Malawi - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

Malawi Monitoring the situation of children and women National Statistical Offi ce United Nations Children’s Fund M alaw i 2006 M ultiple Indicator C luster S urvey Malawi Multiple Indicator Cluster Survey 2006 MULTIPLE INDICATOR CLUSTER SURVEY 2006 MALAWI National Statistical Office United Nations Children’s Fund June 2008 The Malawi Multiple Indicator Cluster Survey (MICS) was carried out by the National Statistical Office (NSO) in collaboration with the United Nations Children’s Fund (UNICEF). The survey has been conducted as part of the third round of MICS surveys (MICS 3), carried out around the world in more than 50 countries, in 2005–2006, following the first two rounds of MICS surveys that were conducted in 1995 and 2000. Survey tools are based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: National Statistical Office and UNICEF. 2008. Malawi Multiple Indicator Cluster Survey 2006, Final Report. Lilongwe, Malawi: National Statistical Office and UNICEF. For more information please write to: Demography & Social Statistics (DSS) Division National Statistical Office (NSO) P.O. Box 333, Zomba, Malawi Ph: 265-1-524 377, 265-1-524 111 Fax: 265-1-525 130 e-mail: enquiries@statistics.gov.mw website: www.nso.malawi.net Planning, Monitoring & Evaluation (PME) Unit UNICEF, P.O. Box 30375, Lilongwe 3, Malawi Ph: 265-1-770 788, 265-1-770 770 Fax: 265-1-773 162 e-mail: lilongwe@unicef.org website: www.unicef.org June 2008 Acknowledgements: Technical and financial support for MICS activity was provided by UNICEF. NSO would also like to acknowledge the financial contribution from the Save the Children Fund (SCF). CONTENTS n TABLES, FIGURES AND MAPS. i n FOREWORD. vii n SUMMARY TABLE OF FINDINGS. ix n EXECUTIVE SUMMARY. xi n MAP OF MALAWI. xvi n CHAPTER 1 INTRODUCTION. 1 1.1 Background. 1 1.2 Survey Objectives. 2 n CHAPTER 2 SAMPLE AND SURVEY METHODOLOGY. 5 2.1 Sample Size. 5 2.2 Sample Design. 5 2.3 Questionnaires. 5 2.4 Fieldwork and Data Processing . 7 n CHAPTER 3 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS. 9 3.1 Sample Coverage. 9 3.2 Household Characteristics. 10 3.3 Characteristics of Household Members . 14 n CHAPTER 4 FERTILITY. 23 4.1 Current Fertility Levels . 23 4.2 Fertility Differentials . 23 4.3 Trends in Age-Specific Fertility Rates. 27 4.4 Children Ever Born and Children Living . 27 4.5 Birth Interval. 29 4.6 Age of Mother at First Birth. 32 4.7 Median Age at First Birth. 33 4.8 Teenage Pregnancy and Motherhood. 33 n CHAPTER 5 CHILD MORTALITY. 37 5.1 Methodological Issues. 37 5.2 Levels and Trends of Early Childhood Mortality. 38 5.3 Socio-Economic and Demographic Differentials in Childhood Mortality. 39 n CHAPTER 6 NUTRITION. 45 6.1 Nutrition Status of Children . 45 6.2 Breastfeeding. 50 6.3 Micronutrients. 61 6.4 Low Birth Weight. 74 n CHAPTER 7 CHILD HEALTH. 79 7.1 Immunisation. 79 7.2 Tetanus Toxoid. 86 7.3 Oral Rehydration Treatment. 89 7.4 Care Seeking and Antibiotic Treatment of Pneumonia. 95 7.5 Use of Solid Fuels. 102 7.6 Malaria. 104 n CHAPTER 8 ENVIRONMENT. 117 8.1 Water. 117 8.2 Sanitation. 128 8.3 Hand Washing Practices. 140 n CHAPTER 9 REPRODUCTIVE HEALTH. 145 9.1 Contraception. 145 9.2 Antenatal Care. 151 9.3 Assistance at Delivery. 160 9.4 Postnatal Care. 164 n CHAPTER 10 EDUCATION. 175 10.1 Primary and Secondary Education Participation. 175 10.2 Adult Literacy. 193 n CHAPTER 11 CHILD PROTECTION. 197 11.1 Child Labour. 197 11.2 Early Marriage and Spousal Age Difference. 205 n CHAPTER 12 HIV AND AIDS, SEXUAL BEHAVIOUR AND ORPHANED AND VULNERABLE CHILDREN . 215 12.1 Knowledge of Preventing HIV Transmission. 215 12.2 Misconception About HIV and AIDS. 219 12.3 Comprehensive Knowledge . 222 12.4 Knowledge of Mother-To-Child Transmission. 228 12.5 Stigma and Discrimination. 232 12.6 Knowledge of HIV Testing Facility. 238 12.7 Counseling and Testing Coverage During Antenatal Care. 240 12.8 Sexual Behaviour. 242 12.9 Orphans and Vulnerable Children. 252 n CHAPTER 13 ADULT AND MATERNAL MORTALITY. 265 13.1 Data. 265 13.2 Direct Estimates of Adult Mortality. 266 13.3 Maternal Mortality. 268 n REFERENCES. 273 n APPENDICES. 275 APPENDIx A: SAMPLE DESIgN. 277 APPENDIx B: LIST OF PERSONNEL INVOLVED IN THE SURVEy. 281 APPENDIx C: ESTIMATES OF SAMPLINg ERRORS. 287 APPENDIx D: DATA QUALITy TABLES. 307 APPENDIx E: MICS INDICATORS : NUMERATORS AND DENOMINATORS. 315 APPENDIx F: QUESTIONNAIRES. 321 APPENDIx g: MILLENNIUM DEVELOPMENT gOALS (MDg) INDICATORS. 371 i TABLES, FIGURES AND MAPS n CHAPTER 3 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS. Table 3.1 Results of household and individual interviews. Table 3.2 Household age distribution by sex. Table 3.3 Household composition. Table 3.4 Women’s background characteristics. Table 3.5 Men’s background characteristics. Table 3.6 Children’s background characteristics. Figure 3.1 Age and sex distribution of household population, Malawi, 2006. n CHAPTER 4 FERTILITY. Table 4.1 Current fertility . Table 4.2 Fertility by background characteristics. Table 4.3 Trends in age-specific fertility rates. Table 4.4 Children ever born and living. Table 4.5 Birth intervals. Table 4.6 Age at first birth. Table 4.7 Teenage pregnancy and motherhood. Figure 4.1 Mean number of children ever born and surviving for women aged 15–49, Malawi, 2006. Map 4.1 Total fertility rate, Malawi, 2006. Map 4.2 Teenage pregnancy, Malawi, 2006. n CHAPTER 5 CHILD MORTALITY. Table 5.1 Early childhood mortality rates. Table 5.2 Early childhood mortality rates by socio-economic and demographic characteristics. Table 5.3 Early childhood mortality rates by district. Figure 5.1 Under-5 mortality rates by background characteristics, Malawi, 2006. Figure 5.2 Infant and neonatal mortality by district, Malawi, 2006. Map 5.1 Under-five mortality rate, Malawi, 2006 . 9 9 10 12 15 17 20 11 23 23 24 27 28 30 32 34 29 26 36 37 38 39 43 40 44 41 ii n CHAPTER 6 NUTRITION. Table 6.1 Child malnourishment. Table 6.2 Initial breastfeeding. Table 6.3 Infant feeding patterns by age. Table 6.4 Breastfeeding status. Table 6.5 Adequately fed infants. Table 6.6 Children’s Vitamin A supplementation. Table 6.7 Source of children’s Vitamin A supplementation. Table 6.8 Post-partum mother’s Vitamin A supplementation. Table 6.9 Iodised salt consumption. Table 6.10 Storage place for salt. Table 6.11 Knowledge and source of information regarding iodised salt. Table 6.12 Reason for not using iodised salt in the household. Table 6.13 Low birth weight infants. Figure 6.1 Percentage of under five children undernourished according to age pattern, Malawi, 2006. Figure 6.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Malawi, 2006. Figure 6.3 Infant feeding patterns by age: Percent distribution of children under 3 years by feeding pattern and age group, Malawi, 2006. Figure 6.4 Proportion of children aged below 6 months who were exclusively breastfed by age, Malawi, 2006. Figure 6.5 Percent of households consuming adequately iodised salt (15 + PPM), Malawi, 2006. Figure 6.6 Percentage of infants weighing less than 2500 grams at birth, Malawi, 2006. Map 6.1 Prevalence of underweight (moderate & severe), Malawi, 2006. Map 6.2 Exclusive breastfeeding rate, Malawi, 2006. Map 6.3 Proportion of children 6–59 months who received a high dose of Vitamin A supplement within the last 6 months, Malawi, 2006. n CHAPTER 7 CHILD HEALTH. Table 7.1 Vaccinations in first year of life. Table 7.2 Vaccinations by background characteristics. Table 7.3 Neonatal tetanus protection. Table 7.4 Oral rehydration treatment. Table 7.5 Home management of diarrhoea. Table 7.6 Care seeking for suspected pneumonia. Table 7.7 Antibiotic treatment of pneumonia. Table 7.8 Knowledge of the two danger signs of pneumonia. 45 46 51 54 57 60 63 66 68 70 72 73 74 76 48 53 53 55 71 77 49 56 65 79 80 81 87 90 93 96 98 100 iii Table 7.9 Solid fuel use. Table 7.10 Solid fuel use by type of stove or fire. Table 7.11 Availability of insecticide treated nets. Table 7.12 Children sleeping under bednets. Table 7.13 Treatment of children with anti-malarial drug. Table 7.14 Source of supplies of insecticide treated nets. Figure 7.1 Percentage of children aged 12–23 months who received the recommended vaccinations at any time before the survey, Malawi, 2006. Figure 7.2 Percentage of children aged 12–23 months fully immunised by district, Malawi, 2006. Figure 7.3 Percentage of children aged 0–59 months with diarrhoea who received oral rehydration treatment , Malawi, 2006. Figure 7.4 Percentage of children aged 0–59 months with diarrhoea who received oral rehydration treatment or increased fluids and continued feeding, Malawi, 2006. Figure 7.5 Percentage of mothers/caretakers of children aged 0–59 months who are knowledgeable of the two signs of pneumonia, Malawi, 2006. Figure 7.6 Percentage of households with any bednet and an insecticide treated net (ITN) , Malawi, 2006. Figure 7.7 Percentage of households with any bednet and with an insecticide treated net (ITN) by district, Malawi, 2006. Figure 7.8 Percentage of children below 5 years who had fever in the last two weeks and who were given anti-malarial drug by district, Malawi, 2006. Map 7.1 Proportion of children aged 12–23 months immunised against measles, Malawi, 2006. Map 7.2 Proportion of children under-5 who slept under an insecticide treated net, Malawi, 2006. n CHAPTER 8 ENVIRONMENT. Table 8.1 Use of improved water sources. Table 8.2 Household water treatment. Table 8.3 Time to source of water. Table 8.4 Storage of water in the household. Table 8.5 Person collecting water. Table 8.6 Use of sanitary means of excreta disposal. Table 8.7 Hand washing facility outside the toilet. Table 8.8 Soap in the household. Table 8.9 Disposal of child’s faeces. 102 103 105 108 112 115 80 83 92 95 101 106 107 114 85 110 117 118 121 123 125 127 129 131 133 136 iv Table 8.10 Use of improved water sources and improved sanitation. Table 8.11 Use of soap by women for different activities. Table 8.12 Use of soap by women for all key hygiene practices. Figure 8.1 Percentage distribution of household members by source of drinking water, Malawi, 2006. Figure 8.2 Percentage distribution of household population by type of water storage, Malawi, 2006. Figure 8.3 Percentage distribution of household population by type of toilet use, Malawi, 2006. Figure 8.4 Percentage of households population using improved sources of drinking water and using sanitary means of excreta disposal (excluding pit latrines), Malawi, 2006. Map 8.1 Proportion of households not having soap/washing powder or liquid, Malawi, 2006. n CHAPTER 9 REPRODUCTIVE HEALTH. Table 9.1 Use of contraception - Women. Table 9.2 Use of contraception - Men. Table 9.3 Antenatal care provider. Table 9.4 Antenatal care content. Table 9.5 Women sleeping under bednets. Table 9.6 Intermittent preventive treatment for malaria. Table 9.7 Assistance during delivery. Table 9.8 Timing of postnatal care to mothers. Table 9.9 Person providing postnatal care to mothers. Table 9.10 Timing of postnatal check-up to children born at home. Table 9.11 Person providing postnatal check-up to children born at home. Table 9.12 Place of postnatal check-up to children born at home. Figure 9.1 Percentage of women aged 15–49 currently married or in union by contraceptive method used, Malawi, 2006. Figure 9.2 Percentage of women aged 15–49 currently married or in union by type of contraceptive method used, Malawi, 2006. Figure 9.3 Antenatal care content, Malawi, 2006. Map 9.1 Proportion of births attended by skilled health personnel, Malawi, 2006. 138 141 143 120 126 130 139 135 145 146 149 152 155 157 159 161 165 167 169 171 173 148 148 154 163 v n CHAPTER 10 EDUCATION. Table 10.1 Primary school entry. Table 10.2 Primary school (6–13 years) attendance ratios. Table 10.3 Secondary school (14–17 years) attendance ratios. Table 10.4 Secondary school age (14–17 years) children attending primary school. Table 10.5 Children reaching grade 5 and grade 8. Table 10.6 Primary school completion and transition to secondary education. Table 10.7 Education gender parity. Table 10.8 Adult literacy. Figure 10.1 Primary school net attendance ratio, Malawi, 2006. Figure 10.2 Secondary school net attendance ratio, Malawi, 2006. Figure 10.3 Adult literacy, Malawi, 2006. Map 10.1 Proportion of children of primary school entry age attending grade 1 and grade 8, Malawi, 2006. Map 10.2 Adult literacy - Women, Malawi, 2006. n CHAPTER 11 CHILD PROTECTION. Table 11.1 Child labour. Table 11.2 Labourer students and student labourers. Table 11.3 Early marriage. Table 11.4 Spousal age difference - Women. Figure 11.1 Child labour, Malawi, 2006. Figure 11.2 Percentage of women and men aged 15–49 married or in union before their 18th birthday, Malawi, 2006. Figure 11.3 Spousal age difference of women aged 20–24, Malawi, 2006. Map 11.1 Proportion of children 5–14 years performing child labour, Malawi, 2006. Map 11.2 Percentage of women 15–19 currently married/in union, Malawi, 2006. n CHAPTER 12 HIV AND AIDS, SEXUAL BEHAVIOUR AND ORPHANED AND VULNERABLE CHILDREN . Table 12.1 Knowledge of preventing HIV transmission – Women. Table 12.2 Knowledge of preventing HIV transmission – Men. Table 12.3 Identifying misconceptions about HIV & AIDS – Women. Table 12.4 Identifying misconceptions about HIV & AIDS – Men. Table 12.5 Comprehensive knowledge of HIV & AIDS transmission – Women. 175 176 178 181 183 186 189 191 194 180 182 193 177 196 197 198 203 207 211 201 210 212 200 209 215 216 218 220 222 224 vi Table 12.6 Comprehensive knowledge of HIV & AIDS transmission – Men. Table 12.7 Knowledge of mother-to-child HIV transmission – Women. Table 12.8 Knowledge of mother-to-child HIV transmission – Men. Table 12.9 Attitudes toward people living with HIV & AIDS – Women. Table 12.10 Attitudes toward people living with HIV & AIDS – Men. Table 12.11 Knowledge of a facility for HIV testing – Women. Table 12.12 Knowledge of a facility for HIV testing – Men. Table 12.13 HIV testing and counseling coverage during antenatal care . Table 12.14 Sexual behaviour that increases risk of HIV infection – Women. Table 12.15 Sexual behaviour that increases risk of HIV infection – Men. Table 12.16 Condom use at last high-risk sex – Women. Table 12.17 Condom use at last high-risk sex – Men. Table 12.18 Prevalence of orphanhood and vulnerability among children. Table 12.19 Children’s living arrangements. Table 12.20 School attendance of orphaned and vulnerable children. Table 12.21 Support for children orphaned and vulnerable due to AIDS. Table 12.22 Malnutrition among orphaned and vulnerable children. Table 12.23 Sexual behaviour among young women by orphanhood and vulnerability status. Figure 12.1 Sexual behaviour that increases risk of HIV infection – Women, Malawi, 2006. Map 12.1 Proportion of women aged 15–49 years who have comprehensive knowledge of HIV and AIDS, Malawi, 2006 (identify 2 prevention methods and 3 misconceptions) . Map 12.2 Proportion of children aged 0–17 years who are orphaned and/or vulnerable, Malawi, 2006. n CHAPTER 13 ADULT AND MATERNAL MORTALITY. Table 13.1 Completeness of reported data on siblings. Table 13.2 Adult mortality rates. Table 13.3 Maternal mortality. Figure 13.1 Age-specific mortality rates, Malawi, 2006. Figure 13.2 Maternal mortality ratio, Malawi, 2006. 227 229 231 233 235 237 239 241 243 246 248 250 253 257 259 261 263 263 244 226 255 265 266 266 270 267 268 vii The 2006 Multiple Indicator Cluster Survey (MICS) is the largest nationally representative sample survey conducted by the National Statistical Office (NSO). It covered a total of 31,200 households (1,200 households per district) . The primary objective of the 2006 MICS was to provide up to date estimates at district level for policymakers, planners, researchers, and programme managers for monitoring the situation of children and women on a number of social development indicators related to the Malawi Growth and Development Strategy (MGDS), the Millennium Development Goals (MDGs) and the goals of A World Fit for Children (WFFC). Information on more than 20 of the 48 MDG indicators has been collected in MICS, offering the largest single source of data for MDG monitoring coming from a sample survey. Specifically, the 2006 MICS collected information on fertility, child mortality, nutrition, child health, environment, reproductive health, education, child protection, HIV and AIDS and orphans and maternal mortality. The 2006 MICS results indicate evidence of a decline in infant and child mortality levels and increase in the use of family planning methods compared to the earlier household surveys. I wish to acknowledge the efforts of a number of organisations and individuals who contributed immensely towards the success of the survey. First I would like to acknowledge the technical and financial assistance from the United Nations Children’s Fund (UNICEF). Acknowledgements are also due to the Save the Children Fund for partially funding the survey. The hard work and dedication of the staff of the NSO and the staff of the UNICEF should also be acknowledged for making the survey results available. Last but not least, I am grateful to the survey respondents who generously gave their time to provide the information that forms the basis of this report. Charles Machinjili Commissioner of Statistics FOREWORD viii ix SUMMARY TABLE FINDINGS TOPIC MDG NO. INDICATOR VALUE UNIT Fertility Total fertility rate 6.3 Per woman Crude birth rate 44 Per 1,000 population Teenage pregnancy 35 Percent Child mortality Neonatal mortality rate 33 Per 1,000 live births 13 Infant mortality rate 72 Per 1,000 live births 14 Under-five mortality rate 122 Per 1,000 live births Nutrition Stunting prevalence 46 Percent Wasting prevalence 4 Percent 4 Underweight prevalence 21 Percent Exclusive breastfeeding rate (0–3 months) 72 Percent Exclusive breastfeeding rate (6 months) 57 Percent Timely complementary feeding rate (6–9 months) 89 Percent Continued breastfeeding rate (12–15 months) 97 Percent Continued breastfeeding rate (20–23 months) 72 Percent Vitamin A supplementation (Under-5s) 69 Percent Iodised salt (15 + PPM) consumption 50 Percent Low birth weight 14 Percent Child health Tuberculosis immunisation coverage 96 Percent DPT 3 immunisation coverage 86 Percent Polio 3 immunisation coverage 81 Percent 15 Measles immunisation coverage 84 Percent Fully immunisation coverage 70 Percent Antibiotic treatment of suspected pneumonia 30 Percent Incidence of diarrhoea (Under-5s) 24 Percent Use of oral rehydration treatment (ORT) 55 Percent 29 Solid fuel use 99 Percent 22 HHs with at least one bednet 51 Percent HHs with at least one insecticide-treated net (ITN) 38 Percent Under-fives sleeping under bednets 31 Percent Under-fives sleeping under insecticide-treated nets (ITN) 25 Percent Children under-5 with fever given anti-malarials 25 Percent Environment 30 Use of improved drinking water sources 75 Percent 31 Use of improved sanitation facilities (including pit latrine) 88 Percent Use of improved sanitation facilities (excluding pit latrine) 20 Percent Households with soap/washing powder or liquid 67 Percent x TOPIC MDG NO. INDICATOR VALUE UNIT Reproductive health 19c Contraceptive prevalence rate 41 Percent 19 Condom use rate of contraceptive prevalence rate 2 Percent Antenatal care (one or more times) 97 Percent Protected against tetanus 89 Percent Iron supplementation 81 Percent Received Vitamin A supplement 46 Percent Sleeping under a bednet 32 Percent Sleeping under an ITN 26 Percent Received 2 doses of SP or Fansidar 47 Percent Tested for HIV during ANC visit 27 Percent 17 Skilled attendant at delivery 54 Percent Institutional deliveries 54 Percent Postnatal check-up within 6 weeks - Mother 33 Percent Postnatal check-up within 6 weeks - Child (Born at home) 25 Percent 16 Maternal Mortality Ratio 807 Per 100,000 live births Education Net intake rate in primary schools 67 Percent 6 Net primary school attendance rate 86 Percent Net secondary school attendance rate 13 Percent 7 Children reaching grade 5 86 Percent Children reaching grade 8 71 Percent Transition rate to secondary school 40 Percent 7b Primary school completion rate 9 Percent 9 gender Parity Index (Primary/Secondary) 0.92/0.78 Ratio 8 Adult literacy rate 69 Percent Child protection Child labour 26 Percent Marriage before age 15 and age 18 (for women) 10/50 Percent young women 15–19 currently married or in union 33 Percent HIV and AIDS & orphanhood 19b Comprehensive knowledge about HIV prevention (15–24 women/men) 41/42 Percent 19a Condom use at last high-risk sex (15–24 women/men) 40/58 Percent Children not living with a biological parent 18 Percent Prevalence of orphans 12 Percent Prevalence of single orphans 9 Percent Prevalence of double orphans 3 Percent 20 School attendance of orphans versus non-orphans 0.97 Ratio xi The Malawi Multiple Indicator Cluster (MICS) 2006 survey is a nationally representative survey of children, women and men. A total of 22,994 children under the age of five, 26,259 women aged 15–49, and 7,636 men aged 15–49 were interviewed in 26 districts of Malawi. With 30,553 households interviewed in the survey, MICS 2006 is one of the largest household surveys undertaken in the country. MICS 2006 is a major achievement for Malawi. For the first time in the country’s history, key indicators on the situation of children and women at sub-national level have been captured, making the survey an indispensable planning and monitoring and evaluation tool for policy makers, programme planners and development partners. MICS 2006 has also been able to canvass nearly 20 out of 48 Millennium Development Goals (MDGs) indicators and will be used to help the Government of Malawi track progress towards the achievement of the MDGs. The survey used a two-stage sampling methodology and included four questionnaires: household, children under five, women and men aged 15–49. The survey was designed to produce indicators for national, regional and district levels as well as by background characteristics of respondents. Twenty six teams carried out fieldwork between mid-July to mid–November 2006. Data entry started in August and completed by the end of December 2006. MICS 2006 was implemented by the National Statistical Office of Malawi, with technical and financial support from UNICEF. Below is a summary of the findings. FERTILITY Total Fertility Rate (TFR) in Malawi for 1-year preceding the survey is 6.3. That means a woman • in Malawi will have on average 6.3 children during her reproductive years. TFR in rural areas is 6.6 whereas in urban areas it is 4.5. Crude Birth Rate (CBR) is reported at 43.9 - urban with 40.2 and rural 44.5 per 1,000 • population. The median age at first birth is 20 years for women in all age groups.• Women in Malawi space their births on average every 2 years although the length of birth • intervals increases as the mother gets older. Teenage pregnancy is reported at 35 percent. Eight percent of teenagers are pregnant with their • first child and 27 percent have had a live birth. CHILD MORTALITY The infant mortality rate is estimated at 72 per 1,000 live births, while the under-five mortality • is 122 per 1,000 live births estimates for 5 years preceding the survey. Neonatal mortality rate stands at 33 per 1,000 live births.• NUTRITIONAL STATUS More than one in five children under the age of 5 in Malawi are underweight (21 percent), more • than two in five children under 5 are stunted (46 percent) and 4 percent of children in the same age group are wasted. Close to 4 percent children under the age of 5 are severely underweight, 21 percent are severely • stunted and 1 percent severely wasted. In Malawi, 6 percent of children under 5 are overweight.