Monitoring the Situation of Children and Women: Albania Multiple Indicator Cluster Survey 2005

Publication date: 2008

Monitoring the Situation of Children and Women Albania Multiple Indicator Cluster Survey 2005 FINAL REPORT NATIONAL INSTITUTE OF STATISTICS UNITED NATIONS CHILDREN’S FUND Albania Multiple Indicator Cluster Survey 2005 INSTAT National Institute of Statistics UNICEF United Nations Children’s Fund February 2008 Contributors to the report: Ines Nurja, General Director, INSTAT Lantona Sado, Social Research Center, INSTAT Trevor Croft, Blancroft Research International Arlinda Ymeraj, UNICEF, Albania The Albania Multiple Indicator Cluster Survey (MICS) was carried by the National Institute of Statistics (INSTAT). Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) The survey has been conducted as part of the third round of MICS surveys (MICS3), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MICS surveys that were conducted in 1995 and the year 2000. Survey tools 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: Albanian National Institute of Statistics. 2007. Albania Multiple Indicator Cluster Survey 2005, Final Report. Tirana, Albania: Albanian National Institute of Statistics. i Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Albania, 2005 Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY 1 13 Under-five mortality rate 19 Per thousand Child mortality 2 14 Infant mortality rate 18 Per thousand NUTRITION 6 4 Underweight prevalence 7.5 Percent 7 Stunting prevalence 22.3 Percent Nutritional status 8 Wasting prevalence 6.6 Percent 45 Timely initiation of breastfeeding 29.9 Percent 15 Exclusive breastfeeding rate with plain water only 2.3 36.9 Percent Percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 57.8 20.0 Percent Percent 17 Timely complementary feeding rate 38.4 Percent 18 Frequency of complementary feeding 45.9 Percent Breastfeeding 19 Adequately fed infants 22.2 Percent 42 Vitamin A supplementation (under-fives) 8.0 Percent Vitamin A 43 Vitamin A supplementation (post-partum mothers) 26.1 Percent 9 Low birth weight infants 6.9 Percent Low birth weight 10 Infants weighed at birth 96.5 Percent CHILD HEALTH Tetanus toxoid 32 Neonatal tetanus protection 52.2 Percent 33 Use of oral rehydration therapy (ORT) 89.1 Percent 34 Home management of diarrhoea 8.6 Percent 35 Received ORT or increased fluids, and continued feeding 50.3 Percent 23 Care seeking for suspected pneumonia 45.3 Percent Care of illness 22 Antibiotic treatment of suspected pneumonia 37.5 Percent Solid fuel use 24 29 Solid fuels 55.5 Percent ENVIRONMENT 11 30 Use of improved drinking water sources 97.5 Percent 13 Water treatment 9.3 Percent 12 31 Use of improved sanitation facilities 98.9 Percent Water and Sanitation 14 Disposal of child's faeces 38.5 Percent REPRODUCTIVE HEALTH Contraception 21 19c Contraceptive prevalence 60.1 Percent 20 Antenatal care 97.1 Percent 44 Content of antenatal care Blood sample taken Blood pressure measured Urine specimen taken Weight measured 86.0 87.2 87.6 78.9 Percent Percent Percent Percent 4 17 Skilled attendant at delivery 99.8 Percent Maternal and newborn health 5 Institutional deliveries 98.0 Percent ii Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD DEVELOPMENT 46 Support for learning 68.0 Percent 47 Father's support for learning 46.3 Percent 48 Support for learning: children’s books 56.6 Percent 49 Support for learning: non-children’s books 32.3 Percent 50 Support for learning: materials for play 16.6 Percent Child development 51 Non-adult care 12.9 Percent EDUCATION 52 Pre-school attendance 39.8 Percent 53 School readiness 70.2 Percent 54 Net intake rate in primary education 82.4 Percent 55 6 Net primary school attendance rate 91.9 Percent 56 Net secondary school attendance rate 78.2 Percent 57 7 Children reaching grade five 99.7 Percent 58 Transition rate to secondary school 99.0 Percent 59 7b Primary completion rate 95.4 Percent Education 61 9 Gender parity index primary school secondary school 1.00 0.97 Ratio Ratio Literacy 60 8 Adult literacy rate 98.9 Percent CHILD PROTECTION Birth registration 62 Birth registration 97.6 Percent 71 Child labour 12.0 Percent 72 Labourer students 92.3 Percent Child labour 73 Student labourers 12.2 Percent Child discipline 74 Child discipline Any psychological/physical punishment 49.2 Percent 67 Marriage before age 15 Marriage before age 18 0.6 7.8 Percent Percent 68 Young women aged 15-19 currently married/in union 5.0 Percent Early marriage 69 Spousal age difference (women aged 20-24) 19.9 Percent Domestic violence 100 Attitudes towards domestic violence 29.8 Percent Disability 101 Child disability 11.1 Percent 75 Prevalence of orphans 2.1 Percent Orphaned children 78 Children’s living arrangements 0.4 Percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 82 19b Comprehensive knowledge about HIV prevention among young people 5.5 Percent 89 Knowledge of mother- to-child transmission of HIV 53.3 Percent 86 Attitude towards people with HIV/AIDS 6.8 Percent 87 Women who know where to be tested for HIV 27.9 Percent 88 Women who have been tested for HIV 1.4 Percent HIV/AIDS knowledge and attitudes 90 Counselling coverage for the prevention of mother- to-child transmission of HIV 46.0 Percent iii Table of Contents Summary Table of Findings .i Table of Contents. iii List of Tables . v List of Figures . vii List of Abbreviations .viii Acknowledgements . ix Executive Summary .x I. Introduction.1 Background.1 Survey Objectives .2 II. Sample and Survey Methodology .3 Sample Design.3 Questionnaires .3 Training and Fieldwork.4 Data Processing.4 III. Sample Coverage and the Characteristics of Households and Respondents .6 Sample Coverage .6 Characteristics of Households.6 Characteristics of Respondents .7 IV. Child Mortality.9 V. Nutrition.11 Nutritional Status .11 Breastfeeding.13 Salt Iodization.15 Vitamin A Supplements .16 Low Birth Weight .17 VI. Child Health .19 Immunization.Error! Bookmark not defined. Tetanus Toxoid.Error! Bookmark not defined. Oral Rehydration Treatment .20 Care Seeking and Antibiotic Treatment of Suspected Pneumonia .21 Solid Fuel Use.22 VII. Environment.23 Water and Sanitation.23 VIII. Reproductive Health.26 Contraception.26 Antenatal Care .27 Assistance at Delivery.28 IX. Child Development .30 X. Education .32 Pre-School Attendance and School Readiness.32 iv Primary and Secondary School Participation .33 Adult Literacy .36 XI. Child Protection .37 Birth Registration.37 Child Labour .37 Child Discipline .38 Early Marriage.39 Domestic Violence .41 Child Disability .41 Orphaned Children and Children’s Living Arrangements.42 XII. HIV/AIDS.43 Knowledge of HIV Transmission .43 Attitudes Towards People with HIV.44 HIV Counselling and Testing.45 List of References.46 Tables. .47 Appendix A. Sample Design.109 Sample Size and Sample Allocation .109 Sampling Frame and Selection of Clusters.110 Listing Activities .110 Selection of Households .111 Calculation of Sample Weights .111 Appendix B. List of Personnel Involved in the Survey .113 Appendix C. Estimates of Sampling Errors.114 Appendix D. Data Quality Tables .119 Appendix E. MICS Indicators: Numerators and Denominators.129 Appendix F. Questionnaires.135 v List of Tables Table HH.1: Results of household and individual interviews.47 Table HH.2: Household age distribution by sex .48 Table HH.3: Household composition.49 Table HH.4: Women's background characteristics .50 Table HH.5: Children's background characteristics .51 Table CM.1: Child mortality .52 Table CM.2: Children ever born and proportion dead .52 Table NU.1: Child malnourishment.52 Table NU.2: Initial breastfeeding.54 Table NU.3: Breastfeeding .55 Table NU.4: Adequately fed infants.56 Table NU.5: Brand of salt .57 Table NU.6: Children's vitamin A supplementation.57 Table NU.7: Post-partum mothers' vitamin A supplementation .58 Table NU.8: Low birth weight infants .58 Table CH.1: Neonatal tetanus protection.59 Table CH.2: Oral rehydration treatment .60 Table CH.3: Home management of diarrhoea .61 Table CH.4: Care seeking for suspected pneumonia .62 Table CH.5: Antibiotic treatment of pneumonia .63 Table CH.6: Knowledge of the two danger signs of pneumonia.64 Table CH.7: Solid fuel use.65 Table EN.1: Use of improved water sources .66 Table EN.2: Household water treatment .67 Table EN.3: Time to source of water .68 Table EN.4: Person collecting water .69 Table EN.5: Use of sanitary means of excreta disposal .70 Table EN.6: Disposal of child's faeces .71 Table EN.7: Use of improved water sources and improved sanitation .72 Table RH.1: Use of contraception.73 Table RH.2: Antenatal care provider .74 Table RH.3: Antenatal care.75 Table RH.4: Assistance during delivery.76 Table CD.1: Family support for learning.77 Table CD.2: Learning materials .78 Table CD.3: Children left alone or with other children.79 Table ED.1: Early childhood education .80 Table ED.2: Primary school entry .81 Table ED.3A: Primary school net attendance ratio .82 Table ED.3B: Basic education net attendance ratio .83 Table ED.4A: Secondary school net attendance ratio.84 Table ED.4B: Upper secondary school net attendance ratio.85 Table ED.5A: Secondary school age children attending primary school.86 Table ED.5B: Upper secondary school age children attending primary/lower secondary school .87 vi Table ED.6: Children reaching grade 5 .88 Table ED.7A: Primary school completion and transition to secondary education .89 Table ED.7B: Lower secondary school completion and transition to upper secondary education .90 Table ED.8: Education gender parity .91 Table ED.9: Adult literacy.92 Table CP.1: Birth registration .93 Table CP.2: Child labour .94 Table CP.3: Labourer students and student labourers .95 Table CP.4: Child discipline .96 Table CP.5: Early marriage .97 Table CP.6: Spousal age difference.98 Table CP.7: Attitudes toward domestic violence.99 Table CP.8: Child disability .100 Table CP.9: Children's living arrangements and orphanhood.101 Table HA.1: Knowledge of preventing HIV transmission .102 Table HA.2: Identifying misconceptions about HIV/AIDS.103 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission.104 Table HA.4: Knowledge of mother-to-child HIV transmission.105 Table HA.5: Attitudes toward people living with HIV/AIDS.106 Table HA.6: Knowledge of a facility for HIV testing .107 Table HA.7: HIV counselling coverage during antenatal care .108 Table SD.1: Allocation of sample clusters (Primary Sampling Units) to sampling domain .110 Table SE.1: Indicators selected for sampling error calculations .115 Table SE.2: Sampling errors: Total sample.116 Table SE.3: Sampling errors: Urban areas .117 Table SE.4: Sampling errors: Rural areas.118 Table DQ.1: Age distribution of household population.119 Table DQ.2: Age distribution of eligible and interviewed women .120 Table DQ.3: Age distribution of eligible and interviewed under-5s .120 Table DQ.4: Age distribution of under-5 children .121 Table DQ.5: Heaping on ages and periods .122 Table DQ.6: Completeness of reporting .123 Table DQ.7: Presence of mother in the household and the person interviewed for the under-5 questionnaire .123 Table DQ.8: School attendance by single age .124 Table DQ.9: Sex ratio at birth among children ever born and living .125 Table DQ.10: Distribution of women by time since last birth .125 Table DQ.11: Vaccinations .125 Table DQ.12: Digit preference in height and weight measurements .126 vii List of Figures Figure HH.1: Age and sex distribution of household population .6 Figure CM.1: Under-5 mortality rates by background characteristics.10 Figure CM.2: Trend in under-5 mortality rates .10 Figure NU.1: Percentage of children under-5 who are undernourished.12 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth.14 Figure NU.3: Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group .15 Figure CH.1: Percentage of women with a live birth in the last 2 years who are protected against neonatal tetanus .Error! Bookmark not defined. Figure EN.1: Percentage distribution of household members by source of drinking water.24 Figure RH.1: Percentage of women aged 15-49 years currently married or in union who are using (or whose partner is using) a contraceptive method .26 Figure ED.1: Percentage of children aged 36-59 months who are attending some form of organized early childhood education programme .32 Figure ED.2: Net attendance ratios for basic, primary, lower secondary, upper secondary and total secondary education by sex of the child .35 Figure CP.1: Percentage of children aged 2-14 years according to method of disciplining the child.38 Figure CP.2: Percentage of women aged 15-49 years who believe a husband is justified in beating his wife/partner in various circumstances .41 Figure HA.1: Percent of women who have comprehensive knowledge of HIV/AIDS transmission.44 Figure HA.2: Percent of women expressing discriminatory attitudes towards people with HIV/AIDS.45 Figure DQ.1: Scatterplot of weight by height (unweighted) .127 Figure DQ.2: Scatterplot of weights of children by age in months (unweighted).127 Figure DQ.3: Scatterplot of heights of children by age in months (unweighted) .127 Figure DQ.4: Number of male household population by single ages (unweighted).128 Figure DQ.5: Number of female household population by single ages (unweighted).128 Figure DQ.6: Number of male household population by single ages (weighted).128 Figure DQ.7: Number of female household population by single ages (weighted) .128 viii List of Abbreviations AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CDC US Centers for Disease Control CEDAW Convention on the Elimination of all Forms of Discrimination against Women CRC Committee on the Rights of the Child CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization FP Family Planning GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IMR Infant mortality rate IUD Intrauterine Device INSTAT National Institute of Statistics LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH Ministry of Health NAR Net Attendance Rate NCHS US National Center for Health Statistics NSDI National Strategy for Development and Integration ORS Oral Rehydration Salts ORT Oral Rehydration Therapy PSU Primary sampling unit RHF Recommended Home Fluid RHS Reproductive Health Survey SAp Stabilization and Association process SPSS Statistical Package for Social Sciences UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund U5MR Under Five Mortality Rate WFFC World Fit for Children WHO World Health Organization ix Acknowledgements Based on international methodologies, the Multiple Indicator Cluster Survey (MICS3) provides an excellent chance to reveal a comprehensive picture of the lives of children and women in Albania, and to compare it with the situation in more than 50 countries also implementing MICS3. The survey supplements government statistical data on some issues, thus drawing the attention of the government and the public to new aspects. The survey results will provide one of the most important sources of alternative information to help monitor the progress towards achieving the Millennium Development Goals (MDGs). The National Institute of Statistics (INSTAT), responsible for implementing MICS 2005 in Albania expresses its gratitude to the United Nations Children’s Fund (UNICEF) for providing methodological and advisory assistance in conducting the survey. We would particularly like to thank UNICEF for its generous financial and technical contributions. The UNICEF country and regional offices and the Global MICS team provided invaluable and ongoing support and we hope to continue to work in such a productive way in the future. We address special thanks to the survey team from INSTAT and to the inter-ministerial working group which contributed on the data analysis and the drafting of conclusions. Special thanks to Mr. Trevor Croft for his kind and professional technical assistance on reviewing data quality and for contributing to the writing of the final report. The survey could not have been carried out without the dedication and professionalism of over one hundred people, involved in technical and field work. The survey teams, including coordinators, field staff and data entry staff, carried out the work diligently. We would also like to thank the 5,150 households which agreed to participate and be interviewed. x Executive Summary The Albania Multiple Indicator Survey is a nationally representative sample survey of households, women and children. The primary objectives of the survey were to provide new information for assessing the situation of children and women in Albania and to furnish data needed for monitoring progress toward goals established by the Millennium Development Goals, the goals of A World Fit for Children (WFFC), and other internationally agreed upon goals, as a basis for future action. Interviews were completed with 5150 households, 5091 women aged 15-19 years and the mothers or caretakers of 1093 children under the age of five. Child mortality ! The under five mortality rate (U5MR) has declined from a high of close to 50 per thousand live births in the early 1990s to a low of 19 per thousand around 2002. Nutritional status ! Eight percent of children under the age of five are considered moderately underweight, 22 percent are moderately stunted or too short for their age and 7 percent are moderately wasted or too thin for their height. ! Twenty percent of children under five are considered moderately overweight. Breastfeeding ! Thirty percent of children are breastfed within one hour of birth and 74 percent within the first day of life. ! Only two percent of children under the age of 6 months are exclusively breastfed, a level much lower than recommended. This figure rises to 37 percent for children who received breastfeeding and only plain water. ! Twenty two percent of children aged 0-11 months are considered appropriately fed, based on WHO/UNICEF recommendations. Vitamin A supplementation ! Eight percent of children age 6-59 months received vitamin A supplementation within the six months prior to the survey. ! Twenty six percent of women who gave birth in the two years preceding the survey received vitamin A supplementation before the infant was 8 weeks old. Low birth weight ! Ninety-seven percent of births were weighed at birth and seven percent of infants were estimated to weigh less than 2500 grams at birth. Tetanus toxoid ! Fifty-two percent of women who had a birth in the past 2 years were protected against tetanus. Oral rehydration treatment ! Seven percent of children under the age of five had diarrhoea in the two weeks preceding the survey. Diarrhoea prevalence is higher in the poorer households (9 percent) than the richer households (4 percent). xi ! Almost ninety percent of children with diarrhoea received one or more of the recommended home treatments (oral rehydration solution or recommended homemade fluids). ! Just 12 percent of under five children with diarrhoea drank more than usual while 86 percent drank the same or less. ! Only nine percent children received increased fluids and at the same time continued feeding. ! Overall, half of all children with diarrhoea either received oral rehydration therapy or fluid intake was increased, and at the same time, feeding was continued, as is the recommendation. Care seeking and antibiotic treatment of pneumonia ! Four percent of children aged 0-59 months were reported to have had acute respiratory infection, symptoms of pneumonia, during the two weeks preceding the survey. ! Of these children, 45 percent were taken to an appropriate provider. ! Thirty eight percent of under-5 children with suspected pneumonia received an antibiotic during the two weeks prior to the survey. ! Thirty five percent of women know of the two danger signs of pneumonia – fast and difficult breathing. Solid fuel use ! More than half (55 percent) of all households in Albania are using solid fuels for cooking, principally wood. This figure is very high in rural areas, where almost four out of five households (79 percent) are using solid fuels. Water and sanitation ! Ninety-eight percent of the