central 8.2 8.2 26.9 44.6 67.0 83.2 90.3 49.9 Southern 3.6 13.8 30.7 42.9 60.3 77.6 85.5 45.5 Education No education 9.7 16.9 23.7 39.4 57.6 76.2 86.4 59.5 Primary 4.2 8.6 24.6 39.7 62.4 79.7 88.7 45.4 Secondary 5.5 11.9 34.1 53.3 77.4 92.2 92.1 37.6 More than secondary 0.0 18.7 53.3 88.4 100.0 100.0 na 47.3 Wealth quintile Lowest 3.1 9.1 20.4 34.4 56.9 72.2 86.2 44.3 Second 4.9 7.7 21.3 34.0 56.8 75.6 86.9 43.4 Middle 3.6 8.5 23.7 35.6 60.4 77.5 88.0 44.6 Fourth 7.8 10.1 28.0 46.9 65.5 80.7 87.8 49.6 Highest 4.4 15.2 38.3 58.5 76.4 93.0 91.4 51.9 Total 5.0 10.4 27.3 42.5 62.8 79.5 87.9 46.9 Note: Women who have been sterilised are considered to want no more children. na = Not applicable 1 The number of living children includes the current pregnancy. The desire to limit childbearing is higher among women with no education than among women with some education. Overall, 60 percent of women with no education want to limit childbearing compared with 47 percent of women with more than a secondary education and 38 percent with secondary education. This is because more educated women have, on average, much lower fertility (i.e., much lower average parity; see Table 4.2). As such, interpretation of the relationship between education level and fertility preferences needs to be based on comparisons within parity categories. For example, there is minimal difference in desire for future children by level of education among women with six or more children, but among women with three to five living children, the desire to limit childbearing increases markedly with women’s education. Men exhibit similar patterns of desired fertility. Men’s desire to limit childbearing is highest among men living in urban residences, men with more than a secondary education, men with three or more living children, and men in the fourth and highest wealth quintiles. This is particularly true at parity three and above for women and men. 88 | Fertility Preferences Table 7.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Malawi 2010 Background characteristic Number of living children Total 0 1 2 3 4 5 6+ Residence Urban 4.3 8.1 29.3 55.9 80.4 75.5 82.2 45.6 Rural 9.8 7.3 23.7 36.8 54.4 61.0 69.4 41.7 Region Northern 15.6 3.8 15.5 29.3 54.6 60.2 62.2 36.8 Central 5.9 7.7 24.6 47.8 62.5 69.0 76.2 45.5 Southern 9.9 8.3 27.2 35.8 54.9 58.4 66.9 40.5 Education No education 14.8 5.6 34.3 13.9 42.2 60.8 67.8 40.9 Primary 9.6 5.5 18.6 39.7 56.5 61.5 69.8 42.3 Secondary 4.5 10.2 26.3 46.3 65.7 66.3 77.3 40.0 More than secondary 0.0 16.5 73.6 87.6 85.2 91.6 82.1 67.5 Wealth quintile Lowest 14.2 5.3 12.9 40.5 47.7 56.0 70.9 37.4 Second 5.7 6.5 20.9 27.9 41.6 63.6 64.9 36.4 Middle 17.4 10.0 18.8 43.3 64.7 52.6 66.6 41.9 Fourth 0.0 5.6 31.8 37.2 57.8 71.9 78.4 47.3 Highest 5.3 9.3 38.1 52.4 76.8 67.2 73.6 47.8 Total 15-49 8.9 7.5 24.8 40.7 58.2 63.4 70.6 42.4 50-54 85.2 86.6 89.4 71.5 72.3 90.4 90.1 87.0 Total men 15-54 10.3 8.3 26.5 41.6 59.0 65.5 74.7 45.8 Note: Men who have been sterilised or who state in response to the question about desire for children that their wife has been sterilised are considered to want no more children. 1 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 7.3 NEED FOR FAMILY PLANNING SERVICES This section discusses the extent of need and potential demand for family planning services in Malawi. Family planning methods can be used to space or limit childbearing. In the 2010 MDHS, women who indicated that they either want no more children (limiters) or want to wait for two or more years before having another child (spacers), but are not using contraception, are a group identified as having an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted, respectively. Similarly, amenorrhoeic women are classified as having unmet need if their last birth was mistimed or unwanted. Women who are currently using a family planning method are said to have a met need for family planning. Women with an unmet need for family planning and those who are currently using contraception together constitute the total demand for family planning. This information is important not only to determine the total demand but also to measure the percentage of that demand that is satisfied. Table 7.3.1 presents information on unmet need, met need, and total demand for family planning among currently married women surveyed in the 2010 MDHS. Overall, 26 percent of currently married women have an unmet need for family planning (14 percent for spacing and 12 percent for limiting). Unmet need does not vary much by age, except for women age 45-49 who have the lowest unmet need (20 percent). Unmet need for spacing is highest in the 15-19 age group, with 23 percent of women having an unmet need for spacing their births, while the unmet need for limiting is highest in the 40-44 age group, with 22 percent of women wanting no more children but not using family planning. It is notable that up to age 34, a sizeable proportion of unmet need for family planning is for spacing purposes. After age 35, most unmet need is for limiting childbearing. The table also shows that more women in rural areas (27 percent) have an unmet need for family planning (15 percent for spacing and 12 percent for limiting) compared with urban women (24 percent), whose unmet need for both spacing births and limiting childbearing is 11 percent and 12 percent, respectively. At the regional level, total unmet need for family planning is highest in the Central Region (27 percent) and lowest in the Northern Region (24 percent), while need in the Southern Region is 26 percent. Fertility Preferences | 89 Table 7.3.1 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Malawi 2010 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 22.6 2.3 24.9 26.9 1.9 28.8 49.5 4.2 53.7 53.6 1,171 20-24 21.7 4.8 26.5 33.5 8.3 41.8 55.2 13.1 68.3 61.2 3,469 25-29 17.1 8.9 26.0 28.2 19.6 47.8 45.3 28.5 73.8 64.8 3,718 30-34 12.6 15.3 27.9 16.1 34.3 50.4 28.6 49.6 78.2 64.4 2,636 35-39 7.5 20.1 27.6 8.4 45.1 53.5 15.8 65.2 81.1 66.0 2,040 40-44 4.3 22.0 26.3 2.9 47.5 50.4 7.2 69.5 76.7 65.7 1,339 45-49 1.4 18.9 20.3 0.4 43.0 43.4 1.8 61.9 63.8 68.1 1,155 Residence Urban 11.4 12.2 23.5 23.3 30.4 53.7 34.7 42.6 77.3 69.5 2,686 Rural 14.8 11.9 26.7 19.8 24.8 44.5 34.6 36.6 71.2 62.5 12,841 Region Northern 14.6 9.2 23.8 23.2 23.9 47.1 37.9 33.1 71.0 66.4 1,871 Central 13.9 13.2 27.0 20.1 27.9 48.0 34.0 41.0 75.0 64.0 6,678 Southern 14.5 11.5 25.9 19.8 24.2 44.0 34.3 35.6 70.0 62.9 6,979 Education No education 11.0 16.6 27.6 11.9 28.3 40.3 22.9 45.0 67.9 59.3 2,826 Primary 15.3 11.7 27.0 20.6 25.5 46.0 35.8 37.2 73.0 63.0 10,231 Secondary 14.1 7.2 21.3 29.7 23.1 52.8 43.7 30.3 74.1 71.3 2,275 More than secondary 9.7 7.4 17.1 23.8 33.5 57.3 33.5 40.9 74.4 77.0 195 Wealth quintile Lowest 16.0 13.7 29.8 18.3 20.5 38.7 34.3 34.2 68.5 56.6 2,639 Second 16.1 11.7 27.7 21.2 22.8 44.0 37.3 34.4 71.7 61.3 3,120 Middle 16.2 10.7 26.9 20.4 24.6 45.0 36.6 35.3 71.8 62.6 3,303 Fourth 13.5 11.6 25.1 20.3 28.1 48.4 33.8 39.7 73.5 65.9 3,197 Highest 9.8 12.2 22.0 21.3 31.7 53.0 31.1 44.0 75.1 70.6 3,268 Total 14.2 11.9 26.1 20.4 25.7 46.1 34.6 37.7 72.3 63.8 15,528 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. The total demand for family planning in Malawi among married women is 72 percent with 64 percent of the demand for family planning satisfied. Currently married women age 15-19 have the lowest demand for contraception as well as the lowest demand satisfied amongst all age groups (54 percent). Total demand for family planning increases with increasing levels of education and household wealth. Table 7.3.2 presents data on family planning need and demand for all women and for women who are not currently married. Overall, 19 percent of all women have an unmet need for family planning. Total demand for family planning is 54 percent, with 66 percent of the demand satisfied. Among women who are not currently married, 3 percent have an unmet need for family planning. For these women, total demand for family planning is 16 percent, with 84 percent of the demand satisfied. 90 | Fertility Preferences Table 7.3.2 Need and demand for family planning for all women and for women who are not currently married Percentage of all women and not currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning and the percentage of the demand for contraception that is satisfied, by background characteristics, Malawi 2010 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total ALL WOMEN Age 15-19 7.1 0.7 7.8 9.0 0.7 9.8 16.1 1.5 17.6 55.6 5,005 20-24 17.3 3.7 21.0 28.6 7.5 36.1 45.9 11.2 57.1 63.2 4,555 25-29 14.6 7.8 22.4 25.6 18.9 44.5 40.2 26.7 66.9 66.5 4,400 30-34 10.4 12.6 22.9 14.6 31.5 46.1 24.9 44.1 69.1 66.8 3,250 35-39 6.2 16.4 22.6 7.3 40.9 48.2 13.5 57.3 70.8 68.1 2,522 40-44 3.3 17.6 20.9 2.3 41.9 44.1 5.6 59.5 65.1 67.8 1,730 45-49 1.0 14.2 15.3 0.5 36.7 37.2 1.5 50.9 52.5 70.9 1,558 Residence Urban 7.8 7.8 15.6 18.3 21.5 39.7 26.0 29.3 55.3 71.9 4,302 Rural 10.8 8.3 19.1 15.0 19.4 34.4 25.8 27.8 53.5 64.3 18,718 Region Northern 10.8 6.6 17.4 17.6 18.8 36.4 28.4 25.4 53.8 67.7 2,677 Central 9.9 9.1 19.0 15.1 21.0 36.1 25.0 30.0 55.1 65.6 9,857 Southern 10.4 7.9 18.3 15.5 19.0 34.5 25.9 26.9 52.8 65.4 10,485 Education No education 8.9 13.6 22.5 10.3 25.7 36.0 19.2 39.3 58.5 61.6 3,505 Primary 11.2 8.3 19.5 15.5 20.0 35.5 26.6 28.3 54.9 64.6 14,916 Secondary 8.3 4.1 12.4 20.1 14.5 34.6 28.4 18.6 47.0 73.6 4,177 More than secondary 5.7 4.1 9.7 19.7 17.2 36.8 25.3 21.2 46.6 79.1 422 Wealth quintile Lowest 10.7 8.8 19.5 12.7 16.1 28.8 23.5 24.9 48.3 59.6 4,268 Second 12.2 8.5 20.8 16.6 18.7 35.4 28.9 27.3 56.1 63.0 4,332 Middle 12.4 8.0 20.4 16.1 20.1 36.2 28.5 28.1 56.6 64.0 4,517 Fourth 10.1 8.4 18.5 16.2 22.2 38.4 26.3 30.6 56.9 67.5 4,515 Highest 6.5 7.7 14.2 16.1 21.4 37.5 22.6 29.0 51.7 72.6 5,388 Total 10.2 8.2 18.5 15.6 19.8 35.4 25.8 28.1 53.9 65.7 23,020 WOMEN NOT CURRENTLY MARRIED Age 15-19 2.4 0.3 2.6 3.6 0.4 4.0 5.9 0.7 6.6 60.4 3,834 20-24 3.2 0.3 3.5 13.1 4.8 17.9 16.3 5.1 21.4 83.6 1,086 25-29 1.3 2.0 3.2 11.5 15.0 26.5 12.7 17.0 29.7 89.1 682 30-34 0.9 0.8 1.7 8.3 19.7 28.0 9.1 20.5 29.7 94.4 614 35-39 0.7 0.4 1.2 3.0 23.0 26.0 3.7 23.5 27.2 95.6 482 40-44 0.1 2.5 2.6 0.1 22.5 22.6 0.3 25.0 25.3 89.7 391 45-49 0.0 0.7 0.7 0.6 18.9 19.4 0.6 19.6 20.1 96.7 403 Residence Urban 1.7 0.5 2.3 9.8 6.6 16.4 11.5 7.1 18.7 87.9 1,615 Rural 2.0 0.6 2.6 4.6 7.8 12.4 6.5 8.4 15.0 82.6 5,877 Region Northern 1.8 0.6 2.4 4.5 6.9 11.4 6.3 7.5 13.8 82.9 807 Central 1.6 0.4 2.0 4.6 6.5 11.1 6.2 6.9 13.1 84.6 3,180 Southern 2.2 0.8 3.0 7.0 8.6 15.6 9.2 9.4 18.6 83.8 3,506 Education No education 0.3 0.9 1.2 3.7 14.6 18.3 4.0 15.5 19.5 94.0 678 Primary 2.3 0.7 3.0 4.3 8.1 12.4 6.6 8.8 15.4 80.7 4,684 Secondary 1.5 0.3 1.8 8.5 4.2 12.7 10.1 4.5 14.5 87.6 1,902 More than secondary 2.2 1.2 3.4 16.1 3.2 19.3 18.3 4.3 22.7 85.1 227 Wealth quintile Lowest 2.1 0.8 2.9 3.8 9.0 12.8 5.9 9.8 15.6 81.6 1,628 Second 2.4 0.5 2.8 4.8 8.4 13.2 7.2 8.9 16.0 82.4 1,212 Middle 2.1 0.6 2.7 4.3 8.1 12.3 6.4 8.7 15.0 82.1 1,214 Fourth 1.9 0.6 2.5 6.2 7.8 14.1 8.1 8.5 16.6 85.0 1,319 Highest 1.4 0.6 2.0 8.2 5.5 13.6 9.6 6.0 15.6 87.2 2,120 Total 1.9 0.6 2.5 5.7 7.5 13.2 7.6 8.2 15.8 84.0 7,492 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Fertility Preferences | 91 7.4 IDEAL FAMILY SIZE The discussion of fertility preferences earlier in this chapter focused on respondents’ current childbearing preferences. These preferences are influenced by the number of children a respondent already has. The 2010 MDHS asked women and men about the total number of children they would like to have in their lifetime. For respondents who already had living children, the question was posed hypothetically: ‘If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?’ Table 7.4 shows the distribution of women and men age 15-49 by their ideal number of children, according to the number of living children. The mean ideal number of children is 4.0 for all women and 4.2 for currently married women. Sixty-four percent of all women consider four or more children to be ideal, while one-third of women think three or fewer children is ideal (34 percent). Among all women, the mean ideal number of children increases with the number of living children, from 3.1 for those with no children to 5.5 among those with six or more children. Malawian men, on average, want almost the same number of children as women: 3.9 children for all men age 15-49 compared with 4.0 for all women. A similar pattern is observed for currently married men and women (currently married men report 4.3 as a mean ideal number compared with 4.2 reported by currently married women). These findings are similar to those from the 2004 MDHS. Table 7.4 Ideal number of children Percent distribution of women and men 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to number of living children, Malawi 2010 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN 0 3.4 0.3 0.1 0.4 0.6 1.4 1.9 1.3 1 1.6 2.9 0.6 0.2 0.5 0.3 0.4 1.0 2 30.6 22.4 15.8 6.8 5.1 3.2 2.8 14.6 3 23.6 29.1 21.3 16.5 5.7 6.9 4.4 17.1 4 29.5 34.6 47.7 49.4 44.4 28.2 25.5 37.3 5 7.0 6.4 8.8 15.7 21.2 27.4 13.8 12.8 6+ 3.1 3.5 4.9 9.5 20.8 28.7 44.3 13.7 Non-numeric responses 1.2 0.9 0.8 1.5 1.7 3.9 7.0 2.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,867 3,479 3,663 3,454 2,745 2,077 2,735 23,020 Mean ideal number children for: All 3.1 3.3 3.7 4.1 4.6 4.9 5.5 4.0 Number 4,807 3,448 3,632 3,403 2,699 1,995 2,543 22,528 Currently married 3.4 3.4 3.7 4.1 4.6 4.9 5.5 4.2 Number 590 2,569 3,034 2,814 2,238 1,698 2,230 15,173 MEN 0 1.9 0.1 0.4 1.4 0.1 1.1 2.3 1.3 1 0.9 1.5 0.6 0.7 0.2 0.2 0.3 0.7 2 25.1 19.8 12.4 7.2 6.7 3.2 3.7 15.8 3 24.1 33.1 24.3 18.0 7.7 8.0 7.2 20.2 4 34.9 36.1 45.4 47.5 45.8 26.8 25.9 36.9 5 7.5 6.8 9.5 13.9 16.4 27.1 13.5 11.1 6+ 4.6 2.5 6.8 10.5 20.9 31.7 43.3 12.8 Non-numeric responses 1.0 0.1 0.3 0.8 2.1 1.9 3.8 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,792 756 773 706 562 464 766 6,818 Mean ideal number children for: All 3.4 3.4 3.8 4.0 4.5 5.1 5.5 3.9 Number 2,764 755 770 700 550 456 736 6,731 Currently married 3.1 3.3 3.7 4.0 4.5 5.1 5.5 4.3 Number 127 622 710 667 533 451 727 3,836 Mean ideal number children for men 15-54: All 3.4 3.4 3.8 4.0 4.5 5.1 5.7 4.0 Number 2,773.0 761.1 795.5 725.8 585.3 496.8 938.5 7,076.1 Currently married 3.1 3.4 3.8 4.0 4.5 5.1 5.7 4.4 Number 129.1 627.5 730.1 687.3 565.9 489.5 917.6 4,146.9 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 92 | Fertility Preferences Table 7.5 shows the mean ideal number of children for all women, by background characteristics. The mean ideal number of children increases steadily with age, from 3.2 children among women age 15-19 to 5.3 children among women age 45-49. Urban women prefer to have fewer children than rural women (3.4 children compared with 4.1 children, respectively). The mean ideal number of children is similar for all the regions (Northern 4.1, Central 4.0, and Southern 4.0). The mean ideal number of children desired decreases as women’s level of education and wealth status increase. Women with no education want 4.9 children, while those with more than a secondary education want 2.8 children. Women in the lowest wealth quintile want a mean of 4.3 children, while women in the highest wealth quintile want 3.4 children. 7.5 FERTILITY PLANNING The issue of unplanned and unwanted fertility was further investigated in the 2010 MDHS by asking women with births in the five years preceding the survey whether the births were wanted at the time (planned), wanted at a later time (mistimed), or not wanted at all (unwanted). For women who were pregnant at the time of the interview, this question was asked with reference to the current pregnancy. Table 7.6 shows that 55 percent of the births in the five years preceding the survey were wanted at the time they occurred, 19 percent were wanted later (mistimed), and 26 percent were unwanted. Women who have four or more children, and those who are age 35-49, are the most likely to want no more children. Table 7.6 Fertility planning status Percent distribution of births to women 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Malawi 2010 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 68.7 12.4 18.5 0.4 100.0 4,445 2 62.9 20.8 16.0 0.3 100.0 4,214 3 59.2 21.0 19.4 0.3 100.0 3,709 4+ 44.3 20.1 35.4 0.2 100.0 9,402 Mother’s age at birth <20 63.1 16.3 20.3 0.3 100.0 3,915 20-24 61.4 20.1 18.2 0.3 100.0 6,742 25-29 54.8 20.7 24.2 0.3 100.0 5,142 30-34 49.4 19.0 31.4 0.2 100.0 3,237 35-39 40.6 17.4 41.7 0.3 100.0 1,886 40-44 31.6 11.2 57.0 0.2 100.0 703 45-49 39.2 8.3 52.6 0.0 100.0 144 Total 55.4 18.8 25.5 0.3 100.0 21,770 Table 7.5 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Malawi 2010 Background characteristic Mean Number of women Age 15-19 3.2 4,942 20-24 3.5 4,528 25-29 3.9 4,358 30-34 4.3 3,191 35-39 4.7 2,425 40-44 5.1 1,650 45-49 5.3 1,436 Residence Urban 3.4 4,211 Rural 4.1 18,317 Region Northern 4.1 2,562 Central 4.0 9,698 Southern 4.0 10,268 Education No education 4.9 3,338 Primary 4.0 14,628 Secondary 3.2 4,149 More than secondary 2.8 414 Wealth quintile Lowest 4.3 4,154 Second 4.2 4,236 Middle 4.1 4,423 Fourth 4.0 4,437 Highest 3.4 5,279 Total 4.0 22,528 1 Number of women who gave a numeric response Fertility Preferences | 93 7.6 WANTED FERTILITY RATES The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. It is calculated in the same manner as the total fertility rate, except that only wanted births are included. A birth is considered wanted if the number of living children at the time of conception are fewer than the ideal number of children reported by the respondent. The gap between wanted and actual fertility shows how successful women are in achieving their reproductive intentions. A comparison of the total wanted fertility rate and the total fertility rate for the three years preceding the survey is presented in Table 7.7 by background characteristics. Overall, the total fertility rate (5.7 children per woman) is higher than the total wanted fertility rate (4.5 children per woman). Women living in the Central Region have the largest difference between actual and wanted fertility (a difference of 1.3 children per woman), followed by women in the Southern and then Northern Regions (a difference of 1.1 children and 0.9 children per woman, respectively). The largest differences between wanted fertility rates and actual fertility rates are seen among women living in rural areas, women with no education or primary education, and women in the bottom three wealth quintiles. Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Malawi 2010 Background characteristic Total wanted fertility rates Total fertility rates Residence Urban 3.3 4.0 Rural 4.8 6.1 Region Northern 4.8 5.7 Central 4.5 5.8 Southern 4.5 5.6 Education No education 5.6 6.9 Primary 4.7 5.9 Secondary 3.1 3.8 More than secondary 1.9 2.1 Wealth quintile Lowest 5.5 6.8 Second 5.3 6.8 Middle 5.0 6.3 Fourth 4.2 5.3 Highest 3.0 3.7 Total 4.5 5.7 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 95 INFANT AND CHILD MORTALITY 8 In this chapter, results from the 2010 MDHS are presented for the levels, trends, and differentials in mortality among children five years of age. Specifically, this chapter provides information on the levels and trends of neonatal, postneonatal, infant, child, and under-5 mortality, as well as perinatal mortality and patterns of fertility associated with high childhood mortality. Mortality differentials are shown according to socioeconomic and demographic characteristics, such as place of residence (rural or urban), child’s sex, birth order, birth interval, mother’s level of education, and household wealth quintiles.1 Infant and child mortality rates are basic indicators of a country’s socioeconomic situation and quality of life (UNDP, 2007). One of the goals of the Malawi Growth and Development Strategy is to improve the health of all Malawians. An expected outcome for this goal is reduced infant mortality. The childhood mortality rates are also important for monitoring progress towards the fourth Millennium Development Goal, which is to reduce child mortality by two-thirds by the year 2015. 8.1 BACKGROUND AND ASSESSMENT OF DATA QUALITY Childhood mortality estimates are based on information from women’s birth histories recorded in section 2 of the Woman’s Questionnaire. All women age 15-49 were asked questions about the number of sons and daughters they had, and whether they were living with them, or elsewhere, or were dead. For each of these births, information was collected on sex, month and year of birth, survival status, current age, and, if the child had died, age at death. Age-specific childhood mortality rates are presented as follows: Neonatal mortality: the probability of dying within the first month of life Postneonatal mortality: the difference between infant and neonatal mortality Infant mortality: the probability of dying before the first birthday Child mortality: the probability of dying between the first and fifth birthdays Under-5 mortality: the probability of dying between birth and the fifth birthday All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. The reliability of mortality estimates depends on the sampling variability of the estimates and on nonsampling errors. Sampling variability and sampling errors are discussed in Appendix B. Non- sampling errors depend on the completeness with which child deaths are recalled and reported, the accuracy of the date of birth information given by the mother for living children, and the accuracy of age at death information given by the mother for deceased children. Serious omission of births and deaths affects mortality estimates; displacement of dates of such vital events affects mortality trends, and misreporting of age at death distorts the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths for children who were not living at the time of the survey. Mothers may be reluctant to talk about their dead children either because the subject brings back sad memories or because their culture discourages mention of the dead. Even if a respondent is willing to talk about a dead child, she may forget events that happened in the more distant past, particularly if a child was alive only for a short time. When selective omission of childhood deaths occurs, it is usually most severe for deaths in early infancy. Appendix Tables D.3 through D.6 show the level of such omissions that may affect the 2010 MDHS childhood mortality estimates. Table D.3 shows that the percentage of missing information for birth 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 96 | Infant and Child Mortality dates (births in the past 15 years), age at death, age at first union, and mother’s education is below 1 percent. Table D.4 shows the rates of completeness of birth dates to be 99 to 100 percent. The rate is 100 percent for the years under observation (2006-2010). Sex ratio at birth in Table D.4 shows a high level of accuracy in female-male birth reporting. Table D.5 shows the distribution of reported deaths under age 1 month by age at death in days and the percentage of neonatal deaths reported to occur at age 0-6 days, for five-year periods preceding the survey. For all infant deaths reported in days, for the period 0-4 years preceding the survey, 77 percent were neonatal deaths occurring in the first week of life. For all infant deaths reported in days for the 20 years preceding the survey, 72 percent were neonatal deaths. These rates are relatively high, suggesting that there has not been severe underreporting of early infant deaths in the 2010 MDHS. Another issue affecting childhood mortality estimates is the quality of reporting of age at death. If age at death is misreported, estimates may be biased, especially if the net effect of age misreporting results in the transfer of deaths from one childhood mortality category to another. To minimise this error, interviewers were instructed to record the age at death in days for deaths under age 1 month, and in months for deaths under age 2. They were also asked to probe for deaths reported at one year to determine a more precise age at death in terms of months. Table D.6 shows that there may have been death transfers or heaping of deaths at age 12 months because the number of deaths at this age is almost three times the number of deaths at 11 months of age. Reporting of infant deaths at 12 months is more accurate for 0-4 years prior to the survey than for the other five-year periods, which is consistent with the reporting for the 20 years preceding the survey. It is possible that some of these deaths may have occurred before age 1 but are not included in the infant mortality rate. However, the excess deaths reported at 12 months would have no effect on estimates of under-5 mortality rates. 8.2 INFANT AND CHILD MORTALITY LEVELS AND TRENDS Early childhood mortality rates based on data from the 2010 MDHS are presented in Table 8.1 for the three five-year periods preceding the survey. For the five years immediately preceding the survey (2005-2010), the infant mortality rate is 66 deaths per 1,000 live births. The estimate of child mortality (age 12 months to 4 years) is 50 deaths per 1,000 live births, while the overall under-5 mortality rate for the same period is 112 deaths per 1,000 live births. The neonatal mortality rate is 31 deaths per 1,000 live births. The post-neonatal mortality rate is 35 deaths per 1,000 live births. An examination of mortality levels across the three successive five-year periods shows that under-5 mortality rates have declined from 180 deaths per 1,000 live births during the late 1900s (circa 1995-2000) to 112 deaths per 1,000 live births in the late part of this decade (2005-2010). Most of the decrease in mortality occurred outside of the neonatal and postneonatal periods. Infant mortality decreased from 92 deaths per 1,000 live births to 66 deaths per 1,000 live births in the same period. Table 8.1 Early childhood mortality rates Neonatal, post-neonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Malawi DHS 2010 Years preceding the survey Approximate time period of estimated rates Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 2005-2010 31 35 66 50 112 5-9 2000-2005 36 46 81 69 145 10-14 1995-2000 40 52 92 97 180 Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. 1 Computed as the difference between the infant and neonatal mortality rates Infant and Child Mortality | 97 Table 8.2 shows trends in early childhood mortality for five-year periods before the 1992 MDHS, 2000 MDHS, 2004 MDHS and 2010 MDHS. The under-5 mortality rate has declined from 234 deaths per 1,000 live births in 1992 to 112 deaths per 1,000 live births in 2010. The results indicate a decline in each of the age-specific childhood mortality rates during the 18-year period between the 1992 and 2010 MDHS. Neonatal mortality has declined from 41 deaths per 1,000 live births to 31 deaths per 1,000 live births. Post-neonatal mortality has declined from 94 deaths per 1,000 live births to 35 deaths per 1,000 live births, while infant mortality has declined from 134 deaths per 1,000 live births to 66 deaths per 1,000 live births. Child mortality declined from 115 deaths per 1,000 children age 12-59 months to 50 deaths in the same period. The declining trend in childhood mortality rates over the past 18 years is shown in Figure 8.1. Table 8.2 Trends in early childhood mortality Neonatal, post-neonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Malawi 1992-2010 Survey Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) MDHS 2010 31 35 66 50 112 MDHS 2004 27 49 76 62 133 MDHS 2000 42 62 104 95 189 MDHS 1992 41 94 134 115 234 Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. 1 Computed as the difference between the infant and neonatal mortality rates Figure 8.1 Trends in Childhood Mortality, 1992-2010 MDHS 2010 41 94 134 115 234 42 62 104 95 189 27 49 76 62 133 31 35 66 50 112 Neonatal Post-neonatal Infant Child Under-5 0 50 100 150 200 250 300 Deaths per 1,000 live births MDHS 1992 MDHS 2000 MDHS 2004 MDHS 2010 8.3 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Table 8.3 presents mortality differentials by background characteristics. The mortality estimates are calculated for the 10-year period before the survey in order to have a sufficient number of cases in each category to ensure statistically reliable estimates. Childhood mortality rates vary by some socioeconomic characteristics. Under-5 mortality is higher in rural areas (130 deaths per 1,000 live births) compared with urban areas (113 deaths per 1,000 live births). Child mortality is also 98 | Infant and Child Mortality higher in rural areas at 61 deaths per 1,000 children age 12-59 months compared with 44 deaths per 1,000 children age 12-59 months in urban areas. There is no variation in infant mortality by place of residence. At the regional level, the pattern of childhood mortality is mixed. Post-neonatal mortality, infant mortality, and under-5 mortality rates are highest in the Southern Region (47, 79, and 130 deaths per 1,000 live births, respectively). Neonatal mortality is highest in the Northern Region (39 deaths per 1,000 live births). Child mortality rates are highest in the Central Region (66 deaths per 1,000 live births). Higher levels of educational attainment are generally associated with lower mortality rates. Children born to mothers with no education have the highest under-5 mortality rate (138 deaths per 1,000 live births). Rates decline sharply as mother’s level of education increases. Under-5 mortality is 55 deaths per 1,000 live births for children whose mothers have more than a secondary education. Children in households in the second wealth quintile have the highest under-5 mortality rate (140 deaths per 1,000 live births). Under-5 mortality rates are lowest for children in households in the highest wealth quintile (105 deaths per 1,000 live births). Table 8.3 Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Malawi DHS 2010 Background characteristic Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 31 42 73 44 113 Rural 34 40 73 61 130 Region Northern 39 31 70 40 108 Central 33 35 68 66 129 Southern 32 47 79 56 130 Mother’s education No education 29 42 71 73 138 Primary 35 40 76 58 129 Secondary 31 36 67 32 96 More than secondary 28 14 42 13 55 Wealth quintile Lowest 31 38 69 68 133 Second 37 42 79 67 140 Middle 32 41 73 60 129 Fourth 33 40 74 56 126 Highest 33 38 71 36 105 Total 33 40 73 58 127 Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. 1 Computed as the difference between the infant and neonatal mortality rates 8.4 DEMOGRAPHIC DIFFERENTIALS IN CHILDHOOD MORTALITY The demographic characteristics of both mother and child, such as sex of the child, mother’s age at birth, birth order, previous birth interval, and birth size, have an impact on child survival. This section examines early childhood mortality rates by demographic differentials for the 10-year period preceding the survey. Table 8.4 shows that across all childhood mortality indicators the rates for male children are higher than those for female children. The under-5 mortality rate for male children is 138 deaths per 1,000 live births and that for female children is 117 deaths per 1,000 live births. Infant and Child Mortality | 99 In general, childhood mortality rates are higher for children with younger mothers (less than age 20), except for child mortality where children who have older mothers (age 40-49) have the highest child mortality rate (84 deaths per 1,000 children age 12-59 months). The infant mortality rate is 97 deaths per 1,000 live births for children whose mothers’ age at childbirth is less than 20 years compared to 59 deaths per 1,000 live births for children whose mothers were 40-49 years at the time of the birth. Childhood mortality rates are described as having a U-shaped relationship with birth order; first-order births and higher-order births experience a higher mortality risk than middle-order births. Neonatal mortality for first-order births is 46 deaths per 1,000 live births; which then decreases to 27 deaths per 1,000 live births for infants who are a second or third birth order, and once again increases for infants born of a birth order of seven and higher (37 births per 1,000 live births). Studies have shown that a longer birth interval has a positive effect on a child’s chances of survival. Table 8.4 shows that childhood mortality rates generally exhibit a U-shaped pattern with the previous birth interval, declining through birth intervals up to 3 years and then increasing for birth intervals that are 4 or more years. Infant mortality for infants whose birth interval is less than 2 years is higher (120 deaths per 1,000 live births) than for those infants whose birth interval is 3 years (48 deaths per 1,000 live births). The difference in the child mortality rate between births with intervals of less than two years and births with intervals of four or more years is also substantial: 91 deaths per 1,000 children age 12-59 months compared with 47 deaths per 1,000 children age 12-59 months, respectively. Another important indicator of childhood survival is the child’s weight at birth. Mothers were asked about their infant’s weight at birth. Mothers who could not recall or refer to the exact weight from the child’s records were asked whether the infant was very large, larger than average, average, smaller than average, or small at birth. These descriptions have been used effectively as proxies for children’s weight. The results show that babies who were small or very small at birth have higher mortality rates than those reported to be average or larger in size. Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, Malawi DHS 2010 Demographic characteristic Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 39 42 81 62 138 Female 27 38 65 55 117 Mother’s age at birth <20 49 49 97 58 149 20-29 28 38 66 56 119 30-39 33 37 70 61 127 40-49 26 33 59 84 138 Birth order 1 46 43 89 52 136 2-3 27 38 66 56 118 4-6 30 39 69 61 126 7+ 37 42 79 71 145 Previous birth interval2 <2 years 53 67 120 91 200 2 years 25 36 61 59 116 3 years 21 27 48 49 94 4+ years 26 33 59 47 104 Birth size3 Small/very small 65 57 122 na na Average or larger 23 31 55 na na Don’t know/Missing 113 39 152 na na Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey 100 | Infant and Child Mortality 8.5 PERINATAL MORTALITY Perinatal deaths include pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths within the first seven days of life (early neonatal deaths). The perinatal death rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. The distinction between a stillbirth and an early neonatal death may be a fine one, depending often on the observed presence or absence of some faint signs of life after delivery. The causes of stillbirths and early neonatal deaths overlap, and examining just one or the other can understate the true level of mortality around delivery. For these reasons, both events are usually combined and examined together. Information on stillbirths for the five years preceding the survey was derived from the calendar at the end of the Woman’s Questionnaire. Table 8.5 presents the number of stillbirths, early neonatal deaths, and perinatal mortality rate for the five-year period preceding the 2010 MDHS, by selected demographic and socioeconomic characteristics. The perinatal mortality rate in Malawi is 40 deaths per 1,000 pregnancies. The perinatal mortality rate is highest among children whose mothers are younger than age 20 and among children with older mothers age 40-49 (55 and 47 deaths per 1,000 pregnancies, respectively). Pregnancies that occurred fewer than 15 months after the previous pregnancy have the highest perinatal mortality rate (67 deaths per 1,000 pregnancies). Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five- year period preceding the survey, by background characteristics, Malawi DHS 2010 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother’s age at birth <20 72 129 55 3,651 20-29 165 197 33 10,890 30-39 58 135 41 4,675 40-49 21 16 47 797 Previous pregnancy interval in months4 First pregnancy 77 134 55 3,867 <15 25 27 67 786 15-26 71 95 44 3,788 27-38 45 74 22 5,305 39+ 97 147 39 6,267 Residence Urban 48 79 45 2,868 Rural 268 398 39 17,146 Region Northern 31 78 46 2,341 Central 166 189 41 8,615 Southern 119 211 36 9,057 Mother’s education No education 61 65 36 3,502 Primary 213 334 40 13,559 Secondary 41 71 40 2,806 More than secondary 1 7 57 147 Wealth quintile Lowest 75 91 38 4,327 Second 84 114 45 4,392 Middle 60 95 36 4,336 Fourth 59 91 40 3,708 Highest 38 88 39 3,249 Total 316 477 40 20,013 1 Stillbirths are foetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1,000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. Infant and Child Mortality | 101 8.6 HIGH-RISK FERTILITY BEHAVIOUR Studies have shown that the chances of dying in early childhood are much higher when children are born to mothers who are too young or too old, when children are born at less than a two- year birth interval, and when they are high birth order children. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Older women may also experience age-related problems during pregnancy and delivery. In this analysis, a mother is considered to be ‘too young’ if she is less than 18 years and ‘too old’ if she is older than 34 years at the time of delivery. A ‘short birth interval’ is a birth occurring within 24 months of a previous birth. Table 8.6 shows the percent distribution of children born in the five-year period preceding the survey by risk category (no high risk, unavoidable risk, single high-risk, and multiple high-risk). First births, which make up 14 percent of births, are considered ‘unavoidable’ and are shown as a separate risk category. Thirty percent of children born in the five-year period preceding the survey were born to mothers not in any of the high-risk categories. Fifty-five percent of births occurring in the five years preceding the survey were in an avoidable high-risk category: 38 percent were births to mothers in a single high-risk category and 17 percent were births to mothers in a multiple high-risk category. Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Malawi DHS 2010 Risk category Births in the five years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 30.3 1.00 28.8a Unavoidable risk category First order births between ages 18 and 34 years 14.4 1.49 3.5 Single high-risk category Mother’s age <18 6.5 1.51 1.1 Mother’s age >34 0.3 0.68 1.9 Birth interval <24 months 5.2 2.06 10.3 Birth order >3 26.1 1.21 20.8 Subtotal 38.1 1.38 34.1 Multiple high-risk category Age <18 and birth interval <24 months2 0.3 1.72 0.4 Age >34 and birth interval <24 months 0.0 13.48 0.1 Age >34 and birth order >3 10.6 1.28 17.7 Age >34 and birth interval <24 months and birth order >3 1.6 3.70 4.1 Birth interval <24 months and birth order >3 4.8 1.95 11.3 Subtotal 17.2 1.70 33.5 In any avoidable high-risk category 55.3 1.48 67.6 Total 100.0 na 100.0 Number of births/women 19,697 na 15,528 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women 102 | Infant and Child Mortality The risk ratio represents the increased risk of dying among births in various high-risk categories relative to births with no high-risk characteristics. The risk ratio for single high-risk categories is 1.38, while the risk ratio for multiple high-risk categories is 1.70. The single high-risk category associated with the highest risk ratio is a birth interval of less than 24 months. Children born less than 24 months after the most recent birth are at a 2.06 times higher risk of dying than children who are not in any high-risk category. The last column in Table 8.6 shows the distribution of currently married women by the risk category into which a birth would fall if conceived at the time of the survey. This column is based on assumptions that do not take into account family planning, postpartum infecundity, and prolonged abstinence. The data show that 29 percent of currently married women are not in any elevated mortality risk category; however, 68 percent of currently married women have the potential for having a high-risk birth. Maternal Health | 103 MATERNAL HEALTH 9 The health care services that a mother receives during pregnancy, childbirth, and the immediate postnatal period are important for the survival and well-being of both mother and infant. The 2010 MDHS obtained information on the extent to which women in Malawi receive care during each of these stages. These findings are important to those who design policy and implement programmes to improve maternal and child health care services. 9.1 ANTENATAL CARE Antenatal care from a skilled attendant is important to monitor the pregnancy and reduce the risk of morbidity for mother and baby during pregnancy and delivery. Antenatal care enables (1) early detection of complications and prompt treatment (e.g., detection and treatment of sexually transmitted infections); (2) prevention of diseases through immunisation and micronutrient supplementation; (3) birth preparedness and complication readiness; and (4) health promotion and disease prevention through health messages and counselling of pregnant women. In Malawi, the Focused Antenatal Care (FANC) approach, which emphasises the quality of care over the quantity of visits, is part of an essential health care package of maternal and neonatal health guidelines by the Ministry of Health. These guidelines are outlined in the National Reproductive Health Strategy, 2006-2010, and the Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (MOH, 2007). Early detection of problems in pregnancy leads to more timely treatment and referral of complications. Women who do not receive antenatal care during pregnancy are at high risk of obstetrical emergencies and adverse outcomes. The National Reproductive Health Strategy also provides guidelines for improving access to skilled attendants at childbirth and for improving the availability of and access to quality emergency obstetrical care. According to a joint statement by the World Health Organisation (WHO), the International Federation for Midwives (ICM), and the Federation for International Gynaecology and Obstetrics (FIGO), a skilled attendant is ‘an accredited health professional—such as a doctor, nurse, or midwife—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate post-partum period, and in the identification, management, and referral of complications in women and newborns’ (WHO, 2004). WHO further states that traditional birth attendants (TBAs), trained or untrained, are excluded from the category of skilled attendants. In this context, the term TBA refers to traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth, and the postnatal period. In Malawi, a skilled attendant is a health professional who is trained to manage normal labour and to identify and refer obstetric complications during labour, delivery, and the postnatal period. The skilled attendant is also trained to identify and refer complications in the newborn. In Malawi, skilled attendants include doctors, clinical and medical officers, nurses, and midwives. A skilled attendant in Malawi is neither a patient attendant nor a trained or untrained traditional birth attendant. In the 2010 MDHS, women who had given birth in the five years preceding the survey were asked questions about their care. For the last live birth in that period, mothers were asked whether they had received antenatal care. For women with two or more live births during the five-year period, they were asked about the most recent birth.1 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 104 | Maternal Health Table 9.1 presents information about the type of provider from whom antenatal care services were received for the most recent birth. For women who reported more than one source of antenatal services, only the provider with the highest qualifications is presented in the table. Ninety-five percent of women age 15-49 received antenatal care (ANC) from a skilled attendant (doctor, clinical officer, nurse, or midwife) during their last pregnancy. Eighty-three percent of women received ANC services from a nurse or midwife, and 12 percent received ANC services from a doctor or clinical officer. The percentage of women who received ANC services from an unskilled attendant includes 2 percent from a patient attendant and 1 percent each from a health surveillance attendant and a traditional birth attendant. Two percent of women did not receive any ANC services. Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled attendant for the most recent birth, according to background characteristics, Malawi 2010 Background characteristic Skilled attendant Unskilled attendant Other No one Missing Total Percent- age receiving antenatal care from a skilled attendant1 Number of women Doctor/ clinical officer Nurse/ midwife Patient attendant Health surveil- lance attendant Traditional birth attendant Mother’s age at birth <20 12.7 82.9 1.7 0.8 0.8 0.0 1.1 0.0 100.0 95.6 2,185 20-34 11.7 82.9 1.9 1.0 0.7 0.1 1.6 0.1 100.0 94.6 9,580 35-49 11.2 82.6 1.9 1.1 1.2 0.0 2.0 0.0 100.0 93.8 1,899 Birth order 1 13.4 83.0 1.4 0.7 0.5 0.1 0.9 0.0 100.0 96.4 2,499 2-3 11.7 83.1 1.9 1.1 0.6 0.2 1.3 0.1 100.0 94.8 4,978 4-5 10.9 83.3 2.2 0.8 0.9 0.0 1.9 0.0 100.0 94.2 3,424 6+ 11.6 81.8 1.7 1.3 1.3 0.1 2.2 0.0 100.0 93.4 2,763 Residence Urban 11.7 84.5 2.1 0.3 0.0 0.0 1.4 0.0 100.0 96.2 2,107 Rural 11.8 82.6 1.8 1.1 1.0 0.1 1.6 0.1 100.0 94.4 11,558 Region Northern 8.1 88.2 1.5 1.4 0.1 0.1 0.6 0.0 100.0 96.3 1,595 Central 12.4 81.1 2.4 0.9 0.8 0.1 2.3 0.1 100.0 93.5 5,819 Southern 12.2 83.2 1.4 1.0 1.0 0.1 1.2 0.0 100.0 95.4 6,251 Mother’s education No education 12.5 79.0 1.9 1.1 1.4 0.3 3.6 0.2 100.0 91.5 2,277 Primary 11.7 83.2 2.0 0.9 0.8 0.1 1.3 0.0 100.0 94.8 9,144 Secondary 10.5 86.4 1.4 1.0 0.2 0.0 0.6 0.0 100.0 96.8 2,119 More than secondary 30.4 69.6 0.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 125 Wealth quintile Lowest 11.1 81.3 2.8 0.9 1.0 0.1 2.7 0.1 100.0 92.4 2,821 Second 13.0 81.0 1.9 1.1 1.2 0.2 1.7 0.0 100.0 94.0 2,894 Middle 11.1 82.9 2.0 1.2 1.2 0.2 1.3 0.0 100.0 94.1 2,906 Fourth 10.9 85.2 1.0 1.0 0.4 0.0 1.4 0.0 100.0 96.1 2,602 Highest 13.0 84.3 1.3 0.7 0.2 0.0 0.5 0.1 100.0 97.2 2,442 Total 11.8 82.9 1.8 1.0 0.8 0.1 1.6 0.0 100.0 94.7 13,664 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled attendant includes doctor, clinical officer, nurse, and midwife. Usage of antenatal care services by a skilled attendant does not vary much by the mother’s age: 96 percent of mothers younger than age 20 and 94 to 95 percent of mothers age 20 and older receive care from a skilled attendant. The child’s birth order is inversely related to the use of antenatal care: women with higher-order births are less likely to receive antenatal care from a skilled attendant: 96 percent of women pregnant with their first child received antenatal care from a skilled attendant compared with 93 percent of women with births of order six or higher. Ninety-six percent of women residing in urban areas obtained ANC services from a skilled attendant during their last birth compared with 94 percent of women residing in rural areas. Among the regions, 96 percent of women in the Northern Region received ANC from a skilled attendant compared with 95 percent of women in the Southern Region and 94 percent of women in the Central Region. Maternal Health | 105 Although the majority of women received ANC from a skilled attendant regardless of their education, increasing education is directly associated with an increase in the use of a skilled attendant for ANC services. All women with more than a secondary education (100 percent) obtained ANC services from a skilled attendant compared with 92 percent of women with no education. Similarly, among wealth quintiles, use of ANC services is greatest among those in the highest wealth quintile (97 percent) and declines with each wealth quintile to a low of 92 percent among women in the lowest wealth quintile. 9.2 NUMBER OF ANC VISITS AND TIMING OF FIRST VISIT The antenatal care policy in Malawi follows the newest WHO antenatal care (FANC) approach to promote safe pregnancies. At least four ANC visits are recommended for women without complications. The new schedule of visits is as follows: the first visit should occur by the end of 16 weeks of pregnancy; the second visit should be between 24 and 28 weeks of pregnancy; the third visit at 32 weeks; and the fourth visit at 36 weeks. However, women with complications, special needs, or conditions beyond the scope of basic care may require additional visits. Table 9.2 presents information on the number of antenatal visits and the timing of the first antenatal visit for the most recent birth in the five years preceding the survey. Forty-six percent of women who had a live birth in the five years preceding the survey reported visiting antenatal clinics at least four times during pregnancy, and 49 percent reported two or three antenatal visits during their last pregnancy. Three percent of women had just one antenatal care visit. Twelve percent of women had their first antenatal visit in the first trimester of pregnancy, and almost half (48 percent) had their first ANC visit between 4 and 5 months after pregnancy. Thirty-six percent of women had their first antenatal visit in their sixth or seventh month of pregnancy. Differentials do not vary much by urban or rural residence. There has been a decline in the proportion of women who did not receive antenatal care between the 2004 MDHS (5 percent) and the 2010 MDHS (2 percent). The median number of months pregnant at the first visit has remained 5.6 months over the five-year period. Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Malawi 2010 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 1.4 1.6 1.6 1 1.9 2.9 2.7 2-3 47.2 49.8 49.4 4+ 48.6 44.9 45.5 Don’t know/missing 1.0 0.8 0.8 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.4 1.6 1.6 <4 12.6 12.4 12.4 4-5 49.1 48.1 48.2 6-7 35.2 35.6 35.6 8+ 1.6 2.1 2.0 Don’t know/missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Number of women 2,107 11,558 13,664 Median months pregnant at first visit (for those with ANC) 5.5 5.6 5.6 Number of women with ANC 2,077 11,367 13,443 106 | Maternal Health 9.3 COMPONENTS OF ANTENATAL CARE The content of antenatal care is an essential component of the quality of services. Focused antenatal care hinges on the principle that every pregnancy is at risk of complications. Therefore, apart from receiving basic care, every pregnant woman should be monitored for complications. Ensuring that pregnant women receive information on and undergo screening for complications should be a routine part of all antenatal care visits. To assess ANC services, the 2010 MDHS respondents were asked a number of questions about the care they received during pregnancy for their most recent live birth. Table 9.3 presents information on the content of ANC services, including the percentages of women who took iron tablets or syrup, who took intestinal antiparasitic drugs, were informed of the symptoms of pregnancy complications, and received selected routine services during ANC visits for their most recent birth in the past five years. For each of the specified components of antenatal care, women in urban areas were more likely to receive the components of care than women in rural areas. Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Malawi 2010 Background characteristic Among women with a live birth in the last five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the last five years, the percentage with selected services: Took iron tablets or syrup Took intestinal parasite drugs Number of women with a live birth in the last five years Informed of signs of pregnancy complica- tions Weighed Blood pressure measured Urine sample taken Blood sample taken Received informa- tion on which foods to eat Number of women with ANC for their most recent birth Mother’s age at birth <20 92.7 33.3 2,185 76.8 97.3 78.9 25.4 84.2 79.1 2,160 20-34 91.2 26.9 9,580 80.1 97.9 84.4 28.2 81.9 81.4 9,422 35-49 89.4 23.0 1,899 79.7 97.6 86.6 26.8 78.3 81.4 1,861 Birth order 1 93.3 33.8 2,499 79.7 97.4 82.5 31.0 86.9 82.3 2,477 2-3 91.5 29.2 4,978 79.0 98.0 83.8 27.8 82.7 80.5 4,907 4-5 90.4 24.6 3,424 79.8 97.9 83.3 26.1 79.5 81.1 3,357 6+ 89.8 21.8 2,763 80.0 97.3 85.8 25.6 78.1 80.8 2,702 Residence Urban 92.7 29.9 2,107 82.4 99.4 90.5 40.6 92.3 84.5 2,077 Rural 90.9 26.9 11,558 79.0 97.4 82.6 25.2 79.8 80.4 11,367 Region Northern 94.5 24.7 1,595 85.0 98.2 90.0 29.2 83.5 79.8 1,585 Central 90.5 23.6 5,819 75.5 96.9 82.4 27.4 79.5 76.6 5,683 Southern 91.0 31.6 6,251 81.9 98.4 83.6 27.3 83.4 85.4 6,175 Mother’s education No education 86.3 25.2 2,277 78.6 97.0 82.9 28.3 77.0 79.0 2,191 Primary 91.7 27.3 9,144 78.2 97.6 82.9 25.0 81.4 80.3 9,021 Secondary 93.9 30.4 2,119 85.3 98.9 88.2 35.7 87.4 85.9 2,106 More than secondary 97.9 23.9 125 92.6 100.0 96.4 62.9 96.4 84.5 125 Wealth quintile Lowest 90.1 26.8 2,821 75.3 97.3 81.3 24.1 78.1 77.7 2,741 Second 90.2 27.1 2,894 77.7 97.3 81.3 22.0 78.0 79.8 2,846 Middle 91.2 26.5 2,906 80.6 97.4 83.0 24.0 80.7 80.0 2,867 Fourth 90.8 25.9 2,602 80.4 98.1 85.4 26.3 83.8 84.0 2,564 Highest 94.2 31.0 2,442 84.2 98.7 88.9 43.3 89.4 84.4 2,427 Total 91.2 27.4 13,664 79.5 97.7 83.8 27.5 81.8 81.0 13,443 Maternal Health | 107 Responses indicate that 91 percent of women took iron supplements during pregnancy. Mothers less than age 20 (93 percent) were more likely to take iron supplements than women age 20- 34 (91 percent) and age 35-49 (89 percent). Iron supplementation declines with higher birth order. Women having their first child are most likely to have taken iron supplements (93 percent) and women with a sixth or higher order birth are least likely to have taken iron supplements (90 percent). There is slight variation by urban-rural residence in the proportion of women who took iron supplements (93 percent in urban areas compared with 91 percent in rural areas). The percentage of women who took iron supplements increases with level of education (98 percent of women with more than a secondary education compared with 86 percent of women with no education). Ninety-four percent of women in the highest wealth quintile took iron supplements compared with 90 to 91 percent of women in the other wealth quintiles. As a component of antenatal care, the administration of intestinal antiparasitic drugs is less common than the administration of iron supplements. Twenty-seven percent of women took drugs to combat intestinal parasites during their last pregnancy. Thirty-three percent of women age 20 and younger took intestinal parasite drugs compared with 27 percent of women age 20-34 and 23 percent of women age 35-49. Similarly, 34 percent of women with their first pregnancy are more likely to have taken drugs against intestinal parasites than their counterparts with higher birth orders. Women in urban areas (30 percent) are slightly more likely than women in rural areas (27 percent) to have taken drugs to prevent intestinal parasites during their last pregnancy. Thirty-two percent of women in the Southern Region took drugs to fight intestinal parasites compared with a quarter of women in the Northern and Central Regions (25 and 24 percent, respectively). Women with a secondary education (30 percent) were more likely to take drugs for intestinal parasites than women with more than a secondary education (24 percent). Women in the highest wealth quintile (31 percent) are more likely than women in other wealth quintiles to have taken drugs to prevent intestinal parasites. Eighty percent of women who received antenatal care during their last pregnancy were informed of the symptoms of pregnancy complications. Women age 20 and younger at the time of their most recent birth were least likely to receive information on pregnancy complications during antenatal care (77 percent) when compared with their older counterparts (80 percent). Women in urban areas are more likely to receive such information than those in rural areas (82 percent compared with 79 percent). Among the various components of ANC received, overall, 98 percent of women were weighed, 84 percent had their blood pressure measured, 28 percent had a urine sample taken, 82 percent had a blood sample taken, and 81 percent received information on what foods to eat. Among the background indicators, the greatest variations are observed by urban-rural residence. Almost all women in urban areas (99 percent) and rural areas (97 percent) were weighed. Ninety-one percent of women in urban areas had their blood pressure measured compared with 83 percent of women in rural areas. Four in ten urban women had a urine sample taken (41 percent) compared with a quarter of rural women (25 percent). Ninety-two percent of women in urban areas had a blood sample taken compared with 80 percent of women in rural areas. 9.4 TETANUS TOXOID VACCINE DOSES Neonatal tetanus is a leading cause of neonatal death in developing countries where a proportion of deliveries take place at home or in places where hygienic conditions may be poor. Tetanus toxoid vaccine (TTV) is given to women during pregnancy to prevent infant deaths caused by neonatal tetanus, which can occur when sterile procedures are not followed in cutting the umbilical cord after delivery. In the 2010 MDHS, information was collected on the number of TTV doses the mother received during pregnancy for her most recent birth in the five years preceding the survey. If the mother did not receive at least two TTV doses during the pregnancy, additional questions were asked about the number and timing of TTV doses that she may have received prior to that pregnancy. Malawi follows the Expanded Programme on Immunisation (EPI) guidelines for administering TTV to pregnant women (MOH, 1994). 108 | Maternal Health Table 9.4 shows the percentage of women with a live birth in the five years preceding the survey who reported receiving TTV during the pregnancy for the last live birth. Also shown is whether the last birth was fully protected against neonatal tetanus. An infant is considered fully protected if any of the following criteria are met: (1) the mother had two tetanus toxoid vaccine doses during the pregnancy; (2) the mother had two lifetime TTV doses, with the last dose received within three years of the last birth; (3) the mother had three lifetime TTV doses, with the last dose received within five years of the last birth; (4) the mother had four lifetime doses, with the last dose received within 10 years of the last birth; or (5) the mother had at least five lifetime TTV doses. Table 9.4 Tetanus toxoid vaccine (TTV) Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid vaccine (TTV) doses during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Malawi 2010 Background characteristic Percentage receiving two or more doses of TTV during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 76.1 81.9 2,185 20-34 68.1 90.3 9,580 35-49 64.8 90.0 1,899 Birth order 1 78.8 81.4 2,499 2-3 70.2 90.5 4,978 4-5 64.2 91.0 3,424 6+ 63.5 90.2 2,763 Residence Urban 73.7 89.5 2,107 Rural 68.1 88.8 11,558 Region Northern 63.6 85.7 1,595 Central 70.9 90.2 5,819 Southern 68.4 88.5 6,251 Mother’s education No education 67.7 88.7 2,277 Primary 68.2 88.9 9,144 Secondary 73.3 89.1 2,119 More than secondary 73.2 89.7 125 Wealth quintile Lowest 68.9 87.3 2,821 Second 68.5 88.8 2,894 Middle 67.7 89.0 2,906 Fourth 69.6 90.4 2,602 Highest 70.2 89.0 2,442 Total 68.9 88.9 13,664 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth. Sixty-nine percent of women received two or more TTV doses during the pregnancy. Women between age 35 and 49 were less likely to have received two or more TTV doses (65 percent) than their counterparts less than 20 years of age (76 percent). The likelihood of receiving two doses of TTV during pregnancy decreases with birth order. Women in urban areas are more likely to have received two or more TTV doses during their last pregnancy than women in rural areas (74 and 68 percent, respectively). The Central Region has the highest proportion of women who received two or more TTV doses during pregnancy (71 percent), and the Northern Region has the lowest proportion (64 percent). Maternal Health | 109 The proportion of women who received two or more TTV doses during pregnancy varies by level of education and wealth. Seventy-three percent of women with secondary and more than secondary education received two or more TTV doses during the last pregnancy compared with 68 percent of women with no education or primary education. Women in the middle wealth quintile were the least likely to receive two or more TTV doses (68 percent). Overall, 89 percent of women’s last births were protected against neonatal tetanus. Births to women less than age 20 were least likely to have been protected (82 percent) compared with births to older women (90 percent). The Central and Southern Regions have the highest proportions of births protected against neonatal tetanus (90 and 89 percent, respectively); the Northern Region has the lowest proportion (86 percent). Eighty-nine percent of births to mothers, irrespective of education level, were protected against neonatal tetanus. Births to women in the fourth wealth quintile had the greatest protection against neonatal tetanus (90 percent). 9.5 PLACE OF DELIVERY Increasing the percentage of births delivered in health facilities is an important factor in reducing deaths arising from the complications of pregnancy. The expectation is that if a complication arises during delivery in a health facility, a skilled attendant can manage the complication or refer the mother to the next level of care. Table 9.5 shows the percent distribution of all live births in the five years preceding the survey by place of delivery, according to background characteristics. Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Malawi 2010 Background characteristic Health facility Home Other Missing Total Percent- age delivered in a health facility Number of births Public sector Private sector Mother’s age at birth <20 60.8 15.5 21.9 1.4 0.4 100.0 76.2 3,579 20-34 57.2 16.3 23.9 2.3 0.3 100.0 73.4 13,673 35-49 52.8 14.2 29.3 3.4 0.3 100.0 67.0 2,446 Birth order 1 63.2 18.6 16.7 1.0 0.4 100.0 81.8 4,039 2-3 58.5 15.6 23.6 1.9 0.4 100.0 74.1 7,192 4-5 54.6 15.3 27.0 2.8 0.3 100.0 69.9 4,752 6+ 51.9 14.2 29.9 3.7 0.3 100.0 66.1 3,714 Residence Urban 74.5 11.4 12.7 1.4 0.1 100.0 85.9 2,819 Rural 54.4 16.6 26.1 2.4 0.4 100.0 71.0 16,878 Region Northern 64.8 14.1 18.2 2.4 0.4 100.0 79.0 2,310 Central 53.6 17.4 26.7 2.0 0.3 100.0 71.0 8,449 Southern 58.8 14.9 23.4 2.5 0.4 100.0 73.7 8,938 Mother’s education No education 49.6 13.5 34.1 2.6 0.3 100.0 63.1 3,441 Primary 57.0 15.2 24.9 2.5 0.4 100.0 72.2 13,345 Secondary 68.5 20.5 9.9 1.0 0.1 100.0 89.0 2,765 More than secondary 55.2 42.6 0.9 0.0 1.2 100.0 97.8 145 Antenatal care visits1 None 15.5 1.4 79.6 3.5 0.0 100.0 16.9 215 1-3 58.0 15.9 23.3 2.7 0.1 100.0 74.0 7,126 4+ 62.3 18.3 17.3 2.1 0.1 100.0 80.5 6,213 Don’t know/missing 61.9 21.4 13.8 2.3 0.5 100.0 83.4 110 Wealth quintile Lowest 51.1 13.8 32.2 2.7 0.2 100.0 64.9 4,252 Second 52.6 15.0 29.3 2.7 0.5 100.0 67.6 4,307 Middle 54.6 15.3 27.5 2.1 0.5 100.0 69.9 4,276 Fourth 62.5 16.0 18.7 2.3 0.4 100.0 78.5 3,650 Highest 69.5 20.4 8.6 1.5 0.1 100.0 89.8 3,211 Total 57.3 15.9 24.2 2.3 0.4 100.0 73.2 19,697 1 Includes only the most recent birth in the five years preceding the survey 110 | Maternal Health Seventy-three percent of births in Malawi are delivered in a health facility; 57 percent of deliveries occur in public sector facilities, and 16 percent occur in private sector facilities. Twenty- four percent of births occur at home. By age, women 35-49 are most likely to deliver at home (29 percent). Women having their first baby are more likely than women with a higher birth order to deliver in a health facility; the proportion of births occurring in a facility declines as birth order increases. Women in urban areas are more likely to deliver in a health facility than their rural counterparts (86 percent compared with 71 percent). The Northern Region has the highest proportion of institutional deliveries (79 percent), followed by the Southern Region (74 percent), while the Central Region has the lowest proportion (71 percent). Women with higher levels of educational attainment are more likely to deliver in a health facility than women with less education or no education. For example, women with more than secondary education (98 percent) are more likely to deliver in a health facility than women with no education (63 percent). The proportion of births occurring in a health facility increases steadily with increasing wealth quintile, from 65 percent of births in the lowest wealth quintile to 90 percent among those in the highest quintile. Similarly, 51 percent of births to mothers in the lowest wealth quintile occur in a public health facility compared with 70 percent of births to women in the highest wealth quintile. Women in the highest wealth quintile are more likely to give birth in a private facility than women in the lowest wealth quintiles (20 percent compared with 14 percent, respectively). The majority of women who received no ANC services delivered at home (80 percent) compared with 17 percent of women who delivered at a public or private health facility. 