• EXECUTIVE SUMMARY xii BREASTFEEDING A high proportion of children (94 percent) are reported to be put to the breast within 24 hours • of birth while only 58 percent are breastfed within the recommended one-hour after birth. Exclusive breastfeeding is not fully practiced in Malawi. Among children under 6 months of • age, only 57 percent are exclusively breastfed. Eighty-nine percent of children aged 6–9 months are receiving breast milk and some solid or • semi-solid foods. By age 12–15 months, 97 percent of children continue to be breastfed. A significant proportion • of the children are completely weaned off the breast by age 20–23 months, with only 72 percent still being breastfed in combination with solid and semi-solid foods. MICRONUTRIENTS Sixty-nine percent of children aged 6–59 received a Vitamin A supplement within the last 6 • months preceding the survey. Only 46 percent of women aged 15–49 years are given Vitamin A within the recommended • eight weeks of the postnatal period. Fifty percent of households in Malawi are using adequately iodised salt (15 + PPM). • BIRTH WEIGHT Only 48 percent of children are weighed at birth.• An estimated 14 percent of babies in Malawi are born with low birth weight (Weighed less than • 2,500 grams at birth). IMMUNISATION The percentage of children 12–23 months who received all the recommended vaccinations • stands at 70 percent which means that they have received 1 dose of BCG, 3 doses of DPT- HepB+Hib (Pentavalent), 3 doses of Polio and 1 dose of measles before reaching one year. Approximately 96 percent of children aged 12–23 months receive a BCG vaccination, 86 percent • of children in the same group get a third dose of pentavalent, and 81 percent of children receive their third dose of polio. Coverage for measles is lower than for other vaccines at 84 percent. In Malawi, 89 percent of pregnant women are protected against tetanus.• DIARRHOEA AND ORAL REHYDRATION TREATMENT Overall, 24 percent of children under 5 have had a bout of diarrhoea in the two weeks preceding • the MICS survey. This implies an average rate of 6 diarrhoea episodes per child per year. The peak of diarrhoea prevalence tends to occur in the weaning period, when children are • between 6 and 23 months of age. Of the children receiving treatment for diarrhoea, oral rehydration treatment (ORT) use rate • is 55 percent. Fifty-one percent receive fluids from packets of oral rehydration salts (ORS), 12 percent receive pre-mixed ORS fluids and one percent gets recommended homemade fluids. PNEUMONIA Nine percent of children under 5 were found to have suspected pneumonia, a leading cause of • death in children. Of children with symptoms of pneumonia, 52 percent are taken to an appropriate provider • such as a government health centre. In Malawi, only a third of children under 5 with suspected pneumonia receive antibiotic • treatment. xiii USE OF SOLID FUELS There is almost universal use of solid fuels for cooking in Malawi, at 99 percent.• The most common type of solid fuel use is an open stove or fire with no chimney or hood. • This has implications for the health of women and children as stoves or fires without a smoke extractor do not protect people from indoor air pollution. MALARIA Overall, 51 percent of households own at least one mosquito net, while 38 percent have at least • one insecticide-treated net (ITN). Only 31 percent of children under 5 sleep under a mosquito net and 25 percent sleep under an • ITN. Thirty-five percent of children under 5 become ill with fever and 25 percent of children with • fever are treated with an anti-malarial drug. Around 21 percent of children with fever are treated with an appropriate anti-malarial drug within 24 hours of the onset of symptoms. The most common appropriate treatment given is SP/Fansidar while a larger percentage of • children with fever (49 percent) are given other types of medicine that are not anti-malarials such as paracetamol. Among women who gave birth in the two years preceding the survey, 32 percent slept under • a bed net and 26 percent slept under an ITN. WATER In Malawi, 75 percent of the population uses an improved source of drinking water such as • piped water, a public tap, a borehole, protected wells and springs, and rainwater collection. Only 19 percent of households treat water using an appropriate treatment method. The most • common way of treating water in Malawi is boiling, followed by the use of bleach or chlorine and straining water through a cloth. Only six percent of households have a source of water located on the premises. Nearly 46 • percent of households take 30 minutes or more to get to a water source. Ninety-one percent of the population in Malawi stores drinking water in a covered container.• SANITATION Overall, 88 percent of people in Malawi live in households that use improved sanitation • facilities such as a piped sewer system, septic tanks, latrines and pit latrines. Seventy-nine percent of people have a hand-washing facility outside the toilet while 73 percent • of households have soap or washing powder/liquid. Seventy-eight percent of young children’s faeces (aged 0–2) are disposed of safely, either rinsed • into a toilet or a latrine or disposed of by the children themselves when they go to the toilet. Use of soap by women aged 15–49 for all four key hygiene practices – after defecation, after • cleaning a child, before feeding a child and before preparing food – is negligible. CONTRACEPTION In Malawi, 41 percent of married women or those in union report use of a contraceptive • method. Thirty-eight percent of women report the use of modern contraception, with injectables being • the most popular method, followed by female sterilisation, the contraceptive pill and male condoms. Hardly any use of male sterilisation is reported.• xiv ANTENATAL AND POSTNATAL CARE Among women aged 15–49 who gave birth in the two years preceding the survey, 97 percent • received at least one antenatal care visit and 92 percent were attended by a skilled personnel during antenatal care. However, only 7 percent of antenatal care providers are doctors and clinical officers, while 84 percent received care from nurses and midwives. Among women aged 15–49 who gave birth in the two years preceding the survey, 85 percent • were given at least one TT injection; 81 percent received iron tablets; blood pressure was measured for 75 percent; blood sample taken for 37 percent; urine specimen taken for 16 percent and weight measured for 93 percent of pregnant women. Eighty-three percent of pregnant women in Malawi take an anti-malarial drug for prevention • of malaria during pregnancy. However, only 47 percent of these women received two or more doses of SP/Fansidar. Overall, 54 percent of births are assisted by a skilled personnel and the same proportion are • delivered in a health facility. Among those births assisted by skilled personnel, 6 percent were assisted by a doctor, 47 percent by a nurse or midwife and the rest by traditional birth attendants, community health workers, friends and family. Only 33 percent of women receive postnatal care while only a quarter of children receive a • health check-up within 6 weeks of birth. EDUCATION Only 67 percent of children of primary school entry age are currently attending grade 1.• The primary school Gross Attendance Ratio (GAR) is 111 and the primary school Net Attendance • Ratio (NAR) is 86. The Gender Parity Index (GPI) for primary school is 0.92. Eighty-six percent of children entering 1st grade of primary school are eventually reaching • grade 5 and 71 percent grade 8. Though 40 percent of primary school children are eventually reaching secondary education, • the net primary school completion rate is only 9 percent. Forty-nine percent of children of secondary school age (14–17) are currently attending primary • school. The secondary school Gross Attendance Ratio (GAR) is 26 and the secondary school Net • Attendance Ratio (NAR) is 13. The Gender Parity Index (GPI) for secondary school is 0.78. Overall, 69 percent of adults in Malawi are literate; 77 percent of men compared to 67 percent • of women. CHILD LABOUR In Malawi, 26 percent of children aged 5–14 are involved in child labour.• Fifteen percent of children are involved in family business and 5 percent in household chores. • Eight percent of children do unpaid work and 3 percent are engaged in paid work. Eighty-six percent of child labourers are able to attend school (Labourer students). Twenty-• eight percent of students are also involved in child labour (Student labourers). EARLY MARRIAGE In Malawi, 10 percent of women aged 15–49 marry before the age of 15 and 50 percent of • women aged 20–49 marry before the age of 18. One in every three female teenagers is either married or in union.• Early marriage is less common for men than it is for women. Only 1 percent of men marry • before they reach 15 and 7 percent of men in the 20–49 age group marry before age 18. xv HIV & AIDS Overall, 97 percent of women and almost all men in Malawi have heard of HIV & AIDS.• However, only 55 percent of women and men know all three means of preventing HIV infection • – having one faithful uninfected partner, using a condom every time and abstaining from sex. Ninety-one percent of women and 95 percent of men know that HIV can be transmitted from • mother to child. However, only 65 percent of women and 62 percent of men know all the three modes of mother-to-child transmission – during pregnancy, at delivery and through breast milk. Nearly 80 percent of women and 56 percent of men show a discriminatory attitude towards • people living with HIV. Eighty-seven percent of women know a facility for HIV testing and 25 percent have been tested. • Around 92 percent of men know where to go for testing and 26 percent have been tested. Of the women who attended antenatal care for their last pregnancy, 63 percent were provided • with information on HIV, 27 percent were tested for HIV and 24 percent received their results at the visit. SEXUAL BEHAVIOUR Overall, 14 percent of girls aged 15–19 have had sex before age 15 while 65 percent of women • aged 20–24 have had sex before age 18. Around 8 percent of women aged 15–24 have had sex with a man 10 or more years older • during the 12 months preceding the survey. Only 40 percent of women and 58 percent of men use a condom with a non-marital, non-• cohabiting partner. ORPHANS AND VULNERABLE CHILDREN In Malawi, 12 percent of children aged 0–17 are orphaned. • Among orphans, 9 percent are single orphans (lost one parent) and 3 percent are double • orphans (lost both parents). Nearly 7 percent of children aged 0–17 are considered to be vulnerable.• In total, there are about 18 percent orphaned and vulnerable (OVC) children in Malawi. • Eighty-nine percent of children whose mothers or fathers have died attend school compared to • 91 percent of children whose parents are alive and who live with their parents. Orphaned and vulnerable children have higher levels of malnutrition than children who are • not orphaned and vulnerable. The OVC to non-OVC ratio is 1.14 for underweight, 1.10 for stunting and 1.08 for wasting. Support provided to OVC is not sufficient in Malawi. Only 6 percent of OVC households • receive medical support, 4 percent get psychosocial support and 9 percent receive material support. Six percent benefit from educational support. ADULT AND MATERNAL MORTALITY Male adult mortality stands at 7 per 1,000 and the female mortality rate is 9 per 1,000. Mortality • for both men and women peaks in the early 40s. The maternal mortality ratio (MMR) for Malawi is estimated at 807 per 100,000 live births with • confidence interval of (696, 918). MMR for urban areas is 861 and for rural areas 802. Southern Region reported highest MMR of 1029 compared to Central Region (678) and Northern Region (543). xvi Dedza Dowa Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Mulanje Chiradzulu Phalombe Mangochi Ntcheu Balaka Machinga Mwanza Lake Malawi Likoma Lilongwe Northern Region Central Region Southern Region Nkhota kota ZAMBIA TANZANIA MOZAMBIQUE ★ MAP OF MALAWI N INTRODUCTION 1 1.1 BACKGROUND This report is based on the Multiple Indicator Cluster Survey (MICS), conducted in Malawi in 2006 by the National Statistical Office (NSO). The survey was based, in large part, on the needs to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children (WFFC), adopted by 189 Member States at the United Nations General Assembly Special Session (UNGASS) on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see box below). The governments that signed the Millennium Declaration and WFFC and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (WFFC, paragraph 60) “.We will conduct periodic reviews at the national and sub-national levels of progress in order to address obstacles more effectively and accelerate actions.” (WFFC, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “. As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with governments, relevant funds, programmes and the specialised agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “.We request the general Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-general to issue periodic reports for consideration by the general Assembly and as a basis for further action.” A COMMITMENT TO ACTION: NATIONAL AND INTERNATIONAL REPORTING RESPONSIBILITIES 1 INTRODUCTION CHARLES MACHINJILI INTRODUCTION2 The Government of Malawi has been developing and implementing long and medium term strategies that translate national and international goals and objectives into a reality. In 2000, the Government launched the Malawi Vision 2020. This policy framework sets out a long-term development perspective for Malawi. In May 2002, the Government launched a three-year Malawi Poverty Reduction Strategy (MPRS), which presented a first attempt to translate the long-term strategy of Malawi Vision 2020 into medium-term focused action plans. The MPRS was built around four cross cutting issues: HIV and AIDS, gender, environment and science and technology besides the main goal of achieving sustainable poverty reduction through empowerment of the poor. The lessons learnt in the implementation of MPRS have resulted in the development of a comprehensive policy, namely the Malawi Growth and Development Strategy (MGDS), aimed at stimulating economic growth. Malawi remains committed to achieving the Millennium Development Goals (MDGs) localised to the Malawian context. The MDGs and the commitments made to the other international conventions are addressed with specific targets and strategies. Some of the key international conventions for which Malawi is signatory are - WFFC, UNGASS on HIV and AIDS, the Abuja targets on malaria, the Convention on the Rights of the Children (CRC) and Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). A number of national policies and action plans have been prepared and are being implemented to meet the goals set by the international community. MICS 2006 can serve as one of the main monitoring tools for national and global development goals by providing the necessary data at national, regional and district levels. The information gathered in MICS 2006 can serve as a baseline for new initiatives and assess the success of ongoing programmes. MICS 2006 also strengthens the monitoring and evaluation component of the new United Nations Development Assistance Framework (UNDAF) 2008–2011 by providing the latest data on a number of key indicators related to the Government of Malawi/UN programme of cooperation. This report presents the full set of results on the topics covered in the survey1. The results in this report are final. Since MICS 2006 aims at providing statistically significant results at district level for the effective monitoring of development programmes in the district, it is envisaged to publish and disseminate separate district level reports for all the districts of the country during 2008. 1.2 SURVEY OBJECTIVES Despite the existence of a number of data sources, one of the challenges faced by policy makers and programme managers in Malawi is the lack of sub-national data. Many national and international agencies are interested in identifying districts with poor socio-economic indicators for intensive intervention but present data sources are unable to meet this demand. They either provide district level data for a selected number of districts, such as the Malawi Demographic and Health Survey, or calculate district estimates based on small sample sizes as in the Integrated Household Survey. In light of the decentralisation of governance and initiation of the MGDS, statistically significant 1 For more information on the definitions, numerators, denominators and algorithms of multiple indicator cluster surveys and MDG indicators covered in the survey: see chapter 1, appendix 1 and appendix 7 of the Multiple Indicator Cluster Survey Manual 2005: Monitoring the Situation of Children and Women, also available at www.childinfo.org. INTRODUCTION 3 district level estimates are warranted for a number of socio-economic indicators for planning sub- national interventions by District Assemblies and to provide a baseline to measure progress of these interventions over time. A number of new intervention programmes have been implemented by the Government in the recent past, which will have an impact on indicators and are expected to change over a short period of time. These include immunisation coverage, malaria prevention methods, access to water and sanitation and knowledge on HIV and AIDS. The latest data on these indicators will help programme managers to better plan and monitor development activities. The primary objectives of Malawi MICS are to: n Provide up-to-date information at the district level for assessing the situation of children and women in Malawi; n Support the monitoring of MGDS indicators; n Furnish data needed for monitoring progress toward goals established by the MDGs, WFFC goals and other internationally agreed upon goals, as a basis for future action; n Contribute to the improvement of data and monitoring systems in Malawi and to strengthen technical expertise in the design, implementation, and analysis of such systems. INTRODUCTION4 SAMPLE & SURVEY METHODOLOGY 5 2 SAMPLE AND SURVEY METHODOLOGY 2.1. SAMPLE SIZE Since the objective of the MICS 2006 is to obtain estimates at district level on the key indicators related to the well being of children and women, it is estimated that a sample size of 1,200 households (HHs) is required per district to obtain statistically valid estimates at 95 percent confidence interval for majority of the indicators. Each district was considered as a sampling domain and an equal allocation of 1,200 households was used. Presently there are 28 districts in Malawi; however, 26 districts were included in the survey and two districts (namely Likoma and Neno) were merged with other districts for the following reasons: The district of Likoma is too small an island to draw 1,200 households out of the total available households. Therefore, the population of Likoma was merged with Nkhata Bay district and the few selected clusters that have fallen in Likoma island have been canvassed. In the Southern Region, Neno district was part of Mwanza district as per the census frame used for sample selection. Therefore, Neno was not considered as a separate district, but rather was merged with Mwanza. 2.2. SAMPLE DESIGN A two-stage sampling methodology was adopted in MICS 2006 to select the 1,200 households. Within each district, 40 census enumeration areas (clusters) were selected with probability proportional to size. A household listing was carried out within the cluster and a systematic sample of 30 households was drawn to obtain 1,200 households per district. For reporting results at the regional and national levels, sample weights were used. A total of 31,200 HHs (26 districts x 1200 HHs) were selected in 1,040 clusters (26 districts x 40 clusters). All the selected 1,040 clusters were covered during the fieldwork period. MICS 2006 is thus one of the largest household surveys undertaken in Malawi. 2.3. QUESTIONNAIRES Four questionnaires were used in the survey. In addition to a household questionnaire that was used to collect information on all household members, the household, and the dwelling, questionnaires were administered in each household to women aged 15–49. Mothers or caretakers of children under the age of five1 were identified in each household, and these individuals were interviewed about the children. Questionnaires were also administered to men aged 15–49 years in every third household selected for the survey. 1 The terms “children under the age of five”, “children age 0–4 years”, and “children aged 0–59 months” are used interchangeably in this report. MERCY KANYUKA SAMPLE & SURVEY METHODOLOGY6 The Household Questionnaire included the following modules: n Household Listing n Education n Water and Sanitation n Household Characteristics n Insecticide Treated Nets n Orphanhood n Child Labour n Salt Iodisation The Questionnaire for Children under Five was administered to mothers or caretakers of children under five living in the households. In cases where the mother was not listed in the household roster, a primary caregiver was identified and interviewed. The questionnaire included the following modules: n Vitamin A n Breastfeeding n Care of Illness n Malaria n Immunisation n Anthropometry The Questionnaire for Individual Women was administered to all women aged 15–49 years living in the households, and included the following modules: n Child Mortality n Birth History n Tetanus Toxoid n Maternal and Newborn Health n Marriage/Union n Contraception n Sexual Behaviour n HIV and AIDS n Maternal Mortality The Questionnaire for Individual Men was administered to men aged 15–49 in every third household selected for the survey and included the following modules: n Marriage/Union n Contraception n Sexual Behaviour n HIV and AIDS SAMPLE & SURVEY METHODOLOGY 7 The questionnaires are based on the global MICS 3 model questionnaire. For this survey, the global questionnaires were customised for Malawi’s needs, translated into Chichewa and Tumbuka and were pre-tested during the month of June 2006. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. 