population are using an improved source of drinking water. In urban areas, 78 percent of the population uses drinking water that is piped into their dwelling, compared with 43 percent in the rural areas. Water piped into the yard (30 percent), or protected well (13 percent) are common in rural areas. ! Only nine percent of households treat their water, principally by boiling the water. ! For 87 percent of households, the drinking water source is on the premises. For those without water on the premises the average time to the source of drinking water is 18 minutes – longer in urban areas than rural areas. ! Ninety-nine percent of the population of Albania is living in households using improved sanitation facilities, although the type of facility varies between urban and rural areas. In rural areas less than two thirds of the population use a flush toilet connected to the sewer system, and 21 percent use a toilet connected to a septic tank and 15 percent use a pit latrine with a slab. Contraception ! Current use of any method of contraception was reported by 60 percent of women currently married or in union. ! One in four married women uses withdrawal, while condoms and the pill are each used by around one in ten married women. ! Urban woman and women from richer households are twice as likely to use modern contraceptive methods than rural women or women from poorer households. xii Antenatal care ! Ninety-seven percent of women received skilled antenatal care from a doctor, nurse, midwife, or auxiliary midwife at least once during the last pregnancy in the two years preceding the survey. ! Doctors provided antenatal care to 82 percent of urban women, compared with 62 percent of rural women, while nurses or midwifes provided the antenatal care to 14 percent of urban women and 33 percent of rural women. Skilled attendance at delivery ! Virtually all births occurring in two years prior to the MICS survey were delivered by skilled personnel. Doctors assisted with the delivery of the births in 87 percent of cases. ! Overall, 98 percent of deliveries took place in a health facility. Child development ! For more than two-thirds (68 percent) of under-five children, an adult engaged in more than four of the activities that promote learning and school readiness during the 3 days preceding the survey. The average number of activities that adults engaged in with children was 4.5. ! Father’s involvement with just one or more activities was only 46 percent, with a mean number of activities of 1.0. ! Fifty-seven percent of children are living in households where at least three non- children’s books are present. Only 32 percent of children aged 0-59 months have three or more children’s books. ! Seventeen percent of children aged 0-59 months had 3 or more types of playthings to play with in their homes, while 8 percent had none of the types of playthings asked to the mothers/caretakers. ! Twelve percent of children aged 0-59 months were left in the care of other children, while 2 percent were left alone during the week preceding the interview. Pre-school attendance and school readiness ! About 40 percent of the 36-59 month old children attend an early childhood education programme. ! Seventy percent of children who are currently age 6 or 7 and attending the first grade of primary school were attending pre-school the previous year. Primary and secondary school participation ! Overall, 92 percent of primary school age children (6-9) are attending primary school and 96 percent of basic school age children (6-13) are attending basic schooling. ! Seventy eight percent of the children of secondary school age (10-17) are attending secondary or higher. ! After the compulsory years of education, secondary school attendance drops off consistently from 83 percent for 14 year olds to 58 percent for 17 year olds. ! Fifty-seven percent of children aged 14-17 are attending upper secondary education. ! Of all children starting grade one, virtually all of them (more than 99 percent) will eventually reach grade five. ! Ninety-five percent of the children of primary completion age were attending the last grade of primary education. ! Ninety-five percent of children of lower secondary completion age completed secondary, however a quarter of children did not continue to upper secondary education. xiii ! Gender parity for primary school and lower secondary school is close to 1.00, indicating no difference in the attendance of girls and boys to primary and lower secondary school. However, the indicator drops to 0.96 for upper secondary education. Adult literacy ! Literacy is almost universal for all women aged 15-24 at 99 percent. Birth registration ! The births of 98 percent of the children aged less than five years in Albania have been registered. Child labour ! Twelve percent of children are involved in child labour activities and gender disparity is evident as boys are more likely to be performing child labour than girls. This is mostly present in the rural areas; four times higher than in urban areas. ! Of the 12 percent of the children classified as child labourers, 92 percent of them are also attending school. Child discipline ! Forty-nine percent of children aged 2-14 years have experienced some kind of psychological or physical punishment. ! Minor physical punishment is the most reported form of discipline (46 percent of children). Around 9 percent of children experience severe physical punishment. Early marriage ! Five percent of women currently aged 15-19 years are married. ! Less than 1 percent of women aged 15-49 were married by age 15, but almost 8 percent of women aged 20-49 were married before age 18. ! About half of women aged 20–24 married men with a difference of 5-9 years of age, and around one in five married men more than 10 years older. Domestic violence ! About 30 percent of women believe that a man is justified in hitting or beating his wife or partner in certain situations. Poorer women (39 percent) are twice as likely to hold these beliefs as richer women (17 percent). Child disability ! Mothers or caretakers report that 11 percent of children 2-9 years old have at least one disability, most commonly not speaking or being understood in words, not understanding instructions, and not learning to things other children can do. Orphaned children and children’s living arrangements ! Ninety-five percent of children are living with both parents. ! Two percent of children are orphans (one or both parents are dead). ! Less than half a percent of children aged 0-15 years are not living with a biological parent – in virtually all cases because both parents are dead. Knowledge of HIV transmission ! Ninety-four percent of the interviewed women have heard of AIDS. xiv ! The percentage of women who know of all three main ways of preventing HIV transmission is only 41 percent. While 84 percent of women know at least one way, 16 percent of women do not know any of the three ways. ! Of the interviewed women, 7 percent reject the two most common misconceptions and know that a healthy-looking person can be infected with HIV. ! Overall, only six percent of women in Albania have comprehensive correct knowledge about HIV. ! Eighty-two percent of women know that HIV can be transmitted from mother to child. Attitudes towards people with HIV ! The level of discrimination toward the people living with HIV/AIDS is very high, as only 7 percent of them seem to be accepting of people with HIV/AIDS. ! Attitudes vary from a low of four percent not accepting to care for family members with HIV/AIDS to a high of 81 percent that would not buy fresh vegetables from a person with HIV/AIDS. HIV counselling and testing ! Ninety seven percent of women received antenatal care from a health care professional for the last pregnancy, but only 46 percent of them were provided information about HIV prevention. ! Only 28 percent of women know where to be tested, while just one percent has actually been tested. 1 I. Introduction Background This report is based on the Albanian Multiple Indicator Cluster Survey, conducted in 2005 by the National Institute of Statistics (INSTAT). The survey provides valuable information on the situation of children and women in Albania and 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, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized 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.” 2 The government has developed the new central strategy, the National Strategy for Development and Integration (NSDI) and efforts are being made in order to achieve the successful adaptation and integration of the Millennium Development Goals (MDGs) into the NSDI, as well as further integration of the Stabilization and Association process (SAp). The NSDI, MDGs and SAp all require regular monitoring and evaluation. In this context MICS analysis can be used to support each framework, especially if common indicators are identified, shared and coordinated in all of them. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2005 Albania Multiple Indicator Cluster Survey had as its primary objectives: ! To provide up-to-date information for assessing the situation of children and women in Albania ! To furnish data needed for monitoring progress toward goals established by the Millennium Development Goals, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action; ! To contribute to the improvement of data and monitoring systems in Albania and to strengthen technical expertise in the design, implementation, and analysis of such systems. 3 II. Sample and Survey Methodology Sample Design The sample for MICS Albania was designed to provide estimates of various indicators on the situation of children and women at the national level, and for urban and rural areas. The sample was selected in two stages. At the first stage, 387 Primary Sampling Units (PSU) were systematically selected from a total of 8974 PSU. At the second stage, households were selected systematically within each PSU. The total sample had 5418 households: 2800 of them in urban and 2618 in rural areas. The sample, stratified by urban and rural areas, is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15- 49 years; and 3) an under-5 questionnaire, administered to mothers or caretakers of all children under 5 living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: o Household Listing o Education o Water and Sanitation o Child Labour o Child Discipline o Disability o Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules: o Child Mortality o Tetanus Toxoid o Maternal and Newborn Health o Marriage and Union o Contraception o Attitudes Towards Domestic Violence o HIV knowledge The Questionnaire for Children Under Five was administered to mothers or caretakers of children under 5 years of age1 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the 1 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 4 household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Birth Registration and Early Learning o Child Development o Vitamin A o Breastfeeding o Care of Illness o Immunization o Anthropometry The questionnaires are based on the MICS3 model questionnaire2. From the MICS3 model English version, the questionnaires were translated into Albanian and were pre-tested in Tirana in September 2005. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Albania MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork The field staff, 19 regional supervisors plus controllers and interviewers of Tirana city, were trained for five days in early September 2005. After that it was realized the second stage of training of the field staff by each supervisor in its own region. The data were collected by 19 teams, which included 19 supervisors, 11 editors and 58 interviewers. Fieldwork began in October 2005 and finished in November 2005. Training for the fieldwork was first conducted in Tirana for Tirana based interviewers, editors and all supervisors over a five day period in early September 2005. This was followed by the second stage of training of the field staff conducted over 4 days by each supervisor in their own region. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Most interviewers and supervisors were staff working in regional offices with prior experience with other national household surveys. Towards the end of the training period, trainees spent 7 days in practice interviewing during the pilot survey. The data were collected by 19 teams, which included 19 supervisors, 11 editors and 58 interviewers. Fieldwork began in October 2005 and concluded in November 2005. Data Processing Data were entered using the CSPro software. The data were entered on 6 microcomputers and carried out by 10 data entry operators and 1 data entry supervisor. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS3 project 2 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. 5 and adapted to the Albanian questionnaire were used throughout. Data processing began in November 2005 and was completed in February 2006. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 14, and the model syntax and tabulation plans developed by UNICEF for this purpose. 6 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 5,418 households selected for the sample, 5,347 were found to be occupied. Of these, 5,150 were successfully interviewed for a household response rate of 96.3 percent. In the interviewed households, 5,128 women (age 15-49) were identified. Of these, 5,091 were successfully interviewed, yielding a response rate of 99.3 percent. In addition, 1,100 children under age five were listed in the household questionnaire. Questionnaires were completed for 1,093 of them, which corresponds to a response rate of 99.4 percent. Overall response rates of 95.6 and 95.7 are calculated for the women’s and under-5’s interviews respectively (Table HH.1). Characteristics of Households The age and sex distribution of survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 5,150 households successfully interviewed in the survey, 20,609 household members were listed. Of these, 10,353 were males, and 10,257 were females. These figures also indicate that the survey estimated the average household size at 4. Figure HH.1: Age and sex distribution of household population, Albania, 2005 6 4 2 0 2 4 6 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 The population distribution from the survey closely resembles the pattern seen from the 2001 census. It is characterized by a declining child population due to lower recent fertility following relatively high fertility ten to twenty years before the survey. The population distribution also shows a deficit of people due to migration out of Albania in the age groups 20-44, and this is particularly noticeable in the age groups 25-34. From age 55 onwards, the population size steadily diminishes. The sex distribution shows a sex ratio of between 1.05 and 1.20 in the age groups between 0-19, but this is similar to the sex ratio reported in the statistical yearbook 2004. For older age groups the sex ratio is slightly below 1 in almost all 7 groups and is lowest (0.85) in the age group 25-29 consistent with the high levels of migration of these age groups, indicating that more men than women emigrated from Albania. Children age 0-17 make up 26 percent of the total population of Albania. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, urban/rural status, number of household members, and religion of the head of household are shown in the table. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The sample design over sampled urban compared to rural areas and the weighted distribution adjusts for the differences. The table also shows the proportions of households where at least one child under 18, at least one child under 5, and at least one eligible woman age 15-49 were found. The data from this table shows that only 12 percent of heads of the interviewed households are females. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to region, urban- rural areas, age, marital status, motherhood status, education3, wealth index quintiles4, and ethnicity. Sixty percent of female respondents were from rural areas, two thirds were currently married or in union, sixty four percent had given birth to at least one child. Two percent of them had no education or only primary education. Fifty percent had lower secondary education, with the remainder having upper secondary or higher education. 3 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 4 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: Number of persons per sleeping room, type of floor, roof and wall material, type of cooking fuel, household ownership of television, mobile telephone, fixed line telephone, refrigerator, washing machine, watch, bicycle, motorbike, car, type of drinking water, type of sanitary facility, ). 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. 8 Some background characteristics of children under 5 are presented in Table HH.5. These include distribution of children by several attributes: sex, age in months, mother’s or caretaker’s education, and wealth. Fifty five percent of the children selected for interview were male and 45 percent female. The remaining characteristics reflect the roughly same distribution as for the female respondents. 9 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. The infant mortality rate (IMR) is the probability of dying before the first birthday. The under-five mortality rate (U5MR) is the probability of dying before the fifth birthday. In MICS surveys, infant and under five mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). The data used in the estimation are: the mean number of children ever born for five year age groups of women from age 15 to 49, and the proportion of these children who are dead, also for five-year age groups of women. The technique converts these data into probabilities of dying by taking into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Albania the East model life table was selected as most appropriate. Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the mortality rates for the national total. The infant mortality rate is estimated at 18 per thousand, while the probability of dying under-5 mortality rate is around 19 per thousand. These estimates have been calculated by averaging mortality estimates obtained from women age 25-29 and 30-34, and refer to the beginning of 2002. The results agree with those reported by the Ministry of Health, where the under five mortality rate in 2002 was 21 per thousand and in 2005 was 18 per thousand (Ministry of Health, 2005). There is some difference between the probabilities of dying among males and females, but no difference is seen between urban and rural areas. There are significant differences in mortality in terms of educational levels and wealth for both IMR and U5MR. Children of less educated mother’s are twice as likely to die before age five (25 per thousand) than children of better educated mothers (12 per thousand). Child mortality is closely linked to poverty: the probability of dying among infants and under-5s living in the richest households (6 per thousand) is a third of the national average (19 per thousand), while the U5MR rates for the poorest household (26 per thousand) are four times that of the richest households. Improvements in public health services, including safe water and better sanitation, are of key importance as are improvements in education, especially for girls and mothers, and will save children's lives. Raising incomes can help, but little will be achieved unless a greater effort is made to ensure that services reach those who need them most. Differentials in under-5 mortality rates by background characteristics are also shown in Figure CM.1. 