9.6 ASSISTANCE DURING DELIVERY In addition to place of birth, assistance during childbirth is an important variable influencing the birth outcome and the health of the mother and infant. The skills and performance of the person providing assistance during delivery determine whether complications are managed and hygienic practices are observed. Table 9.6 shows the percent distribution of live births in the five years preceding the survey by person providing assistance at delivery and percentage of births delivered by caesarean section (C-section), according to background characteristics. Seventy-one percent of births in the five years preceding the survey were assisted by a skilled attendant (doctor, clinical officer, and nurse midwife), with 11 percent assisted by a doctor or clinical officer and 61 percent aided by a nurse or midwife. In the absence of a skilled attendant, a traditional birth attendant was the next most common person assisting at delivery (14 percent). Nine percent of births were assisted by a relative, friends, or other person; 3 percent of births were attended by no one; and 2 percent were assisted by a patient attendant. Women age 35-49 (65 percent) are least likely to receive assistance from a skilled attendant at delivery. Younger women, less than age 20, are most likely to deliver with the assistance of a skilled attendant (74 percent). The likelihood of a skilled attendant delivering a birth decreases with increasing birth order, from 80 percent for first order births to 64 percent for births of order six or more. Eighty-four percent of births to urban women were attended by a skilled attendant compared with 69 percent of births to women in rural areas. Women in urban areas are more likely than women in rural areas to be assisted by a nurse or midwife (67 and 60 percent, respectively), while women in rural areas are more likely than women in urban areas to be assisted by a traditional birth attendant (15 and 8 percent, respectively). Births to mothers living in the Central Region (19 percent) are more likely to be assisted by a traditional birth attendant than births to women in the Southern and Northern Regions (12 and 9 percent, respectively). A mother’s level of education and wealth have a positive association with the likelihood that her delivery will be assisted by a skilled attendant. Maternal Health | 111 Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of birth assisted by a skilled attendant and percentage delivered by caesarean-section, according to background characteristics, Malawi 2010 Background characteristic Person providing assistance during delivery Percent- age delivered by a skilled attendant1 Percent- age delivered by C- section Number of births Skilled attendant Unskilled attendant Relative/ friends No one Don’t know/ missing Total Doctor/ clinical officer Nurse/ midwife Patient attendant Tradi- tional birth attendant Mother’s age at birth <20 11.8 62.2 2.0 15.4 7.1 0.6 0.9 100.0 74.0 6.2 3,579 20-34 10.8 61.0 1.6 14.0 8.9 2.5 1.2 100.0 71.7 4.4 13,673 35-49 8.6 56.4 1.4 15.1 9.7 6.3 2.5 100.0 65.1 3.3 2,446 Birth order 1 14.4 65.3 1.9 12.1 4.8 0.5 0.9 100.0 79.8 9.1 4,039 2-3 10.8 61.6 1.6 14.3 9.1 1.6 1.2 100.0 72.3 4.1 7,192 4-5 9.3 58.8 1.8 15.6 10.1 3.1 1.3 100.0 68.1 3.0 4,752 6+ 8.4 56.0 1.2 15.6 10.5 6.3 2.0 100.0 64.4 2.6 3,714 Place of delivery Health facility 14.5 82.5 2.1 0.2 0.1 0.4 0.2 100.0 97.0 6.2 14,410 Elsewhere 0.4 0.8 0.3 53.7 32.6 8.8 3.4 100.0 1.1 0.0 5,218 Missing 7.7 21.0 0.0 3.0 0.0 4.8 63.4 100.0 28.8 0.0 70 Residence Urban 17.4 66.7 1.4 8.3 3.3 2.1 1.0 100.0 84.0 8.2 2,819 Rural 9.6 59.6 1.7 15.4 9.6 2.7 1.4 100.0 69.2 4.0 16,878 Region Northern 11.0 67.5 0.8 8.7 8.0 2.8 1.3 100.0 78.5 5.3 2,310 Central 10.7 58.3 1.6 18.7 6.8 2.5 1.3 100.0 69.1 4.5 8,449 Southern 10.6 61.0 1.8 11.8 10.6 2.7 1.3 100.0 71.7 4.4 8,938 Mother’s education No education 9.2 52.3 1.3 17.5 13.0 4.5 2.1 100.0 61.5 2.5 3,441 Primary 10.1 60.3 1.7 15.3 8.8 2.5 1.3 100.0 70.4 3.8 13,345 Secondary 14.0 73.0 1.6 6.9 3.0 1.0 0.5 100.0 87.0 9.2 2,765 More than secondary 40.8 56.8 0.2 0.0 0.9 0.0 1.2 100.0 97.6 33.4 145 Wealth quintile Lowest 9.2 54.1 1.7 18.7 11.6 3.6 1.1 100.0 63.3 2.9 4,252 Second 9.5 56.0 1.7 17.6 10.8 2.8 1.6 100.0 65.5 3.4 4,307 Middle 9.4 58.2 2.0 16.5 10.0 2.5 1.4 100.0 67.6 3.9 4,276 Fourth 10.0 66.8 1.5 11.0 6.6 2.4 1.7 100.0 76.8 4.6 3,650 Highest 16.9 71.6 1.1 5.6 2.7 1.4 0.7 100.0 88.5 9.1 3,211 Total 10.7 60.6 1.6 14.4 8.7 2.6 1.3 100.0 71.4 4.6 19,697 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1 Skilled provider includes doctor, clinical officer, nurse, and midwife. Malawi follows the United Nations (UN) process indicators, which recommend that a minimum of 5 percent and a maximum of 15 percent of all births should be delivered by C-section (MOH, 2005). In Malawi, 5 percent of births in the last five years were delivered by C-section. Caesarean births are most common among first order births (9 percent). Women in urban areas are twice as likely as women in rural areas to have had a birth delivered by C-section (8 and 4 percent, respectively). C-sections are more common among women with more than secondary education (33 percent) than they are among women with no education (3 percent). 9.7 POSTNATAL CARE A large proportion of maternal and neonatal deaths occur during the first 24 hours after delivery. Thus, prompt postnatal care is important, for both the mother and the infant, to treat complications arising from the delivery as well as to provide the mother with important information on caring for herself and her baby. According to the Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi, it is recommended that all women who deliver in a health facility receive a postnatal health checkup within the first 24 hours after delivery and also that women giving birth outside of a health facility should be referred to a health facility for a postnatal check-up within 12 hours of giving birth (MOH, 2005 and 2008). To assess the extent of postnatal care, women with a live birth during the five years prior to the survey were asked questions about any postnatal care they may have received related to the last birth. If they reported receiving 112 | Maternal Health care, they were asked about the timing of the first checkup and the type of health provider performing it. This information is presented according to background characteristics in Tables 9.7 and 9.8. Table 9.7 shows that nearly half (48 percent) of women did not receive any postnatal care. Among women who did receive a postnatal checkup within two days of delivery (43 percent), 26 percent were seen in less than 4 hours, 6 percent were seen in 4 to 23 hours, and 11 percent were seen within two days. Seven percent of women received their first postnatal checkup between 3 and 41 days after delivery. A checkup within the first four hours after delivery does not vary much by background characteristics. Within the first two days after delivery urban women (52 percent) were more likely than rural women (41 percent) to obtain postnatal care. The highest regional percentage of women who received postnatal care within the first two days after delivery is found in the Southern Region (45 percent). The lowest percentage of women utilising postnatal care services within the first two days after delivery is in the Northern Region (41 percent). As with other health services surrounding childbirth, educated and wealthier mothers are more likely to receive a postnatal checkup within the first two days after delivery (62 and 54 percent, respectively). Table 9.7 Timing of first postnatal checkup Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution of the mother’s first postnatal checkup for the last live birth by time after delivery, according to background characteristics, Malawi 2010 Background characteristic Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Less than 4 hours 4-23 hours 2 days 3-41 days Don’t know/ missing Mother’s age at birth <20 27.4 5.1 9.7 7.2 2.2 48.4 100.0 42.2 2,185 20-34 25.8 6.5 11.3 7.5 1.8 47.3 100.0 43.6 9,580 35-49 26.1 4.9 10.6 7.5 2.5 48.4 100.0 41.6 1,899 Birth order 1 28.1 6.1 11.8 8.4 2.7 42.9 100.0 46.0 2,499 2-3 25.1 7.1 11.2 7.0 1.9 47.7 100.0 43.4 4,978 4-5 26.3 5.7 9.9 7.6 1.8 48.7 100.0 41.9 3,424 6+ 25.7 4.5 10.8 7.1 1.6 50.3 100.0 41.0 2,763 Residence Urban 26.4 8.2 17.0 11.6 2.4 34.4 100.0 51.6 2,107 Rural 26.0 5.6 9.8 6.7 1.9 50.0 100.0 41.4 11,558 Region Northern 19.1 6.1 15.3 10.9 2.5 46.2 100.0 40.5 1,595 Central 27.6 5.9 8.4 6.7 1.8 49.6 100.0 41.9 5,819 Southern 26.4 6.2 12.1 7.2 1.9 46.2 100.0 44.7 6,251 Education No education 24.1 4.4 9.9 5.2 1.5 54.9 100.0 38.4 2,277 Primary 26.1 5.8 9.9 7.0 1.9 49.2 100.0 41.8 9,144 Secondary 27.8 8.2 15.7 11.0 2.1 35.0 100.0 51.7 2,119 More than secondary 28.2 13.0 20.7 19.0 8.7 10.3 100.0 61.9 125 Wealth quintile Lowest 24.2 4.6 9.2 6.0 2.0 54.0 100.0 38.0 2,821 Second 25.2 5.0 7.7 4.8 1.5 55.8 100.0 37.9 2,894 Middle 26.4 6.2 9.6 7.6 1.6 48.7 100.0 42.2 2,906 Fourth 27.9 6.3 12.4 7.7 1.8 44.0 100.0 46.6 2,602 Highest 27.0 8.6 16.8 11.7 2.9 33.1 100.0 52.4 2,442 Total 26.1 6.0 10.9 7.4 2.0 47.6 100.0 43.0 13,664 1 Includes women who received a checkup after 41 days Maternal Health | 113 Table 9.8 presents information on the type of health provider performing the first postnatal checkup. The skills of the provider determine ability to diagnose problems and to recommend appropriate treatment or referral. Eight percent of women received a postnatal checkup from a doctor or clinical officer, 41percent from a nurse or midwife, 2 percent from a traditional birth attendant, and 1 percent from a patient attendant. Urban women and women who are well educated are more likely to receive postnatal care from a doctor, clinical officer, nurse, or midwife after delivery. For example, 13 percent of women in urban areas received postnatal care from a doctor or clinical officer and 50 percent received care from a nurse or midwife compared with 7 and 39 percent of women in rural areas. Table 9.8 Type of provider of first postnatal checkup Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check for the last live birth, according to background characteristics, Malawi 2010 Background characteristic Type of health provider of mother’s first postnatal checkup No postnatal checkup1 Total Number of women Skilled attendant Unskilled attendant Other Missing Doctor, clinical officer Nurse, midwife Patient attendant HSA Traditional birth attendant Mother’s age at birth <20 8.2 40.3 1.1 0.3 1.5 0.2 0.1 48.4 100.0 2,185 20-34 8.6 40.8 0.7 0.2 2.2 0.2 0.1 47.3 100.0 9,580 35-49 6.6 41.5 1.0 0.2 2.2 0.1 0.1 48.4 100.0 1,899 Birth order 1 10.1 44.1 1.0 0.4 1.1 0.2 0.2 42.9 100.0 2,499 2-3 8.9 40.4 0.6 0.1 2.1 0.2 0.1 47.7 100.0 4,978 4-5 7.5 39.5 1.0 0.4 2.8 0.2 0.1 48.7 100.0 3,424 6+ 6.2 40.5 0.7 0.0 2.0 0.2 0.0 50.3 100.0 2,763 Residence Urban 13.1 49.9 1.0 0.1 1.3 0.1 0.1 34.4 100.0 2,107 Rural 7.3 39.2 0.8 0.2 2.2 0.2 0.1 50.0 100.0 11,558 Region Northern 10.2 42.8 0.2 0.1 0.5 0.0 0.0 46.2 100.0 1,595 Central 7.2 38.6 1.1 0.1 3.0 0.3 0.1 49.6 100.0 5,819 Southern 8.7 42.4 0.6 0.3 1.7 0.1 0.1 46.2 100.0 6,251 Education No education 5.5 35.7 0.8 0.2 2.5 0.4 0.0 54.9 100.0 2,277 Primary 7.5 39.8 0.8 0.2 2.2 0.1 0.1 49.2 100.0 9,144 Secondary 12.8 50.0 0.7 0.2 0.9 0.3 0.1 35.0 100.0 2,119 More than secondary 34.5 55.2 0.0 0.0 0.0 0.0 0.0 10.3 100.0 125 Wealth quintile Lowest 5.8 35.7 0.8 0.3 3.1 0.1 0.1 54.0 100.0 2,821 Second 6.6 34.1 0.9 0.1 2.4 0.1 0.1 55.8 100.0 2,894 Middle 7.1 40.2 1.1 0.3 2.3 0.2 0.1 48.7 100.0 2,906 Fourth 9.3 44.3 0.5 0.4 1.3 0.1 0.1 44.0 100.0 2,602 Highest 13.1 51.7 0.7 0.0 1.0 0.2 0.1 33.1 100.0 2,442 Total 8.2 40.8 0.8 0.2 2.1 0.2 0.1 47.6 100.0 13,664 1 Includes women who received a checkup after 41 days 9.9 PERCEIVED PROBLEMS IN ACCESSING HEALTH CARE Many factors prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers that some women face in seeking care during pregnancy and at delivery. In the 2010 MDHS, women respondents were asked whether each of the following factors would be a big problem in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to health facility, transport cost, not wanting to go alone, concern there may not be a female provider or any health provider, and concern that drugs may not be available. Table 9.9 and Figure 9.1 present information on the extent to which women reported that each of these factors was a serious problem for them in accessing health care. 114 | Maternal Health Table 9.9 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Malawi 2010 Background characteristic Problems in accessing health care Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available Concern no drugs available At least one problem accessing health care Number of women Age 15-19 12.6 49.4 54.9 52.4 34.1 26.1 48.1 59.8 81.4 5,005 20-34 10.6 50.0 53.8 51.4 29.1 20.3 46.6 60.0 81.4 12,205 35-49 11.7 57.0 59.5 59.5 33.3 21.6 48.1 62.3 84.3 5,810 Number of living children 0 11.7 47.9 52.9 50.2 33.0 24.9 47.0 58.7 79.9 5,344 1-2 10.3 48.6 51.9 50.2 29.2 19.6 46.4 59.6 80.9 7,079 3-4 11.1 53.3 56.6 55.2 29.5 20.3 47.1 60.5 83.2 6,006 5+ 12.7 58.5 62.4 61.1 34.7 23.9 49.4 64.1 85.2 4,592 Marital status Never married 11.3 48.2 52.5 49.7 32.5 24.5 46.1 58.4 78.9 4,538 Married or living together 11.4 50.6 55.8 53.8 30.8 21.5 47.7 61.2 82.5 15,528 Divorced/separated/widowed 10.6 62.2 58.2 59.1 31.6 20.1 47.4 60.6 85.5 2,954 Employed last 12 months Not employed 13.8 49.0 53.5 51.7 30.5 22.9 42.2 55.1 79.2 6,230 Employed for cash 9.2 48.1 51.8 50.4 29.2 19.2 46.1 59.2 80.4 9,072 Employed not for cash 11.7 58.0 61.5 59.2 34.3 24.3 53.0 66.6 86.7 7,674 Missing 20.0 55.4 52.6 40.1 14.6 12.6 47.4 51.3 76.8 44 Residence Urban 4.9 35.2 33.9 33.2 16.8 10.0 26.9 42.6 66.1 4,302 Rural 12.8 55.4 60.4 58.4 34.6 24.6 52.0 64.7 85.8 18,718 Region Northern 8.9 35.1 48.8 46.6 27.2 18.9 36.2 46.4 72.6 2,677 Central 12.2 57.0 59.7 58.2 36.7 24.8 53.5 68.8 86.3 9,857 Southern 11.1 50.8 53.2 51.2 27.2 19.9 44.4 56.4 80.6 10,485 Education No education 14.6 63.6 64.9 63.2 37.5 27.2 51.3 66.0 88.4 3,505 Primary 12.1 53.7 57.6 56.5 33.1 22.8 49.3 62.1 84.1 14,916 Secondary 6.9 38.3 43.8 39.6 21.8 15.9 39.7 52.9 73.0 4,177 More than secondary 1.4 13.2 18.4 14.2 8.9 5.3 22.0 36.7 50.3 422 Wealth quintile Lowest 13.9 65.2 66.2 65.5 39.9 28.7 54.8 66.9 88.6 4,268 Second 14.9 59.8 64.3 62.4 37.2 26.7 51.5 65.6 87.7 4,332 Middle 12.1 54.7 59.9 59.1 35.0 23.6 51.3 64.4 85.8 4,517 Fourth 10.2 51.3 56.3 53.5 29.9 19.6 47.2 61.6 84.1 4,515 Highest 6.7 32.0 35.5 32.9 17.6 13.1 34.9 47.3 67.9 5,388 Total 11.3 51.6 55.5 53.7 31.3 21.9 47.3 60.5 82.1 23,020 Eighty-two percent of women reported that they have at least one problem in accessing health care. The leading barrier to health care for women in Malawi is concern that there will be no drugs available at the health facility (61 percent). Fifty-six percent of women said that distance to a health facility was a concern. Fifty-four percent of women said having to take transport to a health facility was a concern. Getting money for treatment was a concern of 52 percent. Forty-seven percent of women were concerned that there would be no health provider available to attend to them. Not wanting to go alone (31 percent) and problems getting permission to go for treatment (11 percent) were less likely to be reported as hindrances to seeking care. Maternal Health | 115 Figure 9.1 Problems in Accessing Health Care MDHS 2010 11 52 56 54 31 22 47 61 82 Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concerned no female provider available Concerned no provider available Concerned no drugs available At least one problem accessing health care 0 20 40 60 80 100 Percent Child Health | 117 CHILD HEALTH 10 This chapter presents findings on several areas of importance to child survival: birth weight, vaccination status, and treatment practices of acute respiratory infection (ARI), fever, and diarrhoea, the three most common childhood illnesses. Many early childhood deaths can be prevented by immunising children against preventable diseases and by ensuring that they receive prompt and appropriate treatment when they become ill. Results are presented on the prevalence of ARI and treatment with antibiotics, the prevalence and treatment of fever with antimalarial drugs, and the prevalence of diarrhoeal diseases and treatment with oral rehydration therapy (including increased fluids).1 10.1 CHILD’S WEIGHT AT BIRTH Birth weight is an important indicator for assessing child health in terms of early exposure to childhood morbidity and mortality. Children whose birth weight is less than 2.5 kilograms, or children reported to be ‘very small’ or ‘smaller than average,’ are considered to have a higher-than-average risk of early childhood death. In the 2010 MDHS, for births in the five years preceding the survey, birth weight was recorded in the Woman’s Questionnaire based on either a written record or the mother’s report. The mother’s estimate of the infant’s size at birth was also obtained because birth weight may be unknown for many infants. Although the mother’s estimate of size is subjective, it can be a useful proxy for the child’s weight. Table 10.1 shows that birth weight is reported for 67 percent of the live births that occurred in the five years preceding the survey; 12 percent of these infants had low birth weights (less than 2.5 kg). Younger mothers (age 20 or less) and older mothers (age 35-49) are most likely to have infants with low birth weight when compared with mothers age 20-34. By birth order, first births (15 percent) are more likely than subsequent births to result in low birth weight. Among the regions, the Southern Region has the lowest proportion of low birth weight infants, and the Central Region has the highest proportion (11 and 14 percent, respectively). There is an inverse relationship between low birth weight and mother’s education. The same trend is observed among wealth quintiles. As level of education and household wealth increase, the percentage of low birth weight infants decreases. For example, the percentage of births in which the infant weighs less than 2.5 kg decreases from 13 percent among mothers with no education to 7 percent among mothers with more than a secondary education. Likewise, the percentage of births in which the infant weights less than 2.5 kg decreases from 14 percent among mothers in the lowest wealth quintile to 11 percent among mothers in the highest wealth quintile. Table 10.1 also includes information on the mother’s estimate of the infant’s size at birth. Four percent of births are reported as very small, and 12 percent are reported as smaller than average. Ten percent and 15 percent of births are described as very small or smaller than average among women who smoke cigarettes or tobacco. Similar patterns in education level and wealth quintile are seen for births categorised as very small or smaller than average, as was seen for births less than 2.5 kg. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 118 | Child Health Table 10.1 Child’s weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percent distribution of all live births in the five years preceding the survey by mother’s estimate of baby’s size at birth and percentage of all births with a reported birth weight, according to background characteristics, Malawi 2010 Background characteristic Percent distribution of births with a reported birth weight1 Total Number of births Percentage of all births with a reported birth weight Percent distribution of all live births by size of child at birth Total Number of births Less than 2.5 kg 2.5 kg or more Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 15.4 84.6 100.0 2,346 65.5 4.6 14.4 78.2 2.7 100.0 3,579 20-34 11.2 88.8 100.0 9,303 68.0 3.7 10.8 83.5 2.0 100.0 13,673 35-49 14.5 85.5 100.0 1,458 59.6 5.3 10.9 81.6 2.3 100.0 2,446 Birth order 1 15.0 85.0 100.0 2,898 71.7 4.6 14.4 78.5 2.5 100.0 4,039 2-3 11.0 89.0 100.0 4,906 68.2 3.3 11.1 83.8 1.8 100.0 7,192 4-5 11.0 89.0 100.0 3,066 64.5 4.4 10.1 83.4 2.0 100.0 4,752 6+ 13.3 86.7 100.0 2,238 60.3 4.2 10.9 82.3 2.5 100.0 3,714 Mother’s smoking status Smokes cigarettes/tobacco (14.0) (86.0) 100.0 38 62.2 10.4 15.4 71.3 2.9 100.0 62 Does not smoke 12.3 87.7 100.0 13,064 66.6 4.0 11.5 82.4 2.1 100.0 19,629 Missing * * 100.0 5 67.3 32.4 0.0 * * 100.0 7 Residence Urban 12.2 87.8 100.0 2,269 80.5 3.1 11.8 84.3 0.8 100.0 2,819 Rural 12.3 87.7 100.0 10,837 64.2 4.2 11.4 82.0 2.4 100.0 16,878 Region Northern 11.6 88.4 100.0 1,767 76.5 5.2 9.7 82.5 2.5 100.0 2,310 Central 13.5 86.5 100.0 5,579 66.0 3.9 11.3 82.9 1.8 100.0 8,449 Southern 11.3 88.7 100.0 5,761 64.5 3.8 12.1 81.7 2.4 100.0 8,938 Mother’s education No education 13.3 86.7 100.0 1,814 52.7 4.7 12.9 80.2 2.2 100.0 3,441 Primary 12.8 87.2 100.0 8,728 65.4 4.1 11.8 81.7 2.4 100.0 13,345 Secondary 10.2 89.8 100.0 2,423 87.6 3.0 8.7 87.5 0.8 100.0 2,765 More than secondary 7.0 93.0 100.0 141 97.4 2.9 5.5 89.2 2.3 100.0 145 Wealth quintile Lowest 13.5 86.5 100.0 2,426 57.0 4.7 12.8 80.1 2.4 100.0 4,252 Second 13.2 86.8 100.0 2,568 59.6 4.0 12.7 80.7 2.6 100.0 4,307 Middle 12.6 87.4 100.0 2,743 64.1 4.4 10.6 82.9 2.0 100.0 4,276 Fourth 11.8 88.2 100.0 2,653 72.7 3.6 11.0 83.1 2.4 100.0 3,650 Highest 10.6 89.4 100.0 2,717 84.6 3.2 9.9 85.8 1.1 100.0 3,211 Total 12.3 87.7 100.0 13,107 66.5 4.0 11.5 82.3 2.1 100.0 19,697 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Based on either a written record or the mother’s recall 10.2 VACCINATION OF CHILDREN According to the World Health Organisation, a child is considered fully vaccinated if he or she has received a vaccination against tuberculosis (BCG); three doses the diphtheria, pertussis, and tetanus (DPT) vaccine; at least three doses of polio vaccine; and one dose of measles vaccine. These vaccinations should be received during the first year of life. Since 2002, Malawi has replaced the DPT vaccines with a pentavalent vaccine that protects against DPT, hepatitis B (HepB), and Haemophilus influenza type b (Hib). In Malawi, the BCG and polio 0 vaccine should be given within the first 14 days after birth, and the DPT-HepB-Hib and polio vaccines should be given at approximately 6, 10, and 14 weeks of age. The measles vaccine should be given at or soon after the child reaches 9 months of age. It is also recommended that children receive the complete schedule of vaccinations before their first birthday and that the vaccinations be recorded on a health card given to the parents or guardians. The 2010 MDHS collected information on coverage for these vaccinations among all children born in the five years preceding the survey. For the 2010 MDHS, information on vaccination coverage was obtained in two ways – from health cards and from mothers’ verbal reports. All mothers were asked to show the interviewer health cards in which immunisation dates were recorded for all children born since January 2005. If a card was available, the interviewer recorded onto the questionnaire the dates of each vaccination received by the child. If a child never received a health card, if the mother was unable to show the card to the Child Health | 119 interviewer, or if a particular vaccination was not recorded on the health card, the vaccination information for the child was based on the mother’s report. Questions were asked for each vaccine type. Mothers were asked to recall whether the child had received BCG, polio, DPT or pentavalent (DPT-HepB-Hib), and measles vaccinations. If the mother indicated that the child had received the polio or DPT/pentavalent vaccines, she was asked about the number of doses that the child received. The mother was then asked whether the child had received other vaccinations that were not recorded on the card, and they too were noted on the questionnaire. The results presented here are based on both health card information and, for children without a card, information provided by the mother. Table 10.2 shows vaccination coverage by source of information for children age 12-23 months, the age by which they should have received all vaccinations. Overall, 81 percent of children age 12-23 months were fully vaccinated at the time of the survey: 97 percent had received the BCG vaccination, 93 percent had received DPT 1-3 or DPT-HepB-Hib 1-3, 86 percent had received polio 1-3, and 93 percent had received the measles vaccine. Two percent of children age 12-23 months did not receive any vaccinations. During the last six years, the vaccination coverage estimate for children in the same age group has increased from 64 percent, as reported in the 2004 MDHS. Table 10.2 also shows vaccination coverage for children who have reached age 12 months. The rates for each vaccination by the time the child reaches 12 months of age is a measure of children receiving vaccines on time. Overall, 72 percent of children are fully immunised by 12 months of age. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage vaccinated by 12 months of age, Malawi 2010 Source of information BCG DPT/Pentavalent (DPT-HepB-Hib) Polio1 Measles All basic vaccina- tions2 No vaccina- tions Number of children 1 2 3 0 1 2 3 Vaccinated at any time before survey Vaccination card 80.0 80.2 79.7 78.7 62.1 80.2 79.8 78.3 76.2 74.3 0.1 3,050 Mother’s report 17.2 17.1 16.3 14.3 11.9 16.5 14.6 7.4 16.8 6.6 1.4 724 Either source 97.2 97.3 96.0 93.0 74.1 96.6 94.5 85.6 93.0 80.9 1.5 3,774 Vaccinated by 12 months of age3 96.3 96.5 95.3 91.9 73.6 95.8 93.7 84.4 82.6 71.8 2.3 3,774 1 Polio 0 is the polio vaccination given within the first 14 days after birth. 2 BCG, measles, and three doses each of DPT or pentavalent (DPT-HepB-Hib) and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. Table 10.3 presents information on vaccine coverage among children age 12-23 months from vaccination cards and mothers’ reports, by background characteristics. Vaccination cards were seen for 81 percent of children. A higher percentage of vaccination cards was observed for children in rural areas (83 percent) than in urban areas (68 percent). Children in rural areas are more likely than urban children to be fully vaccinated; 82 percent compared with 76 percent, respectively. At the regional level, full vaccination coverage ranges from a high of 84 percent in the Northern Region to a low of 78 percent in the Central Region. A mother’s level of education relates to immunisation coverage; 84 percent of children whose mothers have a secondary education are fully immunised compared with 75 percent of children whose mothers have no education. Children in the fourth wealth quintile are more likely to be fully vaccinated (83 percent) than their counterparts in other wealth quintiles (78 to 82 percent). 120 | Child Health Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and percentage with a vaccination card, by background characteristics, Malawi 2010 Background characteristic BCG DPT/Pentavalent (DPT- HepB-Hib) Polio1 Measles All basic vaccina- tions2 No vaccina- tions Percentage with a vaccina- tion card seen Number of children 1 2 3 0 1 2 3 Sex Male 96.6 96.6 95.4 92.7 73.8 95.8 93.3 86.1 91.7 81.1 2.0 80.6 1,895 Female 97.8 98.0 96.7 93.4 74.3 97.5 95.6 85.1 94.3 80.8 1.0 81.0 1,880 Birth order 1 97.5 98.1 96.5 93.5 79.5 97.0 93.8 85.0 95.4 81.9 1.4 80.8 706 2-3 98.2 98.0 96.8 93.3 74.6 97.5 95.1 84.8 92.9 80.3 1.2 79.9 1,390 4-5 95.7 95.7 94.9 93.4 70.6 95.3 93.6 86.9 91.3 81.2 2.0 81.4 950 6+ 96.8 97.2 95.7 91.5 72.3 96.5 94.9 86.2 93.0 80.8 1.6 82.0 728 Residence Urban 97.8 97.8 97.1 94.1 83.8 95.8 94.3 79.3 96.0 75.8 0.7 67.7 549 Rural 97.1 97.2 95.9 92.8 72.4 96.8 94.5 86.7 92.5 81.8 1.6 83.0 3,226 Region Northern 98.7 97.7 97.3 95.2 84.2 98.2 95.1 90.0 93.4 84.2 0.6 85.2 420 Central 96.5 96.5 94.3 90.0 71.7 95.1 92.3 83.0 91.5 77.7 2.0 77.6 1,615 Southern 97.4 97.9 97.3 95.3 73.8 97.7 96.3 87.0 94.3 83.1 1.3 82.7 1,739 Mother’s education No education 95.1 95.2 93.7 88.1 64.9 94.8 93.0 83.2 89.2 75.3 2.2 78.2 627 Primary 97.3 97.4 96.0 93.3 73.8 96.7 94.1 85.5 93.3 81.5 1.5 81.0 2,545 Secondary 99.2 99.2 98.8 97.0 84.8 98.1 97.2 88.0 95.2 83.5 0.6 82.1 571 More than secondary * * * * * * * * * * * * 30 Wealth quintile Lowest 96.0 96.4 94.9 91.3 68.6 95.2 92.3 85.2 90.2 78.3 1.9 79.3 838 Second 97.0 97.6 96.6 93.3 70.0 97.7 95.8 85.5 92.5 81.4 1.7 81.9 794 Middle 96.8 97.2 95.6 92.0 72.4 95.5 93.1 86.8 91.5 80.6 2.2 84.8 802 Fourth 98.6 98.2 96.7 94.8 79.4 98.0 96.1 85.0 96.0 82.8 0.6 80.4 723 Highest 97.9 97.2 96.7 94.3 82.8 97.3 95.5 85.6 95.9 82.0 0.7 76.7 616 Total 97.2 97.3 96.0 93.0 74.1 96.6 94.5 85.6 93.0 80.9 1.5 80.8 3,774 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases. 1 Polio 0 is the polio vaccination given within 14 days after birth. 2 BCG, measles, three doses each of DPT or pentavalent (DPT-HepB-Hib), and polio vaccine (excluding polio vaccine given at birth) Table 10.4 presents data from the 1992, 2000, 2004, and 2010 MDHS surveys showing trends in vaccination coverage for children age 12-23 months who received specific vaccines at any time before the survey. Although vaccination coverage in Malawi steadily decreased between 1992 and 2004, data from 2010 indicate that vaccination coverage has returned to levels of coverage similar to those observed in 1992. Over the 6-year period between the 2004 and 2010 MDHS surveys, the percentage of children with no vaccinations has decreased from 4 to 2 percent. Table 10.4 Trends in vaccination coverage Percentage of children age 12-23 months who received specific vaccines at any time before the survey, Malawi 1992-2010 Source BCG DPT/Pentavalent (DPT- HepB-Hib) Polio1 Measles All basic vaccina- tions2 No vaccina- tions Percentage with a vaccina- tion card seen Number of children 1 2 3 0 1 2 3 1992 MDHS 97.0 96.9 94.3 88.6 na 96.9 94.2 88.1 85.8 81.8 2.5 86.3 722 2000 MDHS 92.4 95.9 92.6 84.2 46.9 95.7 91.3 79.8 83.2 70.1 2.8 81.1 2,238 2004 MDHS 91.4 95.0 90.6 81.5 37.1 94.9 89.7 77.7 78.7 64.4 3.5 74.3 2,194 2010 MDHS 97.2 97.3 96.0 93.0 74.1 96.6 94.5 85.6 93.0 80.9 1.5 80.8 3,774 na = Not applicable 1 Polio 0 is the polio vaccination given within 14 days after birth. 2 BCG, measles and three doses each of DPT or pentavalent (DPT-HepB-Hib) and polio vaccine (excluding polio vaccine given at birth) 10.2.1 Trends in Vaccination Coverage One way to measure trends in vaccination coverage is to compare coverage among children of different ages within the same survey. Table 10.5 shows, by current age, the percentage of children age 12-59 months who received vaccinations during the first year of life. Child Health | 121 Malawi has shown improvements in vaccination coverage over the past five years. The percentage of children who received no vaccinations by 12 months of age has decreased from 7 percent among children age 48-59 months to 2 percent among children age 12-23 months. The percentage of children fully immunised by age 12 months has increased from 55 to 72 percent for the same age groups. Vaccination cards were seen for 81 percent of children age 12-23 months, compared with only 55 percent of children age 48-59 months. This difference may be because vaccination cards for older children have been discarded or lost. Ninety-four percent of children age 12-59 months received a BCG vaccination by 12 months of age, while 88 percent received the third dose of DPT or pentavalent within the same time period. Seventy-six percent of children received polio 3, and 78 percent received the measles vaccine. Overall, 63 percent of children age 12-59 months received all basic vaccinations on time, that is, by age 12 months. Table 10.5 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Malawi 2010 Age in months BCG DPT/Pentavalent (DPT-HepB-Hib) Polio1 Measles All basic vaccina- tions2 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children 1 2 3 0 1 2 3 12-23 96.3 96.5 95.3 91.9 73.6 95.8 93.7 84.4 82.6 71.8 2.3 80.8 3,774 24-35 95.0 95.5 93.6 88.4 71.4 94.7 91.2 78.4 78.3 64.7 4.1 69.2 3,675 36-47 92.8 93.1 91.5 84.7 67.9 92.6 88.4 71.1 74.0 56.8 6.0 61.4 3,471 48-59 92.0 92.4 89.2 83.6 67.3 91.6 87.4 69.0 72.8 55.1 6.6 55.4 3,376 Total 94.2 94.6 92.7 87.6 70.3 93.9 90.4 76.2 77.7 62.8 4.6 67.1 14,296 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. For children whose information was based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given within 14 days after birth. 2 BCG, measles, and three doses each of DPT or pentavalent (DPT-HepB-Hib) and polio vaccine (excluding polio vaccine given at birth) 10.3 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large number of deaths caused by ARI. In the 2010 MDHS, ARI prevalence was estimated by asking mothers whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms are compatible with ARI. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 10.6 shows the prevalence of ARI symptoms among children under age 5 during the two-week period preceding the interview and the actions that mothers took in response to their children’s illness. Overall, 7 percent of children are reported to have had ARI symptoms in the two weeks preceding the survey. Children age 6-11 months are most likely to have had ARI symptoms (10 percent) compared with children in other age groups. Children in the Northern Region and in the Central Region are more likely to have ARI symptoms (8 percent each) than those in the Southern Region (5 percent). ARI symptoms among children show no apparent pattern with regard to the level of the mother’s education or wealth. Among children with ARI symptoms, advice or treatment was sought from a health facility or a health provider for 70 percent. Children age 6-11 months were more likely to be taken to a health facility (84 percent) than other children. As with ARI symptoms, the proportion of children who were taken to a health facility show no clear correspondence with the mother’s level of education or wealth. 122 | Child Health Table 10.6 Prevalence and treatment of symptoms of ARI Among children under age 5, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and among children with symptoms of ARI, the percentage for whom advice or treatment was sought from a health facility or provider, according to background characteristics, Malawi 2010 Background characteristic Children under age 5 Children under age 5 with symptoms of ARI Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a health facility or provider2 Number of children Age in months <6 6.0 1,698 63.1 101 6-11 9.6 2,018 84.3 193 12-23 7.1 3,774 72.1 268 24-35 6.9 3,675 68.6 252 36-47 5.9 3,471 62.4 203 48-59 6.0 3,376 68.2 204 Sex Male 7.1 8,864 71.2 628 Female 6.5 9,149 69.4 594 Mother’s smoking status Smokes cigarettes/tobacco 6.5 54 * 4 Does not smoke 6.8 17,952 70.4 1,218 Missing * 6 na 0 Cooking fuel Electricity or gas 4.4 192 * 8 Coal/lignite * 7 na 0 Charcoal 5.8 1,802 75.6 104 Wood/straw3 6.9 16,008 69.8 1,108 Other fuel * 3 na 0 Missing * 1 na 0 Residence Urban 6.6 2,559 67.0 168 Rural 6.8 15,454 70.8 1,053 Region Northern 8.4 2,130 75.9 179 Central 8.0 7,749 67.9 618 Southern 5.2 8,134 71.3 423 Mother’s education No education 5.9 3,144 69.0 185 Primary 7.1 12,168 69.5 865 Secondary 6.4 2,565 75.2 164 More than secondary 5.4 136 * 7 Wealth quintile Lowest 6.6 3,927 61.8 258 Second 6.5 3,896 66.8 254 Middle 7.4 3,924 76.8 289 Fourth 7.0 3,300 71.5 230 Highest 6.4 2,966 75.2 189 Total 6.8 18,013 70.3 1,221 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases. na = Not applicable 1 Symptoms of ARI (cough accompanied by short, rapid breathing which was chest-related) is considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Includes grass, shrubs, and crop residues 10.4 FEVER Fever is a symptom of malaria, but it may also accompany other childhood illnesses. Malaria and other illnesses that cause fever contribute to high levels of malnutrition, morbidity, and mortality in young children. Although fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Because malaria is a major cause of death in infancy and Child Health | 123 childhood in many developing countries, the presumptive treatment of fever with antimalarial medication is advocated in many countries where malaria is endemic. Information relating to the prevention and treatment of malaria is discussed in detail in Chapter 12. Table 10.7 shows the percentage of children under age 5 with fever during the two weeks preceding the survey and the percentage for whom treatment was sought, by background characteristics. Thirty-five percent of children under age 5 are reported to have had fever in the two weeks preceding the survey. The prevalence of fever varies with children’s age. Children age 6-11 months and 12-23 months are more likely to be sick with fever (44 and 41 percent, respectively) than children in other age groups. Slightly more children were reported to have fever in rural areas, compared with urban areas (35 and 31 percent, respectively). Table 10.7 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage of children for whom treatment was sought from a health facility or provider, by background characteristics, Malawi 2010 Background characteristic Among children under age 5: Children under age 5 with fever Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Number of children Age in months <6 23.9 1,698 57.4 407 6-11 44.0 2,018 69.1 889 12-23 40.9 3,774 67.2 1,545 24-35 37.0 3,675 65.4 1,359 36-47 31.4 3,471 61.4 1,091 48-59 27.4 3,376 61.7 924 Sex Male 35.7 8,864 64.7 3,161 Female 33.4 9,149 64.4 3,053 Residence Urban 30.7 2,559 68.5 786 Rural 35.1 15,454 64.0 5,428 Region Northern 29.4 2,130 72.4 626 Central 38.1 7,749 62.7 2,954 Southern 32.4 8,134 64.8 2,634 Mother’s education No education 30.3 3,144 58.9 952 Primary 36.4 12,168 64.4 4,429 Secondary 30.8 2,565 72.0 791 More than secondary 31.0 136 (72.5) 42 Wealth quintile Lowest 35.6 3,927 60.8 1,397 Second 34.8 3,896 61.0 1,357 Middle 37.4 3,924 68.3 1,469 Fourth 34.1 3,300 63.4 1,127 Highest 29.2 2,966 71.6 865 Total 34.5 18,013 64.6 6,214 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner Among regions, 38 percent of children in the Central Region had fever in the two weeks preceding the survey, followed by 32 percent in the Southern Region, while 29 percent of children in the Northern Region had fever. Children of mothers in the highest wealth quintile have the lowest prevalence of fever (29 percent). 124 | Child Health Two in three children (65 percent) with fever were taken to a health facility or health provider for treatment. Although children living in rural areas are more likely than those in urban areas to report having had fever (35 percent compared with 31 percent), children living in urban areas are more likely than those living in rural areas to have received treatment from a health facility or provider (69 percent compared with 64 percent). Children in the Northern Region (72 percent) are more likely to be treated at a health facility or by a health provider compared with children in other regions. Children of mothers with a secondary education and mothers in the fifth wealth quintile (72 percent each) are each more likely to receive treatment from a health facility or provider than children of other women with less education or wealth. Table 10.8 shows the percentage of children with fever who received specific antimalarial drugs when the child became ill. Forty-three percent of children with fever received an antimalarial drug. The majority of children took lumefantrine and artemether (LA), an artemisinin-based combination therapy (ACT) drug, which is the recommended course of treatment for malaria in children in Malawi (36 percent). Two percent of children took sulfadoxine/pyrimethamine (SP/Fansidar), 5 percent took quinine, and 1 percent took other antimalarial drugs. Table 10.8 Antimalarial drugs taken by children Among children under age five who had fever in the two weeks preceding the survey, the percentage who took specific antimalarial drugs, Malawi 2010 Drug Percentage who took specific antimalarial drugs Number of children who took a specific antimalarial drug1 Sulfadoxine/pyrimethamine (SP/Fansidar) 1.9 120 Chloroquine * 1 Quinine 4.8 298 Lumefantrine and artemether (LA) 36.2 2,251 Amodiaquine * 6 Artesunate * 2 Artesunate and amodiaquine (AA, ASAQ) * 16 Other antimalarial 1.2 77 Any antimalarial drugs 43.4 2,696 Note: Artemisinin-based combination therapy (ACT) is recommended for treatment of Plasmodium falciparum malaria. Companion compounds include sulfadoxine/pyrimethamine, lumefantrine and artemether, artesunate and amodiaquine. 1 6,214 children had fever in the two weeks preceding the survey. 10.5 PREVALENCE OF DIARRHOEA Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children. A simple and effective response to dehydration is a prompt increase in fluid intake. Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. When interpreting the 2010 MDHS findings, it should be borne in mind that diarrhoea prevalence is subject to seasonal variability. The 2010 MDHS obtained information on the prevalence of diarrhoea among young children by asking mothers whether their children under age 5 had diarrhoea during the two weeks preceding the interview. When a child was identified as having had diarrhoea, information was collected on treatment and feeding practices during the diarrhoeal episode. The mother was also asked whether there was blood in the child’s stools. Diarrhoea with blood in the stools indicates cholera or other diseases that need to be treated differently from diarrhoea in which there is no blood in the stools. Mothers of children who were ill with any form of diarrhoea in the preceding two weeks were asked what actions they had taken to treat the diarrhoea and about feeding practices during the diarrhoeal episode. Other information included the respondent’s knowledge of oral rehydration salt (ORS) packets or pre-packaged liquids for treatment of diarrhoea (oral rehydration therapy). Child Health | 125 Table 10.9 shows that 18 percent of the children under age 5 had a diarrhoeal episode in the two weeks preceding the survey and 2 percent had blood in the stool. The prevalence of diarrhoea varies by age of children. Young children age 6-23 months are more prone to diarrhoea than children in the other age groups (33 percent). This is expected because children in this age group are introduced to complementary foods. Diarrhoea is more prevalent among children whose households do not have an improved toilet facility or who share a facility with other households (18 percent) compared with households that have an improved, non-shared toilet facility (15 percent). The prevalence of diarrhoea varies regionally: children in the Central Region are more susceptible to episodes of diarrhoea (20 percent) than children in other regions. The lowest proportion of children with diarrhoea is in the Northern Region (15 percent). Table 10.9 Prevalence of diarrhoea Percentage of children under age 5 who had diarrhoea in the two weeks preceding the survey, by background characteristics, Malawi 2010 Background characteristic Diarrhoea in the two weeks preceding the survey All diarrhoea Diarrhoea with blood Number of children Age in months <6 9.0 0.9 1,698 6-11 38.6 3.8 2,018 12-23 30.2 3.5 3,774 24-35 15.6 3.1 3,675 36-47 9.0 1.5 3,471 48-59 5.9 1.2 3,376 Sex Male 18.4 2.7 8,864 Female 16.7 2.1 9,149 Source of drinking water1 Improved 17.1 2.2 14,102 Not improved 19.0 3.1 3,909 Toilet facility2 Improved, not shared 15.2 2.6 1,247 Non-improved or shared 17.7 2.4 16,736 Residence Urban 18.2 1.6 2,559 Rural 17.4 2.5 15,454 Region Northern 14.6 2.3 2,130 Central 19.9 2.6 7,749 Southern 16.0 2.2 8,134 Mother’s education No education 16.7 3.1 3,144 Primary 18.0 2.3 12,168 Secondary 16.4 1.7 2,565 More than secondary 13.8 2.2 136 Wealth quintile Lowest 18.3 2.8 3,927 Second 17.5 2.4 3,896 Middle 18.1 2.2 3,924 Fourth 16.3 2.4 3,300 Highest 17.3 1.8 2,966 Total 17.5 2.4 18,013 Note: Total includes 2 cases for which the source of drinking water is missing and 31 cases for which information on type of toilet facility is missing 1 See Table 2.6 for definition of categories. 2 See Table 2.7 for definition of categories. 126 | Child Health 10.6 DIARRHOEA TREATMENT For children who had diarrhoea in the two weeks preceding the survey, mothers were asked what they did to treat the illness. Table 10.10 shows, by various background characteristics, the percentage of children with diarrhoea who received specific treatments. Sixty-two percent of the children with diarrhoea were taken to a health care facility or provider where advice or treatment was sought. Looking at the age pattern, the largest proportion of children that received treatment for diarrhoea is children age 12-23 months (66 percent). The distribution of diarrhoea treatment by residence shows that treatment and advice are sought more often for children in rural areas (63 percent) than children in urban areas (55 percent). Seeking treatment for diarrhoea from a health provider is highest in the Northern Region (71 percent) and lowest in the Central Region (57 percent). Table 10.10 includes information on oral rehydration therapy. Seventy-four percent of children with diarrhoea were treated with oral rehydration therapy (ORT) or increased fluids. Sixty- nine percent were treated with ORS, a solution prepared from a packet of oral rehydration salts; and 22 percent received increased fluids. Twenty percent of children were given antibiotic drugs and 25 percent received home remedies or other treatments. Fifteen percent of children with diarrhoea did not receive any treatment at all. Table 10.10 Diarrhoea treatment Among children under age 5 who had diarrhoea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Malawi 2010 Background characteristic Percentage of children with diarrhoea for whom advice or treatment was sought from a health facility or provider1 Oral rehydration therapy (ORT) Other treatments No treatment Number of children ORS packets or pre- packaged liquid Increased fluids ORT or increased fluids Antibiotic drugs Antimotility drugs Zinc supple- ments Intra- venous solution Home remedy/ other Missing Age in months <6 49.0 39.6 19.0 52.8 23.9 2.1 0.0 0.3 25.7 0.8 24.2 153 6-11 61.3 67.3 18.8 71.3 17.5 0.7 0.5 0.2 23.2 0.1 19.6 779 12-23 65.9 73.1 23.6 77.7 20.7 2.0 0.0 0.9 25.5 0.2 11.2 1,139 24-35 61.4 71.5 23.1 75.8 21.4 2.1 0.0 0.5 27.8 0.3 12.9 575 36-47 60.4 68.3 26.9 74.7 15.7 0.3 0.3 0.1 26.4 0.9 11.9 312 48-59 59.0 68.5 21.2 72.8 18.4 0.5 0.0 0.0 24.3 0.0 15.7 200 Sex Male 61.3 68.4 22.5 73.7 20.3 1.3 0.1 0.4 24.4 0.3 14.2 1,627 Female 63.0 69.6 22.1 74.3 18.8 1.6 0.3 0.6 26.4 0.3 14.9 1,531 Type of diarrhoea Non bloody 62.1 69.5 23.0 74.7 19.4 1.4 0.2 0.5 23.7 0.0 15.0 2,624 Bloody 63.7 67.6 17.4 71.5 19.1 2.1 0.0 0.3 36.4 0.7 11.9 429 Missing 55.7 62.7 23.5 67.2 24.6 0.0 0.0 0.0 22.0 3.8 12.2 104 Residence Urban 55.2 71.5 30.0 76.1 13.5 3.3 0.0 0.6 17.9 0.0 17.8 467 Rural 63.3 68.6 21.0 73.6 20.6 1.1 0.2 0.5 26.7 0.3 14.0 2,691 Region Northern 70.8 73.0 17.6 77.5 26.3 1.4 0.0 0.3 28.9 0.6 11.6 310 Central 57.1 68.9 21.9 73.7 16.2 1.9 0.2 0.7 23.7 0.2 15.8 1,545 Southern 66.1 68.1 23.8 73.4 22.0 0.9 0.2 0.3 26.6 0.3 13.7 1,302 Mother’s education No education 58.2 69.5 16.7 74.4 16.5 1.2 0.1 0.6 24.5 0.1 12.9 524 Primary 62.7 68.3 22.6 73.3 19.7 1.2 0.2 0.5 26.1 0.3 14.9 2,194 Secondary 64.4 72.0 26.6 76.2 23.2 2.5 0.0 0.2 23.1 0.3 14.6 422 More than secondary * * * * * * * * * * * 19 Wealth quintile Lowest 63.8 66.9 18.3 71.0 17.7 1.0 0.2 0.5 26.1 0.4 16.4 717 Second 63.2 69.9 15.9 74.0 19.1 0.7 0.3 0.4 27.7 0.3 12.9 682 Middle 60.5 67.6 24.0 74.0 19.1 1.3 0.4 0.8 26.5 0.1 16.0 709 Fourth 64.5 68.9 27.1 73.8 25.9 2.1 0.0 0.1 24.7 0.4 13.4 538 Highest 58.2 72.7 28.9 78.1 16.9 2.5 0.0 0.4 20.6 0.2 13.5 512 Total 62.1 69.0 22.3 74.0 19.6 1.4 0.2 0.5 25.4 0.3 14.5 3,158 Note: ORT includes solution prepared from oral rehydration salts (ORS) and pre-packaged ORS packet. An asterisk indicates that a figure is based on fewer than 25 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner Child Health | 127 Children age 12-23 months (78 percent), children living in the Northern Region (78 percent), children with mothers who have a secondary education (76 percent), and children in the highest wealth quintile (78 percent) are most likely to receive some kind of ORT. 10.7 FEEDING PRACTICES When a child has diarrhoea, mothers are encouraged to continue feeding their child the same amount of food as they would if the child did not have diarrhoea and also encouraged to increase the child’s fluid intake. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea on the child’s nutritional status. In the 2010 MDHS, mothers were asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual. Table 10.11 shows, by feeding practices, the percent distribution of children under age 5 who had diarrhoea in the two weeks preceding the survey, according to background characteristics. Table 10.11 Feeding practices during diarrhoea Percent distribution of children under age 5 who had diarrhoea in the two weeks preceding the survey by the amount of liquids and food offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrhoea episode, and the percentage of children who continued feeding and were given ORT and/or increased fluids during the episode of diarrhoea, by background characteristics, Malawi 2010 Background characteristic Amount of liquids offered Total Amount of food offered Total Percentage given increased fluids and continued feeding1 Percentage who continued feeding and were given ORT and/or increased fluids1,2 Number of children with diarrhoea More Same as usual Some- what less Much less None Don’t know/ missing More Same as usual Some- what less Much less None Never gave food Don’t know/ missing Age in months <6 19.0 35.4 20.4 10.9 14.2 0.0 100.0 3.1 14.6 9.6 6.6 1.7 64.4 0.0 100.0 3.5 10.7 153 6-11 18.8 38.5 20.2 15.7 6.6 0.1 100.0 5.8 30.1 25.3 20.6 9.2 9.0 0.0 100.0 10.9 42.3 779 12-23 23.6 32.1 25.4 13.5 5.2 0.1 100.0 8.0 24.5 32.3 16.7 15.0 3.4 0.1 100.0 14.7 50.2 1,139 24-35 23.1 32.3 24.2 13.8 6.1 0.4 100.0 11.4 31.9 25.7 17.4 11.3 1.9 0.4 100.0 17.9 51.3 575 36-47 26.9 31.7 18.3 15.2 7.8 0.1 100.0 6.3 35.7 33.2 16.5 7.5 0.6 0.1 100.0 20.9 56.6 312 48-59 21.2 32.7 25.3 11.5 7.6 1.6 100.0 9.3 38.8 32.1 15.0 4.4 0.4 0.0 100.0 18.9 56.7 200 Sex Male 22.5 32.2 24.7 14.3 6.3 0.0 100.0 8.4 27.4 29.2 17.0 11.7 6.3 0.0 100.0 15.2 47.4 1,627 Female 22.1 35.7 21.1 13.8 6.8 0.5 100.0 7.1 30.2 27.4 17.3 10.0 7.8 0.2 100.0 14.1 47.8 1,531 Type of diarrhoea Non bloody 23.0 35.5 22.5 12.5 6.2 0.2 100.0 8.2 29.9 28.7 15.8 10.4 7.0 0.1 100.0 15.4 49.6 2,624 Bloody 17.4 24.3 25.6 23.8 8.9 0.0 100.0 6.6 21.4 26.1 26.8 12.7 6.4 0.0 100.0 10.4 35.6 429 Missing 23.5 32.1 25.0 13.2 5.2 1.1 100.0 2.2 31.2 28.5 12.0 14.9 10.1 1.1 100.0 13.6 45.6 104 Residence Urban 30.0 30.2 25.9 7.4 6.1 0.5 100.0 10.8 26.0 28.3 12.4 13.9 8.2 0.5 100.0 20.4 48.9 467 Rural 21.0 34.5 22.5 15.2 6.7 0.2 100.0 7.2 29.3 28.3 18.0 10.3 6.8 0.1 100.0 13.7 47.3 2,691 Region Northern 17.6 25.2 22.6 29.3 5.3 0.0 100.0 7.5 20.9 27.4 27.4 9.0 7.8 0.0 100.0 10.8 39.8 310 Central 21.9 34.3 24.7 11.4 7.3 0.4 100.0 5.4 30.3 30.4 13.6 12.2 8.0 0.2 100.0 14.6 48.1 1,545 Southern 23.8 35.5 21.0 13.5 6.0 0.1 100.0 10.6 28.9 26.1 18.9 9.8 5.6 0.1 100.0 15.7 48.9 1,302 Mother’s education No education 16.7 33.2 27.9 15.5 6.6 0.1 100.0 4.6 30.4 27.8 20.3 11.0 5.8 0.1 100.0 10.6 45.6 524 Primary 22.6 34.0 22.1 14.1 7.0 0.2 100.0 8.1 28.7 27.6 17.2 11.1 7.2 0.1 100.0 14.8 47.0 2,194 Secondary 26.6 34.7 21.1 12.2 4.8 0.5 100.0 9.2 27.0 33.2 13.6 9.8 6.7 0.5 100.0 17.9 52.6 422 More than secondary * * * * * * 100.0 * * * * * * * 100.0 * * 19 Wealth quintile Lowest 18.3 34.4 23.3 17.8 5.9 0.2 100.0 6.7 31.3 28.0 16.9 9.8 7.1 0.2 100.0 12.9 45.0 717 Second 15.9 35.2 25.4 17.0 6.5 0.0 100.0 5.6 26.3 30.2 20.7 10.0 7.3 0.0 100.0 9.1 46.4 682 Middle 24.0 33.9 21.9 12.8 6.8 0.5 100.0 8.0 30.9 28.3 14.9 12.4 5.5 0.0 100.0 15.4 48.6 709 Fourth 27.1 31.4 22.9 10.0 8.5 0.0 100.0 10.6 25.1 25.6 17.2 12.2 9.3 0.0 100.0 17.7 45.7 538 Highest 28.9 33.9 20.9 10.7 5.1 0.4 100.0 8.8 29.5 29.1 15.8 10.2 6.2 0.4 100.0 20.5 53.3 512 Total 22.3 33.9 23.0 14.0 6.6 0.2 100.0 7.7 28.8 28.3 17.1 10.9 7.0 0.1 100.0 14.7 47.6 3,158 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases. 1 Continued feeding practices includes children who were given more, the same as usual, or somewhat less food during the diarrhoea episode 2 Equivalent to the UNICEF/WHO indicator ‘Home management of diarrhoea’. MICS Indicator 34 128 | Child Health Thirty-four percent of children with diarrhoea were given the same amount of liquids as usual, and 22 percent were given more. It is of concern that 23 percent of the children were given somewhat less to drink than usual, and 14 percent were given much less to drink during the diarrhoea episode. Twenty-nine percent of children were given the same amount of food as usual, 28 percent were given somewhat less, 17 percent were given much less food, and 8 percent were given more food. Seven percent of children were not given any food during the diarrhoea episode. Overall, only 15 percent of children had increased fluid intake and continued feeding. Forty-eight percent of children were given ORT, increased fluids, and continued feeding. 10.8 KNOWLEDGE OF ORS PACKETS To ascertain respondents’ knowledge of ORS in Malawi, women were asked whether they knew about THANZI-ORS packets. Table 10.12 presents information on the percentage of mothers with a birth in the five years preceding the survey who had heard about THANZI-ORS packets. Ninety-six percent of women age 15-49 have heard about THANZI-ORS. Knowledge is higher in urban areas (98 percent) compared with rural areas (95 percent). At the regional level, knowledge is highest among women in the Southern Region (97 percent) and lowest in the Northern Region (94 percent). Education and wealth are directly associated with higher proportions of women knowing about THANZI-ORS packets. Table 10.12 Knowledge of ORS packets or pre-packaged liquids Percentage of mothers age 15-49 who gave birth in the five years preceding the survey who know about ORS packets or ORS pre-packaged liquids for treatment of diarrhoea by background characteristics, Malawi 2010 Background characteristic Percentage of women who know about ORS packets or ORS pre- packaged liquids (THANZI-ORS) Number of women Age 15-19 95.1 1,002 20-24 95.8 3,710 25-34 96.5 6,241 35-49 94.9 2,712 Residence Urban 98.4 2,107 Rural 95.4 11,558 Region Northern 93.5 1,595 Central 95.5 5,819 Southern 96.8 6,251 Education No education 92.7 2,277 Primary 96.1 9,144 Secondary 98.3 2,119 More than secondary 99.4 125 Wealth quintile Lowest 94.2 2,821 Second 94.7 2,894 Middle 96.1 2,906 Fourth 96.9 2,602 Highest 97.8 2,442 Total 95.9 13,664 ORS = Oral rehydration salts Nutrition of Children and Adults | 129 NUTRITION OF CHILDREN AND ADULTS 11 Nutritional status is the result of complex interactions between food consumption and the overall status of health and care practices. Numerous socioeconomic and cultural factors influence decisions on patterns of feeding and nutritional status. The 2010 MDHS asked questions about early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding until at least age 2, timely introduction of complementary foods at age 6 months (with increasing frequency of feeding solid/semisolid foods), and diet diversity. Height and weight for all children under age 5 and women age 15-49 were measured. This chapter presents findings on infant feeding practices, maternal eating patterns, household testing of salt for adequate levels of iodine and the nutritional status of women and children.1 11.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2010 MDHS permit the measurement and evaluation of the nutritional status of young children in Malawi. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. Marked differences, especially with regard to height-for-age, weight-for-height, and weight-for-age, are often seen among different subgroups of children within the country. 11.1.1 Measurement of Nutritional Status among Young Children The 2010 MDHS collected data on the nutritional status of children by measuring the height and weight of children under age 5 in all sampled households, regardless of whether their mother was interviewed in the survey. Data were collected with the aim of calculating three indices – namely, height-for-age, weight-for-height, and weight-for-age. Weight measurements were obtained using lightweight SECA mother-infant scales with a digital screen, designed and manufactured under the guidance of UNICEF. Height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down on the board (recumbent length), and standing height was measured for older children. For the 2010 MDHS, the nutritional status of children was calculated using the new growth standards published by WHO in 2006. These standards were generated using data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). The study, with a sample size of 8,440 children drawn from six countries across the world, was designed to describe how children should grow under optimal conditions. The WHO Child Growth Standards can therefore be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. Each of the three nutritional status indicators described below is expressed in standard deviation units from the median of the Multicentre Growth Reference Study sample. The nutritional status of children in the 2010 MDHS, according to the NCHS/CDC/WHO reference population, which was used in previous MDHS reports, is shown in Appendix Table E.1. Each of these indices – height-for-age, weight-for-height, and weight-for-age – provides different information about growth and body composition, which is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) are considered short for their age, or stunted, and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 130 | Nutrition of Children and Adults adequate nutrition over a long period and is also affected by recurrent and chronic illness. Height-for age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) are considered thin, or wasted, and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey. It may result from inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. 11.1.2 Results of Data Collection Height and weight measurements were obtained for 4,849 children under age 5 who were present in households selected for the MDHS at the time of the survey. The following analysis focuses on the children for whom complete and credible anthropometric and valid age data were collected. Table 11.1 and Figure 11.1 show the percentage of children under age 5 classified as malnourished according to the three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age. Height-for-age Table 11.1 indicates that 47 percent of children under age 5 are stunted and 20 percent are severely stunted. Stunting is apparent even among children under 6 months (17 percent). As shown in Figure 11.1, stunting increases with the age of the child through the first two years of life before declining in the third and fourth year. The increase is especially rapid during the first two years of life, as seen in the rise from 25 percent among children age 6-8 months to 61 percent among children age 18-23 months. Male children (51 percent) are more likely to be stunted than female children (43 percent), and rural children are more likely to be stunted (48 percent) than urban children (41 percent). There is little regional variation in nutritional status of children, as stunting is high in all regions: Southern Region (48 percent), Central Region (47 percent), and Northern Region (45 percent. Education and wealth are both inversely related to stunting levels. Stunting decreases with increasing levels of the mother’s education. More than half of children born to mothers with no education are stunted (53 percent) compared with 48 percent of children born to mothers with a primary education and 39 percent of children born to mothers with a secondary education. Nutrition of Children and Adults | 131 Table 11.1 Nutritional status of children Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Malawi 2010 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percent- age below -3 SD Percent- age below -2 SD2 Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Age in months <6 5.7 17.4 -0.6 2.1 7.0 19.9 0.5 1.9 6.5 3.7 -0.1 352 6-8 12.2 25.2 -0.9 3.2 6.1 10.1 0.2 3.3 9.5 2.0 -0.5 271 9-11 10.7 27.6 -1.1 3.9 6.9 8.4 0.1 1.5 11.1 2.9 -0.6 246 12-17 20.9 45.9 -1.7 2.6 6.7 8.9 0.1 4.5 16.3 2.1 -0.7 483 18-23 29.2 61.3 -2.2 2.1 6.0 8.5 0.2 4.9 14.6 0.3 -0.9 576 24-35 25.5 56.0 -2.1 0.9 2.4 8.6 0.4 3.0 13.6 0.9 -0.9 985 36-47 17.7 51.6 -2.0 0.7 2.7 7.0 0.4 2.3 12.8 0.2 -0.9 986 48-59 18.4 47.6 -1.9 0.6 1.9 3.9 0.3 2.6 13.0 0.4 -1.0 951 Sex Male 23.0 51.1 -1.9 1.7 4.2 9.1 0.3 3.2 14.0 1.3 -0.9 2,364 Female 16.3 43.3 -1.6 1.3 3.8 7.5 0.3 2.8 11.7 0.9 -0.8 2,485 Birth interval in months3 First birth4 20.8 46.9 -1.9 1.2 4.3 8.6 0.3 3.4 14.8 0.6 -0.9 881 <24 24.9 53.8 -2.0 0.9 3.4 8.4 0.3 4.4 18.0 0.7 -1.0 497 24-47 19.8 48.7 -1.8 1.9 4.3 7.4 0.3 2.8 12.1 1.0 -0.8 2,297 48+ 13.4 39.0 -1.5 1.3 3.8 9.5 0.3 2.1 9.2 1.9 -0.6 874 Size at birth3 Very small 21.4 61.8 -2.2 0.4 6.4 5.0 -0.0 8.5 26.8 0.0 -1.3 124 Small 29.1 63.8 -2.3 2.0 6.5 6.5 0.1 7.2 24.9 1.1 -1.2 484 Average or larger 17.8 44.1 -1.7 1.5 3.8 8.4 0.3 2.3 10.7 1.1 -0.7 3,853 Missing 26.4 62.4 -2.1 0.8 2.1 12.5 0.5 1.4 12.3 0.8 -0.8 88 Mother’s interview status Interviewed 19.3 47.0 -1.8 1.5 4.1 8.2 0.3 2.9 12.7 1.1 -0.8 4,549 Not interviewed but in household 32.9 54.3 -2.2 0.0 0.0 4.7 0.3 6.5 27.0 2.8 -1.1 79 Not interviewed, and not in the household5 20.0 46.0 -1.7 0.7 2.7 11.2 0.4 2.8 10.5 0.5 -0.7 220 Mother’s nutritional status6 Thin—BMI<18.5 21.7 52.1 -1.9 3.7 7.6 4.5 -0.0 6.5 22.0 2.1 -1.1 260 Normal—BMI 18.5-24.9 19.9 48.7 -1.8 1.5 4.3 8.2 0.3 2.9 13.5 1.0 -0.9 3,530 Overweight/obese—BMI ≥25 16.5 37.7 -1.5 0.5 1.8 9.1 0.5 2.2 6.3 1.2 -0.5 741 Missing 23.0 52.8 -1.9 2.8 4.3 10.2 0.2 3.0 24.0 3.6 -1.0 83 Residence Urban 15.5 40.7 -1.6 0.6 2.4 8.9 0.4 1.9 10.1 1.1 -0.6 721 Rural 20.3 48.2 -1.8 1.6 4.3 8.2 0.3 3.2 13.3 1.1 -0.8 4,128 Region Northern 18.0 44.7 -1.8 0.5 2.4 9.7 0.4 1.2 10.6 1.0 -0.7 543 Central 19.4 47.2 -1.8 1.8 4.3 9.2 0.3 3.5 13.5 1.3 -0.8 2,226 Southern 20.2 47.6 -1.8 1.4 4.0 6.9 0.3 3.0 12.8 0.9 -0.8 2,080 Mother’s education7 No education 24.5 53.4 -1.9 2.3 4.9 7.7 0.3 3.4 15.8 1.6 -0.9 793 Primary 19.6 47.6 -1.8 1.6 4.1 8.1 0.3 3.2 13.4 1.0 -0.8 3,137 Secondary 14.0 38.8 -1.5 0.4 2.7 8.5 0.4 1.6 7.7 1.1 -0.6 675 More than secondary * * * * * * * * * * * 23 Wealth quintile Lowest 24.1 55.5 -2.0 2.8 5.0 8.6 0.3 4.5 16.5 1.9 -1.0 862 Second 22.3 50.8 -1.9 1.8 4.5 7.4 0.3 4.5 14.3 0.7 -0.9 1,085 Middle 19.8 46.5 -1.8 1.9 4.6 7.8 0.3 3.0 12.3 0.7 -0.8 1,062 Fourth 18.0 46.8 -1.7 0.4 3.8 7.8 0.2 1.9 13.7 1.0 -0.8 913 Highest 13.5 36.0 -1.5 0.5 1.9 10.0 0.5 1.0 7.4 1.2 -0.5 926 Total 19.6 47.1 -1.8 1.5 4.0 8.3 0.3 3.0 12.8 1.1 -0.8 4,849 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units -SD from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used 1977 NCHS/CDC/WHO reference. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Table is based on children with valid dates of birth month and year and valid measurement of both height and weight. 1 Recumbent length is measured for children under age 2; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations -SD from the WHO Child Growth standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins -triplets, etc. are counted as first births because they do not have a previous birth interval 5 Includes children whose mothers are deceased 6 Excludes children whose mothers were not weighed and measured. Mother’s nutritional status in terms of BMI -Body Mass Index is presented in Table 11.10 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 132 | Nutrition of Children and Adults Weight-for-height Four percent of children under age 5 are wasted. Wasting is higher among children younger than 24 months (6-7 percent), and lowest among children age 48-59 months (2 percent). Boys and girls are equally likely to be wasted (4 percent each). Children reported to be small at birth and those born to thin mothers (BMI less than 18.5) are more likely to be wasted than other children. Children in rural areas (4 percent) are twice as likely to be wasted as children in urban areas (2 percent). At the regional level, the Central and Southern Regions have levels of wasting that are the same as the national average (4 percent); whereas, the percentage of children wasted in the Northern Region is lower than average (2 percent). As seen for stunting, wasting decreases with an increase in the level of education and wealth quintile. For example, children in households in the highest wealth quintile are less likely to be wasted (2 percent) than those in the three lowest wealth quintiles (5 percent each). It should be noted that 8 percent of children under age 5 in Malawi are overweight, with Z-scores more than two standard deviations (+2 SD) above the median. Weight-for-age Nationally, 13 percent of children under age 5 are underweight, with 3 percent being severely underweight. Table 11.1 shows that the percentage of children who are underweight doubles from 7 percent among children less than 6 months of age to 16 percent among children age 12-17 months. This may be explained by the fact that foods for weaning are typically introduced to children in the latter group, thus increasing their exposure to infections and susceptibility to illness. This tendency, coupled with inappropriate and/or inadequate feeding practices, may contribute to faltering nutritional status among children in these age groups. As with the other two nutritional indicators, male children are more likely to be underweight (14 percent) than female children (12 percent), and smaller size at birth is associated with lower weight-for-age. Children born to thin or underweight mothers (BMI less than 18.5) are more likely to be underweight than those born to normal mothers with a normal BMI (22 percent compared with 14 percent). The proportion of children who are underweight is higher in rural areas (13 percent) than in urban areas (10 percent). At the regional level, children in the Northern Region are the least likely (11 percent) to be underweight, while children in the Central and Southern Regions are the most likely to be underweight (14 and 13 percent, respectively). The proportion of children who are underweight decreases as mother’s level of education increases. Similarly, underweight is more prevalent among children in the four lowest wealth quintiles than among those in the highest wealth quintile. Nutrition of Children and Adults | 133 Figure 11.1 Nutritional Status of Children by Age MDHS 2010 # ###### ### #### ######## ######### ######### ####### ############ #) ) ))))))))))))))))))))))))))))))))))))))))))))))))))))))))) ) 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Age in months 0 10 20 30 40 50 60 70 Percent Height-for-age Weight-for-height Weight-for-age) # 11.1.3 Trends in Malnutrition Figure 11.2 shows trends in the nutritional status of children in Malawi using anthropometric measurements from the 2004 MDHS and the 2010 MDHS. For this purpose, the anthropometric measures for the 2004 survey were recalculated using the new WHO growth standards. The results show that the nutritional status of children has improved since the 2004 MDHS. The percentage of children who are stunted has decreased from 53 to 47 percent, wasting has decreased from 6 to 4 percent, and the percentage of children who are underweight has decreased from 17 percent to 13 percent. 134 | Nutrition of Children and Adults Figure 11.2 Trends in Nutritional Status of Children Under Five, 2004 MDHS and 2010 MDHS MDHS 2010 53 6 17 47 4 13 Height-for-age Weight-for-height Weight-for-age 0 10 20 30 40 50 60 Percent 2004 MDHS 2010 MDHS 11.