2.4. FIELDWORK AND DATA PROCESSING The field staff were trained for 15 working days (three weeks) during June/July 2006. Twenty-six teams collected the data; each team comprised of four interviewers, one editor/measurer, one supervisor and a driver. The interviewers and editors were selected from the districts but the supervisors were NSO core staff. Fieldwork took four months from mid-July to mid-November 2006 and included a house listing operation, sample selection, interviewing the respondents and taking anthropometry measurements for children. Data were entered on 20 microcomputers using the CSPro software. To ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS 3 project were adapted to the Malawi questionnaire and used throughout. Data entry began simultaneously in August 2006 and completed by the end of December 2006. Data were analysed using the SPSS software program and the model syntax and tabulation plans developed for this purpose. SAMPLE & SURVEY METHODOLOGY8 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 9 3 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 3.1. SAMPLE COVERAGE The 2006 MICS was designed to provide estimates of key indicators related to the well-being of children and women at national, regional and district levels. Table 3.1 Results of household and individual interviews Numbers of households, women, children under 5 and men by results of the household, women’s, under-five’s and men’s interviews, and household, women’s, under-five’s and men’s response rates, Malawi, 2006 Result Residence Region Total Urban Rural Northern Central Southern Sampled households 3,489 27,711 6,000 10,800 14,400 31,200 Occupied households 3,489 27,711 6,000 10,800 14,400 31,200 Interviewed households 3,409 27,144 5,871 10,551 14,131 30,553 Household response rate 97.7 98.0 97.9 97.7 98.1 97.9 Eligible women 3,620 23,453 5,430 9,766 11,877 27,073 Interviewed women 3,526 22,733 5,301 9,368 11,590 26,259 Women response rate 97.4 96.9 97.6 95.9 97.6 97.0 Women’s overall response rate 95.2 94.9 95.5 93.7 95.8 95.0 Eligible children under 5 2,367 20,871 4,622 8,536 10,080 23,238 Mother/Caretaker Interviewed 2,347 20,647 4,572 8,405 10,017 22,994 Child response rate 99.2 98.9 98.9 98.5 99.4 98.9 Children’s overall response rate 96.9 96.9 96.8 96.2 97.5 96.9 Eligible men 1,272 7,284 1,748 3,177 3,631 8,556 Eligible men interviewed 1,153 6,483 1,599 2,744 3,293 7,636 Men response rate 90.6 89.0 91.5 86.4 90.7 89.2 Men’s overall response rate 88.6 87.2 89.5 84.4 89.0 87.4 Table 3.1 displays results of interviews with whole households plus individuals. Categories of response fall under the four sectors: households, women, children under 5 and men. Results reveal that all of the selected 31,200 households were occupied. Of these, 30,553 were successfully interviewed, providing a household response rate of 98 percent. A total of 27,073 women aged between 15 and 49 years were identified as living within the households surveyed. Of these, 26,259 were interviewed successfully, yielding a response rate of 97 percent. For the child questionnaire, 23,238 children under five were listed in the household questionnaire. Of these, questionnaires MERCY KANYUKA CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS10 were completed for 22,994, corresponding to a response rate of 99 percent. In addition, 8,556 men (ages 15–49 years) were identified and of these, 7,636 have been interviewed, giving a response rate of 89 percent. Overall response rates of 95, 97 and 87 percent are calculated for interviewed women, under-fives and men respectively. The results do not reveal significant urban-rural and regional response rate differentials. 3.2. HOUSEHOLD CHARACTERISTICS Table 3.2 shows the age and sex distribution of the survey population. The same data are used to produce the population pyramid in Figure 3.1. In the 30,553 households successfully interviewed, 131,021 household members were listed. Of these, 63,561 were males, and 67,452 were females. These data also reveal that the average household size is estimated at 4.3 and that there are no notable sex differentials among dependency age groups of < 15 years and 65+ years. Table 3.2 Household age distribution by sex Percent distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0–17 years, by sex, Malawi, 2006 Characteristic Sex Total Male Female Number Percent Number Percent Number Percent Age 0–4 11,553 18.2 11,810 17.5 23,363 17.8 5–9 10,700 16.8 11,215 16.6 21,918 16.7 10–14 8,933 14.1 9,471 14.0 18,408 14.0 15–19 5,767 9.1 5,359 7.9 11,126 8.5 20–24 5,013 7.9 6,627 9.8 11,640 8.9 25–29 4,885 7.7 5,164 7.7 10,049 7.7 30–34 4,051 6.4 3,785 5.6 7,835 6.0 35–39 3,040 4.8 2,617 3.9 5,657 4.3 40–44 2,162 3.4 1,910 2.8 4,073 3.1 45–49 1,692 2.7 1,509 2.2 3,201 2.4 50–54 1,306 2.1 2,301 3.4 3,607 2.8 55–59 1,314 2.1 1,532 2.3 2,846 2.2 60–64 1,053 1.7 1,391 2.1 2,445 1.9 65–69 7,06 1.1 916 1.4 1,622 1.2 70+ 1,363 2.1 1,788 2.7 3,152 2.4 Missing/DK 21 0.0 57 0.1 78 0.1 Dependency age groups <15 31,186 49.1 32,495 48.2 63,689 48.6 65+ 2,070 3.3 2,705 4.0 4,774 3.6 Other age groups Children aged 0–17 34,752 54.7 35,516 52.7 70,276 53.6 Adults 18+/Missing/DK 28,809 45.3 31,936 47.3 60,745 46.4 Total 63,561 100.0 67,452 100.0 131,021 100.0 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 11 Table 3.3a provides household composition by selected characteristics. The table shows that in Malawi, 85 percent of households are situated in rural areas and therefore only 15 percent in urban areas. The results show that there are more households in the Southern Region (47 percent) than the Central Region (43 percent) and the Northern Region (10 percent). Lilongwe district has more households (16 percent) than any other district in Malawi. As expected, table 3.3b shows that three-quarters of households in Malawi are male-headed and only one in four are female-headed. These proportions have not changed since the 1992 Malawi Demographic and Health Survey. The table also shows that 36 percent of people living in Malawi are Chewa by tribe, followed by Lomwe (17 percent), Yao (16 percent) and Ngoni (12 percent). The remaining groups constitute less than 10 percent of the population. Eighty-three percent of households include at least one child under 18 years, 55 percent have at least one child under the age of five and three-quarters of households have at least one woman aged 15–49. 10 8 6 4 2 0 2 4 6 8 10 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Percent Males Females Figure 3.1 Age and sex distribution of household population, Malawi, 2006 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS12 Table 3.3a Household composition Percent distribution of households by selected characteristics, Malawi, 2006 Background characteristic Weighted percent Number of households weighted Number of households unweighted Malawi Total 100.0 30,553 30,553 Urban 14.7 4,481 3,409 Rural 85.3 26,072 27,144 Region Northern 10.2 3,132 5,871 Central 42.9 13,121 10,551 Southern 46.8 14,300 14,131 District Balaka 2.3 695 1,180 Blantyre 7.6 2,316 1,189 Chikwawa 3.7 1,137 1,148 Chiradzulu 2.0 610 1,182 Chitipa 1.2 358 1,184 Dedza 5.7 1,740 1,178 Dowa 4.0 1,236 1,145 Karonga 2.0 604 1,174 Kasungu 3.6 1,096 1,183 Lilongwe 16.0 4,894 1,186 Machinga 4.0 1,235 1,168 Mangochi 8.5 2,611 1,155 Mchinji 3.6 1,106 1,195 Mulanje 3.9 1,179 1,179 Mwanza 1.7 515 1,194 Mzimba 4.8 1,460 1,185 Nkhata Bay 1.3 385 1,132 Nkhotakota 1.6 493 1,157 Nsanje 1.8 549 1,192 Ntcheu 3.5 1,078 1,189 Ntchisi 1.2 374 1,175 Phalombe 2.1 643 1,178 Rumphi 1.1 325 1,196 Salima 3.6 1,105 1,143 Thyolo 4.7 1,445 1,183 Zomba 4.5 1,364 1,183 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 13 Table 3.3b Household composition Percent distribution of households by selected characteristics, Malawi, 2006 Background characteristic Weighted percent Number of households weighted Number of households unweighted Sex of household head Male 74.5 22,754 22,558 Female 25.5 7,799 7,995 Number of household members 1 7.6 2,321 2,370 2–3 31.9 9,742 9,516 4–5 34.5 10,544 10,308 6–7 18.8 5,750 5,924 8–9 5.7 1,729 1,932 10+ 1.5 467 503 Ethnicity Chewa 35.9 10,960 9,067 Tumbuka 6.9 2,122 3,129 Lomwe 17.2 5,267 5,431 Tonga 1.5 452 895 Yao 16.3 4,983 3,801 Sena 4.4 1,334 1,706 Nkhonde 1.1 333 579 Ngoni 11.8 3,597 3,568 Other 4.9 1,506 2,377 At least one child aged < 18 years 83.4 30,553 30,553 At least one child aged < 5 years 54.8 30,553 30,553 At least one woman aged 15–49 years 74.6 30,553 30,553 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS14 3.3. CHARACTERISTICS OF HOUSEHOLDS MEMBERS Tables 3.4a and 3.4b provide information on the background characteristics of female respondents between the ages of 15 and 49 years, by place of residence, age category, marital status, motherhood status, education1, wealth index quintiles2 and ethnicity. As expected, the majority of respondents reside in rural areas (82 percent). Across the regions, 45 percent live in the Southern Region, 44 percent in the Central Region while 11 percent in the Northern Region. Lilongwe has the highest percentage of women (16 percent). The results in table 3.4b reveal that one in four women is aged between 20 and 24 years, that 20 percent are between 15 and 19 years, and 19 percent are within the 25–29 age group. Seventy- two percent report that they are either currently married or in union, 16 percent have never been married/in union while 12 percent were formerly married/in union. Eighty-one percent have given birth at some time in their lives leaving 19 percent who have never given birth. In addition, the table reveals that 64 percent of women are educated at primary level, 15 percent at secondary level and one in five have no education at all. There are no major differentials across the wealth index quintiles. Table 3.5a and 3.5b provide information on the background characteristics of men in the survey by place of residence, age category, marital status, education level, wealth index quintile and ethnicity. The majority of men live in rural areas (81 percent). Across the regions, 46 percent live in the Central Region, 43 percent in the Southern Region while 11 percent in the Northern Region. Of all the districts surveyed, Lilongwe has the highest number of male residents (18 percent). The results in table 3.5b show that one in five men falls in to the 15–19 years age range, 19 percent are between 20–24 years and another 19 percent are between 25–29 years. Sixty-four percent of men report to be either currently married or in union, 32 percent have never been married/in union while 4 percent have formerly been married/in union. Furthermore, results reveal that 65 percent of men have attended primary school, 26 percent have had secondary education and one in ten have had no education at all. 1 Unless otherwise stated, “education” refers to educational level attained by the respondent throughout this report when it is used as a background variable. 2 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and to obtain wealth scores for each household in the sample. The assets used in these calculations were as follows: person’s sleeping room, type of floor, type of roof, type of wall, type of cooking fuel and other type of assets. Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 15 Table 3.4a Women’s background characteristics Percent distribution of women aged 15–49 years by background characteristics, Malawi, 2006 Background characteristic Weighted percent Number of women weighted Number of women unweighted Malawi Total 100.0 26,259 26,259 Urban 17.6 4,624 3,526 Rural 82.4 21,635 22,733 Region Northern 10.6 2,772 5,301 Central 44.4 11,665 9,368 Southern 45.0 11,822 11,590 District Balaka 2.2 571 978 Blantyre 8.4 2,209 1,177 Chikwawa 3.4 885 861 Chiradzulu 1.9 507 967 Chitipa 1.2 312 1,035 Dedza 5.8 1,521 1,003 Dowa 4.3 1,135 998 Karonga 2.1 545 1,076 Kasungu 4.1 1,079 1,122 Lilongwe 16.2 4,252 1,064 Machinga 3.8 985 931 Mangochi 8.4 2,206 946 Mchinji 3.6 956 1,051 Mulanje 3.4 886 891 Mwanza 1.8 467 1,100 Mzimba 4.8 1,264 1,054 Nkhata Bay 1.2 326 912 Nkhotakota 1.8 465 1,081 Nsanje 1.6 422 938 Ntcheu 3.4 904 1,008 Ntchisi 1.2 324 1,010 Phalombe 1.9 512 970 Rumphi 1.2 324 1,224 Salima 3.9 1,028 1,031 Thyolo 4.2 1,101 893 Zomba 4.1 1,072 938 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS16 Table 3.4b Women’s background characteristics Percent distribution of women aged 15–49 years by background characteristics, Malawi, 2006 Background characteristic Weighted percent Number of women weighted Number of women unweighted Age 15–19 19.5 5,124 5,213 20–24 24.5 6,427 6,283 25–29 19.4 5,088 4,899 30–34 14.0 3,680 3,742 35–39 9.7 2,550 2,544 40–44 7.2 1,900 2,009 45–49 5.7 1,490 1,569 Marital/Union status Currently married/in union 72.4 19,005 18,762 Formerly married/in union 11.9 3,125 3,321 Never married/in union 15.7 4,129 4,176 Motherhood status Ever gave birth 80.7 21,198 21,123 Never gave birth 19.3 5,061 5,136 Woman’s education None 20.8 5,463 5,113 Primary 63.8 16,758 17,215 Secondary + 15.1 3,960 3,852 Other 0.3 78 79 Wealth index quintile Lowest 19.7 5,161 5,178 Second 19.1 5,022 5,223 Middle 19.3 5,058 5,241 Fourth 18.7 4,915 5,181 Highest 23.2 6,103 5,436 Ethnicity Chewa 36.1 9,483 7,920 Tumbuka 7.8 2,036 3,032 Lomwe 16.3 4,284 4,391 Tonga 1.6 422 782 Yao 16.1 4,219 3,154 Sena 4.1 1,082 1,339 Nkhonde 1.1 292 501 Ngoni 12.3 3,236 3,178 Other 4.6 1,204 1,962 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 17 Table 3.5a Men’s background characteristics Percent distribution of men aged 15–49 years by background characteristics, Malawi, 2006 Background characteristic Weighted percent Number of men weighted Number of men unweighted Malawi Total 100.0 7,636 7,636 Urban 19.2 1,466 1,153 Rural 80.8 6,170 6,483 Region Northern 11.1 847 1,599 Central 45.7 3,490 2,744 Southern 43.2 3,299 3,293 District Balaka 2.2 171 303 Blantyre 8.8 671 385 Chikwawa 3.9 299 278 Chiradzulu 1.7 126 223 Chitipa 1.1 83 290 Dedza 5.0 381 232 Dowa 4.6 349 273 Karonga 2.1 160 326 Kasungu 4.9 375 381 Lilongwe 17.6 1343 348 Machinga 3.0 226 183 Mangochi 7.4 567 246 Mchinji 4.0 304 354 Mulanje 3.2 243 267 Mwanza 1.7 133 350 Mzimba 5.4 413 363 Nkhata Bay 1.3 96 258 Nkhotakota 1.7 130 286 Nsanje 1.6 120 286 Ntcheu 2.8 215 245 Ntchisi 1.4 107 348 Phalombe 1.8 139 243 Rumphi 1.2 95 362 Salima 3.8 287 277 Thyolo 3.5 268 225 Zomba 4.4 335 304 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS18 Table 3.5b Men’s background characteristics Percent distribution of men aged 15–49 years by background characteristics, Malawi, 2006 Background characteristic Weighted percent Number of men weighted Number of men unweighted Age 15–19 20.5 1,567 1,622 20–24 19.2 1,468 1,514 25–29 18.8 1,434 1,376 30–34 15.0 1,147 1,136 35–39 10.7 821 815 40–44 8.7 668 642 45–49 7.0 531 531 Marital/Union status Currently married/in union 64.1 4,896 4,804 Formerly married/in union 3.6 278 272 Never married/in union 32.2 2,462 2,560 Man’s education None 9.0 691 574 Primary 64.9 4,958 5,000 Secondary + 25.9 1,979 2,050 Other 0.1 8 12 Wealth index quintile Lowest 16.4 1,253 1,260 Second 17.4 1,331 1,400 Middle 20.5 1,566 1,577 Fourth 20.5 1,568 1,618 Highest 25.1 1,917 1,781 Ethnicity Chewa 37.6 2,869 2,347 Tumbuka 7.8 598 891 Lomwe 17.0 1,301 1,304 Tonga 1.6 122 220 Yao 13.5 1,027 780 Sena 4.5 347 428 Nkhonde 1.3 96 151 Ngoni 11.7 896 924 Other 5.0 380 591 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 19 Tables 3.6a and 3.6b provide information on children’s background characteristics by place of residence, sex, age, mother’s level of education, wealth index quintile and ethnicity. Nearly 85 percent of children live in rural areas with only 15 percent residing in urban areas. Across the regions, 46 percent live in the Central Region, 44 percent in the Southern Region and only 10 percent are in the Northern Region. More children live in Lilongwe (17 percent) than any other district. The results in table 3.6b show that 51 percent of children in Malawi are female and 49 percent male. Of the children covered by MICS 2006, 10 percent are less than six months old, 12 percent are 6–11 months, 22 percent fall within the 12–23 months age group, 22 percent are aged 24–35 months, 20 percent are between 36–47 months, 14 percent are aged 48–49 months. CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS20 Table 3.6a Children’s background characteristics Percent distribution of children under five years of age by background characteristics, Malawi, 2006 Background characteristic Weighted percent Number of under-5 children weighted Number of under-5 children unweighted Malawi Total 100.0 22,994 22,994 Urban 14.6 3,366 2,347 Rural 85.4 19,628 20,647 Region Northern 10.1 2,315 4,572 Central 46.0 10,569 8,405 Southern 44.0 10,111 10,017 District Balaka 2.2 498 859 Blantyre 6.6 1,527 796 Chikwawa 3.5 802 791 Chiradzulu 1.9 434 843 Chitipa 1.4 313 1,035 Dedza 5.8 1,345 911 Dowa 4.1 942 835 Karonga 2.0 449 886 Kasungu 4.5 1,026 1,098 Lilongwe 17.2 3,965 918 Machinga 3.8 872 826 Mangochi 9.5 2,186 981 Mchinji 3.7 861 935 Mulanje 2.8 633 640 Mwanza 1.8 412 964 Mzimba 4.3 995 826 Nkhata Bay 1.2 270 753 Nkhotakota 1.9 430 1,003 Nsanje 1.8 404 868 Ntcheu 3.5 794 886 Ntchisi 1.3 294 919 Phalombe 2.1 478 895 Rumphi 1.2 287 1,072 Salima 4.0 911 900 Thyolo 4.4 1,015 824 Zomba 3.7 852 730 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 21 Table 3.6b Children’s background characteristics Percent distribution of children under five years of age by background characteristics, Malawi, 2006 Background characteristic Weighted percent Number of under-5 children weighted Number of under-5 children unweighted Sex Male 49.4 11,368 11,396 Female 50.6 11,626 11,598 Age < 6 months 10.2 2,353 2,298 6–11 months 11.6 2,673 2,583 12–23 months 22.1 5,080 5,085 24–35 months 21.9 5,027 5,052 36–47 months 19.7 4,540 4,603 48–59 months 14.4 3,322 3,373 Mother’s education None 24.4 5,614 5,168 Primary 64.7 14,875 15,307 Secondary + 10.6 2,442 2,449 Other 0.3 63 70 Wealth index quintile Lowest 22.2 5,112 5,150 Second 20.4 4,686 4,920 Middle 20.6 4,736 4,895 Fourth 18.5 4,243 4,372 Highest 18.3 4,217 3,657 Ethnicity Chewa 36.6 8,418 7,012 Tumbuka 7.1 1,628 2,524 Lomwe 15.8 3,638 3,792 Tonga 1.4 324 616 Yao 16.8 3,857 2,878 Sena 4.5 1,042 1,264 Nkhonde 1.0 222 389 Ngoni 12.0 2,763 2,670 Other 4.8 1,102 1,849 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS22 FERTILITY 23 4 FERTILITY SOPHIE KANG’OMA Table 4.1 Current fertility Age-specific and cumulative fertility rates, the total fertility rate, the general fertility rate, and the crude birth rate for the 1-year preceding the survey, by urban-rural residence, Malawi, 2006 Age group Urban Rural Total 15–19 144 186 177 20–24 238 295 284 25–29 176 291 269 30–34 182 230 222 35–39 138 184 177 40–44 14 97 86 45–49 15 39 36 TFR 4.5 6.6 6.3 GFR 175 236 225 CBR 40.2 44.5 43.9 4.1 CURRENT FERTILITY LEVELS Table 4.1 provides the widely used current fertility measure and the summary, namely the total fertility rate (TFR), which is defined as the number of births a woman would have if she survived to age 50 and experienced the currently observed age-specific fertility rates (ASFR). ASFRs are defined as the number of live births to women in a particular age group divided by the number of woman-years in that age group during the specified period. They are valuable measures of the age pattern of childbearing. In MICS 2006, the one-year period prior to the survey has been used to estimate the fertility. The TFR is estimated at 6.3, which indicates that if the fertility rate was to remain constant at the current levels measured in MICS 2006, a woman in Malawi would have on an average 6.3 children during her reproductive years. TFR is significantly higher among women in rural areas (6.6) than that of women in urban areas (4.5). Whilst the table shows a general fertility rate of 225 live births per 1,000 women aged 15–49 and a crude birth rate of 43.9 births per 1,000 population, the ASFR is highest amongst women in the age group 20–24, where 28.4 percent of women have had a baby each year. The table also highlights that women in rural areas have higher ASFR than women in urban areas, a factor that is consistent across all the age groups. 4.2 FERTILITY DIFFERENTIALS Data in tables 4.2a and 4.2b show a variation in fertility rates amongst women aged 15–49, according to a number of factors including area of residence, region and district, education and position in the wealth index. The TFR is used to measure fertility differentials in the percentage of currently pregnant Population growth heavily influences the achievement of national goals. Measurement of current fertility is therefore an essential component of any large-scale survey. In MICS 2006, birth histories of sampled women between the ages of 15 and 49 years were gathered in order to measure current fertility rates in Malawi. Each woman was asked a series of questions related to her live births. Data were collected on the number of sons and daughters residing with her, the number living elsewhere and the number who had died. Detailed information on each child was then recorded, starting with the child’s name, the month and year of their birth, sex, survival status and if dead, the age at death. FERTILITY24 Table 4.2a Fertility by background characteristics Total fertility rate for the 1-year preceding the survey, percentage of women 15–49 currently pregnant, and mean number of children ever born to women age 40–49 years, by background characteristics, Malawi, 2006 Background characteristic Total fertility rate Percentage currently pregnant Mean number of children ever born to women age 40–49 Malawi Total 6.3 11.4 6.4 Urban 4.5 10.2 5.5 Rural 6.6 11.7 6.5 Region Northern 5.5 10.7 6.3 Central 6.5 11.4 7.1 Southern 6.2 11.7 5.7 District Balaka 6.3 12.6 5.8 Blantyre 4.6 8.7 4.9 Chikwawa 6.9 12.2 6.3 Chiradzulu 5.6 11.2 5.9 Chitipa 6.8 11.0 6.8 Dedza 7.0 8.6 7.3 Dowa 6.2 12.9 7.1 Karonga 5.6 11.6 5.9 Kasungu 6.1 10.6 7.1 Lilongwe 6.8 11.3 7.3 Machinga 6.9 14.4 5.4 Mangochi 8.0 11.0 6.3 Mchinji 5.7 14.9 7.7 Mulanje 4.5 16.6 4.8 Mwanza 6.0 13.5 6.2 Mzimba 5.3 9.4 6.5 Nkhata Bay 4.5 13.2 5.4 Nkhotakota 6.2 12.8 6.9 Nsanje 6.7 11.1 7.2 Ntcheu 5.6 10.8 6.6 Ntchisi 6.1 8.9 7.1 Phalombe 6.9 12.5 5.9 Rumphi 6.2 11.7 6.3 Salima 7.1 12.2 6.5 Thyolo 6.2 10.8 4.5 Zomba 5.5 11.8 6.2 women, and those with completed fertility in terms of the mean number of births to women aged 40–49 by these characteristics. FERTILITY 25 TFR is higher among rural women (6.6) compared to urban women (4.5). Regionally, TFR is higher in the Central Region (6.5) than the other regions. In the Northern and Southern Regions, TFR is 5.5 and 6.2 respectively. TFR varies substantially at the district level (Map 4.1). TFR is highest in Mangochi (8.0) and lowest in Mulanje and Nkata Bay (4.5). Chikwawa, Dedza, Machinga, Salima and Phalombe are all districts with TFR close to 7.0 while TFRs for Chiradzulu, Karonga, Mchinji, Mzimba, Ntcheu and Zomba districts range from 5.0 to 5.9. The table also shows that 11.4 percent of women aged 15–49 were pregnant at the time of the survey and that the highest number of pregnant women reside in rural areas and in the Southern Region. Blantyre, Dedza, Mzimba and Ntchisi have the lowest proportion of pregnant women (less than 10 percent) and the highest proportion is observed in Mulanje, Mchinji and Machinga (more than 14 percent). Table 4.2a further shows the mean number of children ever born (CEB) to women aged 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. If fertility had remained stable over time, the two fertility measures, TFR and CEB, would be equal or similar. The findings show that the mean number of children ever born to women aged 40–49 (6.4 children per woman) is similar to the TFR for the one year preceding the survey (6.3 children per woman). This indicates stability in fertility over the past several decades. While the data reveal no substantial change in fertility over the past several decades in rural areas, the higher number of children born in urban areas compared to TFRs indicates a greater percentage fall there. Chitipa and Rumphi are the two districts with similar TFR and CEB, an indication that fertility has remained stable over time in these two districts. Machinga, Mangochi and Thyolo are districts which suggest a recent rise in fertility. However, as there are only about 50 percent of women aged 40–49 in each of the districts, the CEB may well be underestimated. The high calculated TFR in Mangochi is not consistent with either the prevalence of pregnancy nor the CEB, making this estimate a suspect as well. Such outliers are expected with smaller sample sizes found in districts as opposed to regions or national estimates. Table 4.2b Fertility by background characteristics Total fertility rate for the 1-year preceding the survey, percentage of women 15–49 currently pregnant, and mean number of children ever born to women age 40–49 years, by background characteristics, Malawi, 2006 Background characteristic Total fertility rate Percentage currently pregnant Mean number of children ever born to women age 40–49 Mother’s education No education 8.0 9.5 6.5 Primary 6.2 12.5 6.5 Secondary + 3.6 9.8 4.6 Wealth index quintile Lowest 7.6 10.3 7.1 Second 7.0 12.8 6.6 Middle 6.7 13.1 6.6 Fourth 6.0 12.5 5.8 Highest 4.4 9.0 5.9 FERTILITY26 Map 4.1 Total fertility rate, Malawi, 2006 Dedza Dowa Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Mulanje Chiradzulu Phalombe Mangochi Ntcheu Balaka Machinga Mwanza Lake Malawi Likoma Births per woman Below National Average (6.3) 6.4–7.0 Above 7.0 Nkhota kota FERTILITY 27 There is a substantial variation in the TFR between women who have attended higher education compared to those with primary education or no education at all. Women with secondary education have a TFR of 3.6 compared to 6.2 for women with primary education and 8.0 for those with no education. Similarly, women in the poorest quintile have the highest TFR (7.6) while those in the wealthiest group have a TFR of 4.4. However, both education and wealth show substantial differences only in the top categories of secondary+ education and the highest wealth quintile. 