10 Figure CM.1 Under-5 mortality rates by background characteristics, Albania, 2005 20 19 25 12 26 6 19 0 5 10 15 20 25 30 Area Urban Rural Mother's Education Lower secondary or less Upper secondary or higher Wealth Quintiles Poorest 60 % Richest 40 % Albania Under 5 mortality rate per 1000 live births (reference date: Jan. 2002) Figure CM.2 shows the series of U5MR estimates of the survey, based on responses of women in different age groups, and referring to various points in time, thus showing the estimated trend in U5MR based on the survey. The MICS estimates indicate a decline in mortality during the last 15 years. The most recent U5MR estimate (19 per thousand live births) from MICS is about 20 percent higher than the estimate from the vital registration data reported by INSTAT for the same year (INSTAT, 2006), but agrees well with the Ministry of Health estimates in recent years. The trend indicated by the survey results is in broad agreement with that estimated in the MICS survey in 2000 (INSTAT, 2002), but at a slightly higher level. The U5MR is also a little higher than the rate estimated from the 2002 Reproductive Health Survey (RHS) (Centers for Disease Control, 2002) around 1997. Overall the mortality trend depicted by all sources is of a decline from highs in the early 90s of around 50 per thousand live births to a low of around 15 per thousand recently. Figure CM.2: Trend in under-5 mortality rates, Albania, 2005 0 10 20 30 40 50 60 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year pe r 1 ,0 00 l iv e bi rth s INSTAT MoH MICS 2000 RHS 2002 MICS 2005 11 V. Nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all children deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight- for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. A preliminary review of the quality 12 of the heights and weights measurements indicates some issues in the recording of the measurements, with digit preference for digits 0 and 5 in the decimal places of the weight measurement and, particularly, the height measurement5. Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (approximately 1 percent of children) and those whose measurements are outside a plausible range are excluded. About one in twelve children under age five in Albania are underweight (8 percent) and just over 1 percent are classified as severely underweight (Table NU.1). Almost a quarter of children (22 percent) are stunted or too short for their age and 7 percent are wasted or too thin for their height. Each of these indicators is lower than the figure measured in MICS 2000, dropping from 14 percent for underweight, 32 percent for stunting and 11 percent for wasting (INSTAT 2002). Children whose mothers have upper secondary or higher education are the least likely to be underweight compared to children of mothers with lesser education. Boys appear to be slightly more likely to be underweight and stunted than girls. Children from the poorer households are much more likely to be underweight or stunted than children from the richer households. The age pattern shows that the levels of under nourishment vary little by age according to all three indices (Figure NU.1). This pattern is unusual and may indicate that children are exposed to contamination in water, food, and environment from birth, and may not be getting the full protection provided by exclusive breastfeeding in the first 6 months of life. It is particularly unusual that stunting is high under 6 months of age and this finding warrants further analysis. Figure NU.1: Percentage of children under-5 who are undernourished, Albania, 2005 0 5 10 15 20 25 30 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) P er ce nt Underweight Stunted Wasted 5 See data quality tables in Appendix D. 13 Around one in five children is overweight according to their weight for height, however this may be because many children are somewhat stunted, rather than that they weigh too much. In contrast, when looking at weight for age, 8 percent of children are more than 2 standard deviations above the median. With the exception of the richest group, children from richer households are more likely to be overweight for their age than children from poorer households. Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate (< 6 months & < 4 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 & 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). Thirty percent of children are breastfed within one hour of birth and 74 percent within the first day of life. There is little difference between the poorest and the richest mothers who start breastfeeding within one hour of birth and this can be related with the place and conditions where they give birth to their children. The same differential is noticed between urban and rural areas, and between children of less educated and better educated mothers. 14 Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Albania, 2005 73 74 73 74 74 27 34 32 29 30 0 10 20 30 40 50 60 70 80 Lowr secondary Upper secondary + Urban Rural Albania P er ce nt Within one day Within one hour Breastfeeding has been traditionally used in Albania, but “modern life” has brought changes and many mothers stop breastfeeding too soon and switch to industrial types of milk or infant formula. In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk and vitamins, mineral supplements, or medicine but excluding the water. 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. Approximately 2 percent of children aged less than six months are exclusively breastfed, a level considerably lower than recommended. In Albania, the use of small quantities of water given to the children aged less than six months is very common; if we refer to the cases of the children who received only water in addition to breast milk the percentage increases to 37 percent.6 At age 6-9 months, 38 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 58 percent of children are still being breastfed and by age 20-23 months, 20 percent are still breastfed. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed or receiving only water is around 3 percent. Only about 5 percent of children are receiving breast milk after 2 years. 6 This conclusion is based also on the comments of the Ministry of Health, which underlines that the cases when to the child was given limited quantity of water (a spoon of water very rarely) should be counted because exclusive breastfeeding does not definitely exclude the use of very limited quantity of water. As well the results coming from two studies carried out from UNICEF and Ministry of Health for monitoring breastfeeding in 2001 and 2006, shows that exclusive breastfeeding was over 23 percent. 15 Figure NU.3 Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Albania, 2005 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 Age (in Months) P er ce nt Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed The adequacy of infant feeding in children under 12 months is provided in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they are receiving breastmilk and complementary food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they are receiving breastmilk and eating complementary food at least three times a day. Roughly half of children aged 6-11 months are adequately fed, with 47 percent of children 6-8 months and 44 percent of children 9-11 months are adequately fed according to the above criteria. Overall only about a quarter of children 0-11 months are adequately fed. Allowing for the common practice of providing small quantities of water at young ages, this figure rises to 41 percent. Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). The lack of national systematic data on the prevalence of iodine disorders in Albania before 1990 prompted an epidemiological study in 1993 by the Institute of Public Health in conjunction with UNICEF. This survey, by determining the levels of iodine in urine, showed that 63% of those surveyed suffered from severe forms of iodine deficiency. In 1997 a decision of the Council of Ministers stipulated that imported salt should also be iodized. Today the prevalence of Iodine on the children under 9 years old and on pregnant women is monitored periodically by Institute of Public Health and UNICEF programmes. 16 During the survey implementation in Albania, the salt was tested, however it was only tested for potassium iodide content and not for potassium iodate, and the neutraliser was not used. As salt in Albania is commonly iodized with potassium iodate the results do not represent the real situation concerning the iodisation of salt in Albania and are therefore not presented. In the Salt Iodisation module, an additional question was included on the brand of salt. The results regarding the type/brand of salt used by the households (see Table NU.5) were almost the same as those that the Institute of Public Health reports from its monitoring system of salt iodization. So the fact that 77 percent of Albanians use Niki brand (iodized salt) matches up well with the results of the official monitoring system. Vitamin A Supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under- five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programs, the definition of the indicator is the percent of children 6-59 months of age receiving at least one high dose vitamin A supplement in the last six months. It is also recommended that mothers take a Vitamin A supplement within eight weeks of giving birth due to increased Vitamin A requirements during pregnancy and lactation. Albania is not considered to be a country with a Vitamin A problem and there is no vitamin A supplementation program in Albania, however, doctors may recommend and parents may decide to give their children Vitamin A supplementation. 17 Within the six months prior to the MICS, eight percent of children aged 6-59 months received a high dose Vitamin A supplement (Table NU.6). Approximately 12 percent did not receive the supplement in the last 6 months but did receive one prior to that time. Seven percent of children received a Vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when. The age pattern of Vitamin A supplementation shows that supplementation in the last six months is highest in the youngest age group at 23 percent among children aged 6-11 months and then declines with age to around six percent among the oldest children. The mother’s level of education is also related to the likelihood of Vitamin A supplementation. The percentage receiving a supplement in the last six months increases from six percent among children whose mothers have only lower secondary education to 11 percent of those whose mothers have upper secondary education. About a quarter of mothers with a birth in the previous two years before the MICS received a Vitamin A supplement within eight weeks of the birth (Table NU.7). This percentage is highest in the urban areas at 38 percent compared with rural areas at 20 percent. Vitamin A coverage increases with the education of the mother from 20 percent among women with lower secondary education to 34 percent among mothers with upper secondary education. Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. 18 One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth7 . Overall, ninety-seven percent of births were weighed at birth and approximately seven percent of infants were estimated to weigh less than 2500 grams at birth (Table NU.8). The percentage of low birth weight varies little by urban and rural areas, mother’s education, or wealth quintiles. The figure of seven percent is slightly higher than the figure from the 2002 RHS, but the difference is likely to be due to an improved definition of the estimation of low birth weight that results in higher estimates than previously available. 7 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996 and Blanc and Wardlaw, 2005. 19 VI. Child Health Immunization The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis meningitis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and measles vaccination by the age of 12 months and 5 years old. In Albania health providers should provide mothers with vaccination cards and child health notes and at the same time the immunization and vaccine shots are registered in health care registry. Mothers were asked to show vaccination cards or Child Health Notes8 for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. Overall, 58 percent of children of children aged 18 to 29 months had health cards or child health notes showing vaccinations (Table DQ.11). If the child did not have the card, the mother was asked to recall whether or not the child received the vaccinations in the past as well as the number of doses for DPT and Polio. During data collection and data analysis a number of problems were reported. " Vaccination cards are not well kept by families among the population and health care workers face difficulties to assure them. " In the child health notes the DPT and polio vaccinations are recorded together with only one line of information according to the date due vaccination schedule by age. As DPT and polio immunizations are generally implemented at the same time the results for these two antigens would be expected to be very similar. " After recording all vaccinations from the health card or child health note, respondents were asked if the child had received other vaccines that were already not recorded however we could not find reasonable answers. " When no vaccination card or child health note was available, mothers or caretakers were asked if the child received immunization and specifically the number of doses for Polio and DPT. It appears that the mother’s reporting of immunizations was not very reliable and would underestimate immunization coverage. This is particularly the case concerning the number of DPT and polio immunizations. Additionally there 8 The “Child Health Note” is kept in the house to record data about the development of the child from birth to six years of age. 20 was a high proportion of “Don’t know” responses in the mother’s reporting, particularly for DPT. The information from the administrative records of the Institute of Public Health based on immunization registries of every health care center, show high rates of vaccination at the national level – 98 percent for BCG and DPT, and 97 percent for Polio and Measles (WHO/UNICEF, 2007). Due to the problems identified in the data, the immunization results are not presented in this report. It is clear that in future surveys it would be advisable to have a special training of interviewers and visit the primary health care units to record the immunization information of children rather than relying on vaccination cards held at home or the mother or caretaker’s reporting. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: ! Prevalence of diarrhoea ! Oral rehydration therapy (ORT) ! Home management of diarrhoea ! (ORT or increased fluids) AND continued feeding In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, seven percent of children under the age of five had diarrhoea in the two weeks preceding the survey (Table CH.2). Diarrhoea prevalence was slightly higher in rural areas and among boys (both 8 percent), compared with urban areas and girls (both 5 percent). The peak of diarrhoea prevalence occurs in the weaning period, among children age 6-23 months. Diarrhoea prevalence is also higher in the poorer households (9 percent) than the richer households (4 percent). Table CH.2 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. About 52 percent received 21 fluids from ORS packets; 8 percent received pre-packaged ORS fluids, and 76 percent received recommended homemade fluids (RHF). Almost ninety percent of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or RHF), while 11 percent received no treatment. Only 12 percent of under five children with diarrhoea drank more than usual while 86 percent drank the same or less (Table CH.3). Half of children with diarrhoea ate somewhat less, the same or more (continued feeding), but forty-seven percent ate much less or ate almost none. Given these figures, only nine percent children received increased fluids and at the same time continued feeding (an indicator known as home management of diarrhoea). Combining the information in Table CH.3 with those in Table CH.2 on oral rehydration therapy, it is observed that half of all children with diarrhoea either received ORT or fluid intake was increased, and at the same time, feeding was continued, as is the recommendation. Care Seeking and Antibiotic Treatment of Suspected Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia (acute respiratory infection) are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: ! Prevalence of suspected pneumonia ! Care seeking for suspected pneumonia ! Antibiotic treatment for suspected pneumonia ! Knowledge of the danger signs of pneumonia Table CH.4 presents the prevalence of suspected pneumonia (or acute respiratory infection) and, if care was sought outside the home, the site of care. Four percent of children aged 0-59 months were reported to have had acute respiratory infection, symptoms of pneumonia, during the two weeks preceding the survey. Children from poorer households were more likely to show these symptoms than richer children. Of these children, 45 percent were taken to an appropriate provider, principally government hospitals and health centres. Table CH.5 presents the use of antibiotics for the treatment of suspected pneumonia in under-5s by sex, age, region, residence, age, and socioeconomic factors. Thirty eight percent of under-5 children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.6. Obviously, mothers’ knowledge of the danger signs is an important determinant of care- seeking behaviour. Overall, 35 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is when a child develops a fever (89 percent). Fifty-five percent of mothers identified fast breathing and 59 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. There are 22 few differences between groups according to the background characteristics in their knowledge of the danger signs of pneumonia. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Overall, more than half (55 percent) of all households in Albania are using solid fuels for cooking (Table CH.7). Use of solid fuels is lower in urban areas (26 percent), but very high in rural areas, where almost four out of five households (79 percent) are using solid fuels. Differentials with respect to household wealth and the educational level of the household head are also significant. The findings show that use of solid fuels is very uncommon among the richest households. The table also clearly shows that the overall percentage is high due to high level of use wood for cooking purposes. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Unfortunately, data on the type of stove and chimney was not collected in this survey. 23 VII. Environment Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The indicators used in MICS are as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tubewell/borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. Overall, 98 percent of the population are using an improved source of drinking water. The main important sources of drinking water in Albania are water piped into dwelling, used by 57 percent of the population; water piped into yard or plot (19 percent) and protected well (8 percent). 24 Figure EN.1 Percentage distribution of household members by source of drinking water, Albania, 2005 Piped into yard or plot 19% Public tap/standpipe 3% Tubewell/borehole 3% Piped into dwelling 57% Other unimproved 0% Unprotected well or spring 1% Protected well or spring 10% Tanker truck 1% Bottled water 6% Sources of drinking water for the population vary between urban and rural areas. In urban areas, 78 percent of the population uses drinking water that is piped into their dwelling, compared with 43 percent in the rural areas. In the rural areas other important sources of drinking water are also available, including water piped into the yard (30 percent), or protected well (13 percent) which is historically the most widespread among the rural population in Albania. However, it should be mentioned that this data does not estimate the real access of the population to safe drinking water due to a rapidly deteriorating infrastructure and insufficient investments in this area. The conditions of the protected well and protected spring sources in Albania are not assured to provide access to safe drinking water. In this context, the fact that nearly 90 percent of population doesn’t use any method of treatment for water reduces the population percentage using safe drinking water. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all households, for households using improved and unimproved drinking water sources. Only nine percent of households treat their water. Urban households (12 percent) are more likely to treat the water than rural households (7 percent). Treatment of water is also more likely in better educated households and in the richer households. The most common form of treatment of water is boiling (7 percent), while other forms of treatment are used in less than two percent of households. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. Table EN.3 shows that for 87 percent of households, the drinking water source is on the premises. For nine percent of all households, it takes less than 15 minutes to get to the water source and bring water, while less than two percent of households spend more than 1 hour 25 for this purpose. Excluding those households with water on the premises, the average time to the source of drinking water is 18 minutes. The time spent in urban areas in collecting water is slightly higher than in rural areas. Table EN.4 shows that for two thirds of households, an adult female is usually the person collecting the water, when the source of drinking water is not on the premises. Adult men collect water in only 29 percent of cases, while for the rest of the households, female or male children under age 15 collect water (less than 4 percent). A higher proportion of women collect the water in the poorer households than in the richer households. Inadequate disposal of human excreta and personal hygiene are associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include: flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine, pit latrine with slab, and composting toilet. Ninety-nine percent of the population of Albania is living in households using improved sanitation facilities (Table EN.5), although the type of facility varies between urban and rural areas. In urban areas, almost all households (97 percent of the population) use a flush toilet piped to the sewer system. In rural areas less than two thirds of the population (61 percent) use this type of facility, while 21 percent use a toilet connected to a septic tank and 15 percent use a pit latrine with a slab. There are strong differentials between the poorest and richest households with all of the richest households having access to a flush toilet piped to the sewer system, while only 14 percent of the poorest households use this type of toilet, and 31 percent use a pit latrine with a slab. An appreciable change has happened during the last five years according to type of toilet facility used by households. Only one percent of the population use an unimproved sanitation facility (open pit) compared to 14 percent in MICS 2000. Safe disposal of a child’s faeces is defines as whether the last stool by the child was disposed of by use of a toilet or rinsed into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table EN.6. Overall, for 39 percent of children, their faeces were disposed of safely. For 46 percent of children the faeces were thrown in the garbage, presumably because most of these children are using disposable diapers. This would only be considered safe disposal if the garbage is safely disposed of and not just left outside the house. This method of disposal is mostly likely to be used in richer households (64 percent) than in poorer households (35 percent) and is also more common in urban areas and among better educated households. An overview of the percentage of households with improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. Overall 96 percent of households have access to an improved source of water and a sanitary means of excreta disposal. Only in the poorest households does this figure drop to 93 percent. 26 VIII. Reproductive Health Contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Family planning services in Albania started after 1993, when they were legally approved by the government. The aim of these activities was and remains the improvement of maternal and child health. After their approval the Ministry of Health (MOH) developed policies and strategies for family planning services, which were implemented all over the country. Protocols and guidelines about contraception were prepared and used by all clinics. Starting in January 1996 all contraceptives in Albania were provided free of charge in all of the public health services. During the same year the social marketing of contraceptives throughout the country also started. Current use of contraception was reported by 60 percent of women currently married or in union (Table RH.1). The most popular method is withdrawal which is used by one in four married women in Albania. The next most popular methods are the condom and the pill, which account for 11 percent and 10 percent of married women, respectively. Seven percent of women use periodic abstinence, and one and three percent of women reported use of female sterilization and lactational amenorrhea method (LAM). Less than one percent use male sterilization, injections, diaphragm, or other methods. Figure RH.1 Percentage of women aged 15-49 years currently married or in union who are using (or whose partner is using) a contraceptive method, Albania, 2005 Not currently using 40% Other 0% Withdrawal 28% Periodic abstinence 7% LAM 3% Diaphragm 0% Condom 11% Injections 1% Pill 9% Female sterilization 1% Male sterilization 0% Comparing the results with the results from the 2002 RHS, the contraceptive prevalence rate is lower than the figure from 2002 (75 percent for married women), however, the prevalence of modern methods has increased from eight percent in 2002 to 22 percent in 2005, with significant increases in the use of condoms and the pill. Use of withdrawal, which 27 accounted for most of the prevalence estimate from 2002, has declined from 67 percent to 28 percent. Overall contraceptive prevalence is similar between urban and rural areas and between poorer and richer women, but the mix of methods varies between these groups, with the prevalence of modern methods being almost twice as high in urban areas (32 percent) and richer households (34 percent) than in rural areas (17 percent) and poorer households (18 percent). This is compensated for by higher use of traditional methods, principally withdrawal, by rural women and women from poorer households. Adolescents are far less likely to use contraception than older women. Around 40 percent of married or in union women aged 15-24 currently use a method of contraception compared to more than 60 percent of 30-44 year old women. Women’s education level is strongly associated with modern contraceptive prevalence. The percentage of women using a modern method of contraception rises from 11 percent among those with no education to 16 percent among women with lower secondary education, and to 31 percent among women with upper secondary or higher education. Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: ! Blood pressure measurement ! Urine testing for bateriuria and proteinuria ! Blood testing to detect syphilis and severe anaemia ! Weight/height measurement (optional) 28 Coverage of antenatal care is high in Albania with 97 percent of women receiving skilled antenatal care from a doctor, nurse, midwife, or auxiliary midwife at least once during the pregnancy, and differs little across background characteristics. The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding is presented in Table RH.2. Doctors provided antenatal care to 82 percent of urban women, compared with 62 percent of rural women, while nurses or midwifes provided the antenatal care to 14 percent of urban women and 33 percent of rural women. A similar pattern is noticed between women with upper secondary or higher education, compared with women with lower secondary education. This pattern is more exaggerated when comparing the poorest and richest households, where 45 percent of poor households received antenatal care from a doctor compared with 92 percent of the richer households. The types of services pregnant women received are shown in Table RH.3. Eighty six percent of women who had a live birth in the two years preceding the survey had a blood test taken, 87 percent had their blood pressure measured, 88 percent had a urine specimen taken and 79 percent were weighed. There are small differences in the content of the antenatal care received according to type of place of residence and level of education, but the largest differences are seen according to wealth quintiles, where each of the measures of the content of antenatal care are about twenty points higher for the richest women at around 95 percent for each measure than for the poorest where the measures range from 63 to 77 percent. Comparing the results with the available data from the 2002 RHS shows close agreement with the estimates for the three recommended elements – blood testing, urine testing and blood pressure – with no significant change in the estimates. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. Virtually all births occurring in two years prior to the MICS survey were delivered by skilled personnel (Table RH.4). Doctors assisted with the delivery of the greater part of the births (87 percent). About one in eight births (13 percent) in the two years prior to the MICS survey were delivered with assistance by a nurse, midwife or auxiliary midwife. In rural areas the percentage of births delivered by nurse, midwife or auxiliary midwife are higher than in urban areas. The administrative figures reported by INSTAT also show that in 2005 approximately 99 percent of births were assisted by skilled personnel (UNICEF, 2007a). 29 In urban areas 95 percent of births were assisted by a doctor, while only 83 percent of births in rural areas were assisted by a doctor. The poorest women were assisted by a doctor in 80 percent of cases, while 97 percent of the richest women received assistance from a doctor. Overall, 98 percent of deliveries took place in a health facility, representing a small increase from the 94 percent reported in the 2002 RHS. 30 IX. Child Development It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, adult activities with children, presence of books in the home, for the child, and the conditions of care are important indicators of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, or drawing things. For more than two-thirds (68 percent) of under-five children, an adult engaged in more than four of the activities that promote learning and school readiness during the 3 days preceding the survey (Table CD.1). The average number of activities that adults engaged in with children was 4.5. The table also indicates that the father’s involvement in such activities was somewhat limited. Father’s involvement with just one or more activities was 46 percent and the mean number of activities the father engaged in was 1.0. Only four percent of children were living in a household without their fathers. There are no gender differences in terms of adults engaging in activities with children; about half of fathers are engaged in activities with male and female children (respectively 46 and 47 percent). However, there is a larger number of adults engaged in learning and school readiness activities with children in urban areas (76 percent) than in rural areas (64 percent). Strong differences by socio-economic status are also observed: Adult engagement in activities with children was 82 percent for children living in the richest households, as opposed to 53 percent for those living in the poorest households. Father’s involvement showed a similar pattern in terms of household wealth. More educated mothers and fathers were also more engaged in the activities with children. Exposure to books in early years not only provides the child with greater understanding of the nature of print, but may also give the child opportunities to see others reading, such as older siblings doing schoolwork. Presence of books is important for later school performance and IQ scores. In Albania, around 57 percent of children are living in households where at least three non- children’s books are present (Table CD.2). The median number of non-children’s books is five. However, only 32 percent of children aged 0-59 months have three or more children’s books and slight gender differences are observed between girls and boys (35 percent and 30 percent respectively). The median number of children’s books is zero -- this means that more than half of all children have no children’s books. While no gender differentials are observed, urban children appear to have more access to both types of books than those living in rural households. Sixty two percent of under-5 children living in urban areas live in households with more than 3 non-children’s books, while the figure is 54 percent in rural households. The proportion of under-5 children who have 3 or more children’s books is 43 31 percent in urban areas, compared to 26 percent in rural areas. The presence of both non- children’s and children’s books is positively correlated with the child’s age; in the homes of 63 percent of children aged 24-59 months there are 3 or more non-children’s books, while the figure is 44 percent for children aged 0-23 months. Not surprisingly, similar but larger differentials exist in terms of children’s books. The table also shows large differences according to household wealth, with only 16 percent of children in the poorest households having three or more children’s books compared with 52 percent of children in the richest households. Table CD.2 also shows that 17 percent of children aged 0-59 months had 3 or more types of playthings to play with in their homes, while 8 percent had none of the types of playthings asked to the mothers/caretakers (Table CD.2). The playthings in MICS included household objects, homemade toys, toys that came from a store, and objects and materials found outside the home. It is interesting to note that 74 percent of children play with toys that come from a store; however, the percentages for other types of toys is 44 percent for household objects and below 25 percent for homemade toys and for objects and materials found outside the home. Slight urban-rural differentials are observed in this respect mainly referring to the objects and materials found outside home which is more common in rural areas. Differentials are small by socioeconomic status of the households. The only background variable which appears to have a strong correlation with the number of playthings children have is the age of the child, a somewhat expected result. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In MICS, two questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the interview, and whether children were left in the care of other children under 10 years of age. Table CD.3 shows that 12 percent of children aged 0-59 months were left in the care of other children, while 2 percent were left alone during the week preceding the interview. Combining the two care indicators, it is calculated that 13 percent of children were left with inadequate care during the week preceding the survey. There is a slight difference observed by the sex of the child or between urban and rural areas. Children aged 24-59 months were left with inadequate care more (15 percent) than those who were aged 0-23 months (9 percent). 32 X. Education Pre-School Attendance and School Readiness Attendance to pre-school education in an organized learning or child education programme is important for the readiness of children to go to school. One of the World Fit for Children goals is the promotion of early childhood education. About 40 percent of the 36-59 month old children attend an early childhood education programme (Table ED.1). This indicator closely matches the administrative reporting of pre- primary enrolment of children 3-5 years old, which is 38 percent in 2005 (UNICEF, 2007b). Urban, rural and regional differences are significant – this figure is as high as 49 percent in urban areas, compared to 35 percent in rural areas. There are no significant gender differences: 42 percent of the girls aged 36-59 months attend kindergarten compared to 39 percent of the same aged boys. There are, however, significant differences regarding the classification by wealth status of the household: 60 percent of children living in the richest households attended an early childhood education programme, while the figure for children in the poorest households drops to 26 percent. As foreseen pre-school attendance depends on the mother’s education: 50 percent of 36-59 month aged children of mothers with upper secondary or higher education attend kindergarten compared to 35 percent of the children whose mothers have only lower secondary education. The proportions of children attending pre-school increases with age from 33 percent at ages 36-47 months to 45 percent at 48-59 months. Figure ED.1 Percentage of children aged 36-59 months who are attending some form of organized early childhood education programme, Albania, 2005 48 35 35 50 26 60 40 0 10 20 30 40 50 60 70 Area Urban Rural Mother's Education Lower secondary Upper secondary + Wealth quintiles Poorest Richest Albania Percent The table also shows the proportion of children in the first grade of primary school who attended pre-school the previous year (Table ED.1), an important indicator of school readiness. Overall, 70 percent of children who are currently age 6 or 7 and attending the first grade of primary school were attending pre-school the previous year. Seventy-four percent of children in urban areas had attended pre-school the previous year compared to 68 percent among children living in rural areas. Socioeconomic status appears to have a positive 33 correlation with school readiness – while the indicator is 66 percent among the poorest households, it increases to 75 percent among those children living in the richest households. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. The indicators for primary and secondary school attendance include: ! Net intake rate in primary education ! Net primary school attendance rate ! Net secondary school attendance rate ! Net primary school attendance rate of children of secondary school age ! Female to male education ratio (GPI) The indicators of school progression include: ! Survival rate to grade five ! Transition rate to secondary school ! Net primary completion rate Of children who are of primary school entry age (typically age 6 or 7) in Albania, 82 percent are attending the first grade of primary school (ED.2). Sex differentials do not exist, nor between urban and rural areas. A positive correlation with mother’s education and socioeconomic status is observed; for children ages 6 and 7 whose mothers have at least upper secondary school education, 86 percent were attending the first grade. In rich households, the proportion is also around 86 percent, while it is 77 percent among children living in the poorest households. Overall, in Albania about 92 percent of primary school age children (6-9) are attending primary school (Table ED.3A) and 96 percent of basic school age children (6-13) are attending basic schooling (Table ED.3B). The low rate for children 6 years old is related with the fact that children often start school at 7 years old. With the exception of this group of young children who are starting school late, primary schooling is virtually universal. There are no significant differences between urban and rural areas. A positive association with mother’s education and household wealth is observed. The percentage of children attending primary school increases from 91 percent to 94 percent as the mother’s education Classification of education system in Albania Age 6-9 – Primary school Age 10-13 – Lower secondary Age 14-17 – Upper secondary Compulsory basic schooling is 8 years, covering 4 years of primary and 4 years of lower secondary education 34 increases from lower secondary to upper secondary & higher education. A similar pattern is seen for household wealth with 90 percent of the poorest children attending primary school and 94 percent of the richest attending (Table ED.3A). The secondary school net attendance ratio is presented in Table ED.4A. Overall 78 percent of the children of secondary school age (10-17) are attending secondary or higher, but 22 percent of the children are not attending secondary school. Of these children some of them are either out of school or still attending primary school (see below). Almost half of all 10 year olds are not yet in secondary school. At ages 11-13 (the last 3 years of compulsory education) between 94 and 99 percent of children are attending secondary school. After the compulsory years of education, secondary school attendance drops off consistently from 83 percent for 14 year olds to 58 percent for 17 year olds. Eighty four percent of urban children aged 10-17 are attending secondary school, compared with 75 percent of rural children. The secondary school net attendance ratio is strongly associated with socio-economic status, with only two thirds of children from the poorest households attending secondary school, but 9 out of 10 from the richest households attending secondary school. Education of the mother has a strong effect on secondary school attendance with 91 percent of children whose mothers attended upper secondary or higher currently attending upper secondary, but only 52 percent of children whose mothers had only primary or less education. Table ED.4B presents the net upper secondary school attendance ratio for children aged 14- 17. Fifty-seven percent of children aged 14-17 are attending upper secondary education. The same disparities seen for the eight year secondary school net attendance ratio are seen for the upper secondary net attendance ratio, with urban children (69 percent) more likely to attend upper secondary than rural children (51 percent). Similarly, 78 percent of children from the richest households are attending upper secondary school but only 35 percent of children from the poorest households. Attendance at upper secondary school is also strongly associated with the mother’s education level – 69 percent of children of mother’s with upper secondary or higher education compared with 43 percent of children of mother’s with lower secondary education. The primary school net attendance ratio of children of secondary school age is presented in Table ED.5A. Six percent of the children of secondary school age are attending primary school when they should be attending secondary school. Virtually all of these are age 10 and are probably because they started school at age 7 rather than at age 6 or were held back a year. The lower secondary attendance rate of upper secondary school age children is presented in Table ED.5B. Thirteen percent of children of upper school age are still attending lower secondary school, with the majority of these being 14 years old. The percentage of children entering first grade who eventually reach grade 5 is presented in Table ED.6. Of all children starting grade one, virtually all of them (more than 99 percent) will eventually reach grade five. Notice that this number includes children that repeat grades and that eventually move up to reach grade five. The net primary school completion rate and transition rate to lower secondary education is presented in Table ED.7A. At the time of the survey, only 95 percent of the children of primary completion age (10 years9) were attending the last grade of primary education. This 9 As it is common for children to start school at ages 6 or 7, allowing for 4 years of primary school, age 10 was 35 value should be distinguished from the gross primary completion ratio which includes children of any age attending the last grade of primary. There are no significant differentials between groups. Almost all children (99 percent) that completed successfully the last grade of primary school were found at the time of the survey to be attending the first grade of secondary school. In Table ED.7B, the completion rate of lower secondary education and the transition rate to upper secondary education are presented. Ninety-five percent of children of lower secondary completion age (14 years) completed secondary, however a quarter of children did not continue to upper secondary education. There are slight differentials in the completion of lower secondary by wealth quintile where virtually all the richest group completed lower secondary, but only 92 percent of the poorest group completed lower secondary. The transition rate to upper secondary shows bigger differentials between urban and rural areas (89 percent versus 68 percent). Children of mother’s with upper secondary education were much more likely to continue to upper secondary (93 percent) than children whose mothers only had lower secondary or lesser education (67 percent). As with the lower secondary completion rate, the wealth quintiles also show significant differences between children from the poorest (62 percent) and the richest (91 percent) households. Figure ED.2 Net attendance ratios for basic, primary, lower secondary, upper secondary and total secondary education by sex of the child, Albania, 2005 96 92 87 56 77 96 92 86 58 79 0 10 20 30 40 50 60 70 80 90 100 Basic education Primary education Lower secondary education Upper secondary education Total secondary P er ce nt Girls Boys The ratio of girls to boys attending primary and secondary education is provided in Table ED.8. These ratios are better known as the Gender Parity Index (GPI). Notice that the ratios included here are obtained from net attendance ratios (NAR) rather than gross attendance ratios. The gross attendance ratios provide an erroneous description of the GPI mainly because the majority of over-aged children attending primary education tend to be boys. The table shows that gender parity for primary school and lower secondary school is close to 1.00, indicating no difference in the attendance of girls and boys to primary school. However, the indicator drops to 0.96 for upper secondary education. Gender disparity which is more evident at the upper secondary level is driven by the patterns of school attendance in rural and urban areas and household wealth. The disadvantage of girls is particularly pronounced in the poorest households. While poor families prefer to send their boys to upper secondary school (the NAR of boys is 10 selected for the calculation of the primary completion rate. 36 percentage points higher than the NAR of girls), this figure is different in the richest families (the NAR of girl is 6 percentage points higher than the NAR of boys). Poor families are more likely to send boys to school when they cannot afford education for all their children. In urban areas the NAR of girl is 4 percentage points higher than the NAR of boys, and in rural areas the NAR of boys is 6 points higher than the NAR of girls. To reach the Millennium Development Goal of gender parity, policy makers have to focus their efforts on rural Albania and on households that suffer from poverty. Adult Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. In MICS, since only a women’s questionnaire was administered, the results are based only on females age 15-24. Literacy was assessed on the ability of women to read a short simple statement or on school attendance. The percent literate is presented in Table ED.9. Literacy is almost universal for all women aged 15-24 at almost 99 percent, but only about a third of women with no education or only primary education are literate. 37 XI. Child Protection Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under 5 years of age whose birth is registered. The births of 98 percent of the children aged less than five years in Albania have been registered (Table CP.1). There are no significant variations in birth registration across sex, or education categories. The youngest children are the least likely to be registered (93 percent of children aged 0-11 months), but by five years of age 99 percent of children are registered. Child Labour Article 32 of the Convention on the Rights of the Child states: "States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child's education, or to be harmful to the child's health or physical, mental, spiritual, moral or social development." The World Fit for Children mentions nine strategies to combat child labour and the MDGs call for the protection of children against exploitation. In the MICS questionnaire, a number of questions addressed the issue of child labour, that is, children 5-14 years of age involved in labour activities. A child is considered to be involved in child labour activities at the moment of the survey if during the week preceding the survey: ! Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. ! Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows differentiating child labour from child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained before. Table CP.2 presents the results of child labour by the type of work. Twelve percent of children are involved in child labour activities and gender disparity is evident as boys are more likely to be performing child labour than girls. This is mostly present in the rural areas; four times higher than in urban areas. The tendency decreases from 19 percent in the poorest quintile to less than 2 percent in the richest quintile. Table CP.3 presents the percentage of children classified as student labourers or as labourer students. Student labourers are the children attending school that were involved in child labour activities at the moment of the surveys. More specifically, of the 91 percent of the children 5-14 years of age attending school, 12 percent are also involved in child labour 38 activities. On the other hand, out of the 12 percent of the children classified as child labourers, the majority of them are also attending school (92 percent). The proportion of children involved in child labour attending school declines from 98 percent in age group 5-9 to 78 percent in age group 10-14, indicating that children involved in child labour are dropping out of school in the older ages. Child Discipline As stated in A World Fit for Children, “children must be protected against any acts of violence …” and the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In the Albania MICS survey, mothers/caretakers of children age 2-14 years were asked a series of questions on the ways parents use to discipline their children when they misbehave. Note that for the child discipline module, one child aged 2-14 per household was selected randomly during fieldwork. Out of these questions, the two indicators used to describe aspects of child discipline are: 1) the proportion of children 2-14 years that experience psychological aggression as punishment or minor physical punishment or severe physical punishment; and 2) the proportion of parents/caretakers of children 2-14 years of age that believe that in order to raise their children properly, they need to physically punish them. Figure CP.1 Percentage of children aged 2-14 years according to method of disciplining the child, Albania, 2005 36 15 55 11 56 51 9 40 5 43 45 12 46 9 49 0 10 20 30 40 50 60 Only non-violent discipline Psychological punishment Minor physical punishment Severe physical punishment Any psychological or physical punishment P er ce nt Poorest quintile Richest quintile Total Parents react with anger to a child’s misbehaviour. A consequence of such a reaction is scolding the child, but what is said in anger may have a lasting impact on the child’s development, particularly if certain messages are repeated over a period of time. In MICS, almost half of children (45 percent) are reported to have experienced non-violent behaviour as a means of discipline or punishment, while 49 percent of children have experienced some kind of psychological or physical punishment (Table CP.4). Twelve percent of children were reported as having been subjected to psychological punishment10. Minor physical punishment is the most reported form of discipline (46 percent of children). Around 9 percent of children experience severe physical punishment - higher in rural areas, among parents with lower levels of education, and in poorer households. 10 Due to a printing error in the questionnaire, the proportion reported as subjected to psychological punishment may be under-reported. 39 It looks unusual that only 6 percent of mothers believe that punishment is a suitable means to control child discipline when in reality they apply some forms of punishment. Often influenced by culture and tradition, the mothers behave in a contradictory way. On balance it is probably fair to adopt one of the conclusions of the Human Development Centre report (Tamo and Karaj, 2005) that: “even though it is commonly held that violence should be used where necessary, in day-to-day practice physical and psychological violence are the chief means of ensuring discipline… at home”. Male children are subjected more to both minor and severe physical discipline (50 and 9 percent) than female children (42 and 7 percent). It is also interesting that differences with respect to many of the background variables were relatively small. Early Marriage Marriage before the age of 18 is a reality for many young girls. According to UNICEF's worldwide estimates, over 60 million women aged 20-24 were married/in union before the age of 18. Factors that influence child marriage rates include: the state of the country's civil registration system, which provides proof of age for children; the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children in hopes that the marriage will benefit them both financially and socially, while also relieving financial burdens on the family. In actual fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to 'free and full' consent to a marriage is recognized in the Universal Declaration of Human Rights - with the recognition that consent cannot be 'free and full' when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) mentions the right to protection from child marriage in article 16, which states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights - such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful traditional practices - and is frequently addressed by the Committee on the Rights of the Child (CRC). Other international agreements related to child marriage include the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while still children themselves, married girls and child mothers face constrained decision-making and reduced life choices. Boys are also affected by child marriage but the issue impacts girls in far larger numbers and with more intensity. Cohabitation - when a couple lives together as if married - raises the same human rights concerns as marriage. Where a girl lives with a man and takes on the role of caregiver for him, the assumption is often that she has become an adult woman, even if she has not yet 40 reached the age of 18. Additional concerns due to the informality of the relationship - for example, inheritance, citizenship and social recognition - might make girls in informal unions vulnerable in different ways than those who are in formally recognized marriages. Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered as significant factors in determining a girl's risk of becoming married while still a child. Women who married at younger ages were more likely to believe that it is sometimes acceptable for a husband to beat his wife and were more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. There is evidence to suggest that girls who marry at young ages are more likely to marry older men which puts them at increased risk of HIV infection. Parents seek to marry off their girls to protect their honour, and men often seek younger women as wives as a means to avoid choosing a wife who might already be infected. The demand for this young wife to reproduce and the power imbalance resulting from the age differential lead to very low condom use among such couples. Two of the indicators are to estimate the percentage of women married before 15 years of age and percentage married before 18 years of age. The percentage of women married at various ages is provided in Table CP.5. Less than 1 percent of women aged 15-49 were married by age 15, but almost 8 percent of women aged 20-49 were married before age 18. Consulting this table we find that there is no great difference in wealth index for women in marriage or union before their 18th birthday. So the main reasons to marry at an early age is not the economic situation of families but reasons that have to do with religion, as well as the education level of the woman. The greatest proportion of women married before age 15 or age 18 is among families where the woman has a low level of education. Thus the choice to be married or not at a very young age is very often driven by the social attitudes of certain groups of the population which have inherited strong beliefs of the importance of creating a family rather than attending school or further developing skills for greater involvement in society. The proportion of women aged 15-19 who are married or living in union provides a more recent view of practices in age at marriage. Five percent of women currently aged 15-19 years are married. While there are only small differences between most background characteristics, level of education is correlated with delaying marriage. Another component is the spousal age difference with an indicator being the percentage of married/in union women with a difference of 10 or more years of age compared to their current spouse. Table CP.6 presents the results of the age difference between husbands and wives. About half of women aged 20–24 married men with a difference of 5-9 years of age, and around one in five married men more than 10 years older. Among the group of women with a difference of 5-9 years there is no major difference in the distribution according to the wealth status or urban/rural area. The situation is quite different for the woman of the same age group currently married or in union with a man 10 or more years older. This 41 phenomenon is more frequent in the wealthiest households and among those living in urban areas. Domestic Violence A number of questions were asked of women age 15-49 years to assess their attitudes towards whether husbands are justified to hit or beat their wives/partners for a variety of scenarios. These questions were asked to have an indication of cultural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that women that agree with the statements indicating that husbands/partners are justified to beat their wives/partners under the situations described in reality a more likely to be abused by their own husbands/partners. The responses to these questions can be found in Table CP.7. About 30 percent of women believe that a man is justified in hitting or beating his wife if the woman is not respecting some of those so-called “family rules” such as going out without telling the husband, neglecting the child, burning the food or refusing to have sex with him. Less educated women are more accepting of these beliefs towards men’s behaviour - 41 percent of primary educated woman compared to 22 percent of upper secondary educated women. Poorer women are also twice as likely to hold these beliefs as richer women. Older women are also more likely to hold these beliefs. Figure CP.2 Percentage of women aged 15-49 years who believe a husband is justified in beating his wife/partner in various circumstances, Albania, 2005 30 30 9 7 4 39 5 9 6 7 2 1717 20 9 9 3 30 0 10 20 30 40 50 When she goes out without telling him When she neglects the children When she argues with him When she refuses sex with him When she burns the food For any of these reasons P er ce nt Poorest quintile Richest quintile Total Child Disability One of the World Fit for Children goals is to protect children against abuse, exploitation, and violence, including the elimination of discrimination against children with disabilities. For children age 2 through 9 years, a series of questions were asked to assess a number of disabilities/impairments, such as sight impairment, deafness, and difficulties with speech. This approach rests in the concept of functional disability developed by WHO and aims to identify the implications of any impairment or disability for the development of the child (e.g. health, nutrition, education, etc.). The questions do not seek to provide an objective measure of disability, but rather a subjective measure based on the assessment of the mother or caretaker. Table CP.8 presents the results of these questions. 