Mozambique - Multiple Indicator Cluster Survey - 2008

Publication date: 2008

INSTITUTO NACIONAL DE ESTATÍSTICAS Mozambique Multiple Indicators Cluster Survey 2008 FINAL REPORT OF THE MULTIPLE INDICATOR CLUSTER SURVEY, 2008 © 2009 National Statistics Institute PRESIDENCY João Dias Loureiro President Manuel da Costa Gaspar Deputy President Valeriano da Conceição Levene Deputy President Title Final Report of the Multiple Indicator Cluster Survey, 2008. Editor National Statistics Institute Directorate of Demographic, Life and Social Statistics Av. Fernão de Magalhães, n° 34, 2º Andar Caixa Postal 493 Maputo Telephones: + 258-21-327925/6 Fax: + 258-21-327927 E-Mail: info@ine.gov.mz Homepage: www.ine.gov.mz Authors Stélio Napica de Araujo, Abdulai Dade, Maria de Fátima Zacarias, Cassiano Soda Chipembe, Xadreque Hermínio Maunze, Carlos Creva Singano Quality Analysis João Dias Loureiro, Manuel da Costa Gaspar, Maria de Fátima Zacarias, Cassiano Soda Chipembe Management Maria de Fátima Zacarias Data Processing Nordino Titus Machava Pierre Martel Coordination and Supervision of Field Work: Arão Balate, Cristóvão Muahio Sample Implementation Carlos Creva Singano, David Megill Technical and Financial Assistance UNICEF Distribution Distribution Department, INE's Directorate for Coordination, Integration and Foreign Relations iii Table of Results Indicators of the Multiple Indicator Cluster Survey (MICS), Mozambique, 2008 Topic M IC S In di ca to r N um be r M D G In di ca to r N um be r Indicator Value CHILD MORTALITY 1 4.1 Under-five mortality rate (< 5 years) 141 per thousand 2 4.2 Infant mortality rate (<= 1 year) 95 per thousand NUTRITION Nutritional Status 6 1.8 Underweight prevalence 18 per cent 7 Stunting prevalence 44 per cent 8 Wasting prevalence 4 per cent Breastfeeding 45 Timely initiation of breastfeeding (first hour) 63 per cent 15 Exclusive breastfeeding rate 0–5 months 37 per cent 16 Continued breastfeeding rate at 12–15 months 91 per cent at 20–23 months 54 per cent 17 Timely complementary feeding rate 84 per cent 18 Frequency of complementary feeding 51 per cent 19 Adequately fed infants (0–11 months) 44 per cent Salt iodization 41 Iodized salt consumption (> 15 ppm) 25 per cent Iodized salt consumption 58 per cent Vitamin A 42 Vitamin A supplementation (children under five) 72 per cent 43 Vitamin A supplementation (mothers in first two months after birth) 66 per cent Low birthweight 9 Low birthweight infants 16 per cent 10 Infants weighed at birth 58 per cent CHILD HEALTH Immunization 25 Immunization coverage (BCG) 84 per cent 26 Immunization coverage (polio 3) 70 per cent 27 Immunization coverage (DPT3) 70 per cent 28 4.3 Immunization coverage (measles) 64 per cent 31 Full immunization coverage 48 per cent Tetanus toxoid 32 Neonatal tetanus protection 79 per cent Care of illness 33 Use of oral rehydration therapy (ORT) 54 per cent 34 Home management of diarrhoea 19 per cent 35 Use of ORT, or increased fluids, and continued feeding 47 per cent 23 Care-seeking for suspected pneumonia 65 per cent 22 Antibiotic treatment of suspected pneumonia 22 per cent Solid fossil fuel use 24 Solid fossil fuels 97 per cent Malaria 36 Household availability of insecticide-treated nets (ITNs) 55 per cent 37 6.7 Children under five sleeping under ITNs 23 per cent 38 Children under five sleeping under untreated nets 42 per cent 39 6.8 Antimalarial treatment (children under five) 23 per cent 40 Intermittent preventive malaria treatment (pregnant women) 67 per cent ENVIRONMENT Water and sanitation 11 7.8 Use of improved drinking water sources 43 per cent 13 Water treatment 10 percent 12 7.9 Use of improved sanitation facilities 19 per cent 14 Safe disposal of children’s faeces 32 per cent iv Topic M IC S In di ca to r N um be r M D G In di ca to r N um be r Indicator Value REPRODUCTIVE HEALTH Maternal and newborn health 20 5.5 Women receiving antenatal care 92 per cent 44 Content of antenatal care Blood test taken 62 per cent Blood pressure measured 62 per cent Urine specimen taken 37 per cent Weight measured 87 per cent 4 5.2 Skilled attendant at delivery 55 per cent 5 Institutional deliveries 58 per cent CHILD DEVELOPMENT Child development 46 Support for learning 31 per cent 47 Father’s support for learning 16 per cent 48 Support for learning: children’s books 3 per cent 49 Support for learning: non-children’s books 52 per cent 51 Children under inadequate care 33 per cent EDUCATION Education 54 Timely entry into primary school 65 per cent 55 2.1 Net attendance rate (primary school) 81 per cent 56 Net attendance rate (secondary school) 20 per cent 57 2.2 Children entering primary school who reach 5th grade 77 per cent 58 Rate of transition to secondary school 73 per cent 59 Rate of timely completion of primary school 15 per cent 61 3.1 Gender parity index Primary school Secondary school 0.97 (ratio) 0.98 (ratio) Literacy 60 2.3 Literacy rate of women aged 15–24 47 per cent CHILD PROTECTION Birth registration 62 Birth registration 31 per cent Child labour 71 Child labour 22 per cent 72 Working students 25 per cent 73 Student workers 78 per cent Early marriage and polygamy 67 Women married before the age of 15 Women married before the age of 18 18 per cent 52 per cent 68 Young women (15–19) currently married/in unions 40 per cent 70 Polygyny 24 per cent 69 Percentage of women aged 15–19 and 20–24 currently married/in union with a spouse at least 10 years older Women aged 15–19 Women aged 20–24 22 per cent 21 per cent Domestic violence 100 Percentage of women aged 15–49 who believe that violence by the husband is justifiable 36 per cent Disability 101 Children with disabilities 14 per cent v Topic M IC S In di ca to r N um be r M D G In di ca to r N um be r Indicator Value HIV and AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV and AIDS knowledge and attitudes among women 82 6.3 Knowledge of HIV and AIDs prevention among young people 12 per cent 89 1. Knowledge of mother-to-child transmission of HIV 55 per cent 86 2. Positive attitude towards people with HIV and AIDS 23 per cent 87 Women who know where to be tested for HIV infection 77 per cent 88 3. Women who have been tested for HIV infection 30 per cent 90 Counselling coverage for preventing mother-to-child transmission of HIV 59 per cent 91 Testing coverage for preventing mother-to-child transmission of HIV 43 per cent Women’s sexual behaviour 84 First sexual relation at an early age 29 per cent 92 Great difference in age between sexual partners 16 per cent 83 6.2 Condom use with non-regular partners 44 per cent 85 High-risk sex in the past year 32 per cent Support to orphaned and vulnerable children 75 Prevalence of orphans 12 per cent 78 Children not living with their biological parents 15 per cent 76 Prevalence of vulnerable children 6 per cent 77 6.4 School attendance ratio between orphans and non-orphans 0.89 81 Support to children orphaned or made vulnerable because of AIDS 22 per cent 79 Undernutrition among children orphaned or made vulnerable because of AIDS 1.1 (ratio) 80 Early sexual relations among girls orphaned or made vulnerable because of AIDS 0.91 (ratio) vii Contents Table of results . iii List of tables . ix List of graphs . xi List of abbreviations. xiii Preface . xv Executive summary . xvii I. Introduction . 