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the uterus to contract and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 11.2 shows the percentage of all children born in the two years before the survey by breastfeeding status and the timing of initial breastfeeding, by background characteristics. It also considers the prevalence of the practice of prelacteal feeding, that is, giving the infant other liquids during the period between the birth and when the mother’s milk flows freely. This practice is discouraged because it limits the frequency of breastfeeding by the infant and exposes the baby to the risk of infection. Nutrition of Children and Adults | 135 Table 11.2 Initial breastfeeding Among last born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth; and among last born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Malawi 2010 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last- born children Percentage who received a prelacteal feed2 Number of last- born children ever breastfed Sex Male 98.4 93.7 95.2 3,945 2.5 3,882 Female 98.8 95.4 97.2 3,780 2.6 3,736 Assistance at delivery Health professional3 98.7 94.9 96.4 5,969 2.0 5,893 Traditional birth attendant 99.3 94.5 96.2 785 5.0 779 Other 97.0 92.3 94.3 746 3.5 724 No one 98.8 92.5 95.5 222 4.3 219 Place of delivery Health facility 98.8 94.9 96.4 5,996 2.0 5,923 At home 98.3 94.1 95.6 1,513 4.6 1,487 Other 96.6 87.0 92.4 207 1.6 200 Residence Urban 98.3 94.8 95.4 1,138 1.7 1,118 Rural 98.7 94.4 96.3 6,586 2.7 6,500 Region Northern 98.1 93.9 95.2 889 5.2 871 Central 98.6 94.6 95.6 3,375 2.9 3,329 Southern 98.7 94.6 97.0 3,461 1.5 3,418 Mother’s education No education 98.7 93.9 95.7 1,249 2.8 1,232 Primary 98.6 94.6 96.2 5,236 2.5 5,161 Secondary 99.1 95.0 96.7 1,169 2.0 1,158 More than secondary (94.4) (91.4) (91.4) 70 (7.4) 67 Wealth quintile Lowest 98.7 93.9 96.2 1,669 2.0 1,647 Second 98.1 93.9 95.7 1,669 2.6 1,638 Middle 99.1 95.6 97.0 1,689 3.6 1,674 Fourth 98.6 95.2 96.5 1,409 1.9 1,389 Highest 98.7 94.0 95.3 1,288 2.3 1,271 Total 98.6 94.5 96.2 7,724 2.5 7,618 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children are living or dead at the time of interview. Totals include 3 children with information missing on assistance at delivery and 8 children with information missing on place of delivery. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, clinical officer, nurse/midwife, or patient attendant According to the results, nearly all children (99 percent) born in the two years preceding the survey were breastfed; this occurred regardless of background characteristics. Ninety-five percent of infants were put to the breast within one hour of birth and 96 percent started breastfeeding within the first day. The proportion of children breastfed within one hour of birth is much higher than in the 2004 MDHS (70 percent of children). Breastfeeding is widely practiced across all subgroups of women; the timing of initial breastfeeding is also very similar across the background characteristics. Prelacteal feeding is not widely practiced in Malawi. Only 3 percent of last-born children received a prelacteal feed. There are no marked differences in the proportions of children who received a prelacteal feed by sex of the child. Children born at home and those whose births were attended by a traditional birth attendant were slightly more likely than other children to have received a prelacteal feed. By region, prelacteal feeding is most likely to occur in the Northern Region (5 percent), followed by the Central Region (3 percent), and least often in the Southern Region (2 percent). 136 | Nutrition of Children and Adults 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that children be given solid or semisolid complementary foods in addition to breast milk from age 6 months to 24 months (or more) when the child is fully weaned. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to the risk of infection. Second, it decreases infants’ intake of breast milk and therefore the frequency of breastfeeding, which reduces breast milk production. Third, in low resource settings, supplementary food is often nutritionally inferior. Table 11.3 and Figure 11.3 show the percent distribution of youngest children under age 2 living with their mother by breastfeeding status. Table 11.3 also includes the percentage of all children under age 2 who use a bottle with a nipple, according to age in months. The survey results indicate that exclusive breastfeeding for the first six months is widely practiced in Malawi. Seventy- one percent of infants under age 6 months are exclusively breastfed. Within this age group, younger children are more likely to be exclusively breastfed. Ninety-three percent of infants under age 2 months are exclusively breastfed, compared with 41 percent of infants age 4-5 months. After age 6 months, children need to start receiving food to meet all of their nutritional requirements. As shown in Table 11.3, the percentages of children breastfeeding and receiving complementary foods are high among children over age 6 months, with 86 percent of children age 6-8 months, 94 percent of children 9-11 months, 93 percent of children 12-17 months, and 79 percent of children 18-23 months both breastfeeding and receiving complementary foods. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under age 2 who are living with their mother by breastfeeding status; the percentage currently breastfeeding; and the percentage of all children under age 2 using a bottle with a nipple, according to age in months, Malawi 2010 Age in months Percent distribution of youngest children under age 2 living with their mother by breastfeeding status Percentage currently breast- feeding Number of youngest children under age 2 Percentage using a bottle with a nipple Number of all children under age 2 Not breast- feeding Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming non-milk liquids/ juice Breast- feeding and consuming other milk Breast- feeding and consuming comple- mentary foods Total 0-1 0.0 92.9 1.6 1.3 2.4 1.9 100.0 100.0 465 1.4 477 2-3 0.9 81.9 4.7 1.2 2.7 8.6 100.0 99.1 649 1.4 661 4-5 0.7 40.5 6.6 2.6 3.1 46.5 100.0 99.3 542 2.9 561 6-8 2.0 6.8 3.7 1.3 0.3 85.8 100.0 98.0 1,075 4.3 1,088 9-11 1.6 0.8 2.8 1.0 0.1 93.7 100.0 98.4 917 3.2 930 12-17 4.9 0.7 1.4 0.1 0.1 92.8 100.0 95.1 1,685 6.0 1,718 18-23 19.9 0.2 0.6 0.4 0.1 78.9 100.0 80.1 1,950 3.6 2,056 0-3 0.5 86.4 3.4 1.2 2.6 5.8 100.0 99.5 1,114 1.4 1,137 0-5 0.6 71.4 4.5 1.7 2.8 19.1 100.0 99.4 1,656 1.9 1,698 6-9 1.9 5.7 3.4 1.3 0.3 87.3 100.0 98.1 1,352 3.6 1,368 12-15 3.9 0.9 1.3 0.2 0.1 93.7 100.0 96.1 1,154 6.8 1,178 12-23 12.9 0.4 0.9 0.3 0.1 85.4 100.0 87.1 3,635 4.7 3,774 20-23 23.2 0.2 0.6 0.1 0.0 75.9 100.0 76.8 1,246 2.8 1,331 Note: Breastfeeding status refers to a ‘24-hour’ period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and non-milk liquids and who do not receive other milk and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. National guidelines regarding breast milk substitutes, adopted from the WHO International Code of Marketing Breast Milk Substitutes (WHO, 1981), are very strict and discourage the use of bottles with nipples. The use of a bottle with a nipple, regardless of the contents (breast milk, formula, or any other liquid), requires hygienic handling to avoid contamination that may cause infection in the infant. Table 11.3 shows that 2 percent of infants age 0-5 months are fed using a bottle with a nipple. Nutrition of Children and Adults | 137 Figure 11.3 Infant Feeding Practices by Age 2010 MDHS <2 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 Age in months 0 20 40 60 80 100 Percent Exclusively breastfed Breast milk and plain water only Breast milk and non-milk liquids/juice Breast milk and other milk Breast milk and complementary foods Not breastfeeding Figure 11.4 shows changes in feeding practices between the 2004 and 2010 MDHS. Compared with the results of the 2004 MDHS, there has been improvement in breastfeeding practices. The proportion of children under age 6 months that are exclusively breastfed increased from 53 percent in the 2004 MDHS to 71 percent in the 2010 MDHS. This increase in exclusive breastfeeding is accompanied by a decrease in the percentage of children under age 6 months who receive plain water only in addition to breast milk. By contrast, the proportion of children less than age 6 months who receive complementary foods remains the same at 19 percent in the 2004 MDHS and 2010 MDHS. Figure 11.4 also shows that there has been an increase in the proportion of children age 6-9 months who received timely introduction of complementary foods – from 78 percent in the 2004 MDHS to 87 percent in the 2010 MDHS. 138 | Nutrition of Children and Adults Figure 11.4 Trends in Infant Feeding Practices for Children 0-5 Months and 6-9 Months, 2004 MDHS and 2010 MDHS 0-5 months 6-9 months 0-5 months 6-9 months 0% 20% 40% 60% 80% 100% Percent Complementary foods Other milk Non-milk liquids/juice Plain water only Exclusively breastfed Not breastfeeding 2004 MDHS 2010 MDHS Figure 11.5 shows 2010 MDHS results on Infant and Young Child Feeding (IYCF) practices indicators. As noted above, 71 percent of children under the age of six months are exclusively breastfed and 86 percent of children are given a timely introduction to complementary foods. Furthermore, almost all children (96 percent) are still breastfeeding at one year of age, and three- quarters are still breastfeeding at the age of two years (77 percent). Four out of five Malawian children age 0-23 months are given age appropriate breastfeeding. This includes exclusive breastfeeding for children 0-5 months and continued breastfeeding plus complementary foods for children age 6-23 months. Seventy-eight percent of children under six months are predominantly breastfed. This percentage includes children who are exclusively breastfed, plus those who receive breast milk and only plain water or nonmilk liquids such as juice. Finally, 4 percent of children under age 2 are bottle fed. Nutrition of Children and Adults | 139 Figure 11.5 Indicators on Breastfeeding Status, Malawi 2010 MDHS 2010 71.4 96.1 85.8 76.8 83.3 77.5 3.8 IYCF Indicator 2: Exclusive breastfeeding under 6 months 3: Continued breastfeeding at 1 year 4: Introduction of solid, semi-solid, or soft food 5: Continued breastfeeding at 2 years 11: Age-appropriate breastfeeding 12: Predominant breastfeeding 14: Bottle feeding 0 20 40 60 80 100 Percent 11.4 DURATION OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by selected background characteris- tics. The estimates of median and mean durations of breastfeeding are based on current status infor- mation, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The me- dian duration of any breastfeeding in Malawi is 24 months (the mean duration is 23). The median du- ration of any breastfeeding does not vary much by background characteristics. At the national level, the median duration of exclusive breastfeeding is 3.7 months. Table 11.4 also shows the median dura- tion of predominant breastfeeding, which is de- fined as exclusive breastfeeding or breastfeeding in combination with plain water, water-based liq- uids, or juices. The median length of predominant breastfeeding in Malawi is 4.2 months. There is little variation by background characteristics. 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the intro- duction of solid food to infants around age 6 months because by that age breast milk alone is no longer adequate to maintain a child’s optimal growth. In the transition to introducing the child to the family diet in addition to breastfeeding, Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, Malawi 2010 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 24.0 3.6 4.0 Female 23.4 3.9 4.4 Residence Urban 22.5 3.6 4.0 Rural 23.9 3.8 4.2 Region Northern 23.2 3.9 4.3 Central 24.4 3.5 4.1 Southern 23.4 3.9 4.2 Mother’s education No education 24.2 3.4 3.9 Primary 23.9 3.8 4.2 Secondary 22.6 3.9 4.4 More than secondary * * * Wealth quintile Lowest 24.8 3.5 3.9 Second 23.8 3.4 4.0 Middle 23.4 4.1 4.6 Fourth 23.7 4.1 4.4 Highest 22.9 3.6 4.0 Total 23.7 3.7 4.2 Mean for all children 22.9 4.6 5.3 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water, and/or nonmilk liquids, only 140 | Nutrition of Children and Adults children from age 6 months forward should be fed more frequently in small quantities of solid and semisolid foods throughout the day. During this transition period (age 6-23 months), the prevalence of malnutrition increases substantially in many countries because of an increase in infections and poor feeding practices. Table 11.5 provides information on the types of foods given on the day and night preceding the survey to the youngest children under age 2 living with their mother, according to breastfeeding status. The results show that, among all breastfeeding children under age 2, very few (2 percent) consume infant formula. However, a slightly higher proportion (5 percent) receives other milk, and 49 percent receive other liquids. Among children age 6-23 months, foods made from grains are consumed more often than foods from any other food group. Among breastfeeding children in this age group, 93 percent ate foods made from grains, and 65 percent ate fruits and vegetables rich in vitamin A during the day and night preceding the interview. Comparing dietary intake of children by breastfeeding status shows that a higher proportion of nonbreastfeeding children are consuming solid and semisolid foods (96 percent) than breastfeeding children (77 percent). As expected, more nonbreastfeeding children than breastfeeding children consume milk other than breast milk (14 percent compared with 5 percent). However, the percentage of nonbreastfeeding children consuming milk other than breast milk is still very low, considering that they are not benefiting from breast milk. Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Malawi 2010 Age in months Liquids Solid or semi-solid foods Any solid or semi- solid food Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vegetables rich in vitamin A4 Other fruits and vegetables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry, and eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 1.3 1.1 1.6 0.0 1.4 0.8 0.0 0.2 0.5 0.6 0.0 1.9 465 2-3 0.2 3.8 3.5 0.7 8.2 0.5 0.4 0.4 0.4 0.4 0.3 8.7 643 4-5 2.4 4.9 13.6 2.3 44.5 3.5 1.0 0.9 2.6 2.3 0.0 46.8 538 6-8 2.4 3.6 45.3 4.2 84.4 31.9 12.1 12.0 19.2 21.1 0.8 87.5 1,054 9-11 2.6 4.4 60.8 3.9 93.0 64.3 24.0 27.0 31.8 43.9 1.2 95.2 902 12-17 2.2 8.3 68.2 3.0 94.8 75.0 30.6 35.4 34.5 52.2 1.3 97.5 1,603 18-23 1.7 6.1 68.9 1.8 95.9 77.6 29.0 38.6 37.9 49.2 2.1 98.7 1,563 6-23 2.1 6.0 62.4 3.0 92.7 65.1 25.1 30.1 31.9 43.4 1.4 95.4 5,121 Total 1.9 5.4 48.8 2.5 74.6 49.6 19.1 22.9 24.4 33.1 1.1 76.9 6,767 NONBREASTFEEDING CHILDREN 0-11 (33.4) (15.9) (55.0) (17.9) (71.5) (42.4) (12.9) (17.4) (16.3) (29.5) (0.0) (77.7) 46 12-17 16.4 11.7 79.7 4.1 97.4 72.6 24.3 43.7 25.8 63.4 2.5 99.2 82 18-23 6.3 14.8 73.3 4.9 96.0 75.0 41.3 39.3 43.4 57.8 3.2 96.8 387 6-23 9.8 14.2 74.1 6.0 95.3 73.1 36.8 38.8 38.7 57.2 2.9 96.8 505 Total 10.3 14.4 72.7 6.0 94.1 71.7 36.1 38.0 38.2 56.2 2.8 95.5 515 Note: Breastfeeding status and food consumed refer to a ‘24-hour’ period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. 1 Other milk includes fresh, tinned and powdered cow or other animal milk 2 Does not include plain water 3 Includes fortified baby food 4 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mangoes, papayas, and guavas 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Infant and Young Child Feeding (IYCF) practices include three components for children age 6-23 months. In addition to continuing breastfeeding, from age 6 months children should be fed solid/semisolid foods a minimum number of times a day. As a child ages the number of food groups introduced and the frequency of feeding should increase. For the average, healthy breastfed child, solid/semisolid foods should be provided two to three times per day at age 6-8 months and three to four times per day from age 9-23 months, with an additional snack being offered one to two times per day, as desired. The minimum feeding frequencies are based upon the energy needs from complementary foods according to age-specific total daily energy requirements plus 2 SD (to meet the Nutrition of Children and Adults | 141 needs of almost all children), minus the average energy intake from breast milk for children in developing countries. Infants with low breast milk intake would need to be fed more frequently. However, feeding frequencies greater than necessary may lead to the displacement of breast milk (PAHO/WHO, 2003). Although it is internationally recommended that infants should be breastfed for up to two years, some infants are not breastfed and therefore do not receive the benefits of breastfeeding, while others stop breastfeeding before age 2. Guidelines have been developed for this group of children who may not be breastfed because of the mother’s known HIV-positive status, or the mother having died, or some other reason (WHO, 2005). It is recommended that the nonbreastfed child be fed solid/semisolid foods four to five times per day from age 6-23 months, with an additional snack being offered once or twice per day, as desired. Appropriate nutrition includes feeding children a variety of foods to ensure that nutrient requirements are met. Studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO/UNICEF, 1998). Therefore, it has been advised that meat, poultry, fish, or eggs should be eaten daily, or as often as possible. Vegetarian diets may not meet children’s nutrient requirements unless supplements or fortified products are used. Vitamin A-rich fruits and vegetables should be consumed daily. Children’s diets should also include adequate fat content. Fat is important in the diets of infants and young children because it provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A), and enhances dietary energy, density, and palatability. Tea and coffee contain compounds that inhibit iron absorption and are not recommended for children. Sugary drinks and excessive juice consumption should be avoided because, other than energy, they contribute little to the diet and as a result decrease the child’s appetite for more nutritious foods (PAHO/WHO, 2003). The nutritional requirements of children age 6-23 months can be summarised as follows: Breastfed children age 6-23 months should receive animal-source foods and vitamin A-rich fruits and vegetables daily (PAHO/WHO, 2003). Because first foods almost universally include a grain- or tuber-based staple, it is unlikely that young children who eat foods from two or fewer food groups will receive both an animal-source food and a vitamin A-rich fruit or vegetable. Therefore, four food groups are considered the minimum appropriate number of food groups for breastfed infants (Arimond and Ruel, 2004). Breastfed infants age 6-8 months should be fed meals of complementary foods two or three times per day, with one or two snacks as desired; breastfed children age 9-23 months should be fed meals three or four times per day, with one or two snacks (PAHO/WHO, 2003). Nonbreastfed children age 6-23 months should receive milk products to ensure that their calcium needs are met. In addition, they need animal-source foods and vitamin A-rich fruits and vegetables. Therefore, four food groups are considered the minimum appropriate number of food groups for nonbreastfed young children. Nonbreastfed children age 6-23 months should be fed meals four or five times per day, with one or two snacks as desired (WHO, 2005). Table 11.6 presents summary indicators for three IYCF practices based on the percentage of breastfed and nonbreastfed children for whom feeding practices met minimum standards with respect to food diversity (i.e., the number of food groups consumed), feeding frequency (i.e., the number of times the child was fed), and the consumption of breast milk or other milk or milk products. According to the results presented in Table 11.6 and Figure 11.6, only 19 percent of youngest children age 6-23 months living with their mother are fed in accordance with IYCF practices. Nine in ten children (92 percent) received breast milk or milk products during the 24-hour period before the survey, and 29 percent of children were fed according to minimum standards with respect to food diversity (three or more food groups for breastfed children and four or more food groups for nonbreastfed children). Over half of children (54 percent) were fed at least the minimum number of times. Older children and children in urban areas are more likely to be fed according to the IYCF 142 | Nutrition of Children and Adults practices than other children. In addition, feeding practices improve as the wealth quintile and the education level of the mother increase. Among breastfed children age 6-23 months, 28 percent receive foods from at least four food groups, while 56 percent are fed the minimum number of times or more. Nonbreastfed children age 6- 23 months are much less likely than breastfed children to be fed according to IYCF practices (5 percent versus 20 percent). Fourteen percent receive any milk or milk products, and 34 percent are fed four or more times per day. Forty-five percent are fed foods from at least four food groups. Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups and times they are fed during the day or night preceding the survey, by background characteristics, Malawi 2010 Background characteristic Among breastfed children 6-23 months, percentage fed: Among non-breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: 4+ food groups1 Minimu m meal frequen- cy2 Both 4+ food groups and minimum meal frequen- cy Number of breastfed children 6-23 months Milk or milk products3 4+ food groups1 Minimum meal frequen- cy4 With 3 IYCF practices5 Number of non- breastfed children 6-23 months Breast milk, milk, or milk products6 4+ food groups1 Minimum meal frequen- cy With 3 IYCF practices Number of all children 6-23 months Age in months 6-8 12.3 65.9 11.6 1,054 * * * * 21 99.0 12.3 65.7 11.5 1,075 9-11 27.2 45.8 17.6 902 * * * * 15 98.9 27.7 46.0 17.5 917 12-17 33.4 56.4 23.8 1,603 23.7 38.0 49.1 8.4 82 96.3 33.6 56.0 23.1 1,685 18-23 33.1 54.7 22.6 1,563 9.7 48.3 27.9 4.0 387 82.1 36.1 49.4 18.9 1,950 Sex Male 27.5 56.7 20.2 2,632 16.9 46.4 34.5 6.4 247 92.9 29.1 54.8 19.0 2,879 Female 28.3 55.1 19.5 2,490 11.9 44.4 32.6 3.3 258 91.7 29.8 53.0 17.9 2,747 Residence Urban 36.7 67.4 27.3 723 24.6 50.7 54.2 7.3 112 89.9 38.6 65.7 24.6 835 Rural 26.4 54.0 18.6 4,398 11.4 43.9 27.6 4.1 394 92.7 27.9 51.9 17.4 4,792 Region Northern 30.5 56.9 19.9 591 9.9 41.5 27.6 6.5 52 92.7 31.4 54.6 18.8 644 Central 29.2 54.3 21.2 2,298 16.7 42.7 36.4 4.8 185 93.8 30.2 52.9 20.0 2,482 Southern 25.8 57.4 18.4 2,233 13.6 48.0 32.7 4.5 268 90.7 28.2 54.7 16.9 2,501 Mother’s education No education 18.2 47.9 12.8 861 5.4 33.1 14.2 0.5 73 92.6 19.3 45.3 11.8 934 Primary 28.1 55.8 19.8 3,478 13.8 41.0 31.8 4.3 313 92.9 29.2 53.8 18.5 3,790 Secondary 37.0 64.1 26.6 745 22.2 63.9 47.5 8.8 110 90.0 40.4 62.0 24.3 855 More than secondary * * * 38 * * * * 10 (81.7) (53.6) (85.8) (41.5) 47 Wealth quintile Lowest 21.1 51.0 14.8 1,156 6.7 30.5 19.2 1.9 83 93.8 21.7 48.9 13.9 1,239 Second 22.9 50.5 15.0 1,096 9.4 31.9 28.6 4.4 91 93.1 23.6 48.9 14.1 1,187 Middle 29.7 52.5 21.2 1,139 6.3 43.0 21.7 2.6 83 93.7 30.6 50.5 19.9 1,221 Fourth 29.9 63.3 22.9 916 20.2 58.4 41.6 5.5 124 90.4 33.3 60.7 20.9 1,041 Highest 39.3 66.7 28.3 815 22.5 53.8 46.3 8.0 124 89.8 41.2 64.0 25.6 939 Total 27.9 55.9 19.9 5,121 14.3 45.4 33.5 4.8 505 92.3 29.4 53.9 18.5 5,627 Note: Parentheses indicate that a figure is based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Food groups:1) infant formula, milk other than breast milk, cheese or yogurt or other milk products; 2) foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; 3) vitamin A-rich fruits and vegetables (and red palm oil); 4) other fruits and vegetables; 5) eggs; 6) meat, poultry, fish, and shellfish (and organ meats); 7) legumes and nuts 2 For breastfed children, minimum meal frequency is receiving solid or semi-solid food at least twice a day for infants 6-8 months and at least three times a day for children 9-23 months 3 Includes two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 4 For nonbreastfed children age 6-23 months, minimum meal frequency is receiving solid or semi-solid food or milk feeds at least four times a day 5 Nonbreastfed children age 6-23 months are considered to be fed with a minimum standard of three IYCF practices if they receive other milk or milk products at least twice a day, receive the minimum meal frequency, and receive solid or semi-solid foods from at least four food groups not including the milk/milk product group 6 Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 7 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in footnotes 2 and 4 Nutrition of Children and Adults | 143 Figure 11.6 IYCF Feeding Practices MDHS 2010 28 56 20 45 34 5 29 54 19 IYCF 5: Minimum dietary diversity IYCF 6: Minimum meal frequency IYCF 7: Minimum acceptable diet 0 10 20 30 40 50 60 70 Percent Breastfed children Non-breastfed children All children 6-23 months 11.7 PREVALENCE OF ANAEMIA IN CHILDREN Anaemia is a serious concern for young children because it can result in impaired cognitive performance, behavioural and motor development, coordination, language development, and scholastic achievement, as well as increased morbidity from infectious diseases. Information on the prevalence of anaemia can be useful for the development of health intervention programmes designed to prevent anaemia, such as iron fortification programmes. Table 11.7 shows that 63 percent of children age 6-59 months are anaemic. Almost one in every four children (23 percent) has mild anaemia, 36 percent have moderate anaemia, and 3 percent have severe anaemia. Anaemia prevalence is highest among children age 6-11 months (over 80 percent), and decreases steadily with age between 12 and 59 months. Fifty-three percent of children in urban areas have anaemia, compared with 64 percent of children in rural areas. Similarly, regional variation of anaemia in children is observed, with the Northern Region slightly lower (58 percent) than the Central and Southern Regions (64 and 62 percent, respectively). Anaemia among children decreases with an increase in mother’s education and in wealth quintile. 144 | Nutrition of Children and Adults Table 11.7 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Malawi 2010 Background characteristic Any anaemia (<11.0 g/dl) Anaemia status by haemoglobin level Number of children Mild anaemia (10.0-10.9 g/dl) Moderate anaemia (7.0-9.9 g/dl) Severe anaemia (below 7.0 g/dl) Age in months 6-8 80.2 24.0 48.9 7.3 253 9-11 85.0 23.3 56.9 4.9 249 12-17 75.0 23.7 47.9 3.4 497 18-23 70.8 24.4 42.6 3.8 585 24-35 64.8 23.5 36.8 4.4 970 36-47 53.9 22.9 28.9 2.1 1,010 48-59 47.0 22.7 23.5 0.8 950 Sex Male 63.2 23.9 36.2 3.1 2,224 Female 61.8 22.8 35.8 3.2 2,291 Mother’s interview status Interviewed 62.7 23.1 36.4 3.2 4,203 Not interviewed but in household 58.4 18.6 37.5 2.3 82 Not interviewed, and not in the household1 60.2 30.7 27.9 1.6 229 Residence Urban 53.2 20.8 30.0 2.4 636 Rural 64.0 23.8 37.0 3.2 3,879 Region Northern 58.3 26.3 29.7 2.3 512 Central 63.6 21.3 38.6 3.7 2,102 Southern 62.3 24.8 34.8 2.7 1,901 Mother’s education2 No education 64.9 23.4 37.4 4.0 767 Primary 63.4 22.7 37.5 3.2 2,900 Secondary 55.6 23.7 29.8 2.1 607 More than secondary * * * * 12 Wealth quintile Lowest 68.4 22.8 40.8 4.8 819 Second 64.5 23.2 38.3 3.0 1,038 Middle 65.4 23.9 37.1 4.4 997 Fourth 61.5 23.2 36.2 2.1 833 Highest 51.5 23.6 26.8 1.1 828 Total 62.5 23.4 36.0 3.1 4,515 Note: Table is based on children who stayed in the household the night before the interview. Prevalence of anaemia, based on haemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Haemoglobin in grams per decilitre (g/dl). An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Anaemia prevalence among children has declined from 73 percent in the 2004 MDHS to 63 percent in the 2010 MDHS. 11.8 MICRONUTRIENT INTAKE AMONG CHILDREN Table 11.8 summarises information collected in the 2010 MDHS on the intake of vitamin A and iron and on receipt of deworming medications by children. Vitamin A is an essential micronutrient for the immune system that plays an important role in maintaining the epithelial tissue in the body. Severe Vitamin A Deficiency (VAD) can cause eye damage. VAD can also increase severity of infections, such as measles and diarrhoeal diseases in children, and slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin A for four to six months. Periodic dosing (usually Nutrition of Children and Adults | 145 every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. Table 11.8 shows that three of the four youngest children age 6-23 months living with their mother consumed foods rich in vitamin A in the 24 hours preceding the interview. The proportion of children who consumed foods rich in vitamin A increases with age, from 40 percent of children age 6- 8 months to 89 percent of children age 18-23 months. Nonbreastfeeding children (88 percent) are more likely to consume foods rich in vitamin A than breastfeeding children (76 percent). Urban children (81 percent) are more likely than rural children (76 percent) to consume foods rich in vitamin A. With regard to regions, children living in the Northern Region (79 percent) are somewhat more likely to consume foods rich in vitamin A than children in the Central and Southern Regions (76 percent and 77 percent, respectively). Mother’s level of education is directly related to the consumption of foods rich in vitamin A: 73 percent of children whose mothers have no education consumed foods rich in vitamin A in the 24 hours before the survey, which compares with 82 percent of children whose mothers have a secondary education. Likewise, as wealth status increases, so does the proportion of children who receive foods rich in vitamin A, from 73 percent among children in the lowest wealth quintile to 79 percent among children in the highest wealth quintile. The 2010 MDHS collected information on children’s intake of iron. Iron is essential for cognitive development. Low iron intake can also contribute to anaemia. Iron requirements are greatest between age 6 and 11 months, when growth is most rapid. Table 11.8 shows that 45 percent of the youngest children age 6-23 months who live with their mother consumed foods rich in iron in the 24 hours preceding the interview. The proportion of children who are fed foods rich in iron increases with age, from 21 percent among children age 6-8 months to 51 percent or more among children age 12-23 months. As expected, breastfeeding children (43 percent) are less likely to consume iron-rich foods than those that are not breastfeeding (58 percent). Urban children (62 percent) are more likely than rural children (42 percent) to receive iron-rich foods. By region, the proportion of children who consumed iron-rich foods ranges from 43 percent in the Central Region to 48 percent in the Northern Region. Children whose mothers were age 40-49 at the time of their birth are less likely than children born to younger mothers to consume foods rich in iron. The proportion of children who are fed foods rich in iron increases with mother’s level of education, from 34 percent among children whose mothers have no education to 59 percent among children whose mothers have secondary education. Similarly, the proportion of children who are fed foods rich in iron increases with wealth status, from 33 percent among children in households in the lowest wealth quintile to 63 percent among children in households in the highest wealth quintile. The 2010 MDHS also collected information on vitamin A supplementation. As shown in Table 11.8, four in five children age 6-59 months received vitamin A supplements in the six months preceding the survey. Almost nine in ten rural children, compared with eight in ten urban children, received vitamin A supplements in the six months preceding the survey. Mother’s level of education is closely associated with children receiving vitamin A supplements; 83 percent of children whose mothers have no education had received vitamin A supplements in the past six months compared with 93 percent of children whose mothers have more than a secondary education. However, the proportion of children who received vitamin A supplements does not differ with household wealth status. Infection with helminths or intestinal worms has been shown to have an adverse impact on the physical development of children and is associated with high levels of iron deficiency anaemia and other nutritional deficiencies. Regular treatment with deworming medication is a simple, cost- effective measure to address these infections. Table 11.8 shows that almost seven in ten children age 6-59 months received deworming medication during the six months preceding the survey. 146 | Nutrition of Children and Adults Table 11.8 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey, and among all children 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, who were given iron supplements in the past seven days, and who were given deworming medication in the six months preceding the survey, and among all children age 6-59 months who live in households that were tested for iodised salt, the percentage who live in households with iodised salt, by background characteristics, Malawi 2010 Background characteristic Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Among children age 6-59 months living in households tested for iodised salt Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Percentage given deworming medication in last 6 months3 Number of children Percentage living in households with iodised salt4 Number of children Age in months 6-8 40.2 21.2 1,075 69.2 18.2 1,088 97.9 876 9-11 76.1 44.1 917 86.1 38.2 930 98.0 737 12-17 86.3 52.7 1,685 87.6 55.3 1,718 97.3 1,381 18-23 88.6 50.9 1,950 88.0 72.9 2,056 97.0 1,679 24-35 na na na 89.0 77.6 3,675 97.3 3,017 36-47 na na na 85.7 77.9 3,471 97.0 2,821 48-59 na na na 84.5 78.3 3,376 96.7 2,700 Sex Male 76.0 43.7 2,879 85.3 68.1 8,037 97.2 6,513 Female 77.3 45.6 2,747 85.9 69.2 8,277 97.1 6,698 Breastfeeding status Breastfeeding 75.5 43.4 5,121 84.8 53.6 5,923 97.4 4,784 Not breastfeeding 88.3 57.7 490 86.2 77.5 10,202 96.9 8,263 Missing * * 15 78.1 63.5 190 98.5 164 Mother’s age at birth 15-19 72.7 43.8 477 82.3 53.5 746 97.3 590 20-29 75.2 46.0 3,266 85.8 69.8 9,344 96.8 7,629 30-39 74.4 44.7 1,552 85.8 69.4 4,984 97.8 4,022 40-49 75.7 32.4 333 85.5 66.4 1,240 96.6 971 Residence Urban 80.8 61.9 835 79.3 60.1 2,332 95.7 1,970 Rural 75.9 41.7 4,792 86.7 70.1 13,983 97.4 11,241 Region Northern 79.0 47.9 644 88.7 73.0 1,920 96.9 1,666 Central 75.8 43.0 2,482 83.8 62.5 7,022 97.2 5,673 Southern 76.8 45.5 2,501 86.5 73.4 7,373 97.2 5,872 Mother’s education No education 72.6 33.8 934 83.1 65.6 2,892 97.4 2,269 Primary 76.4 43.8 3,790 85.9 69.5 11,006 97.0 8,823 Secondary 81.5 58.6 855 86.9 68.7 2,303 97.6 2,016 More than secondary (82.8) (77.3) 47 93.1 63.9 114 95.0 103 Wealth quintile Lowest 72.7 33.1 1,239 85.0 67.0 3,556 96.7 2,755 Second 72.7 37.7 1,187 84.9 69.4 3,515 97.0 2,708 Middle 79.9 44.5 1,221 87.3 70.1 3,541 97.5 2,899 Fourth 79.7 50.0 1,041 86.1 70.1 2,999 97.9 2,506 Highest 79.1 62.9 939 84.5 66.4 2,702 96.7 2,343 Total 76.6 44.7 5,627 85.6 68.7 16,315 97.1 13,211 Note: Information on vitamin A is based on both mother’s recall and the immunisation card (where available). Information on iron supplements and deworming medication is based on the mother’s recall. Figures in parentheses are based on 25 to 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, papaya, and guava 2 Includes meat (including organ meat), fish, poultry, and eggs 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 4 Salt containing 15 parts per million (ppm) of iodine or more. Excludes children in households in which salt was not tested. The proportion of children who received the deworming medication increases with age from 18 percent among children age 6-8 months to 73 percent among children age 18-23 months, and to 78 percent among children age 24-59 months. Nutrition of Children and Adults | 147 The proportion of children who received deworming medication is much higher among non- breastfeeding children (78 percent) than among those who are breastfeeding (54 percent). The proportion of children receiving this medication is higher among rural children (70 percent) than urban children (60 percent). By region, the proportion of children who received deworming medication is highest in the Southern and Northern Regions (73 percent each) and lowest in the Central Region (63 percent). The likelihood that a child has received deworming medication is not associated with mother’s level of education or household wealth quintile. The 2010 MDHS collected information on household salt quality by testing for the level of iodine. Iodised salt prevents goitre and aids mental development, especially in children. The results of the testing of household salt indicated that almost all children age 6-59 months (97 percent) live in households with adequately iodised salt. 11.9 PRESENCE OF IODISED SALT IN HOUSEHOLDS Salt is used for several purposes in a household. It plays a role in cooking and food preservation, but not all types of salt are fit for consumption. In line with food and drug regulations, household salt should be iodised to at least 15 parts per million (ppm). Iodised salt is essential in the prevention of goitre among children and adults. The 2010 MDHS tested the quality of household salt in all households possessing salt (79 percent of households). Table 11.9 shows that, among these households, 97 percent have salt with adequate iodine content. There is almost no variation in the percentage of households with adequately iodised salt by residence, region, or household wealth. Table 11.9 Presence of iodised salt in households Among all households, percentage of households tested for iodine content and percentage of households without salt; and among households with salt tested, the percentage with iodine present in salt , according to background characteristics, Malawi 2010 Background characteristic Among all households, the percentage Number of households Among households with tested salt: Number of households With salt tested With no salt Percentage with iodine present Residence Urban 84.1 15.9 4,116 96.0 3,463 Rural 77.7 22.3 20,709 97.4 16,089 Region Northern 83.6 16.4 2,716 96.2 2,271 Central 78.0 22.0 10,627 97.5 8,289 Southern 78.3 21.7 11,482 97.1 8,992 Wealth quintile Lowest 73.2 26.8 5,253 97.0 3,843 Second 75.1 24.9 5,128 97.1 3,853 Middle 78.5 21.5 4,869 97.7 3,823 Fourth 80.6 19.4 4,808 97.6 3,875 Highest 87.2 12.8 4,767 96.5 4,159 Total 78.8 21.2 24,825 97.2 19,552 11.10 NUTRITIONAL STATUS OF WOMEN Anthropometric measurements of height and weight were collected for women age 15-49. In this report, two indicators of nutritional status based on these data are presented: the percentage of women with very short stature (less than 145 cm) and the body mass index (BMI). The body mass index (BMI), or the Quetelet Index, is used to measure thinness and obesity. BMI is defined as weight in kilograms divided by height in metres squared (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition, and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. Low pre-pregnancy BMI and short stature are risk factors 148 | Nutrition of Children and Adults for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is the leading risk factor for preventable deaths and diseases. Table 11.10 shows the percentage of women with height under 145 cm, the mean BMI, and the proportion of women falling into high-risk categories, according to background characteristics. Respondents for whom there was no information on height or weight and for whom a BMI could not be estimated are excluded from this analysis. The data analysis on BMI is based on 6,684 women, while the height analysis is based on 7,547 women age 15-49 years. Table 11.10 shows that 2 percent of women have short stature. Short stature decreases with increasing level of education and wealth status. Seventy-four percent of women have a normal BMI. The proportion of women with normal BMI decreases with age from 77 percent among women age 15-19 to 68 percent among women age 40-49. Normal BMI also decreases with increasing level of education and wealth quintile. Nine percent of women are thin, of which 2 percent are moderately or severely thin. The proportion of women who are thin is higher among women age 15-19, those in rural areas, those in the Central and Southern Regions, and those with lower levels of education and wealth. Nearly one in five women is either overweight or obese (17 percent). Thirteen percent of women are overweight and 4 percent are obese. Overweight and obesity increase by age from 7 percent among women age 15-19 to 25 percent among women age 40-49. Overweight and obesity also increase with level of education and wealth quintile. Obesity and overweight are more common among urban women (28 percent) than rural women (14 percent). Overweight and obesity are slightly higher for women in the Northern and Central Regions (18 percent each) than in the Southern Region (16 percent). Since the 2004 MDHS, the proportion of women who are thin has remained the same, the proportion of women who are normal has decreased from 77 to 74 percent, and the percentage who are overweight or obese has increased from 14 to 17 percent. Table 11.10 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Malawi 2010 Background characteristic Height Body Mass Index1 Percentage below 145 cm Number of women Mean Body Mass Index (BMI) 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Moderately and severely thin) ≥25.0 (Total over- weight or obese) 25.0-29.9 (Over- weight) ≥30.0 (Obese) Number of women Age 15-19 4.4 1,619 21.1 77.3 15.6 11.6 4.0 7.1 5.9 1.3 1,478 20-29 1.5 3,002 22.4 77.4 6.8 5.3 1.5 15.9 12.3 3.5 2,503 30-39 2.8 1,865 23.0 70.2 6.9 5.4 1.5 22.9 17.2 5.7 1,668 40-49 1.3 1,061 23.2 68.1 6.7 5.8 0.9 25.3 18.9 6.3 1,035 Residence Urban 1.3 1,476 23.6 64.7 7.3 5.9 1.4 28.0 18.0 10.0 1,386 Rural 2.7 6,071 22.1 76.6 9.1 7.0 2.1 14.3 11.9 2.4 5,297 Region Northern 2.8 858 22.5 76.1 6.4 4.7 1.7 17.5 14.2 3.3 742 Central 2.2 3,241 22.5 73.3 8.5 7.0 1.5 18.2 13.9 4.3 2,904 Southern 2.5 3,448 22.3 74.4 9.6 7.1 2.4 16.0 12.1 3.9 3,038 Education No education 2.7 1,146 22.1 78.1 8.4 6.8 1.6 13.5 10.9 2.6 1,014 Primary 2.8 4,889 22.2 73.9 9.6 7.4 2.2 16.4 13.3 3.2 4,292 Secondary 0.9 1,368 23.1 72.8 6.1 4.9 1.3 21.1 13.9 7.1 1,249 More than secondary 0.0 143 23.7 61.2 7.3 4.9 2.3 31.5 19.1 12.4 128 Wealth quintile Lowest 2.8 1,278 21.6 80.8 10.0 7.9 2.1 9.2 7.7 1.5 1,083 Second 2.6 1,484 21.9 77.5 9.9 7.8 2.1 12.7 9.9 2.8 1,312 Middle 2.7 1,468 21.9 77.4 9.4 6.5 2.9 13.2 12.2 1.0 1,260 Fourth 2.4 1,475 22.4 75.3 8.4 6.6 1.8 16.3 13.7 2.6 1,318 Highest 1.8 1,841 23.7 64.0 6.9 5.7 1.2 29.1 19.3 9.8 1,711 Total 2.4 7,547 22.4 74.1 8.8 6.8 1.9 17.1 13.1 4.0 6,684 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months Nutrition of Children and Adults | 149 11.11 PREVALENCE OF ANAEMIA AMONG WOMEN A woman’s nutritional status has important implications for the health status of the woman herself and her children. A woman who has poor nutritional status has a greater risk of adverse pregnancy outcomes as well as giving birth to a baby who is underweight. Table 11.11.1 shows the prevalence of anaemia among nonpregnant women, and Table 11.11.2 shows the prevalence of anaemia among women who are currently pregnant. Table 11.11.1, shows that 28 percent of nonpregnant women are anaemic: 22 percent have mild anaemia, 6 percent have moderate anaemia, and less than 1 percent has severe anaemia. The prevalence of anaemia is higher among women age 40-49, those who smoke, those in rural areas, and those in the lowest wealth quintile. Prevalence of anaemia by region ranges from 25 percent of women in the Northern Region to 29 percent of women in the Southern Region. Anaemia decreases with increasing education. Pregnant women are more likely to suffer from anaemia than nonpregnant women (38 percent versus 28 percent). One in five pregnant women has mild anaemia, a similar proportion has moderate anaemia, and less than 1 percent has severe anaemia. Table 11.11.1 Prevalence of anaemia in nonpregnant women Percentage of women age 15-49 with anaemia, by background characteristics, Malawi 2010 Background characteristic Any anaemia (<12.0 g/dl) Anaemia status by haemoglobin level Number of women Mild anaemia (10.0-11.9 g/dl) Moderate anaemia (7.0-9.9 g/dl) Severe anaemia (<7.0 g/dl) Age 15-19 27.7 22.7 4.5 0.5 1,472 20-29 26.9 21.0 5.5 0.3 2,520 30-39 27.7 21.0 6.2 0.6 1,654 40-49 31.8 23.1 7.5 1.3 1,010 Number of children ever born 0 27.6 22.6 4.4 0.7 1,417 1 26.0 18.6 7.1 0.3 855 2-3 28.5 21.7 6.5 0.4 1,831 4-5 28.9 22.6 5.6 0.7 1,246 6+ 28.1 21.9 5.5 0.7 1,308 Maternity status Breastfeeding 27.0 21.8 4.9 0.4 2,439 Not breastfeeding 28.6 21.6 6.3 0.7 4,217 Smoking status Smokes cigarettes/ tobacco 32.4 25.8 6.6 0.0 78 Does not smoke 28.0 21.7 5.7 0.6 6,576 Residence Urban 24.8 18.5 5.8 0.5 1,345 Rural 28.8 22.5 5.7 0.6 5,311 Region Northern 25.3 19.6 5.1 0.6 751 Central 27.5 22.0 5.0 0.4 2,928 Southern 29.2 21.9 6.6 0.7 2,976 Education No education 31.7 23.1 8.0 0.5 1,039 Primary 28.1 21.9 5.6 0.6 4,259 Secondary 25.5 20.5 4.5 0.4 1,232 More than secondary 20.4 15.1 4.4 1.0 126 Wealth quintile Lowest 31.6 24.9 5.9 0.8 1,109 Second 28.4 21.3 6.4 0.7 1,309 Middle 29.9 23.1 6.4 0.5 1,274 Fourth 25.8 19.7 5.8 0.4 1,284 Highest 25.6 20.4 4.7 0.5 1,680 Total 28.0 21.7 5.8 0.6 6,656 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. Total includes 3 women with information missing on smoking status. 150 | Nutrition of Children and Adults Table 11.11.2 Prevalence of anaemia in pregnant women Percentage of women age 15-49 with anaemia, by background characteristics, Malawi 2010 Background characteristic Any anaemia (<11.0 g/dl) Anaemia status by haemoglobin level Number of women Mild anaemia (10.0-10.9 g/dl) Moderate anaemia (7.0-9.9 g/dl) Severe anaemia (<7.0 g/dl) Age 15-19 40.1 21.6 18.5 0.0 113 20-29 37.5 19.8 17.4 0.3 387 30-39 35.1 16.0 19.1 0.0 148 40-49 * * * * 18 Number of children ever born 0 48.7 23.3 24.9 0.4 151 1 36.1 20.8 15.2 0.0 129 2-3 31.9 18.2 13.7 0.0 184 4-5 31.5 15.9 15.3 0.3 148 6+ 45.4 20.0 25.4 0.0 54 Smoking status Smokes cigarettes/ tobacco * * * * 3 Does not smoke 37.6 19.6 17.9 0.2 662 Residence Urban 37.3 17.8 19.6 0.0 70 Rural 37.5 19.7 17.6 0.2 596 Region Northern 35.0 23.8 11.1 0.0 83 Central 39.9 22.0 18.0 0.0 264 Southern 36.1 16.4 19.5 0.3 319 Education No education 34.7 10.9 23.8 0.0 92 Primary 35.4 18.6 16.7 0.1 478 Secondary 49.9 32.3 17.0 0.7 84 More than secondary * * * * 11 Wealth quintile Lowest 43.1 18.6 24.2 0.3 143 Second 34.9 16.6 18.2 0.0 136 Middle 37.8 20.0 17.8 0.0 155 Fourth 31.1 18.5 12.2 0.4 133 Highest 41.3 25.4 15.8 0.0 98 Total 37.5 19.5 17.8 0.2 666 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Anaemia prevalence among women has decreased since the 2004 MDHS. Among nonpregnant, nonbreastfeeding women, the percentage with any anaemia has decreased from 46 percent in 2004 to 29 percent in 2010. Among pregnant women, the percentage with any anaemia has decreased from 47 percent to 38 percent. 11.12 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Table 11.12 includes a number of measures that are useful in assessing the extent to which women are receiving adequate intake of vitamin A and iron. Breastfeeding children benefit from the micronutrient supplementation that mothers receive, especially vitamin A. Table 11.12 includes several measures of vitamin A and iron supplementation among mothers with young children and shows the proportion of mothers reporting night blindness during pregnancy, a condition associated with vitamin A deficiency (VAD). Nutrition of Children and Adults | 151 Table 11.12 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child; and the percentages who, during the pregnancy of the last child born in the five years prior to the survey, took iron tablets or syrup for specific numbers of days and took deworming medication; and among women age 15-49 with a child born in the past five years and who live in households that were tested for iodised salt, the percentage who live in households with iodised salt, by background characteristics, Malawi 2010 Background characteristic Among women with a child born in the past five years Among women with a child born in the last five years, who live in households that were tested for iodised salt Percentage who received vitamin A dose postpartum1 Number of days women took iron tablets or syrup during pregnancy of last birth Percentage of women who took deworming medication during pregnancy of last birth Number of women Percentage living in households with iodised salt2 Number of women None <60 60-89 90+ Don’t know/ missing Age 15-19 52.9 6.9 34.3 17.0 38.9 2.8 37.1 1,002 96.5 801 20-29 56.6 8.3 36.2 18.2 33.2 4.1 29.1 7,464 96.9 6,120 30-39 57.1 9.5 36.6 19.5 29.7 4.7 23.3 4,116 97.8 3,341 40-49 56.9 10.5 39.4 16.9 29.7 3.5 22.1 1,084 96.9 863 Residence Urban 54.6 7.2 32.6 15.5 40.0 4.8 29.9 2,107 95.6 1,816 Rural 56.8 9.0 37.1 18.9 30.9 4.0 26.9 11,558 97.4 9,309 Region Northern 61.1 5.5 47.6 16.4 22.3 8.2 24.7 1,595 96.8 1,396 Central 55.9 9.4 35.3 18.9 32.5 3.9 23.6 5,819 97.0 4,701 Southern 55.9 8.9 34.7 18.5 34.7 3.3 31.6 6,251 97.3 5,027 Education No education 54.4 13.6 33.5 19.9 29.3 3.7 25.2 2,277 97.6 1,795 Primary 55.7 8.2 38.1 18.5 31.1 4.0 27.3 9,144 97.1 7,353 Secondary 62.0 6.0 33.6 16.1 39.3 4.9 30.4 2,119 97.2 1,863 More than secondary 57.7 0.9 17.8 19.8 54.5 7.0 23.9 125 93.1 113 Wealth quintile Lowest 55.9 9.8 37.8 19.5 29.5 3.4 26.8 2,821 96.8 2,193 Second 53.8 9.8 38.1 18.5 29.6 3.9 27.1 2,894 97.2 2,245 Middle 55.7 8.7 36.0 18.8 32.5 4.0 26.5 2,906 97.5 2,359 Fourth 59.5 9.2 35.5 17.7 33.2 4.4 25.9 2,602 97.7 2,178 Highest 58.0 5.7 34.5 17.2 37.5 5.1 31.0 2,442 96.5 2,150 Total 56.5 8.7 36.4 18.4 32.3 4.1 27.4 13,664 97.1 11,124 1 In the first two months after delivery 2 Excludes women in households where salt was not tested The survey results indicate that 57 percent of women with children born in the five years preceding the survey received a dose of vitamin A in the first two months after the birth of the last child. Post-partum vitamin A supplementation is higher among rural women, those with secondary education, and those in the highest two wealth quintiles compared with other women. By region, the proportion of women who received a postpartum vitamin A supplement ranges from 56 percent in the Southern and Central Regions to 61 percent in the Northern Region. Table 11.12 shows the percent distribution of women who gave birth during the five years preceding the survey by the number of days they took iron tablets or syrup during the pregnancy for the last child. According to the results, 32 percent of women took iron supplements for 90 days or more, 36 percent took the iron tablets for fewer than 60 days, and 9 percent did not take any iron supplements at all. By region, the percentage of women who did not take any iron supplements during the pregnancy for the last birth ranges from 6 percent in the Northern Region to 9 percent in the Southern and Central Regions. Women age 40-49, those in rural areas, and those with no education are most likely not to have taken any iron supplements during pregnancy. Twenty-seven percent of women took deworming medication during their last pregnancy. The use of deworming medication during pregnancy is highest among urban women (30 percent), those with secondary education (30 percent), and those in the highest wealth quintile (31 percent). By region, the proportion of women who received deworming medication during pregnancy ranges from 24 percent in the Central Region to 32 percent in the Southern Region. Malaria | 153 MALARIA 12 12.1 INTRODUCTION Malaria is endemic throughout Malawi and continues to be a major public health problem, with an estimated six million cases occurring annually (NMCP, 2010a). It is the leading cause of morbidity and mortality in children under age 5 and pregnant women (NMCP, 2005). Ninety-eight percent of malaria infections in Malawi are caused by Plasmodium falciparum—with Anopheles funestus, A. gambiae, and A. arabiensis as the primary mosquito vectors. Malaria transmission is largely determined by climatic factors, including temperature, humidity, and rainfall. Vector abundance follows seasonal rainfall patterns, and an increase in temperature raises the parasite’s reproductive rate, thereby influencing the prevalence rate of malaria in the population. Transmission is higher in areas with high temperatures and during the rainy season (October through April), particularly along the lakeshore and lowland areas of the lower Shire Valley. The National Malaria Control Programme (NMCP) aims to reduce the burden of malaria to a level of no public health significance in Malawi. The NMCP, in collaboration with multiple partners, set high targets for coverage of interventions and reductions in malaria burden from 2005 to 2010 (NMCP, 2005). Principal strategic areas include case management, intermittent preventive treatment (IPT) among pregnant women, and vector control, consisting of insecticide-treated mosquito nets (ITNs), including long-lasting insecticidal nets (LLINs), and indoor residual spraying (IRS). The specific targets for 2005–2010 were based on the Abuja Declaration’s goal of halving malaria mortality and morbidity by the year 2010. Intervention targets were outlined as follows: 1. At least 80 percent of those suffering from fever due to malaria have access to and are able to use correct and appropriate treatment within 24 hours. 2. At least 80 percent of pregnant women have access to appropriate treatment by 2010. 3. At least 80 percent of pregnant women have access to malaria prevention by 2010. 4. At least 80 percent of children under age 5 and pregnant women sleep under ITNs (including LLINs) by 2010. Global and regional political commitment to preventing and controlling malaria has steadily increased in the past decade. The African Union heads of state jointly manifested this commitment in 2000 under the Abuja Declaration by calling for universal access to HIV/AIDS, tuberculosis, and malaria services by 2010 for all Africans (RBM/WHO, 2003). The Malawi government and its bilateral and multilateral partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the President’s Malaria Initiative (PMI), the United States Agency for International Development (USAID), the Department for International Development (DFID), as well as the World Health Organization (WHO) and other agencies under the United Nations system, have increased their provisions for financial and technical resources for malaria control interventions in the country in response to the continuing high burden. These resources have broadened coverage for malaria intervention within a short period of time. There are challenges, however, such as a continued rise in the number of reported suspected cases due to a lack of diagnostic equipment and training in health facilities, low coverage of ITNs per household, and low utilisation of proven LLINs. There are also inadequate surveillance mechanisms to assess disease burden and challenges in supply chain management of antimalarial medications, basic diagnostics, equipment for treatment, and other supplies. 154 | Malaria 12.2 MOSQUITO NETS The ownership and use of both treated and untreated mosquito nets is the primary prevention strategy for reducing malaria transmission in Malawi. The ITN policy includes free distribution of ITNs for pregnant women at their first visit to an antenatal care (ANC) clinic, for children born in health facilities, and for children attending their first visit under the Expanded Programme on Immunisation (EPI), if an ITN was not received at birth. To increase coverage, timely mass ITN distribution campaigns are conducted. Since 2007, Malawi has been moving to the use of long-lasting insecticidal nets (LLINs), which are heavy duty and pre-treated. In the past five years, over 6 million ITNs have been distributed country-wide in Malawi (NMCP, 2010a). This chapter presents the 2010 MDHS findings at the household level on the ownership and use of mosquito nets, particularly by children under age 5 and pregnant women.1 12.2.1 Ownership of Mosquito Nets All household respondents in the 2010 MDHS were asked if their household owned any mosquito nets and, if so, how many and what type. Interviewers were instructed to look at the nets whenever possible. Table 12.1 shows that 67 percent of all households owned at least one net, 57 percent of households owned at least one ITN, and 41 percent owned at least one LLIN. About 35 percent of households had more than one mosquito net, 27 percent of households had more than one ITN, and 16 percent of household had more than one LLIN. The average number of ITNs per household was 1.0, compared with an average of 1.2 for any type of mosquito net. Table 12.1 Household possession of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), insecticide treated net (ITN) and long-lasting insecticidal net (LLIN), and the average number of nets per household, by background characteristics, Malawi 2010 Background characteristic Any type of mosquito net Insecticide treated mosquito net (ITN)1 Long-lasting insecticidal net (LLIN) Number of households Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Percentage with at least one Percentage with more than one Average number of LLINs per household Residence Urban 74.8 44.7 1.5 64.3 35.1 1.2 41.5 17.9 0.7 4,116 Rural 65.8 33.5 1.1 55.4 25.5 0.9 41.2 15.8 0.6 20,709 Region Northern 69.8 43.9 1.4 56.5 31.3 1.1 43.7 21.2 0.7 2,716 Central 64.9 33.3 1.1 54.4 25.7 0.9 38.4 14.5 0.6 10,627 Southern 68.9 35.2 1.2 59.1 27.4 1.0 43.3 16.4 0.7 11,482 Wealth quintile Lowest 50.8 16.7 0.7 41.0 12.5 0.6 31.7 8.5 0.4 5,253 Second 61.9 26.3 1.0 51.3 19.4 0.8 39.7 13.0 0.6 5,128 Middle 68.8 35.9 1.2 58.3 26.9 0.9 44.1 16.6 0.6 4,869 Fourth 71.9 40.1 1.3 61.2 30.4 1.0 44.3 18.3 0.7 4,808 Highest 85.0 60.2 2.0 74.3 48.2 1.6 47.6 25.1 0.9 4,767 Total 67.3 35.4 1.2 56.8 27.1 1.0 41.3 16.1 0.6 24,825 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months Three-quarters of households in urban areas reported owning at least one net, compared with 66 percent of households in rural areas. Sixty-four percent of households in urban areas reported having at least one ITN, compared with 55 percent of households in rural areas. Ownership of LLINs is about the same in urban and rural areas (42 percent and 41 percent, respectively). By region, household ownership of ITNs is slightly higher in the Southern Region (59 percent compared with 57 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. Malaria | 155 percent or lower), and ownership of an LLIN is higher in the Northern and Southern Regions (44 percent and 43 percent, respectively) than in the Central Region (38 percent). Ownership of any type of mosquito net is also slightly higher in the Northern and Southern Regions than in the Central Region. Wealthier households are more likely to own mosquito nets. Eighty-five percent of the households in the highest wealth quintile own any type of mosquito net, 74 percent own an ITN, and 48 percent own an LLIN. Forty-one percent of the households in the lowest wealth quintile own at least one ITN. There has been remarkable progress in net ownership, which has increased from 42 percent in the 2004 MDHS to 67 percent in the 2010 MDHS. 12.2.2 Use of Mosquito Nets by Persons in the Household Table 12.2 shows that 35 percent of the household population slept under any net the night before the survey, compared with 29 percent who slept under an ITN and 19 percent who slept under an LLIN, respectively. This information serves as baseline information for the government policy promoting universal coverage of, or access to LLINs. In households that own at least one ITN, 48 percent of the household population slept under an ITN the night before the survey. Table 12.2 Use of mosquito nets by persons in the household Percentage of the de facto household population who slept the night before the survey under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), and under a long-lasting insecticidal net (LLIN); and among the de facto household population in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Malawi 2010 Background characteristic Household population Household population in households with at least one ITN1 Slept under any net last night Slept under an ITN1 last night Slept under an LLIN last night Number Slept under an ITN1 last night Number Age <5 45.2 37.9 27.0 23,431 57.5 15,460 5-14 24.9 20.1 13.0 32,126 34.4 18,803 15-34 37.3 31.4 21.2 34,780 50.4 21,718 35-49 43.0 35.3 22.8 11,844 56.9 7,342 50+ 28.7 21.8 13.0 11,347 49.3 5,012 Residence Urban 46.2 38.2 21.8 17,896 56.8 12,032 Rural 33.1 27.3 19.0 95,677 46.4 56,318 Region Northern 34.6 26.7 19.4 13,521 45.0 8,033 Central 33.1 27.2 17.4 49,376 47.2 28,471 Southern 37.3 31.3 21.4 50,676 49.8 31,846 Wealth quintile Lowest 23.1 18.6 14.0 22,627 41.4 10,135 Second 29.4 24.3 18.0 22,708 44.6 12,365 Middle 35.3 28.7 20.6 22,679 47.0 13,855 Fourth 37.5 30.6 20.7 22,744 47.5 14,628 Highest 50.4 42.8 23.9 22,817 56.2 17,366 Total 35.2 29.0 19.4 113,574 48.2 68,350 Note: Total includes 46 persons missing information on age. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.2.3 Use of Mosquito Nets by Children Under Five Years Children under age 5 are most vulnerable to severe complications of malarial infection due to their reduced immunity. 156 | Malaria Table 12.3 shows the use of mosquito nets by children under age 5. Almost half of all children (47 percent) slept under a mosquito net the night before the survey, 39 percent slept under an ITN, and 28 percent slept under an LLIN. However, in households with at least one ITN, 59 percent of children slept under an ITN the night before the survey. Table 12.3 Use of mosquito nets by children Percentage of children under age 5 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), and under a long-lasting insecticidal net (LLIN); and among children under age 5 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Malawi 2010 Background characteristic Children under age 5 in all households Children under age 5 in households with an ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Number of children Percentage who slept under an ITN1 last night Number of children Age in years <1 54.0 47.4 37.1 3,830 63.4 2,865 1 51.8 42.6 30.3 3,919 63.4 2,634 2 44.8 37.7 27.8 3,971 58.2 2,573 3 42.2 34.9 24.0 3,886 56.1 2,419 4 42.2 34.4 22.9 3,814 52.9 2,479 Sex Male 46.6 38.6 27.5 9,514 58.1 6,327 Female 47.4 40.2 29.2 9,905 59.9 6,643 Residence Urban 59.0 48.4 29.3 2,634 68.5 1,860 Rural 45.1 38.0 28.2 16,785 57.4 11,109 Region Northern 45.9 36.5 28.9 2,312 54.5 1,549 Central 46.0 38.5 26.7 8,404 59.2 5,469 Southern 48.2 41.1 29.9 8,703 60.1 5,951 Wealth quintile Lowest 34.6 28.8 22.7 4,344 53.9 2,322 Second 41.9 35.1 27.4 4,200 54.9 2,690 Middle 49.5 41.5 30.9 4,158 59.2 2,915 Fourth 51.3 42.1 31.0 3,587 59.4 2,542 Highest 62.7 54.0 31.3 3,130 67.6 2,501 Total 47.0 39.4 28.4 19,420 59.0 12,969 Note: Table is based on children who stayed in the household the night before the interview. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. There is no variation by gender in the use of ITNs and conventional nets. Children in urban areas are slightly more likely to use ITNs (48 percent) than those in rural areas (38 percent), but there is no variation in the use of LLINs by area of residence. Additionally, children under age 2 are more likely to use any type of net for sleeping than children age 2 and older. It is worth noting that these estimates for net use among children under age 5 are lower than those found in the 2010 Malawi National Malaria Indicator Survey (MIS) (NMCP, 2010b). The differences may be due in part to the seasonal nature of malaria transmission and the timing of data collection for the two surveys. The fieldwork for the 2010 MIS was conducted during March and April, the peak malaria transmission season. Fieldwork for the 2010 MDHS, on the other hand, was conducted from June to November, when transmission rates are lower. The results for net ownership at the household level are comparable between the two surveys. 12.2.4 Use of Mosquito Nets by Pregnant Women To prevent complications from malaria during pregnancy, such as anaemia, low birth weight, and trans-placental parasitaemia, all pregnant women are encouraged to sleep under ITNs. Malaria | 157 Table 12.4 shows that 43 percent of all pregnant women age 15 to 49 years slept under any net the night before the survey. Use of any net was higher among urban pregnant women (50 percent) than rural women (42 percent). Thirty-five percent of pregnant women slept under an ITN the night before the survey, including 44 percent of pregnant women in urban areas and 34 percent of pregnant women in rural areas. However, among pregnant women in households with at least one ITN, 57 percent slept under an ITN the night before the survey. Among pregnant women living in households with an ITN, more urban women slept under an ITN (71 percent) than their rural counterparts (55 percent). Women with secondary education were more likely to have slept under an ITN the night before the survey (50 percent) than those with primary and no education (33 percent and 31 percent, respectively). Women in the highest three wealth quintiles were more likely to have slept under an ITN than those in the lowest two quintiles. Table 12.4 Use of mosquito nets by pregnant women Percentages of pregnant women age 15-49 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), and under a long-lasting insecticidal net (LLIN); and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Malawi 2010 Background characteristic Among pregnant women age 15-49 in all households Among pregnant women age 15-49 in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Number of women Percentage who slept under an ITN1 last night Number of women Residence Urban 49.8 43.6 24.5 248 71.1 152 Rural 42.1 34.1 25.0 1,838 54.6 1,149 Region Northern 48.4 35.5 23.3 249 57.9 153 Central 40.1 32.4 24.2 860 55.6 500 Southern 44.3 37.7 26.0 977 56.9 648 Education No education 36.8 31.4 24.9 309 54.6 177 Primary 40.7 32.6 24.3 1,464 54.2 881 Secondary 57.7 50.0 28.5 289 65.9 219 More than secondary * * * 25 * 24 Wealth quintile Lowest 29.9 22.5 20.2 416 48.9 191 Second 37.8 28.6 23.4 478 49.1 278 Middle 44.7 38.1 28.3 481 56.2 326 Fourth 49.2 42.2 26.4 370 61.8 252 Highest 57.4 48.5 26.6 341 65.5 253 Total 43.1 35.2 24.9 2,086 56.5 1,301 Note: Table is based on women who stayed in the household the night before the interview. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.3 INDOOR RESIDUAL SPRAYING Nationally, indoor residual spraying (IRS) has not yet been fully implemented as a malaria prevention method. At the time of fieldwork for the 2010 MDHS, IRS activities had been limited to Nkhotakota District and limited private spraying in Blantyre City and Sugar Estates in Nkhotakota and Chikhwawa. The programme expanded to a total of seven districts in 2011, after the 2010 MDHS fieldwork was completed. 