42 Mothers or caretakers report that 11 percent of children 2-9 years old have at least one disability. The most commonly reported disabilities are not speaking/not being understood in words (5 percent), not understanding instructions (4 percent), and not learning to do things other children can do (4 percent). The figures vary only slightly according to age, and there is no real difference according to the other background characteristics. Orphaned Children and Children’s Living Arrangements Children growing up without one or more of their parents often have different physical, emotional and intellectual outcomes than those that live with both parents. The frequency of children living with neither parent, mother only, and father only is presented in Table CP.911. Results are presented only for children aged 0-15 as this information was not collected for children aged 16 and 17. Less than half a percent of children are not living with a biological parent – in virtually all cases because both parents are dead. Four percent live with their mother only and around half a percent live with their father only. Ninety-five percent of children are living with both parents. Two percent of children are orphans (one or both parents are dead). Not surprisingly, the prevalence of orphans increases with the age of the child, and is highest among the poorest households. 11 As MICS is a household survey, the results do not include any children living in institutions, however, the number of children living in institutions in Albania is very small and they would have a negligible effect on the results presented here. 43 XII. HIV/AIDS Knowledge of HIV Transmission One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. Correct information is the first step toward raising awareness and giving young people the tools to protect themselves from infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions although some appear to be universal (for example that sharing food can transmit HIV or mosquito bites can transmit HIV). The UN General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal as well as the MDG of reducing HIV infections by half include improving the level of knowledge of HIV and its prevention, and changing behaviours to prevent further spread of the disease. The HIV module was administered to women 15-49 years of age. One indicator which is both an MDG and UNGASS indicator is the percent of young women who have comprehensive and correct knowledge of HIV prevention and transmission. Women were asked whether they knew of the three main ways of HIV transmission – having only one faithful uninfected partner, using a condom every time, and abstaining from sex. The results are presented in Table HA.1. In Albania, 94 percent of the interviewed women have heard of AIDS. However, the percentage of women who know of all three main ways of preventing HIV transmission is only 41 percent. Seventy six percent of women know of having one faithful uninfected sex partner, 70 percent now of using a condom every time, and 50 percent know of abstaining from sex as main ways of preventing HIV transmission. While 84 percent of women know at least one way, 16 percent of women do not know any of the three ways. Both the level of education of the woman and household wealth are positively correlated with the level of comprehensive and correct knowledge of HIV prevention and transmission. Table HA.2 presents the percent of women who can correctly identify misconceptions concerning HIV. The table provides information on whether women know that HIV cannot be transmitted by sharing food or by mosquito bites. Fifty two percent of women know that sharing food cannot transmit HIV, and 32 percent of women know that mosquito bites cannot transmit HIV, while 32 percent of women know that a healthy-looking person can be infected. Of the interviewed women, seven percent reject the two most common misconceptions and know that a healthy-looking person can be infected. As expected, the ability of the woman to correctly identify the misconceptions concerning HIV is mostly related with of her level of education and the type of area she lives in (urban/rural). The percentages tend to be higher when the woman has completed upper secondary education or is living in an urban area. A key indicator used to measure countries’ responses to the HIV epidemic is the proportion of young people 15-24 years who know two methods of preventing HIV (having one faithful uninfected sex partner and using a condom every time), reject two misconceptions and know that a healthy looking person can have HIV. Table HA.3 presents the percentage of women 15-49 years with comprehensive correct knowledge about HIV. Only six percent of 44 all women and the same percentage of women aged 15-24 in Albania have comprehensive correct knowledge about HIV. While two thirds of women know two ways of preventing HIV transmission, only seven percent of women do not have misconceptions concerning HIV. Comprehensive correct knowledge of HIV is three times higher in the richest households than the poorest households, but still only around nine percent of women in those households have comprehensive knowledge. As expected, the percent of women with comprehensive correct knowledge of HIV increases with the woman’s education level. Figure HA.1 Percent of women who have comprehensive knowledge of HIV/AIDS transmission, Albania, 2005 21 59 72 64 2 6 9 7 1 4 7 6 0 10 20 30 40 50 60 70 80 None/Primary Lower secondary Upper secondary + Albania P er ce nt Knows 2 ways to prevent HIV Identify 3 misconceptions Comprehensive knowledge Knowledge of mother-to-child transmission of HIV is also an important first step for women to seek HIV testing when they are pregnant to avoid infection in the baby. Women should know that HIV can be transmitted during pregnancy, delivery, and through breastfeeding. The level of knowledge among women age 15-49 years concerning mother-to-child transmission is presented in Table HA.4. Overall, 82 percent of women know that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 53 percent, while 12 percent of women did not know of any specific way. Knowledge of all three ways of mother-to-child transmission varies little by age, but varies considerably between urban and rural areas (60 percent versus 49 percent), by wealth (63 percent of the richest women compared with 37 percent of the poorest women) and particularly by education (62 percent of women with upper secondary education compared with 17 percent of women with no more than primary education). Attitudes Towards People with HIV The indicators on attitudes towards people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four questions: 1) would care for family member sick with AIDS; 2) would not want to keep HIV status of a family member a secret; 3) thinks that a female teacher who is HIV positive should be allowed to teach in school; and 4) would buy fresh vegetables from a vendor who was HIV positive. Table HA.5 presents the attitudes of women towards people living with HIV/AIDS. This table shows that the level of discrimination toward the people living with HIV/AIDS is very high, as only 7 percent of them seem to be accepting of people with HIV/AIDS based on the above mentioned attitudes. The attitudes vary from a low of four percent not accepting to care for family 45 members with HIV/AIDS to a high of 81 percent that would not buy fresh vegetables from a person with HIV/AIDS. The discriminatory attitudes vary little according to age, level of education, wealth, or type of place of residence. Figure HA.2 Percent of women expressing discriminatory attitudes towards people with HIV/AIDS, Albania, 2005 4 70 72 81 93 0 10 20 30 40 50 60 70 80 90 100 Would not care for a family member who was sick with AIDS If a family member had HIV would want to keep it a secret Believe that a teacher with HIV should not be allowed to work Would not buy food from a person with HIV/AIDS Agree with at least one discriminatory statement P er ce nt HIV Counselling and Testing Another important indicator is the knowledge of where to be tested for HIV and use of such services. Questions related to knowledge among women of a facility for HIV testing and whether they have ever been tested is presented in Table HA.6. Only 28 percent of women know where to be tested, while just one percent has actually been tested. Women who live in good economic conditions, urban areas and have a better level of education have greater knowledge of places where they can get an HIV test. 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World Bank, 2007b: Albania Living Standard Measurement Survey 2005, Washington. www.childinfo.org. 47 Tables Table HH.1: Results of household and individual interviews Urban Rural Total Number of households Sampled 2800 2618 5418 Occupied 2770 2577 5347 Interviewed 2658 2492 5150 Response rate 96.0 96.7 96.3 Number of women Eligible 2423 2705 5128 Interviewed 2414 2677 5091 Response rate 99.6 99.0 99.3 Overall response rate 95.6 95.7 95.6 Number of children under 5 Eligible 473 627 1100 Mother/Caretaker interviewed 471 622 1093 Response rate 99.6 99.2 99.4 Overall response rate 95.6 95.9 95.7 Number of households, women, and children under 5 by results of the household, women's and under-five's interviews, and household, women's and under-five's response rates, Albania, 2005 Residence 48 Table HH.2: Household age distribution by sex Number Percent Number Percent Number Percent Age 0-4 625 6.0 517 5.0 1142 5.5 5-9 900 8.7 794 7.7 1694 8.2 10-14 1065 10.3 1017 9.9 2082 10.1 15-19 1061 10.3 990 9.7 2052 10.0 20-24 735 7.1 751 7.3 1487 7.2 25-29 552 5.3 647 6.3 1199 5.8 30-34 608 5.9 667 6.5 1275 6.2 35-39 690 6.7 721 7.0 1411 6.8 40-44 706 6.8 764 7.5 1470 7.1 45-49 737 7.1 682 6.7 1419 6.9 50-54 704 6.8 717 7.0 1421 6.9 55-59 512 4.9 517 5.0 1029 5.0 60-64 457 4.4 453 4.4 909 4.4 65-69 381 3.7 364 3.6 745 3.6 70+ 618 6.0 650 6.3 1268 6.2 Missing/DK 1 0.0 5 0.0 6 0.0 Dependency age groups < 15 2590 25.0 2328 22.7 4918 23.9 15-64 6762 65.3 6910 67.4 13673 66.3 65 + 999 9.7 1014 9.9 2013 9.8 Missing/DK 1 0.0 5 0.0 6 0.0 Children aged 0-17 3280 31.7 2946 28.7 6226 30.2 Adults 18+/Missing/ DK 7073 68.3 7311 71.3 14384 69.8 Total 10353 100.0 10257 100.0 20609 100.0 Total 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, Albania, 2005 Males Females 49 Table HH.3: Household composition Weighted percent Weighted Unweighted Sex of household head Male 88.1 4536 4502 Female 11.9 614 648 Residence Urban 44.2 2275 2658 Rural 55.8 2875 2492 Number of household members 1 5.0 260 280 2-3 32.4 1667 1720 4-5 45.4 2337 2330 6-7 14.9 769 714 8-9 1.7 85 80 10+ 0.6 32 26 Religion Muslim 79.9 4117 4150 Orthodox/Catholic/Other 20.1 1033 1000 Total 100.0 5150 5150 At least one child aged < 18 years 61.2 - - At least one child aged < 5 years 18.8 - - At least one woman aged 15-49 years 74.6 - - Percent distribution of households by selected characteristics, Albania, 2005 Number of households 50 Table HH.4: Women's background characteristics Percent distribution of women aged 15-49 years by background characteristics, Albania, 2005 Weighted percent Weighted Unweighted Residence Urban 39.8 2028 2414 Rural 60.2 3063 2677 Age 15-19 18.9 961 927 20-24 14.4 731 736 25-29 12.3 625 636 30-34 12.9 655 656 35-39 13.9 706 700 40-44 14.7 749 767 45-49 13.0 664 669 Marital/Union status Currently married/in union 65.5 3333 3335 Formerly married/in union 1.9 95 103 Never married/in union 32.7 1663 1653 Motherhood status Ever gave birth 63.5 3235 3237 Never gave birth 36.5 1856 1854 Education None/Primary 2.0 103 98 Lower secondary 50.5 2570 2401 Upper Secondary + 47.5 2418 2592 Wealth index quintiles Poorest 20.3 1033 894 Second 20.4 1041 941 Middle 19.3 981 964 Fourth 20.0 1018 1077 Richest 20.0 1018 1215 Religion Muslim 82.3 4189 4226 Orthodox/Catholic/Other 17.7 902 865 Total 100.0 5091 5091 Number of women 51 Table HH.5: Children's background characteristics Weighted percent Weighted Unweighted Sex Male 54.8 599 596 Female 45.2 494 497 Residence Urban 35.4 387 471 Rural 64.6 706 622 Age < 6 months 8.9 97 99 6-11 months 7.4 81 74 12-23 months 17.5 191 199 24-35 months 19.3 211 212 36-47 months 20.7 226 224 48-59 months 26.2 286 285 Mother’s education None/Primary 3.4 38 32 Lower secondary 54.4 594 573 Upper Secondary + 42.2 461 488 Wealth index quintiles Poorest 22.7 248 218 Second 21.3 233 212 Middle 18.1 197 199 Fourth 21.0 230 240 Richest 16.9 185 224 Religion Muslim 85.4 933 942 Orthodox/Catholic/Other 14.6 160 151 Total 100.0 1093 1093 Percent distribution of children under five years of age by background characteristics, Albania, 2005 Number of under-5 children 52 Table CM.1: Child mortality Infant and under-five mortality rates, Albania, 2005 Infant mortality rate* Under-five mortality rate** Sex Male 24 27 Female 11 12 Residence Urban 18 20 Rural 18 19 Women’s education None/Primary/Lower secondary 22 25 Upper secondary + 11 12 Wealth index quintiles Poorest 60% 23 26 Richest 40% 6 6 Total 18 19 * MICS indicator 2; MDG indicator 14 ** MICS indicator 1; MDG indicator 13 Mortality rates are based on indirect estimation using East model. Reference date is January 2002. Table CM.2: Children ever born and proportion dead Mean number of children ever born Mean number of children surviving Proportion dead Number of women Age 15-19 0.012 0.000 0.000 961 20-24 0.165 0.002 0.013 731 25-29 0.666 0.019 0.028 625 30-34 1.083 0.022 0.021 655 35-39 1.321 0.048 0.037 706 40-44 1.431 0.067 0.047 749 45-49 1.573 0.069 0.044 664 Total 0.846 0.031 0.037 5091 Mean number of children ever born, children surviving and proportion dead by age of women, Albania, 2005 53 Table NU.1: Child malnourishment Weight for age Height for age Weight for height children aged 0-59 % below % below % above % below % below % below % below % above - 2 SD* - 3 SD + 2 SD - 2 SD** - 3 SD - 2 SD*** - 3 SD + 2 SD Sex Male 8.1 1.3 6.9 23.6 9.3 6.4 2.1 19.5 592 Female 6.8 1.1 9.1 20.7 8.2 6.7 1.2 21.1 486 Residence Urban 4.9 0.5 11.9 22.6 9.3 4.8 0.7 24.1 383 Rural 9.0 1.5 5.7 22.1 8.5 7.5 2.2 18.1 694 Age < 6 months 7.7 0.8 6.9 22.7 3.8 7.3 1.2 20.8 92 6-11 months 9.0 0.9 2.3 22.7 12.1 5.8 0.0 19.6 80 12-23 months 7.4 1.5 9.6 19.5 7.8 6.5 0.9 16.3 190 24-35 months 8.5 1.9 10.7 21.6 10.1 5.3 2.6 17.4 208 36-47 months 5.9 0.0 7.7 24.6 6.8 6.6 1.9 19.6 226 48-59 months 7.6 1.5 6.8 22.5 10.8 7.5 2.0 25.5 282 Mother’s education None/Primary (7.4) (0.0) (6.4) (28.2) (13.3) (12.8) (0.0) (9.4) 36 Lower secondary 8.8 1.8 6.5 22.3 6.9 6.9 2.1 20.2 584 Upper secondary + 5.8 0.5 9.8 21.7 10.9 5.7 1.3 21.2 458 Wealth index quintiles Poorest 12.9 2.0 5.4 30.1 12.8 5.3 2.0 18.7 244 Second 9.2 1.6 5.9 22.9 5.9 12.1 1.8 16.4 229 Middle 8.0 1.4 6.5 24.1 14.1 2.4 0.4 20.9 193 Fourth 3.2 0.6 11.8 18.4 5.6 6.4 2.3 26.5 229 Richest 3.0 0.0 10.6 13.9 5.5 5.9 1.7 18.5 183 Religion Muslim 7.9 1.2 7.4 23.2 9.4 6.7 1.8 19.7 918 Orthodox/Catholic/ Other 5.5 1.0 10.9 16.8 5.5 5.6 1.2 23.0 160 Total 7.5 1.2 7.9 22.3 8.8 6.6 1.7 20.2 1078 * MICS indicator 6; MDG indicator 4 ** MICS indicator 7 *** MICS indicator 8 (…) – Figures are based on 25-49 unweighted cases. Percentage of children aged 0-59 months who are severely or moderately malnourished, Albania, 2005 54 Table NU.2: Initial breastfeeding Percentage who started breastfeeding within one hour of birth* Percentage who started breastfeeding within one day of birth Number of women with a live birth in the two years preceding the survey Residence Urban 32.2 73.0 136 Rural 28.7 74.0 264 Months since birth < 6 months 31.6 75.8 104 6-11 months 28.3 68.8 80 12-23 months 30.8 75.7 200 Mother’s education None/Primary (*) (*) 11 Lower secondary 26.9 73.5 224 Upper secondary + 34.0 74.0 164 Wealth index quintiles Poorest 29.6 75.7 102 Second 34.1 73.2 72 Middle 18.3 72.6 78 Fourth 32.5 72.2 84 Richest 36.3 74.0 64 Religion Muslim 28.2 70.2 331 Orthodox/Catholic/ Other 38.3 90.5 68 Total 29.9 73.7 399 * MICS indicator 45 (*) – Figures are based on less than 25 unweighted cases. Percentage of women aged 15-49 years with a birth in the two years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Albania, 2005 55 Ta bl e NU .3 : B re as tfe ed in g Pe rc en ta ge o f l ivi ng c hi ld re n ac co rd in g to b re as tfe ed in g st at us a t e ac h ag e gr ou p, A lb an ia , 2 00 5 Pe rc en t ex cl us ive ly br ea st fe d Br ea st fe d an d on ly gi ve n pl ai n wa te r N um be r o f ch ild re n Pe rc en t ex cl us ive ly br ea st fe d* Br ea st fe d an d on ly gi ve n pl ai n wa te r N um be r o f ch ild re n Pe rc en t re ce ivi ng br ea st m ilk a nd so lid / m us hy fo od ** N um be r o f ch ild re n Pe rc en t br ea st fe d ** * N um be r o f ch ild re n Pe rc en t br ea st fe d ** * N um be r o f ch ild re n Se x M al e (8 .4 ) (5 1. 6) 26 4. 2 35 .7 53 43 .8 36 (5 7. 3) 48 (1 6. 9) 32 Fe m al e (0 .0 ) (4 7. 3) 32 (0 .0 ) 38 .3 44 (* ) 24 (5 8. 6) 34 (* ) 21 Re si de nc e U rb an (3 .7 ) (5 4. 1) 26 (2 .9 ) (4 5. 7) 33 (* ) 16 (5 2. 6) 23 (3 7. 2) 19 R ur al (3 .8 ) (4 5. 5) 33 2. 0 32 .3 63 (3 9. 4) 43 59 .9 58 (1 0. 2) 34 M ot he r’s e du ca tio n N on e/ Pr im ar y (* ) (* ) 0 (* ) (* ) 0 (* ) 4 (* ) 5 (* ) 2 Lo we r s ec on da ry (6 .4 ) (4 4. 1) 35 4. 0 31 .1 56 (4 9. 8) 28 (6 0. 1) 49 (2 8. 9) 29 U pp er s ec on da ry + (0 .0 ) (5 6. 6) 24 (0 .0 ) (4 4. 7) 41 (2 6. 4) 28 (5 0. 9) 28 (1 0. 2) 22 Re lig io n M us lim 4. 3 51 .3 52 2. 7 35 .4 83 (3 4. 0) 44 54 .9 68 (1 9. 9) 44 O rth od ox /C at ho lic / O th er (* ) (* ) 7 (* ) (* ) 14 (* ) 16 (* ) 14 (* ) 10 To ta l 3. 8 49 .2 59 2. 3 36 .9 97 38 .4 59 57 .8 82 20 .0 54 * M IC S in di ca to r 1 5 ** M IC S in di ca to r 1 7 ** * M IC S in di ca to r 1 6 (* ) – F ig ur es a re b as ed o n le ss th an 2 5 un we ig ht ed c as es . (… ) – F ig ur es a re b as ed o n 25 -4 9 un we ig ht ed c as es . Ch ild re n 20 -2 3 m on th s Ch ild re n 0- 3 m on th s Ch ild re n 0- 5 m on th s Ch ild re n 6- 9 m on th s Ch ild re n 12 -1 5 m on th s 56 Table NU.4: Adequately fed infants 0-5 months exclusively breastfed 0-5 months breastfed and receiving plain water only 6-8 months who received breastmilk and comple- mentary food at least 2 times in prior 24 hours 9-11 months who received breastmilk and comple- mentary food at least 3 times in prior 24 hours 6-11 months who received breastmilk and comple- mentary food at least the minimum recomm- ended number of times per day* 0-11 months who were appro-priately fed** 0-11 months who were appro-priately fed*** Number of infants aged 0- 11 months Sex Male 4.2 35.7 (*) (*) (46.6) 24.3 40.9 100 Female (0.0) (38.3) (*) (*) (44.8) 19.4 41.1 78 Residence Urban (2.9) (45.7) (*) (*) (39.8) 18.1 43.3 57 Rural 2.0 32.3 (50.8) (*) (48.3) 24.1 39.9 121 Mother’s education None/Primary (*) (*) (*) (*) (*) (*) (*) 4 Lower secondary 4.0 31.1 (*) (41.1) (44.3) 21.4 36.8 98 Upper secondary + (0.0) (44.7) (*) (*) (41.9) 19.3 43.4 76 Wealth index quintiles Poorest (*) (*) (*) (*) (*) (23.2) (28.4) 50 Second (*) (*) (*) (*) (*) (26.0) (50.6) 34 Middle (*) (*) (*) (*) (*) (17.1) (38.4) 37 Fourth (*) (*) (*) (*) (*) (27.7) (46.8) 29 Richest (*) (*) (*) (*) (*) (16.8) (49.1) 28 Religion Muslim 2.7 35.4 39.0 52.4 45.1 20.6 39.5 143 Orthodox/Catholic/ Other (*) (*) (*) (*) (*) (28.7) (47.0) 35 Total 2.3 36.9 (47.2) (44.2) 45.9 22.2 41.0 178 * MICS indicator 18 ** MICS indicator 19 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. 