1 II. Methodology . 3 Design and size of the sample . 3 Survey questionnaires . 3 Training the survey staff . 4 Organization of fieldwork . 5 Data processing. 5 III. Sample coverage and characteristics of households and respondents. 6 Sample coverage. 6 IV. Child mortality . 8 Introduction . 8 Methodology . 8 Mortality levels and trends . 8 Mortality differentials . 9 V. Nutrition . 13 Nutritional status of children . 13 Breastfeeding and infant feeding . 18 Duration of breastfeeding . 19 Salt iodization . 26 Vitamin A supplements . 28 Low birthweight . 31 VI. Child health . 34 Child immunization . 34 Tetanus toxoid . 37 Oral rehydration treatment. 39 Care-seeking and antibiotic treatment of pneumonia . 44 Solid fuel use . 49 Malaria . 51 viii VII. Environment . 58 Water and sanitation . 58 Access to drinking water. 58 Sanitation. 65 VIII. Reproductive health. 70 Contraception . 70 Antenatal care . 72 Assistance at delivery . 75 Fertility . 77 IX. Child development . 79 X. Education . 83 Primary – and secondary – school attendance . 83 Adult literacy . 96 XI. Child protection . 100 Birth registration . 100 Child labour . 102 Child marriage, polygamy and spousal age difference . 106 Domestic violence . 110 Child disability. 112 XII. HIV and AIDS, sexual behaviour and orphaned and vulnerable children . 114 Knowledge of HIV transmission and condom use. . 114 Knowledge of mother-to-child transmission of HIV. 118 Attitudes towards people living with HIV and AIDS . 120 Knowledge of and access to HIV testing facilities . 122 Sexual behaviour that increases the risk of HIV transmission. 125 Orphaned and vulnerable children . 128 Appendix A – Additional tables . 135 Appendix B – Sample design . 137 Appendix C – Estimate of sampling errors . 139 Appendix D – Data quality tables . 157 Appendix E – Staff involved in the survey . 168 ix List of tables Table 3.1: Results of household and individual questionnaires 6 Table 3.2: Response rate by province and area of residence 7 Table 4.1: Child mortality rates 9 Table 4.2: Child mortality rates (average in the 10 years prior to the survey) 10 Table 5.1: Undernourished children 15 Table 5.2a: Initiation of breastfeeding 20 Table 5.2b: Breastfeeding with colostrum 21 Table 5.3a: Breastfeeding 22 Table 5.3b: Breastfeeding and other specific food status, by age 24 Table 5.4: Adequately fed children 25 Table 5.5: Iodized salt consumption 27 Table 5.6: Children who received vitamin A supplements 30 Table 5.7: Post-partum vitamin A supplementation 31 Table 5.8: Low birthweight 33 Table 6.1: Vaccination in the first year of life 35 Table 6.2: Vaccination in the first year of life 37 Table 6.3: Neonatal protection against tetanus 38 Table 6.4: Oral rehydration treatment 41 Table 6.5: Home management of diarrhoea 43 Table 6.6: Care-seeking for suspected pneumonia 45 Table 6.6a: Cough accompanied by fever 46 Table 6.7a: Use of antibiotics to treat pneumonia 47 Table 6.7b: Knowledge of two danger signs of pneumonia 48 Table 6.8: Use of solid fuels 49 Table 6.9: Use of solid fuels by type of stove or fire 51 Table 6.10a: Availability of mosquito nets 52 Table 6.10b: Availability of insecticide-treated mosquito nets 53 Table 6.11: Children sleeping under mosquito nets 54 Table 6.12: Treatment of children suffering from fever with antimalarial drugs 55 Table 6.13: Intermittent preventive treatment against malaria 56 Table 7.1: Use of improved sources of drinking water 59 Table 7.2: Household water treatment 62 Table 7.3: Time taken to reach the source, fetch water and return 63 Table 7.4: Person who fetches water 64 Table 7.5: Type of sanitation used to dispose of excreta 66 Table 7.6: Disposal of children’s faeces 68 Table 7.7: Use of both improved water sources and improved sanitation 69 Table 8.1: Use of contraceptives 71 Table 8.2a: Antenatal care 73 x Table 8.2b: Content of antenatal care 74 Table 8.3: Assistance during delivery 76 Table 8.4 Actual fertility rate 78 Table 9.1: Family support for learning 79 Table 9.2: Learning materials 81 Table 9.3: Children left alone or with other children 82 Table 10.1a: Primary school entry 84 Table 10.1b: Age at which studies began 85 Table 10.2a: Primary-school attendance rate 86 Table 10.2b: Failure rate 87 Table 10.2c: Frequency of failure 88 Table 10.3a: Net secondary-school attendance rate 90 Table 10.3b: Children of secondary-school age attending primary school 91 Table 10.4: Children completing primary education 93 Table 10.5: Net primary-school completion rate and rate of transition to secondary education 94 Table 10.6: Gender parity in education 95 Table 10.7a: Literacy 97 Table 10.7b: Literacy 98 Table 11.1: Birth registration 101 Table 11.2: Child labour 104 Table 11.3: Working students and student workers 105 Table 11.4: Child marriage 107 Table 11.5: Spousal age difference 109 Table 11.6: Attitudes towards domestic violence 111 Table 11.7: Child disability 113 Table 12.1: Knowledge about preventing HIV transmission 115 Table 12.2: Identifying misconceptions about HIV and AIDS 116 Table 12.3: Comprehensive knowledge of HIV transmission 118 Table 12.4: Knowledge of mother-to-child transmission of HIV 119 Table 12.5: Attitudes towards people living with HIV and AIDS 120 Table 12.6: HIV testing 122 Table 12.7: HIV testing and counselling coverage during antenatal care 124 Table 12.8: Sexual behaviour that increases the risk of HIV infection 126 Table 12.9: High-risk sexual relations 127 Table 12.10: Survival of parents and residence of children aged 0–17 years 129 Table 12.11: Prevalence of orphaned and vulnerable children 130 Table 12.12: School attendance by orphaned and vulnerable children 132 Table 12.13: Support for children orphaned and vulnerable due to AIDS 133 Table 12.14: Sexual behaviour among young women by state of orphanhood and vulne- rability due to HIV and AIDS 134 xi List of graphs Graph 4.1 Infant and child mortality trends, Mozambique, 1997, 2003 and 2008 9 Graph 4.2: Child mortality rate by province (average in the 10 years prior to the sur- vey), Mozambique, 2008 11 Graph 4.3. Under-five mortality rate by area of residence, Mozambique, 1997, 2003 and 2008 (average in the 10 years prior to the survey) 12 Graph 4.4: Infant mortality rate (children under one year old), by area of residence, Mozambique, 1997, 2003 and 2008 (average in the 10 years prior to the survey) 12 Graph 5.1: Nutritional status of children under five, Mozambique, 2003 and 2008 17 Graph 5.2: Nutritional status of children under five, by age, Mozambique, 2008 17 Graph 5.3: Chronic undernutrition among children under five, by the level of education of their mothers, Mozambique, 2008 17 Map 5.1: Chronic undernutrition by province, Mozambique, 2008. 