158 | Malaria Table 12.5 shows that coverage of IRS at the national level is limited. Two percent of all households were sprayed in the past 12 months. By combining IRS with use of an ITN, it is possible to look at a combined indicator of malaria protection at the household level. Overall, 58 percent of households are protected either by owning an ITN or having received IRS in the past 12 months. Table 12.5 Indoor residual spraying against mosquitoes Percentage of households in which someone has come into the dwelling to spray the interior walls against mosquitoes (IRS) in the past 12 months, and the percentage of households with at least one insecticide treated net (ITN) and/or IRS in the past 12 months, by background characteristics, Malawi 2010 Background characteristic Percentage of households with interior walls sprayed in the past 12 months Percentage of households with at least one ITN1 and/or IRS in the past 12 months Number of households Residence Urban 1.7 64.9 4,116 Rural 2.3 56.2 20,709 Region Northern 0.7 56.7 2,716 Central 4.2 56.0 10,627 Southern 0.7 59.4 11,482 Wealth quintile Lowest 2.0 42.0 5,253 Second 2.2 52.1 5,128 Middle 2.1 58.9 4,869 Fourth 2.3 62.0 4,808 Highest 2.4 75.1 4,767 Total 2.2 57.6 24,825 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. Table 12.6 shows that 31 percent of the household population slept under an ITN or in a dwelling that received IRS in the past 12 months, while 41 percent of children under age 5 slept under an ITN or in a dwelling that received IRS. Thirty-six percent of pregnant women slept under an ITN or in a dwelling that received IRS in the past 12 months. Malaria | 159 Table 12.6 Use of mosquito nets or sleeping in a house which received IRS Percentages of the de facto household population, of children under age 5, and of pregnant women age 15-49 who, the night before the survey, slept under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes in the past 12 months (IRS), by background characteristics, Malawi 2010 Background characteristic Household population Children under age 5 Pregnant women Slept under an ITN1 last night or in a dwelling with IRS in the past 12 months Number of persons Slept under an ITN1 last night or in a dwelling with IRS in the past 12 months Number of children Slept under an ITN1 last night or in a dwelling with IRS in the past 12 months Number of pregnant women Residence Urban 39.5 17,896 49.2 2,634 43.9 248 Rural 28.9 95,677 39.3 16,785 35.2 1,838 Region Northern 27.0 13,521 36.8 2,312 35.8 249 Central 30.4 49,376 41.1 8,404 34.5 860 Southern 31.7 50,676 41.3 8,703 37.8 977 Wealth quintile Lowest 20.5 22,627 30.3 4,344 23.8 416 Second 26.0 22,708 36.6 4,200 29.7 478 Middle 30.2 22,679 42.4 4,158 39.2 481 Fourth 32.0 22,744 43.4 3,587 42.8 370 Highest 44.1 22,817 55.0 3,130 49.1 341 Total 30.6 113,574 40.7 19,420 36.2 2,086 Note: Table is based on those who stayed in the household the night before the interview. IRS = Indoor residual spraying 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.4 USE OF INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY Pregnant women are particularly vulnerable to malaria because their immune systems are suppressed. Malaria can cause anaemia, low birth weight, and spontaneous abortion. For over a decade, the Ministry of Health (MOH) has been implementing intermittent preventive treatment during pregnancy (IPTp) by provision of at least two doses of sulfadoxine-pyrimethamine (SP)/Fansidar to protect the mother and her child from malaria during routine antenatal care visits in the second and third trimesters of pregnancy. Table 12.7 presents the results for use of IPTp by women during pregnancy for their last live birth in the two years preceding the survey. Eighty-nine percent (89 percent) of mothers reported taking any antimalarial drugs during pregnancy, with 55 percent receiving IPTp (taking the recommended two or more doses of SP/Fansidar). Fifty-four percent of pregnant women received two or more doses of SP/Fansidar and received at least one of them during ANC. Women in the Central Region are more likely than women in the Northern and Southern Regions to do so (59 percent versus 50 percent). The percentage of women taking two or more doses of SP/Fansidar during pregnancy and receiving at least one dose during ANC increases from 51 percent among women with no education to 58 percent among women with a secondary education. 160 | Malaria Table 12.7 Prophylactic use of antimalarial drugs and use of Intermittent Preventive Treatment (IPTp) by women during pregnancy Percentages of women age 15-49 with a live birth in the two years preceding the survey who, during the pregnancy, took any antimalarial drug for prevention, who took one dose of SP/Fansidar, and who received Intermittent Preventive Treatment (IPTp)1, by background characteristics, Malawi 2010 Background characteristic Percentage who took any antimalarial drug SP/Fansidar Intermittent Preventive Treatment1 Number of women with a live birth in the two years preceding the survey Percentage who took any SP/Fansidar Percentage who received any SP/Fansidar during any ANC visit Percentage who took 2+ doses of SP/Fansidar Percentage who took 2+ doses of SP/Fansidar and received at least one during an ANC visit Residence Urban 94.2 92.9 91.6 55.9 55.2 1,138 Rural 87.8 86.7 84.8 54.8 53.6 6,586 Region Northern 91.0 89.9 88.3 51.1 50.3 889 Central 88.8 88.0 86.6 60.1 59.1 3,375 Southern 88.1 86.7 84.3 51.0 49.7 3,461 Education No education 82.7 82.1 79.7 52.5 51.1 1,249 Primary 89.0 87.8 86.1 54.7 53.5 5,236 Secondary 94.2 92.6 90.4 59.2 58.1 1,169 More than secondary (89.6) (89.6) (89.6) (53.3) (53.3) 70 Wealth quintile Lowest 83.5 82.8 81.1 52.7 51.6 1,669 Second 87.2 86.2 84.4 54.3 53.3 1,669 Middle 90.0 88.7 86.3 56.9 55.4 1,689 Fourth 91.4 90.4 88.6 56.2 55.2 1,409 Highest 92.9 91.3 89.8 55.1 53.9 1,288 Total 88.7 87.6 85.8 55.0 53.8 7,724 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 1 IPTp: Intermittent Preventive Treatment during pregnancy is preventive treatment with two or more doses of SP/Fansidar 12.5 PREVALENCE AND PROMPT TREATMENT OF FEVER Malaria case management, including the identification, diagnosis, and rapid treatment of all malaria cases with appropriate and effective antimalarial drugs, is one of the key strategic areas for malaria control in Malawi. Most malarial fevers occur at home, and prompt and effective treatment is critical to prevent severe morbidity and mortality related to malaria. Table 12.8 shows that 35 percent of children under age 5 had fever during the two weeks preceding the survey, with a slightly higher proportion of children having fever in rural areas (35 percent) than in urban areas (31 percent). Children in the highest wealth quintile were slightly less likely to have experienced fever (29 percent) than those in the lower wealth quintiles (34 percent or higher). Malaria | 161 Table 12.8 Prevalence and prompt treatment of fever Percentage of children under age 5 with fever in the two weeks preceding the survey, and among children under age 5 with fever, the percentage who had blood taken from a finger or heel, the percentage who took antimalarial drugs and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Malawi 2010 Background characteristic Among children under age 5: Among children under age 5 with fever: Percentage with fever in the two weeks preceding the survey Number of children Percentage who had blood taken from finger or heel for testing Percentage who took antimalarial drugs Percentage who took antimalarial drugs same or next day Number of children Age (in months) <12 34.9 3,717 18.0 32.1 20.5 1,296 12-23 40.9 3,774 17.4 47.3 31.2 1,545 24-35 37.0 3,675 19.3 48.1 30.5 1,359 36-47 31.4 3,471 16.2 44.9 29.7 1,091 48-59 27.4 3,376 15.5 43.9 29.0 924 Residence Urban 30.7 2,559 28.8 42.6 24.3 786 Rural 35.1 15,454 15.8 43.5 28.8 5,428 Region Northern 29.4 2,130 14.3 46.8 28.2 626 Central 38.1 7,749 18.0 44.4 28.8 2,954 Southern 32.4 8,134 17.6 41.4 27.7 2,634 Mother’s education No education 34.1 3,068 14.9 41.7 27.4 1,045 Primary 34.9 12,227 17.7 44.0 28.4 4,271 Secondary 33.0 2,674 19.3 42.4 28.0 884 More than secondary (33.3) 44 * * * 15 Wealth quintile Lowest 35.6 3,927 12.6 40.8 27.3 1,397 Second 34.8 3,896 12.9 42.5 26.9 1,357 Middle 37.4 3,924 16.9 44.9 28.2 1,469 Fourth 34.1 3,300 17.7 43.6 30.6 1,127 Highest 29.2 2,966 32.9 46.1 28.8 865 Total 34.5 18,013 17.4 43.4 28.2 6,214 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Among children under age 5 with fever, 17 percent had blood taken from a finger or heel for testing. Forty-three percent of children under age 5 with fever took antimalarial drugs. However, only 28 percent of children under age 5 took antimalarial drugs the same day or the day after the fever started. There is no substantial difference among children under age 5 who took antimalarial drugs the same or next day by mothers’ educational status, region, or wealth quintiles. Children under age 12 months were less likely than older children to take antimalarial drugs or to take them the same day or day after the fever started. In line with the revised NMCP malaria treatment policy, introduced in December 2007, all fevers are to be treated with artemisinin combination therapy (ACT) (NMCP, 2009). Table 12.9 shows that 36 percent of children under age 5 with fever took ACTs (lumefantrine-artemether, commonly known as LA), 5 percent took quinine, and 2 percent took SP. On the same or next day following the onset of fever, 24 percent of children took ACTs, 3 percent took quinine, and 1 percent took SP/Fansidar. There are no substantial differences in the use of ACTs for treatment of fever by residence, region, or wealth quintile. 16 2 | M al ar ia T ab le 1 2. 9 T yp e an d tim in g of a nt im al ar ia l d ru gs ta ke n by c hi ld re n w ith fe ve r A m on g ch ild re n un de r ag e 5 w ith f ev er i n th e tw o w ee ks p re ce di ng t he s ur ve y, p er ce nt ag e w ho t oo k sp ec ifi c an tim al ar ia l dr ug s an d pe rc en ta ge w ho t oo k ea ch t yp e of d ru g th e sa m e or n ex t da y af te r de ve lo pi ng th e fe ve r, by b ac kg ro un d ch ar ac te ris tic s, M al aw i 2 01 0 B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge o f c hi ld re n w ho to ok d ru g: Pe rc en ta ge o f c hi ld re n w ho to ok d ru g th e sa m e or n ex t d ay : N um be r of ch ild re n w ith fe ve r SP / Fa ns id ar C hl or o- qu in e Am od ia - qu in e Q ui ni ne AC T Ar te su na te AA /A SA Q O th er an ti- m al ar ia l SP / Fa ns id ar C hl or o- qu in e Am od ia - qu in e Q ui ni ne AC T AA /A SA Q O th er an ti- m al ar ia l A ge (i n m on th s) < 12 1. 8 0. 0 0. 0 3. 2 26 .0 0. 0 0. 2 1. 5 1. 5 0. 0 0. 0 2. 2 16 .7 0. 2 0. 3 1, 29 6 12 -2 3 1. 9 0. 0 0. 1 5. 8 39 .6 0. 0 0. 8 1. 1 1. 3 0. 0 0. 1 3. 7 26 .1 0. 8 0. 3 1, 54 5 24 -3 5 2. 1 0. 0 0. 0 4. 9 40 .7 0. 1 0. 0 1. 2 1. 4 0. 0 0. 0 2. 9 26 .3 0. 0 0. 2 1, 35 9 36 -4 7 1. 7 0. 1 0. 0 5. 1 37 .7 0. 1 0. 0 1. 3 1. 0 0. 0 0. 0 2. 3 26 .2 0. 0 0. 2 1, 09 1 48 -5 9 2. 1 0. 1 0. 4 4. 9 36 .6 0. 0 0. 1 1. 1 1. 6 0. 0 0. 4 3. 2 24 .1 0. 0 0. 1 92 4 R es id en ce U rb an 0. 7 0. 0 0. 2 7. 1 34 .4 0. 1 0. 0 1. 4 0. 7 0. 0 0. 2 3. 6 19 .8 0. 0 0. 2 78 6 Ru ra l 2. 1 0. 0 0. 1 4. 5 36 .5 0. 0 0. 3 1. 2 1. 5 0. 0 0. 1 2. 8 24 .5 0. 3 0. 2 5, 42 8 R eg io n N or th er n 3. 3 0. 0 0. 0 2. 4 33 .4 0. 3 0. 6 10 .1 1. 9 0. 0 0. 0 1. 7 23 .6 0. 6 1. 8 62 6 C en tra l 1. 5 0. 0 0. 1 5. 9 37 .3 0. 0 0. 4 0. 1 0. 9 0. 0 0. 1 3. 4 24 .3 0. 4 0. 0 2, 95 4 So ut he rn 2. 1 0. 0 0. 1 4. 1 35 .7 0. 0 0. 0 0. 4 1. 7 0. 0 0. 1 2. 6 23 .6 0. 0 0. 1 2, 63 4 M ot he r’ s ed uc at io n N o ed uc at io n 2. 1 0. 0 0. 0 4. 2 35 .0 0. 0 0. 1 0. 8 1. 0 0. 0 0. 0 2. 9 23 .0 0. 1 0. 4 1, 04 5 Pr im ar y 2. 0 0. 0 0. 1 4. 8 36 .6 0. 0 0. 2 1. 5 1. 4 0. 0 0. 1 2. 9 24 .1 0. 2 0. 3 4, 27 1 Se co nd ar y 1. 7 0. 0 0. 2 5. 4 35 .9 0. 0 0. 7 0. 6 1. 4 0. 0 0. 2 2. 9 23 .7 0. 6 0. 1 88 4 M or e th an s ec on da ry 0. 0 0. 0 0. 0 20 .3 45 .6 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 5. 4 32 .6 0. 0 0. 0 15 W ea lth q ui nt ile Lo w es t 2. 4 0. 0 0. 0 3. 6 34 .8 0. 0 0. 3 1. 3 1. 8 0. 0 0. 0 2. 1 23 .9 0. 3 0. 0 1, 39 7 Se co nd 1. 4 0. 0 0. 0 3. 2 37 .1 0. 0 0. 2 0. 9 1. 0 0. 0 0. 0 2. 4 23 .4 0. 2 0. 1 1, 35 7 M id dl e 2. 8 0. 0 0. 2 3. 3 38 .7 0. 0 0. 0 0. 9 1. 9 0. 0 0. 2 2. 1 24 .0 0. 0 0. 4 1, 46 9 Fo ur th 1. 5 0. 0 0. 2 6. 6 35 .1 0. 0 0. 6 1. 2 1. 2 0. 0 0. 2 3. 6 25 .6 0. 6 0. 2 1, 12 7 H ig he st 1. 1 0. 0 0. 1 9. 5 34 .4 0. 2 0. 2 2. 2 0. 6 0. 0 0. 1 5. 3 22 .4 0. 2 0. 6 86 5 To ta l 1. 9 0. 0 0. 1 4. 8 36 .2 0. 0 0. 3 1. 2 1. 4 0. 0 0. 1 2. 9 23 .9 0. 2 0. 2 6, 21 4 A C T = A rt em isi ni n co m bi na tio n th er ap y AA /A SA Q = C om bi ne d am od ia qu in e an d ar te su na te 162 | Malaria Malaria | 163 12.6 PREVALENCE OF ANAEMIA IN CHILDREN One of the objectives of the 2010 MDHS was to assess anaemia prevalence in children age 6-59 months. Table 11.7 in the previous chapter presents the percentage of children with anaemia according to the cutoffs of 11.0 g/dl for any anaemia and 7.0 g/dl for severe anaemia. In addition to poor dietary intake of iron, malaria infection can also result in anaemia. A haemoglobin concentration of less than 8.0 g/dl is considered an indication that an individual may have malaria. Table 12.10 shows that 9 percent of children age 6-59 months have haemoglobin lower than 8.0 g/dl. Children under age 3 experience higher levels of anaemia, ranging from 17 percent of children age 6-8 months to 10 percent of children age 24-35 months. There is no substantial difference in anaemia levels by gender. The Central Region has the highest levels of anaemia (11 percent) while levels in the Northern and Southern Regions are lowest (8 percent and 7 percent, respectively). Rates of anaemia in rural children were slightly higher than those in urban children (9 percent and 7 percent, respectively). Haemoglobin below 8.0 g/dl is highly associated with wealth status; decreas- ing from 11 percent of children in the lowest wealth quintile to 5 percent of children in the highest wealth quintile. Table 12.10 Percentage of children with haemoglobin <8.0 g/dl in children Percentage of children age 6-59 months with haemoglobin lower than 8.0 g/dl, by background characteristics, Malawi 2010 Background characteristic Haemoglobin <8.0 g/dl Number of children Age in months 6-8 16.8 253 9-11 13.2 249 12-17 10.4 497 18-23 13.7 585 24-35 10.4 970 36-47 5.6 1,010 48-59 2.9 950 Sex Male 9.1 2,224 Female 8.2 2,291 Mother’s interview status Interviewed 8.8 4,203 Not interviewed but in household 10.3 82 Not interviewed, and not in the household1 5.8 229 Residence Urban 6.8 636 Rural 9.0 3,879 Region Northern 8.4 512 Central 10.6 2,102 Southern 6.6 1,901 Mother’s education2 No education 10.5 813 Primary 8.7 3,042 Secondary 6.3 646 More than secondary * 13 Wealth quintile Lowest 11.4 819 Second 9.3 1,038 Middle 9.3 997 Fourth 7.9 833 Highest 5.3 828 Total 8.7 4,515 Note: Table is based on children who stayed in the household the night before the interview. Prevalence of anaemia is based on haemoglobin levels and is adjusted for altitude using CDC formulas (CDC, 1998). Haemoglobin is measured in grams per decilitre (g/dl). 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 165 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 13.1 INTRODUCTION The first case of AIDS in Malawi was identified in 1985. The Joint United Nations Programme on HIV/AIDS (UNAIDS) in its 2010 global report stated that there were 920,000 adults and children living with HIV in Malawi in 2009 (UNAIDS, 2010). Major factors in the transmission of HIV in Malawi are poverty, low literacy levels, high rates of casual and transactional unprotected sex in the general population, particularly among youth between the ages of 15 and 24, low levels of male and female condom use, cultural and religious factors, and stigma and discrimination (UNAIDS, 2010). In July 2001, the National AIDS Commission was established and replaced the National AIDS Control Programme. The National HIV and AIDS Policy was launched in 2003 in Malawi (OPC, 2003). This policy was developed through a consultative process that involved civil society organisations, the public and private sectors, the media, and persons living with HIV. The National HIV and AIDS Policy now provides guiding principles for all programmes and interventions in Malawi. In October 2004, Malawi developed the National HIV and AIDS Action Framework (NAF), which guided the national response for the period 2005-2009 (NAC, 2004). The NAF is a tool used to mobilise an expanded, multisectoral national response to the HIV epidemic. The overall goal of the NAF is to prevent the spread of HIV, to provide access to treatment for people living with HIV, and to mitigate the health, socioeconomic, and psychosocial impact of HIV on individuals, families, communities, and the nation. To achieve this goal, nine priority areas have been identified: (1) prevention and behaviour change; (2) treatment, care, and support; (3) impact mitigation; (4) mainstreaming, partnerships, and capacity building; (5) research and development; (6) monitoring and evaluation; (7) resource mobilisation and utilisation; (8) policy coordination; and (9) programme planning. National efforts, coupled with support from various donors and development partners, have contributed to a significant scaling up of prevention, care, and treatment programmes aimed at combating the disease. Similarly, efforts have been made to strengthen monitoring and evaluation systems for HIV response activities as the country seeks to continue supporting evidence-based decision making for a more efficient and effective response. The future course of the national response to the HIV and AIDS epidemic in Malawi depends on a number of factors. Included are levels of HIV and AIDS-related knowledge among the general population; social stigmatisation; risk behaviour modification; access to quality services for sexually transmitted infections (STI); provision and uptake of HIV counselling and testing; and access to care and antiretroviral therapy (ART), including prevention and treatment of opportunistic infections. The principal objective of this chapter is to show the level of HIV and AIDS-related knowledge, perceptions, and behaviours at the national level, by residence, and by selected demographic and socioeconomic characteristics in Malawi.1 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 166 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.2 HIV AND AIDS KNOWLEDGE, TRANSMISSION AND PREVENTION METHODS 13.2.1 Awareness of AIDS The 2010 MDHS respondents were asked whether they had heard of AIDS. Those who reported having heard of AIDS were asked a number of questions about whether and how the virus that causes AIDS can be avoided. Table 13.1 shows that 99 percent of women and men in Malawi have heard of AIDS. There are no significant variations in awareness by background characteristics. Knowledge of AIDS among women and men in Malawi is almost universal. This is true across age groups and by urban or rural residence, marital status, wealth index, and educational level. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Malawi 2010 Background characteristic Women Men Have heard of AIDS Number of women Have heard of AIDS Number of men Age 15-24 99.3 9,559 98.7 2,987 15-19 99.0 5,005 98.2 1,748 20-24 99.7 4,555 99.5 1,239 25-29 99.7 4,400 99.7 1,099 30-39 99.6 5,772 100.0 1,746 40-49 99.1 3,288 99.4 986 Marital status Never married 99.0 4,538 98.6 2,689 Ever had sex 99.5 1,415 99.4 1,690 Never had sex 98.8 3,123 97.1 999 Married/living together 99.5 15,528 99.8 3,895 Divorced/separated/widowed 99.5 2,954 99.9 234 Residence Urban 99.8 4,302 99.4 1,440 Rural 99.3 18,718 99.3 5,379 Region Northern 99.4 2,677 98.9 744 Central 99.1 9,857 99.4 3,074 Southern 99.7 10,485 99.3 3,001 Education No education 98.4 3,505 97.3 422 Primary 99.5 14,916 99.2 4,270 Secondary 100.0 4,177 99.9 1,904 More than secondary 100.0 422 100.0 223 Wealth quintile Lowest 98.6 4,268 99.0 997 Second 99.2 4,332 99.4 1,309 Middle 99.6 4,517 99.6 1,367 Fourth 99.7 4,515 99.0 1,376 Highest 99.9 5,388 99.4 1,770 Total 15-49 99.4 23,020 99.3 6,818 50-54 na na 100.0 357 Total men 15-54 na na 99.3 7,175 na = Not applicable 13.2.2 Knowledge of HIV Prevention In Malawi, HIV in adults is mainly transmitted through heterosexual contact between an HIV- positive partner and an HIV-negative partner. Malawi’s national HIV prevention programme has sought to reduce sexual transmission of the virus by promoting three behaviour change models— sexual abstinence, mutually faithful monogamy between HIV-negative partners, and condom use for people not practicing abstinence. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 167 In the 2010 MDHS, men and women were asked if it is possible to reduce the risk of acquiring HIV through consistently using condoms, limiting sexual intercourse to one HIV-negative partner who has no other sex partners, and abstaining from sexual intercourse. Table 13.2 shows that about three-quarters of women and men age 15-49 (72 and 73 percent, respectively) know that consistent use of condoms prevents the spread of HIV. Eighty-seven percent of women and 85 percent of men know that limiting sexual intercourse to one, uninfected HIV- negative partner can reduce the chances of contracting HIV. Sixty-six percent of women and men know that using condoms and limiting sexual intercourse to one HIV-negative partner can reduce the risk of HIV infection. Seventy-nine percent of women and 77 percent of men know that abstaining from sexual intercourse can reduce the risk of HIV infection. Although there are variations in knowledge of HIV prevention methods across the age groups, they are not consistent. Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of being infected with HIV by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage who say HIV can be prevented by: Number of women Percentage who say HIV can be prevented by: Number of men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Age 15-24 71.1 84.9 65.0 77.6 9,559 73.2 84.4 66.1 75.1 2,987 15-19 68.3 83.2 61.8 77.2 5,005 73.1 84.6 66.1 75.0 1,748 20-24 74.2 86.8 68.6 78.1 4,555 73.3 84.1 66.0 75.3 1,239 25-29 75.6 89.6 70.9 81.8 4,400 73.8 85.9 66.5 75.9 1,099 30-39 72.7 87.9 67.3 80.9 5,772 73.2 86.2 67.3 81.1 1,746 40-49 68.3 85.9 63.0 78.4 3,288 68.3 85.9 62.8 78.6 986 Marital status Never married 68.7 83.6 62.4 78.4 4,538 72.5 84.2 65.2 75.7 2,689 Ever had sex 76.2 87.9 71.4 81.2 1,415 75.9 86.0 68.1 77.7 1,690 Never had sex 65.3 81.7 58.4 77.1 3,123 66.7 81.3 60.3 72.2 999 Married/living together 72.6 87.6 67.4 79.3 15,528 72.7 86.5 66.7 78.6 3,895 Divorced/separated/widowed 73.7 86.7 67.7 81.0 2,954 71.0 78.9 61.8 74.4 234 Residence Urban 75.5 89.3 70.1 80.7 4,302 73.6 90.3 69.2 78.8 1,440 Rural 71.1 86.1 65.6 79.0 18,718 72.3 84.0 65.1 76.9 5,379 Region Northern 66.8 87.1 62.2 78.1 2,677 67.9 83.9 60.5 74.2 744 Central 65.9 82.9 59.7 75.8 9,857 72.8 83.1 66.3 77.0 3,074 Southern 79.0 90.1 73.8 83.1 10,485 73.6 87.9 67.0 78.3 3,001 Education No education 66.2 82.6 59.8 73.2 3,505 69.7 77.4 59.8 72.4 422 Primary 71.9 86.4 66.3 79.3 14,916 72.1 83.8 64.6 76.2 4,270 Secondary 76.7 90.4 71.6 83.7 4,177 75.6 90.3 71.4 80.7 1,904 More than secondary 77.6 95.8 76.3 87.9 422 61.0 85.9 57.9 77.3 223 Wealth quintile Lowest 68.7 84.2 62.7 76.0 4,268 70.5 80.7 62.1 74.1 997 Second 70.2 85.2 64.7 77.7 4,332 75.8 82.9 67.1 78.7 1,309 Middle 71.1 86.4 65.8 80.3 4,517 74.8 86.5 67.7 78.5 1,367 Fourth 73.7 87.4 68.2 80.6 4,515 70.6 86.8 65.1 75.8 1,376 Highest 75.2 89.6 69.8 81.6 5,388 71.2 87.7 66.6 78.3 1,770 Total 15-49 72.0 86.7 66.4 79.3 23,020 72.6 85.3 66.0 77.3 6,818 50-54 na na na na na 73.5 87.1 66.7 83.1 357 Total men 15-54 na na na na na 72.6 85.4 66.0 77.6 7,175 na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners Among women, knowledge of HIV prevention measures is highest among those age 25-29. On the other hand, women who have never had sex are least likely to know about HIV prevention measures. For example, 65 percent of women who have never had sex know that condoms can reduce the risk of HIV infection compared with 73 percent of currently married women. Knowledge of HIV 168 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour prevention methods is higher among women in urban areas and those in the Southern Region than among other women. Three-quarters of women (74 percent) in the Southern Region know that both using condoms and being faithful reduce the risk of HIV transmission compared with 62 percent of women in the Northern Region and 60 percent of women in the Central Region. Knowledge of HIV prevention methods increases with level of education and wealth quintile. Among men, those age 40-49 and those who have never had sex are less likely than other men to know HIV prevention methods; however, knowledge of prevention methods is higher among men in the Southern Region than among men in the Northern and Central Regions. Unlike the pattern for women, men with secondary education are more likely than those with more than a secondary education to know each of the three HIV prevention methods. Differentials in knowledge of HIV prevention methods by wealth quintile among men are less pronounced than among women. 13.2.3 Comprehensive Knowledge and Misconceptions about HIV/AIDS As part of the effort to assess HIV and AIDS knowledge, the 2010 MDHS obtained information on common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV and whether they believe HIV is transmitted through mosquito bites, supernatural means, or sharing food with a person who has HIV or AIDS. Comprehensive knowledge means knowing that consistent condom use and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy- looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV transmission—that HIV can be transmitted by mosquito bites, and that HIV can be transmitted by supernatural means. Tables 13.3.1 and 13.3.2 show the proportion of women and men age 15-49 who know that a healthy-looking person can have HIV, who reject common misconceptions about HIV transmission, and who have comprehensive knowledge about AIDS. Eighty-seven percent of women know that a healthy-looking person can have HIV compared with 93 percent of men. The most common misconception about HIV transmission in Malawi is that it can be transmitted by mosquitoes. Three- quarters of women and men know that HIV cannot be transmitted by mosquitoes (74 percent and 75 percent, respectively). Eighty-five percent of women and 88 percent of men believe HIV cannot be transmitted by supernatural means, and 91 percent of women and 94 percent of men believe a person cannot contract HIV by sharing food with a person who has AIDS. Forty-one percent of women and 45 percent of men have comprehensive knowledge about AIDS. Comprehensive knowledge about HIV among women has almost doubled from 22 percent in the 2004 MDHS. For men, the increase in comprehensive knowledge about HIV has been more moderate, and is up from 39 percent in the 2004 MDHS. Men and women age 40-49 are less likely to have comprehensive knowledge about AIDS than their younger counterparts. By marital status, both men and women who have never married but who have had sex, are most knowledgeable about AIDS. For women, those who have never had sex are least knowledgeable whereas the least knowledgeable men are those who are divorced, widowed, or separated. Respondents in urban areas are more likely than those in rural areas to have comprehensive knowledge about AIDS. By region, the level of comprehensive knowledge is highest in the Southern Region (48 percent for women and 47 percent for men). The proportion with comprehensive knowledge about AIDS generally rises with increasing level of education and wealth quintile. For men, the proportion with comprehensive knowledge about AIDS increases from 27 percent of men with no education to 57 percent of men with secondary education before decreasing slightly to 53 percent among men with more than a secondary education. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 169 Table 13.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Malawi 2010 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy- looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 84.8 76.5 87.5 91.1 60.7 41.8 9,559 15-19 82.2 76.8 87.0 90.8 59.3 39.5 5,005 20-24 87.6 76.2 88.0 91.5 62.2 44.2 4,555 25-29 90.4 73.9 86.1 91.3 62.0 45.5 4,400 30-39 89.1 70.6 82.4 89.9 56.4 39.7 5,772 40-49 85.4 69.6 78.2 88.6 51.3 35.4 3,288 Marital status Never married 84.1 80.0 89.0 92.3 64.2 43.6 4,538 Ever had sex 89.8 81.9 91.7 95.1 71.0 52.9 1,415 Never had sex 81.5 79.1 87.7 91.1 61.2 39.3 3,123 Married/living together 87.5 71.7 83.7 89.8 56.8 40.1 15,528 Divorced/separated/widowed 88.9 73.4 82.8 91.1 58.8 42.0 2,954 Residence Urban 93.4 83.1 91.0 95.4 73.9 54.6 4,302 Rural 85.6 71.4 83.1 89.4 55.0 37.9 18,718 Region Northern 73.4 66.1 85.7 85.9 45.7 30.5 2,677 Central 85.6 73.3 84.1 91.0 56.9 36.2 9,857 Southern 91.9 75.7 84.9 91.2 63.3 48.3 10,485 Education No education 81.8 66.0 75.9 83.7 45.9 29.8 3,505 Primary 85.8 71.0 83.6 90.1 54.8 38.1 14,916 Secondary 94.7 86.7 94.4 96.8 79.3 58.1 4,177 More than secondary 97.6 96.0 95.3 97.8 90.2 70.1 422 Wealth quintile Lowest 82.1 68.9 79.4 87.0 49.3 33.3 4,268 Second 84.4 68.8 81.7 88.1 51.5 35.1 4,332 Middle 85.4 70.9 83.4 89.7 54.5 38.1 4,517 Fourth 88.6 74.1 86.0 91.9 60.3 42.4 4,515 Highest 93.1 82.9 91.0 94.7 73.4 53.3 5,388 Total 15-49 87.0 73.6 84.6 90.5 58.5 41.0 23,020 1 Two most common local misconceptions: ‘AIDS can be transmitted by mosquito bites.’ and ‘AIDS can be transmitted by supernatural means.’ 2 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 170 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Malawi 2010 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy- looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of men A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 90.5 75.8 88.7 93.7 65.3 44.7 2,987 15-19 87.9 77.2 88.3 92.0 65.4 44.7 1,748 20-24 94.0 73.9 89.2 96.0 65.3 44.7 1,239 25-29 94.3 74.7 90.1 94.9 67.9 46.3 1,099 30-39 94.4 75.3 86.6 93.2 65.3 45.5 1,746 40-49 93.2 73.5 85.7 92.0 63.6 42.3 986 Marital status Never married 90.2 78.3 89.5 93.2 68.0 45.7 2,689 Ever had sex 92.8 77.6 89.9 94.2 68.3 46.9 1,690 Never had sex 85.8 79.5 88.8 91.4 67.5 43.7 999 Married/living together 94.0 72.9 86.9 93.9 63.8 44.5 3,895 Divorced/separated/widowed 93.3 76.0 87.2 91.3 63.8 39.4 234 Residence Urban 95.3 85.9 93.1 96.6 79.0 55.5 1,440 Rural 91.8 72.3 86.6 92.7 61.9 41.9 5,379 Region Northern 84.0 66.3 87.6 90.9 53.6 35.1 744 Central 93.9 74.5 87.2 94.3 65.4 44.9 3,074 Southern 93.2 78.1 88.8 93.4 68.5 47.1 3,001 Education No education 88.4 57.2 71.9 83.3 40.4 26.7 422 Primary 91.2 70.5 86.9 92.8 60.5 40.6 4,270 Secondary 95.7 87.7 93.3 96.9 79.9 57.2 1,904 More than secondary 98.5 91.9 92.0 96.7 85.4 52.6 223 Wealth quintile Lowest 89.8 66.3 83.2 91.6 53.3 35.5 997 Second 91.0 69.8 85.7 92.5 58.4 40.4 1,309 Middle 93.3 69.6 86.2 93.1 60.8 42.5 1,367 Fourth 92.2 78.8 90.1 93.2 69.9 46.9 1,376 Highest 94.7 85.6 91.9 95.9 77.8 53.4 1,770 Total 15-49 92.5 75.2 87.9 93.5 65.5 44.8 6,818 50-54 94.4 71.3 88.9 91.3 63.1 42.9 357 Total men 15-54 92.6 75.0 88.0 93.4 65.4 44.7 7,175 1 Two most common local misconceptions: ‘AIDS can be transmitted by mosquito bites,’ and ‘AIDS can be transmitted by supernatural means.’ 2 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 13.3 KNOWLEDGE ABOUT MOTHER-TO-CHILD TRANSMISSION Increasing knowledge about mother-to-child transmission (MTCT) of HIV and using antiretroviral medication before delivery to reduce transmission is critical. To assess MTCT knowledge, respondents were asked if HIV can be transmitted from a mother to a child through breastfeeding and if a mother with HIV can reduce the risk of transmission to her baby by taking certain drugs during pregnancy. Table 13.4 shows that 91 percent of women and 86 percent of men know that HIV can be transmitted through breastfeeding. Eighty-five percent of women and 78 percent of men know that the risk of MTCT can be reduced if the mother takes special drugs during pregnancy. Knowledge of MTCT has improved dramatically since the 2004 MDHS. The percentage who know that HIV can be transmitted through breastfeeding and that MTCT can be reduced by taking special drugs has HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 171 increased from 37 percent to 83 percent among women and from 29 percent to 71 percent among men. As with other aspects of knowledge about AIDS, women and men who have never had sex are less likely than their counterparts to know that HIV can be transmitted through breastfeeding and can be prevented by the mother taking drugs during pregnancy. Knowledge of MTCT increases with level of education and wealth quintile, and is higher in urban areas than in rural areas. Among women, knowledge of MTCT is highest among those in the Southern Region (86 percent), followed by those in the Central Region (81 percent), and those in the Northern Region (76 percent). Among men, those in the Central and Southern Regions are most likely to have knowledge of MTCT (72 percent), and those in the Northern Region are least likely (62 percent). Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage who know that: Number of women Percentage who know that: Number of men HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Age 15-24 89.3 81.6 79.1 9,559 84.4 72.5 66.9 2,987 15-19 85.6 75.0 72.1 5,005 81.3 68.5 62.5 1,748 20-24 93.3 88.9 86.9 4,555 88.8 78.1 73.2 1,239 25-29 94.8 91.3 89.4 4,400 85.9 80.7 73.4 1,099 30-39 91.9 88.1 85.6 5,772 87.6 82.4 74.9 1,746 40-49 90.2 82.8 80.5 3,288 87.0 80.1 74.3 986 Marital status Never married 85.4 75.0 72.0 4,538 83.7 71.9 66.2 2,689 Ever had sex 91.2 84.9 82.3 1,415 87.6 76.3 70.6 1,690 Never had sex 82.8 70.5 67.3 3,123 77.3 64.5 58.8 999 Married/living together 92.4 87.9 85.6 15,528 87.6 81.5 74.8 3,895 Divorced/separated/widowed 93.1 87.5 85.6 2,954 80.7 73.4 64.6 234 Currently pregnant Pregnant 90.9 86.9 83.5 2,072 na na na na Not pregnant or not sure 91.1 85.1 82.8 20,948 na na na na Residence Urban 93.4 90.1 87.6 4,302 89.3 84.1 78.7 1,440 Rural 90.6 84.2 81.8 18,718 84.9 75.7 69.0 5,379 Region Northern 88.0 78.5 75.8 2,677 81.5 68.8 61.8 744 Central 90.3 83.5 81.4 9,857 85.6 79.7 72.2 3,074 Southern 92.7 88.7 86.2 10,485 87.2 77.3 72.2 3,001 Education No education 87.2 79.3 76.7 3,505 82.5 64.2 58.9 422 Primary 90.8 84.7 82.3 14,916 84.0 75.2 68.3 4,270 Secondary 95.2 91.0 89.0 4,177 89.7 84.2 78.2 1,904 More than secondary 96.6 97.4 94.3 422 94.4 89.3 86.5 223 Wealth quintile Lowest 88.5 79.8 77.8 4,268 81.9 69.3 62.1 997 Second 89.7 83.3 80.9 4,332 85.4 76.5 69.7 1,309 Middle 91.3 84.5 82.2 4,517 84.2 77.3 70.1 1,367 Fourth 92.0 87.7 85.1 4,515 86.6 77.0 70.9 1,376 Highest 93.5 89.9 87.3 5,388 89.0 83.3 78.0 1,770 Total 15-49 91.1 85.3 82.9 23,020 85.8 77.5 71.1 6,818 50-54 na na na na 86.9 77.5 72.1 357 Total men 15-54 na na na na 85.9 77.5 71.1 7,175 na = Not applicable 172 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.4 ATTITUDES TOWARDS PEOPLE LIVING WITH HIV AND AIDS The HIV/AIDS epidemic has generated fear, anxiety, and prejudice against people living with HIV and AIDS. There is widespread stigma and discrimination against people who are HIV-positive. These societal attitudes can adversely affect both people’s willingness to be tested for HIV and also their initiation of and adherence to antiretroviral therapy. Reducing stigma and discrimination is therefore an important factor in prevention, management, and control of the HIV epidemic. In the 2010 MDHS, women and men who had heard of AIDS were asked a number of questions to assess the level of stigma associated with HIV and AIDS. Tables 13.5.1 and 13.5.2 present these results for women and men, age 15-49, respectively. Almost the same proportion of women and men reported that they would be willing to take care of a family member with HIV at home (97 and 98 percent, respectively). However, men are slightly more likely than women to say that they would buy fresh vegetables from a shopkeeper who has HIV (90 percent versus 81 percent) and to think that a female teacher with HIV should be allowed to continue teaching (92 percent versus 88 percent). Men are much more likely than women not to want to keep secret a family member’s infection with HIV (42 percent versus 29 percent). Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with AIDS, by background characteristics, Malawi 2010 Background characteristic Percentage of women who: Percentage expressing acceptance attitudes on all four indicators Number of women who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 95.2 78.2 85.0 30.9 19.2 9,495 15-19 93.6 73.5 81.7 31.3 16.8 4,956 20-24 96.9 83.3 88.6 30.4 21.8 4,539 25-29 98.0 85.7 90.2 27.4 20.3 4,386 30-39 98.0 83.1 89.4 27.9 20.3 5,750 40-49 97.6 81.1 87.6 29.1 19.4 3,259 Marital status Never married 94.3 76.0 84.0 32.3 18.8 4,495 Ever had sex 97.6 85.9 89.0 29.8 22.8 1,409 Never had sex 92.8 71.5 81.8 33.4 17.0 3,086 Married/living together 97.3 82.6 88.2 28.8 20.2 15,455 Divorced/separated/widowed 97.8 82.6 89.2 26.6 18.6 2,939 Residence Urban 98.9 89.7 94.9 25.6 21.1 4,294 Rural 96.3 79.3 85.8 30.1 19.4 18,595 Region Northern 96.6 83.7 87.4 30.8 21.5 2,662 Central 95.0 78.8 84.9 34.7 21.6 9,769 Southern 98.5 82.9 89.9 23.7 17.5 10,458 Education No education 95.2 71.3 79.7 27.8 14.2 3,450 Primary 96.4 79.6 86.2 29.7 19.1 14,840 Secondary 99.0 93.9 97.4 28.1 25.2 4,177 More than secondary 99.7 98.0 98.9 34.5 33.7 422 Wealth quintile Lowest 94.3 72.0 79.3 33.1 17.6 4,209 Second 96.3 76.7 84.1 30.0 18.0 4,296 Middle 96.0 79.5 85.8 29.9 19.3 4,498 Fourth 97.9 84.6 90.8 27.3 20.0 4,504 Highest 98.9 90.8 95.3 26.7 22.9 5,383 Total 15-49 96.8 81.3 87.5 29.2 19.7 22,889 HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 173 Overall, men are more likely to express accepting attitudes regarding all four situations when compared with women (36 percent compared with 20 percent, respectively). Accepting attitudes are generally more common among respondents in urban areas than among those in rural areas and increase with education and wealth. Women in the Northern Region and the Central Region are more likely to express accepting attitudes towards people living with HIV or AIDS (22 percent) than women in the Southern Region (18 percent). Among men, those in the Central Region are more likely to express accepting attitudes (40 percent) than those in the Southern Region (33 percent) or Northern Region (30 percent). Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Malawi 2010 Background characteristic Percentage of men who: Percentage expressing acceptance attitudes on all four indicators Number of men who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 97.1 87.6 89.2 39.9 32.2 2,950 15-19 96.2 85.0 86.9 39.0 29.9 1,717 20-24 98.3 91.3 92.4 41.1 35.5 1,232 25-29 97.7 93.7 94.6 42.9 38.3 1,095 30-39 98.9 92.6 93.6 43.5 39.1 1,745 40-49 98.3 89.7 93.7 42.4 36.9 981 Marital status Never married 96.9 87.5 89.4 40.7 32.5 2,651 Ever had sex 97.3 88.2 89.6 41.9 33.8 1,681 Never had sex 96.3 86.3 89.0 38.7 30.3 970 Married/living together 98.6 92.4 93.8 42.2 38.0 3,886 Divorced/separated/widowed 96.0 84.4 88.7 45.3 33.0 234 Residence Urban 98.3 94.4 97.0 42.2 37.7 1,431 Rural 97.7 89.0 90.5 41.6 35.1 5,340 Region Northern 95.6 87.5 89.4 35.8 29.6 735 Central 97.3 91.1 91.2 46.5 40.0 3,056 Southern 98.9 89.9 93.2 38.2 32.7 2,979 Education No education 96.1 83.0 79.4 37.5 29.0 411 Primary 97.2 88.0 90.0 42.5 34.9 4,236 Secondary 99.3 95.8 98.1 40.6 38.2 1,902 More than secondary 99.5 97.4 98.0 43.9 40.9 223 Wealth quintile Lowest 96.6 85.3 85.0 41.7 32.2 987 Second 96.7 87.2 89.2 42.2 36.1 1,301 Middle 97.9 90.2 91.7 40.6 35.1 1,361 Fourth 98.1 91.0 94.1 43.1 36.5 1,363 Highest 99.0 94.6 96.1 41.1 37.0 1,759 Total 15-49 97.8 90.2 91.9 41.7 35.7 6,771 50-54 97.5 87.7 94.2 42.8 35.3 357 Total men 15-54 97.8 90.1 92.0 41.8 35.6 7,127 It should be noted that slight changes in the questions on stigma and discrimination between the 2004 and 2010 surveys prevent comparison over time between women and men who express accepting attitudes on all four indicators. The percentage of respondents who would buy fresh vegetables from a shopkeeper with HIV increased from 67 to 81 percent for women and from 84 to 90 percent for men. A similar increase is observed in the percentages of women and men who say that a female teacher with HIV should be allowed to continue teaching. 174 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.5 ATTITUDES TOWARDS NEGOTIATING SAFER SEXUAL RELATIONS WITH HUSBANDS Knowledge about HIV transmission and ways to prevent it is less useful if people feel powerless to negotiate safer sex with their partners. To gauge attitudes towards safer sex, respondents to the 2010 MDHS were asked if they think a wife is justified in refusing to have sex with her husband, and in asking that they use a condom if she knows he has an infection that can be transmitted through sexual contact. Table 13.6 shows that 70 percent of women and 78 percent of men in Malawi believe that if a husband has a sexually transmitted infection (STI), his wife is justified in refusing to have sexual intercourse with him. A higher proportion of women and men believe a wife would be justified in asking a husband or partner to use a condom (85 and 91 percent, respectively). Overall, 90 percent of women and 94 percent of men believe that a wife is justified in taking some action to protect herself from HIV, either by refusing to have sexual intercourse or by requesting that her husband or partner use a condom if she thinks he has an STI. Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that, if a husband has a sexually transmitted disease, his wife is justified in refusing to have sexual intercourse with him or asking that they use a condom, by background characteristics, Malawi 2010 Background characteristic Women Men Woman is justified in: Number of women Woman is justified in: Number of men Refusing to have sexual intercourse Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Refusing to have sexual intercourse Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Age 15-24 68.4 84.1 88.5 9,559 75.6 89.2 93.6 2,987 15-19 68.6 81.1 86.3 5,005 76.8 88.3 93.2 1,748 20-24 68.3 87.5 90.9 4,555 73.8 90.4 94.1 1,239 25-29 70.0 87.4 91.4 4,400 77.9 90.9 94.6 1,099 30-39 72.0 87.7 92.2 5,772 79.5 93.3 95.5 1,746 40-49 69.3 80.4 87.3 3,288 82.0 89.4 94.2 986 Marital status Never married 70.6 81.1 86.4 4,538 77.1 89.3 93.8 2,689 Ever had sex 74.5 86.6 90.6 1,415 78.0 90.9 95.3 1,690 Never had sex 68.8 78.6 84.6 3,123 75.7 86.6 91.3 999 Married/living together 69.2 85.8 90.4 15,528 78.6 91.7 94.9 3,895 Divorced/separated/widowed 71.3 87.7 92.0 2,954 74.5 84.9 90.5 234 Residence Urban 76.2 90.0 94.1 4,302 85.5 94.9 97.2 1,440 Rural 68.3 84.0 88.8 18,718 75.8 89.4 93.6 5,379 Region Northern 65.6 82.2 87.1 2,677 74.9 88.0 92.8 744 Central 69.0 81.4 87.4 9,857 78.2 89.2 92.9 3,074 Southern 71.5 89.4 92.7 10,485 78.2 92.6 96.2 3,001 Education No education 65.2 79.1 85.8 3,505 71.8 81.3 86.5 422 Primary 68.3 84.5 89.2 14,916 75.5 88.6 92.9 4,270 Secondary 76.6 91.5 94.6 4,177 83.1 96.5 98.7 1,904 More than secondary 89.9 94.5 98.2 422 90.2 94.3 99.2 223 Wealth quintile Lowest 67.9 80.6 86.5 4,268 73.2 85.5 90.1 997 Second 66.3 83.3 88.0 4,332 75.3 89.4 93.5 1,309 Middle 68.8 84.4 89.4 4,517 76.3 89.6 93.7 1,367 Fourth 69.1 86.5 90.3 4,515 76.6 91.4 95.2 1,376 Highest 75.4 89.7 93.8 5,388 84.5 94.3 97.2 1,770 Total 15-49 69.8 85.1 89.8 23,020 77.9 90.5 94.3 6,818 50-54 na na na na 85.6 89.3 94.4 357 Total men 15-54 na na na na 78.3 90.5 94.3 7,175 na = Not applicable HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 175 People living in rural areas have less favourable attitudes towards a wife negotiating safer sex with her husband. Eighty-nine percent of women in rural areas have a favourable attitude, compared with 94 percent in urban areas. Among men, the comparable figures are 94 percent in rural areas and 97 percent in urban areas. Agreement with a wife’s ability to negotiate safer sex with her husband increases with education and wealth quintile. 13.6 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH Condom use is one of the most effective strategies for combating the spread of HIV. However, educating youth about condoms is sometimes controversial, with some people believing it promotes early sexual initiation. To gauge attitudes towards condom education for youth, the 2010 MDHS asked respondents if they thought that young people age 12-14 should be taught about using a condom to avoid AIDS. Because the table focuses on adult opinions, results are tabulated for respondents age 18-49. Table 13.7 shows that more than half of women (58 percent) and about two-thirds of men (64 percent) agree that young people age 12-14 should be taught about condoms for AIDS prevention. Among women, support for condom education for youth is lowest in the 40-49 age group, while among men there is no substantial variation in agreement with condom education by age group. Respondents with higher education and those in higher wealth quintiles are most likely to agree with condom education for youth. Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage who agree Number of women Percentage who agree Number of men Age 18-24 61.1 6,246 64.9 1,844 18-19 58.6 1,691 64.8 605 20-24 62.1 4,555 64.9 1,239 25-29 60.6 4,400 62.0 1,099 30-39 56.7 5,772 63.8 1,746 40-49 50.6 3,288 62.5 986 Marital status Never married 59.1 1,642 63.4 1,562 Married or living together 57.7 15,153 63.4 3,880 Divorced/separated/widowed 58.5 2,912 66.9 233 Residence Urban 62.7 3,684 68.3 1,210 Rural 56.9 16,023 62.3 4,464 Region Northern 46.6 2,278 57.8 631 Central 54.5 8,412 63.7 2,620 Southern 64.1 9,017 64.9 2,424 Education No education 47.5 3,418 50.8 408 Primary 58.5 12,350 61.9 3,331 Secondary 64.8 3,519 69.0 1,715 More than secondary 68.5 420 70.2 221 Wealth quintile Lowest 53.3 3,698 57.2 824 Second 56.5 3,767 62.9 1,093 Middle 57.4 3,852 63.5 1,150 Fourth 58.6 3,846 61.7 1,146 Highest 62.9 4,544 69.2 1,462 Total 18-49 58.0 19,707 63.6 5,675 50-54 na na 61.6 357 Total men 18-54 na na 63.5 6,032 na = Not applicable 176 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.7 MULTIPLE SEXUAL PARTNERS Limiting the number of sexual partners and practicing protected sex are crucial steps in the fight against the epidemic of sexually transmitted infections, including HIV. Respondents to the 2010 MDHS were asked detailed questions about their sexual behaviour, including the number of partners they had in the 12 months preceding the survey and their condom use. The results are shown for women age 15-49 in Table 13.8.1 and for men age 15-49 in Table 13.8.2. Table 13.8.1 Multiple sexual partners in the past 12 months: Women Among all women age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among women having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during her lifetime for women who ever had sexual intercourse, by background characteristics, Malawi 2010 Background characteristic All women Among women who had 2+ partners in the past 12 months: Among women who ever had sexual intercourse1 Percentage who had 2+ partners in the past 12 months Number of women Percentage who reported using a condom during last sexual intercourse Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 0.7 9,559 31.4 69 1.5 6,465 15-19 0.7 5,005 (41.7) 33 1.4 2,195 20-24 0.8 4,555 (22.1) 36 1.5 4,270 25-29 0.7 4,400 (42.7) 31 1.7 4,355 30-39 0.6 5,772 (14.1) 32 1.8 5,740 40-49 0.6 3,288 * 20 1.8 3,280 Marital status Never married 0.8 4,538 (63.2) 37 1.5 1,408 Married or living together 0.5 15,528 4.4 78 1.6 15,496 Divorced/separated/widowed 1.2 2,954 (40.3) 36 2.1 2,936 Residence Urban 0.9 4,302 (52.5) 39 1.8 3,602 Rural 0.6 18,718 18.7 113 1.7 16,237 Region Northern 0.5 2,677 * 15 1.5 2,304 Central 0.5 9,857 (30.4) 53 1.5 8,329 Southern 0.8 10,485 25.8 84 1.9 9,206 Education No education 0.6 3,505 * 21 1.8 3,428 Primary 0.7 14,916 19.1 100 1.7 12,782 Secondary 0.5 4,177 * 21 1.7 3,281 More than secondary 2.3 422 * 10 2.0 350 Wealth quintile Lowest 0.6 4,268 * 24 1.7 3,762 Second 0.7 4,332 (8.3) 32 1.7 3,849 Middle 0.6 4,517 (4.0) 29 1.7 3,941 Fourth 0.7 4,515 (43.0) 30 1.7 3,905 Highest 0.7 5,388 (48.1) 37 1.7 4,382 Total 15-49 0.7 23,020 27.3 151 1.7 19,839 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. A much larger proportion of men than women reported having two or more sexual partners. Nine percent of men reported having two or more sexual partners in the 12 months preceding the survey, compared with only one percent of women. Twenty-seven percent of women and 25 percent of men who reported having two partners or more in the past 12 months used a condom at last sex. Men have a mean of four lifetime sexual partners, compared with a mean of two partners for women. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 177 Table 13.8.2 Multiple sexual partners in the past 12 months: Men Among all men age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among men having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during his lifetime for men who ever had sexual intercourse, by background characteristics, Malawi 2010 Background characteristic All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1 Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 6.5 2,987 40.5 195 2.9 2,014 15-19 4.9 1,748 36.1 85 2.5 947 20-24 8.9 1,239 44.0 110 3.2 1,068 25-29 10.7 1,099 31.0 118 3.7 1,058 30-39 10.2 1,746 13.5 179 4.1 1,685 40-49 13.7 986 10.5 136 4.7 940 Marital status Never married 6.4 2,689 51.4 173 3.1 1,681 Married or living together 11.1 3,895 11.6 432 3.9 3,788 Divorced/separated/widowed 9.5 234 (66.9) 22 5.4 229 Type of union Polygynous union 68.8 295 6.1 203 5.8 286 Non-polygynous union 6.3 3,592 16.6 227 3.7 3,494 Not currently in union 6.7 2,923 53.2 195 3.3 1,910 DK/missing 16.7 8 11.0 1 8.2 8 Residence Urban 6.6 1,440 35.2 95 3.7 1,161 Rural 9.9 5,379 22.6 531 3.7 4,537 Region Northern 9.4 744 37.3 70 3.7 592 Central 8.6 3,074 23.0 264 3.4 2,593 Southern 9.8 3,001 22.9 293 4.0 2,513 Education No education 10.8 422 (12.7) 45 4.2 386 Primary 9.0 4,270 21.2 384 3.6 3,511 Secondary 9.3 1,904 34.1 177 3.9 1,616 More than secondary 9.3 223 * 21 3.5 186 Wealth quintile Lowest 10.7 997 22.7 106 3.5 849 Second 8.6 1,309 16.5 113 3.4 1,130 Middle 9.5 1,367 21.0 131 3.7 1,181 Fourth 9.3 1,376 28.2 127 4.0 1,149 Highest 8.5 1,770 32.0 150 3.9 1,390 Total 15-49 9.2 6,818 24.6 627 3.7 5,698 50-54 9.6 357 (4.2) 34 6.0 341 Total men 15-54 9.2 7,175 23.5 661 3.8 6,039 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. There is little variation by background characteristics in the percentage of women with two or more sexual partners in the past 12 months. The percentage of women with multiple partners is higher among women with more than a secondary education and among divorced, widowed, or separated women than it is among other women. The results of condom use at last sex among women who had two or more sexual partners in the past 12 months must be interpreted with caution due to the small number of women, but it appears that women in urban areas and those in the highest two wealth quintiles are more likely than other women with multiple sexual partners to have used a condom at last sex. As expected, women who are currently married are much less likely to have used a condom at last sex than never-married women or women who are divorced, separated, or widowed. 178 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour For men, the percentage with two or more sexual partners in the past 12 months increases from 5 percent among men age 15-19 to 14 percent among men age 40-49. Men who are married or living together with a partner (11 percent) are slightly more likely to have had two or more sexual partners in the past 12 months than men who are divorced, separated, or widowed (10 percent) or never-married (6 percent). Rural men are more likely than urban men to have had two or more sexual partners in the past 12 months. There is little variation in the percentage of men with two or more partners by region. The percentage with two or more partners is highest among men in the lowest wealth quintile (11 percent) and among men with no education (11 percent). Among men who had two or more sexual partners in the past 12 months, men who are married are less likely to have used a condom at last sex (12 percent) than men who have never married (51 percent). Men in urban areas, those with a secondary education, and those in the highest two wealth quintiles are most likely to have used a condom at last sex. 13.8 CONCURRENT SEXUAL PARTNERS According to UNAIDS, concurrent sexual partnerships are defined as ‘overlapping sexual partnerships where intercourse with one partner occurs between two acts of intercourse with another partner’ (UNAIDS, 2009). If an individual has multiple sexual partners in the same year, it is important to know whether these partnerships are serial or concurrent. Concurrent sexual partnerships are theoretically more risky than serial sexual partnerships because concurrent partnerships can create large interconnected sexual networks whose members are at heightened risk of infection. The 2010 MDHS collected information on the time since the first and most recent sexual intercourse with each sexual partner in the past 12 months. This information is used to determine if sexual intercourse with one partner occurred between two acts of intercourse with another partner, i.e. whether two partnerships are concurrent. There are two indicators to measure concurrent sexual partnerships. Point prevalence of concurrent sexual partnerships is defined as the proportion of women and men age 15-49 with more than one ongoing sexual partnership at the point in time six months before the survey. Cumulative prevalence of concurrent sexual partnerships is defined as the proportion of women and men age 15-49 who have had any overlapping sexual partnerships in the past 12 months (UNAIDS, 2009). A partnership that consists of a single sexual encounter is considered overlapping if it occurs during another ongoing partnership. The point prevalence is generally lower than the cumulative prevalence because the point prevalence only includes relationships ongoing on a particular day rather than over an entire year. For males, overlapping polygynous unions are considered concurrent partnerships in both the point prevalence and cumulative prevalence concurrency indicators. Table 13.9.1 shows that less than 1 percent of women age 15-49 had concurrent sexual partnerships in the last 12 months, by either the point prevalence or cumulative prevalence definition. Among women who had two or more sexual partnerships in the past 12 months, almost half of them (46 percent) had sexual partnerships that were concurrent. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 179 Table 13.9.1 Point prevalence and cumulative prevalence of concurrent sexual partnerships: Women Percentage of all women 15-49 who had overlapping sexual partnerships six months before the survey (point prevalence1), and percentage of all women 15-49 who had any overlapping sexual partnerships during the 12 months before the survey (cumulative prevalence2), and among women 15-49 who had multiple sexual partners during the past 12 months, percentage who had concurrent sexual partnerships, Malawi 2010 Background characteristic Among all women Among women who had multiple partners during the 12 months before the survey Point prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of women Percentage who had concurrent sexual partners2 Number of women Age 15-24 0.2 0.3 9,559 45.5 69 15-19 0.1 0.2 5,005 (34.3) 33 20-24 0.2 0.4 4,555 (55.6) 36 25-29 0.1 0.2 4,400 (34.0) 31 30-39 0.1 0.2 5,772 (40.0) 32 40-49 0.0 0.5 3,288 * 20 Marital status Never married 0.1 0.3 4,538 (40.5) 37 Married or living together 0.1 0.3 15,528 51.5 78 Divorced/separated/widowed 0.2 0.5 2,954 (38.9) 36 Residence Urban 0.2 0.5 4,302 (59.4) 39 Rural 0.1 0.2 18,718 41.2 113 Region Northern 0.1 0.3 2,677 * 15 Central 0.1 0.3 9,857 (51.0) 53 Southern 0.1 0.3 10,485 41.5 84 Education No education 0.1 0.2 3,505 * 21 Primary 0.1 0.3 14,916 48.1 100 Secondary 0.2 0.2 4,177 * 21 More than secondary 0.5 1.2 422 * 10 Wealth quintile Lowest 0.1 0.2 4,268 * 24 Second 0.1 0.3 4,332 (38.4) 32 Middle 0.1 0.3 4,517 (43.6) 29 Fourth 0.1 0.3 4,515 (40.2) 30 Highest 0.1 0.4 5,388 (62.5) 37 Total 15-49 0.1 0.3 23,020 45.8 151 Note: Two sexual partners are considered to be concurrent if the date of the most recent sexual intercourse with the earlier partner is after the date of the first sexual intercourse with the later partner. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 The percentage of respondents who had two (or more) sexual partners that were concurrent at the point in time six months before the survey 2 The percentage of respondents who had two (or more) sexual partners that were concurrent anytime during the 12 months preceding the survey Table 13.9.2 shows that 4 percent of men had concurrent sexual partnerships according to the point prevalence indicator, while 7 percent of men had concurrent sexual partnerships according to the cumulative prevalence indicator. The percentage of men with concurrent sexual partnerships, according to the cumulative prevalence indicator, increases with age from 3 percent of men age 15-19 to 13 percent of men age 40-49. Differences in the cumulative prevalence of concurrent sexual partnerships by urban or rural residence and by region are small. Men with no education are more likely than men who have been to school to have had concurrent sexual partners in the past 12 months. Generally, concurrency decreases with wealth quintile, though the relationship is not linear. Men who are currently married (10 percent) are more likely than men who have never been married (4 percent), or who are divorced, widowed, or separated (5 percent) to report concurrent sexual partnerships in the past 12 months. As might be expected, men in polygynous unions are more likely than other men to have reported concurrent sexual partnerships in the past 12 months (64 percent compared with 5 percent or less). Men who are married with one wife and men who are not 180 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour currently married (including those who have never been married) are equally likely to have had concurrent sexual partnerships in the past 12 months (5 percent and 4 percent, respectively). Among men with two or more partners in the past 12 months, 79 percent had concurrent partners. An examination of men with multiple partners in the past 12 months by type of union shows that men who are in polygynous unions are most likely to have concurrent sexual partners in the past 12 months (93 percent), followed by men who are currently married with one wife (83 percent), and men who are not currently married (58 percent). Table 13.9.2 Point prevalence and cumulative prevalence of concurrent sexual partnerships: Men Percentage of all men 15-49 who had overlapping sexual partnerships six months before the survey (point prevalence1), and percentage of all men 15-49 who had any overlapping sexual partnerships during the 12 months before the survey (cumulative prevalence2), and among men 15-49 who had multiple sexual partners during the past 12 months, percentage who have had concurrent sexual partnerships, Malawi 2010 Background characteristic Among all men Among men who had multiple partners during the 12 months before the survey Point prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of men Percentage who had concurrent sexual partners2 Number of men Age 15-24 1.1 4.1 2,987 62.8 195 15-19 0.4 2.7 1,748 55.8 85 20-24 1.9 6.1 1,239 68.3 110 25-29 4.1 8.4 1,099 78.3 118 30-39 4.6 8.6 1,746 84.3 179 40-49 10.2 12.9 986 93.7 136 Marital status Never married 0.7 3.8 2,689 59.0 173 Married or living together 6.0 9.7 3,895 87.7 432 Divorced/separated/widowed 1.8 4.9 234 (52.4) 22 Type of union Polygynous union 54.7 63.8 295 92.7 203 Non-polygynous union 2.0 5.3 3,592 83.2 227 Not currently in union 0.7 3.9 2,923 58.3 195 Residence Urban 1.8 5.5 1,440 83.2 95 Rural 4.3 7.7 5,379 77.7 531 Region Northern 2.8 7.5 744 80.2 70 Central 4.6 6.9 3,074 80.6 264 Southern 3.1 7.4 3,001 76.2 293 Education No education 6.1 10.4 422 (96.4) 45 Primary 4.2 7.0 4,270 78.2 384 Secondary 2.6 6.9 1,904 74.1 177 More than secondary 1.3 7.8 223 * 21 Wealth quintile Lowest 5.0 8.8 997 82.4 106 Second 4.4 7.1 1,309 82.6 113 Middle 4.7 7.7 1,367 80.4 131 Fourth 3.4 7.0 1,376 75.4 127 Highest 2.2 6.2 1,770 73.7 150 Total 15-49 3.8 7.2 6,818 78.5 627 50-54 8.0 9.6 357 100.0 34 Total men 15-54 4.0 7.3 7,175 79.6 661 Note: Two sexual partners are considered to be concurrent if the date of the most recent sexual intercourse with the earlier partner is after the date of the first sexual intercourse with the later partner. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 8 men with information missing on type of union. 1 The percentage of respondents who had two (or more) sexual partners that were concurrent at the point in time six months before the survey 2 The percentage of respondents who had two (or more) sexual partners that were concurrent anytime during the 12 months preceding the survey HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 181 13.9 PAYMENT FOR SEX Transactional sex is the exchange of money, favours, or gifts for sexual intercourse. This type of sexual intercourse is associated with a greater risk of contracting HIV and other STIs because of compromised power relations and the likelihood of having multiple partners as a result. Male respondents in the 2010 MDHS were asked if they had ever paid anyone in exchange for sex. Men who had sexual intercourse in the 12 months preceding the survey were asked if they had paid anyone for sexual intercourse during that time. Further, respondents who had engaged in paid sexual intercourse in the past 12 months were asked if they had used a condom the last time they paid for sexual intercourse. The results are shown in Table 13.10. Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, and among them, the percentage reporting that a condom was used the last time they paid for sexual intercourse, by background characteristics, Malawi 2010 Background characteristic Among all men Among men who paid for sex in the past 12 months Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Percentage reporting condom use Number of men Age 15-24 6.4 5.7 2,987 52.0 169 15-19 4.8 5.5 1,748 41.9 96 20-24 8.7 5.9 1,239 65.3 73 25-29 12.1 4.9 1,099 81.9 54 30-39 12.6 4.7 1,746 67.2 82 40-49 11.3 3.7 986 (56.6) 36 Marital status Never married 5.9 5.9 2,689 53.5 158 Married or living together 11.6 4.1 3,895 66.0 159 Divorced/separated/widowed 20.8 10.4 234 * 24 Residence Urban 8.6 3.7 1,440 (69.8) 53 Rural 9.9 5.4 5,379 59.2 289 Region Northern 4.9 3.1 744 (74.5) 23 Central 6.9 3.6 3,074 73.1 109 Southern 13.6 7.0 3,001 53.0 209 Education No education 7.3 5.9 422 * 25 Primary 10.8 5.4 4,270 57.3 233 Secondary 7.4 3.9 1,904 87.1 74 More than secondary 10.6 4.6 223 * 10 Wealth quintile Lowest 8.7 4.9 997 52.3 49 Second 9.8 6.6 1,309 58.5 86 Middle 10.2 4.9 1,367 60.7 67 Fourth 11.8 5.0 1,376 68.4 69 Highest 8.0 4.0 1,770 62.5 70 Total 15-49 9.6 5.0 6,818 60.9 341 50-54 11.5 0.8 357 * 3 Total men 15-54 9.7 4.8 7,175 60.7 344 Overall, 10 percent of men age 15-49 reported that they had paid someone in exchange for sex. Men who are divorced, separated, or widowed (21 percent) are more likely to have paid for sex than men who are currently married (12 percent) or have never married (6 percent). By region, men in the Southern Region are twice as likely to have paid for sex (14 percent) as men in the Central Region and the Northern Region (7 percent and 5 percent, respectively). Five percent of men reported paying for sex at least once during the past 12 months. The same proportion was reported in the 2004 MDHS. Sixty-one percent of the men who engaged in paid sex 182 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour reported that they used a condom the last time they paid for sex. This is an increase from 43 percent in 2004 MDHS. Although men in the Southern Region are more likely to have paid for sex in the past 12 months, they are less likely than men in other regions to have used a condom. 13.10 MALE CIRCUMCISION Circumcision is a common practice in many parts of Malawi for traditional, health, and other reasons. It often serves as a rite of passage into adulthood. Recently, male circumcision has been associated with a lower risk of HIV transmission (WHO and UNAIDS, 2007). To examine this practice at the national level, men interviewed in the 2010 MDHS were asked whether they had been circumcised and when they were circumcised. The results are presented in Table 13.11. Table 13.11 Male circumcision Percentage of men age 15-49 who report having been circumcised, and percent distribution of circumcised men by age of circumcision, according to background characteristics, Malawi 2010 Background characteristic Percentage circumcised Number of men Among circumcised men: age at circumcision Total Number of men circumcised During infancy/ before 5 years 5-13 years old 14-19 years old 20 or more years Don’t know/ missing Age 15-24 21.9 2,987 2.6 72.6 21.3 0.9 2.6 100.0 655 15-19 21.7 1,748 1.9 77.0 18.5 0.0 2.6 100.0 380 20-24 22.2 1,239 3.6 66.5 25.2 2.1 2.6 100.0 275 25-29 18.3 1,099 0.2 61.9 31.9 3.7 2.2 100.0 201 30-39 22.5 1,746 3.2 69.1 19.0 6.1 2.6 100.0 394 40-49 21.7 986 0.0 72.7 16.6 7.6 3.1 100.0 214 Residence Urban 23.5 1,440 1.8 67.4 23.0 5.0 2.8 100.0 338 Rural 20.9 5,379 2.1 71.1 21.0 3.3 2.6 100.0 1,126 Region Northern 2.5 744 4.9 59.6 25.5 5.1 4.9 100.0 19 Central 10.1 3,074 2.6 72.9 19.3 2.5 2.6 100.0 311 Southern 37.8 3,001 1.9 69.6 22.0 3.9 2.6 100.0 1,134 Ethnicity Chewa 6.2 2,274 1.6 62.6 26.6 4.6 4.6 100.0 141 Tumbuka 1.0 590 * * * * * 100.0 6 Lomwe 28.9 1,211 1.3 60.5 29.9 6.2 2.1 100.0 350 Tonga 2.0 123 * * * * * 100.0 3 Yao 86.8 897 2.1 80.6 14.7 0.9 1.8 100.0 779 Sena 9.0 300 (1.6) (61.9) (17.0) (16.9) (2.7) 100.0 27 Nkhonde 2.0 65 * * * * * 100.0 1 Ngoni 6.0 877 5.7 35.4 37.1 10.5 11.4 100.0 53 Mang’anja 22.9 191 (0.0) (68.1) (19.0) (9.0) (3.9) 100.0 44 Lambya 0.0 26 na na na na na na 0 Ndali 2.1 23 * * * * * 100.0 0 Nyanja 36.3 109 (4.0) (48.8) (37.7) (9.6) (0.0) 100.0 40 Other 15.6 133 * * * * * 100.0 21 Total 15-49 21.5 6,818 2.1 70.2 21.5 3.7 2.6 100.0 1,464 50-54 24.2 357 1.9 59.9 26.4 7.7 4.2 100.0 86 Total men 15-54 21.6 7,175 2.0 69.6 21.7 3.9 2.7 100.0 1,550 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Overall, 22 percent of the men age 15-49 reported that they are circumcised, and there is widespread regional and ethnic variation. The majority of Yao are circumcised (87 percent), followed by 36 percent of the Nyanja, and 29 percent of the Lomwe. Seventy percent of circumcised men underwent the procedure between the ages of 5 and 13, whereas 22 percent were circumcised at age 14-19, and only 4 percent were circumcised at age 20 or older. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 183 13.11 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS In the 2010 MDHS, respondents who had had sexual intercourse were asked if in the past 12 months they had experienced an infection acquired through sexual contact, or if they had experienced either of two symptoms associated with STIs: a bad-smelling, abnormal discharge from the vagina or penis or a genital sore or ulcer. Table 13.12 shows the self-reported prevalence of STIs and STI symptoms in the population for both women and men. Twelve percent of women and 7 percent of men reported having had an STI or experiencing STI symptoms during the 12 months preceding the survey. Table 13.