4.3 TRENDS IN AGE-SPECIFIC FERTILITY RATES Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates for 1-year period preceding the survey, by mother’s age at the time of the birth, Malawi, 2006 Mother’s age at birth Number of years preceding the survey 0–1 1–2 2–3 3–4 15–19 177 184 189 165 20–24 284 281 306 285 25–29 269 260 285 244 30–34 222 215 220 195 35–39 177 164 183 166 40–44 86 99 121 104 45–49 36 45 64 38 Table 4.3 lays out trends in age-specific fertility rates for successive one year periods preceding the survey. Observing ASFR for the cohort of women, the findings indicate that ASFR is actually declining in more recent periods compared to two or three years ago. Fertility drops as women get older but can still be considered high among women aged 20–34. Since women aged 50 and above were not interviewed in the survey, the rates are successively truncated as the number of years preceding the survey increases. 4.4 CHILDREN EVER BORN AND CHILDREN LIVING Table 4.4 shows the percentage of all women and currently married women by number of CEB (live births), the mean number of CEB and living children. The distribution of CEB is the outcome of lifetime fertility. Information on lifetime fertility is useful for examining the momentum of childbearing and for estimating levels of primary infertility. The number of CEB or current parity is based on a cross-sectional view at the time of survey. It does not refer directly to the timing of fertility of the individual respondent but is a measure of her completed fertility up to her age at the time of survey. The data also display rates of infertility amongst Malawian women. Only 2 percent of women in the last reproductive age groups reported to be childless. Since voluntary childlessness is rare in Malawi, it is assumed that married women who reach the end of their reproductive years without giving birth are either infertile, or their husbands are. The percentage of women who are childless at the end of the reproductive period is an indirect measure of primary infertility (the proportion of women who are unable to bear children at all). Table 4.4 further shows that only 15 percent of all women in their early twenties have not yet started childbearing, 28 percent of those in their early thirties have less than four children and by the end of their reproductive age, 54 percent of women have seven or more children and 15 percent have 10 or more children. The remarkable feature here is the high fertility in the older age group and the decline in the younger, even late in reproductive life. This implies falling fertility in the high parity numbers. FERTILITY28 Table 4.4 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born and mean number of living children, according to age group, Malawi, 2006 Age Number of children ever born Total N u m b er o f w o m en M ea n n u m b er o f ch ild re n e ve r b o rn M ea n n u m b er o f ch ild re n li vi n g 0 1 2 3 4 5 6 7 8 9 10 + All women 15–19 73.0 23.3 3.4 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 5,124 0.31 0.28 20–24 14.6 32.9 34.8 14.0 3.1 0.6 0.1 0.0 0.0 0.0 0.0 100.0 6,427 1.60 1.43 25–29 4.0 10.1 20.8 30.8 21.8 9.1 2.6 0.7 0.0 0.0 0.0 100.0 5,088 2.98 2.58 30–34 1.8 3.9 8.9 15.6 23.7 23.7 15.0 4.6 2.1 0.5 0.1 100.0 3,680 4.27 3.63 35–39 1.6 2.6 6.1 7.0 13.7 18.9 20.1 13.6 10.7 4.6 1.3 100.0 2,550 5.41 4.46 40–44 1.7 2.6 2.7 6.5 8.7 11.4 16.5 16.0 15.7 9.6 8.5 100.0 1,900 6.32 5.05 45–49 1.9 3.2 4.7 8.4 7.3 9.0 11.2 14.8 12.7 12.0 14.7 100.0 1,490 6.51 5.02 Total 19.2 15.7 15.5 13.3 10.7 8.4 6.4 4.1 3.2 1.9 1.6 100.0 26,259 2.98 2.50 Currently married women 15–19 36.6 54.0 8.9 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,708 0.73 0.66 20–24 7.5 33.8 38.8 15.4 3.6 0.7 0.1 0.0 0.0 0.0 0.0 100.0 5,163 1.76 1.58 25–29 2.3 8.8 20.3 32.3 22.9 9.8 2.8 0.8 0.0 0.0 0.0 100.0 4,295 3.09 2.69 30–34 1.2 3.1 7.4 15.2 23.7 24.3 16.8 5.1 2.3 0.5 0.2 100.0 3,076 4.42 3.75 35–39 1.0 1.9 4.8 6.3 13.1 20.0 21.3 14.5 11.4 4.4 1.3 100.0 2,120 5.57 4.63 40–44 1.6 2.5 2.2 5.6 7.9 11.4 16.9 16.5 16.3 10.4 8.8 100.0 1,537 6.45 5.17 45–49 1.9 2.4 5.0 5.9 6.8 8.4 10.8 14.5 14.1 13.8 16.5 100.0 1,105 6.80 5.25 Total 6.4 17.1 18.1 15.5 12.5 10.0 7.8 4.8 3.8 2.2 1.8 100.0 19,005 3.50 2.95 FERTILITY 29 Information on CEB and the number of children surviving gives some indication of the extent of childhood mortality. Figure 4.1 shows the difference between the mean number of CEB and mean number of children still living. By the end of the reproductive period, women have lost on average 17 percent of the children born to them. 4.5 BIRTH INTERVAL Birth interval is one of the important determinants of total fertility. A number of studies have observed that women with closely spaced births experience higher fertility than those who have longer birth intervals. It has also been shown that short birth intervals, particularly those less than 24 months, elevate the risk of death for children on 0.3 1.4 2.6 3.6 4.5 5.1 5.0 2.5 0.3 1.6 3.0 4.3 5.4 6.3 6.5 3.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 All A g e Mean number of children ever born Mean number of children living either side of the interval. Closely spaced births also jeopardise maternal health. Tables 4.5a and 4.5b describe the distribution of children after the first birth, in the five years preceding the survey by months since the preceding birth. Information is provided according to selected demographic and socio-economic variables. Results from MICS 2006 indicate that the median interval of births in Malawi is 28 months. In other words, for women in Malawi, the space between births is on average more than two years. The median length of birth intervals increases slightly with the increasing age of the mother. Teenagers have marginally shorter birth intervals (26 months) than other women. There is no substantial difference on the length of birth intervals by parity and sex of the child. Survivor status of a preceding child influences a mother’s decision whether to fall pregnant again or not. Data show that the median length of birth intervals is longer among women with living preceding children (29 months) than those with dead preceding children (24 months). This could well be due to the physiologic effect of breastfeeding, delaying fecundity in mothers with surviving children compared to those whose child or children have not survived. There is no significant variation in the length of birth intervals between rural and urban residence. However, there is some regional variation, with children in the Northern Region experiencing longer birth intervals (31 months) than those in the Central and Southern Regions (28 months). At district level, the birth interval is longer in Rumphi and Mzimba (32 months) and a month or more shorter than the national average in Dowa, Mchinji, Mulanje Nkhotakota, Ntchisi, Phalombe and Salima. The birth interval for children born to women with higher education and to those in the highest wealth quintile is longer by two to three months compared to those born to women who fall within other education levels and wealth quintiles. MICS 2006 data further indicate that 20 percent of non-first borns are born within an interval of 36–47 months, 48 percent are born within an interval of 24–35 months, and 29 percent are born within an interval of less than two years (Table 4.5a). The former two intervals seem healthy while the latter is associated with higher mortality of both mother and child. Figure 4.1 Mean number of children ever born and surviving for women aged 15–49, Malawi, 2006 FERTILITY30 Table 4.5a Birth intervals Percent distribution of non-first births in the 5-years preceding the survey by number of months since preceding birth, according to background characteristics, Malawi, 2006 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 48–54 55–59 Malawi Total 11.9 17.5 48.3 19.6 2.4 0.2 100.0 7,436 28.4 Urban 9.7 16.8 51.4 19.1 2.8 0.2 100.0 1,008 29.4 Rural 12.3 17.6 47.8 19.7 2.4 0.2 100.0 6,429 28.2 Region Northern 7.6 13.3 53.1 24.0 1.7 0.2 100.0 670 31.1 Central 14.1 17.1 47.4 18.6 2.5 0.3 100.0 3,597 28.3 Southern 10.3 18.9 48.2 19.8 2.6 0.2 100.0 3,169 28.1 District Balaka 8.8 20.0 49.4 19.1 2.6 0.0 100.0 171 28.1 Blantyre 7.1 19.2 47.1 23.5 3.1 0.0 100.0 396 29.2 Chikwawa 8.8 15.8 47.1 23.1 5.1 0.0 100.0 260 29.4 Chiradzulu 13.4 20.3 42.5 21.3 2.4 0.0 100.0 135 28.7 Chitipa 7.8 14.8 54.4 21.7 1.2 0.3 100.0 102 29.7 Dedza 15.1 16.1 43.9 24.2 0.7 0.0 100.0 443 28.3 Dowa 11.7 21.4 44.7 16.0 4.9 1.4 100.0 296 27.3 Karonga 8.9 20.2 48.5 19.5 1.9 1.0 100.0 128 29.1 Kasungu 11.0 17.3 52.5 16.5 2.6 0.0 100.0 335 28.1 Lilongwe 14.6 15.9 47.2 19.1 2.7 0.4 100.0 1,432 29.0 Machinga 10.9 16.0 52.1 20.0 1.0 0.0 100.0 261 28.5 Mangochi 10.7 22.8 46.9 17.0 2.6 0.0 100.0 777 26.8 Mchinji 13.9 17.7 47.3 18.8 2.3 0.0 100.0 265 27.5 Mulanje 16.3 18.8 44.1 17.2 2.6 1.0 100.0 164 26.9 Mwanza 10.2 19.0 54.5 14.4 1.5 0.3 100.0 138 28.3 Mzimba 6.5 9.7 58.8 24.5 0.6 0.0 100.0 277 32.0 Nkhata Bay 10.6 13.7 43.9 28.4 3.4 0.0 100.0 82 30.5 Nkhotakota 15.0 17.6 49.9 14.4 3.1 0.0 100.0 157 27.1 Nsanje 12.0 13.4 49.1 21.7 3.1 0.6 100.0 146 30.0 Ntcheu 10.9 12.9 57.8 15.7 2.7 0.0 100.0 240 28.5 Ntchisi 14.4 20.2 43.4 19.0 2.7 0.4 100.0 102 27.4 Phalombe 14.2 17.2 52.7 12.8 2.0 1.1 100.0 163 27.0 Rumphi 6.0 12.8 49.0 28.3 4.0 0.0 100.0 80 32.2 Salima 18.0 20.4 42.9 17.5 1.0 0.1 100.0 327 27.4 Thyolo 9.9 17.5 49.5 20.2 2.6 0.3 100.0 303 28.7 Zomba 7.9 17.4 47.3 26.2 1.3 0.0 100.0 256 28.8 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 31 Table 4.5b Birth intervals Percent distribution of non-first births in the 5-years preceding the survey by number of months since preceding birth, according to background characteristics, Malawi, 2006 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 48–54 55–59 Age 15–19 17.7 22.9 48.7 10.1 0.6 0.0 100.0 168 25.6 20–29 12.0 18.1 49.2 18.2 2.2 0.2 100.0 4,870 28.1 30–39 10.8 15.5 46.7 23.6 3.2 0.3 100.0 2,021 29.3 40–49 14.1 18.2 45.1 20.4 1.8 0.4 100.0 377 28.6 Birth order 2–3 11.6 16.8 50.0 18.3 3.2 0.2 100.0 2,871 28.6 4–6 11.8 14.8 48.7 22.3 2.2 0.3 100.0 1,909 28.9 7+ 12.4 20.3 46.0 19.1 1.9 0.3 100.0 2,656 27.9 Sex of preceding birth Male 10.7 17.9 49.7 19.4 2.1 0.3 100.0 3,656 28.8 Female 13.1 17.2 46.9 19.8 2.8 0.2 100.0 3,781 28.0 Survival of preceding birth Living 10.9 17.1 48.9 20.3 2.5 0.2 100.0 6,960 28.8 Dead 26.7 23.8 38.3 9.8 1.4 0.0 100.0 476 23.9 Mother’s education No education 13.6 17.0 47.8 19.3 2.3 0.1 100.0 1,831 28.0 Primary 11.5 18.4 48.9 18.8 2.2 0.2 100.0 4,991 28.3 Secondary + 10.5 12.2 44.8 27.6 4.3 0.6 100.0 599 31.1 Other 15.4 16.7 37.8 8.4 21.7 0.0 100.0 15 27.9 Wealth index quintile Lowest 13.3 18.0 46.6 19.4 2.5 0.3 100.0 1,762 28.0 Second 12.8 19.0 48.0 18.9 1.3 0.1 100.0 1,571 27.8 Middle 12.1 18.2 46.4 20.8 2.4 0.2 100.0 1,612 28.4 Fourth 11.2 17.6 49.1 18.9 2.9 0.3 100.0 1,393 27.9 Highest 9.2 13.5 53.0 20.3 3.6 0.3 100.0 1,099 30.3 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. FERTILITY32 4.6 AGE OF MOTHER AT FIRST BIRTH Mother’s age at first birth is an important determinant of fertility. It is also a determinant of the health and welfare of the mother and of the child. If a woman starts child bearing at a very young age, she is more likely to have higher parity by the end of her reproductive age, especially in a country where there is a low prevalence of contraceptive use and relatively short birth intervals. Table 4.6 shows the median age at first birth among all women, by exact age and the median age at first birth, according to current age. In Malawi, the median age at first birth is 19 years for women in all age groups except for the 45–49 age group, which is 20 years. More than half of women in all age groups have given birth by the age of 20 and almost all women (90 or more percent) in the relevant age groups have given birth by age 25. Only 27 percent of women in the 45–49 age group have their first child by age 18. However, this could be more of a memory problem than a true reflection of difference as the median ages at first birth are very close. Two percent and 7 percent of women aged 15–19 and 35–39 respectively, have their first birth by age 15. Five to 7 percent of older women have their first birth by age 15, but the percentage has recently fallen, with only 1.7 percent of current 15–19 year olds having given birth before age 15. However, an indication of earlier child bearing is seen in the trend of those who give birth by age 20, rising from 50 percent 25 years ago to 66 percent in the present 20–24 year olds. Table 4.6 Age at first birth Among all women, percentage who gave birth by exact ages, percentage who have never given birth, and median age at first birth, by current age, Malawi, 2006 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth15 18 20 22 25 15–19 1.7 na na na na 73.0 5,124 a 20–24 4.2 31.9 66.3 a na 14.6 6,427 a 25–29 5.4 32.7 62.3 82.8 93.5 4.0 5,088 19.1 30–34 5.8 33.6 60.6 81.1 93.0 1.8 3,680 19.2 35–39 6.8 33.8 59.9 77.6 90.1 1.6 2,550 19.2 40–44 6.0 33.6 61.3 77.9 90.0 1.7 1,900 19.2 45–49 4.8 27.0 50.3 68.0 84.0 1.9 1,490 20.0 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group FERTILITY 33 4.7 MEDIAN AGE AT FIRST BIRTH Data from MICS 2006 show that the median age at first birth is 19 years for women aged 20–49 and women aged 25–49. There is no substantial variation in the age of birth by place of residence, region and wealth quintile. However, the median age at first birth is higher (21.4 years) among women who have had higher education compared to 19 years for those with primary or no education in all age groups. At district level, the lowest median age at first birth is among women in Balaka (18.6 years) and the highest is 19.6 years for women in Blantyre, Dowa, Lilongwe and Ntchisi. 4.8 TEENAGE PREGNANCY AND MOTHERHOOD Adolescent childbearing has a negative impact on the health of both mothers and their children. Teenage mothers are more likely to have complications during delivery than older mothers, resulting in higher morbidity and mortality. In addition, early childbearing may impact on a young woman’s life chances by limiting her ability to pursue educational or job opportunities. Table 4.7a describes the distribution of women aged 15–19 who are mothers or pregnant with their first child and those who have begun childbearing by background characteristics. One in every three adolescents has started childbearing, 8 percent are pregnant with their first child and 27 percent have had a live birth. The data indicate a disparity between rural and urban adolescents, with those in rural areas more likely to become mothers or become pregnant. Thirty-six percent of the adolescents in rural areas have begun childbearing as compared to 29 percent in urban areas. At the regional level, early childbearing is less common in the Central Region (31 percent) than in the Northern Region and Southern Region (both at 37 percent). At district level, the start of childbearing during adolescence is the lowest in Ntchisi (20 percent) and highest in Chiradzulu (48 percent) (Map 4.2). More than half of adolescents (53 percent) aged 18 have begun childbearing and amongst those aged 15, 6 percent have begun childbearing. More than half of adolescents aged 19 (60 percent) are mothers compared to 3 percent of those aged 15 (Table 4.7b). The percentage of adolescents who have begun childbearing declines dramatically with an increasing level of education. More than half (57 percent) of the adolescents who have no education have begun child bearing compared to 36 percent with primary education and 23 percent with secondary or higher education. Adolescents in the second wealth index quintile are more likely to start childbearing (43 percent) than those in the lowest quintile (35 percent). This proportion is lowest amongst adolescents in the highest wealth status (24 percent). FERTILITY34 Table 4.7a Teenage pregnancy and motherhood Percentage of women aged 15–19 who are mothers or pregnant with their first child and percentage who have begun childbearing, by background characteristics, Malawi, 2006 Background characteristic Percentage who: Percentage who have begun childbearing Number of womenHave had a live birth Are pregnant with first child Malawi Total 27.0 7.5 34.5 5,124 Urban 22.8 6.1 28.9 1,013 Rural 28.0 7.8 35.8 4,110 Region Northern 29.0 7.9 36.9 583 Central 24.2 6.7 30.9 2,240 Southern 29.2 8.1 37.2 2,300 District Balaka 25.4 11.5 36.8 139 Blantyre 23.2 4.2 27.4 482 Chikwawa 27.4 12.3 39.8 161 Chiradzulu 37.0 10.9 47.9 98 Chitipa 31.5 5.2 36.7 61 Dedza 27.5 5.2 32.7 345 Dowa 12.2 8.8 21.0 217 Karonga 29.2 11.6 40.8 125 Kasungu 29.6 7.3 36.9 211 Lilongwe 23.2 7.6 30.7 748 Machinga 31.0 10.4 41.4 211 Mangochi 35.6 5.6 41.1 374 Mchinji 23.8 7.1 30.9 179 Mulanje 26.9 14.7 41.6 181 Mwanza 22.8 9.6 32.4 92 Mzimba 26.5 7.5 33.9 279 Nkhata Bay 36.1 5.2 41.3 54 Nkhotakota 23.7 4.5 28.2 95 Nsanje 27.9 8.2 36.1 85 Ntcheu 34.9 8.1 43.0 167 Ntchisi 16.3 4.1 20.4 65 Phalombe 37.7 9.0 46.7 85 Rumphi 31.1 7.4 38.4 65 Salima 24.0 4.0 28.0 213 Thyolo 41.1 3.7 44.8 181 Zomba 21.3 9.2 30.5 211 FERTILITY 35 Table 4.7b Teenage pregnancy and motherhood Percentage of women aged 15–19 who are mothers or pregnant with their first child and percentage who have begun childbearing, by background characteristics, Malawi, 2006 Background characteristic Percentage who: Percentage who have begun childbearing Number of womenHave had a live birth Are pregnant with first child Age 15 3.1 2.9 6.0 1,049 16 6.5 4.9 11.5 993 17 19.1 10.2 29.4 826 18 41.2 11.5 52.6 1,220 19 60.3 7.6 67.9 1,035 Mother’s education No education 48.0 8.5 56.5 252 Primary 28.0 7.7 35.7 3,925 Secondary + 17.0 6.4 23.4 945 Other 33.6 0.0 33.6 1 Wealth index quintile Lowest 28.2 7.0 35.2 959 Second 34.5 8.1 42.6 901 Middle 31.5 9.3 40.7 928 Fourth 24.9 10.0 35.0 960 Highest 19.6 4.4 24.0 1,376 FERTILITY36 Map 4.2 Teenage Pregnancy, Malawi, 2006 Dedza Dowa Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Mulanje Chiradzulu Phalombe Mangochi Ntcheu Balaka Machinga Mwanza Lake Malawi Likoma Nkhota kota Percent Below National Average (35%) 35.1%–40.0% Above 40% CHILD MORTALITY 37 5 CHILD MORTALITY One of the overarching objectives of the MDGs and WFFC is to reduce infant and under-five mortality. Specifically, the MDGs call for a two-thirds reduction in the mortality rate for under- fives between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Most MICS surveys use indirect techniques for estimating child mortality. However, child mortality in the Malawi MICS 2006 was calculated using direct measures from birth histories collected from the female respondents, to produce robust estimates that are comparable with the ones obtained from other sources in the country like the Malawi Demographic and Health Survey. Information from the birth history of female respondents includes a series of aggregate questions on the total number of sons and daughters living with the mother, the number of children who live elsewhere and the number of children who have died. Details collected for each live birth include the child’s name, date of birth, sex, whether the birth was single or multiple and whether the child resides with his/her mother. In addition, dates of death were collected in cases where children had not survived. The infant mortality rate refers to the probability of dying before the first birthday. The under- five mortality rate refers to the probability of dying before the fifth birthday. The neonatal mortality rate is the probability of dying within the first month of life. Early neonatal rate is the probability of death during the first seven days of life and late neonatal death is the difference between neonatal mortality and early neonatal mortality. The post neonatal mortality rate is the difference between infant mortality and neonatal mortality. The child mortality rate is defined as the probability of dying between the first and the fifth birthday. All mortality 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. 5.1 METHODOLOGICAL ISSUES The direct technique used in MICS 2006 estimates mortality for specific time periods preceding the survey, typically five year periods, i.e. 0–4 years, 5–9 years and 10–14 years. The issue of the quality and accuracy of retrospective data cannot be overlooked. Reports given by women on their complete birth histories are likely to suffer from data quality issues; mortality for the most recent five years before the survey will tend to be underestimated while estimates for an earlier five year period will tend to be overestimated. As the information used from birth histories is only available from surviving women, bias can be introduced where the mortality experience for surviving and non-surviving women is substantially different. In addition, data on older women are not available as information is only collected for women aged between 15–49. As such, there is no picture available from the mortality risk for children born to older women. ANGELA MSOSA CHILD MORTALITY38 The estimation method used assumes that maternal mortality is independent of child mortality. Child mortality estimates in this report should be treated with caution due to high mortality in Malawi where maternal mortality rates are estimated at over 807 deaths per 100,000 live births. Under-reporting of deaths is assumed to be high for deaths when they occur very early in infancy. Selective under-reporting would result in unusually lower ratios of neonatal deaths to all infant deaths. MICS 2006 data show that early infant deaths have not been omitted as shown in the ratios (See appendix D under ‘data quality tables’). The proportion of deaths in the first seven days of life compared to all infant deaths is high, between 70 and 76 percent. Also, the proportion of neonatal deaths to all infant deaths is relatively stable over the 15 year period before the survey. The proportion for the five year period immediately preceding the survey was higher at 46 percent than in the periods 5–9 years (44 percent) and 10–14 years preceding the survey (42 percent). 5.2 LEVELS AND TRENDS OF EARLY CHILDHOOD MORTALITY In this chapter, the term ‘childhood mortality’ is generally used to refer to mortality during childhood and has no specific meaning regarding the specific age period of risk. Table 5.1 provides estimates of childhood mortality for three five year periods preceding the survey. For the most recent five year period, corresponding approximately to 2002–2006, the infant mortality rate was estimated at 72 per 1,000 live births, while the under-five mortality rate was around 122 per 1,000 live births. Table 5.