18 Graph 5.4.: Exclusive breastfeeding among children aged 0–3 months and 0–6 months, Mozambique, 2003 and 2008 23 Graph 5.5: Breastfeeding and specific food status (in percentages), by age (in weeks), Mozambique, 2008 24 Graph 5.6.: Consumption of iodized salt, by province, Mozambique, 2008 28 Graph 5.7.: Consumption of iodized salt, by level of household wealth, Mozambique, 2008 28 Graph 5.8: Live births weighing less than 2,500 grams, Mozambique, 2008 33 Graph 6.1: Rate of immunization before 12 months of age, by dose and type of vacci- ne, Mozambique, 2008 35 Graph 6.2: Rate of immunization at 12 months of age among children aged 12–23 months, Mozambique, 1997, 2003 and 2008 36 Graph 6.3. Percentage of children aged 12–23 months who were vaccinated at any moment prior to the date of the survey, by area of residence and province, Mozambique, 2008 36 Graph 6.4: Percentage of women who had at least one birth in the last 24 months and were protected against neonatal tetanus, Mozambique, 2008 39 Graph 6.5: Percentage of children aged 0–59 months who had diarrhoea and received oral rehydration treatment (ORT), Mozambique, 2008 42 Graph 6.6: Percentage of children aged 0–59 months who had diarrhoea and received ORT or increased fluids and increased food, Mozambique, 2008 44 Graph 6.7: Percentage of women aged 15–49 who gave birth in the two years prior to the survey and who received intermittent preventive treatment against mala- ria during pregnancy, by selected characteristics, Mozambique, 2008 57 Graph 7.1: Improved water sources, Mozambique, 2008 60 Graph 7.2: Access to drinking water by wealth quintile, Mozambique, 2008 60 Graph 7.3: Percentage of households with access to drinking water, Mozambique, 2004 and 2008 61 Graph 7.4: Person who fetches water, Mozambique, 2008 65 xii Graph 7.5: Improved sanitation facilities, Mozambique, 2008 67 Graph 7.6: Percentage of households with access to safe sanitation, Mozambique, 2004 and 2008 67 Graph 8.1: Assistance during delivery, Mozambique, 1997, 2003 and 2008 75 Graph 8.2: Institutional deliveries by wealth quintile, Mozambique, 2008 77 Graph 10.1 Primary- and secondary-school attendance rates, by province, Mozambique, 2008 92 Graph 10.2. Literacy rates by age groups, total, men, women, Mozambique, 2008 96 Graph 11.1: Children aged 0–59 months whose birth was registered, by province, Mozambique, 2008 102 Graph 11.2. Child labour, by sex an by type, Mozambique, 2008 103 Graph 11.3: Prevalence of child labour, by level of mother’s education, Mozambique, 2008 103 Gráfico 12.1: Percentage of women aged 15–49 who correctly identified misconceptions about HIV and AIDS, Mozambique, 1997, 2003 and 2008 117 Graph 12.2: Women aged 15–49 who have heard of AIDS and have discriminatory atti- tudes towards people living with HIV and AIDS, Mozambique, 2008 121 Graph 12.3: Percentage of women aged 15–49 who know where to take the HIV test, and who have already been tested, Mozambique, 2008 123 Graph 12.4: Percentage of women aged 15–49 who were tested and counselled during antenatal visits, Mozambique, 2003 and 2008 125 Graph 12.5: Children orphaned and made vulnerable due to AIDS, by province, Mozambique, 2008 131 Figure D.1: Number of male household population by age (unweighted), Mozambique, 2008 166 Figure D.2: Number of female household population by age (unweighted), 2008 167 Figure D.3: Population pyramid, Mozambique, 2008 167 xiii List of abbreviations BCG Bacillus Calmette-Guérin (vaccine against tuberculosis) CEDAW Convention on the Elimination of All Forms of Discrimination Against Women DPT Vaccine against diphtheria, pertussis (whooping cough) and tetanus EA Enumeration area GPI Gender parity index IDD Iodine Deficiency Disorders IDS Demographic and Health Surveys, Mozambique IFTRAB Labour Force Survey INE National Statistics Institute, Mozambique ITN Insecticide-treated net IUD Intrauterine device MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey ORS Oral rehydration salts ORT Oral rehydration therapy PARPA II Plan for the Reduction of Absolute Poverty, 2006-2009 PQG Government Five-Year Programme, 2005-2009 PSU Primary sampling unit UNAIDS Joint United Nations Programme on HIV/AIDS UNGASS UN General Assembly Special Session on HIV/AIDS UNICEF United Nations Children's Fund TFR Total Fertility Rate WHO World Health Organisation xv Preface This book contains the main results of the Multiple Indicator Cluster Survey, abbreviated as MICS. MICS 2008 was undertaken because of the need for information on social, demographic and health indicators to assess the Government Five-Year Programme (PQG), 2005–2009, and, in particular, the Plan for the Reduction of Absolute Poverty (PARPA II), 2006–2009, and to serve as an instrument for drawing up the next PQG (2010–2014). Generally, these indicators are gathered through the Demographic and Health Surveys (DHS). However, the last DHS was held in 2003 and the next was scheduled for 2010. Hence the pertinence of undertaking MICS in 2008. MICS counted with technical and financial assistance from UNICEF and the collaboration of the Mozambican Ministry of Health. There is a long-standing partnership between the INE (Mozambique’s National Statistics Institute) and UNICEF. It is INE’s intention to preserve and build on this spirit of partnership, which has contributed greatly to joint efforts to obtain informa- tion on time to monitor the government plans mentioned earlier. The success of this survey was made possible thanks to the efforts of many people who were involved at every stage, from creating the methodological design and notation systems, to col- lecting and systemising the data, up to producing the present report. We wish to express our gratitude to all those who worked on carrying out the survey success- fully, especially to the households whose members agreed to provide information which would represent the entire population of Mozambique, to the local organizations which facilitated con- tact with the population, and to everyone involved in the collection, processing and analysis of the data contained in this publication. In short, and so that nobody may feel offended, we express our deepest thanks to all those who, directly or indirectly, contributed to the successful administration of this survey. João Dias Loureiro Leila Gharagozloo-Pakkala President of the INE Representative of UNICEF xvii Mozambique – Multiple Indicators Cluster Survey 2008 Executive summary This report summarizes the results of the Multiple Indicator Cluster Survey (MICS), undertaken in 2008 by the National Statistics Institute (INE) with the support of the United Nations Children’s Fund (UNICEF). MICS 2008 is a household survey, carried out nationally. It provides up-to-date information for assessing the situation of children and women in Mozambique. Characteristics of the households and respondents Of the 14,300 households selected for the sample, 14,269 were contacted for interviews. Of these, 13,995 were interviewed, giving a response rate of 97.9 per cent. In the households in- terviewed, 15,060 women aged 15–49 were identified. Of these, 14,188 were duly interviewed, producing a response rate of 94.2 per cent. 11,818 children under the age of five were identified, for whom responses were obtained from the mother or other person who looks after the child in 11,419 complete interviews, which is a response rate of 96.6 per cent. Child mortality MICS 2008 estimated the probability of a child dying before his/her first birthday (the infant mortality rate) at 95 per thousand live births1 in the five-year period preceding the survey (that is, 2003–2008). This is a reduction when compared with the data from DHS 2003 (101 per thou- sand live births for the 1998–2003 period). Likewise, the probability of dying before five years of age (the under-five mortality rate) was estimated at 141 per thousand, a reduction of 12 compa- red with the estimate from DHS 2003, which was 153 per thousand. The observed reduction in the infant and under-five mortality rates is the result of combining a steep reduction in the rural areas of the country with a lesser decline in the urban areas. Data from the two DHS (1997 and 2003) and from MICS show that, over the past decade, the nationwide under-five mortality rate has fallen by an average of 1.2 points per year (from 150 per thousand to 138 per thousand), while the average reduction in rural areas was almost 7.3 points a year (from 237 per thousand to 164 per thousand).2 Nutrition Although MICS has shown some improvement in the nutritional status of children under five years old, the levels of infant undernutrition, particularly chronic undernutrition, remain very high, according to the World Health Organization (WHO) classification3. The percentage of chro- nically undernourished (stunted) children is 44 per cent, while in 2003 it was 48 per cent4. The percentage of children under five with low weight for their age has also fallen slightly, to 18 per cent; the prevalence of acute undernutrition has also fallen, from 5 per cent in 2003 to 4 per cent in 2008. 1 The infant mortality estimates refer on average to five years before the survey. The estimates of infant and under-five mortality were calculated using the direct method. 2 While the estimate of national infant and under-five mortality is calculated by using for reference the five-year period before the research, disaggregated estimates (by province, sex and area of residence) take as reference points the 10-year period before the research. The longer reference period allows more cases of death to be included in the calculation and thus furnishes more precise estimates. 3 According to the standard WHO classification, rates of chronic undernutrition between 20 and 30 per cent are regarded as ’medium’, ra- tes between 30 and 40 per cent are considered ’high’, and rates above 40 per cent are considered ’very high’. World Health Organization, Technical report series no. 854, WHO, Geneva, 1995. 4 The anthropometric estimates of IDS 2003 were recalculated based on the WHO standard population for 2006. The estimates published in the IDS 2003 report were based on the reference population of NCHS/CDC/OMS. See WHO Growth standards, methods and develo- pment: <http://who.int/childgrowth/standards/en/>. xviii The observed reduction in the rates of chronic undernutrition between 2003 and 2008 results from a strong reduction in rural areas combined with a slower fall in urban areas. Data from DHS 2003 and MICS 2008 show that the rate of chronic undernutrition in urban areas has been falling at an average of 0.4 percentage points per year (from 37 per cent in 2003 to 35 per cent in 2008), while the average annual reduction in rural areas was one percentage point (from 52 per cent to 47 per cent). Breastfeeding Thiry-seven per cent of children aged 0–6 months and 48 per cent of children aged 0–3 months were exclusively breastfed. These figures represent an improvement since 2003, when exclusi- ve breastfeeding in the same age groups was 30 per cent and 38 per cent, respectively. Just as in previous surveys held in Mozambique, MICS 2008 shows that almost two thirds of newborn children are breastfed within the recommended period (an hour after birth), and about 90 per cent are breastfed in the first day of life. Iodized salt Fifty-eight per cent of households consume iodized salt. The consumption of iodized salt ten- ds to be higher in urban areas (69 per cent) than in rural areas (53 per cent). The study also checked the amount of iodine present in the salt and found that only a quarter (25 per cent) of households use salt that contains the minimum necessary amount of iodine5. The likelihood that the salt is not sufficiently iodized is much greater in rural areas, where only 20 per cent of households use properly iodized salt, compared with 37 per cent in urban areas. Vitamin A Seventy-two per cent of children aged 6–59 months received vitamin A in the six months prior to the survey, compared with 50 per cent in 2003. Children who live in urban areas are more likely to receive vitamin A supplements than those living in rural areas; the figures are 78 per cent and 69 per cent, respectively. However, it is important to note that the difference between urban and rural has diminished substantially over the past five years. Low birthweight The data from MICS show that 58 per cent of newborns were weighed at birth. It is estimated that 16 per cent of children born in Mozambique weigh less than 2,500 grams. Immunization Eighty-seven per cent of children under one year old have received the vaccine against tuber- culosis (BCG), and 70 and 70 per cent have received DPT-3 and polio-3, respectively. About 64 per cent of children received the vaccine against measles, which is in line with the average in sub-Saharan African countries. Children living in urban areas of Mozambique are more likely to be vaccinated than those living in rural areas. Fifty-five per cent of children aged 12–23 months who live in rural areas received all the vaccines, compared to 74 per cent of those who live in urban zones. Eleven per cent of children in rural areas did not receive any vaccination, compa- red with four per cent in urban areas. Immunization rates among children under one year old have increased over the decade. The rate of immunization against polio has increased the most, rising from 55 per cent in 1997 to 70 per cent in 2008. The BCG coverage rate has shown a lesser increase, rising from 78 per cent in 5 Salt is considered adequately iodized when the concentration of iodine is above 15 parts per million (ppm). xix Mozambique – Multiple Indicators Cluster Survey 2008 1997 to 87 per cent in 2008. For every individual vaccine, the increases in vaccination coverage in the 1997–2003 period were greater than those recorded in the 2003–2008 period. Tetanus toxoid Eighty per cent of women are protected against tetanus. Most of them (67 per cent) are pro- tected because they received at least two doses of tetanus toxoid injection during their most recent pregnancy, while 11 per cent are protected because they received at least two doses of the vaccine in the last three years. Oral rehydration treatment Eighteen per cent of children under five had diarrhoea in the two weeks prior to the survey. The peak prevalence of diarrhoea in children aged 6–11 months, which generally corresponds to the period of weaning, reached 32 per cent. Among children aged 12–23 months, the figure is 29 per cent. Around 38 per cent of children with diarrhoea were treated with fluids with packets of oral rehydration salts (ORS); 15 per cent received fluids with pre-packaged (commercial) ORS, and 19 per cent received recommended home-prepared fluids. Approximately 54 per cent of children with diarrhoea received oral rehydration treatment (ORT), which means that they received ORS or the recommended home-prepared liquids, while 46 per cent did not receive adequate treatment. The rate of use of ORT is similar in urban (56 per cent) and rural (53 per cent) areas. Care-seeking and antibiotic treatment of pneumonia Five per cent of children aged 0–59 months were reported as presenting symptoms suggestive of pneumonia in the two weeks prior to the survey. This figure suggests a decline in the last five years, since in 2003 the percentage was 10 per cent. Of the children with suspected pneumo- nia, 65 per cent were taken to an appropriate health provider. 