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage of women who reported having in the past 12 months: Number of women who ever had sexual inter- course Percentage of men who reported having in the past 12 months: Number of men who ever had sexual inter- course STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Age 15-24 1.2 4.1 5.6 8.9 6,480 1.3 5.3 3.5 8.1 2,028 15-19 0.7 4.7 4.2 8.4 2,203 0.4 6.1 3.9 8.5 950 20-24 1.4 3.9 6.4 9.1 4,277 2.2 4.5 3.2 7.7 1,077 25-29 2.3 4.6 8.7 12.0 4,369 1.9 1.8 4.3 6.2 1,074 30-39 2.8 4.8 10.9 14.1 5,760 2.1 2.1 4.4 6.2 1,734 40-49 2.6 4.9 8.5 12.4 3,288 1.4 1.6 3.9 5.5 984 Marital status Never married 0.1 3.5 3.5 6.3 1,415 1.1 5.6 3.3 8.0 1,690 Married or living together 2.2 4.7 8.4 11.8 15,528 1.7 2.0 4.0 6.0 3,895 Divorced/separated/widowed 2.9 4.4 10.0 13.5 2,954 5.7 2.9 8.1 10.9 234 Male circumcision Circumcised na na na na na 1.8 2.5 4.4 7.2 1,322 Not circumcised na na na na na 1.6 3.2 3.9 6.6 4,491 Residence Urban 2.6 4.9 7.6 11.4 3,616 1.1 2.6 4.2 6.7 1,202 Rural 2.0 4.5 8.5 11.7 16,281 1.8 3.2 3.9 6.7 4,617 Region Northern 1.8 3.7 2.9 6.0 2,314 0.8 2.2 2.0 3.5 601 Central 2.1 4.5 8.2 11.7 8,339 1.4 3.3 3.0 6.0 2,625 Southern 2.2 4.8 9.7 13.0 9,244 2.1 3.0 5.4 8.2 2,594 Education No education 2.2 3.7 8.0 11.5 3,434 0.9 2.4 1.0 3.0 399 Primary 2.1 5.1 8.8 12.4 12,816 2.0 3.6 5.0 8.2 3,572 Secondary 2.0 3.3 6.9 9.4 3,294 1.2 2.2 2.6 4.9 1,651 More than secondary 2.0 3.9 5.7 7.0 353 1.2 1.1 2.8 4.1 197 Wealth quintile Lowest 1.9 4.0 7.2 10.3 3,771 2.4 3.3 3.0 6.5 859 Second 2.0 4.1 8.3 11.4 3,861 1.7 3.3 4.5 7.3 1,148 Middle 1.8 5.0 8.8 12.2 3,950 1.4 2.2 3.1 5.1 1,204 Fourth 2.8 5.4 10.1 14.1 3,916 1.7 4.0 4.3 7.4 1,170 Highest 2.2 4.2 7.2 10.3 4,399 1.4 2.7 4.6 7.2 1,438 Total 15-49 2.1 4.5 8.3 11.7 19,897 1.7 3.1 4.0 6.7 5,819 50-54 na na na na na 1.5 2.2 1.9 4.5 356 Total men 15-54 na na na na na 1.7 3.0 3.9 6.6 6,175 Note: Total includes 5 men with information missing on circumcision. na = Not applicable Among women, 2 percent reported having an STI in the past 12 months; 5 percent had a bad- smelling, abnormal discharge, and 8 percent had a genital sore or ulcer. The prevalence of STIs and STI symptoms is lower among never-married women (6 percent) than among ever-married women (12 percent or higher). By region, the prevalence of STIs or STI symptoms is higher among women in the Southern and Central Regions (13 and 12 percent, respectively) than among women in the Northern Region (6 percent). Reporting of STIs or STI symptoms generally decreases with level of education, but increases from the first to the fourth wealth quintile. 184 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Among men, 2 percent reported having had an STI in the past 12 months; 3 percent had a bad- smelling, abnormal discharge, and 4 percent had a genital sore or ulcer. Men who were divorced, separated, or widowed were more likely to have an STI or STI symptoms (11 percent) than those who were married (6 percent) or who have never been married but had sex (8 percent). Men who are circumcised are roughly equally likely to report having had an STI or STI symptoms in the past 12 months as men who are not circumcised. Self-reported STI prevalence is highest in the Southern Region (8 percent). If women or men reported having an STI or STI symptoms in the past 12 months, they were asked whether they had sought any advice or treatment. Figure 13.1 shows that 39 percent of women and 34 percent of men sought advice or treatment from a clinic, hospital, private doctor, or other health professional. However, 42 percent of women and 46 percent of men sought no advice or treatment. Figure 13.1 Women and Men Seeking Treatment for STIs MDHS 2010 38.9 1.4 15.6 41.7 33.9 0 9 46.3 Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment 0 10 20 30 40 50 60 Percent Women Men Clinic/hospital/private doctor/other health professional 13.12 PREVALENCE OF MEDICAL INJECTIONS Reuse of injection equipment, including needles and syringes, in a health care setting can contribute to the transmission of blood-borne pathogens. The proportion of people receiving medical injections is an important indicator for programme initiatives to prevent and control the spread of HIV. To obtain information for this indicator, respondents in the 2010 MDHS were asked if they had received any medical injection in the 12 months preceding the survey and, if so, how many. It should be noted that medical injections can also be self-administered (e.g., insulin for diabetes); these injections were not included in the calculation. Table 13.13 shows the reported prevalence of injections. Thirty-five percent of women and 18 percent of men reported receiving a medical injection from a health worker during the 12-month period preceding the survey. Generally, the average number of medical injections received over the 12-month period was one per person for women and 0.4 per person for men. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 185 Table 13.13 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the last 12 months, and the average number of medical injections per person in the past 12 months, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of women Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of men Age 15-24 38.0 0.8 9,559 23.3 0.4 2,987 15-19 34.5 0.7 5,005 29.6 0.5 1,748 20-24 41.9 1.0 4,555 14.4 0.4 1,239 25-29 40.5 1.1 4,400 13.6 0.4 1,099 30-39 33.1 1.0 5,772 14.2 0.4 1,746 40-49 18.6 0.6 3,288 15.7 0.5 986 Residence Urban 37.3 1.0 4,302 19.9 0.4 1,440 Rural 33.8 0.9 18,718 17.9 0.4 5,379 Region Northern 33.3 0.8 2,677 14.8 0.4 744 Central 34.1 0.9 9,857 17.2 0.4 3,074 Southern 35.1 0.9 10,485 20.3 0.5 3,001 Education No education 25.6 0.7 3,505 12.8 0.5 422 Primary 35.2 0.9 14,916 18.6 0.4 4,270 Secondary 39.7 1.0 4,177 19.1 0.4 1,904 More than secondary 30.7 0.8 422 15.9 0.8 223 Wealth quintile Lowest 29.8 0.7 4,268 18.2 0.5 997 Second 33.3 0.8 4,332 16.3 0.4 1,309 Middle 34.6 0.9 4,517 16.1 0.3 1,367 Fourth 35.0 0.9 4,515 19.6 0.4 1,376 Highest 38.6 1.0 5,388 20.6 0.5 1,770 Total 15-49 34.5 0.9 23,020 18.3 0.4 6,818 50-54 na na na 14.8 0.3 357 Total men 15-54 na na na 18.1 0.4 7,175 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. na = Not applicable The differentials indicate that injection prevalence is highest among women age 20-24 (42 percent), urban residents (37 percent), and women with a secondary education (40 percent). Injection use increases with increasing wealth quintile, from 30 percent of women in the lowest wealth quintile to 39 percent of women in the highest wealth quintile. Among men, the percentage receiving at least one medical injection in the past 12 months is highest among men age 15-19 (30 percent), men in urban areas (20 percent), men in the Southern Region (20 percent), men with a secondary education (19 percent), and men in the highest wealth quintile (21 percent). 13.13 HIV AND AIDS-RELATED KNOWLEDGE AND BEHAVIOUR AMONG YOUTH This section addresses HIV and AIDS-related knowledge among Malawian youth age 15-24 and assesses the extent to which Malawian youth are engaged in behaviours that may place them at risk of contracting HIV. 13.13.1 Knowledge about HIV and AIDS and Sources for Condoms Knowledge of how HIV is transmitted is crucial for people to avoid contracting HIV. Young people are often at greatest risk because they have short relationships with more partners or engage in 186 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour other risky behaviours. Table 13.14 shows the level of comprehensive knowledge of HIV and AIDS among youth and the percentage of youth who know of a source where they can obtain condoms. Comprehensive knowledge of HIV and AIDS is defined as (1) knowing that condom use and having just one HIV-negative faithful partner can reduce the chances of contracting HIV, (2) knowing that a healthy-looking person can have HIV, and (3) rejecting the two most common misconceptions about HIV transmission—that HIV can be transmitted by mosquito bites and that HIV can be transmitted by supernatural means. Table 13.14 shows that 42 percent of young women and 45 percent of young men have comprehensive knowledge about AIDS. The table also shows that comprehensive knowledge is higher among youths in urban areas than among youths in rural areas, especially among women. Among both sexes, the proportion with comprehensive knowledge tends to increase with level of education and wealth quintile. Among young women, the level of comprehensive knowledge about HIV is highest in the Southern Region (50 percent), compared with 36 percent in the Central Region, and 31 percent in the Northern Region. A similar trend is observed among young men. Table 13.14 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of men Age 15-19 39.5 71.8 5,005 44.7 86.1 1,748 15-17 38.9 67.4 3,313 43.3 83.3 1,143 18-19 40.8 80.4 1,691 47.1 91.2 605 20-24 44.2 85.8 4,555 44.7 93.9 1,239 20-22 42.8 84.9 2,686 43.5 93.2 791 23-24 46.3 87.3 1,869 46.8 95.1 448 Marital status Never married 43.1 70.5 4,341 45.9 88.4 2,435 Ever had sex 52.0 83.3 1,262 47.2 93.0 1,475 Never had sex 39.5 65.3 3,079 43.9 81.4 959 Ever married 40.6 85.1 5,218 39.4 93.2 552 Residence Urban 56.0 81.6 1,878 53.7 89.5 679 Rural 38.3 77.7 7,681 42.0 89.2 2,308 Region Northern 31.4 79.0 1,132 34.0 85.4 322 Central 36.4 75.6 4,136 43.9 90.0 1,325 Southern 49.6 81.1 4,292 48.0 89.5 1,341 Education No education 24.7 68.7 505 18.7 69.7 79 Primary 37.0 75.2 6,583 40.7 87.5 1,976 Secondary 57.5 89.2 2,316 55.2 94.9 868 More than secondary 64.5 87.4 155 55.9 92.2 64 Wealth quintile Lowest 33.5 73.6 1,710 35.0 85.0 451 Second 34.9 77.2 1,822 41.2 89.4 546 Middle 37.9 77.0 1,907 39.6 90.3 545 Fourth 44.0 80.0 1,793 46.2 87.2 597 Highest 54.7 83.1 2,328 54.2 92.4 849 Total 41.8 78.5 9,559 44.7 89.3 2,987 1 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 For this table, the following responses are not considered sources for condoms: friends, family members, and home. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 187 Seventy-nine percent of young women and 89 percent of young men know a place where they can obtain a condom. Knowledge of a source for condoms is higher among young women in urban areas than those in rural areas (82 and 78 percent, respectively). At the regional level, young women in the Southern Region (81 percent) are most likely to know a condom source, while those in the Central Region (76 percent) are least likely to know where to obtain a condom. Among young men, those in the Central Region and in the Southern Region (90 percent) are more likely to know a condom source than those in the Northern Region (85 percent). 13.13.2 Age at First Sexual Intercourse Age at first sex is an important indicator of both exposure to the risk of pregnancy and exposure to STIs. Young people who initiate sex at an early age are considered to be at a higher risk of becoming pregnant or contracting an STI than young people who delay initiation of sexual activity. Consistent use of condoms further reduces these risks. Table 13.15 shows that 14 percent of women age 15-24 and 22 percent of men age 15-24 initiated sexual activity before age 15. About three in five women age 18-24 (60 percent) and half of men age 18-24 (53 percent) had their first sexual intercourse before age 18. As expected, the proportion initiating sexual activity early is higher among ever-married young women (20 percent) than among those who have not yet married (8 percent); however, among young men, the opposite finding is true. The likelihood of early sexual debut is associated with high knowledge of a condom source, low educational attainment, and low wealth quintile for both young women and men. Table 13.15 Age at first sexual intercourse among youth Percentage of young women and of young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and of young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Malawi 2010 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 12.1 5,005 na na 26.4 1,748 na na 15-17 11.9 3,313 na na 29.9 1,143 na na 18-19 12.4 1,691 59.6 1,691 19.9 605 60.0 605 20-24 16.7 4,555 59.5 4,555 16.0 1,239 49.5 1,239 20-22 16.5 2,686 60.5 2,686 17.5 791 50.8 791 23-24 17.0 1,869 58.0 1,869 13.3 448 47.1 448 Marital status Never married 7.9 4,341 28.8 1,445 23.5 2,435 51.6 1,307 Ever married 19.6 5,218 68.8 4,802 15.9 552 56.2 536 Knows condom source1 Yes 15.2 7,502 60.2 5,269 22.9 2,667 54.4 1,714 No 10.8 2,058 55.8 977 15.4 320 33.1 129 Residence Urban 11.4 1,878 50.0 1,261 20.0 679 50.8 450 Rural 15.0 7,681 61.9 4,986 22.7 2,308 53.6 1,394 Region Northern 11.9 1,132 59.6 732 15.0 322 46.9 209 Central 8.9 4,136 52.4 2,691 19.8 1,325 47.4 871 Southern 20.1 4,292 66.3 2,823 26.1 1,341 60.9 764 Education No education 27.0 505 71.3 418 9.3 79 58.1 65 Primary 16.2 6,583 68.9 4,017 25.2 1,976 57.3 1,037 Secondary 6.8 2,316 38.3 1,658 17.2 868 47.4 679 More than secondary 4.5 155 12.6 153 7.8 64 35.2 63 Wealth quintile Lowest 17.6 1,710 64.6 1,141 24.1 451 58.7 278 Second 17.7 1,822 68.2 1,257 25.9 546 52.2 330 Middle 14.2 1,907 63.9 1,241 25.2 545 55.4 328 Fourth 14.7 1,793 61.0 1,123 19.4 597 54.1 367 Highest 8.9 2,328 43.4 1,483 18.5 849 48.2 541 Total 14.3 9,559 59.5 6,246 22.1 2,987 52.9 1,844 na = Not available 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 188 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Young women in rural areas are more likely to have initiated sex by age 15 and by age 18 than their urban counterparts: 15 percent of rural women have initiated sex by age 15 versus 11 percent of urban women. Likewise, 62 percent of rural women versus 50 of urban women have initiated sex by age 18. Analysis by region indicates that women in the Southern Region are more likely to have had their first sexual intercourse before age 15 (20 percent) than women in the Northern and Central Regions (12 percent and 9 percent, respectively). Young men in rural areas are more likely to have initiated sex by age 15 and by age 18 than are young men in urban areas. Twenty-three percent of rural men versus 20 percent of urban men had their first sexual intercourse by the age of 15. Over half (54 percent) of rural men had initiated sexual activity by the age of 18 compared with 51 percent of urban men. As with young women, the proportion of young men initiating sexual intercourse by age 15 is highest in the Southern Region (26 percent); however, young men in the Central Region are more likely than those in the Northern Region to have initiated sex by age 15 (20 percent compared with 15 percent). Trends in age at first sex appear in Figure 13.2. The percentage of women age 15-19 who have had sex by age 15 has steadily decreased over the past three MDHS surveys, from 17 percent in 2000 to 12 percent in 2010. By contrast, the percentage of men age 15-19 who have had sex by the age of 15 appears to have declined between 2000 and 2004, and then increased between 2004 and 2010 from 18 percent to 26 percent. The percentage of men and women age 18-19 who have had sex by age 18 has declined modestly over the time period of the three surveys. Figure 13.2 Trend in Age at First Sexual Intercourse 17 29 67 68 14 18 62 59 12 26 60 60 Women 15-19 Men 15-19 Women 18-19 Men 18-19 0 10 20 30 40 50 60 70 80 Percentage who had sexual intercourse before age 15 and 18 2000 MDHS 2004 MDHS 2010 MDHS 13.13.3 Premarital Sex The period between initiation of sexual intercourse and marriage is often a time of sexual experimentation. Table 13.16 presents information on premarital sexual intercourse and condom use among never-married youth age 15-24 in Malawi. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 189 Table 13.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Malawi 2010 Background characteristic Never-married women age 15-24 Never-married men age 15-24 Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Among women who had sexual intercourse in the past 12 months: Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Among men who had sexual intercourse in the past 12 months: Percentage who used condom at last sexual intercourse Number of women Percentage who used condom at last sexual intercourse Number of men Age 15-19 75.9 15.2 3,693 45.4 561 46.8 30.7 1,704 45.7 523 15-17 80.3 13.2 2,896 41.3 383 55.4 24.0 1,127 36.8 270 18-19 59.6 22.4 797 54.4 179 30.1 43.8 576 55.3 252 20-24 42.9 35.9 648 56.8 233 22.1 46.7 731 59.9 342 20-22 48.0 29.3 462 59.6 135 22.7 47.5 547 58.2 260 23-24 30.2 52.4 186 52.9 97 20.3 44.6 184 65.5 82 Knows condom source1 Yes 65.7 21.9 3,060 50.7 669 36.3 37.3 2,153 52.5 803 No 83.6 9.8 1,281 38.4 125 63.4 22.0 282 36.7 62 Residence Urban 65.4 23.5 1,024 64.1 240 37.1 34.2 603 57.2 206 Rural 72.6 16.7 3,317 42.1 554 40.1 35.9 1,831 49.5 658 Region Northern 75.3 15.1 477 37.2 72 53.1 27.3 260 66.5 71 Central 76.1 14.7 1,964 51.4 288 39.4 34.9 1,085 55.8 379 Southern 64.5 22.8 1,900 48.9 434 36.1 38.1 1,090 44.7 415 Education No education 74.8 16.2 84 * 14 42.5 37.6 49 * 19 Primary 76.5 15.3 2,729 37.6 418 43.1 33.2 1,585 44.5 526 Secondary 61.9 22.2 1,404 59.5 311 32.3 40.0 743 63.2 297 More than secondary 47.0 41.2 125 (75.6) 51 25.8 39.4 57 * 22 Wealth quintile Lowest 72.7 17.3 675 26.7 117 41.9 36.3 326 46.0 118 Second 73.4 15.9 637 34.3 101 37.4 38.8 419 41.4 163 Middle 76.4 14.5 736 35.1 107 37.6 35.4 421 46.2 149 Fourth 72.0 16.9 825 55.9 140 38.3 35.4 498 54.9 176 Highest 65.7 22.5 1,468 62.3 330 41.1 33.5 771 60.6 258 Total 70.9 18.3 4,341 48.8 794 39.4 35.5 2,435 51.4 865 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Seventy-one percent of never-married young women age 15-24 have never had sexual intercourse. Abstinence is most common among those age 15-17 (80 percent). Eighteen percent of never-married young women age 15-24 had sexual intercourse during the 12 months preceding the survey. Among never-married, sexually active young women, condom use at last sexual intercourse was 49 percent. At the regional level, condom use was highest in the Central and Southern Regions (51 and 49 percent, respectively) and lowest in the Northern Region (37 percent). Condom use increased with level of education and wealth quintile. Never-married young men are much more likely than their female counterparts to have ever had sex. Thirty-nine percent of never-married young men age 15-24 have never had sexual intercourse. Abstinence is most common among those age 15-17 (55 percent). Thirty-six percent of never-married young men age 15-24 had sexual intercourse during the 12 months preceding the survey. Among never-married, sexually active young men, condom use at last sexual intercourse was 51 percent. Condom use is highest in the Northern Region (67 percent) and lowest in the Southern Region (45 percent). Condom use increases with level of education and wealth quintile. For example, 68 percent of sexually active, never-married young men who have more than a secondary education used a condom the last time they had sexual intercourse, compared with 45 percent of those with a primary education and 35 percent of those who have never been to school. 190 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.13.4 Multiple Sexual Partners among Youth Tables 13.17.1 and 13.17.2 present infor- mation on young people age 15-24 who had two or more sexual partners during the 12 months preced- ing the survey and, among those with two or more partners, those who used a condom during last sex. Less than 1 percent of young women age 15-24 reported having sex with two or more partners in the 12 months preceding the survey. Women age 15-24 with more than a secondary education are more likely than other women to have had two or more sexual partners in the past 12 months (3 percent compared with 1 percent or less). Overall, 31 percent of young women who had high-risk sexual intercourse used a condom the last time they had higher-risk sexual intercourse (data not shown). Young men are much more likely than young women to report having two or more sexual partners in the past 12 months (7 percent). Among ever-married young men, 10 percent reported having two or more partners in the past 12 months com- pared with 6 percent of never-married men. Varia- tion in the reporting of multiple sexual partners in the past 12 months by region is small, ranging from 5 percent of young men in the Northern Region to 7 percent of young men in the Southern Region. Forty-one percent of young men who had two or more sexual partners in the past 12 months used a condom at last sex. Table 13.17.1 Multiple sexual partners in the past 12 months among youth: Women Percentage of all young women age 15-24 who had more than one sexual partner in the past 12 months, by background characteristics, Malawi 2010 Background characteristic Among all women age 15-24 Percentage who had 2+ partners in the past 12 months Number of women Age 15-19 0.7 5,005 15-17 0.8 3,313 18-19 0.4 1,691 20-24 0.8 4,555 20-22 0.7 2,686 23-24 1.0 1,869 Marital status Never married 0.7 4,341 Ever married 0.7 5,218 Knows condom source1 Yes 0.9 7,502 No 0.2 2,058 Residence Urban 0.9 1,878 Rural 0.7 7,681 Region Northern 0.8 1,132 Central 0.5 4,136 Southern 0.9 4,292 Education No education 0.9 505 Primary 0.8 6,583 Secondary 0.4 2,316 More than secondary 3.4 155 Wealth quintile Lowest 0.6 1,710 Second 0.9 1,822 Middle 0.5 1,907 Fourth 1.0 1,793 Highest 0.6 2,328 Total 15-24 0.7 9,559 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour | 191 Table 13.17.2 Multiple sexual partners in the past 12 months among youth: Men Percentage of all young men age 15-24 who had more than one sexual partner in the past 12 months, and among men having more than one sexual partner in the past 12 months the percentage reporting that a condom was used at last intercourse, by background characteristics, Malawi 2010 Background characteristic Among all men age 15-24 Among men age 15-24 who had 2+ partners in the past 12 months Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom at last intercourse Number of men Age 15-19 4.9 1,748 36.1 85 15-17 3.5 1,143 (27.0) 41 18-19 7.4 605 (44.4) 45 20-24 8.9 1,239 44.0 110 20-22 8.7 791 54.2 69 23-24 9.2 448 (26.9) 41 Marital status Never married 5.7 2,435 47.0 140 Ever married 10.1 552 24.2 56 Knows condom source1 Yes 7.1 2,667 41.1 190 No 1.8 320 * 6 Residence Urban 6.5 679 (37.9) 44 Rural 6.5 2,308 41.3 151 Region Northern 4.5 322 * 14 Central 6.4 1,325 40.5 85 Southern 7.2 1,341 36.2 96 Education No education 8.3 79 * 7 Primary 5.5 1,976 37.9 108 Secondary 8.6 868 46.1 75 More than secondary 9.8 64 * 6 Wealth quintile Lowest 7.0 451 (45.5) 31 Second 6.5 546 (24.6) 35 Middle 6.5 545 (41.6) 35 Fourth 6.8 597 (53.6) 40 Highest 6.2 849 (37.6) 53 Total 15-24 6.5 2,987 40.5 195 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 13.13.5 Age-mixing in Sexual Relationships In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because older men are more likely to have been exposed to these diseases. Using preventive methods such as negotiating safer sex is more difficult when the age differences are large. To examine age-mixing in the 2010 MDHS, young women age 15-19 who had sex in the 12 months preceding the survey were asked whether the man was younger, about the same age, or older than they were. If older, they were asked if they thought he was less than ten years older or ten or more years older. 192 | HIV- and AIDS-related Knowledge, Attitudes, and Behaviour The results presented in Table 13.18 show that, among women age 15-19 who had sexual intercourse in the 12 months preceding the survey, less than 1 percent had sex with a man ten or more years older than them. Age mixing in sexual relationships varies little by background characteristics. Young women who have never been married, those in urban areas, and those in the highest wealth quintile are more likely than other women to have had sex with a man ten or more years older than they are. Table 13.18 Age-mixing in sexual relationships among women age 15-19 Among women age 15-19 who had sexual intercourse in the past 12 months, the percentage who had sexual intercourse with a man who was 10 or more years older than themselves, by background characteristics, Malawi 2010 Background characteristic Percentage of women who had sexual intercourse with a man 10+ years older Number of women who had sexual intercourse in the last 12 months Age 15-17 0.8 780 18-19 0.4 1,020 Marital status Never married 1.8 561 Ever married 0.0 1,238 Knows condom source1 Yes 0.6 1,489 No 0.3 311 Residence Urban 2.0 310 Rural 0.3 1,490 Region Northern 0.9 238 Central 1.1 656 Southern 0.1 906 Education No education 0.4 85 Primary 0.4 1,387 Secondary 1.3 317 More than secondary * 10 Wealth quintile Lowest 0.4 356 Second 0.3 382 Middle 0.0 363 Fourth 0.1 347 Highest 2.1 352 Total 15-19 0.6 1,800 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members and home. HIV Prevalence | 193 HIV PREVALENCE 14 In Malawi much of the information on the national HIV prevalence estimates is derives from sentinel surveillance. Although surveillance data do not provide estimates of HIV prevalence for the general population, they do provide results specific to women attending antenatal clinics. The inclusion of HIV testing in the 2004 and 2010 MDHS offers the opportunity to better understand the magnitude and patterns of infection within the general reproductive-age population not included in sentinel surveillance surveys, especially for men age 15-54. The first such exercise was conducted as part of the 2004 MDHS. The 2010 MDHS is the second MDHS survey to anonymously link HIV testing results with key behavioural and sociodemographic characteristics of survey respondents. For the first time, Malawi has national, population-based trend data for HIV prevalence estimates among women and men. This chapter presents information on the HIV testing coverage rates among eligible survey respondents, the prevalence of HIV infection among those tested, and the factors associated with HIV infection in the population. HIV specimen collection and testing methodologies used in the 2010 MDHS are described in Chapter 1. 14.1 COVERAGE RATES FOR HIV TESTING Table 14.1 shows the distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing status. Eighty-seven percent of all MDHS respondents who were eligible for testing were interviewed and consented to HIV testing. Six percent of respondents were interviewed but refused to be tested for HIV and did not provide a blood sample. Coverage rates were higher for women than for men (91 and 84 percent, respectively). The proportion of respondents who consented to the HIV test was higher in rural areas than in urban areas for both women and men. Ninety-one percent of women in rural areas consented to HIV testing, compared with 88 percent in urban areas. Among men, 84 percent consented to testing in rural areas, compared with 80 percent in urban areas. The Central Region has the largest proportion (89 percent) of respondents who consented to HIV testing. 194 | HIV Prevalence Table 14.1 Coverage of HIV testing by residence and region Percent distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing status, according to residence and region (unweighted), Malawi 2010 Background characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed WOMEN 15-49 Residence Urban 87.7 0.4 7.7 1.7 0.4 1.2 0.6 0.4 100.0 1,134 Rural 91.0 0.4 4.1 0.6 0.7 1.6 1.2 0.5 100.0 7,040 Region Northern 89.7 0.4 4.4 0.4 0.6 2.2 1.6 0.8 100.0 1,451 Central 92.1 0.2 3.5 0.8 0.4 1.1 1.5 0.5 100.0 2,797 Southern 89.7 0.5 5.5 0.9 0.8 1.7 0.6 0.4 100.0 3,926 Total 90.5 0.4 4.6 0.8 0.6 1.6 1.1 0.5 100.0 8,174 MEN 15-54 Residence Urban 79.8 0.3 8.5 2.3 1.1 7.3 0.4 0.4 100.0 1,130 Rural 84.3 0.5 6.1 1.1 1.0 5.2 1.2 0.6 100.0 6,653 Region Northern 83.4 0.3 6.7 1.0 0.9 6.1 1.2 0.4 100.0 1,403 Central 86.5 0.3 5.0 1.2 0.7 4.6 1.3 0.5 100.0 2,787 Southern 81.6 0.6 7.5 1.4 1.3 6.0 0.8 0.8 100.0 3,593 Total 83.7 0.4 6.4 1.3 1.0 5.5 1.1 0.6 100.0 7,783 TOTAL (WOMEN 15-49 AND MEN 15-54) Residence Urban 83.8 0.3 8.1 2.0 0.7 4.2 0.5 0.4 100.0 2,264 Rural 87.7 0.4 5.1 0.9 0.8 3.4 1.2 0.6 100.0 13,693 Region Northern 86.6 0.4 5.5 0.7 0.7 4.1 1.4 0.6 100.0 2,854 Central 89.3 0.2 4.2 1.0 0.6 2.8 1.4 0.5 100.0 5,584 Southern 85.8 0.5 6.4 1.1 1.0 3.7 0.7 0.6 100.0 7,519 Total 87.2 0.4 5.5 1.0 0.8 3.5 1.1 0.6 100.0 15,957 1 Includes all Dried Blood Samples (DBS) tested at the lab and for which there is a result, i.e. positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g. technical problem in the field), 2) lost specimens, 3) non corresponding bar codes, and 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. Table 14.2 shows HIV testing coverage rates for women age 15-49 and men age 15-54 by age, level of education, and wealth quintile. Among women, HIV testing coverage varies from 89 percent in the 15-19 age group to 92 percent among women ages 25-29 and 35-44. Women with more than a secondary education and women in the highest wealth quintile are least likely to participate in HIV testing in the 2010 MDHS (87 and 89 percent, respectively). HIV Prevalence | 195 Table 14.2 Coverage of HIV testing by selected background characteristics Percent distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing status, according to selected background characteristics (unweighted), Malawi 2010 Background characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed WOMEN (15-49) Age 15-19 88.7 0.3 4.4 1.1 0.8 2.4 1.2 1.1 100.0 1,872 20-24 90.6 0.4 4.8 0.8 0.5 1.7 0.8 0.4 100.0 1,546 25-29 91.5 0.2 4.4 0.8 0.4 1.1 1.5 0.1 100.0 1,543 30-34 89.7 0.4 5.8 0.5 0.5 1.6 1.0 0.4 100.0 1,117 35-39 92.1 0.1 4.0 0.9 1.0 0.7 1.1 0.1 100.0 885 40-44 91.6 0.8 3.8 0.6 0.5 1.3 0.6 0.8 100.0 633 45-49 91.3 0.5 4.5 0.2 0.5 1.6 0.9 0.5 100.0 578 Education No education 88.8 0.8 4.5 1.0 1.1 1.5 1.1 1.2 100.0 1,216 Primary 91.1 0.2 4.5 0.7 0.5 1.4 1.2 0.4 100.0 5,448 Secondary 90.1 0.4 4.8 0.8 0.6 2.4 0.7 0.2 100.0 1,398 More than secondary 86.5 0.9 9.0 2.7 0.0 0.9 0.0 0.0 100.0 111 Wealth quintile Lowest 90.4 0.4 4.6 0.8 1.1 1.3 1.1 0.5 100.0 1,513 Second 90.9 0.1 4.3 0.8 0.4 1.6 1.2 0.6 100.0 1,645 Middle 91.7 0.5 4.3 0.7 0.4 1.1 1.1 0.2 100.0 1,659 Fourth 90.9 0.2 3.5 0.6 0.6 1.9 1.2 0.9 100.0 1,698 Highest 88.5 0.5 6.2 1.0 0.6 2.0 0.7 0.3 100.0 1,659 Total 90.5 0.4 4.6 0.8 0.6 1.6 1.1 0.5 100.0 8,174 MEN (15-54) Age 15-19 84.5 0.6 5.0 1.6 1.4 5.4 0.8 0.7 100.0 1,915 20-24 82.6 0.4 7.3 1.0 0.9 5.7 1.3 0.8 100.0 1,322 25-29 83.0 0.5 6.9 1.2 0.9 5.9 1.0 0.5 100.0 1,161 30-34 81.4 0.4 6.9 1.4 1.9 6.3 0.8 1.0 100.0 1,035 35-39 84.0 0.0 5.9 1.7 0.1 6.0 1.8 0.5 100.0 846 40-44 85.9 0.5 6.6 1.2 0.9 4.4 0.5 0.0 100.0 588 45-49 85.1 0.8 7.6 0.8 0.2 3.8 1.5 0.2 100.0 524 50-54 84.9 0.5 7.7 0.3 0.8 4.1 1.0 0.8 100.0 392 Education No education 77.4 1.3 6.3 1.7 1.3 8.6 0.8 2.5 100.0 522 Primary 84.3 0.3 6.5 1.2 0.9 5.1 1.0 0.6 100.0 4,992 Secondary 84.6 0.4 5.7 1.1 1.1 5.4 1.3 0.3 100.0 2,044 More than secondary 75.6 0.9 12.4 1.8 1.3 6.7 1.3 0.0 100.0 225 Wealth quintile Lowest 81.9 0.4 6.7 1.7 1.1 6.6 0.6 1.0 100.0 1,260 Second 85.0 0.4 5.7 1.2 1.0 5.1 1.2 0.4 100.0 1,571 Middle 84.6 0.4 6.7 0.8 0.8 4.8 1.4 0.4 100.0 1,577 Fourth 84.1 0.5 5.7 0.9 1.4 5.2 1.3 0.8 100.0 1,672 Highest 82.5 0.5 7.5 1.8 0.8 5.9 0.7 0.4 100.0 1,703 Total 83.7 0.4 6.4 1.3 1.0 5.5 1.1 0.6 100.0 7,783 Note: Total includes one woman with information missing on education. 1 Includes all Dried Blood Samples (DBS) tested at the lab and for which there is a result, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) non corresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. Age differentials in HIV testing coverage are more pronounced among men than among women, with HIV testing coverage among men ranging from 81 percent for those age 30-34 to 86 percent for those age 40-44. As with women, HIV testing coverage is lowest among men with more than a secondary education (76 percent). Among wealth quintiles, men in the lowest wealth quintile have the lowest proportion of coverage (82 percent) compared with men in the higher wealth quintiles. Additional tables describing the relationship between participation in the HIV testing and characteristics related to HIV risks are presented in Appendix A. 196 | HIV Prevalence 14.2 HIV PREVALENCE 14.2.1 HIV Prevalence by Age and Sex Table 14.3 shows that 11 percent of adults age 15-49 in Malawi are infected with HIV. Among women age 15-49, the HIV prevalence rate is 13 percent, while among men age 15-49 the HIV prevalence rate is 8 percent. HIV prevalence increases with age for both women and men. For women, HIV prevalence is highest among women age 35-39 (24 percent), which is six times the rate among women age 15-19 (4 percent). For men, the prevalence increases sharply from 1 percent among men age 15-19 to 21 percent among those age 40-44, and drops thereafter. Figure 14.1 illustrates the age pattern of HIV prevalence for women and men. Table 14.3 HIV prevalence by age Among the de facto women age 15-49 and men age 15-54 who were interviewed and tested, the percentage HIV positive, by age, Malawi 2010 Age Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 4.2 1,545 1.3 1,703 2.7 3,248 20-24 6.4 1,401 2.8 1,176 4.7 2,577 25-29 13.5 1,407 6.9 1,041 10.7 2,448 30-34 20.7 937 10.8 885 15.9 1,821 35-39 23.8 806 18.1 757 21.0 1,563 40-44 20.4 533 20.9 506 20.7 1,039 45-49 16.1 462 14.9 429 15.5 891 Total 15-49 12.9 7,091 8.1 6,497 10.6 13,588 50-54 na na 13.1 341 na na Total men 15-54 na na 8.4 6,839 na na na=Not applicable Figure 14.1 HIV Prevalence by Sex and Age MDHS 2010 $ $ $ $ $ $ $ 1 3 7 11 18 21 15 & & & & & & & 4 6 14 21 24 20 16 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 5 10 15 20 25 Pe rc en t Women Men& $ HIV Prevalence | 197 14.2.2 Trends in HIV Prevalence Table 14.4 shows trends in HIV prevalence over time, by age. In Malawi, adult HIV prevalence decreased slightly between the 2004 MDHS and the 2010 MDHS, from 12 to 11 percent, respectively. HIV prevalence among women remained at 13 percent over the same period, while among men it decreased from 10 to 8 percent. However, it is important to note that none of these decreases in HIV prevalence are statistically significant. Table 14.4 Trends in HIV prevalence by age Among de facto women age 15-49 and men age 15-54 who were interviewed and tested, the percentage HIV positive, by age, Malawi 2004 and 2010 Age Women Men Total MDHS 2004 MDHS 2010 MDHS 2004 MDHS 2010 MDHS 2004 MDHS 2010 Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 3.7 500 4.2 1,545 0.4 467 1.3 1,703 2.1 967 2.7 3,248 20-24 13.2 661 6.4 1,401 3.9 442 2.8 1,176 9.5 1,103 4.7 2,577 25-29 15.5 477 13.5 1,407 9.8 509 6.9 1,041 12.6 986 10.7 2,448 30-34 18.1 382 20.7 937 20.4 397 10.8 885 19.2 779 15.9 1,821 35-39 17.0 257 23.8 806 18.4 262 18.1 757 17.7 520 21.0 1,563 40-44 17.9 235 20.4 533 16.5 242 20.9 506 17.2 477 20.7 1,039 45-49 13.3 173 16.1 462 9.5 146 14.9 429 11.6 319 15.5 891 50-54 na na na na 10.5 115 13.1 341 na na na na Total 15-49 13.3 2,686 12.9 7,091 10.2 2,465 8.1 6,497 11.8 5,150 10.6 13,588 Total men 15-54 na na na na 10.2 2,580 8.4 6,839 na na na na na = Not applicable Figure 14.2 shows the age pattern for HIV prevalence among women and men for the 2004 and 2010 MDHS surveys. Figure 14.2 HIV Prevalence by Sex and Age MDHS 2004 and 2010 MDHS 2010 , , , , , , , ) ) ) ) ) ) ) $ $ $ $ $ $ $ ! !! ! ! ! ! 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 5 10 15 20 25 Pe rc en t Women MDHS 2004 Men MDHS 2004 Women MDHS 2010 Men MDHS 2010 ! $ ) , 14.2.3 HIV Prevalence by Socioeconomic Characteristics Table 14.5 shows the variation in HIV prevalence by various socioeconomic characteristics, including residence, region, ethnicity, religion, education, employment, and wealth quintile. HIV prevalence in urban areas is twice that of rural areas: 17 percent of women and men age 15-49 in urban areas are infected with HIV compared with 9 percent in rural areas. The Southern Region has 198 | HIV Prevalence the highest HIV prevalence (15 percent), which is about twice that of the Central Region (8 percent) and Northern Region (7 percent). Excluding the category for other ethnicity, respondents who identify themselves specifically as Chewa, Ndali, Nkhonde, and Tumbuka have the lowest prevalence compared with other ethnic groups (7 percent each). HIV prevalence is highest among the Lomwe ethnic group (17 percent), followed by the Nyanja (15 percent), Mang’anja (15 percent), and Yao (13 percent). Table 14.5 HIV prevalence by socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socioeconomic characteristics, Malawi 2010 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Residence Urban 22.7 1,389 12.0 1,383 17.4 2,772 Rural 10.5 5,702 7.1 5,114 8.9 10,816 Region Northern 8.2 799 4.8 712 6.6 1,511 Central 9.0 3,043 6.2 2,927 7.6 5,970 Southern 17.6 3,249 11.0 2,858 14.5 6,107 Ethnicity Chewa 9.0 2,423 5.2 2,180 7.2 4,602 Lambya 7.9 32 15.4 26 11.3 57 Lomwe 20.2 1,172 13.3 1,165 16.8 2,337 Mang’anja 17.6 192 11.6 174 14.7 366 Ndali 9.0 22 (5.1) 21 7.1 44 Ngoni 13.4 928 7.6 837 10.6 1,765 Nkhonde 4.3 77 11.3 62 7.4 139 Nyanja 17.9 104 11.6 98 14.9 202 Sena 13.3 326 9.3 290 11.4 616 Tonga 11.2 147 7.0 123 9.3 269 Tumbuka 9.3 632 4.8 562 7.2 1,194 Yao 16.2 915 9.7 838 13.1 1,753 Other 6.4 119 6.3 122 6.4 241 Missing * 3 * 1 * 4 Religion Anglican 18.7 176 8.9 153 14.1 330 Catholic 10.5 1,547 8.2 1,453 9.4 2,999 CCAP1 12.2 1,158 6.6 1,106 9.5 2,264 Muslim 14.8 911 7.9 771 11.7 1,682 Seventh Day Advent/Baptist 16.7 484 9.1 463 13.0 947 Other Christian 12.8 2,730 8.7 2,292 10.9 5,022 Other * 41 3.4 91 6.5 132 No religion (11.2) 39 10.2 167 10.4 206 Missing * 6 * 1 * 7 Education No education 14.1 1,096 10.9 397 13.2 1,493 Primary 11.6 4,569 7.7 4,052 9.8 8,621 Secondary 16.1 1,292 8.1 1,848 11.4 3,140 More than secondary 16.3 134 11.9 201 13.6 335 Employment (past 12 months) Not employed 9.6 1,984 2.4 725 7.7 2,709 Employed 14.2 5,104 8.9 5,771 11.3 10,875 Missing * 3 * 1 * 4 Wealth quintile Lowest 8.9 1,202 5.6 932 7.5 2,134 Second 9.3 1,392 6.5 1,255 8.0 2,646 Middle 10.6 1,393 8.0 1,298 9.4 2,691 Fourth 13.7 1,369 8.2 1,308 11.0 2,677 Highest 19.7 1,735 10.8 1,704 15.3 3,440 Total 15-49 12.9 7,091 8.1 6,497 10.6 13,588 50-54 na na 13.1 341 na na Total men 15-54 na na 8.4 6,839 na na Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1Church of Central Africa, Presbyterian HIV Prevalence | 199 HIV prevalence by religion varies from 14 percent among Anglicans to 7 percent among respondents who identify themselves with religions in the ‘other’ category. By education, HIV prevalence in Malawi is highest among respondents with more than a secondary education and those with no education (14 and 13 percent, respectively). The same pattern is seen among men; 12 percent of men with more than a secondary education and 11 percent of men with no education are infected with HIV. However, among women, the pattern differs. Women with a secondary education and more than a secondary education have the highest HIV prevalence at 16 percent for both groups. Employed respondents have a higher prevalence rate (11 percent) than those who are unemployed (8 percent). Employed men are four times as likely to be HIV positive as unemployed men (9 percent versus 2 percent). Among women, the difference by employment status is less pronounced; 14 percent of employed women are HIV positive compared with 10 percent of unemployed women. HIV prevalence increases with increasing wealth from 8 percent among respondents in the lowest wealth quintile to 15 percent among those in the highest quintile. Women in the highest wealth quintile (20 percent) are almost twice as likely to be HIV positive as men in the highest wealth quintile (11 percent). 14.2.4 HIV Prevalence by Demographic Characteristics Table 14.6 shows HIV prevalence among women and men by various demographic characteristics. These include marital status, type of union, the number of times the respondent slept away from home in the 12 months before the survey, the total time away in the past 12 months, pregnancy status, ANC attendance, and male circumcision. HIV prevalence is closely related to marital status among both women and men age 15-49. Half of widowed respondents (50 percent) and a quarter of divorced or separated respondents (24 percent) are HIV positive. Twelve percent of respondents who are married or living together as if married are HIV positive. Among respondents who have never been married, the HIV prevalence is 4 percent for those who have had sex and 2 percent for those who have never had sex. This suggests that some women and men incorrectly reported that they were not sexually active, or that there is some degree of nonsexual HIV transmission occurring (e.g., through blood transfusions or non-sterile injections). HIV prevalence is the same for currently married women and men (12 percent each), while it is lower among divorced or separated men than among women in the same category (21 and 25 percent, respectively). HIV prevalence is 12 percent, whether respondents reported being in a polygynous or non- polygynous union, and 9 percent for respondents who are not currently in a union. The pattern varies when observing the disaggregated data for women and men by type of union. For women, HIV prevalence is highest among women who are not currently in a union (15 percent) and lowest among women who are in a non-polygynous union (11 percent). Among men, HIV prevalence is highest among men who report that they are in a non-polygynous union (12 percent), which is three times higher than for men who are not currently in a union (4 percent). Among men in a polygynous union, HIV prevalence is 11 percent. HIV prevalence is highest among respondents who slept away from home five or more times in the past 12 months (15 percent): 22 percent among women and 12 percent among men. With respect to the duration of time away from home over the past year, HIV prevalence is highest among respondents who spent less than one month away from home (12 percent). HIV prevalence is 10 percent for respondents who did not spend any time away from home and 10 percent for those who spent more than one month away from home. Women who were pregnant at the time of the survey were less likely to be HIV positive than women who were not pregnant or who were unsure of their pregnancy status (9 and 13 percent, respectively). HIV prevalence is higher among women who did not receive antenatal care for their last birth or who did not have a birth in the past three years (15 percent) compared with those who 200 | HIV Prevalence received ANC care. Among women who received ANC services, HIV prevalence is 10 percent for those using the public sector and 9 percent for those using services outside of the public sector. Table 14.6 HIV prevalence by demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by demographic characteristics, Malawi 2010 Demographic characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Never married 4.2 1,386 2.1 2,605 2.8 3,991 Ever had sex 8.6 464 2.3 1,656 3.7 2,120 Never had sex 2.0 922 1.6 950 1.8 1,871 Married/living together 11.7 4,775 11.5 3,682 11.6 8,457 Divorced or separated 24.8 665 20.7 183 23.9 848 Widowed 50.1 265 * 27 49.8 292 Type of union In polygynous union 12.8 692 10.8 272 12.2 964 In non-polygynous union 11.4 4,043 11.6 3,401 11.5 7,444 Not currently in union 15.4 2,316 3.7 2,816 9.0 5,132 Missing (22.8) 41 * 8 21.7 49 Times slept away from home in past 12 months None 11.3 4,195 8.0 3,216 9.9 7,410 1-2 14.4 2,022 7.6 1,760 11.3 3,781 3-4 14.1 514 6.5 798 9.5 1,312 5+ 22.1 337 11.6 698 15.0 1,035 Missing (4.5) 24 * 26 (8.2) 50 Time away in past 12 months Away for more than one month 13.6 772 7.1 1,029 9.9 1,801 Away only for less than 1 month 15.9 2,071 8.7 2,180 12.2 4,251 Not away 11.3 4,208 8.0 3,216 9.9 7,424 Missing (11.7) 40 8.7 73 9.7 112 Currently pregnant Pregnant 8.8 645 na na na na Not pregnant or not sure 13.3 6,446 na na na na ANC for last birth in the past 3 years ANC provided by the public sector 10.4 2,593 na na na na ANC provided by other than the public sector 8.6 709 na na na na No ANC/No birth in past 3 years 15.4 3,771 na na na na Total 15-49 12.9 7,091 8.1 6,497 10.6 13,588 50-54 na na 13.1 341 na na Total men 15-54 na na 8.4 6,839 na na Note: Total includes 19 women with information missing on ANC for last birth in the past 3 years. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 14.2.5 HIV Prevalence by Sexual Risk Behaviour Table 14.7 presents HIV prevalence rates among respondents who have ever had sexual intercourse by sexual behaviour indicators. In reviewing these results, it is important to note that responses to questions about sexual risk behaviours may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk, nor is it possible to know the sequence of events, e.g., whether any reported condom use occurred before or after HIV transmission. Among all respondents age 15-49 who have ever had sex and were tested for HIV, 12 percent are HIV positive: 15 percent of women and 9 percent of men. Among women whose sexual debut was at age 15 or younger, 17 percent are HIV positive, a figure that decreases to 11 percent among women whose sexual debut was at age 18-19. Among men the pattern is reversed; HIV prevalence is highest for men whose sexual debut was at age 18-19 (11 percent) and lowest for men whose sexual debut was at age 15 or younger (8 percent). HIV Prevalence | 201 Table 14.7 HIV prevalence by sexual behaviour Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behaviour characteristics, Malawi 2010 Sexual behaviour characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse <16 16.6 2,181 8.4 1,993 12.7 4,173 16-17 14.4 1,752 9.5 958 12.6 2,710 18-19 10.8 1,199 10.7 1,116 10.7 2,315 20+ 12.2 635 9.1 1,379 10.0 2,014 Missing 18.7 400 12.6 95 17.5 494 Multiple sexual partners and partner concurrency in past 12 months 0 24.7 831 4.9 783 15.1 1,614 1 12.7 5,262 9.7 4,137 11.4 9,400 2+ 31.8 64 11.8 614 13.7 678 Had concurrent partners1 * 26 12.1 482 13.5 508 No sexual partners were concurrent (26.6) 38 10.5 132 14.1 170 Missing * 8 * 7 * 15 Condom use Ever used a condom 20.3 1,292 11.8 3,183 14.3 4,475 Never used a condom 13.0 4,865 5.8 2,345 10.6 7,210 Missing * 9 * 13 (16.6) 21 Condom use at last sexual intercourse in past 12 months Used condom 29.1 509 13.9 962 19.2 1,471 Did not use condom 11.2 4,816 9.0 3,785 10.3 8,602 No sexual intercourse in past 12 months 24.4 839 4.8 789 14.9 1,628 Missing * 1 * 5 * 6 Number of lifetime partners 1 7.1 3,298 1.9 1,158 5.7 4,457 2 16.8 1,916 6.5 1,362 12.6 3,278 3-4 33.7 812 10.1 1,746 17.6 2,558 5-9 53.1 104 16.0 875 19.9 980 10+ * 18 20.4 304 20.8 322 Missing * 17 26.2 96 25.4 113 Paid for sexual intercourse in past 12 months2 Yes na na 8.6 320 na na Used condom na na 11.5 192 na na Did not use condom na na 4.1 129 na na No (Did not pay for sexual intercourse/no sexual intercourse in past 12 months) na na 9.3 5,221 na na Total 15-49 14.5 6,166 9.3 5,541 12.0 11,707 50-54 na na 13.1 341 na na Total men 15-54 na na 9.5 5,882 na na Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives. 2 Includes men who report having a prostitute for at least one of their last three sexual partners in the past 12 months HIV prevalence by the number of sexual partners in the past 12 months varies by gender, as very few women report having more than one sexual partner compared with men. Therefore, it is more informative to observe these data disaggregated by gender. Among women, HIV prevalence is highest for women who report having two or more partners in the last 12 months (32 percent). HIV prevalence is 25 percent for women who report that they have not had any sexual partner in the past 12 months and 13 percent for women who have had one partner in the same period. Among men who report having two or more partners in the past 12 months, HIV prevalence is 12 percent, and 5 percent among men who report that they have not had any sexual partners in the past 12 months. 202 | HIV Prevalence Among men who report that they have concurrent sexual partners, that is, those men who report having two or more different sexual partners at the same time, HIV prevalence is 12 percent. Too few women reported concurrent sexual partners to provide a representative prevalence estimate for this indicator. Ever use of condoms is positively correlated with HIV prevalence among both women and men. Women who have never used a condom have a lower HIV prevalence (13 percent) than those who have ever used a condom (20 percent). Similarly, men who have ever used a condom have a prevalence rate of 12 percent compared with 6 percent among those who have never used a condom. A similar pattern exists among women and men with respect to condom use at the last sexual encounter in the 12 months preceding the survey. HIV prevalence increases as the number of lifetime sexual partners increases for both women and men. Prevalence among women increases significantly, from 7 percent for women with one lifetime partner to 17 percent for two lifetime partners, to 34 percent for three to four lifetime partners, and to 53 percent for five to nine lifetime partners. Among men, HIV prevalence ranges from 2 percent among men with one lifetime partner to 20 percent among men with ten or more lifetime partners. Among men who paid for sexual intercourse in the past 12 months, 9 percent are HIV positive. Prevalence is higher for men who used a condom than for men who did not use a condom (12 and 4 percent, respectively). It should be noted that HIV prevalence is the same for men who reported paying for sex as it is for men who did not report paying for sex or who did not have sexual intercourse in the past 12 months (9 percent). 14.3 HIV PREVALENCE AMONG YOUTH Table 14.8 shows HIV prevalence among women and men age 15-24. Overall, 4 percent of youth age 15-24 tested positive for HIV, and prevalence is higher among young women (5 percent) than among young men (2 percent). HIV prevalence increases with age, from 3 percent among youth age 15-19 to 4 percent among youth age 20-22, to 6 percent among youth age 23-24. For young women, HIV prevalence increases from 3 percent among women age 15-17 to 6 percent for women age 18-22, to 8 percent for women age 23-24. For young men, the increase in HIV prevalence is not linear; prevalence is 2 percent for men age 15-17 and decreases to less than 1 percent for men age 18- 19. Prevalence then increases to 2 percent in the age group 20-22 and continues to increase to 5 percent for men age 23-24. Young respondents who have never been married have a lower HIV prevalence (2 percent) than those who are married or living together (5 percent), and a much lower prevalence than youth who are separated, divorced, or widowed (12 percent). Among youth who have never been married, those who have never had sex have a lower prevalence (2 percent) than those who have had sex (3 percent). The differences in prevalence rates are more pronounced among young women than among young men. Eight percent of never-married women who have ever had sex are HIV positive, compared with 2 percent of never-married women who have never had sex. For men, the pattern is reversed and the differences are insignificant; 1 percent of young men who have ever had sex are HIV positive compared with 2 percent of men who have never had sex. Among young women, HIV prevalence is 5 percent for those who are not pregnant or are not sure and 4 percent for women who are pregnant. HIV Prevalence | 203 Table 14.8 HIV prevalence among young people by background characteristics Percentage HIV positive among women and men age 15-24 who were tested for HIV, by background characteristics, Malawi 2010 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 4.2 1,545 1.3 1,703 2.7 3,248 15-17 3.4 1,036 2.0 1,102 2.7 2,138 18-19 5.7 510 0.1 601 2.7 1,110 20-24 6.4 1,401 2.8 1,176 4.7 2,577 20-22 5.6 824 1.8 752 3.8 1,576 23-24 7.5 577 4.6 424 6.2 1,001 Marital status Never married 3.8 1,312 1.5 2,361 2.3 3,673 Ever had sex 7.6 400 1.4 1,445 2.8 1,846 Never had sex 2.1 912 1.6 916 1.9 1,827 Married/living together 5.5 1,441 3.5 480 5.0 1,921 Divorced/separated/widowed 12.9 193 (7.8) 38 12.0 231 Currently pregnant Pregnant 3.8 300 na na na na Not pregnant or not sure 5.4 2,645 na na na na Residence Urban 11.2 589 2.9 666 6.8 1,255 Rural 3.7 2,357 1.6 2,213 2.7 4,570 Region Northern 2.9 368 1.1 313 2.1 680 Central 3.5 1,245 1.7 1,278 2.6 2,523 Southern 7.5 1,333 2.4 1,289 5.0 2,622 Education No education 9.1 185 1.2 70 6.9 255 Primary 3.9 1,994 2.0 1,904 3.0 3,898 Secondary 7.8 719 1.7 847 4.5 1,566 More than secondary (5.6) 48 (2.4) 58 3.8 106 Wealth quintile Lowest 3.2 486 1.3 428 2.3 914 Second 3.5 575 1.0 528 2.3 1,103 Middle 4.0 601 3.2 519 3.6 1,120 Fourth 6.2 535 1.3 570 3.7 1,105 Highest 8.1 749 2.5 835 5.1 1,583 Total 5.2 2,946 1.9 2,879 3.6 5,825 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable HIV prevalence is higher in urban areas than in rural areas, and the same pattern is observed for young women and men in these areas. The difference is very pronounced among women, as women living in urban areas are almost three times more likely to be infected with HIV than their rural counterparts (11 percent versus 4 percent). By region, HIV prevalence is highest in the Southern Region (5 percent) and lowest in the Northern Region (2 percent). The disaggregated data for women and men at the regional level show the same pattern. Among youth, the HIV prevalence by educational attainment is different for women than for men. Young women with no education have an HIV prevalence of 9 percent compared with 8 percent for women with a secondary education and 4 percent for women with a primary education. Among young men, HIV prevalence is highest for those with a primary and secondary education (2 percent each) and lowest for men with no education (1 percent). Overall, HIV prevalence increases with increasing wealth, ranging from 2 percent in the lowest wealth quintile to 5 percent in the highest quintile. However, the patterns for young women and men differ. For young women, the pattern is similar to the overall trend, with prevalence steadily increasing as wealth increases, from 3 percent in the lowest quintile to 8 percent in the highest quintile. For young men, HIV prevalence is 1 percent in the lowest, second, and fourth quintiles and 3 percent in the middle and highest quintiles. 204 | HIV Prevalence 14.3.1 HIV Prevalence by Sexual Behaviour among Youth The 2010 MDHS collected data on behaviours that correlate with sexually transmitted infection (STI) rates. Information on sexual behavioural characteristics is important in designing, targeting, and monitoring HIV prevention interventions for the young adult population. Three behaviours that correlate with STI rates include the number of sexual partners, age at first sexual intercourse, and condom use. It is important to note that responses about sexual behaviour are subject to reporting bias. This section examines data on sexual behaviour related to the spread of HIV and other sexually transmitted infections among respondents who have ever had sexual intercourse. Table 14.9 shows HIV prevalence among youth by sexual behaviour. Overall, 4 percent of respondents age 15-24 who have ever had sex and were tested for HIV in the 2010 MDHS are HIV positive: 7 percent of young women and 2 percent of young men. Respondents were asked about the number of sexual partners they had in the past 12 months. For young men, the proportion who tested positive for HIV increases with the number of sexual partners. For example, 1 percent of men with no sexual partners within the past 12 months are HIV positive, 2 percent with one sexual partner are HIV positive, and 5 percent of men with two or more sexual partners are HIV positive. For young women, HIV prevalence is higher among women who reported that they have not had any sexual partners within the past 12 months than for women who reported having one sexual partner (7 percent compared with 6 percent, respectively). Table 14.9 HIV prevalence among young people by sexual behaviour Percentage HIV-positive among women and men age 15-24 who ever had sex and were tested for HIV, by sexual behaviour, Malawi 2010 Sexual behaviour characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Multiple and concurrent sexual partners in past 12 months 0 7.4 248 0.9 606 2.8 854 1 6.1 1,750 2.1 1,158 4.5 2,908 2+ (32.0) 30 5.4 193 8.9 223 Had concurrent partners1 * 15 6.4 122 10.1 137 No partners were concurrent * 15 3.7 71 7.0 86 Missing * 5 * 2 * 7 Condom use Ever used a condom 9.3 514 2.1 1,130 4.4 1,644 Never used a condom 5.7 1,516 1.9 825 4.4 2,341 Missing * 2 * 4 * 6 Condom use at first sex Used condom 9.9 485 1.8 558 5.6 1,042 Did not use condom 5.6 1,497 1.9 1,379 3.9 2,876 Missing (4.7) 50 * 22 8.3 73 Condom use at last sexual intercourse in past 12 months Used condom 10.2 226 2.1 507 4.6 733 Did not use condom 6.0 1,553 2.9 841 4.9 2,394 No sexual intercourse in past 12 months 7.3 252 0.9 608 2.7 861 Missing * 1 * 4 * 4 Total 6.6 2,032 2.1 1,959 4.4 3,992 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na=Not applicable 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives. Young respondents who report having concurrent sexual partners within the past 12 months have higher HIV prevalence. Among young men who have concurrent sexual partners, 6 percent are HIV positive. HIV Prevalence | 205 Youth who have ever used a condom are equally likely to be HIV positive as those who have never used a condom (4 percent for both). The same pattern is observed among young men: 2 percent of those who have ever used a condom and 2 percent of those who have never used a condom are HIV positive. Nine percent of women who have ever used a condom are HIV positive compared with 6 percent of women who have never used a condom. Similar patterns are observed for condom use among youth at first sexual intercourse. Among all young women who reported using a condom at their last sexual intercourse in the past 12 months, HIV prevalence is 10 percent. Six percent of young women who did not use a condom at the last sexual intercourse are HIV positive. For young men, HIV prevalence is slightly higher for those who report not using a condom at their last sexual intercourse compared with young men who report using a condom (3 and 2 percent, respectively). 14.4 HIV PREVALENCE BY OTHER CHARACTERISTICS 14.4.1 HIV Prevalence and STIs A strong link exists between sexually transmitted infections and the sexual transmission of HIV. Many studies have demonstrated that sexually transmitted infections are a co-factor for HIV transmission. Management and treatment of STIs may potentially play an important role in the reduction of HIV transmission. Respondents in the 2010 MDHS who had ever had sex were asked if they had contracted a disease through sexual contact in the past 12 months, or if they had had any symptoms associated with STIs (a bad-smelling, abnormal discharge from the vagina or penis, or a genital sore or ulcer). Table 14.10 shows HIV prevalence, among women and men age 15-49 who have ever had sex, by whether respondents reported an STI in the 12 months preceding the survey. The data show that respondents with a history of STIs or STI symptoms have substantially higher rates of HIV than those with no history of STIs or STI symptoms. Women who had an STI or STI symptoms in the past 12 months are twice as likely to be HIV positive (27 percent) as women who did not have an STI or STI symptoms (13 percent). Similarly, men who reported having an STI or STI symptoms in the past 12 months (21 percent) are more than twice as likely to be HIV positive as men who did not report an STI or STI symptoms (8 percent). Table 14.10 HIV prevalence by sexually transmitted infections Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by whether they had an STI in the past 12 months, Malawi 2010 Characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection in past 12 months Had STI or STI symptoms 26.8 681 20.8 378 24.6 1,059 No STI, no symptoms 13.0 5,457 8.4 5,128 10.8 10,585 Missing (9.0) 28 (17.0) 35 13.4 63 Total 15-49 14.5 6,166 9.3 5,541 12.0 11,707 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 14.4.2 HIV Prevalence by Male Circumcision In the recent past, several studies in sub-Saharan Africa—including clinical trials conducted in South Africa, Kenya, and Uganda (Auvert et al., 2005; Gray et al., 2007; and Parker et al., 2007)— have documented that male circumcision provides some protection against HIV and other STIs. Although the research supporting circumcision’s protective effects is compelling, it is important to 206 | HIV Prevalence emphasise that circumcised men can still become infected with HIV and can infect their sexual partners. To investigate the relationship between male circumcision and HIV status in the 2010 MDHS, men were asked whether they were circumcised. The majority of men reported that they are not circumcised (78 percent).1 For those men who reported that they are circumcised, 85 percent reported that a traditional practitioner performed the circumcision, and 87 percent of these men reported that the circumcision was performed in a simba, a traditional location for circumcision practices for boys. Eighty-seven percent of circumcised men report that their circumcision occurred between the ages of 0-15 years.2 Table 14.11 presents data on HIV prevalence by male circumcision status. In Malawi, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men age 15-49 have a higher HIV prevalence than men who have not been circumcised (10 percent compared with 8 percent). However, by age, HIV prevalence is higher for younger uncircumcised men age 15-24 than for circumcised men in the same age range. In the 25-29 age group, the pattern changes as circumcised men have a higher HIV prevalence than uncircumcised men. HIV prevalence is highest among circumcised men ages 35-44 (26 percent). Among uncircumcised men, HIV prevalence is highest among those age 40-44 (19 percent). By residence, the HIV prevalence rate among circumcised men is 11 percent in urban areas and 10 percent in rural areas. For uncircumcised men, the prevalence is 12 percent in urban areas and 6 percent in rural areas. HIV prevalence does not vary much by region between circumcised and uncircumcised men. Both groups of men who reside in the Southern Region have the highest HIV rate compared with other regions (11 percent). Both circumcised men and uncircumcised men in the Northern Region have the lowest HIV rate compared with other regions (5 percent for both groups of men). Circumcised men who have attended secondary school (12 percent) are more likely to be HIV positive than those with less education. Among uncircumcised men, HIV prevalence is 12 percent for men with no education and more than a secondary education, and 7 percent for men with a primary and secondary education. Generally, HIV prevalence increases with wealth quintiles among both circumcised and uncircumcised men. In both groups, the lowest HIV prevalence is observed among those in the lowest wealth quintile: 6 percent for circumcised men and 5 percent for uncircumcised men. On the other hand, the highest HIV prevalence is observed among circumcised men in the middle and highest wealth quintiles (12 percent each) and among uncircumcised men in the highest wealth quintile (10 percent). Among ethnic and religious groups, the unweighted number of circumcised men who are HIV positive is too small to make comparisons and draw meaningful conclusions between circumcised and uncircumcised men. 1 See Table 13.11 in Chapter 13. 2 Data not shown. HIV Prevalence | 207 Table 14.11 HIV prevalence by male circumcision Among men age 15-49 who were tested for HIV, the percentage HIV positive by whether circumcised, according to background characteristics, Malawi 2010 Background characteristic Circumcised Not circumcised Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.2 368 1.6 1,332 20-24 2.7 252 2.8 923 25-29 9.0 192 6.4 848 30-34 13.7 180 9.9 705 35-39 25.6 185 15.8 571 40-44 25.9 108 19.3 399 45-49 18.7 93 13.9 337 Residence Urban 11.4 316 12.2 1,066 Rural 10.0 1,062 6.3 4,048 Region Northern (5.0) 18 4.8 692 Central 8.0 285 6.0 2,641 Southern 11.0 1,074 10.9 1,782 Education No education 8.9 128 11.9 268 Primary 10.0 931 7.0 3,117 Secondary 11.9 293 7.4 1,555 More than secondary * 26 12.1 174 Wealth quintile Lowest 6.4 200 5.4 732 Second 8.4 283 6.0 970 Middle 12.3 278 6.8 1,020 Fourth 10.8 276 7.5 1,030 Highest 12.2 341 10.4 1,363 Ethnicity Chewa 7.0 136 5.1 2,043 Lambya * 0 15.4 26 Lomwe 11.2 334 14.2 829 Mang’anja (24.3) 38 8.0 135 Ndali * 0 (5.3) 21 Ngoni (8.3) 55 7.6 782 Nkhonde * 1 11.6 60 Nyanja * 38 (13.4) 59 Sena (13.3) 27 8.9 262 Tonga * 2 6.9 120 Tumbuka * 5 4.8 557 Yao 10.0 720 7.8 118 Other * 19 5.5 102 Missing * 1 na na Religion Anglican (14.6) 39 7.0 114 Catholic 18.3 125 7.3 1,326 CCAP 17.9 92 5.6 1,011 Muslim 7.9 722 (8.8) 49 Seventh Day Advent/Baptist 10.8 79 8.8 384 Other Christian 10.2 309 8.4 1,982 Other * 3 3.5 88 No religion * 7 10.7 160 Missing * 1 na na Total 15-49 10.3 1,378 7.6 5,114 50-54 9.7 85 14.2 257 Total men 15-54 10.3 1,463 7.9 5,371 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 208 | HIV Prevalence 14.5 HIV PREVALENCE AMONG COHABITING COUPLES In the 2010 MDHS, more than 3,000 cohabiting couples were interviewed and tested for HIV. Table 14.12 shows that for 85 percent of cohabiting couples, both partners are HIV negative, while for 6 percent, both partners are HIV positive. Nine percent of cohabiting couples are discordant, that is, one partner is infected and the other is not. Among discordant partners, 5 percent represent cases where the male partner is HIV positive and the female partner is HIV negative, while four percent represent cases where the female partner is HIV positive and the male partner is HIV negative. Table 14.12 HIV prevalence among cohabiting couples Percent distribution of couples living in the same household, both of whom were tested for HIV, by HIV status, according to background characteristics, Malawi 2010 Background characteristic Both HIV positive Man HIV positive, woman HIV negative Woman HIV positive, man HIV negative Both HIV negative Total Number Woman’s age 15-19 2.3 2.2 6.2 89.3 100.0 266 20-29 4.1 3.7 2.8 89.4 100.0 1,687 30-39 10.9 6.2 4.8 78.1 100.0 1,043 40-49 6.1 6.1 3.7 84.1 100.0 466 Man’s age 15-19 * * * * 100.0 29 20-29 2.7 2.5 3.5 91.4 100.0 1,085 30-39 7.0 5.4 3.8 83.8 100.0 1,345 40-49 9.9 6.6 4.6 78.8 100.0 755 50-54 8.3 4.9 2.7 84.2 100.0 247 Age difference between partners Woman older 7.3 9.8 5.9 76.9 100.0 135 Same age/man older by 0-4 years 4.8 3.6 3.2 88.4 100.0 1,584 Man older by 5-9 years 6.5 4.1 4.2 85.2 100.0 1,291 Man older by 10-14 years 10.7 6.7 3.5 79.0 100.0 351 Man older by 15+ years 10.9 15.7 5.6 67.8 100.0 100 Type of union Monogamous 6.1 4.6 3.5 85.9 100.0 3,065 Polygynous 6.4 5.8 6.7 81.0 100.0 370 Missing * * * * 100.0 26 Multiple partners in past 12 months1 Both no 6.2 4.4 3.6 85.8 100.0 2,995 Man yes, woman no 6.6 6.8 4.1 82.5 100.0 441 Woman yes, man no * * * * 100.0 22 Both yes * * * * 100.0 5 Concurrent sexual partners in past 12 months2 Both no 6.3 4.4 3.7 85.6 100.0 3,060 Man yes, woman no 6.1 7.0 3.7 83.2 100.0 387 Woman yes, man no * * * * 100.0 10 Both yes * * * * 100.0 4 Residence Urban 12.6 6.8 3.7 77.0 100.0 541 Rural 5.1 4.3 3.8 86.8 100.0 2,921 Region Northern 3.7 3.7 1.7 90.9 100.0 377 Central 3.8 4.3 3.4 88.4 100.0 1,614 Southern 9.7 5.3 4.7 80.4 100.0 1,470 Woman’s education No education 7.7 6.9 3.6 81.8 100.0 630 Primary 5.6 3.9 3.5 87.1 100.0 2,319 Secondary 7.3 5.9 5.6 81.3 100.0 485 More than secondary * * * * 100.0 28 Man’s education No education 5.2 2.1 3.6 89.1 100.0 303 Primary 6.1 4.3 4.5 85.1 100.0 2,220 Secondary 6.5 6.1 1.7 85.7 100.0 844 More than secondary 13.1 8.2 6.7 71.9 100.0 95 Wealth quintile Lowest 3.8 3.9 3.4 88.9 100.0 521 Second 3.5 4.6 4.0 87.9 100.0 771 Middle 5.8 4.4 3.6 86.2 100.0 774 Fourth 7.5 4.6 4.0 83.9 100.0 718 Highest 10.8 5.7 3.7 79.8 100.0 677 Total 6.3 4.7 3.8 85.3 100.0 3,462 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives. 2 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives. Self-reported Prior HIV Testing and Treatment | 209 SELF-REPORTED PRIOR HIV TESTING AND TREATMENT 15 15.1 COVERAGE OF HIV TESTING SERVICES Knowing one’s HIV status is important for helping individuals decide to adopt safer sex practices to reduce the risk of becoming infected or transmitting HIV. For those who are HIV positive, knowledge of their HIV status allows them to take measures to protect their sexual partners and to access treatment services. To assess awareness and coverage of prior HIV testing behaviour, respondents were asked if they knew where to get an HIV test and whether they had ever been tested for HIV. If they said they had been tested for HIV, respondents were asked if they had received the results of their last test. Tables 15.1.1 and 15.1.2 present information on prior testing for women and men age 15-49, respectively. Table 15.1.