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for 5-year periods preceding the survey, Malawi, 2006 Years preceding the survey Approximate calendar period Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0–4 2002–2006 33 39 72 53 122 5–9 1997–2001 41 50 91 78 162 10–14 1992–1996 36 54 90 99 180 During the 15 year period preceding the survey, the findings show a decline in under-five mortality by 32 percent from 180 to 122 deaths per 1,000 live births. Infant mortality declined by 20 percent from 90 to 72 deaths per 1,000 live births. Child mortality had the largest decline of 46 percent from 99 to 53 deaths per 1,000 live births. During the same period, neonatal mortality remained almost unchanged from 36 to 33 deaths per 1,000. However the period 10–14 years to 5–9 years before the survey saw a slight increase from 36 to 41 deaths per 1,000 live births. It is also interesting to note that the current downward trend of childhood mortality is linked to declines observed in the most recent period. For example, a dramatic fall of 21 percent (from 91 deaths per 1,000 to 72 deaths per 1,000) can be observed in IMR in the last five years. On the other hand, under-five mortality declined by 10 percent (from 180 deaths per 1,000 to 162 deaths per 1,000) 10–14 years ago and 25 percent (from 162 deaths per 1,000 to 122 deaths per 1,000) in the last five year interval. The highest decline, however, can be seen in child mortality from 78 to 53 (32 percent). CHILD MORTALITY 39 5.3 SOCIO-ECONOMIC AND DEMOGRAPHIC DIFFERENTIALS IN CHILDHOOD MORTALITY Tables 5.2a and 5.2b and figure 5.1 show childhood mortality levels by socio-economic and demographic characteristics for the five year period (2002–2006) preceding the survey. Generally, urban mortality rates are lower than rural mortality rates. The mortality rate for under- fives is 113 per 1,000 live births for urban areas, compared to 123 per 1,000 live births for rural areas. Neonatal mortality is also higher for rural areas at 34 per 1,000 live births compared to 30 per 1,000 live births for urban areas. Comparing the three regions, the Northern Region has lower under-five mortality (88 per 1,000 live births), than either the Central Region (129 per 1,000 live births) or the Southern Region (122 per 1,000 live births). The infant mortality rate is similarly lower for the Northern Region (57 per 1,000 live births) compared to the Central and Southern Regions (73 and 75 per 1,000 live births respectively). Post neonatal mortality in the Southern Region is almost twice as high for the Northern Region as shown in table 5.2a. Numerous studies have demonstrated a strong relationship between a mother’s level of education and the survival of her child. These findings are confirmed in this survey where the infant and under-five mortality rates are 73 and 126 per 1,000 live births respectively for mothers with no education while for mothers with secondary or higher education, the infant and under-five Table 5.2a Early childhood mortality rates by socio-economic and demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 5-year period preceding the survey, by socio- economic characteristics, Malawi, 2006 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Malawi Total 33 39 72 53 122 Urban 30 40 70 47 113 Rural 34 39 73 54 123 Region Northern 33 24 57 33 88 Central 35 38 73 60 129 Southern 31 44 75 51 122 Mother’s education No education 32 41 73 57 126 Primary 33 40 73 53 123 Secondary + 36 30 66 43 106 Wealth index quintile Lowest 32 40 72 54 123 Second 34 45 79 61 135 Middle 30 46 76 56 128 Fourth 39 33 71 54 122 Highest 32 30 62 39 99 CHILD MORTALITY40 Figure 5.1 Under-5 mortality rates by background characteristics, Malawi, 2006 113 123 88 129 122 126 123 106 123 99 122 0 20 40 60 80 100 120 140 Malawi Urban Rural Northern Central Southern No education Primary Secondary + Poorest Richest Per 1,000 Table 5.2b Early childhood mortality rates by socio-economic and demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 5-year period preceding the survey, by socio- economic characteristics, Malawi, 2006 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child’s sex Male 38 39 76 52 125 Female 28 40 69 54 119 Mother’s age at birth <20 42 46 88 53 136 20–29 29 36 65 55 116 30–39 32 36 68 49 113 40–49 56 62 118 56 168 Birth order 1 44 43 87 54 136 2–3 24 35 59 51 107 4–6 28 38 66 54 117 7+ 56 51 107 58 159 Previous birth interval <2 years 57 58 115 75 182 2 years 30 34 64 49 109 3 years 21 29 49 52 98 4+ years 19 39 58 41 96 CHILD MORTALITY 41 Map 5.1 Under-five mortality rate, Malawi, 2006 Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Chiradzulu Phalombe Mangochi Balaka Machinga Mwanza Lake Malawi Deaths per 1000 live births Below 100 100–140 141–171 Mulanje Likoma Dedza Dowa Ntcheu Nkhota kota CHILD MORTALITY42 mortality rates are 66 and 106 per 1,000 live births. Notably, neonatal mortality is not influenced by education or wealth while both influence mortality at ages above one month, an indication of the importance of childcare practices at home beyond the neonatal period. Neonatal mortality, on the other hand is most heavily influenced by birth events, low birth weight and congenital problems. Map 5.1 shows under-five mortality rates by district. Of the six districts in the Northern Region, four have mortality rates less than 100 per 1,000 live births whereas Mzimba has an under-five mortality rate in the range of 100–140. Data are missing for Likoma and Neno as MICS 2006 was not carried out in these two districts. Higher estimates of under-five mortality can be observed in the lower Central and Southern Regions. Mother’s age at the time of child birth influences child survival in all periods as seen in table 5.2b, showing the classic ‘J’ shape with the mother’s age (both very young and old mothers have higher child mortality) and same effect also seen with birth order. The birth interval also affects survival when there is less than two years between pregnancies, demonstrating the importance of spacing on child survival. There is no obvious sex differential in child survival seen in Malawi, except for neonatal mortality rate. Information on infant and neonatal mortality at district level is presented in table 5.3 and figure 5.2. Estimates for the 10 year period preceding the survey have been used for the childhood mortality rates at district level to reduce the sampling variability. The 10 year period estimates show that the majority of districts have infant mortality rates lower than the 10 year national average of 81 per 1,000 live births. Three districts, namely Balaka, Nsanje and Phalombe have an infant mortality rate of over 100 per 1,000 live births, which is twice the infant mortality rate for Chitipa and Karonga (52 per 1,000 live births). Even more dramatic is the spread of under-five mortality with rates over 160, which is double the lowest infant mortality rate of 81. The child mortality rate shows the highest disparity of more than a factor of three times, from 25 to 87 per 1,000 live births. Low child survival after the first year of life is related to higher infections and poorer access to quality health services in these districts. These are also ten districts with an under-five mortality rate above 140 deaths per 1,000 live births, which is the national rate for the 10 year period. Districts in the Northern Region, namely Chitipa, Karonga, Nkhata Bay and Rumphi, have shown low levels of under-five mortality rates compared to all other districts. This corroborates with the low mortality rates for the Northern Region compared to the Central and Southern Regions. CHILD MORTALITY 43 Table 5.3 Early childhood mortality rates by district Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Malawi, 2006 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Malawi Total 37 44 81 64 140 Urban 37 40 77 56 129 Rural 36 45 81 65 141 Region Northern 35 28 63 41 101 Central 39 42 81 75 150 Southern 34 50 85 58 138 District Balaka 39 65 104 63 160 Blantyre 30 43 74 51 121 Chikwawa 33 45 78 75 147 Chiradzulu 47 51 98 67 159 Chitipa 31 21 52 49 99 Dedza 43 36 79 87 160 Dowa 36 32 68 76 139 Karonga 28 24 52 32 83 Kasungu 30 50 80 57 132 Lilongwe 49 44 93 80 166 Machinga 43 36 79 41 117 Mangochi 24 66 90 66 150 Mchinji 24 41 65 73 133 Mulanje 39 39 77 33 107 Mwanza 41 37 78 63 137 Mzimba 44 27 71 47 115 Nkhata Bay 21 37 58 25 81 Nkhotakota 22 36 59 63 118 Nsanje 39 64 103 75 171 Ntcheu 31 55 87 68 149 Ntchisi 27 34 61 62 119 Phalombe 40 64 104 63 161 Rumphi 34 33 67 35 99 Salima 34 43 77 73 144 Thyolo 26 49 75 52 123 Zomba 48 36 85 58 138 CHILD MORTALITY44 31 28 21 22 27 24 34 36 44 30 26 39 34 33 41 43 43 30 48 31 24 49 47 39 39 40 52 52 58 59 61 65 67 68 71 74 75 77 77 78 78 79 79 80 85 87 90 93 98 103 104 104 0 20 40 60 80 100 120 Chitipa Karonga Nkhata Bay Nkhotakota Ntchisi Mchinji Rumphi Dowa Mzimba Blantyre Thyolo Mulanje Salima Chikwawa Mwanza Dedza Machinga Kasungu Zomba Ntcheu Mangochi Lilongwe Chiradzulu Nsanje Balaka Phalombe Infant Mortality Rate Neonatal Mortality Rate Figure 5.2 Infant and neonatal mortality by district, Malawi, 2006 NUTRITION 45 6 NUTRITION Malnutrition remains the world’s most prevalent health problem and the single biggest contributor to child mortality. Nearly one-third of children in the developing world are either underweight or stunted and more than 30 percent of the developing world’s population suffers from micronutrient deficiencies. Malnutrition contributes to more than half of all child deaths from all causes. Unless policies and priorities are changed, the scale of the problem will prevent many countries from achieving the MDGs. This is especially pertinent for sub-Saharan Africa, where malnutrition is increasing. 6.1 NUTRITION STATUS OF CHILDREN Children’s nutritional status is a reflection of their overall health and development. When children have access to adequate food, are not exposed to repeated illness and are well cared for, they reach their growth potential and are considered well nourished. The nutritional well being of young children reflects household, community, and national investments in family health. All of these factors contribute in both direct and indirect ways to a country’s development. Satisfactory nutrition does not only help children to grow, but also saves lives and reduces poverty while advancing human development and economic growth. The assessment of nutritional status is based on the rationale that in a well nourished population there is a statistically predictable distribution of children of a given age with respect to height and weight of the child. Use of a standard reference population makes it possible to analyse any given population over time, as well as to make comparisons among population subgroups. The reference population used in this report is the WHO/CDC/NCHS reference, which is recommended for use by UNICEF and WHO. In MICS 2006, weights and heights of all children under five were measured using standardised anthropometric techniques (UNICEF electronic scale - SECA mother/child electronic scale and infant/child height/length measuring board manufactured by Shorr Production, USA). The indicators used in this report to assess the nutritional status of children under five are height- for-age, weight-for-height and weight-for-age. A child is considered stunted if he or she is too short for his or her age, indicating chronic undernutrition typically due to poor nutrition over an extended period. A child is considered wasted if he or she is too thin, that is, weighs too little for his or her height. Wasting is an indicator of recent acute nutrition deficits and is closely tied to mortality risk. Finally, a child is considered underweight if he or she weighs too little for his or her age. A child can be underweight for his or her age because he or she is stunted, wasted, or both. Almost one in five children under five in Malawi are underweight (21 percent) and 4 percent are severely underweight (Table 6.1a). More than two in five children under the age of five (46 percent) are stunted and almost half of these (21 percent) are severely stunted. Wasting stands at 4 percent with 0.5 percent of children found to be severely wasted. This finding in MICS 2006 indicates that undernutrition rates in Malawi have slightly declined compared with the Malawi Demographic and Health Survey 2004. BEATRICE MTIMUNI & BENSON KAZEMBE NUTRITION46 Background characteristic Weight-for-age (Underweight) Height-for-age (Stunting) Weight-for-height (Wasting) Weight-for- height: % above +2 SD (Overweight) Number of children% below - 2 SD % below -3 SD % below - 2 SD % below - 3 SD % below - 2 SD % below - 3 SD Malawi Total 20.5 3.6 46.0 20.5 3.5 0.5 6.1 20,404 Urban 19.0 3.5 37.5 16.7 5.1 0.4 4.3 3,113 Rural 20.8 3.7 47.5 21.2 3.2 0.5 6.4 17,291 Region Northern 16.5 2.7 39.6 14.5 4.4 0.8 6.8 2,139 Central 22.6 4.0 48.0 22.5 3.9 0.6 5.6 9,357 Southern 19.2 3.5 45.4 19.8 2.9 0.4 6.4 8,907 District Balaka 14.7 2.5 40.9 14.1 2.4 0.5 5.0 475 Blantyre 14.5 2.2 41.6 16.1 1.1 0.1 3.9 1,415 Chikwawa 22.4 4.6 39.1 16.2 6.3 0.9 12.2 603 Chiradzulu 18.4 3.6 45.8 17.1 5.4 0.6 4.5 382 Chitipa 18.8 3.3 38.3 13.7 4.7 0.8 4.0 290 Dedza 29.3 5.8 57.1 27.7 4.6 1.1 4.6 1,192 Dowa 18.1 3.9 42.2 19.9 3.4 0.4 7.9 810 Karonga 13.1 1.4 29.7 11.9 7.6 1.2 7.5 392 Kasungu 18.3 3.1 46.9 18.7 1.9 0.2 5.1 961 Lilongwe 24.0 4.3 46.1 22.5 5.0 0.7 4.9 3,580 Machinga 22.3 4.9 57.0 28.4 2.3 0.1 5.8 766 Mangochi 22.3 4.3 44.0 19.5 1.8 0.1 4.0 1,890 Mchinji 20.9 3.1 57.1 30.6 3.0 0.1 12.6 700 Mulanje 15.6 2.3 42.8 18.7 3.1 0.4 20.2 524 Mwanza 18.4 3.0 50.6 20.6 1.9 0.1 3.9 388 Mzimba 18.3 3.0 46.2 16.4 3.1 0.5 7.6 938 Nkhata Bay 15.8 3.6 37.1 15.7 6.4 1.5 7.8 247 Nkhotakota 21.6 3.9 44.0 21.0 3.6 0.5 6.3 373 Nsanje 24.6 4.2 38.5 13.5 4.1 0.9 2.1 356 Ntcheu 21.4 3.2 50.4 22.5 3.4 0.2 4.4 717 Ntchisi 22.1 4.0 56.2 29.1 1.6 0.2 5.3 276 Phalombe 20.3 3.3 46.8 23.1 4.1 0.4 6.5 406 Rumphi 14.0 1.8 35.0 11.8 2.0 0.6 5.0 272 Salima 19.2 2.7 37.6 13.1 3.1 0.4 2.9 748 Thyolo 19.4 3.2 47.3 22.6 4.9 1.0 6.4 913 Zomba 17.7 3.2 51.5 24.6 2.5 0.4 8.3 790 Table 6.1a Child malnourishment Percentage of under-five children who are severely or moderately undernourished, Malawi, 2006 NUTRITION 47 Table 6.1b Child malnourishment Percentage of under-five children who are severely or moderately undernourished, Malawi, 2006 Background characteristic Weight-for-age (Underweight) Height-for-age (Stunting) Weight-for-height (Wasting) Weight-for- height: % above +2 SD (Overweight) Number of children% below - 2 SD % below -3 SD % below - 2 SD % below - 3 SD % below - 2 SD % below - 3 SD Sex Male 21.5 3.9 47.4 21.7 3.9 0.6 5.6 10,122 Female 19.5 3.3 44.5 19.4 3.1 0.4 6.5 10,283 Age < 6 months 2.4 0.2 11.0 2.6 4.6 0.9 16.1 1,726 6–11 months 16.9 2.7 28.8 8.2 4.7 0.7 9.9 2,423 12–23 months 29.3 6.3 56.7 26.8 5.3 0.7 6.4 4,552 24–35 months 23.5 4.1 49.3 21.7 3.2 0.3 3.4 4,624 36–47 months 19.1 2.7 51.8 24.7 1.7 0.3 3.4 4,095 48–59 months 17.7 2.9 50.7 23.7 2.3 0.4 4.4 2,984 Mother’s education None 24.1 4.3 49.7 23.7 3.6 0.5 5.9 4,780 Primary 20.4 3.6 46.6 20.6 3.3 0.5 6.0 13,360 Secondary + 13.2 2.5 33.9 13.3 4.5 0.7 6.9 2,210 Other 22.0 2.3 49.1 12.3 2.5 0.0 2.6 54 Wealth index quintile Lowest 24.6 4.9 50.2 22.9 4.0 0.6 5.7 4,493 Second 20.0 3.7 49.2 22.2 2.6 0.3 6.7 4,143 Middle 21.1 3.5 46.7 20.8 3.2 0.6 5.9 4,139 Fourth 19.9 3.3 45.7 20.8 4.3 0.5 6.4 3,765 Highest 16.2 2.6 37.1 15.3 3.7 0.6 5.5 3,864 In Malawi, 6 per cent of children under five are estimated to be overweight. Three districts, Mulanje (20 percent), Mchinji (13 percent) and Chikwawa (12 percent), have significantly higher overweight rates than the national average. Overall variations among districts in the levels of overweight range from 2 percent to 20 percent. This may simply be an age distribution phenomena as the standards show “overweight” for those under 6 and 12 months of age at high levels. These data probably reflect the close association between continued and complementary breastfeeding and satisfactory nutrition. There is no rise in overweight with age thereafter. The differential in the prevalence of stunting amongst children under five is significant between urban and rural areas with stunting at 38 percent in urban areas compared to 48 percent in rural areas. There are no significant differences in the levels of underweight between urban (19 percent) and rural (21 percent) children. Children under five in the Southern and Central Regions are slightly more likely to be underweight than in the Northern Region. In contrast, the percentage of wasting is higher in the Northern Region than the other two regions. NUTRITION48 0 10 20 30 40 50 60 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) Pe rc en t Underweight Stunted Wasted There are substantial differences in nutritional status across the 26 districts of the country. Children in Dedza, Nsanje and Lilongwe districts have the highest underweight rates of above 24 percent with the lowest rates in Karonga district (13 percent). Almost half of children under five in seven districts, that is, Dedza, Ntcheu, Ntchisi, Mchinji, Machinga, Mwanza and Zomba, are stunted with a high prevalence of severe stunting as well. Surprisingly, Karonga, Nkhata Bay, Chikwawa, Chiradzulu and Lilongwe have wasting rates above 5 percent, with Blantyre district registering the lowest rate of 1 percent (Map 6.1). Boys appear more likely to be underweight, stunted, and wasted than girls, though the difference is not significant. Those children whose mothers received secondary or higher education are the least likely to be underweight and stunted compared to children of mothers with no education. Although the top wealth index quintile has a third less children who are underweight and a quarter less children who are stunted than the bottom quintile, a mother’s education and behaviour as well as the child’s residential environment are more influential factors to cause malnutrition. This concurs well with findings from industrialised countries where malnutrition is less likely to result from insufficient food than from unhealthy diets dominated by inappropriate food choices and lifestyle practices. Figure 6.1 shows the percentage of children under five who are stunted, wasted and underweight, by age in months. The prevalence of all the three indicators is lowest among infants under six months of age but highest in the 12–23 months age group. The extent of underweight and stunting is lowest for children of less than six months of age, then it increases exponentially from six months and reaches the peak at age of 12–23 months (29 percent and 57 percent respectively). Figure 6.1 Percentage of under-five children undernourished according to age pattern, Malawi, 2006 NUTRITION 49 Map 6.1 Prevalence of underweight (moderate and severe), Malawi, 2006 Kasungu Lilongwe Mchinji Nkhota kota Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Chiradzulu Phalombe Mangochi Balaka Machinga Mwanza Lake Malawi Dedza Ntcheu Likoma Dowa Percent MDG Target (14%) 14.1%–21% (National Average) 21.1%–29.3% Mulanje NUTRITION50 MICS 2006 shows high levels of wasting in children aged 12–23 months (5 percent) and the lowest between those aged 36–47 months (2 percent). The important thing here is the age at which children become malnourished – from three months (or perhaps even from birth) onwards, peaking at 18 months. Yet most nutrition programmes target children over two years of age when damage has already been done. The age pattern shows that deterioration in nutritional status begins within the first two years of life, according to all the three indices (Figure 6.1). This pattern is related to factors such as the initiation of complementary feeding before the sixth month of life, inadequate and micronutrient deficient complementary foods plus exposure to infections through water, food and the environment. The findings clearly indicate that children aged between 12–23 months are more prone to malnutrition than the other under-five age groups. Levels of underweight and wasting drop significantly after 23 months unlike the level of stunting, which remains constantly high as recovery of height is not possible while weight deficit is. 6.2 BREASTFEEDING Breastmilk is the best food and drink for a baby and should be the only food given during the first six months. It provides essential nutrients up to two years of age and beyond. During the first few years of life, breastfeeding protects children from infections, provides an ideal source of nutrients and is economical. However, many mothers stop breastfeeding too soon in the face of pressures to switch to complementary feeding, which traditionally comprises of thin plain porridge. The energy and nutrient density in porridge is low and can contribute to growth faltering and micronutrient malnutrition. The Ministry of Health, in line with other global initiatives such as WFFC, promotes exclusive breastfeeding during the first six months of life and continued breastfeeding with safe, appropriate and adequate complementary feeding for up to two years of age and beyond. 6.2.1 Initiation of breastfeeding Early initiation of breastfeeding determines the successful establishment and duration of breastfeeding. It is recommended that a baby should be put to the breast immediately or within an hour of birth. This stimulates production of breastmilk and colostrum, the first breastmilk. Both are an important source of nutrients and antibodies, providing immunity before the baby’s own immune system matures. Early initiation of breastfeeding also encourages bonding between the mother and the baby. Pre-lactal feeding (giving of liquids or foods other than breastmilk) prior to the establishment of regular breastfeeding exposes the newborn infant to infections as well as depriving him/her of the valuable nutrients and protection provided by colostrum and breastmilk. Table 6.2a records the proportion of women who breastfed their infants within one hour of birth, as well as those who started breastfeeding within one day of birth (including starting within one hour). A high proportion of the children (94 percent) are reported to have been put to the breast within 24 hours of birth while only 58 percent are breastfed within the recommended one hour after birth. NUTRITION 51 Background characteristic Percentage who started breastfeeding within one hour of birth Percentage who started breastfeeding within one day of birth Number of women with live birth in the two years preceding the survey Malawi Total 58.3 93.5 10,552 Urban 65.2 95.7 1,507 Rural 57.1 93.2 9,045 Region Northern 59.2 93.2 1,035 Central 53.7 92.6 4,959 Southern 63.1 94.6 4,557 District Balaka 78.0 96.7 231 Blantyre 73.0 93.8 656 Chikwawa 50.1 95.0 391 Chiradzulu 70.9 93.2 196 Chitipa 38.1 95.6 139 Dedza 36.5 78.0 675 Dowa 69.7 96.9 427 Karonga 49.8 98.3 202 Kasungu 53.6 95.7 456 Lilongwe 49.0 95.5 1,907 Machinga 54.3 87.8 386 Mangochi 67.1 95.5 988 Mchinji 58.0 97.9 379 Mulanje 64.1 94.7 271 Mwanza 58.8 95.6 180 Mzimba 62.3 89.9 452 Nkhata Bay 61.2 92.2 118 Nkhotakota 63.1 96.6 200 Nsanje 69.0 98.0 191 Ntcheu 61.5 87.8 360 Ntchisi 60.7 94.0 139 Phalombe 54.8 90.7 226 Rumphi 85.5 95.1 123 Salima 68.9 92.2 417 Thyolo 71.3 94.8 458 Zomba 39.2 99.5 384 Table 6.2a Initial breastfeeding Percentage of women aged 15–49 years with a birth in the 2 years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Malawi, 2006 Table 6.2a clearly shows significant differences across the districts. In Rumphi, 86 percent of children had been put to the breast within one hour of birth followed by Balaka, Blantyre, Thyolo and Chiradzulu where the rates are over 70 percent. The lowest rates are registered in Dedza (37 percent), followed by Chitipa and Zomba with 38 and 39 percents respectively. NUTRITION52 There are hardly any differences in timing of initiation of breastfeeding based on region of residence (Figure 6.2). Children born in urban areas are more likely to be breastfed within one hour of birth. The difference in the percentage between educated and uneducated women that started breastfeeding within one hour of birth is notable. Women in the top wealth index quintile are more likely to start breastfeeding within one hour of birth. 