53 per cent were taken to a health centre or post. Malaria More than half of all households (55 per cent) own at least one mosquito net, treated or untre- ated (Table 6.10a). The availability of mosquito nets is higher in urban areas (63 per cent) than in rural areas (52 per cent). Rather less than a third (31 per cent) of households with children under five have at least one net treated with insecticide (ITN). Forty-two per cent of the children in this age group slept under some mosquito net on the night prior to the survey; of these, about 23 per cent slept under an insecticide-treated net and 17 per cent slept under an untreated net. The use of mosquito nets is more frequent in urban areas (48 per cent) than in rural areas (40 per cent). Water and sanitation Forty-three per cent of households, 70 per cent in urban areas and 30 per cent in rural areas, are using an improved source of drinking water, an improvement compared with the 36 per cent recorded in 2004 (IFTRAB 2004). The great majority of households (89 per cent) do not use any method for treating water. Excluding those households with water on the premises, the average time taken to reach the nearest source of drinking water, collect the water and return home is 49 minutes. In the great majority of households (86 per cent), the person who fetches water is an adult wo- man. In 7 per cent of households, girls under 15 fetch water. xx Only 19 per cent of people in Mozambique live in households that use improved sanitation facilities. This is a small improvement compared with the data from 2004, when the estimated coverage was 12 per cent (IFTRAB 2004). Contraception Only 16 per cent of women currently married or in unions reported using any method of con- traception. 12 per cent use modern methods and 4 per cent use traditional methods. The most popular modern method is the pill, use of which was reported by 6 per cent of women, followed by injections, mentioned by 5 per cent. There are significant differences in contraceptive use depending on area of residence. The per- centage in urban areas is 25 per cent, against 12 per cent in rural areas. Antenatal care About 92 per cent of women who were pregnant in the two years prior to the survey received antenatal care, which is a slight increase over the 85 per cent coverage rate from IDS 2003. Antenatal care coverage is higher in urban areas (99 per cent) than in rural areas (90 per cent). Maputo City has the highest coverage rate (about 100 per cent) and Zambézia province the lowest (only 81 per cent). Antenatal care coverage varies depending on the woman’s level of education and on the household’s wealth. It is 88 per cent among women with no education and 99 per cent among women with at least secondary education. Among specific antenatal care practices, weight measurement is the most prevalent (about 95 per cent). Assistance at delivery Fifty-five per cent of babies born in the two years prior to the survey were delivered by qualified health personnel, which is an increase compared with the figure of 48 per cent recorded in DHS 2003. There is a great difference in assistance by qualified personnel between urban areas (78 per cent) and rural areas (46 per cent). The data show that assistance at delivery by qualified health personnel is more frequent among young women, a trend also found by DHS 2003. MICS also shows that 58 per cent of deliveries take place in institutions, a rise from the DHS 2003 figure of 48 per cent. There are large differences in the prevalence of institutional delive- ries between urban areas (81 per cent) and rural areas (49 per cent). Child development For 31 per cent of children under five, an adult in the household had engaged in activities that promote learning and school readiness during the three days prior to the survey. For about 16 per cent of the children, it was their fathers who were involved in this type of activity. In contrast, 28 per cent of the children were not living with their biological father. There are no significant differences by area of residence and sex of the children. Fifty-two per cent of children under five live in households where there are at least three non- children’s books. Only 3 per cent live in households which have children’s books. The data show that the mother’s level of education has a positive correlation with the presence of books in the household. xxi Mozambique – Multiple Indicators Cluster Survey 2008 MICS also found that 33 per cent of children were left under inadequate care during the week prior to the survey. School attendance Only 65 per cent of children of primary-school entry age are in school, which means that a large proportion of children enter the education system late. Timely entry into school is greater in ur- ban than in rural areas. MICS shows that there is a positive correlation between timely entry into school and the educational level of the mother and the household’s economic situation. Almost one in every four people in the country began school before they were 7 years old, and 40 per cent began when they were ten years old or more. Eighty-one per cent of children of primary-school age are attending primary school. Almost 39 per cent of people aged 5–24 years who have attended school repeated a year at least once, and 57 per cent never repeated. Failure does not vary by sex. Differences are ob- served by area of residence. Failing years is more frequent in urban areas (46 per cent) than in rural areas (35 per cent). Twenty per cent of children of secondary-school age are attending school at this level. There is no great difference in terms of gender. Attendance is higher in urban areas than in rural ones. Of the total number of children who enter school, only 77 per cent reach fifth grade and 60 per cent reach seventh grade. Birth registration Less than a third (31 per cent) of children under five have been registered, 39 per cent in urban areas and only 28 per cent in rural areas. Children who live in southern provinces are more likely to be registered than those from other regions. The mother’s level of education and the household’s wealth are, to some extent, positively correlated with the registration of the child. The main reasons given for not registering children were: registration is complicated (25 per cent), the registry office is far away (23 per cent) and the cost of registration is expensive (20 per cent). Child labour Twenty-two per cent of children aged 5–14 years are involved in some kind of child labour. The most frequent form of labour is family business (16 per cent). Involvement in child labour is at its highest in the 12–14 year age group (27 per cent) and slightly lower in the 5–11 year age group (21 per cent). The mother’s level of education and the level of household wealth correlate with the involvement of children in child labour. Child marriage, polygamy and spousal