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, and the percentage of women ever tested, according to background characteristics, Malawi 2010 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Number of women Ever tested and received results Ever tested did not receive results Never tested1 Age 15-24 95.3 62.6 1.3 36.1 100.0 63.9 9,559 15-19 92.7 43.1 1.0 55.9 100.0 44.1 5,005 20-24 98.2 84.0 1.7 14.4 100.0 85.6 4,555 25-29 99.0 86.7 1.1 12.2 100.0 87.8 4,400 30-39 98.2 80.3 1.7 18.0 100.0 82.0 5,772 40-49 96.6 62.4 1.9 35.7 100.0 64.3 3,288 Marital status Never married 92.1 37.3 0.6 62.1 100.0 37.9 4,538 Ever had sex 95.6 60.7 0.8 38.5 100.0 61.5 1,415 Never had sex 90.5 26.7 0.5 72.8 100.0 27.2 3,123 Married/living together 98.1 80.5 1.6 17.9 100.0 82.1 15,528 Divorced/separated/widowed 98.0 77.9 1.9 20.2 100.0 79.8 2,954 Residence Urban 97.8 75.6 0.9 23.5 100.0 76.5 4,302 Rural 96.7 70.7 1.6 27.7 100.0 72.3 18,718 Region Northern 96.0 75.9 2.3 21.8 100.0 78.2 2,677 Central 96.2 67.6 1.5 30.9 100.0 69.1 9,857 Southern 97.8 74.3 1.2 24.5 100.0 75.5 10,485 Education No education 95.2 68.1 2.2 29.6 100.0 70.4 3,505 Primary 96.5 70.2 1.6 28.2 100.0 71.8 14,916 Secondary 99.5 78.9 0.4 20.8 100.0 79.2 4,177 More than secondary 99.9 79.7 0.7 19.6 100.0 80.4 422 Wealth quintile Lowest 95.1 68.0 1.9 30.1 100.0 69.9 4,268 Second 96.3 69.8 1.9 28.3 100.0 71.7 4,332 Middle 97.1 71.6 1.7 26.7 100.0 73.3 4,517 Fourth 97.3 73.0 1.1 25.9 100.0 74.1 4,515 Highest 98.4 74.9 0.8 24.3 100.0 75.7 5,388 Total 15-49 96.9 71.6 1.4 26.9 100.0 73.1 23,020 1 Includes ‘don’t know/missing’ 210 | Self-reported Prior HIV Testing and Treatment Table 15.1.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Malawi 2010 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of men Ever tested and received results Ever tested did not receive results Never tested1 Age 15-24 95.0 41.8 1.0 57.2 100.0 42.8 28.2 2,987 15-19 93.0 30.6 1.2 68.2 100.0 31.8 21.0 1,748 20-24 97.8 57.6 0.9 41.5 100.0 58.5 38.5 1,239 25-29 98.6 64.9 1.6 33.5 100.0 66.5 38.8 1,099 30-39 97.9 57.8 1.3 40.9 100.0 59.1 33.2 1,746 40-49 96.3 52.7 2.1 45.2 100.0 54.8 28.8 986 Marital status Never married 94.9 40.1 1.0 58.9 100.0 41.1 26.9 2,689 Ever had sex 96.8 48.1 0.8 51.1 100.0 48.9 31.9 1,690 Never had sex 91.8 26.6 1.4 72.0 100.0 28.0 18.4 999 Married/living together 97.8 58.4 1.5 40.0 100.0 60.0 33.9 3,895 Divorced/separated/widowed 93.9 58.5 1.9 39.6 100.0 60.4 39.8 234 Residence Urban 97.0 54.6 0.6 44.7 100.0 55.3 33.2 1,440 Rural 96.4 50.3 1.5 48.2 100.0 51.8 30.8 5,379 Region Northern 96.7 59.8 2.3 37.8 100.0 62.2 36.5 744 Central 96.6 51.3 1.1 47.5 100.0 52.5 32.1 3,074 Southern 96.4 48.9 1.3 49.7 100.0 50.3 29.2 3,001 Education No education 85.9 34.3 3.0 62.6 100.0 37.4 19.2 422 Primary 96.2 45.5 1.4 53.1 100.0 46.9 27.5 4,270 Secondary 99.4 65.1 1.0 33.9 100.0 66.1 41.2 1,904 More than secondary 98.9 72.8 0.3 26.9 100.0 73.1 43.5 223 Wealth quintile Lowest 94.9 44.6 1.6 53.9 100.0 46.1 28.1 997 Second 95.4 47.1 1.9 51.0 100.0 49.0 27.2 1,309 Middle 96.6 49.0 1.2 49.7 100.0 50.3 31.5 1,367 Fourth 97.6 55.5 1.0 43.5 100.0 56.5 33.5 1,376 Highest 97.3 56.3 1.2 42.5 100.0 57.5 34.3 1,770 Total 15-49 96.5 51.2 1.4 47.5 100.0 52.5 31.3 6,818 50-54 94.9 45.4 0.9 53.7 100.0 46.3 23.8 357 Total men 15-54 96.4 50.9 1.3 47.8 100.0 52.2 30.9 7,175 1 Includes ‘don’t know/missing’ Overall, 97 percent of women know a place where they can get an HIV test (Table 15.1.1). Women age 15-19 and those who have not yet initiated sexual activity are less likely than other women to know of a place to obtain an HIV test. Knowledge of a place to obtain an HIV test increases with level of education. There is little variation by residence or region. Almost three in four women in Malawi (73 percent) have ever been tested for HIV. Only 1 percent of women has ever been tested for HIV and did not receive the results of any test. The percentage of women who have ever been tested is high among women age 20-29, those who are currently married, those in urban areas, and those in the Northern Region. The likelihood of ever being tested for HIV increases with each level of education and wealth quintile. Among men, 97 percent know where to get an HIV test, the same percentage as observed for women. Variations by background characteristics are similar to those among women. More than half of men age 15-49 have ever been tested for HIV (53 percent). Men in the Northern Region are more likely to have ever been tested for HIV (62 percent) than men in the Central and Southern Regions (53 percent and 50 percent, respectively). Other patterns are similar to those observed for women. Thirty- one percent of men have been tested for HIV in the past 12 months and received the result of the last test (this indicator is not available for women). The percentage of men who were tested for HIV in the Self-reported Prior HIV Testing and Treatment | 211 past 12 months and received the results of the last test ranges from 29 percent in the Southern Region to 37 percent in the Northern Region. The percentage of men who were tested for HIV in the past 12 months and received the results from their last test increases with level of education and wealth quintile. Coverage of HIV testing has shown remarkable increases between the 2004 and 2010 MDHS surveys. In the 2004 MDHS, only 13 percent of women had ever been tested for HIV and received their results, compared with 72 percent in the 2010 MDHS. Among men, the percentage that has ever been tested for HIV and received the results has increased from 15 percent to 51 percent. 15.2 HIV TESTING AMONG YOUTH Obtaining an HIV test can be more difficult for youth than for adults because many youth lack experience or face barriers in accessing health services. Table 15.2 presents information on sexually active youth age 15-24 who have ever been tested for HIV and received the results of the last test. Overall, 81 percent of young women and 53 percent of young men have ever been tested for HIV and received the results. Table 15.2 HIV testing among youth Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who have ever had an HIV test and received the results of the last test, by background characteristics, Malawi 2010 Background characteristic Women Men Percentage who have ever been tested for HIV and received the results Number of women Percentage who have ever been tested for HIV and received the results Number of men Age 15-19 69.3 1,800 39.4 565 15-17 56.3 780 31.6 286 18-19 79.2 1,020 47.3 279 20-24 86.9 3,854 62.0 840 20-22 88.0 2,213 61.0 500 23-24 85.5 1,641 63.5 340 Marital status Never married 57.9 794 49.7 865 Ever married 85.1 4,859 58.0 540 Knows condom source1 Yes 83.7 4,820 53.2 1,306 No 67.3 834 48.8 99 Residence Urban 86.9 1,056 54.0 281 Rural 80.0 4,598 52.6 1,124 Region Northern 86.5 663 63.8 130 Central 80.8 2,334 55.2 611 Southern 80.5 2,657 48.7 664 Education No education 73.7 404 (40.5) 48 Primary 80.0 4,017 45.8 906 Secondary 88.4 1,152 68.5 420 More than secondary 83.6 81 * 30 Wealth quintile Lowest 75.2 1,063 47.4 240 Second 78.5 1,215 48.3 286 Middle 84.1 1,192 49.8 270 Fourth 83.6 1,048 60.5 273 Highest 85.1 1,135 57.1 334 Total 15-24 81.3 5,654 52.9 1,405 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 212 | Self-reported Prior HIV Testing and Treatment Among women, the percentage who have ever been tested for HIV increases from 56 percent among those age 15-17 to 88 percent among those age 20-22, and then decreases slightly to 86 percent among women age 23-24. Among young men, the percentage who have ever been tested for HIV increases from 32 percent among those age 15-17 to 64 percent among those age 23-24. Young women in urban areas are more likely to have ever been tested for HIV and to have received the results than those in rural areas (87 percent versus 80 percent); however, there is little variation in HIV testing by residence among men. Young women and young men in the Northern Region are most likely to have ever been tested for HIV and to have received the results. Regional differences are greater among men than women. The prevalence of HIV testing and receipt of test results generally increases among both young women and young men with level of education and wealth quintile. 15.3 SELF-REPORTED HIV STATUS AND HIV STATUS ACCORDING TO THE 2010 MDHS The results of the HIV testing conducted as part of the 2010 MDHS are reported in Chapter 14. The questionnaire for the 2010 MDHS also asked respondents who said that they had ever been tested for HIV to disclose the result of their last HIV test to the interviewer. The data for this question are presented in Tables 15.3 and 15.4. Table 15.3 shows HIV prevalence by self-reported HIV status. Among women who have ever had sex and had ever been tested for HIV prior to the survey, 15 percent are HIV-positive, compared with 12 percent of women who have ever had sex, but who had not received an HIV test prior to the survey. According to the results in Chapter 14, the HIV- prevalence among all women who ever had sex is 15 percent. Among women who have ever had sex and reported that their last HIV test result was positive, 95 percent tested positive in the 2010 MDHS. This means that 5 percent of women who said they were HIV-positive had negative or indeterminate test results in the 2010 MDHS HIV test.1 There are several possible reasons for this difference which cannot be fully explained without further investigation. One possibility for the difference is that some individuals may be taking antiretroviral medications (ARVs), which may affect the detection of viral antigens and antibodies. However, for both men and women, approximately half of respondents who reported that they are HIV-positive but had a negative test result in the 2010 MDHS are currently taking ARVs. In other words, ARV use is not the only cause of the difference between the two tests. It is also possible that a combination of false positives with regard to previous testing and false negatives with regard to testing within the 2010 MDHS HIV testing for these 22 unweighted cases of women may contribute to the difference. Due to the high sensitivity and specificity of the HIV tests used in Malawi, this is likely to be a small number of cases. It should be noted that the aforementioned possibilities are hypotheses and cannot be verified because of the limitations of 1 For women age 15-49 who reported that they had previously received an HIV test and the result of that previous test was positive, the total unweighted number of cases is 379. The 2010 MDHS HIV test results for these women are: 356 unweighted cases where the results were positive (208 currently taking ARVs, 8 have ever taken ARVs, and 140 responded with ‘Don’t Know’), 22 unweighted cases were negative (13 currently taking ARVs and 9 responded with ‘Don’t Know’), and 1 unweighted case was indeterminate (currently taking ARVs). Among the women who reported that they had previously received an HIV test and the result of that previous test was negative, the total unweighted number of cases is 4,835. The 2010 MDHS HIV test results for these women are: 4,502 unweighted cases where the results were negative and 333 unweighted cases where the results were positive. Women who self-reported that their previous HIV test results were negative were not asked if they are currently taking ARVS or if they have ever taken ARVs. For men age 15-49 who reported that they had previously received an HIV test and the result of that previous test was positive, the total unweighted number of cases is 154. The 2010 MDHS HIV test results for these men are: 144 unweighted cases where the results were positive (93 currently taking ARVs, 3 have ever taken ARVs, and 48 responded with ‘Don’t Know’), 10 unweighted cases were negative (4 currently taking ARVs and 6 responded ‘Don’t Know’). There were no indeterminate cases for men. Among men who reported that they had previously received an HIV test and the result of that previous test was negative, the total unweighted number of cases is 3,238. Among these men, the 2010 MDHS HIV test results for these men are: 3,049 unweighted cases were the result was negative and 189 cases where the results were positive. Men who self-reported that their previous HIV test results were negative were not asked if they are currently taking ARVs or if they have ever taken ARVs. Self-reported Prior HIV Testing and Treatment | 213 anonymous testing within the context of a large-scale, population-based survey, which does not allow for follow-up interviews and subsequent HIV testing among respondents that would elicit additional information. HIV prevalence is 9 percent among women who ever had sex and reported their last HIV test result prior to the survey was negative. There are a few possible reasons for this difference. First, women could have seroconverted since their last HIV test. Second, women could knowingly report a false HIV status due to discomfort about disclosing that they are HIV positive to the survey interviewer. Third, the respondent could have received a false negative on the prior HIV test or a false positive on the 2010 MDHS HIV test. The third possibility is likely to be very small given the high sensitivity and specificity of HIV tests. The proportion of women who seroconverted between their last HIV test and the survey is also likely to be small, given the estimated incidence rates of HIV and the relatively short duration between the date of the last HIV test and the 2010 MDHS survey for the majority of women.2 As mentioned above, with respect to Table 15.3, it should be noted that the possibilities outlined are hypotheses that are difficult to verify without further follow-up interviews and subsequent HIV testing among respondents that would elicit additional information. Additionally, among women who declined to disclose their status, or who said that their last HIV test result was indeterminate, 12 percent had positive HIV test results in the 2010 MDHS. As observed among women, the HIV prevalence is higher among men who have ever had sex and ever received an HIV test compared with those who have ever had sex and never received an HIV test (11 percent compared with 8 percent). According to the results in Chapter 14, HIV prevalence among all men who have ever had sex is 9 percent. HIV prevalence is 95 percent among men who ever had sex and reported that the result of their last HIV test prior to the survey was positive compared with 6 percent among men who reported that their last HIV test was negative. Table 15.3 HIV prevalence by self-reported prior HIV testing Among women and men age 15-49 who ever had sex and were tested for HIV in the 2010 MDHS, the percentage who tested positive for HIV in the 2010 MDHS, by prior testing for HIV and self-reported HIV status, Malawi 2010 Self-reported HIV status Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Ever tested for HIV 15.1 4,962 10.5 3,184 13.3 8,146 Received results 15.1 4,860 10.6 3,109 13.3 7,970 Positive 95.4 364 95.3 145 95.4 508 Negative 8.5 4,347 6.4 2,936 7.6 7,283 Other1 12.1 150 (14.9) 28 12.5 178 Did not receive results 13.9 102 8.4 74 11.6 176 Never tested for HIV 12.3 1,173 7.6 2,357 9.2 3,530 Total 15-49 14.5 6,166 9.3 5,541 12.0 11,707 Note: The total includes 32 women with missing information on whether or not they were ever tested for HIV. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes respondents who reported their test result as indeterminate, those who declined to disclose their test result, those missing responses, and respondents for whom privacy was not obtained to ask the question on the result of the last HIV test Table 15.4 shows the percent distribution of HIV-positive women and men by self-reported HIV status and the percent distribution of HIV-negative women and men by self-reported HIV status. Table 15.4 differs from Table 15.3 in that the denominators represent different groups of people. In Table 15.3, the denominators for the percentages are the number of respondents self-reporting their HIV status. For example, among women who self-reported their HIV status as positive, 95 percent were found to be HIV positive in the 2010 MDHS testing. In Table 15.4, the denominators are the number of respondents who are HIV positive or HIV negative, according to the 2010 MDHS testing. 2 Due to a problem with the 2010 MDHS Woman’s Questionnaire, data on time since last HIV test is not available for some women. However, it can be concluded that among women who reported they are HIV- negative but tested positive, at least 38 percent were tested in the past 12 months, and more than half were tested in the last two years. Less than 30 percent of these women were tested for HIV more than two years before the survey. (Data are not shown.) 214 | Self-reported Prior HIV Testing and Treatment For example, 39 percent of the women who are HIV positive in the 2010 MDHS self-reported that they are positive. Among women who are HIV-positive, according to the 2010 MDHS HIV test, the proportion of women who self-reported their HIV status as negative is similar to the proportion of women who self-reported their HIV status as positive. Thirty-nine percent of women who are HIV-positive, according to the 2010 MDHS HIV test, reported that they are HIV-positive when asked about their HIV status during the interview. Forty percent of HIV-positive women said that they had received an HIV test prior to the survey and that the result of their last HIV test was negative. It is most likely that some respondents were unwilling to disclose an HIV-positive status to the interviewer. However, the possibility of seroconversion since their last HIV test, receiving a false negative result on the prior HIV test, or receiving a false positive result on the 2010 MDHS HIV test cannot be ruled out; nor can it be verified. Seventeen percent of HIV-positive women said that they had never been tested for HIV prior to the survey. Among HIV-negative women, 68 percent had ever received an HIV test and the result was negative, and 27 percent had never been tested for HIV prior to the survey. The percentage of HIV-positive men who reported that they are HIV-positive when asked their status during the interview is lower than among women because fewer men had been tested for HIV prior to the survey. Only one in four HIV-positive men (26 percent) reported that they are HIV- positive, 36 percent of HIV-positive men reported that they are HIV-negative, and 36 percent of HIV- positive men had never been tested for HIV prior to the survey. Among HIV-negative men, 50 percent reported that they had been tested prior to the survey and that the test result was negative, while 48 percent had never received an HIV test prior to the survey. Table 15.4 Self-reported prior HIV testing by current HIV status Percent distribution of women and men age 15-49 by self-reported HIV status, according to HIV-status from the 2010 MDHS HIV test result, Malawi 2010 Self-reported HIV status Women Men Total HIV positive HIV negative HIV positive HIV negative HIV positive HIV negative Previously tested, received result of last test and test result was: Positive 38.6 0.3 26.1 0.1 34.0 0.2 Negative 40.4 68.0 36.2 50.3 38.9 59.3 Other1 2.0 2.3 0.8 0.4 1.5 1.4 Previously tested, did not receive result of last test 1.5 1.5 1.2 1.4 1.4 1.5 Not previously tested 17.3 27.4 35.7 47.8 24.1 37.4 Prior testing status missing 0.2 0.5 0.0 0.0 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 913 6,178 529 5,969 1,442 12,146 1 Includes respondents who reported their test result as indeterminate, those who declined to disclose their test result, those missing responses, and respondents for whom privacy was not obtained to ask the question on the result of the last HIV test In summary, Tables 15.3 and 15.4 show that there is poor agreement between current HIV status as determined by the 2010 MDHS HIV test result and the HIV status reported by respondents during the interview. Therefore, self-reported HIV status is not a valid measure of actual HIV status in the 2010 MDHS. 15.4 SELF-REPORTED USE OF ANTIRETROVIRAL MEDICATIONS (ARVS) Table 15.5 shows the percentage of respondents who reported that their last HIV test was positive and stated that they are taking ARVs. In the 2010 MDHS, respondents who reported that the result of their last HIV test was positive were asked whether they had ever taken antiretroviral medications and whether they were taking ARVs daily at the time of the survey. As shown in Tables 15.3 and 15.4, self-reported HIV status is a poor proxy for actual HIV status. Due to the fact these Self-reported Prior HIV Testing and Treatment | 215 data are reported only for self-reported positives, the results should not be interpreted to be the coverage of ARVs among the HIV-positive population. Table 15.5 Self-reported HIV status and ARV use Percent distribution of women and men age 15-49 by whether they ever received a test for HIV, received the results of the last HIV test, and the self-reported result of the last HIV test; among women and men who reported that they are HIV-positive, the percentage who ever took ARVs daily and the percentage who were taking ARVs daily at the time of the survey, according to background characteristics, Malawi 2010 Sex Among all respondents Among respondents who have ever been tested for HIV and received the result of the last HIV test Among respondents who reported that they were HIV- positive Ever tested and received the result of the last test Number Positive Negative Other1 Total Number Ever took ARVs daily Currently taking ARVs daily Number ALL RESPONDENTS AGE 15-49 Women 71.6 23,020 6.4 90.6 2.9 100.0 16,490 63.4 61.6 1,061 Men 51.2 6,818 4.3 94.9 0.9 100.0 3,490 61.5 59.5 149 RESPONDENTS 15-49 TESTED FOR HIV IN THE 2010 MDHS Women 71.9 7,091 7.3 89.6 3.1 100.0 5,099 64.4 62.2 370 Men 51.8 6,497 4.3 94.8 0.9 100.0 3,368 60.0 58.0 145 1 Includes respondents who reported their test result as indeterminate, those who declined to disclose their test result, those with missing responses, and respondents for whom privacy was not obtained to ask the question on the result of the last HIV test As shown in Table 15.5, 63 percent of women who reported they are HIV-positive have ever taken ARVs, and 62 percent are currently taking ARVs. The bottom half of Table 15.5 shows the same results among the sub-sample of women who were eligible and tested for HIV in the 2010 MDHS. The results show that 7 percent of women who were tested prior to the survey reported that their last test result was positive. Among them, 62 percent are currently taking ARVs. However, as shown in Table 15.4, the self-reported positives make up only 39 percent of all women who tested positive for HIV in the survey. Women who are HIV-positive, but who did not know their status or chose not to disclose this information during the interview, were not asked whether they are taking ARVs. Figure 15.1 shows a percent distribution of women who tested positive for HIV in the 2010 MDHS, according to their self-reported HIV status and current ARV use. The figure shows that, as a proportion of all women who tested positive for HIV in the survey, only 24 percent are currently taking ARVs. This percentage assumes that all of the women who did not disclose that they are HIV- positive are not currently taking ARVs. It is possible that some women could have known they are HIV-positive and have been taking ARVs, but did not disclose their true HIV status during the interview. The results of the 2010 MDHS indicate that the actual coverage of ARVs among HIV- positive women in Malawi is likely to be somewhere between 24 percent and 62 percent. This finding indicates that population-based surveys, relying on self-reported HIV status without verification of prior HIV testing results and ARV use, are not appropriate for estimating ARV coverage. 216 | Self-reported Prior HIV Testing and Treatment Figure 15.1 Self-reported ARV Use and HIV Status among HIV-positive Women Age 15-49 MDHS 2010 Never tested 18% Tested, other result* 4% Report negative 40% Not on ARVs** 14% On ARVs 24% * Includes respondents who reported their test result as indeterminate, those who declined to disclose their test result, those with missing responses, and respondents for whom privacy was not obtained to ask the question on the result of the last HIV test ** Includes respondents who were taking medicine daily, but were not sure what kind Report positive 39% Table 15.5 shows the same information for men. Sixty-two percent of men age 15-49 who reported that they are HIV-positive have ever taken ARVs, and 60 percent are currently taking ARVs. The results among men who were tested for HIV in the 2010 MDHS are similar. Four percent of men age 15-49 who were tested prior to the survey reported that their last test result was positive. Among them, 58 percent are currently taking ARVs. Among men who tested positive for HIV in the 2010 MDHS, 16 percent reported that they are taking ARVs (Figure 15.2). Figure 15.2 Self-reported ARV Use and HIV Status among HIV-positive Men Age 15-49 MDHS 2010 Never tested 36% Tested, other result* 2% Report negative 36% Not on ARVs** 10% On ARVs 16% Report positive 26% * Includes respondents who reported their test result as indeterminate, those who declined to disclose their test result, those with missing responses, and respondents for whom privacy was not obtained to ask the question on the result of the last HIV test ** Includes respondents who were taking medicine daily, but were not sure what kind Self-reported Prior HIV Testing and Treatment | 217 15.5 HIV TESTING DURING PREGNANCY Table 15.6 presents information on HIV screening during pregnancy among women who gave birth in the two years preceding the survey. This service is a key tool in reducing HIV transmission from mother to child. According to Table 15.6, 86 percent of women who gave birth during the two years preceding the survey received HIV counselling during antenatal care visits. Eighty-seven percent of the women received an HIV test through antenatal care and received the test results. Seventy-nine percent were counselled, offered and accepted an HIV test, and received the results of the test. Women who are more likely to be in the latter group are those age 25-29 (81 percent) and those who live in urban areas (89 percent). Women in the Southern and Northern Regions (82 percent and 81 percent) are more likely than women in the Central Region (75 percent) to have been counselled, to have been offered and accepted an HIV test, and to have received the results. This percentage increases steadily with education and wealth quintile. Two percent of women who gave birth in the two years preceding the survey were offered and accepted an HIV test during antenatal care but did not receive the results. Table 15.6 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV pretest counselling, and the percentage who received an HIV test during antenatal care for their most recent birth by whether they received their test results, and post-test counselling according to background characteristics, Malawi 2010 Background characteristic Percentage who received HIV counselling during antenatal care1 Percentage who were offered and accepted an HIV test during antenatal care and who2: Percentage who were counselled, were offered and accepted an HIV test, and who received results2 Number of women who gave birth in the past two years3 Received results Did not receive results Age 15-24 84.7 87.8 2.2 79.3 3,223 15-19 83.9 88.8 3.0 78.8 813 20-24 84.9 87.5 1.9 79.5 2,410 25-29 88.1 87.3 1.6 80.7 2,001 30-39 85.7 84.6 2.4 77.8 2,057 40-49 81.7 81.9 1.6 73.2 444 Residence Urban 92.9 94.3 1.6 89.2 1,138 Rural 84.4 85.1 2.1 77.1 6,586 Region Northern 89.3 85.7 3.7 81.0 889 Central 81.7 85.3 2.1 75.0 3,375 Southern 88.6 87.8 1.6 82.2 3,461 Education No education 79.3 79.7 2.8 71.0 1,249 Primary 85.4 86.5 2.1 78.4 5,236 Secondary 93.0 93.2 1.1 88.8 1,169 More than secondary (98.6) (97.5) (1.9) (96.1) 70 Wealth quintile Lowest 79.7 82.6 2.2 72.8 1,669 Second 82.9 82.5 2.5 73.9 1,669 Middle 86.4 86.6 2.0 79.4 1,689 Fourth 88.6 89.8 1.9 83.3 1,409 Highest 92.9 93.0 1.6 87.9 1,288 Total 15-49 85.7 86.5 2.0 78.9 7,724 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 In this context, ‘counselled’ means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing the virus, and 3) getting tested for the virus. 2 Only women who were offered the test are included here; women who were either required to take or asked for the test are excluded from the numerator of this measure. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. 218 | Self-reported Prior HIV Testing and Treatment 15.6 SELF-REPORTED USE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) SERVICES In the full sample of 23,020 women, there were 198 women who reported that they are HIV- positive, that they had a child in the past two years, and that they knew they were HIV-positive before their most recent birth. Table 15.7 shows the percentage of these women who received various PMTCT services. Half of women were given nevirapine during labour, and nearly all of them took the medicine. An additional 44 percent of women were taking ARVs daily during pregnancy. In total, 94 percent of women who reported that they knew they were HIV-positive before the birth of their last child born in the past two years were either on ARVs or took nevirapine during labour. Almost 7 in 10 women (69 percent) were given nevirapine during their pregnancy to give to their baby after birth. Overall, 81 percent of most recent births in the past two years born to women who said that they were HIV-positive at the time of the birth were given nevirapine during the first few days of life. From the 2010 MDHS is it not possible to know how many of the women who gave birth in the past two years were actually HIV-positive at the time of the birth. For this reason, the results in Table 15.7 cannot be considered an estimate of the coverage of PMTCT services for HIV-positive pregnant women and their babies. Table 15.7 PMTCT services Among women who reported that they are HIV-positive and who said they knew they were HIV-positive before the birth of their last child in the past two years, percentage who reported receiving various PMTCT services for themselves and their babies, by residence and region, Malawi 2010 ARV or single-dose nevirapine use by the mother Percentage who were given nevirapine during pregnancy or labour1 50.3 Percentage who took nevirapine1 50.2 Percentage who were taking ARVs daily when they gave birth 43.5 Percentage who took nevirapine or were taking ARVs daily 93.7 Nevirapine use by the baby Percentage who received nevirapine to give to their baby1 68.8 Percentage whose baby took nevirapine during the first few days of life1 80.7 Number of women who reported that they were HIV-positive before their last birth 198 ARV = antiretroviral 1 Women were not asked about nevirapine by name. They were asked whether they were given ‘medicine to reduce the risk of passing the AIDS virus to [their] baby.’ Adult and Maternal Mortality | 219 ADULT AND MATERNAL MORTALITY 16 This chapter presents survey results on maternal and adult mortality in Malawi. Although early childhood mortality in the country is relatively high and varies with social and economic development (see Chapter 8), death rates are much lower among adults. Adult mortality is more difficult to measure accurately, because there is not always a unique and reliable person to report the death. This is particularly true for maternal deaths, which, are still very rare events. Maternal death rate estimations can also suffer from misreporting of the cause of death and small sample size may distort estimates for other adult subgroups. 16.1 DATA To estimate adult mortality, the 2010 MDHS included a sibling history in the Woman’s Questionnaire. A series of questions were asked about all of the respondent’s siblings (i.e., brothers and sisters) and their survival status. Each female respondent was asked to report all children born to her biological mother, including herself. She was asked to include in her list all siblings who were still alive, and those who had died. For brothers and sisters who were still alive, only the age of the sibling was asked. For those who had died before reaching age 12, only the number of years since death and age at death were asked. For those who had died at age 12 years or older and were female, three questions were asked, specifically to determine if the death was maternity-related: (1) ‘Was [NAME OF SISTER] pregnant when she died?’ (2) If the answer was positive, ‘Did she die during childbirth?’ and (3) if the response was negative, ‘Did she die within two months of the end of a pregnancy or childbirth?’ These data allow direct estimation of overall adult mortality (by age and sex), and maternal mortality. Adult and maternal mortality estimation by either direct or indirect methods requires accurate reporting of the number of siblings that the respondent has, both the number who died and the number who died during pregnancy, child birth, or in the two months after pregnancy ended (for maternal mortality). Although there is no definitive procedure for establishing the completeness of retrospective data on sibling survivorship, Table 16.1 presents several indicators that can be used to assess the quality of sibling survivorship data. The data do not show any obvious defects that would indicate poor data quality or significant underreporting. A total of 136,918 siblings were recorded in the maternal mortality section of the 2010 MDHS questionnaires. The sex ratio of the enumerated siblings (the ratio of brothers to sisters) is 100.2, which is lower than the expected value. The survival status for only 66 (less than one-tenth of one percent) of the siblings was not reported. For only 186 (two-tenths of one percent) of the surviving siblings, their current age was not reported. Among deceased siblings, both the age at death (AD) and years since death (YSD) were missing for 57 siblings (two-tenths of one percent). Indicators of completeness of data for the 2010 MDHS show some improvement compared with the 2004 MDHS. Rather than exclude the siblings with missing data from further analysis, information on the birth order of siblings in conjunction with other information was used to impute the missing data.1 The sibling survivorship data, including cases with imputed values, have been used in the direct estimation of adult and maternal mortality. 1 The imputation procedure is based on the assumption that the reported birth order of siblings in the history is correct. The first step is to calculate birth dates. For each living sibling with a reported age and each dead sibling with complete information on both age at death and years since death, the birth date was calculated. For a sibling missing these data, a birth date was imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age at the time of the survey was then calculated from the imputed birth date. In the case of dead siblings, if either the age at death or years since death was reported, that information was combined with the birth date to produce the missing information. If both pieces of information were missing, the distribution of the ages at death for siblings for whom the years since death was unreported, but age at death was reported, was used as a basis for imputing the age at death. 220 | Adult and Maternal Mortality Table 16.1 Data on siblings Number of siblings reported by women respondents and completeness of the reported data on age, age at death (AD), and years since death (YSD), according to survival status and sex of the sibling, Malawi 2010 Females Males All Number Percentage Number Percentage Number Percentage Total siblings reported 68,386 100.0 68,532 100.0 136,918 100.0 Surviving 50,089 73.2 49,458 72.2 99,547 72.7 Deceased 18,268 26.7 19,037 27.8 37,305 27.2 Missing information 29 0.0 37 0.1 66 0.0 Surviving siblings 50,089 100.0 49,458 100.0 99,547 100.0 Age reported 50,003 99.8 49,358 99.8 99,362 99.8 Age missing 86 0.2 100 0.2 186 0.2 Deceased siblings 18,268 100.0 19,037 100.0 37,305 100.0 AD and YSD reported 18,164 99.4 18,877 99.2 37,040 99.3 Missing only AD 66 0.4 93 0.5 159 0.4 Missing only YSD 18 0.1 31 0.2 49 0.1 Missing both 21 0.1 36 0.2 57 0.2 16.2 ESTIMATES OF ADULT MORTALITY One way to assess the quality of data used to estimate maternal mortality is to evaluate the plausibility and stability of overall adult mortality. It is reasoned that if rates of overall adult mortality are implausible, rates based on a subset of deaths – i.e., maternal mortality in particular – are unlikely to be free of serious problems. Also, levels and trends in overall adult mortality have important implications in their own right for health and social programs in Malawi, especially with regard to the potential impact of the AIDS epidemic. The direct estimation of adult mortality uses the reported ages at death and years since death of the respondents’ brothers and sisters. Due to the differentials in exposure to the risk of dying, age- and sex-specific death rates are presented in this report. The results are also compared with rates obtained from the 2004 MDHS. The estimated age-specific rates are subject to considerable sampling variation because the number of deaths on which the 2010 MDHS rates are based is not very large. Table 16.2 presents age-specific mortality rates for women and men age 15-49 for the six- year period preceding the survey. The rates are stable, showing expected increases for both sexes as their age increases. The rise is steeper for men at older ages. The overall mortality rates are lower among women than men (8.4 and 8.8 deaths per 1,000 years of exposure, respectively). Between ages 15 and 39, the mortality rates are slightly higher for women than for men. Above age 40, male mortality exceeds female mortality by wider margins as age advances. A comparison of the rates from the 2004 MDHS and the 2010 MDHS indicates a decline in adult mortality for both women and men, but the patterns differ slightly (Table 16.2). Female and male adult mortality rates from the 2010 data are lower for most ages. The summary measure of mortality for the age group 15-49 shows a decrease of about 28 percent in female mortality but only a 16 percent decrease in male mortality from the 2004 MDHS rates. Adult and Maternal Mortality | 221 Table 16.2 Adult mortality rates Age-specific mortality rates for women and men age 15-49 based on the survivor- ship of sisters and brothers of women respondents for the period 0 to 6 years prior to the survey, Malawi 2010 Age 2010 MDHS 2004 MDHS Deaths Exposure Mortality rates Mortality rates WOMEN 15-19 193 52,242 3.7 4.2 20-24 280 57,738 4.9 7.7 25-29 427 52,072 8.2 12.6 30-34 496 38,640 12.8 14.2 35-39 349 25,934 13.4 18.9 40-44 253 16,369 15.5 22.5 45-49 137 9,659 14.2 17.9 15-49 2,134 252,653 8.4a 11.6a MEN 15-19 150 50,354 3.0 4.2 20-24 222 55,733 4.0 4.9 25-29 320 52,700 6.1 7.3 30-34 449 40,500 11.1 14.8 35-39 331 27,315 12.1 17.0 40-44 348 16,024 21.7 23.5 45-49 233 9,236 25.3 25.2 15-49 2,055 251,861 8.8a 10.5a a Age standardised 16.3 ESTIMATES OF MATERNAL MORTALITY Two procedures that use sisterhood data (sibling history data) are generally used to estimate maternal mortality in developing countries; these employ an indirect variant (Graham et al, 1989) and a direct estimation method (Rutenberg et al., 1991). In this report, the direct estimation procedure is applied. Age-specific mortality rates are calculated by dividing the number of maternal deaths by woman-years of exposure. To remove the effect of truncation bias (the upper boundary for eligibility for women interviewed in the MDHS is 50 years), the overall rate for women age 15-49 is standardized by the age distribution of the survey respondents. Maternal deaths are defined as any deaths that occurred during pregnancy or childbirth, or that occurred within two months of the birth or termination of a pregnancy.2 Estimates of maternal mortality are therefore based solely on the timing of the death in relationship to the pregnancy. Table 16.3 presents direct estimates of maternal mortality for the seven-year period prior to the survey. The data indicate that the rate of mortality associated with pregnancy and childbearing is 1.3 maternal deaths per 1,000 woman-years of exposure. The estimated age-specific mortality rates display a generally plausible pattern; the risk of maternal death is higher at older ages. Maternal deaths represent about 16 percent of all deaths to women age 15-49 (data not shown). The maternal mortality rate can be converted to a maternal mortality ratio and expressed per 100,000 live births by dividing the rate by the general fertility rate of 0.197, which prevailed during the same seven-year time period. Using this procedure, the maternal mortality ratio (MMR) during the 7-year period before the survey is estimated to be 675 maternal deaths per 100,000 live births. It appears that there has been a decrease in the maternal mortality ratio since the 2004 MDHS, when the MMR was measured at 984 maternal deaths per 100,000 live births. The difference between the 2004 and 2010 estimates of the maternal mortality ratio is statistically significant, that is, not likely to be due to sampling error. The 95 percent confidence interval for the 2010 estimate, which ranges from 570 to 780, does not overlap with the confidence interval for the 2004 estimate (822, 1,145). 2 This time-dependent definition includes all deaths that occurred during pregnancy and two months after pregnancy, even if the death was due to non-maternal causes. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths to women during the two-month period are due to maternal causes, and maternal deaths are more likely to be underreported than overreported. 222 | Adult and Maternal Mortality Table 16.3 Maternal mortality Maternal mortality rates for 0 to 6 years prior to the survey, based on the survivorship of sisters of women respondents, Malawi 2010 Age Maternal deaths Exposure (years) Mortality rates 15-19 28 52,242 0.5 20-24 51 57,738 0.9 25-29 78 52,072 1.5 30-34 63 38,640 1.6 35-39 63 25,934 2.4 40-44 35 16,369 2.1 45-49 15 9,659 1.5 15-49 331 252,653 1.3a General fertility rate 197a Maternal mortality ratiob 675 a Age standardised b Per 100,000 births; calculated as maternal mortality rate divided by the general fertility rate The MMR in the 2006 Malawi MICS was 807 maternal deaths per 100,000 live births (NSO and UNICEF, 2008). This estimate falls between the 2004 and 2010 MDHS estimates, lending credence to a downward trend in maternal mortality in Malawi over the past several years. However, the 95 percent confidence interval for this estimate (696, 918) overlaps the confidence interval for the MMR from the 2010 MDHS, indicating that the difference between the estimates of the MMR from the 2006 MICS and the 2010 MDHS are not significantly different. Therefore, it cannot be concluded that the maternal mortality ratio has decreased from the 2006 Malawi MICS estimate of 807 to the 2010 MDHS estimate of 675. Women’s Status and Demographic and Health Outcomes | 223 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES 17 The status of women is an important factor in development, poverty reduction, and improvement in the standard of living. In 2000, the government of Malawi launched the National Gender Policy, which has the general goal of ‘mainstream[ing] gender in the national development process to enhance the participation of women, men, boys and girls in sustainable and equitable development for poverty eradication’ (MOGYCS, 2000-2005). The policy was developed as an integral part of Malawi’s development objectives, which were intended to enhance the overall government strategy of growth through poverty eradication. This chapter presents information on factors that affect the status of women in society: employment, type of earnings, control over cash earnings, earnings relative to those of a husband, and participation in decision-making. This chapter also defines two summary indices of women’s empowerment derived from women’s responses. The indices are based on the number of household decisions in which the respondent participates and her agreement with reasons for which wife beating is justified. The ranking of women on these indices is then related to select demographic and health outcomes, including contraceptive use and the receipt of health care services during pregnancy, childbirth, and the postpartum period.1 17.1 WOMEN’S AND MEN’S EMPLOYMENT The 2010 MDHS collected information related to women’s and men’s employment. Women’s employment includes work in the home, on family farms, in family businesses, and in other informal sectors. It is important to be cautious while collecting data on women’s employment because some activities are not perceived by women themselves as employment and hence may not be reported as such. To avoid underestimating women’s employment, the 2010 MDHS asked female respondents several questions to ascertain their employment status. First they were asked, ‘Aside from your own housework, have you done any work?’ Women who answered ‘no’ to this question were then asked, ‘As you know, some women take up jobs for which they are paid in cash or in kind. Others sell things, have a small business, or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?’ 17.1.1 Employment Status Table 17.1 shows the percent distribution of currently married women and men age 15-49, by employment and cash earnings. Overall, 76 percent of currently married women and 98 percent of currently married men were employed in the 12 months preceding the survey. The proportion of employed women increases with age, from 65 percent among women age 15-19 to 81 percent or higher among women age 30-49. Comparing married women and men age 15- 49, 45 percent of women receive payment in cash only compared with 61 percent of men. A higher proportion of married women than married men are not paid for their work (42 versus 29 percent, respectively). Slightly more married women receive in-kind payment for their employment; 3 percent for married women compared with 2 percent for married men. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 224 | Women’s Status and Demographic and Health Outcomes Table 17.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the last 12 months and the percent distribution of currently married women and men employed in the last 12 months by type of earnings, according to age, Malawi 2010 Age Currently married respondents: Percent distribution of currently married respondents employed in the last 12 months, by type of earnings Total Number of women Percentage employed Number of women Cash only Cash and in- kind In-kind only Not paid Missing WOMEN 15-19 65.4 1,171 35.3 10.0 4.5 50.0 0.2 100.0 766 20-24 70.1 3,469 43.6 9.9 3.5 42.8 0.2 100.0 2,430 25-29 75.9 3,718 46.8 9.5 3.8 39.8 0.1 100.0 2,821 30-34 80.5 2,636 45.9 10.9 2.5 40.3 0.5 100.0 2,122 35-39 82.4 2,040 47.2 9.1 2.5 40.9 0.2 100.0 1,680 40-44 81.0 1,339 46.9 10.5 2.6 39.9 0.0 100.0 1,084 45-49 80.9 1,155 40.3 12.3 3.4 43.7 0.2 100.0 934 Total 15-49 76.2 15,528 44.8 10.1 3.2 41.6 0.2 100.0 11,838 MEN 15-19 (85.9) 40 (48.9) (13.2) (0.0) (37.9) (0.0) 100.0 34 20-24 96.7 466 57.4 7.4 2.1 33.2 0.0 100.0 451 25-29 98.3 868 66.1 7.4 1.3 25.2 0.0 100.0 853 30-34 97.8 862 61.8 8.9 1.5 27.9 0.0 100.0 843 35-39 99.0 737 58.8 7.3 2.8 31.0 0.0 100.0 729 40-44 98.7 495 64.2 7.9 1.3 26.6 0.0 100.0 488 45-49 98.1 428 57.9 6.8 1.8 33.5 0.0 100.0 420 Total 15-49 98.0 3,895 61.4 7.7 1.8 29.0 0.0 100.0 3,818 50-54 95.3 323 59.7 4.5 1.3 34.5 0.0 100.0 308 Total men 15-54 97.8 4,218 61.3 7.5 1.7 29.5 0.0 100.0 4,126 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 17.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS To assess women’s autonomy, currently married women who earned cash for their work in the 12 months preceding the survey were asked who usually decides how their earnings are spent. Women who earned cash for their work were also asked the relative magnitude of their earnings compared with those of their husband. This information assesses women’s control over their own earnings, as it is expected that employment and earnings are more likely to empower women if women themselves control their own earnings and perceive them as significant relative to those of their husband. Table 17.2.1 shows the percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey, by the person who decides how the cash earnings are to be used and by the relative magnitude of their earnings compared with those of their husbands, according to background characteristics. Thirty-seven percent of women decide for themselves how their earnings are used, and 21 percent of women make joint decisions with their husbands. Forty percent of the married women responded that decisions regarding how their earnings are spent are made mainly by their husbands. The percentage of women who decide how their earnings are spent is lower among women age 15-19 (29 percent) than among women age 20 or older (35 percent or higher). Decision-making on earnings by women is higher in urban than in rural areas: 56 percent of urban women decide on their own how to spend their earnings compared with 31 percent of rural women. Forty-six percent of currently married women in rural areas reported that their husbands mainly decide how to spend their earnings compared with 21 percent of currently married women residing in urban areas. Decision-making on earnings also varies by region. Forty-four percent of currently married women in the Northern Region decide how to spend their earnings compared with 32 percent in the Central Region and 39 percent in the Southern Region. The Southern Region has the highest proportion of women (24 percent) who report joint decision-making with their husbands regarding their earnings. Women in the Central Region are more likely than women in the other regions to report that their husbands mainly decide how to spend their earnings (48 percent). Women’s Status and Demographic and Health Outcomes | 225 Table 17.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife’s cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Malawi 2010 Background characteristic Person who decides how the wife’s cash earnings are used: Total Women’s cash earnings compared with husband’s cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing More Less About the same Husband/ partner has no earnings Don’t know/ missing Age 15-19 29.1 20.9 46.8 1.3 1.9 100.0 5.4 75.7 13.9 1.3 3.6 100.0 347 20-24 35.2 18.2 44.2 0.7 1.8 100.0 7.1 75.9 12.1 1.3 3.5 100.0 1,301 25-29 39.3 19.4 39.0 0.3 2.0 100.0 9.6 75.8 10.9 0.8 2.9 100.0 1,589 30-34 35.0 23.5 40.3 0.0 1.2 100.0 9.4 74.8 12.8 1.1 1.8 100.0 1,206 35-39 35.5 23.1 39.0 0.0 2.4 100.0 12.2 69.7 13.7 1.4 3.1 100.0 947 40-44 38.9 22.9 35.3 0.0 2.9 100.0 12.5 67.1 16.5 0.2 3.6 100.0 623 45-49 39.6 23.5 36.3 0.0 0.5 100.0 12.7 66.2 14.4 4.7 2.1 100.0 492 Number of living children 0 36.8 25.0 36.8 0.5 1.0 100.0 10.3 72.2 11.3 2.2 4.1 100.0 359 1-2 39.0 19.9 38.2 0.7 2.1 100.0 8.6 75.3 11.8 1.1 3.2 100.0 2,291 3-4 35.2 20.9 42.6 0.0 1.3 100.0 10.1 73.8 12.5 1.3 2.3 100.0 2,170 5+ 34.9 22.5 40.3 0.0 2.2 100.0 10.6 69.7 15.1 1.6 3.0 100.0 1,683 Residence Urban 55.7 22.3 20.8 0.6 0.7 100.0 12.9 79.5 4.6 2.0 1.0 100.0 1,449 Rural 31.1 20.9 45.7 0.2 2.1 100.0 8.8 71.4 15.2 1.1 3.4 100.0 5,054 Region Northern 44.3 21.7 32.0 0.6 1.4 100.0 9.8 74.1 10.4 1.3 4.5 100.0 810 Central 32.0 18.5 47.7 0.1 1.7 100.0 9.1 71.3 16.0 1.4 2.2 100.0 2,887 Southern 39.1 23.8 34.7 0.3 2.1 100.0 10.4 74.9 10.3 1.3 3.2 100.0 2,805 Education No education 31.4 18.2 49.5 0.0 0.9 100.0 9.9 72.4 15.3 0.7 1.7 100.0 1,014 Primary 34.7 19.6 43.1 0.2 2.3 100.0 8.8 72.9 13.3 1.5 3.5 100.0 4,183 Secondary 46.5 27.1 24.6 0.7 1.1 100.0 11.4 75.6 9.8 1.3 1.9 100.0 1,144 More than secondary 48.4 38.5 13.1 0.0 0.0 100.0 20.4 69.9 9.4 0.0 0.3 100.0 162 Wealth quintile Lowest 30.7 14.6 52.6 0.2 2.1 100.0 7.9 72.1 15.3 1.3 3.4 100.0 982 Second 27.2 21.4 49.1 0.1 2.2 100.0 7.3 71.6 15.9 1.8 3.4 100.0 1,149 Middle 30.9 20.6 46.1 0.3 2.0 100.0 7.9 73.1 14.8 1.2 2.9 100.0 1,273 Fourth 38.0 21.4 38.3 0.2 2.1 100.0 11.7 71.3 13.0 1.0 3.1 100.0 1,354 Highest 49.2 25.0 24.3 0.5 1.1 100.0 12.1 76.4 8.0 1.4 2.0 100.0 1,746 Total 36.6 21.2 40.1 0.3 1.8 100.0 9.7 73.2 12.9 1.3 2.9 100.0 6,503 There is wide variation in decision-making about spending women’s earnings and their level of education. Women with no education are the least likely to be the main decision makers (31 percent), and the proportion of decision-makers increases with each level of education to 48 percent of women with more than a secondary education. The trend is similar for joint decision-making by husband and wife on the woman’s earnings, with 18 percent of women with no education and 39 percent of women with more than a secondary education reporting joint decision-making. Fifty percent of women with no education reported that their husbands mainly decide how to spend their earnings, and the proportion decreases with increasing education, reaching 13 percent among women with more than a secondary education. Wealth is also associated with women’s decision-making regarding the spending of their own earnings. Thirty-one percent of women in the lowest wealth quintile reported being the main decision- makers on spending of their earnings compared with 49 percent of women in the highest wealth quintile. Fifty-three percent of women in the lowest quintile reported that their husbands mainly make decisions about how to spend their earnings, compared with 24 percent of women in the highest quintile. Table 17.2.1 also shows women’s earnings relative to their husbands’ earnings during the 12 months preceding the survey. Seventy-three percent of women report that they earn less than their husband, 10 percent of women report that they earn more than their husband, and 13 percent earn about the same as their husband. The proportion of women who earn more than their husband increases with age, from 5 percent among women age 15-19 to 13 percent for women age 40-49. Thirteen percent of women in urban areas earn more than their husband, compared with 9 percent of women in rural areas. Five percent of women in urban areas earn the same as their husband, compared with 15 percent of women in rural areas. The Central Region has the highest proportion of women (16 226 | Women’s Status and Demographic and Health Outcomes percent) reporting that they earn the same as their husband. Regarding education, women with more than a secondary education are more likely than other women to report that they earn more than their husband (20 percent versus 11 percent or less). Women with a secondary education are most likely to earn less than their husband (76 percent), while 72 percent of women with no education earn less than their husband. Table 17.2.2 shows the percent distributions of currently married men age 15-49 who receive cash earnings, and of currently married women age 15-49 whose husbands receive cash earnings, by the person who decides how men's cash earnings are used, according to background characteristics. Table 17.2.2 Control over men’s cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how men’s cash earnings are used, according to background characteristics, Malawi 2010 Background characteristic Men Women Mainly wife Husband and wife jointly Mainly husband Missing Total Number Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number Age 15-19 * * * * 100.0 21 11.5 18.9 69.1 0.3 0.2 100.0 1,151 20-24 7.3 44.4 47.9 0.4 100.0 292 11.2 18.4 70.1 0.2 0.1 100.0 3,422 25-29 6.7 40.8 51.6 0.9 100.0 627 10.9 20.9 67.9 0.3 0.0 100.0 3,683 30-34 7.2 41.9 49.8 1.1 100.0 595 10.0 24.5 65.1 0.2 0.1 100.0 2,602 35-39 4.8 45.9 47.8 1.5 100.0 483 10.7 20.9 68.0 0.2 0.2 100.0 2,004 40-44 7.4 45.6 46.1 0.9 100.0 352 12.4 20.8 66.5 0.1 0.2 100.0 1,331 45-49 5.4 50.8 43.3 0.5 100.0 271 10.6 22.7 66.6 0.0 0.1 100.0 1,121 Number of living children 0 6.8 46.3 46.8 0.1 100.0 172 12.6 24.5 62.6 0.3 0.0 100.0 979 1-2 9.1 40.1 49.9 0.9 100.0 919 11.5 20.9 67.2 0.3 0.1 100.0 5,576 3-4 5.2 45.6 48.0 1.2 100.0 845 10.7 21.0 68.1 0.2 0.0 100.0 4,880 5+ 4.4 46.8 47.9 0.9 100.0 705 10.1 20.0 69.6 0.1 0.3 100.0 3,878 Residence Urban 13.0 37.9 48.3 0.7 100.0 619 14.9 28.7 56.1 0.2 0.0 100.0 2,649 Rural 4.5 45.9 48.6 1.0 100.0 2,023 10.1 19.3 70.2 0.2 0.1 100.0 12,664 Region Northern 6.2 41.1 50.7 2.0 100.0 271 13.6 21.4 64.3 0.5 0.2 100.0 1,852 Central 7.0 41.0 51.5 0.5 100.0 1,158 7.4 17.9 74.5 0.2 0.1 100.0 6,558 Southern 5.9 47.6 45.3 1.2 100.0 1,213 13.7 23.7 62.3 0.1 0.1 100.0 6,904 Education No education 4.8 33.5 60.3 1.4 100.0 174 10.8 16.3 72.6 0.2 0.2 100.0 2,776 Primary 4.6 44.6 49.8 0.9 100.0 1,626 10.7 19.6 69.4 0.2 0.1 100.0 10,094 Secondary 10.6 43.5 45.0 0.9 100.0 727 12.6 29.8 57.4 0.1 0.1 100.0 2,250 More than secondary 9.5 55.3 35.1 0.1 100.0 114 8.7 53.7 37.6 0.0 0.0 100.0 193 Wealth quintile Lowest 6.9 43.3 49.4 0.4 100.0 346 10.8 14.5 74.3 0.4 0.1 100.0 2,583 Second 5.7 41.0 52.1 1.1 100.0 491 10.3 17.7 71.8 0.1 0.1 100.0 3,073 Middle 4.7 42.4 51.7 1.1 100.0 540 9.7 19.4 70.6 0.1 0.2 100.0 3,262 Fourth 4.0 45.3 49.5 1.2 100.0 570 11.4 21.7 66.5 0.4 0.1 100.0 3,167 Highest 10.1 46.7 42.4 0.7 100.0 694 12.7 30.0 57.2 0.1 0.1 100.0 3,228 Total 15-49 6.5 44.0 48.6 0.9 100.0 2,642 11.0 20.9 67.8 0.2 0.1 100.0 15,313 50-54 13.7 37.2 49.0 0.1 100.0 198 na na na na na na 0 Total men 15-54 7.0 43.6 48.6 0.9 100.0 2,839 na na na na na na 0 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable Forty-nine percent of men age 15-49 report that they mainly decide how their cash earnings are used. Forty-four percent state that these decisions are made jointly with their wife, and 7 percent state that these decisions are made mainly by their wives. There is little variation by age, number of living children, region, or wealth quintile in the percentage of men who mainly decide how to spend their decision-making husband’s cash earnings. Men with no education are more likely than other men to be the main decision-maker regarding how to spend their earnings (60 percent compared with 50 percent or less). Wives are more likely to be the main decision-makers regarding the husband’s earnings among men who live in urban areas, those with more education, and those in the highest wealth quintile. Reports by women on who makes the decision about how their husband’s earnings are spent do not closely match the men’s reports. Sixty-eight percent of women whose husbands have cash Women’s Status and Demographic and Health Outcomes | 227 earnings report that their husband mainly decides how his cash earnings are used. This is much higher than the 49 percent reported by men themselves. Twenty-one percent of women report that the decisions are jointly made, compared with 44 percent of men, and 11 percent of women report that they mainly decide how to use their husband’s earnings. The proportion of women reporting that they mainly decide how to spend their husband’s earnings does not vary much by background characteristics. Joint decision-making is more commonly reported by women living in urban areas, those in the Northern and Southern Regions, women with secondary education, and those in the higher wealth quintiles. Table 17.3 shows who controls the wife’s and husband’s earnings by the amount of the wife’s earnings relative to her husband’s. Currently married women who earn more than their husbands are more likely to decide mainly by themselves (47 percent) or jointly with their husbands (22 percent) on how their earnings are spent. Likewise, 22 percent of the same group of women mainly decide how their husbands’ earnings are spent and an additional 25 percent make these decisions jointly with their husbands. Women who earn less than their husbands are more likely to make decisions on their own earnings (40 percent) compared with women who earn the same as their husbands (13 percent). However, women who earn the same as their husbands are more likely than other women to decide how to use their earnings jointly with their husbands (45 percent). Table 17.3 Women’s control over her own earnings and over those of her husband Percent distributions of currently married women age 15-49 with cash earnings in the last 12 months by person who decides how the woman’s cash earnings are used and of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband’s cash earnings are used, according to the relation between woman’s and husband’s cash earnings, Malawi 2010 Women’s earnings relative to husband’s earnings Person who decides how the wife’s cash earnings are used: Total Number Person who decides how husband’s cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Mainly wife Wife and husband jointly Mainly husband Other Missing More than husband/ partner 46.7 22.4 29.6 1.3 0.0 100.0 632 22.0 24.7 53.3 0.0 0.0 100.0 622 Less than husband/ partner 39.8 17.5 42.6 0.1 0.0 100.0 4,760 11.0 21.3 67.7 0.1 0.0 100.0 4,754 Same as husband/partner 13.1 44.6 42.3 0.0 0.0 100.0 837 7.8 44.6 47.4 0.0 0.2 100.0 837 Husband/partner has no cash earnings/did not work 63.3 16.7 17.5 2.5 0.0 100.0 87 na na na na na na 0 Woman has no cash earnings na na na na na na 0 9.5 19.1 71.0 0.3 0.1 100.0 5,266 Woman did not work in last 12 months na na na na na na 0 11.9 17.3 70.2 0.4 0.2 100.0 3,648 Don’t know/missing 12.4 9.7 14.5 0.8 62.5 100.0 188 11.4 16.3 71.5 0.2 0.6 100.0 186 Total1 36.6 21.2 40.1 0.3 1.8 100.0 6,503 11.0 20.9 67.8 0.2 0.1 100.0 15,313 na = Not applicable 1 Excludes cases where a woman or her husband/partner has no earnings and includes cases where a woman does not know whether she earned more or less than her husband/partner 17.3 WOMEN’S PARTICIPATION IN DECISION-MAKING The ability of women to make decisions that affect their personal circumstances is essential for their empowerment and serves as an important factor in national development. To assess women’s decision-making autonomy, the 2010 MDHS collected information on women’s participation in four types of decisions: the respondent’s own health care; making major household purchases; making household purchases for daily needs; and visits to family or relatives. Women are considered to participate in decision-making if they make decisions alone or jointly with their husband or someone else. Table 17.4.1 shows the percent distribution of currently married women by the person who usually makes decisions, as reported by women. Forty-four percent of currently married women report that their husbands mainly make the decisions for their health care, and 69 percent report that their husbands decide on major household purchases. On purchases for daily household needs, 46 percent report that husbands make the decision, and 32 percent of married women report that their husbands decide on visits to their own family or relatives. The data show that purchases of daily household needs is the decision that married women are most likely to make on their own (36 percent). 