6.2.2 Age pattern of breastfeeding The Ministry of Health, UNICEF and WHO recommend that children be exclusively breastfed on demand for the first six months of life. That is, fed on breastmilk only with no other liquids including water. Early introduction of other fluids and food reduces breastmilk intake, decreases absorption of nutrients from breastmilk, and increases the risk of common childhood diseases such as diarrhoea and acute respiratory infections. Table 6.3 and figure 6.3 show the detailed breastfeeding pattern based on a child’s age in months. Even within the early months, only 83 percent of infants aged 0–1 month, 61 percent aged 2–3 months and 26 percent aged 4–5 months are exclusively breastfed. This results in poor weight gain and increased infections, and probably contributes to the high post neonatal mortality rate. Table 6.2b Initial breastfeeding Percentage of women aged 15–49 years with a birth in the 2 years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Malawi, 2006 Background characteristic Percentage who started breastfeeding within one hour of birth Percentage who started breastfeeding within one day of birth Number of women with live birth in the two years preceding the survey Months since last birth < 6 months 56.8 93.6 2,436 6–11 months 60.5 94.4 2,812 12–23 months 58.3 93.6 4,964 Mother’s education None 55.1 93.7 2,407 Primary 59.1 93.3 6,912 Secondary + 59.7 94.3 1,213 Other 63.6 95.6 20 Wealth index quintile Lowest 51.2 91.7 2,442 Second 57.0 92.4 2,225 Middle 59.5 95.2 2,164 Fourth 60.3 94.1 1,899 Highest 65.8 94.7 1,822 NUTRITION 53 Figure 6.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Malawi, 2006 Figure 6.3 Infant feeding patterns by age: Percent distribution of children under 3 years by feeding pattern and age group, Malawi, 2006 0 10 20 30 40 50 60 70 80 90 100 0- 1 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 24 -2 5 26 -2 7 28 -2 9 30 -3 1 32 -3 3 34 -3 5 Age (in Months) Pe rce nt Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk/ formula Breastfed and complementary foods Weaned (not breastfed) 94 96 93 93 93 95 94 93 94 92 95 58 65 57 59 54 63 55 59 60 51 66 0 10 20 30 40 50 60 70 80 90 100 Ma law i Urb an Ru ral No rth ern Cen tra l Sou the rn No ed uca tio n Pri ma ry Sec on dar y + Po ore st Ric hes t Pe rc en t Within one day Within one hour NUTRITION54 It is also evident from table 6.3 that the duration of breastfeeding is about 24 months by which period 55 percent of the children are completely weaned from the breast. By end of 35 months practically all children have been weaned off. Formula is hardly used and hence insignificant (0.2 percent). In Malawi, the use of formula, particularly using a bottle with a nipple, is not recommended. 6.2.3 Breastfeeding status The results on breastfeeding status presented in table 6.4a are based on mother/caretaker recall of their children’s food and fluid consumption over 24 hours (previous day and night) prior to the interviews. The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0–3 months and 0–5 months), as well as complementary feeding of children 6–9 months and continued breastfeeding of children at 12–15 and 20–23 months of age. Age Infant feeding pattern Total Number of childrenExclusively breastfed Breastfed and plain water only Breastfed and non- milk liquids Breastfed and other milk/ formula Breastfed and complementary foods Weaned (not breastfed) 0–1 83.4 5.6 7.0 0.6 1.1 2.3 100.0 788 2–3 60.8 14.8 6.7 1.1 15.2 1.5 100.0 772 4–5 26.3 8.8 6.7 0.5 56.6 1.1 100.0 793 6–7 6.4 5.3 2.6 0.5 84.1 1.1 100.0 832 8–9 1.4 2.5 2.2 0.4 93.0 0.4 100.0 923 10–11 1.4 2.6 1.6 0.1 91.3 3.0 100.0 918 12–13 0.7 1.7 2.0 0.1 93.6 1.9 100.0 933 14–15 0.4 2.6 2.0 0.3 91.4 3.3 100.0 908 16–17 1.5 1.3 3.0 0.2 87.5 6.7 100.0 830 18–19 0.2 1.7 1.3 0.0 85.8 10.9 100.0 799 20–21 0.2 0.6 1.0 0.0 76.8 21.3 100.0 814 22–23 0.0 0.8 1.1 0.3 63.4 34.4 100.0 795 24–25 0.1 1.5 1.1 0.3 42.5 54.6 100.0 852 26–27 0.0 0.9 0.4 0.0 26.4 72.4 100.0 918 28–29 0.0 0.6 0.1 0.0 19.5 79.8 100.0 886 30–31 0.0 0.0 0.0 0.0 13.3 86.6 100.0 826 32–33 0.2 0.0 0.0 0.0 8.3 91.5 100.0 792 34–35 0.0 0.1 0.0 0.0 5.6 94.3 100.0 753 Total 9.5 2.8 2.1 0.2 54.2 31.1 100.0 15,133 Table 6.3 Infant feeding patterns by age Percent distribution of children aged under 3 years by feeding pattern and age group, Malawi, 2006 NUTRITION 55 In table 6.4a ‘exclusively breastfed’ refers to infants who received only breastmilk (vitamins and mineral supplements or medicines may be taken). The results reveal that exclusive breastfeeding is not fully practised, as only 72 percent of 0–3 month old infants are exclusively breastfed and the highest proportion is for children from Kasungu (87 percent) while the lowest is from Karonga (42 percent). For all of the infants under six months of age (0–5 month category), only 57 percent are exclusively breastfed. Phalombe registers the highest proportion of 72 percent while Mwanza registers the lowest with only 36 percent. It follows that the proportion of infants that are exclusively breastfed significantly declines after as soon as the first month of life, as also shown in figure 6.3. National exclusive breastfeeding rates of 72 for 0–3 months and 57 percent for 0–5 months show a steady improvement since 1990, when exclusive breastfeeding for the first four months was only 3 percent. This can be attributed to the increased emphasis by the Ministry of Health for all health facilities to attain the Baby Friendly Hospital Initiative. However, more attention is needed in those districts like Karonga, Mchinji and Mwanza where exclusive breastfeeding rates are less than 50 percent (Map 6.2). Infants from the Northern Region (52 percent) are less likely to be exclusively breastfed than those from the Central Region (56 percent) and the Southern Region (59 percent) for the first six months. Likewise, urban children (68 percent) are more likely to be exclusively breastfed than those from rural areas (55 percent). This may be related to a combination of higher levels of mother’s education and the fact that some urban households are in the highest income quintile. There are no differences on breastfeeding practices between boys and girls but significant differences are seen between wealthy families, with a 63 percent exclusive breastfeeding rate, and the poorest families, with an exclusive breastfeeding rate of 51 percent (Table 6.4b). Mothers with secondary education and higher are more likely to exclusively breastfeed their children (62 percent) compared to mothers with no education (57 percent). Presented in figure 6.4 is the proportion of children aged below six months who are exclusively breastfed at the time of the survey, by age. The results show that exclusive breastfeeding declines Figure 6.4 Proportion of children aged below 6 months who were exclusively breastfed by age, Malawi, 2006 86 81 74 50 35 17 0 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 5 Age in m onths Pe rce nt NUTRITION56 Map 6.2 Exclusive breastfeeding rate (6 months), Malawi, 2006 Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Chiradzulu Phalombe Mangochi Balaka Machinga Mwanza Lake Malawi Nkhota kota Percent Below National Average (57%) 57%–65% Above 65% Mulanje Dedza Ntcheu Likoma NUTRITION 57 Table 6.4a Breastfeeding status Percent of living children according to breastfeeding status by each age group, Malawi, 2006 B ac kg ro u n d ch ar ac te ri st ic Children 0–3 months Children 0–5 months Children 6–9 months Children 12–15 months Children 20–23 months Pe rc en t ex cl u si ve ly b re as tf ed N u m b er o f ch ild re n Pe rc en t ex cl u si ve ly b re as tf ed N u m b er o f ch ild re n Pe rc en t re ce iv in g b re as tm ilk a n d so lid / m u sh y fo o d N u m b er o f ch ild re n Pe rc en t b re as tf ed N u m b er o f ch ild re n Pe rc en t b re as tf ed N u m b er o f ch ild re n Malawi Total 72.2 1,560 56.7 2,353 88.8 1,755 97.4 1,841 72.2 1,609 Urban 80.0 272 68.2 356 88.8 311 95.9 246 62.6 266 Rural 70.5 1,288 54.7 1,997 88.7 1,444 97.6 1,596 74.1 1,343 Region Northern 62.0 148 51.6 220 84.8 158 97.4 171 76.3 175 Central 72.5 733 55.7 1,090 88.5 848 98.2 857 73.0 752 Southern 74.1 679 58.9 1,043 89.9 748 96.6 814 70.3 682 District Balaka 74.0 32 60.0 51 86.8 36 99.0 43 71.4 34 Blantyre 78.1 117 58.6 169 91.4 117 91.2 102 (66.1) 96 Chikwawa 67.7 72 57.8 106 93.5 69 96.3 65 (84.9) 38 Chiradzulu 71.4 27 58.9 42 88.1 25 98.6 35 74.7 27 Chitipa 71.5 22 63.4 30 65.9 20 97.8 26 71.0 22 Dedza 79.1 91 64.9 133 85.5 80 98.7 152 75.1 101 Dowa 79.8 64 61.4 95 93.6 74 99.2 61 76.0 64 Karonga 42.0 30 41.1 48 82.5 37 97.0 30 66.9 34 Kasungu 86.9 67 67.1 104 79.9 66 98.0 77 78.4 74 Lilongwe 74.2 295 53.9 441 88.3 394 99.3 305 69.8 291 Machinga 64.9 56 48.0 87 84.1 69 98.4 64 70.5 56 Mangochi 81.9 136 61.8 229 92.8 176 95.2 197 63.2 148 Mchinji 48.8 58 42.1 90 (78.5) 43 98.0 70 67.7 56 Mulanje (71.6) 43 64.6 58 (93.5) 41 96.5 54 (74.5) 40 Mwanza 48.4 24 36.2 37 93.6 27 96.0 28 74.1 28 Mzimba 59.0 60 45.9 84 90.2 62 98.4 77 80.3 78 Nkhata Bay (69.7) 16 54.7 26 (78.9) 16 91.2 19 82.7 21 Nkhotakota 74.2 29 60.5 42 88.0 32 93.3 41 68.3 27 Nsanje 73.3 23 56.2 37 84.4 30 100.0 31 84.7 31 Ntcheu 70.7 56 55.7 75 91.9 57 96.9 67 79.1 55 Ntchisi 81.8 15 65.9 25 83.1 21 98.2 25 85.4 26 Phalombe 82.1 32 72.1 45 94.2 39 99.4 35 70.5 40 Rumphi 85.2 19 68.6 32 94.1 23 100.0 18 76.1 21 Salima 51.2 58 39.7 85 98.9 81 95.1 60 71.0 58 Thyolo 73.0 68 63.1 105 (77.4) 57 98.7 95 74.3 89 Zomba (76.1) 48 58.0 77 91.4 63 99.0 66 64.7 57 Note: Figures in parantheses are based on 25–49 unweighted cases. NUTRITION58 Table 6.4b Breastfeeding status Percent of living children according to breastfeeding status by each age group, Malawi, 2006 B ac kg ro u n d ch ar ac te ri st ic Children 0–3 months Children 0–5 months Children 6–9 months Children 12–15 months Children 20–23 months Pe rc en t ex cl u si ve ly b re as tf ed N u m b er o f ch ild re n Pe rc en t ex cl u si ve ly b re as tf ed N u m b er o f ch ild re n Pe rc en t re ce iv in g b re as tm ilk an d s o lid / m u sh y fo o d N u m b er o f ch ild re n Pe rc en t b re as tf ed N u m b er o f ch ild re n Pe rc en t b re as tf ed N u m b er o f ch ild re n Sex Male 72.8 760 58.3 1,114 88.7 900 97.8 926 70.5 788 Female 71.6 800 55.3 1,239 88.8 855 97.0 916 73.9 821 Mother’s education None 72.5 338 57.3 513 89.9 451 95.2 399 72.0 374 Primary 71.1 1,007 55.4 1,533 87.8 1,094 98.4 1,221 72.5 1,047 Secondary + 76.8 213 62.2 304 91.3 202 95.8 219 71.3 185 Other 78.5 2 65.7 3 89.0 8 100.0 2 73.9 3 Wealth index quintile Lowest 68.2 348 50.7 552 89.2 394 98.1 450 83.3 332 Second 74.5 299 54.7 484 84.3 376 97.5 354 70.7 362 Middle 64.2 320 53.3 475 91.2 369 97.6 412 69.0 297 Fourth 76.4 294 64.6 412 90.2 279 97.0 330 70.1 353 Highest 79.0 298 63.0 430 89.3 336 96.4 296 66.9 265 gradually and significantly by the fourth month of age. By the end of the fifth month, the percentage of children exclusively breastfed is 17 percent. The early introduction of complimentary foods exposes these infants to pathogens and accounts for the high incidence of diarrhoeal disease, as well as the precipitous fall in nutritional status that starts by the age of six months and continues throughout the first two years of life. Optimal infant and young child feeding practices include continued and frequent on-demand breastfeeding for children aged 6–23 months and beyond. Continued breastfeeding is important for older infants (6–11 months) as well as for young children (12 months and older). For older infants, breastmilk remains an important source of energy, protein, micronutrients particularly Vitamin A, Vitamin C and essential fatty acids while for young children, breastmilk can provide as much as 35–40 percent of total energy needs. Tables 6.4a and 6.4b also give indication of the proportions of children aged 6–23 months receiving breastmilk and other foods. At age 6–9 months, 89 percent of children are receiving breastmilk and solid or semi-solid foods. By age 12–15 months, 97 percent of children (all children in Nsanje and NUTRITION 59 Rumphi) continue to be breastfed. A significant proportion of the children are completely weaned off the breast by age 20–23 months, with only 72 percent still being breastfed in combination with solid and semi-solid foods. The likelihood of a child being completely weaned off the breast by 23 months is higher in urban areas (only 63 percent still being breastfed), compared to 74 percent of rural children who are still being breastfed. 6.2.4 Adequately fed infants The information on adequacy of infant feeding in children less than 12 months is provided in tables 6.5a and 6.5b. Different criteria for assessing adequacy of feeding are used depending on the age of the child. For infants aged 0–5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6–8 months are considered to be adequately fed when they are receiving breastmilk on demand and complementary food at least two times per day, while infants aged 9–11 months are considered to be adequately fed when they are receiving breastmilk and eating complementary food at least three times a day. Table 6.5a shows that only 57 percent of infants less than 6 months are adequately and appropriately fed. The results also show that 70 percent of infants aged 6–8 months and 44 percent of those aged 9–11 months are adequately fed. Overall, only 56 percent of the infants aged 6–11 months or 0–11 months are adequately fed. This dilemma is contributing to a steady increase in the proportion of infants that become malnourished with increasing age. There are wide variations and inconsistencies among the districts. In Salima, only 40 percent of infants below six months are adequately fed compared to 85 percent of those aged 6–8 months. Likewise in Chitipa, 63 percent of children aged 0–5 months receive adequate feeding compared to only 43 percent of those aged 6–8 months. The variations and inconsistencies indicate inadequacies that exist in knowledge and practices in appropriate infant feeding. Children of mothers with secondary school education consistently show higher rates of feeding frequency than the mean for all the age groups (62 percent against 57 percent for infants aged 0–5 months; 72 percent against 65 percent for infants aged 6–8 month and 61 percent against 40 percent for infants in the 9–11 month age group). In general, except for those in the 9–11 month age category, urban infants are more likely to be adequately fed than those living in rural areas. Rates displayed within wealth index quintiles are equally inconsistent, indicating that appropriate feeding may not necessarily be associated with having money. NUTRITION60 Table 6.5a Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6–11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, Malawi, 2006 Background characteristic 0–5 months exclusively breastfed 6–8 months who received breastmilk and com- plementary food at least 2 times in prior 24 hours 9–11 months who received breastmilk and com- plementary food at least 2 times in prior 24 hours 6–11 months who received breastmilk and complementary food at least the minimum recommended number of times per day 0–11 months who were app- ropriately fed Number of infants aged 0–11 months Malawi Total 56.7 69.5 43.7 55.7 56.2 5,026 Urban 68.2 73.8 43.5 59.6 63.6 759 Rural 54.7 68.6 43.7 55.0 54.8 4,267 Region Northern 51.6 69.2 56.9 62.8 57.6 470 Central 55.7 67.3 38.9 52.4 53.9 2,363 Southern 58.9 72.3 45.9 57.7 58.3 2,192 District Balaka 60.0 65.4 50.4 58.0 59.0 103 Blantyre 58.6 78.0 37.7 56.0 57.3 348 Chikwawa 57.8 77.8 44.3 62.5 59.9 196 Chiradzulu 58.9 77.4 48.5 58.2 58.5 87 Chitipa 63.4 43.0 21.8 32.4 47.2 63 Dedza 64.9 54.8 33.3 40.0 51.7 284 Dowa 61.4 60.2 40.6 48.2 54.0 214 Karonga 41.1 64.6 48.4 57.1 49.4 99 Kasungu 67.1 65.2 42.1 51.8 59.5 206 Lilongwe 53.9 66.9 31.6 51.5 52.6 971 Machinga 48.0 66.4 44.1 53.2 50.9 195 Mangochi 61.8 66.1 46.8 55.9 58.6 493 Mchinji 42.1 73.3 54.6 62.0 51.6 172 Mulanje 64.6 75.6 20.0 43.5 53.3 124 Mwanza 36.2 67.4 19.3 38.0 37.2 85 Mzimba 45.9 78.4 69.2 72.8 61.2 196 Nkhata Bay 54.7 63.1 56.1 60.1 57.2 50 Nkhotakota 60.5 70.5 48.6 59.3 59.9 87 Nsanje 56.2 67.4 38.0 52.4 54.1 83 Ntcheu 55.7 66.2 43.7 54.7 55.2 168 Ntchisi 65.9 62.6 52.3 56.6 60.5 59 Phalombe 72.1 75.2 43.8 57.1 63.7 102 Rumphi 68.6 81.2 52.8 71.2 69.9 62 Salima 39.7 84.8 46.6 64.7 54.2 203 Thyolo 63.1 70.6 62.7 65.5 64.3 204 Zomba 58.0 82.1 79.7 80.9 70.8 173 NUTRITION 61 Table 6.5b Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6–11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, Malawi, 2006 Background characteristic 0–5 months exclusively breastfed 6–8 months who received breastmilk and com- plementary food at least 2 times in prior 24 hours 9–11 months who received breastmilk and com- plementary food at least 2 times in prior 24 hours 6–11 months who received breastmilk and complementary food at least the minimum recommended number of times per day 0–11 months who were app- ropriately fed Number of infants aged 0–11 months Sex Male 58.3 71.1 41.2 55.9 57.0 2,443 Female 55.3 67.8 45.9 55.5 55.4 2,583 Mother’s education None 57.3 65.1 39.6 51.5 54.0 1,178 Primary 55.4 70.8 42.5 55.3 55.4 3,238 Secondary + 62.2 72.2 61.4 67.0 64.6 599 Other 65.7 66.1 0.0 66.1 66.0 11 Wealth index quintile Lowest 50.7 68.0 34.9 50.6 50.6 1,163 Second 54.7 63.8 45.6 53.8 54.2 1,052 Middle 53.3 74.9 45.0 58.9 56.3 1,039 Fourth 64.6 69.4 40.3 52.7 58.3 864 Highest 63.0 71.9 54.9 63.4 63.2 907 6.3 MICRONUTRIENTS Over the last few years, there has been a growing interest in micronutrient nutrition. One of the main reasons for this is the realisation that the prevalence of micronutrient malnutrition continues to be high and that effective interventions exist to virtually eliminate it. While micronutrient deficiencies are certainly found to be more frequent and severe among disadvantaged people, they also contribute to public health problems in some industrialised countries. In 2000, the World Health Report identified deficiencies in iodine, iron, Vitamin A and zinc to be among the world’s most serious health risk factors. In addition to the more obvious clinical manifestations, micronutrient malnutrition is responsible for a wide range of non-specific physiological impairments, leading to reduced resistance to infections, metabolic disorders and delayed or impaired physical, mental and psychomotor development. The public health implications of micronutrient malnutrition are potentially huge and are especially significant when it comes to designing strategies for the prevention and control of chronic diseases related to diet. NUTRITION62 The micronutrient disorders that currently constitute a public health concern in Malawi are deficiencies of Vitamin A, iodine and iron/folate. The only national micronutrient survey conducted in 2001 revealed that 59 percent of children under five, 57 percent of non-pregnant women, 38 percent of school aged children and 37 percent of men had sub-clinical Vitamin A deficiency. In addition, 80 percent of children under five, 27 percent of non-pregnant women, 22 percent of school aged children and 17 percent of men were found to have anaemia (MOHP, NSO, UNICEF, CDC, 2003). Deficiencies of key vitamins and minerals continue to be pervasive and they overlap considerably with problems of general undernutrition (underweight and stunting). Hence, in MICS 2006, data were collected to assess Vitamin A supplementation coverage, iodine status in household salt, storage of salt at home, knowledge of iodised salt and source of information for iodised salt. 6.3.1 Vitamin A supplementation Vitamin A is essential for good vision, proper functioning of the immune system, growth, development and reproduction. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables. The amount of Vitamin A readily available to the body from these sources varies widely. Vitamin A Deficiency Disorders (VADD) is the comprehensive term covering the effects of the deficiency. Vitamin A supplements have been shown to improve immunity and to significantly reduce mortality in infants and young children. The Ministry of Health’s policy with this regard is to supplement children aged 6 to 59 months with a Vitamin A capsule once every six months. Vitamin A supplementation is linked to immunisation services and Vitamin A is given when the child has contact with these services after six months of age. It is also recommended that mothers take a Vitamin A supplement within eight weeks of giving birth due to increased micronutrient requirements during pregnancy and lactation, as well as to provide adequate Vitamin A to their infants in breastmilk. 