age difference MICS data show that 52 per cent of women aged 20–49 married before they were 18, and 18 per cent married before they reached 15. As expected, child marriage is more frequent in rural than in urban areas. The central and northern regions of the country have a greater prevalence of child marriage than the south. Almost a quarter (24 per cent) of women aged 15–49 are married/in union in a polygamous setting. This is more frequent in rural areas (27 per cent) than in urban areas (16 per cent). Polygamy is most frequent among women with no level of education (30 per cent) and least common among women with at least secondary education (11 per cent). xxii MICS also collected data on spousal age differences. Twenty-two per cent of women aged 15–19, and 21 per cent of those aged 20–24, are married or in marital union with husbands or partners ten or more years older than they are. There are no significant differences by area of residence and no clearly identifiable pattern of variation among the provinces. Domestic violence The data show that 36 per cent of women think a husband is justified in beating his wife for at least one of the reasons cited in the questionnaire (when the woman leaves without saying goo- dbye to him, when she looks after the children badly, when she argues with her husband, when she refuses to have sex with him, when she burns the food). Acceptance of domestic violence is more common in rural areas (39 per cent) than in urban areas (31 per cent). Attitudes of ac- ceptance are inversely correlated with women’s educational levels. Child disability About 14 per cent of children aged 2–9 years have at least one of the disabilities listed. The difference between areas of residence is small – 15 per cent for rural areas and 13 per cent for urban areas. Serious delay in sitting, standing or walking was the disability most widely reported (6 per cent). Knowledge of HIV transmission and of HIV testing facilities, and attitudes towards people living with HIV and AIDS Ninety-one per cent of women have heard of HIV and AIDS, 97 per cent in urban areas and 87 per cent in rural areas. About 13 per cent of women know all three main ways of preventing HIV transmission: having just one uninfected sexual partner, sexual abstinence and using condoms in sexual relations. Seventy-eight per cent of women aged 15–49 know that HIV can be transmitted from mother to child (vertical transmission), and 55 per cent know the three forms of vertical transmission. Thirteen per cent did not know about any form of vertical transmission. About 77 per cent of women agree with at least one of the discriminatory statements about people living with HIV or AIDS, which shows the continued existence of discrimination in the country. However, these data show a significant improvement when compared with those of DHS 2003. Seventy-seven per cent of women identified a place where HIV tests can be done, and 30 per cent said they had taken the test. Knowledge of the place where the test can be taken is po- sitively correlated with the woman’s level of education. It should be mentioned that, of all the women who took the test, 92 per cent received the results. Fifty-nine per cent of the women who were pregnant in the last two years prior to the survey received information about HIV prevention during antenatal care, which is a slight increase over DHS 2003 data, when the number was 51 per cent. 47 per cent were counselled and tested during antenatal care. This is a great increase compared with the data from DHS 2003, when the figure was a mere 3 per cent. Sexual behaviour which increases the risk of HIV transmission MICS shows that about 16 per cent of women aged 15–24 had sexual relations with a partner ten or more years older than they in the 12 months prior to the survey. The prevalence of inter- generational sex is inversely related to the women’s level of wealth. xxiii Mozambique – Multiple Indicators Cluster Survey 2008 Thirty-two per cent of women aged 15–24 had sexual relations with a non-regular partner in the 12 months prior to the survey, and of these, only 44 per cent used a condom. This is an increase compared with the 29 per cent recorded in DHS 2003. Orphaned and vulnerable children About 15 per cent of children in Mozambique aged 0–17 years are not living with their biological parents. 6 per cent are vulnerable and 12 per cent are orphans who have lost one or both pa- rents. The differences by area of residence are not significant. MICS also shows that 3 per cent of children aged 10–14 years have lost their parents. Of these, 77 per cent are in school. About a quarter of children aged 10–14 and 31 per cent of those aged 15–17 are orphaned and/or vulnerable because of AIDS. Twenty per cent of households with children 0–17 years old who are orphaned or made vulne- rable due to AIDS received support directed towards school activity, and 22 per cent received some kind of support. However, 78 per cent of households in the same situation did not receive any kind of support. 1 Mozambique – Multiple Indicators Cluster Survey 2008 I. Introduction Historical background This report presents the results of the Multiple Indicator Cluster Survey (MICS) in Mozambique. This survey was given in 2008 by the National Statistics Institute (INE), with the technical and financial support of UNICEF. To a large extent, MICS exists to monitor progress towards the objectives and targets set forth in two international agreements: the Millennium Declaration, adopted by all 191 member countries of the United Nations in September 2000, and the Plan of Action for A World Fit for Children, adopted by 189 member states at the United Nations Special Session on Children, held in May 2002. Both undertakings are based on the promises made by the international community at the World Summit on children held in 1990. When they signed these international agreements, governments pledged to improve the con- ditions of children and to monitor progress made in this direction. UNICEF was charged with supporting this task (see the table which follows). 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 re- gional 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, pa- ragraph 60) “We will conduct periodic reviews at the national and sub-national levels of pro- gress 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: Continue F 2 “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 the governments, relevant funds, programmes and the specialised agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this declaration, and ask the Secretary- General to issue periodic reports for consideration by the General Assembly, and as a basis for further action.” Survey objectives The 2008 MICS aims essentially to do the following: Provide up-to-date information for assessing the situation of children and women in Mozambique. Contribute to assessing the Government Five-Year Programme 2005–2009 and the Action Plan for the Reduction of Absolute Poverty 2007–2009 (PARPA II), thus allowing an analysis of progress relative to a series of targets established in the PARPA II monitoring matrix. Provide the data necessary to monitor progress towards the Millennium Development Goals (MDGs) and the goals of A World Fit for