228 | Women’s Status and Demographic and Health Outcomes Table 17.4.1 Women’s participation in decision-making Percent distribution of currently married women by person who usually makes decisions about four kinds of issues, Malawi 2010 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 16.6 38.8 43.8 0.6 0.2 0.1 100.0 15,528 Major household purchases 9.3 20.6 68.9 0.6 0.3 0.2 100.0 15,528 Purchases of daily household needs 36.1 16.7 46.1 0.8 0.2 0.1 100.0 15,528 Visits to her family or relatives 25.2 41.3 32.4 0.7 0.3 0.1 100.0 15,528 Table 17.4.2 shows the percent distribution of currently married men by the person whom they think should have a greater say in making decisions in five areas: major household purchases, purchases of daily household needs, visits to the wife’s family or relatives, how the money their wives earn is spent, and how many children to have. Sixty-three percent of married men think they should have the greater say in decisions concerning major household purchases, 49 percent think husbands should decide on purchases of daily household needs, and 37 percent think they should decide on visits to their wives’ family or relatives. Thirty-one percent of men think that decisions about how to spend the wife’s cash earnings should be made mainly by the husband, while 46 percent think that husbands and wives should decide jointly how to spend money that the wife earns. Fifty-seven percent of men think that the decision on the number of children to have should be made jointly by the husband and wife, and 39 percent of men think that the husband alone should make the decision on the number of children to have. Table 17.4.2 Women’s participation in decision-making according to men Percent distribution of currently married men 15-49 by person who they think should have a greater say in making decisions about five kinds of issues, Malawi 2010 Decision Wife Wife and husband equally Husband Don’t know/ depends Missing Total Number of men Major household purchases 2.5 34.2 63.2 0.2 0.0 100.0 3,895 Purchases of daily household needs 27.8 22.9 49.2 0.1 0.0 100.0 3,895 Visits to wife’s family or relatives 10.8 52.4 36.5 0.2 0.2 100.0 3,895 What to do with the money wife earns 23.2 45.6 30.6 0.6 0.1 100.0 3,895 How many children to have 3.3 56.8 39.4 0.5 0.0 100.0 3,895 Table 17.5.1 shows how women’s participation in decision-making varies by background characteristics such as age and residence. The table presents results on four specific topics in which a married woman makes decisions either by herself or jointly with her husband: her own health care, making major household purchases, making purchases for daily household needs, and visits to her own family or relatives. In addition, the table includes two summary indicators: the proportion of women involved in making decisions in all four areas, and the proportion of women not involved in making any of the decisions. Table 17.5.1 shows that 20 percent of women report taking part in all four decisions, while almost 19 percent have no say in any of the four decisions. The percentage of women participating in all four decisions increases with age and with higher levels of education and wealth; 64 percent of women with more than a secondary education participate in all four decisions compared with 17 percent of women with no education. Twenty-six percent of women that are employed for cash take part in all four decisions compared with 16 percent of women who are not employed and 15 percent of women who are employed but are not paid in cash. Fifty-five percent of women make the decisions regarding their own health care, and 90 percent of women with more than a secondary education decide on their own health care, either alone or jointly with their husband. Women’s Status and Demographic and Health Outcomes | 229 Table 17.5.1 Women’s participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Malawi 2010 Background characteristic Own health care Making major household purchases Making purchases for daily household needs Visits to her family or relatives Percentage who participate in all four decisions Percentage who participate in none of the four decisions Number of women Age 15-19 46.7 23.3 42.2 56.7 13.3 24.8 1,171 20-24 54.7 24.4 46.7 65.0 15.6 19.5 3,469 25-29 57.2 30.2 53.6 66.8 20.4 18.1 3,718 30-34 57.1 30.9 56.7 68.4 21.4 18.1 2,636 35-39 55.2 34.7 56.0 67.6 22.7 18.2 2,040 40-44 56.7 37.8 57.5 70.7 25.2 17.9 1,339 45-49 55.0 33.1 59.3 68.2 23.0 18.2 1,155 Employment (last 12 months) Not employed 47.7 25.3 46.9 59.3 16.2 27.7 3,682 Employed for cash 61.0 36.5 58.8 70.5 25.7 14.8 6,503 Employed not for cash 53.9 25.2 49.6 66.8 15.2 17.8 5,309 Number of living children 0 55.0 28.4 49.1 62.9 19.6 20.6 1,000 1-2 55.7 28.2 51.2 66.8 18.2 18.2 5,643 3-4 56.3 30.6 54.1 66.3 20.7 19.1 4,942 5+ 53.8 32.0 54.4 67.0 21.2 19.4 3,943 Residence Urban 70.4 39.2 66.4 78.1 28.5 8.9 2,686 Rural 52.2 28.0 50.0 64.0 18.1 21.0 12,841 Region Northern 59.1 36.0 65.1 73.8 23.0 11.1 1,871 Central 50.2 27.9 47.0 62.9 17.9 23.2 6,678 Southern 59.3 30.4 55.1 67.9 20.9 16.9 6,979 Education No education 48.0 26.7 45.3 58.4 17.3 27.2 2,826 Primary 54.1 28.4 51.4 66.1 18.5 18.9 10,231 Secondary 67.4 37.3 65.2 75.9 25.4 10.1 2,275 More than secondary 89.9 71.1 91.6 94.3 63.8 1.3 195 Wealth quintile Lowest 48.4 25.4 44.5 58.7 16.2 25.2 2,639 Second 49.1 25.3 45.4 61.5 16.2 24.4 3,120 Middle 52.3 27.5 49.3 65.9 17.1 19.3 3,303 Fourth 57.6 30.3 55.2 67.4 20.6 17.1 3,197 Highest 67.9 40.2 67.7 77.2 28.4 10.0 3,268 Total 55.4 30.0 52.8 66.5 19.9 18.9 15,528 Note: Total includes 33 cases with information missing on employment status. On specific decisions, married women are most likely to be involved in decisions regarding visits to her family or relatives (67 percent), her own health care (55 percent), and purchases for daily household needs (53 percent). Women are least likely to be involved in decisions regarding major household purchases (30 percent). The table shows that women’s participation in household decision- making increases with age. Women in urban areas (29 percent) are more likely than women in rural areas (18 percent) to participate in all four decisions. As shown in Figure 17.1, the population of married women is almost evenly distributed across the number of decisions in which they participate. Women are most likely to participate in two of the four decisions (23 percent), followed by three decisions (21 percent). 230 | Women’s Status and Demographic and Health Outcomes Figure 17.1 Number of Decisions in which Women Participate MDHS 2010 18.9 17.8 22.9 20.5 19.9 0 1 2 3 4 Number of household decisions 0 5 10 15 20 25 Percent The 2010 MDHS also collected information on men’s opinions concerning women’s participation in decision-making in five specified areas. Table 17.5.2 shows the percentage of married men age 15-49 who think that a wife should have equal or greater say than her husband in specific household decisions (i.e., that she should participate in making decisions either jointly with her husband or alone). Table 17.5.2 shows that more than half of the married men age 15-49 (63 percent) think that their wives should participate in decisions about visits to her family or relatives. This proportion is similar to the proportion of women in Table 17.5.1 who say that they do participate in decisions about visiting her family or relatives (67 percent). Nearly seven in ten men (69 percent) think that a wife should participate in decisions about how to spend the money she earns. More than half of men age 15-49 (60 percent) think that a wife should have a say in deciding the number of children to have. Thirty-seven percent of men age 15-49 think a wife should participate in decisions about major household purchases. Nineteen percent of married men are of the opinion that wives, alone or jointly with their husband, should participate in all five of the specified decisions. Across the regions, the highest proportion of men who think that wives should participate in all the specified decisions is found in the Southern Region (21 percent), while men in the Northern and Central Regions are less likely to have this opinion (18 and 17 percent). Men’s support of wives’ participation in decision-making increases with the man’s age and level of education and wealth quintile. Seven percent of men with no education believe that a wife should participate in all five decisions, compared with 61 percent of men with education beyond the secondary level. Women’s Status and Demographic and Health Outcomes | 231 Table 17.5.2 Men’s attitude toward wives’ participation in decision-making Percentage of currently married men age 15-49 who think a wife should have the greater say alone or equal say with her husband on five specific kinds of decisions, by background characteristics, Malawi 2010 Background characteristic Making major household purchases Making purchases for daily household needs Visits to her family or relatives What to do with the money the wife earns How many children to have All five decisions None of the five decisions Number of men Age 15-19 (16.7) (47.2) (42.9) (51.8) (47.8) (6.0) (22.0) 40 20-24 28.5 40.1 57.0 60.6 56.3 12.2 15.3 466 25-29 34.5 48.5 62.7 70.2 58.5 16.2 10.9 868 30-34 40.8 55.4 67.0 69.0 62.7 23.9 11.5 862 35-39 35.6 52.4 63.5 69.2 61.9 17.4 12.2 737 40-44 40.2 53.1 63.0 71.6 60.4 21.4 11.4 495 45-49 40.8 51.0 64.3 71.6 59.8 23.1 11.5 428 Employment (last 12 months) Not employed 38.5 47.1 53.4 48.9 51.0 19.3 22.2 76 Employed for cash 39.3 55.7 64.9 70.0 60.4 21.3 10.8 2,642 Employed not for cash 30.5 39.4 59.8 67.3 60.0 13.8 14.1 1,176 Number of living children 0 33.4 43.1 56.6 57.3 53.1 14.0 16.5 253 1-2 34.5 50.6 65.4 71.1 63.7 19.5 10.2 1,292 3-4 39.9 51.9 64.8 70.3 60.7 21.3 11.8 1,218 5+ 36.3 50.9 60.2 66.9 56.9 17.1 13.4 1,132 Residence Urban 48.9 68.1 69.7 74.9 67.7 31.5 9.7 686 Rural 34.0 46.9 61.7 67.4 58.5 16.3 12.5 3,209 Region Northern 40.2 61.5 54.7 67.1 61.3 17.5 9.0 428 Central 31.7 44.1 64.7 72.9 61.1 17.2 12.2 1,792 Southern 41.0 54.8 63.6 64.7 58.7 21.3 12.6 1,676 Education No education 22.6 35.2 53.6 57.5 47.1 7.0 20.8 333 Primary 31.9 45.2 59.2 64.5 55.4 13.8 14.1 2,460 Secondary 48.6 64.9 73.9 80.1 72.9 30.8 5.2 980 More than secondary 73.9 86.7 81.8 92.7 87.7 61.2 1.6 122 Wealth quintile Lowest 27.0 36.3 55.8 60.3 51.8 12.0 16.2 603 Second 28.8 40.5 57.7 66.1 54.7 11.1 15.4 826 Middle 30.5 49.1 63.1 68.7 59.6 13.8 12.4 850 Fourth 40.1 57.0 65.4 68.9 62.3 20.7 9.4 783 Highest 54.3 66.6 71.6 77.4 69.8 35.5 7.7 833 Total 15-49 36.6 50.6 63.1 68.7 60.1 19.0 12.0 3,895 50-54 34.4 59.6 64.7 72.4 59.9 19.4 8.8 323 Total men 15-54 36.5 51.3 63.2 69.0 60.1 19.0 11.8 4,218 Note: Figures in parentheses are based on 25-49 unweighted cases. 17.4 ATTITUDES TOWARDS WIFE BEATING The 2010 MDHS collected information on the degree of acceptance of wife beating by asking whether a husband is justified in beating his wife in five situations: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual intercourse with him. Tables 17.6.1 and 17.6.2 show the percentages of women and men who agree that a husband is justified in hitting or beating his wife for these specific reasons. The last column on each table shows the summary percentages (of women or men) who feel that wife beating is justified for at least one of the specified reasons. Agreement of a high proportion of women that wife beating is acceptable is an indication that women generally accept the right of a man to control his wife’s behaviour even by means of violence. If a low proportion of women agree that wife beating is acceptable, then the majority of women reject beliefs and behaviours that place them at a low status relative to men. 232 | Women’s Status and Demographic and Health Outcomes Table 17.6.1 shows that 13 percent of women find that wife beating is justified for at least one of the specified reasons. Women are least likely to agree that a man is justified in beating his wife for burning the food and going out without telling him (5 percent each). Women are most likely to agree that a man is justified in beating his wife if she neglects the children (7 percent). Women who have never married are more likely than ever-married women to agree that wife beating is justified for any of the reasons (15 percent compared with 12 percent). Women in urban areas are less likely to agree with at least one of the specified reasons than those in rural areas (10 and 13 percent, respectively). The Northern Region has the highest proportion of women who say that wife beating is justified for at least one of the reasons (26 percent), while the Southern Region has the lowest proportion (8 percent). Women with no education (12 percent) or with primary education (14 percent) are more than twice as likely as women with more than a secondary education (5 percent) to agree that wife beating is justified for at least one reason. Agreement with at least one reason that justifies wife beating decreases with wealth quintile, though the pattern is not linear. Table 17.6.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Malawi 2010 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 6.3 7.2 6.7 10.4 6.5 16.4 5,005 20-24 5.2 6.5 5.8 8.5 6.3 13.3 4,555 25-29 3.2 4.2 4.6 5.9 5.4 10.4 4,400 30-34 3.6 4.6 4.9 5.7 6.0 10.4 3,250 35-39 3.9 4.5 5.0 5.7 5.8 11.4 2,522 40-44 3.9 5.0 4.6 6.0 6.3 11.1 1,730 45-49 4.0 5.4 5.4 6.8 6.5 12.3 1,558 Employment (last 12 months) Not employed 4.6 5.1 5.4 6.8 5.3 11.2 6,220 Employed for cash 4.1 5.0 5.4 7.1 5.8 11.9 9,072 Employed not for cash 5.0 6.5 5.6 8.3 7.1 14.5 7,674 Missing 2.3 2.7 3.1 7.0 3.5 10.3 54 Marital status Never married 5.9 6.5 6.0 9.9 5.7 15.2 4,538 Married or living together 4.3 5.4 5.3 6.9 6.2 12.0 15,528 Divorced/separated/widowed 3.6 5.0 5.1 6.2 5.9 11.2 2,954 Number of living children 0 5.8 6.4 6.0 9.5 6.0 15.0 5,344 1-2 4.6 5.4 5.2 7.3 5.7 11.9 7,079 3-4 3.9 5.3 5.4 6.4 6.2 11.8 6,006 5+ 3.8 4.9 5.1 6.4 6.5 11.7 4,592 Residence Urban 3.5 4.8 4.9 6.7 4.6 10.4 4,302 Rural 4.8 5.7 5.6 7.6 6.4 13.1 18,718 Region Northern 9.8 11.4 14.3 17.0 12.4 26.1 2,677 Central 5.0 6.5 5.6 8.1 7.3 14.0 9,857 Southern 2.8 3.1 3.0 4.3 3.3 7.7 10,485 Education No education 4.1 4.8 5.0 6.2 5.5 11.6 3,505 Primary 5.1 6.3 6.0 8.2 7.0 13.9 14,916 Secondary 3.4 3.7 4.0 6.1 3.8 9.4 4,177 More than secondary 0.8 1.3 2.7 4.0 1.0 5.1 422 Wealth quintile Lowest 5.8 6.5 5.6 8.5 7.7 14.6 4,268 Second 5.2 5.9 5.4 7.4 6.8 13.0 4,332 Middle 5.3 6.6 5.4 7.7 6.8 13.9 4,517 Fourth 3.5 4.5 5.8 6.3 5.1 11.4 4,515 Highest 3.2 4.4 5.0 7.3 4.3 10.4 5,388 Total 4.5 5.5 5.4 7.4 6.1 12.6 23,020 Women’s Status and Demographic and Health Outcomes | 233 Table 17.6.2 shows that the proportion of men age 15-49 who agree with at least one of the reasons justifying wife beating is similar to that of women (13 percent). As was observed for women, men are most likely to agree that a husband is justified in beating a wife if she neglects the children (6 percent) and least likely to agree that a husband is justified in beating his wife when she burns the food (3 percent). Men age 15-19 (21 percent), those who are not currently employed (16 percent), and those who have never been married (18 percent) are more likely than other men to agree with at least one reason justifying wife beating. Rural men are more likely to agree with at least one reason for hitting or beating a wife than urban men (14 and 8 percent, respectively). By region, trends in the approval of wife beating match those for the women. The Northern Region has the highest proportion of men who say wife beating is justified for at least one of the reasons specified (18 percent), while the Southern Region has the lowest proportion (11 percent). Table 17.6.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Malawi 2010 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 4.8 9.2 8.5 10.6 8.7 20.7 1,748 20-24 3.9 5.3 4.5 5.5 3.6 12.0 1,239 25-29 3.0 5.3 5.0 5.4 4.3 10.0 1,099 30-34 1.8 3.7 4.3 4.9 3.8 8.6 948 35-39 2.0 4.2 5.8 3.4 2.9 10.4 798 40-44 2.5 4.0 4.1 4.9 4.1 7.8 529 45-49 2.0 4.0 4.3 5.8 4.3 10.7 458 Employment (last 12 months) Not employed 3.6 7.6 6.9 6.5 8.3 16.2 763 Employed for cash 3.1 5.2 5.5 5.7 4.1 11.4 3,868 Employed not for cash 3.3 6.0 5.5 7.7 5.7 14.2 2,185 Marital status Never married 4.6 7.9 7.5 9.0 7.1 17.8 2,689 Married or living together 2.1 4.1 4.2 4.6 3.4 9.3 3,895 Divorced/separated/widowed 7.1 8.4 9.1 6.7 10.5 14.7 234 Number of living children 0 4.6 7.7 7.3 8.7 7.3 17.6 2,918 1-2 2.2 3.8 4.2 3.7 2.2 7.8 1,485 3-4 1.9 4.5 5.4 5.5 3.6 10.1 1,269 5+ 2.5 4.6 3.7 5.0 4.6 10.3 1,146 Residence Urban 1.8 3.8 5.0 4.6 2.8 8.2 1,440 Rural 3.6 6.3 5.9 6.9 5.7 14.1 5,379 Region Northern 4.2 8.9 7.1 7.7 8.9 18.0 744 Central 3.2 6.0 6.4 7.2 5.3 13.2 3,074 Southern 3.1 4.7 4.7 5.4 3.9 11.2 3,001 Education No education 3.3 8.4 6.5 8.7 5.9 15.2 422 Primary 3.9 6.4 6.0 7.1 5.9 14.4 4,270 Secondary 2.0 4.1 4.9 4.8 3.6 9.7 1,904 More than secondary 0.7 1.8 3.9 3.5 0.2 6.2 223 Wealth quintile Lowest 4.9 7.6 7.2 8.6 7.3 16.4 997 Second 3.7 5.2 5.9 6.5 5.9 13.6 1,309 Middle 3.8 6.4 5.2 6.4 5.6 13.2 1,367 Fourth 3.1 6.4 5.8 7.2 4.9 13.5 1,376 Highest 1.6 4.1 4.9 4.5 2.9 9.6 1,770 Total 15-49 3.2 5.7 5.7 6.4 5.1 12.9 6,818 50-54 1.7 3.4 3.3 4.1 3.3 8.3 357 Total men 15-54 3.2 5.6 5.6 6.3 5.0 12.6 7,175 Note: Total includes 3 cases with information missing on employment status. 234 | Women’s Status and Demographic and Health Outcomes The number of men who agree that a husband is justified in beating a wife for at least one reason decreases as the level of education increases, from 15 percent of men with no education to 6 percent of men with more than a secondary education. The same pattern is seen in relation to the wealth quintile. Sixteen percent of men in the lowest quintile agree with at least one reason for hitting or beating a wife compared with 10 percent of men in the highest wealth quintile. 17.5 WOMEN’S EMPOWERMENT INDICATORS Two sets of empowerment indicators, namely women’s participation in making household decisions and women’s attitudes towards wife beating can be summarised in two indices. The first index shows the number of decisions (see Table 17.5.1 for the list of decisions) in which women participate either alone or jointly with their husband or partner. This index ranges from 0 to 4 and reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives and the level of women’s empowerment in a society. The second index, which ranges from 0 to 5, is the number of reasons (see Table 17.6.1 for a list of reasons) for which a woman thinks that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a higher status of women in the household and society. Table 17.7 shows how these indices relate to each other. There are no clear relationships between the two indices. The percentage of women who disagree with all reasons justifying wife beating is highest among women who do not participate in any of the household decisions (90 percent) and lowest among women who participate in one or two decisions (86 percent). The percentage of women who participate in all five household decisions is high among women who agree with none or with all five of the reasons justifying wife beating and low among women who participate in one to four household decisions. Table 17.7 Indicators of women’s empowerment Percentage of currently married women age 15-49 who participate in all decision making and percentage who disagree with all reasons for justifying wife-beating, by value on each of the indicators of women’s empowerment, Malawi 2010 Empowerment indicator Percentage who participate in all decision making Percentage who disagree with all the reasons justifying wife beating Number of women Number of decisions in which women participate1 0 na 90.1 2,940 1-2 na 86.2 6,318 3-4 na 88.7 6,269 Number of reasons for which wife-beating is justified2 0 20.7 na 13,657 1-2 13.0 na 1,178 3-4 10.4 na 456 5 22.4 na 237 na = Not applicable 1 See Table 17.5.1 for the list of decisions 2 See Table 17.6.1 for the list of reasons 17.6 CURRENT USE OF CONTRACEPTION BY WOMAN’S EMPOWERMENT STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive methods are affected by her status in the household and her own sense of empowerment. A woman who is unable to control other aspects of her life may be less able to make decisions regarding her fertility. She may also feel the need to choose contraceptive methods that are less obvious or do not need the Women’s Status and Demographic and Health Outcomes | 235 approval or knowledge of her husband. Table 17.8 shows the relationship of each of the empowerment indicators with current use of contraceptive methods by currently married women. As expected, contraceptive use is positively associated with participation in household decisions. Use of any contraceptive method and use of any modern method increase as the number of decisions in which a woman participates also increases. The percentage of currently married women who are currently using any method of family planning increases from 40 percent among women who do not participate in any household decisions to 50 percent among women who participate in three to four household decisions. Use of any modern method, female sterilisation, temporary modern methods such as the pill and injectables, the male condom, and traditional methods all increase as the number of decisions in which a woman participates increases. There is not much variation in use of any contraceptive method by number of reasons for which a women believes wife beating is justified. For each number of decisions, the percentage using any method of contraception ranges from 44 to 46 percent. Use of a modern method of contraception, on the other hand, decreases as the number of reasons that justify wife beating increases. Forty-three percent of women who do not agree with any of the reasons for wife beating are using a modern method, compared with 39 percent of women who agree with all reasons for wife beating. Use of temporary modern methods tends to decrease as the number of reasons that a women believes wife beating is justified increases; however, use of traditional methods increases with the number of reasons justifying wife beating. Table 17.8 Current use of contraception by women’s status Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women’s status, Malawi 2010 Empowerment indicator Any method Any modern method Modern methods Any tradi- tional method Not currently using Total Number of women Female sterili- sation Male sterili- sation Tempo- rary modern female methods1 Male condom Number of decisions in which women participate2 0 39.7 37.0 7.3 0.0 28.3 1.3 2.8 60.3 100.0 2,940 1-2 45.8 41.8 9.2 0.1 30.1 2.4 4.0 54.2 100.0 6,318 3-4 49.5 45.2 11.3 0.1 30.9 2.9 4.3 50.5 100.0 6,269 Number of reasons for which wife-beating is justified3 0 46.3 42.6 9.8 0.1 30.3 2.4 3.7 53.7 100.0 13,657 1-2 45.3 40.7 9.7 0.0 29.2 1.7 4.7 54.7 100.0 1,178 3-4 44.2 38.1 8.1 0.0 27.4 2.6 6.1 55.8 100.0 456 5 45.0 38.7 6.9 0.0 27.9 3.9 6.4 55.0 100.0 237 Total 46.1 42.2 9.7 0.1 30.1 2.4 3.9 53.9 100.0 15,528 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly, and lactational amenorrhoea method 2 See Table 17.5.1 for the list of decisions 3 See Table 17.6.1 for the list of reasons 17.7 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Women’s fertility preferences, for example the ideal number of children, are typically lower than those of their husband. As a woman becomes more empowered to negotiate fertility decision- making, she has more control over her ability to access and use contraceptives to space and limit her family size. Women who have a desire to space or limit their births but who are not using family planning are defined as having an unmet need for family planning. Table 17.9 shows how women’s ideal family size and their unmet need for family planning vary by the two indicators of women’s status. 236 | Women’s Status and Demographic and Health Outcomes Women who participate in none of the household decisions have a higher desired family size than women who participate in one or more decisions (4.4 children compared with 4.2). Women who participate in three to four decisions have a lower overall unmet need for family planning (25 percent) compared with women who do not participate in any decisions (27 percent). Women who participate in three to four decisions also have a lower unmet need for spacing, but a higher unmet need for limiting, than women who do not participate in any decision-making. Interestingly, women who participate in one or two decisions have the highest total unmet need for family planning services (27 percent). Desired family size increases with the number of reasons a woman thinks that wife beating is justified, from 4.0 children among women who do not agree with any of the reasons for wife beating to 4.4 children among women who agree with all five reasons for wife beating. The total unmet need for family planning also increases as agreement with reasons justifying wife beating increases. It shifts from 26 percent of women who agree with none of the reasons justifying wife beating to 29 percent of women who agree with all five reasons for wife beating. Table 17.9 Women’s empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women age 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women’s empowerment, Malawi 2010 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of women For spacing For limiting Total Number of decisions in which women participate3 0 4.4 2,882 15.0 11.6 26.5 2,940 1-2 4.2 6,185 15.6 11.8 27.4 6,318 3-4 4.2 6,106 12.5 12.2 24.7 6,269 Number of reasons for which wife beating is justified4 0 4.0 19,713 14.1 11.8 25.9 13,657 1-2 4.0 1,770 14.6 13.0 27.5 1,178 3-4 4.1 712 15.9 11.6 27.6 456 5 4.4 334 17.3 12.0 29.3 237 Total 4.0 22,528 14.2 11.9 26.1 15,528 1 Mean excludes respondents who gave non-numeric responses. 2 See table 7.3.1 for the definition of unmet need for family planning 3 Restricted to currently married women. See Table 17.5.1 for the list of decisions. 4 See Table 17.6.1 for the list of reasons 17.8 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE Table 17.10 shows women’s use of antenatal, delivery, and postnatal care services from health care workers by level of empowerment, as measured by the two indicators of women’s status. Women’s empowerment affects their ability to access reproductive health services. Increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their reproductive health goals, including safe motherhood. The results in Table 17.10 show that, overall, there is not much variation in use of maternal health care services by indicators of women’s empowerment. Women who participate in none of the decisions are slightly less likely to receive antenatal care from a skilled provider and to receive postnatal care from a skilled provider within the first two days after delivery than women who participate in three to four household decisions. The greatest variation in receiving maternal health services by a woman’s participation in decision-making is observed for receiving delivery assistance from a skilled provider. Women who have delivery assistance from a skilled provider increase from 71 percent (among women who participate in no decisions) to 78 percent (among women who participate in three to four decisions). Women’s Status and Demographic and Health Outcomes | 237 Women who agree with three to five reasons that justify wife beating were less likely to receive delivery assistance with and postnatal care from a skilled provider within the first two days following delivery than women who agree with two or fewer reasons. Thirty-four percent of women who agree with all five reasons justifying wife beating received postnatal care within two days following the birth compared with 40 percent of women who agree with none of the reasons justifying wife beating. Table 17.10 Reproductive health care by women’s empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from health personnel for the most recent birth, by indicators of women’s empowerment, Malawi 2010 Empowerment indicator Received antenatal care from a skilled provider Received delivery assistance from a skilled provider Received postnatal care from a skilled provider within the first two days since delivery1 Number of women with a child born in the last five years Number of decisions in which women participate2 0 94.1 70.9 38.2 2,324 1-2 94.3 71.5 37.0 4,878 3-4 95.7 78.1 42.2 4,482 Number of reasons for which wife beating is justified3 0 94.6 74.1 39.5 12,004 1-2 95.9 74.9 37.6 1,045 3-4 92.7 70.4 32.2 416 5 95.5 72.9 33.8 199 Total 94.7 74.0 39.0 13,664 Note: Skilled provider includes doctor, clinical officer, nurse, and midwife. 1 Includes deliveries in a health facility and not in a health facility 2 Restricted to currently married women. See Table 17.5.1 for the list of decisions. 3 See Table 17.6.1 for the list of reasons Domestic Violence | 239 DOMESTIC VIOLENCE 18 18.1 INTRODUCTION Domestic violence, according to Malawi’s Protection against Domestic Violence Act, ‘includes physical, sexual, emotional, psychological, or financial abuse committed against a spouse, child, any other person who is a member of the household, dependant or parent of a child of that household’ (GOM, 2006). It is a form of gender-based violence (GBV) that occurs in the home and is perpetrated by intimate partners or other family members. The MDHS first included questions on domestic violence in 2004; therefore, results from that earlier survey can be compared with the results from the 2010 survey. GBV is defined as any act of violence, in public or private, which results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts and the coercion or arbitrary deprivation of liberty (UN, 1993; UN, 1995). The Government of Malawi not only recognises GBV, especially violence against women, as a severe impediment to poverty reduction, but also recognises its impact on vulnerable groups in relation to the prevalence of HIV infection (Ministry of Women and Child Development, 2008). Efforts have been made at various levels to fight against GBV. At the international level, these efforts include the ratification of the Convention on the Elimination of All Forms of Discrimination against Women and the Convention on the Rights of a Child. At the regional level, Malawi is a signatory to the Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa and the South African Development Community Declaration on Gender and Development, which includes an addendum on the ‘Prevention and Eradication of Violence Against Women and Children’. The signing of these declarations and conventions reaffirms political recognition of the problem of GBV. At the national level, Malawi enacted the Prevention of Domestic Violence Act in May 2006 to address the issue of GBV in the domestic arena, and it also developed and launched the National Response to Combat Gender-Based Violence, 2008-2013 (Ministry of Women and Child Development, 2008). GBV remains a challenge in Malawi despite these efforts. This is mainly because the ratified international and regional instruments have not been effectively implemented at the country level. In addition, Malawi’s cultural traditions have long condoned most forms of domestic violence, treating them as private issues without need for external interference. As a result, most violence against women, particularly domestic violence such as wife battering, incest, and child defilement, goes unreported. To overcome challenges in the collection of data on domestic violence, the data collectors were given special training on GBV. They were also equipped with the knowledge and skills to establish rapport between the interviewer and the respondent. Trust between interviewer and respondent is necessary to collect information on such a sensitive topic. There were three specific protections built into the questionnaire to comply with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001): 1. Only one woman per household was administered the questions on violence. One in every three households was pre-selected for an interview on violence with one female respondent. In households with more than one eligible woman, the respondent to participate in the violence module was randomly selected through a specially designed simple selection procedure based on the Kish Grid, which was built into the Household Questionnaire (Kish, 1965). Interviewing only one person in each household using the violence module allows the selected respondent to keep the information confidential. 240 | Domestic Violence 2. Informed consent to the survey was obtained from each respondent at the start of the individual interview. In addition, at the start of the section on violence, the interviewer read an additional statement informing the respondent that the questions could be sensitive and reassuring her of the confidentiality of her responses. 3. The violence module was implemented only if privacy could be obtained. If privacy could not be obtained, the interviewer was instructed to skip the module, thank the respondent, and end the interview. If a translator needed to conduct the interview, respondents were not asked questions from the violence module in order to maintain privacy.1 18.2 WOMEN EXPERIENCING PHYSICAL VIOLENCE Table 18.1 shows the percentage of women age 15-49 who ever experienced physical violence since age 15 and the percentage that experienced physical violence during the 12 months prior to the survey, by background characteristics. The experience of physical violence varies substantially by background characteristics. The trend by age indicates an increase in physical violence from age 15-19 (21 percent) through age 25-29 (34 percent) and a decline thereafter. Women age 20-29 are more likely than other women to have experienced physical violence during the 12 months prior to the survey (17 percent), while women age 15-19 and age 40-49 are least likely to have experienced physical violence (12 percent). In terms of employment, women who are employed for cash are more likely than other women to have ever experienced physical violence since age 15 and also during the 12 months preceding the survey (31 and 15 percent, respectively). It is interesting to note that unemployed women are the least likely to experience physical violence. Twenty-four percent experienced violence since age 15, and 12 percent experienced physical violence during the 12 months preceding the survey. By marital status, women who are divorced, separated, or widowed are far more likely to have experienced physical violence than other women. Forty-five percent of all women who are divorced, separated, or widowed reported experiencing violence since age 15, and 22 percent reported experiencing physical violence during the 12 months preceding the survey. By contrast, 28 percent of married women and 19 percent of never-married women have experienced physical violence since age 15; 15 percent of currently married women and 8 percent of never-married women experienced physical violence during the 12 months preceding the survey. There are significant differences in experience of physical violence by number of living children: ever having experienced physical violence increases with the number of children, from 21 percent among women with no children to 33 percent among women with three or four children, followed by a decline to 27 percent among women with five or more children. Experience of physical violence in the past 12 months tends to follow a similar trend, with women who have one to four children being more likely to experience physical violence (16 percent) than women with no children or women with five or more children (12 percent or less). Women in urban areas are more likely than women in rural areas to have experienced physical violence since age 15 and during the 12 months prior to the survey (35 percent and 15 percent) compared with women in rural areas (27 and 14 percent) respectively. There is notable variation in experience of physical violence by region. Women in the Northern and Southern Regions are slightly more likely to have experienced physical violence since age 15 (30 percent) compared with women in the Central Region (26 percent). Experience of physical violence in the 12 months prior to the survey is most often reported by women in the Northern Region (18 percent), compared with 15 percent in the Southern Region and 13 percent in the Central Region. Women with more than a secondary education are less likely than women with lower educational attainment to have experienced physical violence since the age of 15; only 11 percent reported having ever experienced violence compared with 26 percent or higher among women with 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. Domestic Violence | 241 lower levels of education. Only 3 percent of women with secondary education reported experiencing physical violence in the 12 months preceding the survey compared with 12 percent or higher of less educated women. There is not much variation in experience of physical violence among women with secondary education or less education. Thirty percent of women with primary education have ever experienced physical violence since age 15 compared with 26 percent of women with secondary education or no education. A similar trend is observed for experience of physical violence in the past 12 months. There is little difference in ever having experienced physical violence by wealth quintile. The percentages vary between 28 and 29 percent for all wealth quintiles. However, there is a decline in the proportion of women who experienced physical violence during the 12 months preceding the survey, from 17 percent in the lowest wealth quintile to 12 percent in the highest wealth quintile. Table 18.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced physical violence during the 12 months preceding the survey, by background characteristics Malawi 2010 Background characteristic Percentage who have ever experienced physical violence since age 151 Percentage who have experienced physical violence in the past 12 months Number of women Often Sometimes Often or sometimes Current age 15-19 20.9 2.4 9.4 11.8 1,306 20-24 29.4 4.2 12.4 16.6 1,183 25-29 33.8 4.9 12.0 16.9 1,281 30-39 29.8 4.1 9.3 13.4 1,559 40-49 26.6 2.6 9.6 12.2 894 Employed last 12 months Not employed 24.2 2.8 9.1 11.9 1,733 Employed for cash 31.3 4.5 10.8 15.3 2,449 Employed not for cash 27.9 3.5 11.4 14.9 2,026 Marital status Never married 18.6 0.5 7.1 7.7 1,173 Married or living together 27.8 3.5 11.0 14.6 4,234 Divorced/separated/widowed 44.5 9.2 12.6 21.8 817 Number of living children 0 21.2 1.5 9.3 10.9 1,394 1-2 30.6 5.2 11.3 16.4 1,911 3-4 32.5 4.8 11.6 16.4 1,643 5+ 26.9 2.4 9.3 11.7 1,275 Residence Urban 34.9 3.6 11.7 15.4 1,217 Rural 26.6 3.7 10.2 13.9 5,007 Region Northern 29.8 3.6 14.3 17.9 697 Central 26.1 3.7 9.3 13.0 2,684 Southern 29.8 3.7 10.8 14.5 2,843 Education No education 26.0 3.3 9.0 12.3 992 Primary 29.9 4.2 11.4 15.6 4,033 Secondary 26.4 2.6 9.6 12.1 1,053 More than secondary 10.8 0.0 2.7 2.7 146 Wealth quintile Lowest 27.5 5.3 11.5 16.8 1,076 Second 27.8 3.4 11.4 14.8 1,221 Middle 28.5 3.6 10.5 14.1 1,215 Fourth 29.1 4.5 10.0 14.4 1,205 Highest 28.2 2.3 9.5 11.8 1,507 Total 28.2 3.7 10.5 14.2 6,224 Note: Total includes 16 women missing information on employment status. 1 Includes in the past 12 months 242 | Domestic Violence A comparison of the results in the 2010 MDHS and the 2004 MDHS shows that the percentage of women who report having ever experienced physical violence since age 15 and the percentage who have experienced physical violence in the past 12 months have remained constant. 18.3 PERPETRATORS OF PHYSICAL VIOLENCE Table 18.2 shows the distribution by marital status of women age 15-49 who have experienced physical violence since age 15 by specific persons who has subjected them to physical violence. The most commonly reported perpetrator of physical violence is the current husband or partner (48 percent), followed by the former husband or partner (20 percent), sister or brother (10 percent), mother or stepmother (6 percent), and other relatives (5 percent). Among ever-married women, the trend is the same, with the current husband or partner as the most likely perpetrator of physical violence (55 percent), followed by the former husband or partner (23 percent). Women who have never married are most likely to suffer physical violence committed by a sister or brother (25 percent), followed by a mother or step-mother and by other relatives, 12 percent each. Table 18.2 Persons committing physical violence Among women age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent’s marital status, Malawi 2010 Person Marital status Total Ever married Never married Current husband/partner 54.5 na 47.7 Former husband/partner 23.2 na 20.3 Current boyfriend 0.1 0.1 0.1 Former boyfriend 0.5 3.4 0.9 Father/step-father 2.5 7.1 3.0 Mother/step-mother 5.6 12.1 6.4 Sister/brother 8.2 24.5 10.2 Daughter/son 0.0 0.0 0.0 Other relative 4.1 12.3 5.1 Mother-in-law 0.3 na 0.2 Other in-law 1.1 na 1.1 Teacher 0.9 5.2 1.4 Employer/someone at work 0.3 0.0 0.2 Other 14.5 39.2 17.5 Number of women 1,539 218 1,757 na = Not applicable 18.4 FORCE AT SEXUAL INITIATION Table 18.3 shows the percent distribution of women age 15-49 who have ever had sexual intercourse by whether their first sexual experience was forced against their will, according to age at first sexual intercourse and whether their first sexual intercourse was at or before the time of their first marriage. The data show that, overall, 15 percent of women who have ever had sex report that their first sexual experience was forced against their will. By age at first intercourse, women who first had sex between the ages of 25 and 29 are more likely than other women to report that their first intercourse was forced (20 percent), followed by women who first had sex before age 15 (18 percent). Women whose first sexual intercourse was before their first marriage are more likely than women who first had sex when they got married (or started living with a man as if married) to report that their first sex was forced (20 percent versus 12 percent). Domestic Violence | 243 Table 18.3 Force at sexual initiation Percentage of women age 15-49 who have ever had sexual intercourse who say that their first experience of sexual intercourse was forced against their will, by age at first sexual intercourse and whether the first sexual intercourse was at the time of first marriage or before, Malawi 2010 Percentage whose first sexual intercourse was forced against their will Number of women who have ever had sex Age at first sexual intercourse <15 17.7 1,082 15-19 14.3 3,419 20-24 13.0 551 25-29 20.3 36 30-49 0.0 7 Missing 11.1 340 First sexual intercourse was: At the time of first marriage/ first cohabitation 12.0 3,101 Before first marriage/first cohabitation1 19.5 1,993 Missing 10.7 339 Total 14.7 5,434 1 Includes never married women 18.5 EXPERIENCE OF SEXUAL VIOLENCE Table 18.4 shows the percentage of women age 15-49 who have ever experienced sexual violence, by background characteristics. The results show that 25 percent of all women age 15-49 have ever experienced sexual violence. There is notable variation in experience of sexual violence by age. The percentage of women who have ever experienced sexual violence increases from 18 percent of women age 15-19 to 33 percent of women age 25-29 and then decreases to 23 percent among women age 40-49. As observed for the relationship between employment status and physical violence, women employed for cash are most likely to have experienced sexual violence (28 percent), followed by women who are employed but not for cash (26 percent). Women who are not employed are least likely to report sexual violence (21 percent). By marital status, women who are divorced, separated, or widowed are most likely to have experienced sexual violence (38 percent), compared with 26 percent of women who are married or living with a partner and 14 percent of never-married women. There are notable differentials in the experience of sexual violence by both residence and region. Rural women are more likely to have experienced sexual violence (26 percent) than urban women (23 percent). Women in the Northern Region are more likely to have experienced sexual violence (32 percent) compared with women in the Central Region (25 percent) and Southern Region (24 percent). By educational attainment, women with primary and secondary education are both more likely to report having experienced sexual violence (26 percent) than women with no education (21 percent) and women with more than secondary education (20 percent). There is no clear relationship between sexual violence and wealth, and differences in experience of sexual violence by wealth quintile are small, ranging from 24 percent in the second and highest wealth quintiles to 27 percent in the middle quintile. 244 | Domestic Violence Table 18.4 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence, by background characteristics, Malawi 2010 Background characteristic Percentage who have ever experienced sexual violence1 Number of women Current age 15-19 17.8 1,306 20-24 25.1 1,183 25-29 32.5 1,281 30-39 27.0 1,559 40-49 23.2 894 Employed last 12 months Not employed 20.5 1,733 Employed for cash 28.3 2,449 Employed not for cash 25.5 2,026 Marital status Never married 13.7 1,173 Married or living together 26.0 4,234 Divorced/separated/widowed 38.4 817 Residence Urban 22.9 1,217 Rural 25.9 5,007 Region Northern 32.2 697 Central 25.2 2,684 Southern 23.7 2,843 Education No education 20.6 992 Primary 26.4 4,033 Secondary 26.3 1,053 More than secondary 19.6 146 Wealth quintile Lowest 25.7 1,076 Second 24.2 1,221 Middle 26.7 1,215 Fourth 25.7 1,205 Highest 24.4 1,507 Total 25.3 6,224 Note: Total includes 16 women missing information on employment status. 1 Includes those whose sexual initiation was forced against their will 18.6 AGE AT FIRST EXPERIENCE OF SEXUAL VIOLENCE Table 18.5 shows, by age at first experience of sexual violence, the distribution of women age 15-49 who have ever experienced sexual violence, according to current age. Overall, women are most likely to experience sexual violence for the first time at age 15-19 (21 percent). Nine percent of women first experience sexual violence at age 10-14, 5 percent at age 20-49, and less than 1 percent before age 10. Domestic Violence | 245 Table 18.5 Age at first experience of sexual violence Percent distribution of women age 15-49 who have experienced sexual violence by age at first experience of sexual violence, according to current age, Malawi 2010 Current age Age at first experience of sexual violence Total Number of women Less than 10 years 10-14 years 15-19 years 20-49 years Don’t know1 Missing 15-19 3.3 23.5 31.9 na 14.8 26.5 100.0 232 20-24 0.1 7.2 22.3 2.6 47.5 20.4 100.0 297 25-29 0.1 5.6 18.3 8.7 41.1 26.3 100.0 417 30-39 0.4 4.7 17.6 5.1 47.3 25.0 100.0 421 40-49 2.1 6.9 16.2 2.8 54.7 17.2 100.0 207 Total 0.9 8.5 20.6 4.5 41.8 23.7 100.0 1,574 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed and whose sexual initiation was not forced against their will. For these women, the age at first experience of sexual violence is not known. na = Not applicable 18.7 PERPETRATORS OF SEXUAL VIOLENCE Table 18.6 shows the percentage of women who have ever experienced sexual violence by specific persons who committed the violence, according to age at first experience and current marital status. Overall, a current husband or partner is the most commonly reported perpetrator of sexual violence (39 percent), followed by a former husband or partner (14 percent), and current or former boyfriend (9 percent). Among ever-married women who have experienced sexual violence, the likelihood of a current husband or partner being reported as the perpetrator of sexual violence increases to 43 percent, and the likelihood of a former husband or partner being reported as a perpetrator increases to 16 percent. Among never-married women, current or former boyfriends are the most commonly reported perpetrators of sexual violence (36 percent), followed by a stranger (15 percent), and a friend or acquaintance (10 percent). Women who first experienced sexual violence when they were age 15 or older are most likely to report their current husband or partner (33 percent) as a perpetrator of the violence, followed by current or former boyfriend (26 percent), and former husband or partner (15 percent). Women who first experienced sexual violence before the age of 15 are most likely to have experienced this violence at the hand of a current or former boyfriend (25 percent) or a stranger (20 percent). Table 18.6 Persons committing sexual violence Among women age 15-49 who have experienced sexual violence, the percentage who report specific persons committing sexual violence, according to age at first experience of sexual violence and current marital status, Malawi 2010 Person Age at first experience of sexual violence Marital status Total <15 years 15 years or higher Don’t know1 Missing Ever married Never married Current husband/partner 8.8 32.9 70.4 0.4 43.0 na 38.6 Former husband/partner 8.2 14.6 23.6 0.0 15.9 na 14.3 Current/former boyfriend 24.5 26.0 0.7 0.0 6.1 35.5 9.1 Father 0.7 1.5 0.3 0.0 0.6 0.0 0.6 Step father 0.0 0.8 0.0 0.0 0.2 0.0 0.2 Grand father 0.8 0.4 0.0 0.0 0.2 0.0 0.2 Other relative 9.9 7.4 0.1 0.5 2.8 4.2 3.0 In-law 2.6 0.2 0.0 0.1 0.3 na 0.3 Own friend/acquaintance 8.9 5.4 0.0 0.0 1.3 9.9 2.2 Family friend 2.0 0.9 0.3 0.0 0.5 0.8 0.6 Teacher 0.2 1.1 0.0 0.0 0.1 2.1 0.3 Employer/someone at work 0.0 0.3 0.0 0.0 0.1 0.0 0.1 Stranger 19.7 4.2 0.0 0.0 1.5 15.3 2.9 Other 13.5 3.8 1.0 0.0 2.3 5.6 2.6 Missing 0.0 0.5 3.6 99.0 25.0 26.0 25.1 Number of women 148 395 659 373 1,413 161 1,574 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed and whose sexual initiation was not forced against their will. For these women, the age of first experience of sexual violence is not known. na = Not applicable 246 | Domestic Violence 18.8 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Table 18.7 presents information by current age on women age 15-49 who reported experiencing various combinations of physical and sexual violence. Overall, two in five women (41 percent) reported that they had experienced either physical or sexual violence. Sixteen percent have experienced physical violence only; this compares with 13 percent who have experienced sexual violence only and 12 percent who have experienced both physical and sexual violence. Women age 25-29 are more likely to have experienced both physical and sexual violence (18 percent) than women in the other age groups. Table 18.7 Experience of different forms of violence Percentage of women age 15-49 who have experienced different forms of violence by current age, Malawi 2010 Age Physical violence only Sexual violence only1 Physical and sexual violence1 Physical or sexual violence1 Number of women 15-19 15.6 12.4 5.4 33.3 1,306 15-17 16.1 9.4 3.6 29.1 867 18-19 14.4 18.5 8.8 41.7 439 20-24 16.0 11.7 13.4 41.1 1,183 25-29 16.1 14.8 17.7 48.6 1,281 30-39 16.2 13.4 13.6 43.3 1,559 40-49 15.4 12.0 11.1 38.6 894 Total 15.9 13.0 12.3 41.2 6,224 1 Includes forced sexual initiation 18.9 VIOLENCE DURING PREGNANCY Respondents to the Domestic Violence module who had ever been pregnant (whether the pregnancy resulted in a live birth or not) were asked specifically whether they have ever experienced physical violence while pregnant and, if so, who the perpetrators of the violence were. Table 18.8 shows, by background characteristics, the percentage of women who have ever been pregnant who reported that they experienced violence while pregnant, by background characteristics. Overall, 6 percent of women experienced physical violence during pregnancy. Although there is no clear pattern between current age and physical violence during pregnancy, it can be noted that women age 15-19 are more likely than older women to report having experienced physical violence during pregnancy. Women who are divorced, separated, or widowed are more likely to have experienced physical violence during pregnancy (9 percent) than women who never-married (7 percent) and women who are currently married (6 percent). It is notable that women who have no living children are twice as likely as women with at least one living child to have experienced violence during pregnancy. By area of residence, women in urban areas are slightly more likely to experience sexual violence during pregnancy than women in rural areas (8 percent versus 6 percent). There is little variation by region in experience of sexual violence by women during pregnancy. Women in the Central Region are only slightly more likely to experience sexual violence during pregnancy (7 percent) than women in the Northern and Southern Regions (6 percent). In relation to education, women with secondary education are most likely to experience violence during pregnancy (7 percent). Women in the lowest two wealth quintiles are more likely than those in the highest three quintiles to have experienced physical violence during pregnancy. Domestic Violence | 247 Table 18.8 Violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, Malawi 2010 Background characteristic Percentage who have ever experienced physical violence during pregnancy Number of women who have ever been pregnant Current age 15-19 9.4 349 20-24 4.5 1,071 25-29 8.0 1,236 30-39 6.2 1,535 40-49 4.5 883 Marital status Never married 6.7 122 Married or living together 5.5 4,157 Divorced/separated/widowed 9.4 794 Number of living children 0 12.0 245 1-2 6.3 1,911 3-4 5.5 1,643 5+ 5.9 1,275 Residence Urban 8.3 935 Rural 5.7 4,139 Region Northern 6.1 562 Central 6.5 2,143 Southern 5.9 2,370 Education No education 5.9 944 Primary 6.1 3,307 Secondary 6.9 745 More than secondary (4.8) 78 Wealth quintile Lowest 7.5 934 Second 7.4 1,021 Middle 5.2 1,012 Fourth 5.5 986 Highest 5.4 1,121 Total 6.2 5,074 Figures in parentheses are based on 25 to 49 unweighted cases. The overall percentage of women who have ever experienced physical violence during pregnancy has remained about the same over the past six years (5 percent in the 2004 MDHS); however, there is an increase in the percentage of women age 15-19 who report having ever experienced physical violence during pregnancy, from 4 percent in 2004 to 9 percent in 2010. The percentage of never-married women who experienced physical violence during pregnancy has also increased, from 4 percent in 2004 to 7 percent in 2010. The number of urban women who report having experienced physical violence during pregnancy increased from 4 percent in 2004 to 8 percent in 2010. 18.10 MARITAL CONTROL BY HUSBAND Marital violence is violence perpetrated by a partner or spouse within the marital union. A series of questions were asked in the 2010 MDHS to determine the degree of marital control exercised by the husband or partner over the respondent. Table 18.9 shows, by selected background characteristics, the percentage of ever-married women whose husband or partner displays each of six listed behaviours. Because the accumulation of such behaviours is more significant than the display of any single behaviour, the proportion of women whose husbands display at least three of the specified behaviours is highlighted. 248 | Domestic Violence The main controlling behaviour women experienced from their husbands was insisting on knowing where they are at all times (51 percent), followed by being jealous or angry if they talk to other men (43 percent), frequently accusing them of being unfaithful (19 percent), not trusting them with any money (13 percent), and limiting contact with their family and not permitting them to meet their female friends (both 10 percent). Twenty-two percent of ever-married women say that their husbands display three or more of these controlling behaviours. Divorced, separated, or widowed women are more likely than other women to report that their husbands or partners display at least three of the controlling behaviours (36 percent). Women in the Northern Region (27 percent) and those in the lowest wealth quintile (27 percent) are more likely than average to report that their husbands or partners engage in three or more controlling behaviours. Table 18.9 Degree of marital control exercised by husbands Percentage of ever-married women age15-49 whose husband/partner ever demonstrates specific types of controlling behaviours, according to background characteristics, Malawi 2010 Background characteristic Percentage of women whose husband: Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Does not trust her with any money Displays 3 or more of the specific behaviours Displays none of the specific behaviours Number of women Current age 15-19 35.0 20.4 10.1 8.8 50.1 11.0 21.1 36.8 350 20-24 38.4 18.9 9.0 9.4 50.8 12.0 20.7 38.9 1,044 25-29 43.8 20.5 10.9 10.7 51.2 13.1 22.2 35.4 1,229 30-39 46.2 17.6 11.5 10.0 51.7 13.8 22.4 35.5 1,533 40-49 46.0 21.4 9.3 10.4 49.6 12.1 21.7 36.7 894 Employed last 12 months Not employed 37.8 17.3 10.8 10.0 44.7 14.3 20.5 42.4 1,190 Employed for cash 44.4 20.2 10.5 10.6 51.2 11.9 22.8 36.4 2,164 Employed not for cash 45.5 19.9 9.9 9.4 54.7 12.5 21.3 32.5 1,684 Missing 45.3 42.2 12.0 4.8 80.6 34.1 42.2 19.4 12 Number of living children 0 44.4 20.2 9.3 6.5 47.3 9.9 20.6 38.7 308 1-2 40.5 20.0 10.9 9.9 53.5 12.7 22.1 35.6 1,827 3-4 44.6 19.5 10.6 9.8 49.8 12.5 22.3 36.6 1,642 5+ 45.0 18.4 9.6 11.4 49.4 13.8 21.0 37.1 1,274 Marital status and duration Currently married woman 41.3 17.4 8.5 8.2 49.5 11.5 19.2 37.6 4,234 Married only once 39.7 16.6 8.2 7.9 49.2 11.4 18.5 38.5 3,277 0-4 years 33.3 14.3 7.6 6.2 47.9 10.3 15.4 41.1 817 5-9 years 37.8 17.6 8.7 8.6 49.0 12.0 19.5 39.0 843 10+ years 43.9 17.3 8.2 8.4 50.1 11.7 19.5 36.9 1,617 Married more than once 47.1 20.1 9.7 9.3 50.6 11.7 21.5 34.5 957 Divorced/separated/widowed 52.9 30.0 19.9 19.6 57.9 19.3 35.5 30.8 817 Residence Urban 46.4 14.3 11.7 10.6 52.4 12.4 20.8 34.9 907 Rural 42.5 20.6 10.1 9.9 50.6 12.8 22.0 36.8 4,143 Region Northern 44.2 26.0 12.6 14.2 57.4 17.5 26.5 30.1 564 Central 42.1 18.9 10.0 10.6 47.5 13.9 22.2 39.9 2,158 Southern 44.1 18.4 10.1 8.5 52.5 10.6 20.4 34.9 2,328 Education No education 42.9 22.3 10.4 11.1 47.3 13.8 22.7 39.7 952 Primary 43.6 19.4 10.2 10.2 51.5 12.6 22.3 36.0 3,304 Secondary 42.9 17.0 11.6 8.6 53.7 12.4 19.1 33.1 727 More than secondary 33.1 6.6 3.8 1.0 40.1 7.1 13.7 50.4 67 Wealth quintile Lowest 44.1 26.3 11.6 11.8 49.0 15.6 27.2 37.6 929 Second 41.8 21.4 10.1 9.1 47.5 10.8 21.3 39.6 1,027 Middle 40.8 18.7 10.6 10.8 49.9 13.3 21.7 38.1 1,019 Fourth 44.9 18.5 9.5 9.2 52.6 12.5 21.0 33.1 986 Highest 44.4 13.3 10.1 9.5 55.1 11.8 18.5 34.1 1,088 Total 43.2 19.4 10.4 10.0 50.9 12.7 21.8 36.5 5,051 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Domestic Violence | 249 On the other hand, 37 percent of ever-married women indicate that their husbands or partners exhibit none of the controlling behaviours. Women with more than secondary education are more likely than women with lower educational attainment to report that their husbands or partners exhibit none of the controlling behaviours. Women who are not employed and those who live in the Central region are more likely than other women to report that their husbands or partners exhibit none of the controlling behaviours. A comparison of the 2004 MDHS and 2010 MDHS shows that the percentage of women whose husbands demonstrate three or more behaviours of marital control has decreased from 30 percent in 2004 to 22 percent in 2010. This decrease is in tandem with an increase in the percentage of women whose husbands display none of the specific behaviours, which increased from 20 percent in the 2004 MDHS to 37 percent in the 2010 MDHS. 18.11 FORMS OF SPOUSAL VIOLENCE Table 18.10 shows the proportion of ever-married women age 15-49 who have experienced various forms of violence by a husband or partner either ever or in the 12 months preceding the survey. It should be noted that different types of violence are not mutually exclusive, and women may report multiple forms of violence. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and, in one-third to more than one half of cases, by sexual abuse (Krug et al., 2002). The results of the 2010 MDHS show that 22 percent of ever-married women reported ever experiencing physical violence from their current or most recent husband or partner, 19 percent reported sexual violence, and 25 percent reported emotional violence. Fifteen percent of ever-married women reported experiencing physical violence at the hand of their husband or partner in the past 12 months, including 11 percent who experienced it sometimes and 4 percent who experienced it often. Thirteen percent of ever-married women experienced sexual violence in the past 12 months, including 9 percent who experienced it sometimes and 4 percent who experienced it often. Twenty-one percent of ever-married women suffered emotional violence from their husband or partner (14 percent sometimes and 8 percent often). Table 18.10 also shows that four in ten ever-married women (40 percent) have ever experienced any form of physical, sexual, or emotional abuse at the hand of their husband or partner. One in ten has experienced both physical and sexual violence, and 7 percent have experienced all three forms of violence by their husband or partner. According to Table 18.10 and Figure 18.1, the most common form of spousal violence is slapping (18 percent). Sixteen percent of ever-married women report having been physically forced to have sexual intercourse by their husband or partner even when they did not want to; 9 percent have been pushed, shaken, or had something thrown at them; the same percentage have been punched; and 8 percent have been kicked, dragged, or beaten up. Six percent of ever-married women also report having been forced by their husband or partner to perform a sexual act they did not want to perform. 250 | Domestic Violence Table 18.10 Forms of spousal violence Percentage of ever-married women age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey, committed by their husband/partner, Malawi 2010 Type of violence Ever In the past 12 months Often Sometimes Often or sometimes Physical violence Any 21.7 4.1 10.6 14.7 Pushed her, shook her, or threw something at her 8.7 2.1 4.6 6.7 Slapped her 18.4 2.8 9.7 12.5 Twisted her arm or pulled her hair 5.9 1.8 2.6 4.4 Punched her with his fist or with something that could hurt her 8.6 2.0 4.5 6.5 Kicked her, dragged her, or beat her up 7.5 2.0 4.0 6.0 Tried to choke her or burn her on purpose 3.7 1.0 1.8 2.9 Threatened her or attacked her with a knife, gun, or any other weapon 2.6 0.5 1.4 1.8 Sexual violence Any 18.9 4.2 9.2 13.4 Physically forced her to have sexual intercourse with him even when she did not want to 15.9 3.8 8.8 12.7 Forced her to perform any sexual acts she did not want to 6.3 1.7 3.3 5.0 Sexual initiation was with current or most recent husband and was forced1 3.4 na na na Emotional violence Any 25.2 7.6 13.6 21.2 Said or did something to humiliate her in front of others 12.8 3.5 6.9 10.4 Threatened to hurt or harm her or someone close to her 11.9 3.2 6.3 9.5 Insulted her or made her feel bad about herself 22.1 6.2 12.0 18.2 Any form of physical and/or sexual violence 31.0 6.9 15.1 22.1 Any form of physical and sexual violence 9.6 1.5 3.7 5.3 Any form of emotional, physical and/or sexual violence 39.9 10.8 19.7 30.5 Any form of emotional, physical and sexual violence 7.1 1.2 2.4 3.6 Number of ever married women 5,051 5,051 5,051 5,051 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. na = Not applicable 1 Excludes women who have been married more than once since their sexual initiation could not have been with the current/most recent partner The forms of spousal violence experienced most often in the 12 months prior to the survey are the same as those most often experienced in the past. Being slapped and being physically forced to have sexual intercourse by their husband or partner even when they did not want to have intercourse are both reported by 13 percent of ever-married women. Seven percent of ever-married women report that their husband or partner pushed, shook, or threw something at them in the past 12 months, and an equal percentage report that their husband or partner punched them with a fist or did something to hurt her. Six percent of ever married women were kicked, dragged, or beaten up by their husband or partner in the past 12 months. Domestic Violence | 251 Figure 18.1 Percentage of Ever-married Women Who have Experienced Specific Forms of Physical and Sexual Violence Committed by their Husband/Partner, Ever and During the Past 12 Months 8.7 18.4 5.9 8.6 7.5 3.7 2.6 15.9 6.3 29.3 6.7 12.5 4.4 6.5 6 2.9 1.8 12.7 5 21.8 Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here 0 5 10 15 20 25 30 35 Percent Ever Past 12 months MDHS 2010 Pushed her, shook her, or threw something at her Punched her with his fist or with something that could hurt her Kicked her, dragged her, or beat her up Tried to choke her or burn her on purpose Threatened her or attacked her with a knife, gun, or any other weapon Physically forced her to have sexual intercourse with him even when she did not want to Forced her to perform any sexual acts she did not want to At least one of these acts Twisted her arm or pulled her hair Slapped her .0 .0 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 18.12 SPOUSAL VIOLENCE BY BACKGROUND CHARACTERISTICS Table 18.11 shows the percentage of ever-married women age 15-49 that have experienced emotional, physical, or sexual spousal violence by selected background characteristics. As noted in Table 18.10, 7 percent of ever-married women have experienced all three forms of spousal violence (emotional, physical, and sexual). Women age 25-29, women who are currently employed, women with four or fewer children, women who are divorced, widowed, or separated, women in the Northern Region, women with primary or secondary education, and women in the lowest wealth quintile are more likely than other women to have experienced all three forms of spousal violence. The percentage of women who have ever experienced each individual type of spousal violence tends to increase with age until the 25-29 age group, and thereafter begins to decline. Women who are not employed are less likely than other women to have ever experienced emotional, physical, or sexual violence committed by their husband or partner. Among employed women, those who earn cash are more likely to report having experienced physical and sexual violence than those who do not earn cash. Although there is no clear trend between number of living children and experience of spousal violence across the types of violence, women with five or more children tend to be least likely to report having experienced each type of spousal violence. As indicated earlier, women who are divorced, separated, or widowed are more likely to have experienced all three forms of spousal violence (15 percent). They are also most likely to have experienced each individual type of spousal violence. The likelihood of having experienced emotional or physical violence by one’s husband or partner increases with marital duration; however, this trend does not hold true for sexual violence. There is not much variation by residence among those having experienced emotional or sexual violence. In contrast, urban women are more likely to have experienced physical violence from their husband or partner (30 percent) than rural women (20 percent). The relationship between region and spousal violence differs by type of violence. Women in the Central Region are most likely to have experienced emotional violence and least likely to have experienced physical violence. Sexual violence ranges from 15 percent in the Southern Region to 26 percent in the Northern Region. 