6.3.1.1 Vitamin A supplementation among children under five Table 6.6a shows that 69 percent of children aged 6–59 months received a Vitamin A supplement six months prior to the survey. Approximately 16 percent did not receive the supplement within the last six months but did receive one prior to that time. About 8 percent of children received a Vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when. Only 7 percent of children never received Vitamin A. The coverage of Vitamin A supplementation was reported higher in the Southern Region (72 percent) where, compared to other regions, coverage was higher on child health days. There were no differences between urban and rural children in terms of the proportion who had received Vitamin A supplements in the last six months prior to MICS 2006. The age pattern of Vitamin A supplementation shows that supplementation in the six months prior to the survey rose from 71 percent among children aged 6–11 months to 76 percent among children aged 12–23 months and then declined steadily with age to 58 percent among the oldest children (Table 6.6b). The coverage of Vitamin A supplementation declines after the child’s second year of life, reflecting the decline in attendance of older children at growth monitoring and promotion centres. However, earlier ages are of greater importance as the child is more susceptible to illness NUTRITION 63 Table 6.6a Children’s Vitamin A supplementation Percent distribution of children aged 6–59 months by whether they received a high dose Vitamin A supplement in the last 6 months, Malawi, 2006 Background characteristic Percent of children who received Vitamin A: Total Number of children aged 6–59 months Within last 6 months Prior to last 6 months Not sure when Total received Not sure if received Never received Vitamin A Missing Malawi Total 68.5 15.6 8.3 92.4 0.7 6.9 0.1 100.0 20,641 Urban 67.7 16.6 9.3 93.6 0.7 5.7 0.1 100.0 3,011 Rural 68.6 15.5 8.1 92.2 0.6 7.1 0.1 100.0 17,631 Region Northern 65.5 13.9 13.7 93.1 1.4 5.5 0.0 100.0 2,095 Central 65.7 17.0 9.2 91.9 0.6 7.5 0.0 100.0 9,479 Southern 72.0 14.6 6.2 92.8 0.5 6.5 0.2 100.0 9,068 District Balaka 82.0 8.6 4.0 94.6 0.3 5.0 0.1 100.0 448 Blantyre 78.2 6.2 6.6 91.0 0.9 8.0 0.1 100.0 1,358 Chikwawa 73.5 17.3 5.9 96.7 0.2 2.8 0.3 100.0 695 Chiradzulu 72.4 9.6 10.2 92.2 0.2 7.5 0.1 100.0 391 Chitipa 64.2 9.0 20.6 93.8 0.7 5.4 0.0 100.0 283 Dedza 66.3 11.4 9.3 87.0 0.0 13.0 0.0 100.0 1,211 Dowa 58.7 19.7 5.6 84.0 0.3 15.8 0.0 100.0 848 Karonga 73.0 9.1 12.4 94.5 1.6 3.9 0.0 100.0 402 Kasungu 59.5 26.4 7.5 93.4 0.8 5.8 0.0 100.0 922 Lilongwe 64.0 18.0 11.2 93.2 0.8 6.0 0.0 100.0 3,524 Machinga 77.4 6.5 8.3 92.2 0.4 7.2 0.2 100.0 784 Mangochi 58.7 23.7 8.7 91.1 0.9 7.7 0.4 100.0 1,957 Mchinji 78.1 12.6 3.8 94.5 0.4 5.0 0.0 100.0 771 Mulanje 64.0 26.3 2.2 92.5 0.6 6.9 0.0 100.0 575 Mwanza 81.9 9.3 4.2 95.4 0.3 4.3 0.1 100.0 375 Mzimba 64.6 15.5 13.2 93.3 1.9 4.8 0.0 100.0 910 Nkhata Bay 59.5 19.2 17.1 95.8 0.7 3.4 0.1 100.0 244 Nkhotakota 62.5 21.4 7.7 91.6 1.3 7.2 0.0 100.0 388 Nsanje 79.7 11.1 4.1 94.9 0.0 5.1 0.0 100.0 366 Ntcheu 67.4 8.0 18.9 94.3 1.3 4.4 0.0 100.0 719 Ntchisi 70.8 20.1 3.3 94.2 0.3 5.6 0.0 100.0 270 Phalombe 56.2 21.6 10.2 88.0 0.5 11.3 0.2 100.0 434 Rumphi 64.4 15.7 6.5 86.6 0.7 12.7 0.0 100.0 255 Salima 73.3 16.5 4.8 94.6 0.0 5.2 0.1 100.0 826 Thyolo 75.6 14.9 5.0 95.5 0.7 3.9 0.0 100.0 909 Zomba 84.2 9.6 0.2 94.0 0.1 5.8 0.0 100.0 775 NUTRITION64 then and diet is also more limited. Table 6.6b also shows that neither maternal education nor wealth affect the likelihood of a child receiving Vitamin A. Table 6.7a shows that half of the children receive a Vitamin A supplement during routine visits to health facilities and 44 percent during national campaigns or child health days. There is a sharp decline in children receiving routine Vitamin A supplements between those aged 6–11 months and those aged 48–59 months (Table 6.7b). The role played by child health days may be quite significant for Vitamin A supplementation in children under five. This is particularly so for those aged 12–59 months as indicated by the sharp increase in routine supplementation. Districts display significant variations in their routine Vitamin A supplementation, ranging from above 70 percent (Mzimba, Chikwawa and Ntchisi) to below 30 percent (Thyolo, Blantyre, Chiradzulu and Machinga). This gives a clear indication of priorities for improvement in health services in these districts (Map 6.3). Variations in Vitamin A supplementation rates by mother’s level of education, socio-economic status and the sex of the child are quite minimal (Table 6.7b) Table 6.6b Children’s Vitamin A supplementation Percent distribution of children aged 6–59 months by whether they received a high dose Vitamin A supplement in the last 6 months, Malawi, 2006 Background characteristic Percent of children who received Vitamin A: Total Number of children aged 6–59 months Within last 6 months Prior to last 6 months Not sure when Total Received Not sure if received Never received Vitamin A Missing Sex Male 68.6 15.4 8.5 92.5 0.7 6.7 0.1 100.0 10,254 Female 68.3 15.9 8.1 92.3 0.6 7.1 0.1 100.0 10,387 Age 6–11 months 71.1 4.1 2.5 77.7 0.2 21.9 0.2 100.0 2,673 12–23 months 76.0 11.2 5.4 92.6 0.2 7.0 0.1 100.0 5,080 24–35 months 70.3 17.5 7.8 95.6 0.5 3.9 0.1 100.0 5,027 36–47 months 64.5 19.8 11.0 95.3 1.0 3.6 0.0 100.0 4,540 48–59 months 57.5 23.2 14.4 95.1 1.3 3.6 0.0 100.0 3,322 Mother’s education None 66.4 16.2 8.3 90.9 0.8 8.2 0.0 100.0 5,100 Primary 69.0 15.1 8.5 92.6 0.7 6.7 0.1 100.0 13,343 Secondary + 69.9 17.9 6.8 94.6 0.4 5.0 0.0 100.0 2,138 Other 68.0 9.4 13.1 90.5 0.0 9.5 0.0 100.0 61 Wealth index quintile Lowest 67.6 15.0 8.5 91.1 0.4 8.5 0.0 100.0 4,560 Second 68.1 14.7 9.6 92.4 0.4 7.2 0.0 100.0 4,202 Middle 69.6 15.5 7.4 92.5 0.8 6.6 0.1 100.0 4,262 Fourth 67.5 18.3 7.5 93.3 0.6 5.9 0.2 100.0 3,831 Highest 69.7 15.0 8.4 93.1 1.0 5.8 0.1 100.0 3,787 NUTRITION 65 Map 6.3 Proportion of children 6–59 months who received a high dose vitamin A supplement within the last 6 months, Malawi, 2006 Dedza Dowa Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Mulanje Chiradzulu Phalombe Mangochi Ntcheu Balaka Machinga Mwanza Lake Malawi Nkhota kota Percent Below National Average (69%) 69%–75% Above 75% Likoma NUTRITION66 Table 6.7a Source of children’s Vitamin A supplementation Percent distribution of children aged 6–59 months who ever received Vitamin A by source of last Vitamin A dose, Malawi, 2006 Background characteristic Place child got last Vitamin A dose Total Number of children aged 6–59 months who ever received Vitamin A On routine visit to health centre Sick child visit to health centre National immunisation day campaign Other DK Missing Malawi Total 50.4 4.0 43.6 1.8 0.1 0.1 100.0 19,088 Urban 46.2 1.9 51.2 0.4 0.1 0.2 100.0 2,818 Rural 51.1 4.3 42.3 2.1 0.1 0.1 100.0 16,270 Region Northern 63.8 1.4 34.3 0.2 0.1 0.2 100.0 1,950 Central 54.5 5.1 38.5 1.7 0.1 0.1 100.0 8,710 Southern 43.1 3.4 51.0 2.3 0.1 0.1 100.0 8,428 District Balaka 31.4 5.5 62.8 0.1 0.0 0.3 100.0 424 Blantyre 18.0 3.5 77.5 0.4 0.4 0.1 100.0 1,237 Chikwawa 70.1 1.2 28.2 0.1 0.1 0.2 100.0 675 Chiradzulu 29.6 1.1 68.9 0.4 0.0 0.0 100.0 361 Chitipa 54.9 1.1 43.6 0.3 0.1 0.0 100.0 265 Dedza 58.8 5.2 35.8 0.2 0.0 0.0 100.0 1,054 Dowa 47.4 5.7 46.5 0.2 0.1 0.0 100.0 712 Karonga 45.5 2.7 50.8 0.3 0.4 0.3 100.0 380 Kasungu 56.0 9.5 33.7 0.8 0.0 0.0 100.0 861 Lilongwe 53.0 3.3 39.7 3.7 0.1 0.2 100.0 3,285 Machinga 23.8 0.9 75.1 0.1 0.0 0.0 100.0 725 Mangochi 64.1 1.1 25.7 9.2 0.0 0.0 100.0 1,790 Mchinji 53.7 7.5 37.9 0.9 0.0 0.1 100.0 729 Mulanje 67.3 5.2 27.0 0.4 0.0 0.0 100.0 532 Mwanza 34.4 1.5 63.8 0.0 0.2 0.0 100.0 358 Mzimba 75.1 0.2 24.6 0.1 0.0 0.0 100.0 850 Nkhata Bay 60.4 4.9 33.5 0.0 0.2 1.0 100.0 234 Nkhotakota 53.7 2.5 42.7 0.9 0.2 0.0 100.0 355 Nsanje 60.8 0.7 37.9 0.4 0.0 0.3 100.0 348 Ntcheu 53.4 4.3 42.1 0.1 0.1 0.0 100.0 679 Ntchisi 74.4 2.7 21.1 1.5 0.1 0.3 100.0 254 Phalombe 54.1 19.2 25.2 1.3 0.0 0.3 100.0 383 Rumphi 66.0 0.4 33.3 0.2 0.0 0.0 100.0 221 Salima 55.8 7.2 36.8 0.2 0.0 0.0 100.0 782 Thyolo 25.5 3.4 70.1 0.7 0.1 0.1 100.0 868 Zomba 35.0 6.5 57.4 0.7 0.0 0.5 100.0 729 NUTRITION 67 Table 6.7b Source of children’s Vitamin A supplementation Percent distribution of children aged 6–59 months who ever received Vitamin A by source of last Vitamin A dose, Malawi, 2006 Background characteristic Place child got last Vitamin A dose Total Number of children aged 6–59 months who ever received Vitamin A On routine visit to health centre Sick child visit to health centre National immunisation day campaign Other DK Missing Sex Male 50.9 3.9 43.2 1.8 0.1 0.1 100.0 9,499 Female 50.0 4.0 44.0 1.8 0.1 0.1 100.0 9,589 Age 6–11 months 72.2 5.5 21.0 1.3 0.0 0.1 100.0 2,082 12–23 months 59.5 3.6 35.3 1.5 0.0 0.1 100.0 4,713 24–35 months 48.5 3.6 46.2 1.5 0.1 0.2 100.0 4,803 36–47 months 41.5 4.1 51.6 2.4 0.2 0.1 100.0 4,331 48–59 months 37.7 3.9 55.9 2.2 0.2 0.1 100.0 3,159 Mother’s education None 52.8 5.3 38.4 3.2 0.1 0.1 100.0 4,645 Primary 50.2 3.6 44.6 1.4 0.1 0.1 100.0 12,366 Secondary 46.4 2.7 49.3 1.1 0.2 0.3 100.0 2,023 Other 35.4 14.7 49.9 0.0 0.0 0.0 100.0 55 Wealth index quintile Lowest 55.8 4.0 37.4 2.5 0.1 0.1 100.0 4,153 Second 50.6 4.5 42.7 2.0 0.1 0.1 100.0 3,883 Middle 48.4 3.8 45.8 1.8 0.0 0.2 100.0 3,944 Fourth 49.9 4.5 43.8 1.6 0.1 0.1 100.0 3,580 Highest 46.6 3.0 49.2 1.0 0.2 0.1 100.0 3,529 6.3.1.2 Vitamin A supplementation among women Pregnancy and lactation require extra Vitamin A and can strain a woman’s nutritional status as well as her micronutrient stores. Providing Vitamin A supplements to postpartum mothers helps to boost and replenish these stores and ensures that babies receive adequate amounts of this vital micronutrient in breastmilk. Table 6.8a shows that 46 percent of mothers aged 15–49 years in the two years prior to MICS 2006 received a Vitamin A supplement within eight weeks of the postnatal period. Supplementation is significantly higher in urban areas (53 percent), in the Northern Region (57 percent) and among women with more education (58 percent). Almost half of postpartum women are not receiving Vitamin A despite countrywide implementation of the supplementation programme. Variations among the districts are quite substantial, ranging from 27 percent (Phalombe) to 70 percent (Karonga). Greater efforts are needed to ensure that postpartum mothers receive Vitamin A supplements either at delivery or during their postpartum examination. NUTRITION68 Table 6.8a Post-partum mother’s Vitamin A supplementation Percentage of women aged 15–49 years with a birth in the two years preceding the survey whether they received a high dose Vitamin A supplement before the infant was 8 weeks old, Malawi, 2006 Background characteristic Received Vitamin A supplement Not sure if received Vitamin A Number of women aged 15–49 years Malawi Total 45.6 0.9 10,552 Urban 52.8 0.9 1,507 Rural 44.3 0.9 9,045 Region Northern 57.0 1.4 1,035 Central 43.5 1.0 4,959 Southern 45.2 0.7 4,557 District Balaka 39.1 1.3 231 Blantyre 50.7 0.4 656 Chikwawa 62.9 0.8 391 Chiradzulu 30.9 0.5 196 Chitipa 47.0 0.7 139 Dedza 31.3 1.4 675 Dowa 39.9 0.7 427 Karonga 69.7 1.5 202 Kasungu 48.0 0.5 456 Lilongwe 43.5 1.4 1,907 Machinga 46.4 0.2 386 Mangochi 31.6 1.1 988 Mchinji 61.9 0.8 379 Mulanje 50.0 0.9 271 Mwanza 61.5 1.8 180 Mzimba 53.4 1.7 452 Nkhata Bay 64.6 2.4 118 Nkhotakota 38.9 0.4 200 Nsanje 40.5 0.3 191 Ntcheu 38.2 1.5 360 Ntchisi 54.1 0.3 139 Phalombe 26.5 0.0 226 Rumphi 53.1 0.4 123 Salima 48.8 0.1 417 Thyolo 59.4 1.2 458 Zomba 47.7 0.0 384 NUTRITION 69 Table 6.8b Post-partum mother’s Vitamin A supplementation Percentage of women aged 15–49 years with a birth in the two years preceding the survey whether they received a high dose Vitamin A supplement before the infant was 8 weeks old, Malawi, 2006 Background characteristic Received Vitamin A supplement Not sure if received Vitamin A Number of women aged 15–49 years Education None 40.6 1.2 2,407 Primary 45.2 0.9 6,912 Secondary + 57.6 0.6 1,213 Other 41.5 0.0 20 Wealth index quintile Lowest 42.8 1.0 2,442 Second 43.9 1.0 2,225 Middle 44.2 0.4 2,164 Fourth 44.9 0.9 1,899 Highest 53.5 1.4 1,822 6.3.2 Iodine Status of household salt The human body requires only about a teaspoon of iodine during the course of a life time but iodine cannot be stored in the body for long periods. Tiny and regular amounts are required for good health. Iodine Deficiency Disorders (IDD) are the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children, resulting in poor school performance, reduced intellectual ability and impaired work performance. In its most extreme form, iodine deficiency causes cretinism. Iodine deficiency is most commonly and visibly associated with goitre. It also increases the risks of stillbirth and miscarriage in pregnant women and deaf mutism in newborns. 6.3.2.1 Consumption of iodised salt The iodine content of household salt can be tested using rapid test kits based on the reaction of potassium iodate to starch, causing the blue colour. The colour change evaluation can be used to log iodine content based on the darkness of the colour change. Salt was tested in 81 percent of the households interviewed. The remaining 19 percent did not have any salt at the date of interview. The results are presented in table 6.9. Of the households with salt, an estimated 50 percent had salt containing adequate iodine (15+ parts per million). A third of sampled households had low levels of iodine (<15 parts per million). The indication is that while the majority of households are buying iodised salt, the level of iodisation is either inadequate, or that high losses occur during storage. The use of iodised salt is not significantly different between the country’s regions. However, there are wide variations in the consumption of iodised salt among districts. Consumption of iodised salt is highest in Chitipa (82 percent), followed by Blantyre (72 percent). The lowest is in Nsanje (14 percent), a district that borders Mozambique. It is possible that people in Nsanje have easy access to salt from Mozambique that is not iodised. Chitipa, on the other hand, is on the border with Zambia where adequately iodised salt may be available. NUTRITION70 Table 6.9 Iodised salt consumption Percentage of households consuming adequately iodised salt, Malawi, 2006 Background characteristic Percent of households in which salt was tested Number of households interviewed Percent of households with salt test result Total Number of households in which salt was tested or with no salt Percent of households with no salt < 15 PPM 15+ PPM Any iodine Malawi Total 80.6 30,553 18.2 32.1 49.7 81.8 100.0 30,100 Urban 83.6 4,481 15.1 21.8 63.2 85.0 100.0 4,413 Rural 80.1 26,072 18.7 33.9 47.4 81.3 100.0 25,687 Region Northern 85.8 3,132 12.4 29.2 58.4 87.6 100.0 3,068 Central 77.9 13,121 21.1 31.4 47.6 79.0 100.0 12,949 Southern 82.0 14,300 16.7 33.5 49.8 83.3 100.0 14,083 District Balaka 80.8 695 18.6 23.7 57.7 81.4 100.0 690 Blantyre 86.8 2,316 11.4 16.2 72.4 88.6 100.0 2,268 Chikwawa 79.7 1,137 19.6 43.7 36.7 80.4 100.0 1,128 Chiradzulu 74.9 610 24.4 17.7 57.9 75.6 100.0 604 Chitipa 93.8 358 6.0 12.4 81.6 94.0 100.0 357 Dedza 80.5 1,740 19.2 36.6 44.3 80.9 100.0 1,734 Dowa 74.8 1,236 23.7 44.5 31.9 76.4 100.0 1,212 Karonga 88.7 604 10.6 47.5 41.9 89.4 100.0 599 Kasungu 79.0 1,096 19.8 17.7 62.4 80.1 100.0 1,080 Lilongwe 77.0 4,894 21.9 27.2 50.9 78.1 100.0 4,822 Machinga 81.4 1,235 17.8 35.5 46.7 82.2 100.0 1,224 Mangochi 77.2 2,611 22.3 28.3 49.4 77.7 100.0 2,594 Mchinji 80.3 1,106 18.3 25.7 55.9 81.6 100.0 1,088 Mulanje 84.8 1,179 14.4 54.3 31.3 85.6 100.0 1,168 Mwanza 91.3 515 8.3 29.7 61.9 91.6 100.0 513 Mzimba 86.0 1,460 13.5 25.5 61.0 86.5 100.0 1,451 Nkhata Bay 79.3 385 18.8 23.6 57.6 81.2 100.0 376 Nkhotakota 81.0 493 17.0 36.6 46.4 83.0 100.0 481 Nsanje 78.9 549 19.8 66.2 14.0 80.2 100.0 540 Ntcheu 82.4 1,078 17.2 33.5 49.3 82.8 100.0 1,074 Ntchisi 83.8 374 16.0 35.3 48.7 84.0 100.0 373 Phalombe 77.5 643 21.8 39.9 38.3 78.2 100.0 636 Rumphi 78.5 325 10.2 38.1 51.7 89.8 100.0 284 Salima 70.1 1,105 28.7 40.6 30.7 71.3 100.0 1,086 Thyolo 86.5 1,445 9.0 44.0 47.0 91.0 100.0 1,374 Zomba 81.9 1,364 16.8 30.8 52.4 83.2 100.0 1,343 Wealth index quintile Lowest 75.4 6,360 23.6 33.9 42.4 76.3 100.0 6,281 Second 78.0 6,297 20.8 32.4 46.8 79.2 100.0 6,197 Middle 81.0 5,976 17.8 32.7 49.5 82.2 100.0 5,892 Fourth 81.7 5,863 17.3 34.4 48.3 82.7 100.0 5,786 Highest 87.5 6,057 10.8 27.2 62.0 89.2 100.0 5,944 NUTRITION 71 63 47 58 48 50 42 62 50 0 10 20 30 40 50 60 70 80 90 100 Ma law i Urb an Ru ral No rth ern Cen tra l Sou th Po ore st Ric hes t Pe rc en t Figure 6.5 Percentage of households consuming adequately iodised salt (15+ PPM), Malawi, 2006 A high proportion (63 percent) of urban households are estimated to be using adequately iodised salt compared with only 47 percent of their rural counterparts. Although this suggests that storage losses of iodine may be the major problem, results displayed in table 6.10 indicate no significant differences in methods of storage. Table 6.10 also shows that 58 percent of households store salt in containers with lid. Interestingly, there are significant differences between the wealthiest and poorest households in terms of iodised salt consumption (Figure 6.5). 6.3.2.2 Knowledge of iodised salt and the source of information A total of 30,553 households were asked about knowledge and use of iodised salt. The results are presented in table 6.11 and reveal that only 66 percent have ever heard of iodine. Knowledge of iodine varies widely within districts, ranging from 48 percent in Ntchisi to 87 percent in Blantyre. The urban population is more likely to know about iodine (87 percent) than its rural counterpart (62 percent). The main source of information for both rural and urban populations is the radio. Knowledge of iodine drops from 88 percent in the highest income quintile to 48 percent in the lowest income quintile. NUTRITION72 Table 6.10 Storage place for salt Percent distribution of storage place of salt of households knowing of iodised salt, Malawi, 2006 Background characteristic Storage Total Number of households knowing of iodised salt Container with lid Container without lid Same packet Open surface Covered surface Other Malawi Total 58.3 3.4 34.3 0.1 0.3 3.5 100.0 20,163 Urban 59.8 1.7 30.9 0.0 0.0 7.6 100.0 3,899 Rural 58.0 3.8 35.1 0.2 0.4 2.6 100.0 16,264 Region Northern 55.3 2.8 39.6 0.0 0.1 2.3 100.0 2,075 Central 59.2 3.0 35.7 0.2 0.5 1.5 100.0 8,231 Southern 58.3 4.0 32.0 0.1 0.2 5.5 100.0 9,858 District Balaka 69.6 7.8 22.2 0.2 0.0 0.3 100.0 541 Blantyre 41.6 2.3 35.2 0.0 0.0 20.9 100.0 2,003 Chikwawa 58.3 3.0 37.2 0.4 0.5 0.6 100.0 654 Chiradzulu 77.1 0.7 22.2 0.0 0.0 0.0 100.0 400 Chitipa 40.6 1.1 58.0 0.0 0.0 0.3 100.0 197 Dedza 66.5 2.2 26.5 0.1 3.4 1.2 100.0 1,123 Dowa 53.2 2.9 42.8 0.1 0.2 0.9 100.0 687 Karonga 55.6 4.3 36.8 0.0 0.0 3.3 100.0 324 Kasungu 46.0 4.5 48.8 0.0 0.0 0.7 100.0 816 Lilongwe 61.4 1.0 37.4 0.2 0.0 0.0 100.0 3,033 Machinga 48.3 8.0 36.6 0.0 0.0 7.1 100.0 924 Mangochi 73.7 3.8 20.5 0.0 0.3 1.7 100.0 1,484 Mchinji 44.3 11.0 43.3 0.3 0.0 1.2 100.0 701 Mulanje 49.8 6.2 42.9 0.0 0.9 0.3 100.0 813 Mwanza 55.2 4.1 37.4 0.4 0.5 2.5 100.0 361 Mzimba 53.3 2.6 40.6 0.0 0.0 3.5 100.0 1,014 Nkhata Bay 79.3 1.9 18.0 0.0 0.5 0.3 100.0 265 Nkhotakota 71.7 1.8 25.8 0.0 0.1 0.6 100.0 337 Nsanje 56.0 3.0 40.5 0.0 0.0 0.4 100.0 329 Ntcheu 63.8 2.7 22.4 0.6 0.0 10.5 100.0 765 Ntchisi 44.3 4.4 50.4 0.3 0.0 0.6 100.0 181 Phalombe 34.1 5.1 59.5 0.0 0.2 1.1 100.0 409 Rumphi 49.6 3.7 46.6 0.1 0.1 0.0 100.0 275 Salima 67.9 3.5 27.1 0.3 0.0 1.3 100.0 588 Thyolo 68.7 3.7 27.1 0.0 0.0 0.5 100.0 947 Zomba 73.4 1.9 23.8 0.3 0.0 0.7 100.0 993 Wealth index quintile Lowest 52.6 3.2 41.3 0.4 1.0 1.5 100.0 3,039 Second 57.1 4.1 34.8 0.1 0.3 3.6 100.0 3,608 Middle 58.9 3.8 34.1 0.1 0.2 3.0 100.0 4,048 Fourth 60.2 4.0 32.7 0.1 0.1 2.9 100.0 4,171 Highest 60.5 2.4 31.3 0.1 0.1 5.7 100.0 5,298 NUTRITION 73 Table 6.11: Knowledge and source of information regarding Iodised salt Percentage of households knowing of iodised salt and percentage of households by specific source of information regarding iodised salt, Malawi, 2006 B ac kg ro u n d C h ar ac te ri st ic H ea rd ab o u t io d is ed sa lt N u m b er o f h o u se h o ld s in te rv ie w ed Pe rc en t w h o h ea rd fr o m t h e ra d io Pe rc en t w h o h ea rd fr o m t h e te le vi si o n Pe rc en t w h o h ea rd fr o m t h e n ew sp ap er Pe rc en t w h o h ea rd fr o m a p o st er Pe rc en t w h o h ea rd fr o m c lo th in g Pe rc en t w h o h ea rd fr o m d ra m a Pe rc en t w h o h ea rd fr o m a n o th er s o u rc e N u m b er o f h o u se h o ld s kn ow in g o f io d is ed s al t Yes No Malawi Total 66.0 34.0 30,553 94.5 8.5 10.7 7.6 6.9 7.2 21.1 20,163 Urban 87.0 13.0 4,481 97.3 26.5 25.2 16.2 16.5 12.4 27.8 3,899 Rural 62.4 37.6 26,072 93.8 4.1 7.3 5.5 4.6 5.9 19.5 16,264 Region Northern 66.3 33.7 3,132 88.5 8.9 14.4 11.9 6.9 8.6 35.8 2,075 Central 62.7 37.3 13,121 95.2 8.2 11.3 7.6 7.1 7.1 19.2 8,231 Southern 68.9 31.1 14,300 95.1 8.6 9.5 6.7 6.7 7.0 19.6 9,858 District Balaka 77.9 22.1 1,105 95.0 7.2 11.6 7.9 4.9 5.0 22.6 541 Blantyre 86.5 13.5 1,364 94.0 19.2 12.0 7.9 9.2 8.0 38.2 2,003 Chikwawa 57.5 42.5 1,236 97.4 3.1 6.9 8.2 10.0 5.1 13.4 654 Chiradzulu 65.6 34.4 1,179 94.2 10.2 16.3 11.1 10.3 16.1 23.7 400 Chitipa 55.1 44.9 610 64.5 1.9 7.7 5.1 5.3 6.8 71.8 197 Dedza 64.5 35.5 2,611 95.3 2.3 4.0 3.1 1.9 5.2 16.1 1,123 Dowa 55.6 44.4 358 96.6 7.2 12.8 7.8 8.6 11.0 17.4 687 Karonga 53.6 46.4 1,137 85.7 6.1 13.1 6.7 3.7 5.5 38.3 324 Kasungu 74.5 25.5 643 97.1 6.8 15.3 12.4 6.9 8.2 18.4 816 Lilongwe 62.0 38.0 1,096 96.3 12.6 14.1 8.3 9.5 6.5 16.4 3,033 Machinga 74.8 25.2 325 93.7 3.7 3.4 2.0 2.4 1.9 11.9 924 Mangochi 56.8 43.2 1,740 95.6 11.0 17.0 12.3 11.7 8.3 17.3 1,484 Mchinji 63.4 36.6 4,894 95.6 6.8 9.3 7.7 7.8 9.2 16.3 701 Mulanje 68.9 31.1 1,460 98.2 3.3 5.0 4.7 5.5 13.8 4.0 813 Mwanza 70.0 30.0 549 96.2 7.0 9.0 5.0 8.4 5.7 20.8 361 Mzimba 69.4 30.6 493 92.1 13.6 19.1 17.8 9.8 12.0 29.1 1,014 Nkhata Bay 68.9 31.1 385 93.2 5.5 7.9 6.5 1.7 5.1 12.3 265 Nkhotakota 68.5 31.5 515 93.0 6.9 10.6 6.5 4.8 6.6 29.9 337 Nsanje 60.0 40.0 604 95.2 3.5 9.2 6.7 6.5 8.7 14.8 329 Ntcheu 70.9 29.1 1,078 87.1 1.6 2.8 2.1 1.6 1.7 31.2 765 Ntchisi 48.3 51.7 695 97.1 2.6 8.1 8.4 2.5 8.9 13.6 181 Phalombe 63.7 36.3 1,235 95.5 4.8 8.9 5.9 4.4 6.1 18.6 409 Rumphi 84.6 15.4 1,445 91.0 3.1 9.7 6.4 6.2 4.0 54.5 275 Salima 53.2 46.8 2,316 96.1 12.2 17.9 13.1 11.8 11.5 26.4 588 Thyolo 65.5 34.5 1,106 95.3 2.4 2.6 1.1 0.5 2.2 7.1 947 Zomba 72.8 27.2 374 93.7 5.9 7.8 4.8 3.3 5.6 19.5 993 Wealth index quintile Lowest 47.8 52.2 6,360 90.6 1.4 3.7 3.5 3.3 3.9 20.4 3,039 Second 57.3 42.7 6,297 91.5 2.1 5.2 4.5 3.6 4.6 21.6 3,608 Middle 67.7 32.3 5,976 95.2 2.9 7.0 5.5 4.6 5.6 17.4 4,048 Fourth 71.1 28.9 5,863 95.6 4.2 8.2 5.7 5.1 7.7 19.6 4,171 Highest 87.5 12.5 6,057 97.4 24.4 23.4 15.2 14.4 11.6 25.2 5,298 NUTRITION74 Table 6.12 Reason for not using iodised salt in the household Percent distribution of main reason for not using iodised salt in the household, Malawi, 2006 Background characteristic Reason for not iodised Total Number of households knowing of iodised salt with no iodised salt at home Too expensive Not available in the market Doesn’t taste good Not considered necessary Didn’t know salt not iodised Others Malawi Total 6.7 3.1 1.9 2.2 84.4 1.7 100.0 604 Urban 11.1 3.9 6.4 3.5 75.1 0.0 100.0 61 Rural 6.2 3.0 1.4 2.1 85.5 1.9 100.0 543 Region Northern 10.4 2.5 .6 1.7 82.6 2.2 100.0 64 Central 5.8 3.0 1.2 2.6 86.7 0.7 100.0 232 Southern 6.5 3.3 2.7 2.0 83.0 2.4 100.0 307 Wealth index quintile Lowest 2.9 6.7 2.2 2.3 82.7 3.1 100.0 112 Second 12.7 1.3 1.9 3.6 77.5 3.1 100.0 106 Middle 5.6 2.7 0.0 2.3 89.1 0.3 100.0 134 Fourth 6.7 2.0 2.0 1.4 87.3 0.7 100.0 136 Highest 6.0 2.9 3.7 1.7 83.7 2.0 100.0 116 6.3.2.3 Reasons for not using iodised salt in the household A total of 604 households out of 20,163 (3 percent) who had knowledge of iodine but did not have iodised salt on the day of the interview were asked about the reasons for not using iodised salt. As shown in table 6.12, the major reason for not using iodised salt was that they did not know the salt was not iodised (84 percent). The results show that not using iodised salt is not a function of income but rather of either inadequate iodisation or losses of iodine during storage at various levels. Better enforcement of iodisation laws is clearly needed to make sure that people can only buy adequately iodised salt. 6.4 LOW BIRTH WEIGHT Weight at birth is a good indicator of a mother’s health and nutritional status. Moreover, birth weight has a direct affect on a newborn’s chances of survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of serious health risks for children. A baby’s low weight at birth is either the result of preterm birth or of restricted foetal (intrauterine) growth. Low birth weight is closely associated with foetal and neonatal mortality and morbidity, inhibited growth and cognitive development as well as chronic diseases later in life. Three factors have the most impact on a mother’s poor health and nutrition: the mother’s poor nutritional status before conception, short stature (due mostly to undernutrition and infections during her childhood), and poor nutrition, heavy work, smoking and alcohol use during pregnancy. Inadequate weight gain during pregnancy is particularly significant since it accounts for a large proportion of foetal growth retardation. NUTRITION 75 6.4.1 Prevalence of Low Birth Weight The results presented are estimated from two items in the questionnaire. These are the mother’s assessment of the child’s size at birth, that is, very small, smaller than average, average, larger than average, very large and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth1. Table 6.13a shows that in Malawi 14 percent of all babies are born with a low birth weight. The low birth weight prevalence by district ranges from 11 percent to 17 percent with wide variation across the country. Three districts with the highest prevalence of low birth weight of 15 percent and above are Salima (17 percent), Dedza (16 percent) and Phalombe (15 percent). The data show that three districts, Blantyre, Ntcheu and Karonga, have a low prevalence of low birth weight of 11 percent. There are no significant disparities according to residence, region, mother’s education and wealth status on the prevalence of low birth weight (Figure 6.6). The high levels of low birth weight reflect a generational cycle of undernutrition, where mothers who are themselves in poor health or undernourished give birth to babies who are underweight. 