Children, as well as progress towards other interna- tionally agreed targets. Serve as a fundamental source of information for the Government on the country’s stage of development as it draws up its next five-year programme. Contribute to the improvement of data and monitoring systems in Mozambique and streng- then specialist technical expertise in the design, implementation and analysis of these systems. v v v v v 3 Mozambique – Multiple Indicators Cluster Survey 2008 II. Methodology Design and size of the sample The universe defined for this survey included all households living in individual homes in Mozambican territory. It excluded households living in collective homes (barracks, hotels, stu- dent residences, etc.), the homeless, and diplomats living in embassies/representations. The MICS 2008 sample was obtained from the preliminary data and the cartography of the 2007 Census. Selection of the MICS 2008 sample followed a two-stage plan: 1) select the Primary Sampling Units (PSU) or Enumeration Areas (EAs); 2) select households within the sample EAs and, within these, exhaustively select units of analysis (that is, women aged 15–49 and children under five). Thus, the MICS sample covered 715 PSUs (or EAs) selected systematically, with probability proportional to the size of each urban or rural stratum within each province. In each of the 715 PSUs 20 households were selected, which resulted in a total national sample of 14,300 hou- seholds. Of the 14,300 households, 6,160 were urban and 8,140 were rural. The division of the sample by urban and rural stratum within each province is proportional, and the unit of measurement is the number of households in each stratum within each province. The minimum number of households expected in each province was 1,200; exceptions were made for Nampula and Zambézia provinces, with 1,600 households each due to their demographic weight, and Maputo City, with 1,500 households due to the greater variability of its socio-demo- graphic characteristics. Survey questionnaires To collect data, the methodology of household interviews was adopted, and three types of ques- tionnaire were used: 1) a questionnaire to gather information on all members of the household and the house; 2) one for women aged 15–49; and 3) one for children under five, administered to mothers or caregivers of all children under five living in the household. The household questionnaire included the following modules: Sheet to list household members Education Water and sanitation Characteristics of the household Security of tenure of the house Mosquito nets and spraying Child labour Disability Orphaned and vulnerable children Income Iodized salt. v v v v v v v v v v v 4 The questionnaire for women was administered to all women aged 15–49. The questionnaire had the following modules: Characteristics of the woman interviewed Matrimonial situation and sexual activity Child mortality Maternal and newborn health Tetanus toxoid Contraception Attitudes towards domestic violence HIV and AIDS. For the questionnaire for children under five, the mothers or caregivers in each household were identified and interviewed. The questionnaire had the following modules: Birth registration and early learning Child development Vitamin A Breastfeeding Care of illness Malaria Immunization Anthropometry. The three survey questionnaires were based on the MICS3 model questionnaires6. Starting with the English version of the MICS3 model, the questionnaires were translated into Portuguese and put into the Mozambican context. Specific themes were added to meet the country’s needs. The pilot survey was held in April 2008 in Maputo City and in Boane district, Maputo province. Based on the results of the pilot survey, modifications were made to the drafting and translation of the questionnaires. Appendix F shows the Mozambique MICS questionnaires. In addition to administering the questionnaires, the fieldwork teams tested the level of iodine in the kitchen salt in use in households and measured the height and weight of all children under five. Details and conclusions from these measurements are presented in the respective sec- tions of the report. Training the survey staff Two regional training sessions were held in Mozambique to train the staff who headed the sur- vey in the province and the technicians responsible for supervising at provincial level. The first training session ran from 30 June to 25 July in Bilene district, Gaza province, and all the provin- ces from the south of the country and two from the north took part. The second ran from 14 July to 8 August in the city of Chimoio, in Manica province, and involved all the provinces of the cen- tral region and one from the north. The training was managed by members of the MICS central 6 The MICS3 model questionnaire can be seen on <www.childinfo.org>, or in UNICEF, 2006. v v v v v v v v v v v v v v v v 5 Mozambique – Multiple Indicators Cluster Survey 2008 management and included theoretical sessions about interviewing techniques, simulated inter- views in the classroom and practical sessions on the ground with households, in Bilene district for the first training session and in Chimoio city and Gondola district for the second. Because of the ethnic and linguistic diversity of Mozambique, all participants were natives of the provinces where they were to work and spoke correctly the dominant languages in these areas. Organization of fieldwork The MICS data were collected by 25 teams of interviewers. There were two teams and one supervisor per province, with the exception of Nampula and Zambézia provinces and Maputo City, which each had three teams. The teams consisted of four interviewers, one driver, one person taking measurements, and one controller. In addition to the teams of interviewers, each province had a coverage team, which sought to assess the coverage and quality of information filled out on the questionnaires and to provide feedback for the teams on the ground, so as to improve the quality of the questionnaire information. The coverage team consisted of two interviewers and one driver. The field work began in August 2008 and ended in November of that year. Sending the completed questionnaires from the provinces to the INE headquarters in Maputo was completed in late January 2009. Data processing Data processing began in October 2008 and ended in April 2009. Survey processing involved both manual and automatic procedures: receiving and verifying questionnaires, criticism (revi- sion and codification), inputting, editing and analysis of inconsistencies. Data were captured using the interactive software CSPro (Census and Survey Processing System) on 20 microcom- puters. Forty data entry operators took part, distributed in two shifts, and a supervisor. To ensure quality control, all the questionnaires were input twice. Throughout the work, procedures and standard programmes developed under the global MICS3 project were used and adapted to the local questionnaire. For cleanness and consistency of data input, the software Stata was used. Data were processed using the programme Statistical Package for Social Sciences (SPSS), version 15, and the model syntax and tabulation plans developed by UNICEF. 