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, Albania, 2005 Percent of infants *** alternative definition - children 0-5 months receiving plain water only in addition to breastmilk 57 Table NU.5: Brand of salt Percent distribution households according to brand of salt used, Albania, 2005 Niki Vlore (E Bardhe) Elka Nelson Other Total Residence Urban 81.2 3.5 9.5 2.2 3.5 100.0 2275 Rural 73.7 11.6 5.2 4.2 5.2 100.0 2875 Wealth index quintiles Poorest 60.2 23.8 3.7 4.4 7.9 100.0 963 Second 77.5 8.7 4.8 4.2 4.7 100.0 967 Middle 82.8 5.2 5.7 3.4 2.9 100.0 1021 Fourth 81.7 2.5 8.8 2.4 4.5 100.0 1074 Richest 81.2 2.0 11.8 2.4 2.7 100.0 1125 Total 77.0 8.1 7.1 3.3 4.5 100.0 5150 Salt brand Number of households Table NU.6: Children's vitamin A supplementation Within last 6 months* Prior to last 6 months Not sure when Sex Male 9.0 11.2 6.5 17.9 55.5 100.0 547 Female 6.8 13.2 8.3 12.4 59.3 100.0 450 Residence Urban 8.9 12.3 11.2 12.8 54.8 100.0 354 Rural 7.5 12.0 5.1 16.9 58.5 100.0 642 Age 6-11 months 23.4 0.0 1.9 11.4 63.3 100.0 81 12-23 months 8.7 12.9 5.2 15.8 57.5 100.0 191 24-35 months 6.0 15.5 4.7 12.9 60.9 100.0 211 36-47 months 7.0 12.6 10.4 17.3 52.8 100.0 226 48-59 months 5.5 12.2 9.6 16.8 55.9 100.0 286 Mother’s education None/Primary (7.9) (13.7) (3.2) (24.1) (51.1) (100.0) 38 Lower secondary 6.1 10.6 6.0 18.2 59.1 100.0 539 Upper secondary + 10.5 13.9 9.3 11.1 55.3 100.0 420 Wealth index quintiles Poorest 4.9 16.6 4.9 23.1 50.5 100.0 224 Second 8.4 9.1 3.3 15.7 63.5 100.0 214 Middle 9.7 8.4 10.1 15.4 56.5 100.0 178 Fourth 7.2 13.7 8.5 11.5 59.2 100.0 214 Richest 11.1 11.8 11.1 9.8 56.2 100.0 166 Religion Muslim 6.9 10.9 6.8 14.8 60.6 100.0 850 Orthodox/Catholic/ Other 14.4 19.4 9.9 19.2 37.1 100.0 146 Total 8.0 12.1 7.3 15.4 57.2 100.0 996 * MICS indicator 42 (…) – Figures are based on 25-49 unweighted cases. Percent distribution of children aged 6-59 months by whether they have received a high dose vitamin A supplement in the last 6 months, Albania, 2005 Total Number of children aged 6- 59 months Percent of children who received vitamin A: Not sure if received vitamin A Never received vitamin A 58 Table NU.7: Post-partum mothers' vitamin A supplementation Received vitamin A supplement* Not sure if received vitamin A Number of women aged 15- 49 years Residence Urban 38.0 4.0 136 Rural 19.9 8.0 264 Education None/Primary (*) (*) 11 Lower secondary 20.2 7.7 224 Upper secondary + 34.0 4.3 164 Wealth index quintiles Poorest 17.7 9.5 102 Second 13.5 9.3 72 Middle 32.3 4.6 78 Fourth 31.9 3.3 84 Richest 38.3 6.1 64 Religion Muslim 22.2 7.3 331 Orthodox/Catholic/Other 44.8 3.7 68 Total 26.1 6.7 399 *MICS indicator 43 (*) – Figures are based on less than 25 unweighted cases. Percentage of women aged 15-49 years with a live birth in the 2 years preceding the survey by whether they received a high dose vitamin A supplement before the infant was 8 weeks old, Albania, 2005 Table NU.8: Low birth weight infants Below 2500 grams* Weighed at birth** Residence Urban 7.0 95.1 136 Rural 6.8 97.2 264 Mother’s education None/Primary (*) (*) 11 Lower secondary 7.3 95.8 224 Upper secondary + 6.4 97.2 164 Wealth index quintiles Poorest 6.8 97.6 102 Second 6.5 97.3 72 Middle 5.5 100.0 78 Fourth 6.9 91.6 84 Richest 8.9 96.1 64 Religion Muslim 7.0 95.8 331 Orthodox/Catholic/Other 6.4 100.0 68 Total 6.9 96.5 399 * MICS indicator 9 ** MICS indicator 10 (*) – Figures are based on less than 25 unweighted cases. Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, Albania, 2005 Percent of live births: Number of live births 59 Table CH.1: Neonatal tetanus protection Received at least 2 doses during last pregnancy Received at least 2 doses, the last within prior 3 years Protected against tetanus* Residence Urban 37.2 6.3 43.5 136 Rural 51.9 4.8 56.7 264 Age 15-19 (*) (*) (*) 17 20-24 44.2 4.4 48.6 112 25-29 48.7 9.4 58.0 139 30-34 45.2 2.5 47.7 85 35+ (44.4) (2.5) (46.9) 47 Education None/Primary (*) (*) (*) 11 Lower secondary 46.5 5.3 51.8 224 Upper secondary + 47.9 5.8 53.7 164 Wealth index quintiles Poorest 42.4 7.6 50.0 102 Second 52.2 4.2 56.4 72 Middle 55.3 2.1 57.4 78 Fourth 43.5 6.4 49.9 84 Richest 42.4 5.4 47.7 64 Religion Muslim 45.4 3.8 49.2 331 Orthodox/Catholic/ Other 54.2 12.9 67.1 68 Total 46.9 5.3 52.2 399 * MICS indicator 32 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Percent of mothers with a birth in the last 2 years who: Number of mothers Percentage of mothers with a birth in the last 2 years protected against neonatal tetanus, Albania, 2005 60 Table CH.2: Oral rehydration treatment Fluid from ORS packet Recommended homemade fluid Pre-packaged ORS fluid No treatment ORT Use Rate * Sex Male 8.1 599 (55.2) (83.8) (5.4) (7.4) (92.6) 49 Female 5.4 494 (*) (*) (*) (*) (*) 27 Residence Urban 5.1 387 (*) (*) (*) (*) (*) 20 Rural 7.8 706 (47.3) (76.0) (6.4) (12.0) (88.0) 55 Age 0-5 months 7.7 97 (*) (*) (*) (*) (*) 7 6-11 months 8.4 81 (*) (*) (*) (*) (*) 7 12-23 months 11.6 191 (*) (*) (*) (*) (*) 22 24-35 months 7.3 211 (*) (*) (*) (*) (*) 15 36-47 months 5.6 226 (*) (*) (*) (*) (*) 13 48-59 months 3.7 286 (*) (*) (*) (*) (*) 11 Mother’s education None/Primary (2.2) 38 (*) (*) (*) (*) (*) 1 Lower secondary 7.0 594 (35.9) (81.3) (8.4) (11.0) (89.0) 42 Upper secondary + 7.0 461 (73.7) (71.7) (8.7) (8.5) (91.5) 32 Wealth index quintiles Poorest 9.0 248 (*) (*) (*) (*) (*) 22 Second 8.6 233 (*) (*) (*) (*) (*) 20 Middle 7.8 197 (*) (*) (*) (*) (*) 15 Fourth 4.6 230 (*) (*) (*) (*) (*) 10 Richest 3.7 185 (*) (*) (*) (*) (*) 7 Religion Muslim 7.1 933 49.8 76.5 8.3 11.0 89.0 66 Orthodox/Catholic/ Other 5.5 160 (*) (*) (*) (*) (*) 9 Total 6.9 1093 51.8 76.2 8.4 10.9 89.1 75 * MICS indicator 33 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. * Percent under fives with diarrhoea in previous 2 weeks who received oral rehydration salts or an appropriate household solution (ORT) Number of children aged 0-59 months Children with diarrhoea who received: Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), Albania, 2005 Had diarrhoea in last two weeks Number of children aged 0- 59 months with diarrhoea 61 Table CH.3: Home management of diarrhoea Drank more Drank the same or less Ate somewhat less, same or more Ate much less or none Sex Male 8.1 599 (12.6) (83.9) (50.3) (49.7) (7.7) (46.5) 49 Female 5.4 494 (*) (*) (*) (*) (*) (*) 27 Residence Urban 5.1 387 (*) (*) (*) (*) (*) (*) 20 Rural 7.8 706 (10.7) (86.2) (51.3) (48.7) (7.3) (48.0) 55 Age 0-11 months 8.1 178 (*) (*) (*) (*) (*) (*) 14 18-29 months 11.6 191 (*) (*) (*) (*) (*) (*) 22 24-35 months 7.3 211 (*) (*) (*) (*) (*) (*) 15 36-47 months 5.6 226 (*) (*) (*) (*) (*) (*) 13 48-59 months 3.7 286 (*) (*) (*) (*) (*) (*) 11 Mother’s education None/Primary (2.2) 38 (*) (*) (*) (*) (*) (*) 1 Lower secondary 7.0 594 (13.5) (86.5) (55.7) (44.3) (11.2) (55.7) 42 Upper secondary + 7.0 461 (9.9) (84.8) (50.4) (49.6) (5.6) (44.8) 32 Wealth index quintiles Poorest 9.0 248 (*) (*) (*) (*) (*) (*) 22 Second 8.6 233 (*) (*) (*) (*) (*) (*) 20 Middle 7.8 197 (*) (*) (*) (*) (*) (*) 15 Fourth 4.6 230 (*) (*) (*) (*) (*) (*) 10 Richest 3.7 185 (*) (*) (*) (*) (*) (*) 7 Religion Muslim 7.1 933 7.7 89.7 54.2 45.8 5.5 52.8 66 Orthodox/Catholic/ Other 5.5 160 (*) (*) (*) (*) (*) (*) 9 Total 6.9 1093 11.8 85.9 52.8 47.2 8.6 50.3 75 * MICS indicator 34 ** MICS indicator 35 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Children with diarrhoea who: Home manage- ment of diarrhoea* ** Received ORT or increased fluids and continued feeding - Percent of under fives with diarrhoea in previous 2 weeks who received [ORS and/or an appropriate household solution (ORT) or took "more" fluids] AND who continued eating somewhat less, the same or more food. Percentage of children aged 0-59 months with diarrhoea in the last two weeks who took increased fluids and continued to feed during the episode, Albania, 2005 * Home management of diarrhoea - Percent of under fives with diarrhoea in previous 2 weeks who took "more" fluids AND continued eating somewhat less, the same or more food. Received ORT or increased fluids AND continued feeding** Number of children aged 0-59 months with diarrhoea Number of children aged 0-59 months Had diarrhoea in last two weeks 62 Table CH.4: Care seeking for suspected pneumonia Govt. Hospital Govt. health centre Village health worker Private physician Pharmacy Sex Male 4.4 599 (12.9) (25.1) (2.5) 0.0 (4.4) (31.7) 26 Female 4.5 494 (22.9) (35.5) (3.2) (6.9) (3.2) (61.3) 22 Residence Urban 3.9 387 (*) (*) (*) (*) (*) (*) 15 Rural 4.8 706 (25.3) (30.9) (4.1) (2.5) (5.6) (53.2) 34 Age 0-11 months 3.4 178 (*) (*) (*) (*) (*) (*) 6 18-29 months 5.4 191 (*) (*) (*) (*) (*) (*) 10 24-35 months 5.9 211 (*) (*) (*) (*) (*) (*) 13 36-47 months 3.6 226 (*) (*) (*) (*) (*) (*) 8 48-59 months 4.0 286 (*) (*) (*) (*) (*) (*) 12 Mother’s education None/Primary (3.0) 38 (*) (*) (*) (*) (*) (*) 1 Lower secondary 4.5 594 (24.0) (37.8) (5.2) (3.1) (7.1) (61.4) 26 Upper secondary + 4.6 461 (10.2) (21.5) 0.0 (3.4) 0.0 (27.5) 21 Wealth index quintiles Poorest 6.3 248 (*) (*) (*) (*) (*) (*) 16 Second 5.6 233 (*) (*) (*) (*) (*) (*) 13 Middle 3.3 197 (*) (*) (*) (*) (*) (*) 6 Fourth 2.9 230 (*) (*) (*) (*) (*) (*) 7 Richest 3.7 185 (*) (*) (*) (*) (*) (*) 7 Ethnicity/ Language/ Religion Muslim 5.0 933 18.4 31.4 3.0 3.3 4.0 47.6 46 Orthodox/Catholic/ Other 1.5 160 (*) (*) (*) (*) (*) (*) 2 Total 4.4 1093 17.5 29.9 2.8 3.2 3.8 45.3 49 * MICS indicator 23 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks taken to a health provider, Albania, 2005 Number of children aged 0-59 months with suspected pneumonia Any appropriate provider* Number of children aged 0-59 months Had acute respiratory infection Children with suspected pneumonia who were taken to: 63 Table CH.5: Antibiotic treatment of pneumonia Percentage of children aged 0-59 months with suspected pneumonia who received antibiotics in the last two weeks* Number of children aged 0-59 months with suspected pneumonia in the two weeks prior to the survey Sex Male (31.7) 26 Female (44.3) 22 Residence Urban (*) 15 Rural (48.2) 34 Mother’s education None/Primary (*) 1 Lower secondary (50.0) 26 Upper secondary + (23.8) 21 Religion Muslim (39.4) 46 Orthodox/Catholic/Other (*) 2 Total 37.5 49 * MICS indicator 22 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Percentage of children aged 0-59 months with suspected pneumonia who received antibiotic treatment, Albania, 2005 64 Ta bl e CH .6 : K no w le dg e of th e tw o da ng er s ig ns o f p ne um on ia Is n ot a bl e to dr in k or br ea st fe ed Be co m es si ck er D ev el op s a fe ve r H as fa st br ea th in g H as d iff ic ul t br ea th in g H as b lo od in s to ol Is d rin kin g po or ly H as o th er sy m pt om s Re si de nc e U rb an 19 .1 42 .2 91 .1 48 .2 63 .6 60 .2 7. 2 1. 3 32 .2 38 7 R ur al 24 .1 47 .9 88 .3 58 .8 56 .2 54 .8 3. 3 1. 6 36 .9 70 6 M ot he r's e du ca tio n N on e/ Pr im ar y (1 0. 5) (3 5. 4) (8 6. 0) (5 5. 2) (3 6. 8) (5 4. 6) 0. 0 0. 0 (2 4. 8) 38 Lo we r s ec on da ry 23 .4 46 .5 87 .0 54 .2 58 .0 53 .3 3. 7 1. 0 34 .9 59 4 U pp er s ec on da ry + 21 .9 45 .9 92 .4 56 .1 61 .6 61 .2 6. 4 2. 2 36 .5 46 1 W ea lth in de x qu in til es Po or es t 23 .0 37 .7 92 .0 48 .8 51 .6 53 .5 3. 6 0. 4 26 .2 24 8 Se co nd 23 .9 55 .7 86 .0 59 .5 57 .5 46 .6 3. 4 3. 7 40 .2 23 3 M id dl e 25 .6 44 .3 87 .3 61 .0 57 .9 60 .4 4. 7 0. 7 39 .8 19 7 Fo ur th 20 .7 45 .9 88 .0 57 .6 64 .9 60 .8 5. 5 0. 6 38 .2 23 0 R ic he st 17 .9 45 .9 93 .3 48 .2 63 .5 64 .8 6. 9 2. 0 32 .4 18 5 Re lig io n M us lim 21 .9 47 .2 89 .8 53 .9 59 .0 55 .7 3. 8 1. 5 34 .6 93 3 O rth od ox /C at ho lic / O th er 24 .6 37 .9 86 .4 61 .8 57 .4 62 .7 10 .1 1. 3 38 .6 16 0 To ta l 22 .3 45 .8 89 .3 55 .0 58 .8 56 .7 4. 7 1. 5 35 .2 10 93 (… ) – F ig ur es a re b as ed o n 25 -4 9 un we ig ht ed c as es . In th is ta bl e, th e pe rc en ta ge s wi ll n ot a dd to 1 00 s in ce s om e m ot he rs /c ar et ak er s m ay h av e in di ca te d m or e th an o ne s ym pt om . Pe rc en ta ge o f m ot he rs /c ar et ak er s of c hi ld re n ag ed 0 -5 9 m on th s w ho th in k th at a c hi ld s ho ul d be ta ke n im m ed ia te ly to a h ea lth fa ci lit y if th e ch ild : Pe rc en ta ge o f m ot he rs /c ar et ak er s of c hi ld re n ag ed 0 -5 9 m on th s by k no wl ed ge o f t yp es o f s ym pt om s fo r t ak in g a ch ild im m ed ia te ly to a h ea lth fa ci lity , a nd p er ce nt ag e of m ot he rs /c ar et ak er s wh o re co gn ize fa st a nd d iff ic ul t b re at hi ng a s si gn s fo r s ee kin g ca re im m ed ia te ly, A lb an ia , 2 00 5 M ot he rs / c ar et ak er s wh o re co gn ize th e tw o da ng er s ig ns o f pn eu m on ia N um be r o f m ot he rs / ca re ta ke rs o f ch ild re n ag ed 0 - 59 m on th s 65 Table CH.7: Solid fuel use Electricity Liquified Petroleum Gas (LPG) Kero- sene Coal, lignite Wood Agri- cultural crop residue Other source Total Solid fuels for cooking* Number of households Residence Urban 22.5 50.1 0.1 0.0 26.1 0.2 0.9 100.0 26.3 2275 Rural 1.9 19.3 0.0 0.1 78.2 0.3 0.2 100.0 78.6 2875 Education of household head None/Primary 9.4 19.7 0.1 0.2 69.8 0.2 0.6 100.0 70.2 881 Lower secondary 7.7 26.1 0.0 0.0 65.6 0.2 0.5 100.0 65.8 2113 Upper secondary + 15.0 45.0 0.1 0.0 39.1 0.3 0.5 100.0 39.4 2156 Wealth index quintiles Poorest 0.8 2.1 0.0 0.0 96.6 0.1 0.4 100.0 96.8 963 Second 2.7 11.4 0.0 0.2 84.5 0.4 0.8 100.0 85.1 967 Middle 5.0 23.1 0.1 0.0 71.3 0.1 0.4 100.0 71.4 1021 Fourth 14.6 50.5 0.2 0.0 33.7 0.3 0.8 100.0 33.9 1074 Richest 29.0 69.9 0.0 0.0 0.6 0.3 0.2 100.0 0.9 1125 Religion Muslim 11.0 31.1 0.1 0.0 57.0 0.2 0.5 100.0 57.3 4117 Orthodox/Catholic/Other 11.1 39.9 0.1 0.0 48.1 0.3 0.5 100.0 48.3 1033 Total 11.0 32.9 0.1 0.0 55.2 0.2 0.5 100.0 55.5 5150 * MICS indicator 24; MDG indicator 29 Percentage of households using: Percent distribution of households according to type of cooking fuel, and percentage of households using solid fuels for cooking, Albania, 2005 66 Ta bl e EN .1 : U se o f i m pr ov ed w at er s ou rc es Pi pe d in to dw el lin g Pi pe d in to ya rd / pl ot Pu bl ic ta p/ st an d- pi pe Tu be - we ll/ bo re - ho le Pr o- te ct ed we ll Pr o- te ct ed sp rin g Bo ttl ed wa te r1 U np ro - te ct ed we ll U np ro - te ct ed sp rin g Ta nk er tru ck Bo ttl ed wa te r1 O th er Re si de nc e U rb an 78 .3 2. 0 1. 9 0. 5 1. 2 1. 1 12 .2 0. 0 0. 0 2. 4 0. 2 0. 1 10 0. 0 97 .2 82 69 R ur al 43 .0 29 .6 3. 9 4. 4 12 .7 3. 2 0. 9 0. 6 0. 9 0. 7 0. 1 0. 0 10 0. 0 97 .8 12 34 0 Ed uc at io n of h ou se ho ld h ea d N on e/ Pr im ar y 50 .6 24 .1 2. 7 3. 4 10 .1 3. 2 2. 1 0. 8 1. 7 1. 2 0. 0 0. 0 10 0. 0 96 .3 33 23 Lo we r s ec on da ry 51 .8 23 .4 3. 9 3. 8 10 .0 2. 7 2. 6 0. 3 0. 3 0. 9 0. 1 0. 1 10 0. 0 98 .3 88 29 U pp er s ec on da ry + 65 .4 11 .3 2. 3 1. 6 5. 3 1. 6 9. 7 0. 3 0. 3 2. 0 0. 2 0. 0 10 0. 0 97 .2 84 58 W ea lth in de x qu in til es Po or es t 8. 6 61 .1 5. 9 2. 0 15 .7 3. 2 0. 4 1. 0 1. 6 0. 5 0. 0 0. 0 10 0. 0 97 .0 41 24 Se co nd 45 .2 23 .7 4. 8 6. 2 13 .2 3. 6 0. 5 0. 7 0. 8 1. 2 0. 0 0. 1 10 0. 0 97 .2 41 16 M id dl e 72 .3 6. 9 2. 7 4. 6 7. 5 2. 0 2. 1 0. 1 0. 2 1. 2 0. 2 0. 2 10 0. 0 98 .1 41 28 Fo ur th 77 .1 1. 0 1. 7 1. 2 3. 5 2. 1 10 .7 0. 0 0. 0 2. 5 0. 2 0. 0 10 0. 0 97 .3 41 19 R ic he st 82 .8 0. 0 0. 2 0. 2 0. 6 0. 7 13 .6 0. 0 0. 0 1. 6 0. 3 0. 0 10 0. 0 98 .1 41 23 Re lig io n M us lim 56 .7 19 .9 2. 8 2. 0 8. 5 2. 7 4. 7 0. 4 0. 6 1. 4 0. 1 0. 1 10 0. 0 97 .4 16 83 8 O rth od ox /C at ho lic / O th er 59 .2 12 .4 4. 3 6. 8 6. 1 0. 7 8. 6 0. 4 0. 0 1. 4 0. 2 0. 0 10 0. 0 98 .1 37 72 To ta l 57 .2 18 .5 3. 1 2. 9 8. 1 2. 3 5. 5 0. 4 0. 5 1. 4 0. 1 0. 1 10 0. 0 97 .5 20 60 9 * M IC S in di ca to r 1 1; M DG in di ca to r 3 0 Pe rc en t d is tri bu tio n of h ou se ho ld p op ul at io n ac co rd in g to m ai n so ur ce o f d rin kin g wa te r a nd p er ce nt ag e of h ou se ho ld p op ul at io n u si ng im pr ov ed d rin kin g wa te r s ou rc es , Al ba ni a, 2 00 5 1 F or h ou se ho ld s us in g bo ttl ed w at er a s th e m ai n so ur ce o f d rin kin g wa te r, th e so ur ce u se d fo r o th er p ur po se s su ch a s co ok in g an d ha nd wa sh in g is u se d to d et er m in e wh et he r t o cl as si fy th e so ur ce a s im pr ov ed . N um be r o f ho us eh ol d m em be rs M ai n so ur ce o f d rin ki ng w at er To ta l Im pr ov ed so ur ce o f dr in kin g wa te r* Im pr ov ed s ou rc es Un im pr ov ed s ou rc es 67 Ta bl e EN .2 : H ou se ho ld w at er tr ea tm en t N on e Bo il Ad d bl ea ch / ch lo rin e St ra in th ro ug h a cl ot h U se wa te r fil te r So la r di si nf - ec tio n Le t i t st an d an d se ttl e O th er D on 't kn ow Ap pr op ria te wa te r tre at m en t m et ho d* N um be r o f ho us eh ol d m em be rs Ap pr op ria te wa te r tre at m en t m et ho d N um be r o f ho us eh ol d m em be rs Ap pr op ria te wa te r tre at m en t m et ho d N um be r o f ho us eh ol d m em be rs Re si de nc e U rb an 87 .1 11 .3 0. 0 0. 3 0. 9 0. 0 0. 2 0. 4 0. 1 12 .2 82 69 12 .5 80 41 0. 0 22 8 R ur al 89 .5 4. 3 2. 7 2. 3 0. 2 0. 1 0. 5 0. 6 0. 1 7. 3 12 34 0 7. 3 12 06 2 10 .5 27 8 Ed uc at io n of h ou se ho ld h ea d N on e/ Pr im ar y 89 .2 4. 6 3. 3 1. 7 0. 2 0. 2 0. 8 0. 2 0. 0 8. 3 33 23 8. 1 32 00 14 .6 12 3 Lo we r s ec on da ry 90 .2 6. 1 1. 4 1. 7 0. 2 0. 0 0. 5 0. 2 0. 0 7. 6 88 29 7. 7 86 79 2. 3 15 0 U pp er s ec on da ry + 86 .5 9. 1 1. 3 1. 2 0. 9 0. 0 0. 1 1. 0 0. 2 11 .3 84 58 11 .5 82 25 3. 4 23 3 W ea lth in de x qu in til es Po or es t 90 .6 2. 5 4. 3 2. 7 0. 1 0. 0 0. 1 0. 0 0. 0 6. 8 41 24 6. 5 40 00 17 .1 12 4 Se co nd 89 .8 4. 2 2. 4 2. 7 0. 0 0. 2 1. 2 0. 1 0. 0 6. 8 41 16 6. 8 40 00 6. 9 11 5 M id dl e 88 .5 7. 5 1. 0 1. 2 0. 3 0. 0 0. 5 1. 0 0. 2 8. 8 41 28 9. 0 40 50 0. 0 78 Fo ur th 84 .7 12 .4 0. 4 0. 6 1. 2 0. 0 0. 0 1. 0 0. 0 13 .8 41 19 14 .2 40 10 0. 0 11 0 R ic he st 89 .0 9. 0 0. 2 0. 3 0. 8 0. 0 0. 1 0. 6 0. 1 10 .0 41 23 10 .2 40 44 0. 0 78 Re lig io n M us lim 89 .6 6. 3 1. 9 1. 4 0. 5 0. 0 0. 3 0. 2 0. 0 8. 7 16 83 8 8. 8 16 40 5 6. 7 43 3 O rth od ox /C at ho lic / O th er 83 .9 10 .6 0. 7 1. 9 0. 2 0. 2 0. 8 1. 9 0. 4 11 .7 37 72 12 .0 36 99 0. 0 73 To ta l 88 .5 7. 1 1. 7 1. 5 0. 5 0. 0 0. 4 0. 5 0. 1 9. 3 20 60 9 9. 3 20 10 4 5. 