252 | Domestic Violence Table 18.11 Spousal violence by background characteristics Percentage of ever-married women age 15-49 by whether they have ever experienced emotional, physical, or sexual violence committed by their husband/partner, according to background characteristics, Malawi 2010 Background characteristic Emotional violence Physical violence Sexual violence Physical and/or sexual violence Physical and sexual violence Emotional, physical, and/or sexual violence Emotional, physical, and sexual violence Number of women Current age 15-19 22.9 19.3 19.7 30.4 8.6 39.5 6.5 350 20-24 24.5 20.9 17.9 30.0 8.8 39.5 6.3 1,044 25-29 25.6 25.3 22.3 34.8 12.8 41.9 9.3 1,229 30-39 25.7 21.5 18.2 30.6 9.1 40.3 6.9 1,533 40-49 25.2 19.1 16.2 28.0 7.3 37.3 5.8 894 Employed last 12 months Not employed 21.5 18.9 15.8 27.2 7.5 35.2 5.9 1,190 Employed for cash 26.1 23.3 20.3 33.0 10.6 42.2 7.7 2,164 Employed not for cash 26.4 21.8 19.2 31.2 9.7 40.4 7.2 1,684 Number of living children 0 26.9 21.9 16.0 28.5 9.4 38.1 8.5 308 1-2 25.8 21.4 20.5 32.1 9.8 41.4 7.2 1,827 3-4 24.8 24.3 19.8 32.6 11.5 40.5 8.1 1,642 5+ 24.2 18.8 16.0 28.0 6.8 37.5 5.4 1,274 Marital status and duration Currently married woman 22.8 19.3 17.0 28.5 7.8 37.1 5.6 4,234 Married only once 22.3 19.3 17.2 28.7 7.8 37.4 5.5 3,277 0-4 years 20.1 16.1 15.9 25.9 6.1 34.4 4.7 817 5-9 years 21.7 18.8 19.0 29.4 8.4 37.6 5.3 843 10+ years 23.8 21.2 17.0 29.8 8.4 38.8 5.9 1,617 Married more than once 24.5 19.2 16.4 27.8 7.8 36.2 6.1 957 Divorced/separated/widowed 37.3 34.5 28.4 44.0 18.8 54.6 15.2 817 Residence Urban 26.0 29.7 18.7 37.6 10.8 45.7 7.5 907 Rural 25.0 20.0 18.9 29.6 9.3 38.7 7.1 4,143 Region Northern 22.5 22.9 25.6 35.1 13.4 40.2 10.4 564 Central 28.5 20.8 20.8 31.9 9.7 43.1 7.5 2,158 Southern 22.7 22.4 15.4 29.2 8.5 36.9 6.0 2,328 Education No education 23.3 16.1 14.4 23.6 6.9 33.6 6.0 952 Primary 25.9 23.5 19.8 32.9 10.4 41.9 7.5 3,304 Secondary 24.6 22.2 20.5 32.8 9.9 40.1 7.5 727 More than secondary (21.0) (10.2) (19.0) (23.6) (5.6) (32.6) (2.4) 67 Wealth quintile Lowest 28.2 22.8 19.0 30.4 11.3 40.6 8.9 929 Second 25.4 19.8 17.4 27.9 9.3 38.0 7.5 1,027 Middle 22.9 21.6 21.3 32.8 10.2 40.3 6.7 1,019 Fourth 25.4 20.1 20.0 32.6 7.4 41.4 5.9 986 Highest 24.2 24.2 16.9 31.3 9.8 39.6 6.8 1,088 Respondent’s father beat her mother Yes 33.6 28.6 26.0 41.0 13.6 50.7 10.8 1,312 No 22.0 18.9 16.1 26.8 8.1 35.4 5.8 3,377 Don’t know 24.3 24.0 18.8 34.6 8.2 44.3 5.9 344 Total 25.2 21.7 18.9 31.0 9.6 39.9 7.1 5,051 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 13 women with information missing on employment status and 17 women with information missing on whether their father beat their mother. Figures in parentheses are based on 25-49 unweighted cases. By education level, women on the extremes—those with no education and those with more than a secondary education—are less likely to experience each of the three types of spousal violence than those with primary and secondary education. There is no clear relationship between wealth and the individual types of spousal violence. A family history of domestic violence is associated with a respondent’s own experience of domestic violence. Among women whose fathers beat their mothers, 51 percent have experienced emotional, physical, or sexual violence, compared with women whose fathers never beat their mothers Domestic Violence | 253 (35 percent). Likewise, women whose fathers beat their mothers are more likely to have experienced all three forms of violence by a spouse (11 percent) than those whose fathers did not beat their mothers (6 percent). 18.13 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S EMPOWERMENT INDICATORS Table 18.12 presents information on ever-married women age 15-49 who have experienced emotional, physical, or sexual violence committed by their husband or partner. Women who are most likely to have experienced all three forms of spousal violence are those whose husbands exhibit five to six marital control behaviours (40 percent), followed by women whose husbands get drunk very often (26 percent). By education level, spousal violence generally declines with increasing level of education of the husband. The greatest variation by husband’s education is observed for emotional violence. Nearly one in three (29 percent) of ever-married women whose husbands have no education have ever experienced emotional violence from him as compared with 23 percent of women whose husbands have secondary education or higher. There is a very strong relationship between experience of spousal emotional, physical, or sexual violence and husband’s alcohol use. Women whose husbands or partners get drunk often are more than twice as likely to experience each of the three types of spousal violence compared with women whose husbands do not drink or who drink but never get drunk. Those whose husbands get drunk sometimes fall in between. There is no consistent relationship between spousal age difference and experience of spousal violence. Women who are ten or more years younger than their husbands are most likely to report emotional violence (26 percent) followed by women who are older than their husbands (24 percent). On the other hand, women who are older than their husbands are least likely to report experience of physical violence (17 percent), while those who are the same age as their husband or partner are most likely to experience this type of spousal violence (22 percent). Finally, women who are the same age as their husbands are the least likely to experience sexual violence (10 percent), with women who are one to nine years older than their husbands being most likely to report sexual violence (18 percent). Controlling behaviours are strongly associated with spousal violence. Spousal violence increases in a linear fashion with the number of controlling behaviours displayed by the husband or partner. Women with husbands who exhibit none of the controlling behaviours are less likely to experience emotional, physical, and sexual violence (less than 1 percent), compared with women whose husbands exhibit five to six of the controlling behaviours (40 percent), followed by women with husbands who exhibit three to four of the marital control behaviours (18 percent), and those whose husbands exhibit one to two of the controlling behaviours (4 percent). There is no clear relationship between women’s empowerment indicators and spousal violence. Women who do not participate in any decision making and those who participate in three to four decisions are less likely to experience spousal violence in the form of emotional, physical, and sexual violence (5 percent), compared with women who participate in one to two decisions (7 percent). Women who agree with one to two reasons as justifying wife beating are more likely to experience each of the three types of spousal violence (14 percent) than are women who agree with all five reasons and those who agree with none of the reasons. 254 | Domestic Violence Table 18.12 Spousal violence by husband’s characteristics and empowerment indicators Percentage of ever-married women age15-49 who have ever suffered emotional, physical, or sexual violence committed by their husband/partner, according to his characteristics, marital characteristics, and empowerment indicators, Malawi 2010 Emotional violence Physical violence Sexual violence Physical and/or sexual violence Physical and sexual violence Emotional, physical and/or sexual violence Emotional, physical and sexual violence Number of women Husband’s/partner’s education No education 28.5 21.9 19.7 31.3 10.3 40.0 9.3 544 Primary 25.7 21.9 18.8 30.8 9.9 40.3 7.3 2,954 Secondary+ 23.2 21.2 18.7 31.5 8.4 39.7 5.7 1,489 Don’t know/missing 15.3 26.5 17.9 28.0 16.4 28.5 13.3 63 Husband’s/partner’s alcohol consumption Does not drink 20.0 16.1 15.5 25.0 6.7 34.0 4.3 3,143 Drinks/never gets drunk 23.4 14.1 15.2 24.4 4.9 37.5 4.9 106 Gets drunk sometimes 25.7 23.0 19.7 34.1 8.6 42.7 5.6 1,186 Gets drunk very often 51.2 50.6 35.3 57.9 28.1 66.3 25.7 599 Spousal age difference1 Wife older 23.5 17.4 13.9 24.3 7.0 33.5 6.5 131 Wife is same age 22.7 21.8 9.6 26.9 4.6 36.3 3.2 93 Wife’s 1-4 years younger 22.1 19.3 17.7 29.1 7.9 36.8 5.8 1,764 Wife’s 5-9 years younger 22.7 20.0 17.9 29.6 8.2 38.5 5.5 1,470 Wife’s 10+ years younger 25.8 18.0 15.6 25.9 7.7 36.4 5.4 700 Missing 13.5 16.3 14.1 26.2 4.2 32.1 4.2 74 Spousal education difference1 Husband better educated 24.6 21.3 17.8 30.1 8.9 39.8 6.3 3,001 Wife better educated 27.8 24.8 23.1 35.9 11.9 43.4 9.7 1,062 Both equally educated 25.1 21.0 18.6 30.3 9.3 39.0 6.5 587 Neither educated 25.0 16.6 16.0 25.1 7.6 34.2 7.0 297 Don’t know/missing 15.8 23.7 17.2 28.5 12.3 29.7 9.3 103 Number of marital control behaviours displayed by husband/partner 0 8.2 9.4 7.5 13.9 2.9 18.5 0.8 1,843 1-2 21.4 20.6 18.0 31.9 6.7 40.2 4.2 2,106 3-4 54.5 40.2 35.4 54.4 21.2 72.7 17.7 822 5-6 79.2 57.0 52.2 67.9 41.3 83.2 39.9 280 Number of decisions in which women participate1 0 20.2 16.1 13.0 22.1 7.0 29.5 5.1 856 1-2 24.1 22.4 19.7 33.5 8.6 41.4 6.7 1,677 3-4 22.9 17.8 16.4 26.8 7.4 36.7 4.8 1,700 Number of reasons for which wife-beating is justified 0 24.7 20.5 17.7 29.4 8.8 38.8 6.4 4,469 1-2 29.4 33.9 31.9 47.0 18.8 52.0 14.4 378 3-4 31.2 29.2 23.1 42.5 9.8 50.3 8.7 128 5 19.7 19.3 18.1 26.4 10.9 31.8 10.0 75 Total 25.2 21.7 18.9 31.0 9.6 39.9 7.1 5,051 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 18 women with information missing on husband’s/partner’s alcohol consumption. 1 Includes only currently married women 18.14 FREQUENCY OF SPOUSAL VIOLENCE Table 18.13 shows the percent distribution of ever-married women who have experienced emotional violence and those who have experienced physical or sexual violence perpetrated by their current or most recent husband or partner, by how often it occurred in the 12 months preceding the survey. Domestic Violence | 255 Table 18.13 Frequency of spousal violence among those who report violence Percent distribution of ever-married women age 15-49 who have ever suffered emotional violence committed by their current or most recent husband/partner by frequency of violence in the 12 months preceding the survey and percent distribution of those who have ever suffered physical or sexual violence committed by their current or most recent husband/partner by frequency of violence in the 12 months preceding the survey, according to background characteristics, Malawi 2010 Background characteristic Frequency of emotional violence in the past 12 months Frequency of physical or sexual violence in the past 12 months1 Often Some- times Not at all Total Number of women Often Some- times Not at all Total Number of women Current age 15-19 22.9 69.1 8.0 100.0 78 37.1 59.8 3.1 100.0 92 20-24 29.4 60.6 10.0 100.0 256 25.6 62.4 12.0 100.0 279 25-29 38.3 46.2 15.4 100.0 311 24.6 50.4 25.1 100.0 394 30-39 27.4 54.3 18.2 100.0 392 22.8 46.0 31.2 100.0 447 40-49 28.3 53.4 18.3 100.0 224 16.7 50.5 32.8 100.0 242 Employed last 12 months Not employed 33.1 53.4 13.4 100.0 251 25.7 54.1 20.3 100.0 287 Employed for cash 31.9 52.8 15.3 100.0 562 24.4 48.3 27.3 100.0 670 Employed not for cash 26.5 57.3 16.2 100.0 443 21.7 55.7 22.7 100.0 495 Number of living children 0 34.2 55.1 10.6 100.0 81 23.7 65.3 11.0 100.0 77 1-2 29.1 55.8 15.1 100.0 469 26.0 53.6 20.3 100.0 543 3-4 32.4 53.7 13.9 100.0 404 25.0 48.6 26.4 100.0 501 5+ 28.8 52.8 18.4 100.0 307 17.9 51.2 30.9 100.0 333 Marital status and duration Currently married woman 29.3 62.1 8.6 100.0 957 22.7 58.3 18.9 100.0 1,102 Married only once 29.1 62.1 8.7 100.0 727 21.9 58.5 19.6 100.0 839 0-4 years 26.7 64.9 8.5 100.0 162 25.7 63.1 11.2 100.0 178 5-9 years 29.9 61.9 8.2 100.0 183 21.3 67.5 11.3 100.0 220 10+ years 29.8 61.1 9.1 100.0 382 20.6 52.2 27.1 100.0 440 Married more than once 29.9 62.0 8.0 100.0 230 25.4 57.8 16.8 100.0 263 Divorced/separated/ widowed 33.8 30.0 36.2 100.0 305 26.7 31.9 41.4 100.0 352 Residence Urban 27.0 51.1 21.9 100.0 233 17.8 49.6 32.6 100.0 304 Rural 31.2 55.1 13.7 100.0 1,028 25.3 52.6 22.2 100.0 1,150 Region Northern 32.1 56.4 11.5 100.0 127 29.2 49.1 21.7 100.0 176 Central 29.3 54.8 16.0 100.0 612 24.8 53.0 22.2 100.0 625 Southern 31.3 53.4 15.3 100.0 523 21.2 51.7 27.1 100.0 653 Education No education 32.7 53.7 13.6 100.0 222 22.8 51.5 25.8 100.0 212 Primary 30.0 54.1 15.9 100.0 849 24.6 51.4 24.0 100.0 1,016 Secondary 31.5 54.5 14.0 100.0 177 21.4 56.0 22.6 100.0 211 More than secondary * * * 100.0 14 * * * 100.0 15 Wealth quintile Lowest 36.0 47.1 16.9 100.0 260 28.4 51.5 20.1 100.0 269 Second 28.6 57.3 14.1 100.0 258 25.8 54.8 19.4 100.0 270 Middle 32.6 50.4 17.0 100.0 231 23.3 53.1 23.6 100.0 307 Fourth 31.1 58.6 10.3 100.0 250 29.3 47.2 23.5 100.0 292 Highest 23.9 58.2 18.0 100.0 262 13.1 53.2 33.7 100.0 317 Total 30.4 54.4 15.3 100.0 1,261 23.7 51.9 24.3 100.0 1,454 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. The table excludes women with missing information on frequency of violence in the past 12 months. Total includes 5 women with a history of emotional violence and 3 women with a history of physical or sexual violence with missing information for employment status. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes respondents whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence Overall, 54 percent of women experienced emotional violence from their husbands or partners sometimes in the past 12 months, compared with 30 percent who experienced it often. Fifteen percent of women who have ever experienced emotional violence from their husband or partner did not experience such violence at all in the past 12 months. Among ever-married women who have experienced physical or sexual violence, 52 percent indicated that they experienced such violence sometimes in the past 12 months, while 24 percent experienced it often. One in four women (24 256 | Domestic Violence percent) who ever experienced physical or sexual violence by their husband or partner did not experience such violence at all during the past 12 months. Among women who have ever experienced emotional violence from their husband or partner, the likelihood of having experienced such violence in the past 12 months decreases with age. Women with no living children are most likely to have experienced emotional violence in the past 12 months while women with five or more children are least likely to have done so. By marital status, among women who have ever experienced emotional violence, those who are divorced, separated, or widowed are much more likely than currently married women not to have experienced this violence in the past 12 months (36 percent). Urban women are more likely not to have experienced emotional violence at all in the past 12 months (22 percent) compared with rural women (14 percent). Rural women are also more likely to have experienced emotional violence often (31 percent compared with 27 percent). By wealth, women in the lowest wealth quintile are most likely to have experienced emotional violence often in the past 12 months. Among women who have ever experienced physical or sexual violence by their husband or partner, the trends in frequency of such violence in the past 12 months are similar to those observed for emotional violence. 18.15 ONSET OF SPOUSAL VIOLENCE To obtain information on the timing of the onset of marital violence, the 2010 MDHS asked ever-married women how long after marriage the spousal violence began, if ever. Table 18.14 shows the interval between marriage and the first episode of physical or sexual violence by a husband or partner. The results show that most of the ever-married women have experienced no physical or sexual violence by their husbands or partners (69 percent); however, 10 percent of all ever-married women report that physical or sexual violence began to occur one to two years after marriage. Seven percent of women report that violence began three to five years after marriage, and a similar proportion said that violence began less than a year after marriage. Fewer women report that violence began six to nine years (2 percent) or ten or more years after marriage (3 percent). Less than 1 percent report that violence began prior to marriage. Table 18.14 Onset of marital violence Percent distribution of ever-married women by number of years between marriage and first experience of physical or sexual violence by their husband/partner, if ever, according to marital status and duration, Malawi 2010 Years between marriage1 and first experience of violence Total Number of women Experi- enced no violence Before marriage1 <1 year 1-2 years 3-5 years 6-9 years 10+ years Don’t know/ missing2 Marital status and duration Currently married 71.5 0.4 6.3 9.3 6.9 2.0 2.4 1.2 100.0 4,234 Married only once 71.3 0.2 6.6 9.1 7.0 2.0 2.4 1.4 100.0 3,277 < 1 year 75.9 0.0 15.8 na na na na 8.3 100.0 171 1-2 years 72.5 0.0 16.6 8.8 na na na 2.0 100.0 339 3-5 years 73.5 0.4 5.6 13.9 5.1 na na 1.4 100.0 484 6-9 years 70.4 0.0 5.8 10.6 10.0 2.6 na 0.5 100.0 665 10+ years 70.2 0.2 4.1 8.2 8.5 3.1 4.9 0.9 100.0 1,617 Married more than once 72.2 1.1 5.2 9.8 6.7 2.0 2.4 0.6 100.0 957 Divorced/separated/widowed 56.0 1.3 10.2 15.0 9.7 2.3 3.4 2.3 100.0 817 Total 69.0 0.5 6.9 10.2 7.4 2.1 2.6 1.4 100.0 5,051 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. 1 For couples who are not married but are living together as if married, the time of marriage refers to the time when the respondent first started living together with her partner. 2 Includes women for whom the timing of the first experience of violence and duration of marriage are inconsistent. na = Not applicable Domestic Violence | 257 18.16 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE Table 18.15 presents, by type of injury, the percentage of ever-married women age 15-49 that experiences specific types of spousal violenceever and in the past 12 months. The results show very little difference in the prevalence of injuries by time period of occurrence. The injuries most commonly resulting from spousal violence were cuts, bruises, or aches. Among women who have ever experienced physical violence by their husband or partner, 40 percent had cuts, bruises, or aches; 13 percent had eye injuries, sprains, dislocations, or burns; and 13 percent had deep wounds, broken bones, broken teeth, or another serious injury, while 44 percent received any of these injuries. Similar percentages were observed for women who experienced physical violence in the past 12 months. Among those who experienced sexual violence, 31 percent had cuts, bruises, or aches; 11 percent had eye injuries, sprains, dislocations, or burns, and a similar percentage suffered deep wounds, broken bones, broken teeth, or another serious injury, while 34 percent received any of these injuries. Among women who experienced this violence in the past 12 months, the injury rates were the same. Among women who experienced either physical or sexual violence, 32 percent had cuts, bruises, or aches; 10 percent had eye injuries, sprains, dislocations, or burns; a similar percentage had deep wounds, broken bones, broken teeth, or another serious injury, while 35 percent received any of these injuries. Among women who experienced physical or sexual violence in the past 12 months, the percentages are comparable. Table 18.15 Injuries to women due to spousal violence Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from what their husband/partner did to them, according to the type of violence and whether they have experienced the violence ever and in the 12 months preceding the survey, Malawi 2010 Cuts, bruises, or aches Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever married women Experienced physical violence1 Ever2 40.1 13.2 12.8 43.7 1,098 In the past 12 months 43.5 15.5 14.8 47.6 744 Experienced sexual violence3 Ever2 31.0 10.7 11.1 33.8 845 In the past 12 months 31.3 11.1 11.0 34.4 678 Experienced physical or sexual violence3 Ever2 32.0 10.0 9.8 35.0 1,482 In the past 12 months 32.9 11.0 10.6 36.3 1,100 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. 1 Excludes women who experienced physical violence only during pregnancy 2 Includes in the past 12 months 3 Excludes women whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence 18.17 VIOLENCE BY WOMEN AGAINST THEIR HUSBANDS Table 18.16 shows the percentage of ever-married women age 15-49 who have committed physical violence against their husband or partner, in the 12 months prior to the survey, when he was not already beating or physically hurting them. Overall, 4 percent of ever-married women reported that they had initiated physical violence against their husband or partner, while 2 percent did so in the past 12 months. Less than 1 percent indicated that they initiated physical violence against their husbands often in the past 12 months. 258 | Domestic Violence Table 18.16 Violence by women against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their husband/partner when he was not already beating or physically hurting them ever and in the past 12 months, according to women’s own experience of spousal violence and their own and husband’s/partner’s characteristics, Malawi 2010 Percentage who have committed physical violence against their current or most recent husband/partner Ever In the past 12 months1 Number of women Often Sometimes Any Woman’s experience of spousal physical violence Ever 11.7 0.7 4.1 4.8 1,098 In the last 12 months 13.3 0.9 5.5 6.4 760 Not last 12 months/widow/missing 8.0 0.4 0.9 1.3 338 Never 2.1 0.1 0.9 1.0 3,953 Current age 15-19 2.2 0.0 2.1 2.1 350 20-24 2.4 0.2 1.3 1.5 1,044 25-29 5.0 0.2 1.4 1.6 1,229 30-39 4.3 0.3 1.8 2.2 1,533 40-49 5.4 0.2 1.6 1.8 894 Employed last 12 months Not employed 3.3 0.2 1.8 2.0 1,190 Employed for cash 5.1 0.2 1.7 2.0 2,164 Employed not for cash 3.5 0.2 1.3 1.5 1,684 Missing 3.8 0.0 3.8 3.8 12 Number of living children 0 4.1 0.0 3.1 3.1 308 1-2 4.3 0.4 1.2 1.6 1,827 3-4 3.7 0.1 1.5 1.6 1,642 5+ 4.4 0.2 1.9 2.1 1,274 Residence Urban 6.1 0.0 2.3 2.3 907 Rural 3.7 0.3 1.4 1.7 4,143 Region Northern 2.7 0.1 1.5 1.5 564 Central 4.3 0.2 1.9 2.1 2,158 Southern 4.3 0.3 1.4 1.7 2,328 Wealth quintile Lowest 3.6 0.2 1.5 1.7 929 Second 3.9 0.1 1.9 2.0 1,027 Middle 3.7 0.2 1.2 1.5 1,019 Fourth 3.9 0.5 1.7 2.3 986 Highest 5.5 0.1 1.6 1.7 1,088 Marital status and duration Currently married woman 3.8 0.3 1.6 1.9 4,234 Married only once 3.7 0.2 1.7 1.9 3,277 0-4 years 2.2 0.3 1.4 1.7 817 5-9 years 4.2 0.2 1.3 1.5 843 10+ years 4.2 0.2 2.0 2.3 1,617 Married more than once 4.2 0.4 1.5 1.8 957 Divorced/separated/widowed 5.7 0.0 1.4 1.4 817 Education No education 4.1 0.1 1.7 1.8 952 Primary 3.9 0.2 1.7 1.9 3,304 Secondary 5.2 0.5 0.9 1.3 727 More than secondary (3.9) (0.0) (0.7) (0.7) 67 Husband’s/partner’s education No education 4.6 0.2 1.7 1.9 544 Primary 3.6 0.2 1.6 1.7 2,954 Secondary+ 4.7 0.4 1.4 1.7 1,489 Don’t know/missing 14.1 0.0 6.3 6.3 63 Husband’s/partner’s alcohol consumption Does not drink 2.6 0.1 1.0 1.1 3,143 Drinks/never gets drunk 2.2 0.0 0.5 0.5 106 Gets drunk sometimes 5.1 0.2 1.9 2.1 1,186 Gets drunk very often 10.7 0.8 4.5 5.2 599 Spousal age difference2 Wife older 2.4 0.8 1.6 2.4 131 Wife is same age 3.0 0.0 1.4 1.4 93 Wife’s 1-4 years younger 3.8 0.3 1.7 2.0 1,764 Wife’s 5-9 years younger 3.4 0.3 1.3 1.7 1,470 Wife’s 10+ years younger 4.6 0.1 2.0 2.0 700 Missing 9.7 0.0 3.7 3.7 74 Spousal education difference Husband better educated 4.1 0.2 1.6 1.8 3,001 Wife better educated 4.4 0.2 1.7 1.9 1,062 Both equally educated 3.3 0.4 0.7 1.1 587 Neither educated 3.1 0.4 1.1 1.5 297 Don’t know/missing 10.5 0.0 5.7 5.7 103 Total 4.1 0.2 1.6 1.8 5,051 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 13 women with information missing on employment status and 17 women with information missing on husband’s/partner’s alcohol consumption. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes widows 2 Currently married women Domestic Violence | 259 Women who have experienced spousal violence from their husband or partner are more likely to have initiated physical violence against him than women who never experienced physical violence from their husband or partner (12 percent versus 2 percent). By age, women age 25-29 and age 40-49 (5 percent each) are more likely to have ever committed physical violence against their husbands than other women. By employment status, women who are employed for cash are slightly more likely to have initiated physical violence against their husbands (5 percent), compared with those employed not for cash (4 percent) and those not employed (3 percent). There is no variation in ever having initiated violence against one’s husband or partner and number of living children; however, women with no living children are slightly more likely than other women to have initiated violence against their husband or partner in the past 12 months. Urban women are more likely than rural women to have initiated sexual violence against their husbands, ever and in the past 12 months. Women in the Northern Region are slightly less likely than their counterparts in other regions to have ever initiated violence against their husband or partner. By wealth quintile women in the highest quintile are more likely to have ever initiated physical violence against their husband (6 percent) than those in the lower wealth quintiles (4 percent or lower). In relation to marital status and duration, divorced, separated, or widowed women are more likely than currently married women to have ever initiated physical violence against their husband or partner (6 percent versus 4 percent). There is little variation in women’s initiation of physical violence against their husbands or partners by either the woman’s education or that of her husband or partner. Women whose husbands get drunk often are more likely to have ever initiated physical violence against their husbands (11 percent) than those whose husbands get drunk sometimes (5 percent), those whose husbands do not drink (3 percent), and those whose husbands drink but never get drunk (2 percent). Women with husbands who get drunk often are also more likely than other women to have initiated physical violence against their husbands in the past 12 months. Women who are ten or more years younger than their husbands are slightly more likely to have ever initiated physical violence against their husbands (5 percent) than those who are older than their husbands (2 percent). There is little difference in women’s initiation of physical violence against their husbands by spousal education difference. The percentage of ever-married women age 15-49 who have ever committed physical violence against their husband or partner when he was not already physically hurting them remains virtually unchanged since the 2004 MDHS (3 percent in the 2004 MDHS versus 4 percent in the 2010 MDHS). 18.18 HELP-SEEKING BEHAVIOUR BY WOMEN WHO EXPERIENCE VIOLENCE This section describes help-seeking behaviour by women age 15-49 who have ever experienced physical or sexual violence. Table 18.17 shows the percent distribution of women who have ever experienced physical or sexual violence by whether they sought help to stop the violence, and for those who did not seek help, whether or not they told anyone. Roughly one in three women (36 percent) who experience physical or sexual violence never tell anyone about it, and nearly half never seek help (48 percent). Women who experience only sexual violence are less likely than women who experience physical violence to seek help. Help-seeking behaviour varies relatively little by age or employment status. Women with no living children are somewhat more likely to have sought help than women with at least one living child. Fifty percent of currently married women have never sought help compared with 45 percent of never-married women and 44 percent of women who are divorced, widowed, or separated. Help-seeking behaviour is fairly constant in urban and rural areas and by region. Women with no education are less likely than women who have been to school to have ever told anyone about the violence or to have sought help. There is no strong relationship between help seeking and wealth. 260 | Domestic Violence Among women who sought help for the violence, most of them sought help from their own family and in-laws (17 and 18 percent, respectively). Four percent each sought help from friends or neighbours and the police, while 3 percent sought help from a traditional authority or chief, and less than 1 percent sought help from a religious leader. Table 18.17 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by whether they have told anyone about the violence and whether they have ever sought help from any source, according to background characteristics, Malawi 2010 Background characteristic Never told anyone Never sought help Percentage who sought help from: Number of women Own family In-laws Friend/ neigh- bour Religious leader Police Tradi- tional authority/ chief Other1 Type of violence Physical only 30.6 43.8 17.8 15.0 3.6 0.9 3.3 2.8 4.6 990 Sexual only 60.1 69.9 8.7 8.6 1.8 0.3 0.2 0.1 0.8 440 Both physical and sexual 28.8 41.2 20.4 27.0 5.2 1.2 5.6 5.5 3.1 767 Current age 15-19 31.8 47.9 17.3 7.6 3.2 0.5 1.3 2.6 2.5 344 20-24 36.5 46.1 16.4 21.6 4.4 1.4 3.6 1.4 3.7 420 25-29 34.8 45.8 20.2 17.0 6.4 1.1 3.9 3.0 3.6 520 30-39 38.5 51.4 15.5 19.1 2.2 0.9 4.2 3.5 2.8 599 40-49 36.0 48.6 14.1 23.6 2.1 0.4 3.6 6.4 4.5 313 Employed last 12 months Not employed 33.8 49.3 19.2 12.3 2.9 1.0 4.8 1.3 3.7 526 Employed for cash 35.7 46.5 14.1 19.5 3.9 0.9 3.5 4.7 4.2 956 Employed not for cash 37.4 48.8 19.1 20.2 4.3 0.7 2.6 2.7 1.9 704 Number of living children 0 30.3 44.0 20.2 6.4 5.9 0.4 1.0 2.5 2.7 353 1-2 35.9 49.8 15.8 20.1 3.7 1.7 3.8 1.8 3.8 748 3-4 38.2 48.3 15.4 17.6 3.8 0.6 5.2 4.4 2.5 657 5+ 36.7 48.4 18.2 23.9 2.1 0.4 2.4 4.5 4.4 438 Marital status and duration Never married 28.9 44.8 21.6 0.7 7.0 0.0 0.1 2.9 3.8 261 Currently married woman 39.4 50.0 16.1 19.6 3.2 1.2 3.4 2.3 3.0 1,497 Married only once 40.1 49.9 16.9 20.8 3.1 1.4 2.8 2.1 3.4 1,116 0-4 years 41.0 53.3 13.7 19.3 2.8 1.6 2.0 0.5 4.0 263 5-9 years 37.0 47.4 19.8 19.8 3.8 2.2 4.4 1.9 2.1 302 10+ years 41.4 49.7 16.8 22.1 2.8 0.8 2.3 2.9 3.9 552 Married more than once 37.4 50.1 13.9 16.0 3.7 0.5 5.3 3.0 1.8 381 Divorced/separated/widowed 27.7 43.7 16.7 22.4 3.6 0.5 5.7 6.6 4.3 438 Residence Urban 33.5 47.0 16.7 15.6 2.8 1.9 6.6 1.8 5.1 479 Rural 36.5 48.4 16.9 18.6 4.0 0.6 2.6 3.6 2.9 1,717 Region Northern 40.7 46.1 24.5 15.7 2.8 0.7 2.4 3.6 3.5 261 Central 35.5 49.2 14.5 16.9 4.3 0.4 3.5 2.3 4.2 933 Southern 35.0 47.6 17.1 19.4 3.5 1.4 3.7 4.0 2.5 1,002 Education No education 43.6 57.1 10.3 15.9 3.0 0.1 3.7 4.8 2.4 323 Primary 36.4 46.8 17.0 19.7 3.3 0.7 3.2 3.3 3.5 1,501 Secondary 26.8 46.5 21.3 13.1 6.1 2.4 4.5 1.8 3.9 348 More than secondary * * * * * * * * * 25 Wealth quintile Lowest 32.6 45.8 18.0 21.4 3.2 0.2 3.7 3.2 3.6 368 Second 38.6 48.5 15.9 19.4 4.1 0.6 2.5 3.7 3.2 422 Middle 36.0 47.3 17.7 18.3 3.0 0.6 3.2 4.7 2.2 450 Fourth 39.0 50.2 15.4 18.2 3.1 0.2 2.7 2.9 3.5 455 Highest 33.0 48.4 17.5 13.5 5.1 2.4 5.1 1.9 4.2 502 Total 35.9 48.1 16.9 17.9 3.8 0.9 3.5 3.2 3.3 2,196 Note: Excludes women whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence. Total includes 11 women with information missing on employment status. An asterisk indicates that a figure is based on fewer than 25 unweighted cases. 1 Includes doctor/medical personnel, husband/partner/boyfriend, social service organisation, employer/someone at work, lawyer, and district social welfare officer Orphans and Vulnerable Children | 261 ORPHANS AND VULNERABLE CHILDREN 19 One of the outcomes of the HIV epidemic has been a growth in the number of children who have been orphaned or whose social and economic vulnerability has increased because of the serious illness of a parent or other adult member of the household. This chapter looks first at the prevalence of orphaned and vulnerable children (OVC) in Malawi. It examines the extent to which such children are disadvantaged compared with other children on several key measures of child welfare, including school attendance. The chapter then reviews information on the care and support given to households in which there are orphaned and vulnerable children. When reviewing the 2010 MDHS results, remember that the survey includes only orphans and vulnerable children living in households. Children living in institutions or other nonhousehold settings, including children living on the street, are not included in the 2010 MDHS results. Thus, the 2010 MDHS results convey a minimum estimate of the number of orphaned and vulnerable children in Malawi.1 19.1 ORPHANED AND VULNERABLE CHILDREN In the 2010 MDHS, an orphan is defined as a child under age 18 with one or both parents deceased. A vulnerable child is defined as a child under age 18 who has a chronically ill parent (sick for three or more consecutive months during the past 12 months) or who lives in a household where an adult was chronically ill or died during the 12 months preceding the survey. 19.1.1 Children’s Living Arrangements and Orphanhood The Household Questionnaire collected information on the living arrangements for all children under age 18 in the households included in the 2010 MDHS sample. Information was also collected on the survival status of the children’s parents. The results are presented in Table 19.1. In the households sampled, 56 percent of children under age 18 are living with both of their parents. Eight percent of children under age 18 are paternal orphans, that is, their father is dead but their mother is alive, while 3 percent are maternal orphans (mother is dead, father is alive). Three percent of children under age 18 are double orphans—both their father and their mother are dead. Nineteen percent of children are not living with a biological parent. The percentage of children who do not live with either of their biological parents increases with age, from 6 percent among children age 0-4 to 34 percent among children age 15-17. Girls are somewhat more likely than boys to live in households with neither biological parent present (20 and 18 percent, respectively). The percentage of children who live in households without a biological parent present ranges from 17 percent in the Central Region to 22 percent in the North Region. Children living in households in the highest wealth quintile are most likely not to be living with a biological parent (22 percent). 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by region. District-level results are available in Appendix A. 262 | Orphans and Vulnerable Children Table 19.1 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by children’s living arrangements and survival status of parents, and the percentage of children not living with a biological parent, according to background characteristics, Malawi 2010 Background characteristic Living with both parents Living with mother but not father Living with father but not mother Not living with either parent Missing informa- tion on father/ mother Total Percent- age not living with a biological parent Number of children Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Age 0-4 70.0 21.1 2.0 0.6 0.1 4.9 0.5 0.3 0.3 0.3 100.0 6.3 19,545 <2 74.9 22.3 1.4 0.1 0.0 0.8 0.2 0.0 0.0 0.3 100.0 1.3 7,804 2-4 66.7 20.3 2.4 0.9 0.1 7.6 0.7 0.5 0.4 0.3 100.0 9.6 11,741 5-9 57.2 17.7 4.7 1.7 0.5 12.8 1.7 1.8 1.5 0.5 100.0 18.3 19,620 10-14 46.7 15.0 7.5 2.2 0.9 15.3 3.3 4.0 4.5 0.7 100.0 27.7 16,876 15-17 40.1 12.7 9.4 2.0 1.2 18.0 3.4 5.3 6.4 1.4 100.0 34.4 7,303 Sex Male 56.6 17.6 5.4 1.7 0.6 10.6 1.9 2.2 2.8 0.5 100.0 18.1 31,530 Female 56.1 17.3 4.9 1.3 0.5 12.6 2.0 2.5 2.1 0.6 100.0 19.8 31,815 Residence Urban 58.6 14.1 4.7 2.4 1.1 11.0 2.0 2.6 3.1 0.4 100.0 19.1 8,945 Rural 56.0 18.0 5.2 1.4 0.5 11.7 2.0 2.3 2.4 0.6 100.0 18.9 54,400 Region Northern 54.3 15.5 4.5 3.1 0.6 14.3 1.8 3.4 1.8 0.6 100.0 22.0 7,642 Central 61.5 15.3 4.4 1.4 0.5 11.5 1.4 1.8 1.8 0.5 100.0 16.9 27,310 Southern 52.0 20.0 6.1 1.2 0.6 11.0 2.5 2.6 3.3 0.6 100.0 20.1 28,392 Wealth quintile Lowest 46.9 24.6 8.0 0.7 0.3 12.2 2.3 2.0 2.5 0.6 100.0 19.5 13,425 Second 58.9 17.3 5.8 1.0 0.4 10.2 1.8 2.1 2.0 0.5 100.0 16.7 12,867 Middle 60.4 17.0 3.8 1.2 0.4 10.7 2.0 1.7 2.1 0.7 100.0 17.2 12,849 Fourth 58.9 14.8 4.2 2.0 0.5 11.9 1.8 2.7 2.6 0.6 100.0 19.5 12,537 Highest 57.2 12.8 3.7 2.8 1.3 13.4 1.9 3.2 3.1 0.5 100.0 22.1 11,667 Total <15 58.5 18.1 4.6 1.4 0.5 10.8 1.8 1.9 2.0 0.5 100.0 16.9 56,042 Total <18 56.4 17.5 5.2 1.5 0.6 11.6 2.0 2.3 2.5 0.6 100.0 19.0 63,345 Note: Table is based only on children who usually live in the household. 19.1.2 Orphaned and Vulnerable Children Children whose parents are ill for an extended period or who live in households where other adults suffer from chronic illness can experience significant hardships as serious illness may limit the resources available to feed, clothe, and educate a family’s youngest members. The 2010 MDHS included several questions to determine if any adults in the household (including the child’s parents) had been chronically ill during the 12-month period before the survey. Adult members of a household age 18-59 were considered to be chronically ill if they had been very sick—i.e., too sick to work or do normal activities—for a period of at least three months during the 12-month period before the survey. Questions were included for children whose parents were not living in the same household at the time of the survey to determine if the parent(s) had been chronically ill in the 12-month period before the survey. Table 19.2 shows the proportion of children considered vulnerable because of chronic illness of a parent or other adult during the 12-month period prior to the 2010 MDHS. The table also shows the overall proportion of children identified in the MDHS as orphaned or vulnerable. Thirteen percent of children under age 18 are orphaned; that is, one or both parents are deceased. The percentage of children who are orphaned rises rapidly with age, from 3 percent among children under age 5 to 26 percent among children age 15-17. The proportions of urban and rural children that are orphaned are similar (14 and 13 percent, respectively). The proportion of children who are orphaned is lowest in the Central Region (10 percent) and highest in the Southern Region (15 percent). Orphans and Vulnerable Children | 263 Table 19.2 Orphans and vulnerable children (OVC) Percentage of de jure children under age 18 years who are orphans or made vulnerable due to illness among adult household members (OVC), according to background characteristics, Malawi 2010 Background characteristic Orphan children Percentage of children who: Vulnerable children OVC children Number of children Percentage of children with one or both parents dead1 Have a very sick parent for at least 3 months in the past 12 months2 Live in a household where at least 1 adult has been very sick for at least 3 months in the past 12 months3 Live in a household where at least 1 adult died in the past 12 months and had been very sick for at least 3 months before he/she died3 Percentage of children who have a very sick parent OR live in a household where an adult has been very sick OR died in the past 12 months Percentage of children who are orphans and/or vulnerable Age 0-4 3.2 2.5 3.1 1.0 4.4 7.1 19,545 <2 1.7 2.2 2.9 0.9 3.9 5.4 7,804 2-4 4.2 2.7 3.3 1.0 4.6 8.3 11,741 5-9 10.2 3.5 4.0 1.1 5.7 14.8 19,620 10-14 20.5 3.7 4.1 1.3 6.3 24.9 16,876 15-17 26.0 4.3 5.0 1.6 7.6 30.9 7,303 Sex Male 13.1 3.3 3.9 1.2 5.7 17.4 31,530 Female 12.1 3.4 3.8 1.2 5.6 16.5 31,815 Residence Urban 13.5 3.3 3.6 0.8 5.3 17.2 8,945 Rural 12.5 3.4 3.9 1.2 5.7 16.9 54,400 Region Northern 12.2 3.7 3.6 0.7 5.6 16.7 7,642 Central 10.0 3.3 3.8 0.7 5.0 14.0 27,310 Southern 15.2 3.4 4.0 1.8 6.3 19.9 28,392 Wealth quintile Lowest 15.2 4.2 4.4 1.1 6.4 20.2 13,425 Second 12.2 3.0 3.6 1.6 5.6 16.7 12,867 Middle 10.2 3.0 3.2 0.9 4.8 14.0 12,849 Fourth 12.0 3.6 4.3 1.2 6.1 16.5 12,537 Highest 13.4 2.9 3.7 1.1 5.4 17.3 11,667 Total <15 10.9 3.2 3.7 1.1 5.4 15.1 56,042 Total <18 12.6 3.4 3.9 1.2 5.7 17.0 63,345 Note: Table is based only on children who usually live in the household. Very sick means person was too sick to work or do normal activities. 1 Includes children with father dead, mother dead, both dead and one parent dead but missing information on survival status of the other parent 2 Whether or not lives in same household as child 3 Limited to adults aged 18 to 59 years who are/were usual residents or who slept in the household the previous night Among children under age 18, 3 percent have a parent who was chronically ill during the past year, 4 percent live in households in which at least one adult (a parent or other adult household member) was chronically ill during the past year, and 1 percent live in households in which at least one adult who had been chronically ill and died during the 12 months preceding the survey. Six percent of children under age 18 are considered to be vulnerable, i.e., they live in households in which at least one adult was chronically ill or died during the past year, or they have at least one parent living in the household or elsewhere who had experienced a chronic illness. Overall, 17 percent of children under age 18 are considered to be orphaned or vulnerable. The percentage of children under age 18 who are orphans and vulnerable children increases with age, from 7 percent among children under age five to 31 percent among children age 15-17. There are no differences in the proportion of orphans and vulnerable children by sex or residence. Fourteen percent of children under age 18 are orphans and vulnerable children in the Central Region compared with 20 percent of children in the Southern Region. By wealth, the percentage of orphans and vulnerable children is highest among those living in households in the lowest wealth quintile. 264 | Orphans and Vulnerable Children 19.2 SOCIAL AND ECONOMIC SITUATION OF ORPHANED AND VULNERABLE CHILDREN Information collected in the 2010 MDHS Household Questionnaire can be used to look at several important aspects of the social and economic situation of orphaned and vulnerable children, including information on school attendance, possession of items considered basic for meeting a child’s material needs, residence with siblings, and nutritional status. These results provide a way to assess the impact on children’s welfare of the chronic illness and death of a parent or other adult household member and to monitor and evaluate OVC programmes (UNICEF, 2005). 19.2.1 School Attendance Orphaned and vulnerable children may be at greater risk of dropping out of school. This can happen for many reasons, such as the inability to pay school fees, the need to help with household labour, or the need to stay at home to care for a sick parent or younger siblings. Table 19.3 presents school attendance rates for children age 10-14 by survivorship of parents and OVC status, according to background characteristics. The first few columns contrast the situations of two groups: children whose parents are both dead and children whose parents are both alive and the child is living with at least one parent. The last few columns compare school attendance for the entire population of orphaned and vulnerable children to that of children who are neither orphaned nor vulnerable. The results in Table 19.3 show that children whose parents are both alive and who live with at least one of them are slightly more likely to be attending school (93 percent) than children whose mother and father are both deceased (91 percent). In urban areas and in the highest three wealth quintiles, children with both parents deceased are least likely to be attending school relative to children whose parents are both alive and who live with at less one parent. On the other hand, in the Northern Region and the lowest and second wealth quintiles, children with both parents deceased are equally likely or more likely to be attending school relative to children whose parents are both alive and who live with at least one parent. Overall, orphaned and vulnerable are slightly less likely to be attending school than those who are not orphaned and vulnerable (89 percent versus 93 percent). Table 19.3 School attendance by survivorship of parents and by OVC status For de jure children 10-14 years of age, the percentage attending school by parental survival and by OVC status and the ratios of the percentages attending for parental survival and OVC status, according to background characteristics, Malawi 2010 Background characteristic Percentage attending school by survivorship of parents Ratio1 Percentage attending school by OVC status Ratio2 Both parents deceased Number Both parents alive and living with at least one parent Number OVC Not OVC Percentage attending school Number Percentage attending school Number Sex Male 89.4 430 93.1 5,467 0.96 88.2 2,170 92.8 6,265 0.95 Female 92.0 321 93.8 5,306 0.98 90.5 2,028 93.4 6,412 0.97 Residence Urban 92.4 135 97.6 1,399 0.95 92.6 599 96.3 1,660 0.96 Rural 90.1 616 92.8 9,374 0.97 88.8 3,600 92.6 11,018 0.96 Region Northern 98.4 64 97.7 1,341 1.01 95.5 496 97.8 1,627 0.98 Central 89.7 247 92.9 4,996 0.97 87.5 1,482 92.3 5,880 0.95 Southern 89.8 440 92.7 4,435 0.97 89.2 2,221 92.5 5,171 0.96 Wealth quintile Lowest 88.1 161 88.0 2,076 1.00 83.4 1,016 88.7 2,449 0.94 Second 92.2 128 90.7 2,155 1.02 88.2 846 90.6 2,469 0.97 Middle 89.6 119 94.1 2,256 0.95 90.5 694 93.6 2,633 0.97 Fourth 89.2 162 95.7 2,290 0.93 90.5 836 95.6 2,633 0.95 Highest 93.1 181 98.6 1,997 0.94 95.7 806 96.7 2,495 0.99 Total 90.5 751 93.4 10,773 0.97 89.3 4,199 93.1 12,678 0.96 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 2 Ratio of the percentage for OVC to the percentage for non-OVC Orphans and Vulnerable Children | 265 19.2.2 Basic Material Needs The 2010 MDHS obtained information on whether the minimum basic material needs of children age 5-17 are being met. Basic material needs are considered to be met if the child has a pair of shoes, two sets of clothes, and a blanket. Table 19.4 shows that the minimum basic material needs are met for 53 percent of all children age 5-17. In terms of the basic items, children are least likely to have a pair of shoes (60 percent) and most likely to have at least two sets of clothes (88 percent). Children who are orphaned and vulnerable are less likely than children who are not to possess the three basic needs (41 and 56 percent, respectively). Table 19.4 shows that among all children age 5-17, rural children are less likely than urban children to have all three minimum basic material needs met (48 percent compared with 77 percent). Children in the Northern Region are more likely than children in the Central and Southern Regions to have met all three basic material needs, and the proportion of children with all three basic material needs met increases incrementally with wealth quintile. These patterns are consistent for children regardless of OVC status. Table 19.4 Possession of basic material needs by orphans and vulnerable children Among de jure children age 5-17 years, the percentage possessing three minimum basic material needs, the percentages of OVC and non-OVC who possess all three basic material needs, and the ratio of the percentage for OVC to the percentage for non-OVC, according to background characteristics, Malawi 2010 Background characteristic Among children 5-17 years of age percentage possessing: Number of children Percentage possessing all three basic needs by OVC status Ratio2 Shoes Two sets of clothes Blanket All three basic needs1 OVC Not OVC Percentage possessing all three basic needs Number Percentage possessing all three basic needs Number Age 5-9 57.2 87.1 70.5 50.4 19,620 35.4 2,897 53.0 16,723 0.67 10-14 58.1 88.8 71.3 51.3 16,876 39.3 4,199 55.3 12,678 0.71 15-17 69.7 90.2 74.5 61.1 7,303 51.9 2,257 65.3 5,046 0.80 Sex Male 57.7 87.3 72.0 51.2 21,986 39.7 4,821 54.5 17,165 0.73 Female 61.5 89.2 70.9 53.9 21,813 42.7 4,531 56.8 17,283 0.75 Residence Urban 83.7 94.9 84.5 77.4 6,283 69.5 1,402 79.6 4,881 0.87 Rural 55.6 87.1 69.3 48.4 37,516 36.1 7,950 51.7 29,566 0.70 Region Northern 67.1 91.1 78.4 61.6 5,327 51.9 1,114 64.2 4,213 0.81 Central 59.7 87.8 73.1 53.1 18,869 40.7 3,310 55.7 15,558 0.73 Southern 57.5 87.9 68.0 49.6 19,604 38.9 4,928 53.2 14,676 0.73 Wealth quintile Lowest 34.7 78.0 51.0 26.6 9,053 18.3 2,315 29.4 6,738 0.62 Second 44.6 83.6 61.7 35.6 8,619 26.3 1,838 38.1 6,781 0.69 Middle 60.2 90.5 74.0 52.6 8,682 38.9 1,563 55.6 7,119 0.70 Fourth 70.4 92.9 79.6 63.3 8,959 49.6 1,830 66.9 7,128 0.74 Highest 89.5 96.8 92.1 86.1 8,487 78.8 1,806 88.1 6,681 0.89 Total 59.6 88.3 71.5 52.6 43,799 41.1 9,352 55.7 34,447 0.74 Note: Table is based only on children who usually live in the household. 1 Shoes, two sets of clothing, a blanket 2 Ratio of the percentage for OVC to the percentage for non-OVC 19.2.3 Nutritional Status Table 19.5 considers the effects of orphanhood and vulnerability on the nutritional status of children under age 5. Overall, 18 percent of children under age 5 are underweight. OVC children are slightly more likely to be underweight than non-OVC children (19 percent versus 18 percent). Differences by background characteristics appear to be similar among OVC and non-OVC children, although caution should be taken in interpreting trends because of the low numbers of OVC children under age 5. 266 | Orphans and Vulnerable Children Table 19.5 Underweight orphans and vulnerable children Percentage of de-jure children under age 5 years who slept in the household the night before who are underweight, total and by OVC status, according to background characteristics, Malawi 2010 Background characteristic Percentage of children under 5 who are underweight1 Number of children Underweight by OVC status Ratio2 OVC Not OVC Percentage underweight1 Number of OVC Percentage underweight1 Number of non-OVC Age < 1 year 8.1 844 (12.5) 38 7.9 805 1.58 1-2 years 23.0 2,018 29.1 89 22.7 1,929 1.28 3-4 years 16.1 1,912 13.5 107 16.2 1,804 0.83 Sex Male 18.9 2,334 20.9 117 18.8 2,217 1.11 Female 16.4 2,440 17.6 117 16.3 2,322 1.08 Residence Urban 14.5 715 * 29 14.9 686 0.32 Rural 18.1 4,059 21.3 206 18.0 3,853 1.18 Region Northern 15.4 525 (8.3) 28 15.8 497 0.53 Central 17.6 2,198 18.1 84 17.6 2,113 1.03 Southern 18.2 2,051 22.6 122 17.9 1,929 1.26 Wealth quintile Lowest 23.3 842 27.2 51 23.1 791 1.18 Second 20.2 1,082 16.3 47 20.4 1,035 0.80 Middle 16.4 1,041 (24.6) 47 16.1 993 1.53 Fourth 18.3 891 (28.3) 33 17.9 859 1.58 Highest 10.0 918 4.9 57 10.3 861 0.48 Total 17.6 4,774 19.3 235 17.5 4,539 1.10 Note: Table is based only on children who usually live in the household and who also slept in household the night preceding the interview. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Two or more standard deviations below mean on the WHO Child Growth Standards for weight for age 2 Ratio of the percentage for OVC to the percentage for non-OVC 19.2.4 Sex before Age 15 Teenage orphans and vulnerable children may be at high risk for early sexual activity because they often lack adult guidance and supervision to help them protect themselves. Table 19.6 shows that among girls age 15-17, those who are OVCs are slightly more likely than non-OVC girls to have initiated sexual activity before age 15 (14 percent compared with 11 percent). This relationship is not true among boys, who are roughly equally likely to have initiated sex by age 15, regardless of OVC status. Table 19.6 Sexual intercourse before age 15 of orphans and vulnerable children Percentage of de-jure children age 15-17 who had sexual intercourse before exact age 15, total and by OVC status, and ratio of the percentage for OVC to the percentage for non-OVC, by sex, Malawi 2010 OVC status Women Men Percentage who had sexual intercourse before exact age 15 Number of women Percentage who had sexual intercourse before exact age 15 Number of men OVC 13.7 954 29.4 343 Non-OVC 11.4 2,242 29.8 779 Total 12.1 3,196 29.7 1,123 Ratio1 1.20 na 0.98 na Note: Table is based only on children who usually live in the household and who also slept in the household the night preceding the interview. NA = Not applicable 1 Ratio of the percentage for OVC to the percentage for non-OVC Orphans and Vulnerable Children | 267 19.3 CARE AND SUPPORT FOR OVCS One of the important challenges in countries like Malawi that have increased OVC populations—partly due to the HIV/AIDS epidemic—is the need to assist families in caring for these children. The 2010 MDHS asked questions to assess the extent to which families and communities recognise and address the need to care for orphaned and vulnerable children. 19.3.1 Property Dispossession and Legal Assistance In the households interviewed, women who had ever been widowed were asked if they had been dispossessed of property after their husband died. Table 19.7 shows that 6 percent of women age 15-49 have ever been widowed, and 36 percent of the widows were dispossessed of property. That is, most of the husband’s property went to someone other than the respondent. Dispossession of property does not vary greatly by background characteristics. Women with at least a secondary education and those in the highest wealth quintile were more likely than other women to be subjected to property dispossession. Among widows dispossessed of property, only 8 percent received any legal assistance. Widows who have not remarried, those in urban areas, those with a secondary education, and those in the highest wealth quintile are more likely than their counterparts to have received legal assistance for the property dispossession. Table 19.7 Widows dispossessed of property Percentage of de facto women age 15-49 who have been widowed, and the percentage of widowed women who have been dispossessed of property, by background characteristics, Malawi 2010 Background characteristic Percentage of ever-widowed women Number of women Among ever-widowed women: Among ever-widowed women dispossessed of property: Percentage who were dispossessed of property1 Number of women Percentage of women who received legal support or assistance Number of women Age 15-19 0.2 5,005 * 12 * 8 20-29 2.3 8,955 34.7 208 4.9 72 30-39 10.5 5,772 41.1 605 9.1 248 40-49 18.4 3,288 29.8 607 6.9 181 Marital status Married 3.9 15,528 39.9 612 4.7 244 Widowed 100.0 819 32.4 819 10.4 265 Age of youngest child No children 0.4 5,029 (44.5) 18 * 8 < 18 years 7.5 17,613 35.7 1,316 7.1 470 18+ years 25.5 378 31.9 96 (7.4) 31 Residence Urban 6.4 4,302 39.5 274 15.5 108 Rural 6.2 18,718 34.6 1,157 5.5 401 Region Northern 6.3 2,677 36.1 168 5.0 61 Central 5.6 9,857 32.8 550 8.4 180 Southern 6.8 10,485 37.6 713 7.8 268 Education No education 10.9 3,505 32.1 383 3.4 123 Primary 5.8 14,916 35.4 866 7.3 306 Secondary 3.8 4,177 44.1 160 13.7 71 More than secondary 4.9 422 42.0 21 * 9 Wealth quintile Lowest 8.0 4,268 34.6 339 4.1 117 Second 6.9 4,332 34.8 299 9.0 104 Middle 5.0 4,517 36.5 228 1.2 83 Fourth 5.6 4,515 29.4 254 6.6 75 Highest 5.8 5,388 41.8 311 14.6 130 Total 6.2 23,020 35.6 1,431 7.7 509 Note: Table is based only on women and men who slept in the household the night preceding the interview. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Dispossessed of property indicates that most of the late husband’s assets went to someone other than the respondent. 268 | Orphans and Vulnerable Children 19.3.2 External Support for Households with OVCs The 2010 MDHS collected information on the extent to which free external care and support services are reaching households with orphaned and vulnerable children. Table 19.8 shows for adults age 18-59 who were chronically ill or died after a chronic illness during the past year, the percentage whose household had received certain types of free external support during the past 30 days (or because of the person’s death). Medical support was received for 23 percent of these households, 6 percent received emotional support, and 4 percent received social or material support. Almost one in three households with chronically ill adults (27 percent) received at least one type of support in the past 30 days, while 1 percent received all three types of support. Most of the households of very sick adults (73 percent) did not receive any medical, emotional, or social/material support. Levels of support in all categories are higher in urban than in rural areas. Table 19.8 External support for very sick persons Percentage of women and men age 18-59 who have been either very sick or who died within the last 12 months after being very sick whose households received certain free basic external support to care for them within the last year, by background characteristics, Malawi 2010 Background characteristic Percentage of very sick persons whose households received: Number of persons Medical support at least once a month during illness Emotional support in the past 30 days1 Social/material support in the past 30 days2 Al least one type of support in the past 30 days All three types of support in the past 30 days None of the three types of support Age 18-29 21.4 4.4 2.1 25.4 0.3 74.6 354 30-39 27.7 8.1 5.3 33.8 1.9 66.2 383 40-49 19.1 6.1 4.1 24.2 0.8 75.8 266 50-59 20.6 5.6 3.4 23.9 1.0 76.1 282 Sex Male 20.6 6.7 3.6 26.5 1.2 73.5 555 Female 24.2 5.7 3.8 27.9 0.9 72.1 729 Residence Urban 28.5 11.7 6.1 36.0 2.1 64.0 162 Rural 21.8 5.3 3.4 26.1 0.9 73.9 1,122 Region Northern 20.5 5.3 2.8 25.3 0.6 74.7 125 Central 23.3 4.5 3.9 27.1 1.3 72.9 490 Southern 22.5 7.4 3.8 27.9 0.9 72.1 669 Wealth quintile Lowest 20.7 2.9 2.6 23.1 0.6 76.9 304 Second 20.9 3.5 1.7 23.6 0.3 76.4 300 Middle 27.7 3.9 4.5 31.7 1.0 68.3 234 Fourth 21.1 10.1 5.6 28.0 2.1 72.0 240 Highest 24.0 12.4 5.3 33.1 1.5 66.9 207 Total 22.6 6.1 3.7 27.3 1.0 72.7 1,284 Note: Table is based only on women and men who usually live in the household and who were very sick (unable to work or do normal activities) in the last 12 months or who died in the last 12 months and were very sick at least 3 of the 12 months before death. Support refers to the past 30 days for living persons and in the 30 days preceding death for deceased persons. 1 Support such as companionship, counselling from a trained counsellor, or spiritual support for which there was no payment 2 Support such as help with household work, training for a caregiver, legal services, clothing, food, or financial support for which there was no payment Table 19.9 looks at the extent to which free external care and support was received by households for OVC members. The results indicate that almost all such children (83 percent) did not receive any type of support. Seventeen percent of OVC households received at least one type of support. Among those that did receive some type of support, the household was most likely to have received medical support (9 percent). Eight percent of OVC households received school-related assistance, and 3 percent of them received emotional support and social or material support. Orphans and Vulnerable Children | 269 In contrast with care and support provided for chronically ill adults, orphaned and vulnerable children in urban and rural areas are roughly equally likely to live in households that receive support. Those in the Southern Region are slightly more likely than their counterparts in other regions to live in households that receive at least one type of support. Children in the top three wealth quintiles are more likely to live in household that receive at least one type of support than are children living in the lowest two wealth quintiles. Table 19.9 External support for orphans and vulnerable children Percentage of orphans and vulnerable children under age 18 whose household received certain free basic external support to care for the child in the last 12 months, by background characteristics, Malawi 2010 Background characteristics Percentage of orphans and vulnerable children whose households received: Number of OVC children Medical support in the past 12 months1 Emotional support in the past 3 months2 Social/material support in the past 3 months3 School-related assistance in the past 12 months4 Al least one type of support5 All of the types of support5 None of the types of support Age 0-4 12.0 2.2 2.3 na 14.5 0.0 85.5 1,394 5-9 9.4 3.6 2.6 7.3 17.5 0.1 82.5 2,897 10-14 8.4 3.1 2.7 9.8 18.5 0.0 81.5 4,199 15-17 7.3 4.0 2.7 8.3 16.8 0.3 83.2 2,257 Sex Male 8.5 3.0 2.5 7.0 16.3 0.1 83.7 5,488 Female 9.3 3.6 2.7 8.2 18.4 0.1 81.6 5,258 Residence Urban 9.3 5.2 2.5 4.9 17.7 0.3 82.3 1,539 Rural 8.9 3.0 2.6 8.0 17.3 0.1 82.7 9,208 Region Northern 6.3 4.3 1.2 8.2 16.0 0.1 84.0 1,276 Central 8.0 3.0 2.4 7.9 16.7 0.1 83.3 3,833 Southern 10.2 3.2 3.1 7.2 18.1 0.1 81.9 5,637 Wealth quintile Lowest 7.7 1.9 2.6 8.3 15.8 0.0 84.2 2,711 Second 8.1 2.2 2.3 7.2 15.4 0.0 84.6 2,145 Middle 10.3 2.9 3.4 7.7 19.4 0.1 80.6 1,801 Fourth 10.2 4.6 2.5 7.6 18.7 0.1 81.3 2,067 Highest 9.0 5.3 2.4 6.8 18.3 0.2 81.7 2,022 Total 8.9 3.3 2.6 7.6 17.3 0.1 82.7 10,746 Note: Table is based on de jure household members, i.e., usual household members. na = Not applicable 1 Medical care, supplies or medicine 2 Companionship, counselling from a trained counsellor, or spiritual support for which there was no payment 3 Help with household work, training for a caregiver, legal services, clothing, food, or financial support for which there was no payment 4 Allowance, free admission, books, or supplies for which there was no payment. 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Appendix A | 273 DISTRICT TABLES Appendix A CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table A-2.3.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age 6 and over by highest level of schooling attended or completed and median grade completed, according to district of residence, Malawi 2010 District of residence No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Northern Chitipa 9.9 68.4 9.7 8.8 2.3 0.1 0.9 100.0 572 4.3 Karonga 8.3 71.4 8.7 7.4 3.7 0.4 0.2 100.0 907 4.0 Mzimba 9.5 68.9 9.0 8.6 3.0 0.7 0.2 100.0 2,690 4.4 Nkhata Bay and Likoma 11.7 67.5 10.1 8.0 2.0 0.1 0.5 100.0 729 4.0 Rumphi 4.2 68.5 8.6 12.5 4.8 0.3 1.1 100.0 593 5.3 Total 9.1 69.0 9.1 8.8 3.1 0.5 0.4 100.0 5,491 4.3 Central Dedza 29.3 60.8 5.3 2.8 1.2 0.1 0.5 100.0 3,087 1.2 Dowa 20.7 62.4 7.9 6.9 2.0 0.0 0.0 100.0 2,117 2.5 Kasungu 13.9 66.5 8.7 7.6 2.7 0.3 0.2 100.0 2,424 3.2 Lilongwe 18.2 62.2 5.7 7.3 4.1 2.2 0.3 100.0 5,613 2.4 Mchinji 17.6 66.8 6.0 6.4 2.7 0.1 0.4 100.0 1,659 2.4 Nkhotakota 19.2 66.7 4.7 7.3 1.6 0.3 0.2 100.0 1,106 2.0 Ntcheu 17.4 67.4 7.5 5.1 1.7 0.1 0.8 100.0 2,021 2.6 Ntchisi 18.1 64.8 8.1 5.6 2.5 0.5 0.3 100.0 726 2.3 Salima 22.0 65.6 5.1 3.6 2.2 0.7 0.8 100.0 1,308 1.6 Total 19.8 64.0 6.4 6.0 2.6 0.8 0.4 100.0 20,060 2.2 Southern Balaka 19.3 64.0 6.6 6.2 2.9 0.7 0.3 100.0 1,280 2.4 Blantyre 9.1 55.2 7.0 14.4 9.2 4.7 0.5 100.0 3,442 5.2 Chikhwawa 24.9 61.7 4.5 5.3 2.0 0.4 1.1 100.0 1,888 1.6 Chiradzulu 15.4 70.9 5.3 5.5 1.9 0.7 0.3 100.0 1,036 2.4 Machinga 27.9 60.1 5.6 3.9 1.5 0.7 0.5 100.0 1,578 1.6 Mangochi 37.8 51.2 4.4 4.2 1.8 0.2 0.4 100.0 3,075 0.7 Mulanje 17.7 67.5 6.8 5.4 1.5 0.6 0.4 100.0 1,747 2.3 Mwanza 18.4 65.8 6.8 5.2 2.7 0.6 0.5 100.0 291 2.5 Neno 19.8 63.3 7.0 6.5 2.0 0.8 0.6 100.0 266 2.6 Nsanje 32.5 56.2 4.5 4.6 1.3 0.6 0.3 100.0 881 1.0 Phalombe 18.7 68.7 7.5 3.4 1.0 0.1 0.6 100.0 962 1.9 Thyolo 14.0 70.4 5.9 5.9 2.9 0.3 0.5 100.0 2,010 2.4 Zomba 13.6 67.3 7.1 6.8 2.6 1.9 0.6 100.0 2,457 2.7 Total 20.5 61.7 6.0 6.7 3.2 1.3 0.5 100.0 20,913 2.3 Total 18.9 63.6 6.5 6.7 2.9 1.0 0.5 100.0 46,465 2.5 Note: Total includes 28 unweighted cases with information missing on educational attainment. 1 Completed 8th grade at the primary level 2 Completed 4th grade at the secondary level 274 | Appendix A Table A-2.3.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age 6 and over by highest level of schooling attended or completed and median grade completed, according to district of residence, Malawi 2010 District of residence No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Northern Chitipa 5.1 67.3 7.3 11.6 7.0 1.3 0.3 100.0 553 5.1 Karonga 4.7 67.6 8.6 9.9 7.2 1.9 0.1 100.0 844 5.1 Mzimba 5.5 69.9 8.0 11.2 4.2 1.1 0.2 100.0 2,573 4.7 Nkhata Bay and Likoma 7.0 67.7 7.8 10.4 5.9 0.8 0.3 100.0 701 4.5 Rumphi 3.0 62.5 7.9 14.3 10.2 1.4 0.8 100.0 559 5.7 Total 5.2 68.2 8.0 11.3 5.8 1.2 0.3 100.0 5,230 4.9 Central Dedza 18.9 67.5 6.4 4.3 1.9 0.6 0.5 100.0 2,544 2.0 Dowa 13.1 66.9 7.3 8.6 3.5 0.6 0.1 100.0 2,139 3.2 Kasungu 7.9 68.0 7.8 9.5 5.4 1.0 0.4 100.0 2,497 4.0 Lilongwe 12.0 60.6 6.1 9.3 8.8 3.0 0.2 100.0 5,430 3.7 Mchinji 11.2 67.2 6.5 9.7 4.7 0.4 0.3 100.0 1,606 3.2 Nkhotakota 11.3 64.9 7.1 8.9 6.4 1.1 0.2 100.0 1,152 3.5 Ntcheu 10.7 68.4 8.4 7.6 4.0 0.4 0.4 100.0 1,845 3.1 Ntchisi 13.4 64.9 6.5 7.3 6.6 1.1 0.2 100.0 705 3.2 Salima 13.9 63.5 6.4 8.4 5.7 1.6 0.6 100.0 1,240 2.7 Total 12.5 65.1 6.8 8.3 5.6 1.4 0.3 100.0 19,158 3.2 Southern Balaka 13.4 67.3 5.4 8.0 4.9 0.8 0.2 100.0 1,097 3.0 Blantyre 6.1 50.1 5.2 16.6 15.2 6.5 0.3 100.0 3,646 6.5 Chikhwawa 13.5 66.4 5.7 6.8 5.8 0.9 0.8 100.0 1,903 3.3 Chiradzulu 7.1 70.4 6.8 9.7 4.6 1.2 0.4 100.0 913 3.4 Machinga 18.6 64.1 6.8 5.8 2.9 1.7 0.2 100.0 1,343 2.4 Mangochi 24.0 61.3 4.4 5.7 3.6 0.7 0.4 100.0 2,621 1.9 Mulanje 9.2 69.5 6.3 8.0 4.9 1.4 0.7 100.0 1,508 3.0 Mwanza 9.0 68.6 5.9 7.7 6.4 2.2 0.2 100.0 249 3.4 Neno 11.8 65.6 7.0 7.4 5.7 1.7 0.9 100.0 264 3.4 Nsanje 13.5 65.2 6.2 9.1 4.3 1.3 0.4 100.0 840 3.0 Phalombe 10.4 73.4 5.3 5.6 4.0 0.5 0.8 100.0 864 2.6 Thyolo 8.5 69.2 6.9 7.7 5.4 1.7 0.7 100.0 1,835 3.2 Zomba 9.0 65.0 6.8 11.0 5.2 2.6 0.4 100.0 2,196 3.7 Total 12.0 63.3 5.8 9.4 6.6 2.3 0.5 100.0 19,279 3.3 Total 11.4 64.7 6.5 9.1 6.1 1.8 0.4 100.0 43,668 3.5 Note: Total includes 21 unweighted cases with information missing on educational attainment. 1 Completed 8th grade at the primary level 2 Completed 4th grade at the secondary level Appendix A | 275 Table A-2.4 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population, by sex and level of schooling; and the gender parity index (GPI), according to district of residence, Malawi 2010 District of residence Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Northern Chitipa 96.9 96.4 96.6 1.0 170.7 171.2 171.0 1.0 Karonga 96.3 96.5 96.4 1.0 172.0 149.5 160.2 0.9 Mzimba 97.1 97.1 97.1 1.0 173.4 159.2 166.6 0.9 Nkhata Bay and Likoma 95.1 95.3 95.2 1.0 161.7 155.5 158.6 1.0 Rumphi 96.4 97.9 97.1 1.0 168.6 160.6 164.5 1.0 Total 96.6 96.8 96.7 1.0 170.8 158.3 164.7 0.9 Central Dedza 81.9 83.7 82.9 1.0 146.4 136.4 141.1 0.9 Dowa 90.3 94.1 92.1 1.0 153.8 162.5 157.9 1.1 Kasungu 95.3 96.9 96.1 1.0 162.7 164.9 163.8 1.0 Lilongwe 86.0 88.5 87.3 1.0 149.7 134.2 141.6 0.9 Mchinji 94.1 95.6 94.9 1.0 160.8 158.8 159.8 1.0 Nkhotakota 89.7 89.7 89.7 1.0 156.2 148.3 152.4 0.9 Ntcheu 92.8 91.1 92.0 1.0 159.3 145.8 152.6 0.9 Ntchisi 88.9 93.2 91.3 1.0 170.0 145.6 156.5 0.9 Salima 84.6 90.9 87.7 1.1 144.9 146.5 145.7 1.0 Total 88.8 90.6 89.7 1.0 154.1 146.3 150.1 0.9 Southern Balaka 89.2 93.6 91.4 1.0 151.9 155.9 153.9 1.0 Blantyre 96.3 96.4 96.3 1.0 155.2 153.8 154.5 1.0 Chikhwawa 82.3 86.4 84.3 1.0 156.6 141.1 148.8 0.9 Chiradzulu 95.0 96.1 95.6 1.0 167.4 163.2 165.3 1.0 Machinga 87.4 90.2 88.9 1.0 140.2 138.3 139.2 1.0 Mangochi 78.9 77.9 78.4 1.0 131.9 119.7 125.6 0.9 Mulanje 90.7 97.0 93.8 1.1 159.4 166.5 162.9 1.0 Mwanza 93.6 94.9 94.3 1.0 167.5 162.3 164.8 1.0 Neno 88.2 89.6 88.9 1.0 157.7 138.6 148.5 0.9 Nsanje 87.0 85.7 86.3 1.0 165.8 139.2 153.0 0.8 Phalombe 89.4 96.0 92.7 1.1 153.0 153.8 153.4 1.0 Thyolo 93.3 94.8 94.0 1.0 159.9 150.9 155.5 0.9 Zomba 92.4 95.3 93.9 1.0 171.7 152.5 161.4 0.9 Total 89.1 91.0 90.0 1.0 154.0 146.3 150.1 0.9 Total 89.9 91.5 90.7 1.0 156.1 147.8 151.9 0.9 Continued. 276 | Appendix A Table A-2.4—Continued District of residence Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender parity index3 SECONDARY SCHOOL Northern Chitipa 10.2 11.2 10.7 1.1 29.9 13.8 21.8 0.5 Karonga 14.6 16.5 15.5 1.1 28.6 23.1 25.8 0.8 Mzimba 12.0 15.9 13.9 1.3 21.5 19.0 20.3 0.9 Nkhata Bay and Likoma 15.9 16.6 16.3 1.0 30.3 22.9 26.7 0.8 Rumphi 17.6 25.5 21.5 1.4 29.1 30.2 29.7 1.0 Total 13.3 16.6 15.0 1.2 25.4 20.9 23.2 0.8 Central Dedza 4.5 4.2 4.3 0.9 7.7 4.6 6.1 0.6 Dowa 10.1 12.8 11.4 1.3 24.3 17.5 21.0 0.7 Kasungu 10.6 10.8 10.7 1.0 20.3 15.1 17.8 0.7 Lilongwe 9.8 14.6 12.1 1.5 19.6 19.3 19.5 1.0 Mchinji 8.5 8.3 8.4 1.0 19.3 15.7 17.5 0.8 Nkhotakota 8.3 9.4 8.8 1.1 20.4 14.1 17.4 0.7 Ntcheu 10.8 9.9 10.4 0.9 19.4 13.3 16.6 0.7 Ntchisi 6.0 8.9 7.4 1.5 14.9 12.8 13.9 0.9 Salima 6.8 8.8 7.8 1.3 20.7 11.5 16.1 0.6 Total 8.8 10.4 9.6 1.2 18.5 14.3 16.4 0.8 Southern Balaka 10.7 12.7 11.7 1.2 19.8 16.1 17.9 0.8 Blantyre 33.8 27.9 31.0 0.8 51.2 37.7 44.7 0.7 Chikhwawa 12.1 10.3 11.3 0.9 16.2 14.7 15.5 0.9 Chiradzulu 13.3 10.2 11.8 0.8 26.0 15.1 20.6 0.6 Machinga 10.2