6.4.2 Percentage of infants not weighted at birth Table 6.13a also shows that only 48 percent of babies born in Malawi are weighed at birth. The proportion of infants who are not weighed at birth is highest in the Central and Southern Regions. Data shows that infants born in the Northern Region (62 percent) are more likely to be weighed at birth than in the Central (45 percent) and Southern (48 percent) Regions. The data also show that Rumphi district (79 percent) has the highest percentage of babies who are weighed at birth while in Mangochi (34 percent) babies are least likely to be weighed at birth There are wide variations in the proportion of infants weighed at birth by residence, mother’s education and socio-economic status. Infants in urban areas (70 percent), born to better-educated mothers (77 percent), and to those in the highest wealth quintile (72 percent) are more likely to be weighed at birth than those born to mothers from rural areas (44 percent), to mothers who are less educated (33 percent), and in lower wealth quintiles (37 percent). This can be attributed to the fact that most urban women attend health facilities where infants are likely to be weighed by a skilled attendant upon birth. Greater emphasis on weighing at birth and immediately thereafter will help to identify infants at particularly high risk. It also initiates close follow up and attention to good breastfeeding practises. 1 For detailed description of the methodology, see Boerma, Weinstern, Rutstein and Sommerfelt, 1996 NUTRITION76 Table 6.13a Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, Malawi, 2006 Background characteristic Percent of live births below 2500 grams Percent of live births weighed at birth Number of live births Malawi Total 13.5 47.7 10,552 Urban 11.2 69.6 1,507 Rural 13.9 44.1 9,045 Region Northern 12.9 61.5 1,035 Central 13.8 44.7 4,959 Southern 13.3 47.9 4,557 District Balaka 13.3 59.6 231 Blantyre 10.6 69.5 656 Chikwawa 14.8 43.3 391 Chiradzulu 13.6 50.7 196 Chitipa 14.2 53.7 139 Dedza 16.3 39.8 675 Dowa 11.8 47.5 427 Karonga 10.8 38.4 202 Kasungu 14.5 54.4 456 Lilongwe 13.2 44.2 1,907 Machinga 14.6 40.5 386 Mangochi 12.9 33.9 988 Mchinji 13.7 50.1 379 Mulanje 12.9 53.0 271 Mwanza 14.7 55.8 180 Mzimba 13.4 68.1 452 Nkhata Bay 12.4 66.7 118 Nkhotakota 14.7 43.5 200 Nsanje 13.3 45.9 191 Ntcheu 10.8 48.1 360 Ntchisi 13.6 39.8 139 Phalombe 15.1 36.0 226 Rumphi 13.4 78.8 123 Salima 16.8 36.1 417 Thyolo 14.6 43.3 458 Zomba 13.4 56.2 384 NUTRITION 77 Figure 6.6 Percentage of infants weighing less then 2500 grams at birth, Malawi, 2006 Table 6.13b Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, Malawi, 2006 Background characteristic Percent of live births below 2500 grams Percent of live births weighed at birth Number of live births Mother’s education None 14.8 33.0 2,407 Primary 13.4 47.6 6,912 Secondary + 11.8 77.3 1,213 Other 16.3 46.0 20 Wealth index quintile Lowest 14.3 37.0 2,442 Second 14.5 40.6 2,225 Middle 13.5 46.4 2,164 Fourth 12.9 47.9 1,899 Highest 12.0 72.2 1,822 11 14 13 14 13 15 13 12 14 12 48 14 0 10 20 30 40 50 60 70 80 90 100 Ma law i Urb an Ru ral No rth ern Cen tra l Sou the rn No ed uca tio n Pri ma ry Sec on dar y + Po ore st Ric hes t % birt hs we igh ed Pe rce nt NUTRITION78 CHILD HEALTH 79 7 CHILD HEALTH This chapter covers key aspects of child health: immunisation, tetanus toxoid, oral rehydration treatment, pneumonia, use of solid fuels, risk of respiratory infections and malaria. 7.1 IMMUNISATION MDG 4 sets out a goal to reduce child mortality by two thirds between 1990 and 2015. Immunisation is key to achieving this goal. It is an active strategy that has saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunisation (EPI) in 1974. Worldwide, there are still 27 million children overlooked by routine immunisation and as a result, vaccine-preventable diseases cause more than two million deaths every year. One of the central goals of WFFC is to achieve full immunisation of 90 percent of children under 12 months of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, before reaching one year, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT–HepB + Hib, a pentavalent vaccine to protect against diphtheria, pertusis, tetanus, hepatitis B and infections caused by haemophylus influenza type b bacteria such as meningitis and pneumonia, three doses of polio vaccine and a measles vaccine. In this survey, mothers were asked to provide health cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS 2006 questionnaire. Overall, 77 percent of children aged 12–23 months had health cards (Table 7.2a). Where children did not have cards, mothers were asked to recall whether or not the child had received each of the vaccinations and in the case of pentavalent and polio, how many times. The percentage of children aged 12–23 months who received each of the vaccinations is shown in table 7.1. The denominator for the table is children aged 12–23 months. This ensures that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the health card or the mother’s report. In the bottom panel, only those who were vaccinated before their first birthday, as is recommended, are included. For children without health cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with health cards. Approximately 96 percent of children aged 12–23 months receive a BCG vaccination and the first dose of pentavalent is given to 96 percent. The percentage declines for subsequent doses of the pentavalent vaccine to 93 percent for the second dose, and 86 percent for the third dose. Similarly, 96 percent of children receive polio 1 and this decline to 81 percent by the third dose. The coverage for the measles vaccine is lower than for the other vaccines at 84 percent. The percentage of children who are given all the recommended vaccinations is 70 percent (Figure 7.1). HABIB SOMANJE & STORN KABULUZI CHILD HEALTH80 Table 7.1 Vaccinations in the first year of life Percentage of children aged 12-23 months immunised against childhood diseases at any time before the survey and before the first birthday, Malawi, 2006 B ac kg ro u n d ch ar ac te ri st ic BCG Pentavalent Polio M ea sl es A ll N o n e N u m b er o f ch ild re n a ge d 12 –2 3 m o n th s 1 2 3 0 1 2 3 Health card 74.9 75.6 74.6 72.7 25.0 75.6 74.5 72.4 65.5 63.6 0.2 5,080 Mother’s report 20.8 20.6 18.5 13.7 10.2 19.9 16.5 8.8 18.9 6.8 2.0 5,080 Either 95.7 96.2 93.1 86.4 35.2 95.5 90.9 81.3 84.4 70.4 2.3 5,080 Vaccinated by 12 months of age 95.2 95.3 92.3 84.4 35.2 95.2 90.2 79.1 75.9 60.7 2.3 5,080 Approximately 95 percent of children aged 12–23 months have received a BCG vaccination by the age of 12 months. By the age of 12 months, 95 percent of children have received the first dose of pentavalent. The percentage declines for subsequent doses of the pentavalent vaccine to 92 percent for the second dose, and 84 percent for the third dose. Similarly, 95 percent of children have received polio 1 by 12 months of age and this declines to 79 percent by the third dose. While the coverage for measles immunisation, an indicator of MDG 4, is 76 percent, the percentage of children who had all the recommended vaccinations by their first birthday is 61 percent only. Tables 7.2a and 7.2b show vaccination coverage rates among children aged 12–23 months by background characteristics. The tables indicate children receiving the vaccinations at any time up to the date of the survey and are based on information from both the health cards and mothers/ caretakers reports. The tables include background characteristics such as sex, region, and district of origin, rural or urban areas, mother’s education and wealth status of the family. Table 7.2b indicates that the percentage of girls who are immunised is slightly higher than boys. The only Figure 7.1 Percentage of children aged 12–23 months who received the recommended vaccinations at any time before the survey, Malawi, 2006 96 96 93 86 96 91 81 84 70 0 10 20 30 40 50 60 70 80 90 100 BCG Pen t1 Pen t2 Pen t3 Pol io1 Pol io2 Pol io3 Me asl es All Pe rc en t CHILD HEALTH 81 Table 7.2a Vaccinations by background characteristics Percentage of children aged 12–23 months currently vaccinated against childhood diseases, Malawi, 2006 Background characteristic BCG Pentavalent Polio M ea sl es A ll N o n e Percent with health card Number of children aged 12–23 months 1 2 3 0 1 2 3 Malawi Total 95.7 96.2 93.1 86.4 35.2 95.5 90.9 81.3 84.4 70.4 2.3 76.8 5,080 Urban 98.1 98.4 96.6 92.9 52.6 97.8 95.4 86.9 86.6 76.8 1.0 80.1 723 Rural 95.2 95.9 92.5 85.3 32.4 95.1 90.2 80.3 84.0 69.3 2.5 76.3 4,356 Region Northern 94.4 95.8 95.2 89.8 52.0 96.2 92.8 84.5 86.3 73.5 2.3 79.6 511 Central 94.6 95.1 90.9 83.4 36.9 93.9 88.6 77.2 80.6 64.9 3.1 74.9 2,388 Southern 97.2 97.7 94.9 88.9 29.5 97.1 93.1 85.0 88.1 75.7 1.4 78.3 2,181 District Balaka 96.9 98.5 96.4 92.8 21.4 98.1 96.4 90.6 90.7 82.4 1.2 90.3 109 Blantyre 98.0 99.0 97.9 92.3 34.9 99.6 95.8 85.5 93.2 81.0 0.4 79.5 283 Chikwawa 98.5 97.3 94.8 90.3 21.4 97.3 94.8 87.6 88.3 78.2 1.5 80.9 172 Chiradzulu 97.8 99.6 96.5 91.9 29.2 99.6 95.9 89.9 90.7 81.2 0.4 84.9 92 Chitipa 94.2 96.5 94.0 85.4 43.3 96.0 89.3 76.3 84.4 59.4 0.7 81.6 69 Dedza 90.7 93.9 87.1 77.4 22.9 92.1 86.1 76.8 75.6 59.9 4.2 78.7 355 Dowa 91.1 92.7 89.1 81.0 45.1 91.8 85.9 80.8 82.0 71.4 6.5 80.9 186 Karonga 89.9 92.1 91.1 89.7 55.2 92.0 89.8 86.6 83.0 75.6 7.1 77.0 97 Kasungu 96.3 97.3 90.6 84.8 20.4 96.5 91.6 83.8 81.4 71.6 2.2 70.1 226 Lilongwe 96.0 94.8 91.6 85.5 45.2 93.0 88.7 77.6 80.1 65.0 2.7 76.0 879 Machinga 96.3 97.4 93.1 83.5 27.5 97.1 88.1 78.1 81.9 68.3 1.9 77.9 176 Mangochi 96.4 97.1 94.0 87.8 26.3 96.0 91.2 85.1 84.3 72.2 1.7 69.0 479 Mchinji 96.1 95.2 91.2 83.9 33.6 94.9 88.7 69.0 83.2 60.9 3.1 72.1 196 Mulanje 98.1 97.4 92.8 87.3 27.6 98.0 90.5 79.2 88.8 72.5 1.3 76.8 136 Mwanza 96.1 97.2 94.3 89.8 31.5 96.7 94.1 89.2 89.5 79.7 2.8 79.5 83 Mzimba 95.6 97.0 97.0 90.0 47.5 98.4 95.7 84.7 88.7 76.0 0.8 81.8 224 Nkhata Bay 93.1 93.7 92.1 86.7 61.8 91.9 84.6 78.8 82.9 65.4 4.4 66.1 60 Nkhotakota 90.4 91.9 85.2 75.3 37.5 90.9 82.0 67.7 76.3 54.1 3.5 67.9 107 Nsanje 92.3 95.0 90.4 83.7 45.8 94.2 91.0 80.7 82.5 71.7 4.2 80.2 95 Ntcheu 95.8 98.5 97.3 93.4 34.8 97.8 98.1 85.8 86.2 74.8 1.0 84.5 180 Ntchisi 94.2 92.0 90.3 76.5 55.5 92.5 87.0 71.6 83.1 59.5 3.5 67.8 73 Phalombe 95.0 93.7 87.9 82.9 25.5 91.3 88.5 80.2 86.4 70.7 3.4 70.8 114 Rumphi 98.4 98.9 99.7 97.1 64.3 99.7 99.0 95.5 88.1 84.9 0.0 86.1 60 Salima 96.3 97.6 94.1 82.3 34.1 97.6 87.0 72.0 83.4 62.0 1.6 62.7 186 Thyolo 98.0 98.0 97.1 88.6 28.7 97.8 93.9 84.6 91.0 74.3 0.5 82.9 240 Zomba 99.7 99.7 98.2 93.9 39.0 97.7 97.4 90.1 91.3 82.0 0.3 85.7 202 CHILD HEALTH82 exceptions are for polio 1, where rates are equal amongst girls and boys and polio 2 where slightly fewer girls are immunised compared to boys. Tables 7.2a and 7.2b also show that in terms of the overall coverage of those fully immunised and for all of the antigen doses, urban areas have higher percentages of immunisation coverage than rural areas. The greatest difference is found amongst children immunised with polio 0 vaccine (20 percent) and the least amongst children immunised with pentavalent 1 vaccine (3 percent). In terms of mother’s education, table 7.2b shows that the higher the mother’s education level, the higher the percentage of children vaccinated by all antigen doses. The percentage coverage for all the vaccines ranges from 65 percent among children whose mothers have no education to 84 percent among children whose mothers attained secondary school education. Seventy percent coverage is found in those children whose mothers had primary education. Table 7.2b also describes coverage by wealth index quintiles. In terms of pentavalent and polio vaccines, similar patterns can be observed with coverage rates becoming lower as they move from the first to the last dose. This pattern is repeated in all the wealth index quintiles. The highest quintile has the highest percentage coverage for almost all of the antigen doses with the exception of BCG, pentavalent 1 and polio 1, where the middle quintile has the highest percentage coverage. However, amongst those children who are fully immunised, the overall trend shows that the higher the quintile, the higher the percentage coverage, ranging from 66 percent in the lowest quintile to 77 percent in the highest quintile. Table 7.2b Vaccinations by background characteristics Percentage of children aged 12–23 months currently vaccinated against childhood diseases, Malawi, 2006 Background characteristic BCG Pentavalent Polio M ea sl es A ll N o n e Percent with health card Number of children aged 12–23 months 1 2 3 0 1 2 3 Sex Male 94.8 96.0 92.6 86.6 36.0 95.5 91.1 81.2 83.8 70.2 2.6 77.8 2,502 Female 96.5 96.5 93.5 86.2 34.6 95.5 90.7 81.3 85.0 70.6 1.9 75.8 2,578 Mother’s education None 94.0 95.6 90.8 81.6 28.3 93.9 87.6 77.7 80.2 64.8 3.1 74.0 1,158 Primary 95.9 96.1 93.1 86.5 34.9 95.6 91.0 81.3 83.9 70.0 2.3 76.8 3,332 Secondary + 97.0 98.2 97.3 95.0 51.1 97.8 96.8 88.2 95.3 83.5 0.6 82.2 580 Other 100.0 100.0 100.0 100.0 26.2 100.0 100.0 100.0 100.0 100.0 0.0 100.0 10 Wealth index quintile Lowest 94.4 94.7 91.8 83.6 30.7 93.8 89.2 78.5 82.0 66.2 3.2 74.0 1,198 Second 94.2 95.5 91.4 84.8 33.4 93.8 89.6 79.8 85.3 69.9 2.6 77.5 1,047 Middle 96.7 97.3 93.6 85.8 33.2 97.0 91.5 79.8 85.0 69.5 1.5 76.8 1,027 Fourth 96.6 96.9 94.0 88.1 34.4 97.1 92.0 83.2 83.1 71.1 1.7 78.2 973 Highest 96.9 97.3 95.2 91.2 47.7 96.3 93.2 86.7 87.2 77.3 2.2 78.5 835 CHILD HEALTH 83 54 59 60 60 61 62 65 65 68 71 71 72 72 72 73 74 75 76 76 78 80 81 81 82 82 85 0 10 20 30 40 50 60 70 80 90 100 Nkhotakota Chitipa Dedza Ntchisi Mchinji Salima Lilongwe Nkhata Bay Machinga Dowa Phalombe Kasungu Mangochi Nsanje Mulanje Thyolo Ntcheu Karonga Mzimba Chikwawa Mwanza Blantyre Chiradzulu Balaka Zomba Rumphi Percent Figure 7.2 Percentage of children aged 12–23 months fully immunised by district, Malawi, 2006 CHILD HEALTH84 In terms of the regions of the country, the Central Region has the lowest percentages of children immunised among all antigen doses (65 percent). The Southern Region has the highest percentages in overall coverage (76 percent) and for most of the antigens except for pentavalent 2 and 3 and polio 0 (95 percent, 89 percent and 30 percent respectively). The most remarkable finding of all is the extremely low percentage of children who have not been vaccinated: 2.5 percent in rural and a mere 1 percent in urban areas. This shows the potential of the health system to reach virtually every child in Malawi. Even the worst covered district, Karonga, had reached all but 7 percent of children at least once and in 15 districts, fewer than 2 percent had not received a vaccine. Overall coverage ranges from a high of 85 percent in Rumphi to a low of 54 percent in Nkhotakota. So far, most of the antigen doses are equal to or above 80 percent with the exception of pentavalent 3 in Dedza (77 percent), Nkhotakota (75 percent) and Ntchisi (77 percent); polio 3 in ten districts such as Chitipa (76 percent), Dedza (77 percent), Lilongwe (78 percent), Machinga (78 percent), Mchinji (69 percent), Mulanje (79 percent), Nkhata Bay (79 percent), Nkhotakota (68 percent), Ntchisi (72 percent) and Salima (72 percent) and measles in two districts of Dedza (76 percent) and Nkhotakota (68 percent). Figure 7.2 summarises the coverage of fully immunised children by district in Malawi and map 7.1 demonstrates the importance of follow-up in the majority of districts where measels immunisation falls far short of the MDG target of 95 percent. CHILD HEALTH 85 Map 7.1 Proportion of children aged 12–23 months immunised against measles, Malawi, 2006 Dedza Dowa Kasungu Lilongwe Mchinji Ntchisi Salima Chitipa Karonga Mzimba Nkhata Bay Rumphi Zomba Blantyre Chikwawa Thyolo Nsanje Mulanje Chiradzulu Phalombe Mangochi Ntcheu Balaka Machinga Mwanza Lake Malawi Nkhota kota Percent Below 80% 80%–90% Above 90% Likoma CHILD HEALTH86 7.2 TETANUS TOXOID One of the stated goals of WFFC was to eliminate maternal and neonatal tetanus by 2005. Tackling tetanus amongst mothers and children is also vital to the achievement of the Millennium Development Goals concerned with the reduction of maternal, child and infant mortality. Eradicating maternal tetanus is a key strategy in reaching the target of reducing the maternal mortality ratio by three quarters. Another target is to reduce the incidence of neonatal tetanus to less than one case per 1,000 live births, in every district. Prevention of maternal and neonatal tetanus can be assured if all pregnant women receive at least two doses of tetanus toxoid vaccine. However, where women do not receive two doses of the vaccine during the pregnancy, they and their newborns are considered to be protected if they have: • Received at least 2 doses, the last within 3 years; • Received at least 3 doses, the last within 5 years; • Received at least 4 doses, the last within 10 years; • Received at least 5 doses during lifetime. 7.2.1 Women’s protection status against neonatal tetanus Tables 7.3a and 7.3b show the protection status from tetanus of women who have had a live birth within the last 12 months by background characteristics. In Malawi, 89 percent of pregnant women are protected against tetanus. There is no major difference in the percent of women protected against tetanus amongst regions. The table also includes data for all the 26 districts. The protection of women against tetanus ranges from 66 percent in Karonga to 95 percent in Lilongwe, Mulanje, Nkhata Bay and Rumphi. In all of the districts except Dedza, Ntcheu and Phalombe, most women are protected against tetanus (80 percent or above). The data also shows no marked variation among women of different educational levels (89 percent, 88 percent and 92 percent for women with no education, primary and secondary+ respectively). Among the seven age groups of women of childbearing age, the percentage of women protected against tetanus ranges from 78 percent for women in the 15–19 age group to 92 percent for women in the 25-29 and 35–39 age groups. Apart from those in the youngest age group, over 85 percent of women in all other age groups are immunised with tetanus toxoid vaccine. This can be explained by the existing priority to reach primiparous women during their pregnancy. CHILD HEALTH 87 Table 7.3a Neonatal tetanus protection Percentage of mothers with a birth in the last 12 months protected against neonatal tetanus, Malawi, 2006 Background characteristic Received at least 2 doses during last pregnancy Received at least 2 doses, the last within 3 years Received at least 3 doses, the last within 5 years Received at least 4 doses, the last within 10 years Received at least 5 doses during lifetime Protected against tetanus Number of mothers Malawi Total 71.2 12.1 2.4 2.2 0.6 88.5 10,552 Urban 79.2 10.1 1.9 2.0 0.5 93.6 1,507 Rural 69.9 12.5 2.5 2.2 0.6 87.7 9,045 Region Northern 69.9 10.8 2.6 3.2 1.2 87.6 1,035 Central 74.0 10.7 2.2 1.7 0.4 89.1 4,959 Southern 68.5 14.0 2.5 2.5 0.6 88.1 4,557 District Balaka 64.9 13.6 2.7 3.2 0.4 84.7 231 Blantyre 66.3 15.9 2.1 4.1 1.1 89.5 656 Chikwawa 67.4 14.0 2.3 4.4 0.7 88.8 391 Chiradzulu 64.6 16.6 4.5 3.4 0.7 89.7 196 Chitipa 63.2 13.5 6.3 5.7 2.4 91.1 139 Dedza 62.4 11.0 1.1 1.8 0.2 76.5 675 Dowa 65.7 14.2 3.9 3.1 1.3 88.1 427 Karonga 50.8 11.5 1.3 2.0 0.5 66.0 202 Kasungu 75.5 9.0 2.5 4.6 1.9 93.5 456 Lilongwe 81.7 9.7 2.4 0.7 0.1 94.6 1,907 Machinga 76.5 10.3 2.5 2.3 0.4 92.1 386 Mangochi 72.9 12.5 1.5 1.2 0.9 88.9 988 Mchinji 74.9 13.8 2.9 2.7 0.2 94.5 379 Mulanje 86.0 5.5 0.8 0.4 0.3 93.0 271 Mwanza 53.0 20.6 4.8 6.8 1.8 86.9 180 Mzimba 80.5 8.9 2.2 1.8 1.5 94.8 452 Nkhata Bay 74.5 6.3 0.7 3.8 0.2 85.5 118 Nkhotakota 65.5 12.6 2.3 1.4 0.4 82.2 200 Nsanje 61.7 21.7 1.6 0.4 0.1 85.4 191 Ntcheu 57.2 17.6 2.5 1.8 0.8 79.8 360 Ntchisi 78.7 4.7 0.3 0.0 0.5 84.2 139 Phalombe 58.2 16.1 3.1 1.4 0.3 79.1 226 Rumphi 65.7 17.7 3.8 6.9 0.8 94.9 123 Salima 80.8 6.1 0.6 0.9 0.0 88.5 417 Thyolo 64.9 16.1 4.4 2.3 0.3 88.0 458 Zomba 66.9 11.9 3.5 2.0 0.2 84.4 384 CHILD HEALTH88 Table 7.3b Neonatal tetanus protection Percentage of mothers with a birth in the last 12 months protected against neonatal tetanus, Malawi, 2006 Background characteristic Received at least 2 doses during last pregnancy Received at least 2 doses, the last within 3 years Received at least 3 doses, the last within 5 years Received at least 4 doses, the last within 10 years Received at least 5 doses during lifetime Protected against tetanus Number of mothers Age 15–19 72.8 4.8 0.2 0.0 0.0 77.8 1,158 20–24 76.7 11.0 1.2 0.3 0.0 89.1 3,599 25–29 71.8 13.7 3.4 2.5 0.2 91.5 2,670 30–34 62.3 16.1 3.4 5.3 1.5 88.6 1,621 35–39 65.9 13.5 4.8 5.0 2.4 91.5 970 40–44 63.8 15.1 3.9 3.9 1.4 88.1 384 45–49 66.4 10.1 0.4 4.5 3.7 85.2 150 Mother’s education None 70.2 13.6 2.3 2.3 0.4 88.7 2,407 Primary 70.4 12.0 2.4 2.4 0.7 87.8 6,912 Secondary + 78.2 10.1 2.4 1.0 0.3 92.1 1,213 Other 50.2 8.4 24.4 0.0 1.7 84.6 20 Wealth index quintile Lowest 72.1 12.2 1.9 1.6 0.5 88.3 2,442 Second 71.1 10.6 2.5 1.9 0.5 86.7 2,225 Middle 68.2 14.2 2.3 2.2 0.4 87.2 2,164 Fourth 70.7 13.2 2.5 3.0 0.8 90.1 1,899 Highest 74.4 10.4 2.9 2.5 0.9 91.1 1,822 CHILD HEALTH 89 7.3 ORAL REHYDRATION TREATMENT (ORT) Diarrhoea is one of the leading causes of morbidity and mortality among children under five in Malawi. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea, either through oral rehydration salts (ORS) or a recommended home fluid can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are important strategies for managing diarrhoea. The goals are to: 1) reduce by one half, deaths due to diarrhoea among children under five by 2010 (WFFC); and 2) reduce by two thirds the mortality rate among children under five by 2015 (MDG). In addition, WFFC calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy • Home management of diarrhoea • ORT or increased fluids and continued feeding In the MICS 2006 questionnaire, mothers (or caretakers) were asked to report on whether their child had experienced diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions to establish what liquids and solids were given to the child during the episode and how this compared to usual eating and drinking patterns. Overall, 24 percent of children under five have had a bout of diarrhoea in the two weeks preceding the survey (Tables 7.4a and 7.4b). This is a remarkably high prevalence of diarrhoea, implying a rate of some 6.2 episodes per child per year (24 x 26 two-week periods divided by 100). Diarrhoea prevalence ranges from 19 percent in the Northern Region to 27 percent in the Central Region. By districts, the prevalence of diarrhoea ranges from 10 percent in Karonga to 32 percent in Ntchisi. Twelve districts display diarrhoea prevalence above the overall national average. The peak of diarrhoea prevalence tends to occur in the weaning period, among children aged 6–23 months with a two-week prevalence of 10 episodes per child, per year if the rate remains constant throughout the year. Table 7.4a also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Fifty-one percent receive fluids made from ORS packets; 12 percent receive pre-mixed ORS fluids, and 1 percent receives recommended homemade fluids. Children born to mothers with secondary education are more likely to receive oral rehydration treatment than other children (Table 7.4b). Fifty-five percent of children of educated mothers with diarrhoea receive one or more of the recommended home treatments, that is, are treated with ORS or recommended home fluids, compared to 48 percent children whose mothers are illiterate. Table 7.4b also shows the prevalence of diarrhoea in relation to other background characteristics such as sex, age and wealth status. The results in the table show that there is no marked difference in the prevalence of diarrhoea among male and female children. In terms of the wealth index quintile, there is a classical vulnerability pattern from 26 percent diarrhoea prevalence among children in the lowest quintile to 20 percent among children in the highest quintile. The pattern is CHILD HEALTH90 Table 7.4a Oral rehydration treatment Percentage of aged 0–59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), Malawi, 2006 Background characteristic Had diarrhoea in last two weeks Number of children aged 0–59 months Fluid from ORS packet Recom- mended home- made fluid Pre– packaged O

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