8 50 5 * M IC S in di ca to r 1 3 * D rin kin g wa te r i s co ns id er ed tr ea te d if on e th e fo llo wi ng m et ho ds o f t re at m en t a re u se d: b oi lin g; a dd in g bl ea ch o r c hl or in e; us in g a wa te r f ilte r; or u si ng s ol ar d is in fe ct io n N ot e th at m ul tip le re sp on se c at eg or ie s m ay b e us ed a nd re sp on se s m ay to ta l t o m or e th an 1 00 p er ce nt . Pe rc en t d is tri bu tio n of h ou se ho ld p op ul at io n ac co rd in g to d rin kin g wa te r t re at m en t m et ho d us ed in th e ho us eh ol d, a nd p er ce nt ag e o f h ou se ho ld p op ul at io n th at a pp lie d an a pp ro pr ia te w at er tr ea tm en t m et ho d, Al ba ni a, 2 00 5 Al l d rin ki ng w at er so ur ce s Im pr ov ed d rin ki ng w at er so ur ce s Un im pr ov ed d rin ki ng w at er s ou rc es W at er tr ea tm en t m et ho d us ed in th e ho us eh ol d 68 Table EN.3: Time to source of water Water on premises Less than 15 minutes 15 minutes to less than 30 minutes 30 minutes to less than 1 hour 1 hour or more Don't know Total Residence Urban 93.0 3.4 1.2 1.4 0.8 0.1 100.0 21.7 2275 Rural 82.1 12.5 1.9 1.8 1.8 0.0 100.0 16.6 2875 Education of household head None/Primary 84.6 10.1 1.4 2.5 1.3 0.1 100.0 16.3 881 Lower secondary 85.0 10.1 1.6 1.5 1.7 0.0 100.0 18.6 2113 Upper secondary + 89.1 6.8 1.6 1.3 1.0 0.1 100.0 17.2 2156 Wealth index quintiles Poorest 78.7 14.6 2.3 2.3 2.1 0.0 100.0 17.7 963 Second 78.1 15.0 2.4 2.6 1.9 0.0 100.0 15.8 967 Middle 89.0 7.0 1.0 1.6 1.3 0.1 100.0 18.6 1021 Fourth 90.4 5.2 1.5 1.3 1.4 0.1 100.0 22.7 1074 Richest 96.4 2.2 0.8 0.4 0.1 0.1 100.0 13.7 1125 Religion Muslim 86.9 8.3 1.5 1.6 1.6 0.0 100.0 19.6 4117 Orthodox/Catholic/ Other 85.3 10.6 1.8 1.9 0.3 0.1 100.0 10.5 1033 Total 86.6 8.8 1.6 1.6 1.4 0.0 100.0 17.7 5150 Percent distribution of households according to time to go to source of drinking water, get water and return, and mean time to source of drinking water, Albania, 2005 * The mean time to source of drinking water is calculated based on those households that do not have water on the premises. Time to source of drinking water Mean time to source of drinking water* Number of households 69 Table EN.4: Person collecting water Adult woman Adult man Female child under age 15 Male child under age 15 Don't know Total Residence Urban 55.6 40.3 2.2 1.8 0.0 100.0 140 Rural 70.4 25.8 1.6 2.1 0.2 100.0 511 Education of household head None/Primary 69.2 28.9 1.0 0.9 0.0 100.0 134 Lower secondary 70.2 26.8 0.9 1.8 0.4 100.0 307 Upper secondary + 61.5 31.9 3.3 3.2 0.0 100.0 210 Wealth index quintiles Poorest 74.0 23.1 1.0 1.8 0.0 100.0 204 Second 69.5 25.5 3.1 1.9 0.0 100.0 211 Middle 62.0 32.8 0.7 3.4 1.0 100.0 110 Fourth 59.2 39.8 0.0 1.1 0.0 100.0 91 Richest (50.5) (42.4) (4.8) (2.3) (0.0) (100.0) 35 Religion Muslim 64.2 31.6 1.4 2.6 0.2 100.0 513 Orthodox/Catholic/ Other 78.5 18.8 2.7 0.0 0.0 100.0 138 Total 67.2 28.9 1.7 2.1 0.2 100.0 651 (…) – Figures are based on 25-49 unweighted cases. Person collecting drinking water Number of households Percent distribution of households according to the person collecting drinking water used in the household, Albania, 2005 70 Table EN.5: Use of sanitary means of excreta disposal Piped sewer system Septic tank Pit latrine Residence Urban 97.2 1.6 0.0 0.0 0.6 0.4 0.2 100.0 99.4 8269 Rural 61.2 21.3 0.3 0.3 15.4 1.0 0.5 100.0 98.5 12340 Education of household head None/Primary 68.2 17.8 0.1 0.1 12.2 1.5 0.2 100.0 98.3 3323 Lower secondary 68.5 17.1 0.2 0.1 12.5 1.0 0.6 100.0 98.4 8829 Upper secondary + 86.0 7.9 0.2 0.3 5.1 0.3 0.1 100.0 99.6 8458 Wealth index quintiles Poorest 13.7 50.2 0.3 0.4 31.4 3.6 0.5 100.0 95.9 4124 Second 68.6 14.8 0.4 0.2 14.6 0.2 1.2 100.0 98.6 4116 Middle 96.3 1.8 0.1 0.3 1.2 0.2 0.1 100.0 99.8 4128 Fourth 99.6 0.4 0.0 0.0 0.0 0.0 0.0 100.0 100.0 4119 Richest 100.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 4123 Religion Muslim 74.5 14.8 0.2 0.2 9.1 0.9 0.3 100.0 98.8 16838 Orthodox/Catholic/ Other 80.8 7.2 0.1 0.2 10.8 0.5 0.6 100.0 99.0 3772 Total 75.7 13.4 0.2 0.2 9.4 0.8 0.3 100.0 98.9 20609 * MICS indicator 12; MDG indicator 31 Other Percent distribution of household population according to type of toilet facility used by the household, and the percentage of household population using sanitary means of excreta disposal, Albania, 2005 Type of toilet facility used by household Total Percentage of population using sanitary means of excreta disposal* Improved sanitation facility Pit latrine without slab/ open pit Number of household members Unimproved sanitation facility Flush/pour flush to: Ventilated improved pit latrine Pit latrine with slab 71 Table EN.6: Disposal of child's faeces Child used toilet Put/rinsed into toilet or latrine Put/rinsed into drain or ditch Thrown into garbage Buried Other Don't know Total Residence Urban 18.5 20.8 0.4 55.2 0.0 0.8 4.3 100.0 39.3 198 Rural 14.7 23.4 5.6 42.0 2.7 5.2 6.4 100.0 38.2 387 Mother’s education None/Primary (*) (*) (*) (*) (*) (*) (*) (*) (*) 21 Lower secondary 12.7 27.0 5.9 41.7 2.9 4.9 4.8 100.0 39.7 315 Upper secondary + 20.3 15.1 1.6 53.6 0.5 2.1 6.7 100.0 35.4 249 Wealth index quintiles Poorest 11.3 31.3 8.7 34.6 2.8 3.0 8.3 100.0 42.5 146 Second 17.4 22.8 0.0 44.2 4.8 7.1 3.6 100.0 40.3 104 Middle 21.6 23.8 2.5 45.6 0.0 1.6 4.9 100.0 45.4 109 Fourth 14.0 20.1 4.4 49.4 1.2 4.3 6.7 100.0 34.1 130 Richest 18.1 10.7 1.3 63.8 0.0 2.7 3.4 100.0 28.8 96 Religion Muslim 15.1 23.7 2.8 46.4 1.3 4.3 6.4 100.0 38.8 486 Orthodox/Catholic/ Other 20.3 16.7 9.2 46.6 4.2 0.8 2.3 100.0 37.0 98 Total 16.0 22.5 3.8 46.4 1.8 3.7 5.7 100.0 38.5 585 * MICS indicator 14 (…) – Figures are based on 25-49 unweighted cases. Percent distribution of children aged 0-2 years according to place of disposal of child's faeces, and the percentage of children aged 0- 2 years whose stools are disposed of safely, Albania, 2005 Place of disposal of child's faeces Proportion of children whose stools are disposed of safely* Number of children aged 0-2 years 72 Table EN.7: Use of improved water sources and improved sanitation Using improved sources of drinking water* Using sanitary means of excreta disposal** Using improved sources of drinking water and using sanitary means of excreta disposal Number of household members Residence Urban 97.2 99.4 96.7 8269 Rural 97.8 98.5 96.3 12340 Education of household head None/Primary 96.3 98.3 94.6 3323 Lower secondary 98.3 98.4 96.8 8829 Upper secondary + 97.2 99.6 96.8 8458 Wealth index quintiles Poorest 97.0 95.9 93.0 4124 Second 97.2 98.6 95.9 4116 Middle 98.1 99.8 97.9 4128 Fourth 97.3 100.0 97.3 4119 Richest 98.1 100.0 98.1 4123 Religion Muslim 97.4 98.8 96.3 16838 Orthodox/Catholic/ Other 98.1 99.0 97.0 3772 Total 97.5 98.9 96.4 20609 * MICS indicator 11; MDG indicator 30 ** MICS indicator 12; MDG indicator 31 Percentage of household population using both improved drinking water sources and sanitary means of excreta disposal, Albania, 2005 Percentage of household population: 73 Ta bl e RH .1 : U se o f c on tra ce pt io n Pe rc en ta ge o f w om en a ge d 15 -4 9 ye ar s cu rre nt ly m ar rie d or in u ni on w ho a re u si ng (o r w ho se p ar tn er is u si ng ) a c on tra ce pt ive m eth od , A lb an ia , 2 00 5 Fe m al e st er ili- za tio n M al e st er ili- za tio n Pi ll In je ct io ns C on do m D ia ph - ra gm LA M Pe rio di c ab st in - en ce W ith - dr aw al O th er To ta l An y m od er n m et ho d An y tra di - tio na l m et ho d An y m et ho d* Re si de nc e U rb an 37 .2 0. 8 0. 1 11 .6 1. 5 17 .7 0. 1 2. 0 7. 1 21 .8 0. 2 10 0. 0 31 .7 31 .1 62 .8 13 09 R ur al 41 .6 1. 4 0. 1 8. 1 0. 3 6. 6 0. 0 2. 9 6. 8 32 .1 0. 1 10 0. 0 16 .5 41 .9 58 .4 20 24 Ag e 15 -1 9 (6 5. 0) (0 .0 ) (0 .0 ) (3 .3 ) (0 .0 ) (1 3. 0) (0 .0 ) (5 .2 ) (3 .4 ) (1 0. 1) (0 .0 ) (1 00 .0 ) (1 6. 3) (1 8. 7) (3 5. 0) 48 20 -2 4 57 .8 0. 0 0. 0 7. 7 0. 0 10 .5 0. 0 9. 1 3. 0 11 .5 0. 3 10 0. 0 18 .3 24 .0 42 .2 25 9 25 -2 9 41 .3 0. 9 0. 0 11 .4 0. 6 13 .9 0. 0 6. 5 6. 9 18 .3 0. 2 10 0. 0 26 .7 32 .0 58 .7 46 6 30 -3 4 36 .6 0. 6 0. 0 13 .2 1. 3 13 .7 0. 0 3. 1 6. 7 24 .7 0. 1 10 0. 0 28 .8 34 .6 63 .4 58 3 35 -3 9 32 .9 1. 8 0. 0 9. 2 1. 6 12 .0 0. 0 1. 1 8. 7 32 .4 0. 3 10 0. 0 24 .7 42 .4 67 .1 65 2 40 -4 4 31 .8 1. 3 0. 1 9. 1 0. 5 9. 8 0. 2 0. 2 8. 5 38 .3 0. 1 10 0. 0 21 .0 47 .2 68 .2 70 5 45 -4 9 49 .0 1. 6 0. 2 6. 3 0. 2 6. 3 0. 0 0. 4 5. 3 30 .6 0. 0 10 0. 0 14 .7 36 .3 51 .0 62 0 Nu m be r o f l iv in g ch ild re n 0 87 .1 0. 0 0. 0 4. 2 0. 0 7. 4 0. 0 0. 0 0. 0 1. 2 0. 0 10 0. 0 11 .6 1. 2 12 .9 19 8 1 52 .2 0. 4 0. 0 7. 8 1. 0 11 .0 0. 3 6. 1 5. 9 15 .4 0. 0 10 0. 0 20 .5 27 .3 47 .8 44 6 2 33 .2 1. 3 0. 1 11 .8 0. 9 14 .3 0. 0 1. 9 8. 1 28 .3 0. 2 10 0. 0 28 .3 38 .5 66 .8 14 62 3 31 .5 1. 6 0. 0 8. 7 0. 7 9. 3 0. 0 3. 0 7. 2 37 .9 0. 1 10 0. 0 20 .3 48 .3 68 .5 82 1 4+ 44 .5 1. 2 0. 3 7. 0 0. 7 3. 8 0. 0 1. 3 6. 4 34 .6 0. 2 10 0. 0 13 .1 42 .4 55 .5 40 6 Ed uc at io n N on e/ Pr im ar y 60 .6 2. 3 0. 0 9. 1 0. 0 0. 0 0. 0 0. 0 1. 4 26 .6 0. 0 10 0. 0 11 .4 28 .0 39 .4 53 Lo we r s ec on da ry 41 .7 0. 9 0. 1 7. 4 0. 4 7. 5 0. 0 2. 8 7. 2 32 .2 0. 0 10 0. 0 16 .2 42 .1 58 .3 18 10 U pp er s ec on da ry + 36 .9 1. 5 0. 1 12 .1 1. 2 15 .6 0. 1 2. 4 6. 8 23 .1 0. 3 10 0. 0 30 .6 32 .6 63 .1 14 70 W ea lth in de x qu in til es Po or es t 39 .1 1. 0 0. 0 11 .4 0. 3 5. 3 0. 0 3. 3 6. 1 33 .6 0. 0 10 0. 0 17 .9 42 .9 60 .9 65 4 Se co nd 45 .0 1. 8 0. 0 6. 1 0. 9 4. 0 0. 0 2. 8 6. 6 32 .5 0. 3 10 0. 0 12 .8 42 .2 55 .0 66 4 M id dl e 42 .8 1. 3 0. 2 8. 5 0. 4 10 .9 0. 0 2. 1 5. 8 27 .9 0. 0 10 0. 0 21 .3 35 .9 57 .2 66 9 Fo ur th 37 .9 0. 8 0. 0 9. 1 0. 5 15 .7 0. 0 2. 1 7. 6 25 .9 0. 2 10 0. 0 26 .2 35 .9 62 .1 68 6 R ic he st 34 .5 0. 9 0. 1 12 .3 1. 7 18 .7 0. 2 2. 4 8. 4 20 .5 0. 2 10 0. 0 33 .9 31 .5 65 .5 66 0 Re lig io n M us lim 39 .0 1. 0 0. 0 8. 9 0. 7 10 .7 0. 0 2. 4 6. 6 30 .4 0. 2 10 0. 0 21 .4 39 .6 61 .0 27 65 O rth od ox /C at ho lic /O th er 44 .1 1. 9 0. 4 12 .0 1. 2 12 .1 0. 0 3. 2 8. 3 16 .8 0. 0 10 0. 0 27 .6 28 .3 55 .9 56 9 To ta l 39 .9 1. 2 0. 1 9. 5 0. 8 10 .9 0. 0 2. 6 6. 9 28 .1 0. 2 10 0. 0 22 .4 37 .7 60 .1 33 33 * M IC S in di ca to r 2 1; M DG in di ca to r 1 9C (… ) – F ig ur es a re b as ed o n 25 -4 9 un we ig ht ed c as es . Pe rc en t o f w om en (c ur re nt ly m ar rie d or in u ni on ) w ho a re u si ng : M od er n m et ho ds o f c on tra ce pt io n in cl ud e: fe m al e an d m al e st er iliz at io n, p ill, IU D , i nj ec tio n, im pl an t, m al e an d fe m al e co nd om , a nd d ia ph ra gm . Tr ad itio na l m et ho ds in cl ud e: L AM (l ac ta tio na l a m en or rh ea m et ho d) , p er io di c ab st in en ce , w ith dr aw al , a nd o th er m et ho ds . N um be r o f wo m en cu rre nt ly m ar rie d or in un io n N ot u si ng an y m et ho d 74 Table RH.2: Antenatal care provider Medical doctor Nurse/ midwife Auxiliary midwife Residence Urban 81.9 14.4 1.8 1.9 100.0 98.1 136 Rural 62.3 33.4 0.9 3.4 100.0 96.6 264 Age 15-19 (*) (*) (*) (*) (*) (*) 17 20-24 70.3 26.5 0.0 3.3 100.0 96.7 112 25-29 70.8 24.2 2.7 2.3 100.0 97.7 139 30-34 66.0 30.8 0.0 3.1 100.0 96.9 85 35+ (66.5) (29.1) (0.0) (4.4) (100.0) (95.6) 47 Education None/Primary (*) (*) (*) (*) (*) (*) 11 Lower secondary 61.8 33.5 1.0 3.7 100.0 96.3 224 Upper secondary + 81.4 17.1 0.9 0.7 100.0 99.3 164 Wealth index quintiles Poorest 45.2 49.8 0.9 4.1 100.0 95.9 102 Second 68.1 24.0 0.0 7.9 100.0 92.1 72 Middle 65.8 32.3 1.9 0.0 100.0 100.0 78 Fourth 84.1 11.0 2.9 2.0 100.0 98.0 84 Richest 92.0 8.0 0.0 0.0 100.0 100.0 64 Religion Muslim 68.4 26.7 1.5 3.5 100.0 96.5 331 Orthodox/Catholic/ Other 71.9 28.1 0.0 0.0 100.0 100.0 68 Total 69.0 26.9 1.2 2.9 100.0 97.1 399 * MICS indicator 20 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. ** If the respondent mentioned more than one provider, only the most qualified provider is considered * Skilled health personnel includes doctors, nurses, midwives, and auxiliary midwives. Percent distribution of women aged 15-49 who gave birth in the two years preceding the survey by type of personnel providing antenatal care, Albania, 2005 Person providing antenatal care** Number of women who gave birth in the preceding two years No antenatal care received Any skilled personnel*Total 75 Table RH.3: Antenatal care Blood sample taken* Blood pressure measured* Urine specimen taken* Weight measured* Residence Urban 98.1 91.7 93.3 92.8 88.3 136 Rural 96.6 83.1 84.1 84.9 74.2 264 Age 15-19 (*) (*) (*) (*) (*) 17 20-24 96.7 88.9 89.7 88.8 84.4 112 25-29 97.7 89.5 89.7 92.3 80.6 139 30-34 96.9 79.2 80.7 81.9 70.7 85 35+ (95.6) (79.6) (81.3) (79.6) (71.6) 47 Education None/Primary (*) (*) (*) (*) (*) 11 Lower secondary 96.3 84.3 85.0 87.3 74.4 224 Upper secondary + 99.3 89.8 91.6 89.3 86.6 164 Wealth index quintiles Poorest 95.9 71.9 74.8 76.5 63.6 102 Second 92.1 80.4 79.4 83.4 71.1 72 Middle 100.0 89.4 94.1 89.4 78.2 78 Fourth 98.0 97.6 97.1 98.4 91.3 84 Richest 100.0 95.6 94.5 93.2 96.9 64 Religion Muslim 96.5 84.8 85.6 86.7 76.3 331 Orthodox/Catholic/ Other 100.0 91.9 95.1 91.9 92.0 68 Total 97.1 86.0 87.2 87.6 78.9 399 * MICS indicator 44 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Percentage of pregnant women receiving antenatal care among women aged 15-49 years who gave birth in two years preceding the survey and percentage of pregnant women receiving specific care as part of the antenatal care received, Albania, 2005 Percent of pregnant women who had:Percent of pregnant women receiving ANC one or more times during pregnancy Number of women who gave birth in two years preceding survey 76 Table RH.4: Assistance during delivery Medical doctor Nurse/ midwife Auxiliary midwife Relative/ friend Residence Urban 94.9 4.4 0.7 0.0 100.0 100.0 99.0 136 Rural 83.1 16.2 0.3 0.4 100.0 99.6 97.4 264 Age 15-19 (*) (*) (*) (*) (*) (*) (*) 17 20-24 93.1 6.9 0.0 0.0 100.0 100.0 99.0 112 25-29 82.9 16.5 0.6 0.0 100.0 100.0 97.7 139 30-34 85.7 12.3 0.9 1.2 100.0 98.8 98.8 85 35+ (85.6) (14.4) (0.0) (0.0) (100.0) (100.0) (93.8) 47 Education None/Primary (*) (*) (*) (*) (*) (*) (*) 11 Lower secondary 84.8 14.5 0.3 0.4 100.0 99.6 99.0 224 Upper secondary + 92.9 6.5 0.5 0.0 100.0 100.0 97.0 164 Wealth index quintiles Poorest 79.5 19.5 0.0 1.0 100.0 99.0 95.7 102 Second 83.7 15.3 1.0 0.0 100.0 100.0 98.3 72 Middle 85.7 14.3 0.0 0.0 100.0 100.0 100.0 78 Fourth 93.1 5.8 1.0 0.0 100.0 100.0 100.0 84 Richest 97.0 3.0 0.0 0.0 100.0 100.0 95.9 64 Religion Muslim 87.7 11.6 0.5 0.3 100.0 99.7 99.3 331 Orthodox/Catholic/ Other 84.6 15.4 0.0 0.0 100.0 100.0 91.2 68 Total 87.1 12.2 0.4 0.2 100.0 99.8 98.0 399 * MICS indicator 4; MDG indicator 17 * Skilled health personnel includes doctors, nurses, midwives, and auxiliary midwives. ** MICS indicator 5 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Percent distribution of women aged 15-49 with a birth in two years preceding the survey by type of personnel assisting at delivery, Albania, 2005 Number of women who gave birth in preceding two years Person assisting at delivery Total Any skilled personnel* Delivered in health facility** 77 Table CD.1: Family support for learning For whom household members engaged in four or more activities that promote learning and school readiness* Mean number of activities household members engage in with the child For whom the father engaged in one or more activities that promote learning and school readiness** Mean number of activities the father engaged in with the child Living in a household without their natural father Number of children aged 0- 59 months Sex Male 67.8 4.5 45.6 0.9 4.4 599 Female 68.2 4.5 47.1 1.0 3.4 494 Residence Urban 76.1 4.9 56.8 1.3 2.1 387 Rural 63.6 4.3 40.5 0.8 5.0 706 Age 0-23 months 39.8 3.4 35.8 0.6 4.4 369 24-59 months 82.4 5.1 51.6 1.2 3.7 724 Mother's education None/Primary (34.7) (3.0) (29.3) (0.4) (10.3) 38 Lower secondary 62.4 4.3 42.1 0.8 5.6 594 Upper secondary + 78.0 4.9 53.0 1.2 1.3 461 Father's education None/Primary (56.1) (3.9) (62.5) (0.9) na 35 Lower secondary 63.4 4.4 41.8 0.8 na 491 Upper secondary + 74.0 4.7 52.6 1.2 na 524 Father not in HH (56.8) (4.2) (7.2) na na 43 Wealth index quintiles Poorest 53.2 3.9 38.1 0.7 6.2 248 Second 64.7 4.3 35.7 0.6 5.2 233 Middle 67.9 4.5 45.3 0.8 1.5 197 Fourth 76.0 4.8 53.7 1.2 4.6 230 Richest 82.2 5.1 62.3 1.7 1.2 185 Religion Muslim 67.1 4.5 47.0 1.0 4.3 933 Orthodox/Catholic/ Other 73.2 4.6 42.3 0.8 1.9 160 Total 68.0 4.5 46.3 1.0 3.9 1093 * MICS indicator 46 ** MICS Indicator 47 (…) – Figures are based on 25-49 unweighted cases. Percentage of children aged 0-59 months for whom household members are engaged in activities that promote learning and school readiness, Albania, 2005 Percentage of children aged 0-59 months 78 Ta bl e CD .2 : L ea rn in g m at er ia ls 3 or m or e no n- ch ild re n' s bo ok s* M ed ia n nu m be r o f no n- ch ild re n' s bo ok s 3 or m or e ch ild re n' s bo ok s* * M ed ia n nu m be r o f ch ild re n' s bo ok s H ou se ho ld ob je ct s O bj ec ts an d m at er ia ls fo un d ou ts id e th e ho m e H om e- m ad e to ys To ys th at ca m e fro m a st or e N o pl ay th in gs m en tio ne d 3 or m or e ty pe s of pl ay th in gs ** * Se x M al e 58 .0 5 29 .8 0 46 .1 22 .7 23 .8 72 .2 8. 4 17 .5 59 9 Fe m al e 54 .9 5 35 .3 0 41 .3 24 .2 25 .2 76 .2 7. 9 15 .4 49 4 Re si de nc e U rb an 61 .7 6 43 .4 2 37 .4 14 .8 21 .0 80 .6 8. 4 10 .9 38 7 R ur al 53 .8 4 26 .2 0 47 .4 28 .1 26 .4 70 .4 8. 0 19 .7 70 6 Ag e 0- 23 m on th s 44 .3 0 17 .2 0 25 .7 6. 5 14 .0 65 .1 23 .1 6. 8 36 9 24 -5 9 m on th s 62 .9 6 40 .0 2 53 .2 32 .0 29 .8 78 .5 0. 5 21 .5 72 4 M ot he r’s e du ca tio n N on e/ Pr im ar y (4 5. 2) 0 (1 6. 2) 0 (6 9. 3) (3 1. 1) (1 6. 8) (2 9. 5) (5 .8 ) (5 .5 ) 38 Lo we r s ec on da ry 50 .7 3 20 .2 0 45 .2 26 .8 26 .4 71 .1 9. 0 18 .2 59 4 U pp er s ec on da ry + 65 .2 6 49 .1 2 40 .2 18 .3 22 .6 81 .3 7. 3 15 .4 46 1 W ea lth in de x qu in til es Po or es t 44 .1 0 15 .5 0 51 .3 29 .2 25 .5 60 .1 9. 7 16 .4 24 8 Se co nd 59 .3 5 28 .0 0 48 .3 34 .8 33 .6 65 .1 8. 1 23 .3 23 3 M id dl e 54 .1 5 27 .0 0 29 .6 16 .6 18 .7 80 .9 10 .8 11 .4 19 7 Fo ur th 63 .9 6 43 .2 2 50 .8 19 .9 20 .4 84 .1 5. 8 18 .2 23 0 R ic he st 63 .6 6 52 .3 3 35 .0 12 .5 22 .8 83 .8 6. 4 11 .6 18 5 Re lig io n M us lim 56 .5 5 31 .2 0 46 .0 25 .9 24 .6 73 .1 8. 4 18 .3 93 3 O rth od ox /C at ho lic / O th er 57 .3 6 38 .6 2 31 .8 8. 8 23 .4 79 .3 6. 5 6. 5 16 0 To ta l 56 .6 5 32 .3 0 43 .9 23 .4 24 .5 74 .0 8. 2 16 .6 10 93 * M IC S in di ca to r 4 9 ** M IC S in di ca to r 4 8 ** * M IC S in di ca to r 5 0 (… ) – F ig ur es a re b as ed o n 25 -4 9 un we ig ht ed c as es . Pe rc en ta ge o f c hi ld re n ag ed 0 -5 9 m on th s liv in g in h ou se ho ld s co nt ai ni ng le ar ni ng m at er ia ls , A lb an ia , 2 00 5 Ch ild re n liv in g in ho us eh ol ds w ith : Ch ild h as : Ch ild p la ys w ith : N um be r o f ch ild re n ag ed 0 -5 9 m on th s 79 Table CD.3: Children left alone or with other children Left in the care of children under the age of 10 years in past week Left alone in the past week Left with inadequate care in past week* Number of children aged 0-59 months Sex Male 13.6 2.3 14.3 599 Female 10.8 2.0 11.2 494 Residence Urban 16.5 3.3 17.1 387 Rural 10.1 1.6 10.5 706 Age 0-23 months 8.0 1.4 8.6 369 24-59 months 14.6 2.5 15.0 724 Mother’s education None/Primary (11.1) (10.7) (15.5) 38 Lower secondary 11.8 2.2 12.3 594 Upper secondary + 13.1 1.4 13.3 461 Wealth index quintiles Poorest 8.1 2.7 8.8 248 Second 16.3 1.6 16.3 233 Middle 8.6 1.8 9.1 197 Fourth 14.4 2.2 14.7 230 Richest 14.6 2.8 15.7 185 Religion Muslim 12.3 1.8 12.8 933 Orthodox/Catholic/Other 12.6 4.4 13.0 160 Total 12.3 2.2 12.9 1093 (…) – Figures are based on 25-49 unweighted cases. * Inadequate care is defined as children left in the care of other children under the age of 10 years or left alone in the past week. Percentage of children aged 0-59 months left in the care of other children under the age of 10 years or left alone in the past week, Albania, 2005 * MICS indicator 51 Percentage of children aged 0-59 months 80 Table ED.1: Early childhood education Percentage of children aged 36-59 months currently attending early childhood education* Number of children aged 36-59 months Percentage of children attending first grade who attended preschool program in previous year** Number of children attending first grade Sex Male 38.6 287 71.3 175 Female 41.5 225 68.9 154 Residence Urban 48.5 190 74.0 130 Rural 34.7 322 67.7 199 Age of child 36-47 months 33.4 225 na na 48-59 months 44.9 286 na na 6 years na na 75.1 213 7 years na na 61.2 116 Mother's education None/Primary (*) 17 (*) 9 Lower secondary 34.9 282 68.9 168 Upper secondary + 49.6 212 73.1 153 Wealth index quintiles Poorest 25.7 102 66.3 61 Second 33.5 130 67.4 76 Middle 41.5 89 65.7 64 Fourth 42.9 102 76.7 78 Richest 60.0 90 74.7 51 Religion Muslim 38.4 447 67.5 278 Orthodox/Catholic/Other 50.0 64 (84.9) 52 Total 39.8 512 70.2 329 * MICS indicator 52 ** MICS indicator 53 (*) – Figures are based on less than 25 unweighted cases. (…) – Figures are based on 25-49 unweighted cases. Percentage of children aged 36-59 months who are attending some form of organized early childhood education programme and percentage of first graders who attended pre-school, Albania, 2005 81 Table ED.2: Primary school entry Percentage of children of primary school entry age currently attending grade 1* Number of children of primary school entry age Sex Male 82.1 348 Female 82.7 289 Residence Urban 81.7 236 Rural 82.8 401 Age of child** 6 68.3 317 7 96.3 320 Mother's education None/Primary (*) 13 Lower secondary 79.7 339 Upper secondary + 85.9 285 Wealth index quintiles Poorest 76.5 136 Second 81.4 138 Middle 86.9 131 Fourth 82.6 131 Richest 85.5 101 Religion Muslim 81.3 539 Orthodox/Catholic/Other 88.3 98 Total 82.4 637 * MICS indicator 54 (*) – Figu

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