6 III. Sample coverage and characteristics of households and respondents Sample coverage Table 3.1 calculates overall response rates, by area of residence and by province, for interviews of women and children under five. Of the 14,300 households selected for the sample (Table 3.1), 14,269 were contacted for interviews, and of these, 13,995 were duly interviewed, giving a response rate of 97.9 per cent at the household level. Among the reasons why interviews of the remaining households were not held, the following stand out: homes unoccupied, destroyed, etc. (Table 3.2). In the households interviewed, 15,060 women aged 15–49 were identified. Of these, 14,188 were duly interviewed, giving a response rate of 94.2 per cent. In MICS 2008, 11,818 children under five were identified, about whom information could be obtained from the mothers or other caregivers. For the children, 11,419 complete interviews were held, which is a response rate of 96.6 per cent. That rate is very reasonable for this sort of survey. Table 3.1: Results of household and individual questionnaires Number of households, women, and children under 5 and household, women’s and under-five’s response rates, Mozambique 2008 Selected characteristics N um be r of sa m pl ed ho us eh ol ds N um be r of in te rv ie w ed ho us eh ol ds H ou se ho ld s re sp on se r at e N um be r of e lig ib le w om en N um be r of in te rv ie w ed w om en W om en ’s re sp on se r at e N um be r of e lig ib le ch ild re n u nd er 5 N um be r of in te rv ie w ed m ot he rs / ca re ta ke rs C hi ld re n’ s re po ns e ra te Total 14,300 13,955 97.9 15,060 14,188 94.2 11,818 11,419 96.6 Area of residence Urban 6,160 6,010 98.0 7,390 6,960 94.2 4,658 4,505 96.7 Rural 8,140 7,945 97.8 7,670 7,228 94.2 7,160 6,914 96.6 Province Niassa 1,200 1,143 95.6 1,076 1,004 93.3 934 907 97.1 Cabo Delgado 1,200 1,191 99.3 1,161 1,123 96.7 943 924 98.0 Nampula 1,600 1,470 92.7 1,322 1,192 90.2 1,077 1,007 93.5 Zambézia 1,600 1,577 99.2 1,376 1,321 96.0 1,242 1,208 97.3 Tete 1,200 1,196 99.7 1,124 1,086 96.6 1,072 1,047 97.7 Manica 1,200 1,177 98.2 1,248 1,159 92.9 1,130 1,084 95.9 Sofala 1,200 1,200 100.0 1,729 1,693 97.9 1,798 1,787 99.4 Inhambane 1,200 1,165 97.1 1,234 1,098 89.0 895 835 93.3 Gaza 1,200 1,180 98.4 1,404 1,263 90.0 1,018 952 93.5 Maputo Province 1,200 1,172 97.8 1,387 1,301 93.8 825 799 96.8 Maputo City 1,500 1,484 99.6 1,999 1,948 97.4 884 869 98.3 Table 3.1 also presents response rates by province and area of residence for MICS 2008. The urban and rural response rates for the household questionnaire at national level (97.6 per cent and 97.6 per cent, respectively) are very similar or identical. With the exception of households living in Nampula (response rate of 91.9 per cent), all the households resident in the other pro- vinces were very receptive in their interviews, since they gave very high response rates (above 95 per cent). The urban and rural response rates for women are also very satisfactory and very similar (94.2 per cent and 94.2 per cent, respectively). However, the provinces of Inhambane (89.0 per cent), Gaza (90.0 per cent) and Nampula (90.2 per cent) show relatively low response rates when compared to the rest of the provinces. From Table 3.2, one may deduce that this fact is because of the rates of absence of the women during the period data collection teams stayed in the se- lected enumeration areas (10.2 per cent, 8.9 per cent and 4.8 per cent respectively). 7 Mozambique – Multiple Indicators Cluster Survey 2008 Likewise, the response rates for children under five in urban and rural areas are very high and similar to each other (96.7 per cent and 96.6 per cent, respectively). This level of response rates and pattern of similarity remain constant in almost all the provinces, with the exception of Inhambane, Nampula and Gaza, where the response rate falls to 93.0 per cent because of the reason mentioned above, since the information concerning the eligible children was obtained from their mothers or other caregivers. Movement (displacement) of children under five in rural areas is strongly associated with that of their mothers and/or caregivers. Table 3.2: Response Rate by province and area of residence Response rate in the household survey, individual survey of women and children under 5 survey by province and area of residence, Mozambique 2008. Selected characteristics Residence Province Total U rb an R ur al N ia ss a C ab o D el ga do N am pu la Z am bé zi a Te te M an ic a S of al a In ha m ba ne G az a M ap ut o P ro vi nc e M ap ut o C ity Households Household (AF) Complete (C ) 97.6 97.6 95.3 99.3 91.9 98.6 99.7 98.1 100.0 97.1 98.3 97.7 98.9 97.6 All absent AF (TAFA) 1.6 1.8 3.8 0.3 5.3 0.8 0.3 1.2 0.0 2.6 1.6 2.1 .2 1.7 Total refusal (RT) 0.3 0.3 0.3 0.4 1.9 0.1 0.0 0.3 0.0 0.3 0.0 0.1 0.1 0.3 Unoccupied house (CD) 0.0 0.1 0.2 0.0 0.2 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0 Other/ house distroyed (Cdes) 0.1 0.1 0.3 0.0 0.1 0.0 0.0 0.3 0.0 0.1 0.0 0.0 0.1 0.1 House not found (CNE) 0.4 0.1 0.3 0.0 0.7 0.6 0.0 0.1 0.0 0.0 0.1 0.1 0.7 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of AF 6,160 8,140 1,200 1,200 1,600 1,600 1,200 1,200 1,200 1,200 1,200 1,200 1,500 14,300 Response rate (TRAF) (a) 98.0 97.8 95.6 99.3 92.7 99.2 99.7 98.2 100.0 97.1 98.4 97.8 99.6 97.9 Women Eligible women (MEC) 94.2 94.2 93.3 96.7 90.2 96.0 96.6 92.9 97.9 89.0 90.0 93.8 97.4 94.2 Absent (MEA) 4.4 4.5 4.6 2.9 4.8 2.3 2.2 6.0 1.5 10.2 8.9 5.4 1.7 4.4 Total refusal (MR) 0.1 0.1 0.1 0.0 0.3 0.1 0.1 0.3 0.1 0.0 0.1 0.1 0.0 0.1 Refusal during the interview /incomplete (MEII) 0.1 0.1 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.2 0.1 0.1 0.0 0.1 Not able to answer (MEI2) 0.3 0.2 0.4 0.2 0.3 0.3 0.4 0.1 0.2 0.1 0.4 0.2 0.5 0.3 Other (MEO)* 1.0 0.9 1.7 0.2 4.2 1.3 0.7 0.7 0.3 0.5 0.5 0.4 0.4 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women* 7,390 7,669 1,076 1,161 1,322 1,376 1,124 1,248 1,729 1,234 1,404 1,387 1,999 15,060 Eligible women’s response rate (TRME) (b) 94.2 94.2 93.3 96.7 90.2 96.0 96.6 92.9 97.9 89.0 90.0 93.8 97.4 94.2 Women’s total response rate (TRMT) (c ) 92.3 92.2 89.2 96.0 83.6 95.2 96.3 91.2 97.9 86.4 88.5 91.8 97.1 92.2 Children under 5 Children under 5 complete (C5C) 96.7 96.6 97.1 98.0 93.5 97.3 97.7 95.9 99.4 93.3 93.5 96.8 98.3 96.6 All AF absent (C5A) 1.8 2.3 2.0 1.5 2.0 1.3 1.1 3.5 .5 5.0 5.1 1.9 .8 2.1 Total refusal (CRT) 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Refusal during the interview /incomplete (CRDE) 0.2 0.2 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.8 0.9 0.5 0.0 0.2 Not able to answer (C5INC) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other (C5O) 1.3 0.9 0.7 0.5 4.3 1.4 1.2 0.6 0.1 0.9 0.5 0.7 0.9 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of children under 5 4,658 7,160 934 943 1,077 1,242 1,072 1,130 1,798 895 1,018 825 884 11,818 Eligible children’s response rate (TRCE) (d) 96.7 96.6 97.1 98.0 93.5 97.3 97.7 95.9 99.4 93.3 93.5 96.8 98.3 96.6 Children’s total response rate (TRCT) (e) 94.8 94.4 92.9 97.3 86.7 96.5 97.3 94.2 99.4 90.6 92.0 94.7 97.9 94.6 * Women with missing information for residence are not included (a) TRAF=C/(C+TAFA+RT+CD+Cdes+CNE)*100; (b)TRME = MEC/(MEC+MEA+MR+MEII+MEI2+MEO); (c)TRMT= (TRAF * TRME)/100; (d) TRCE= C5C/(C5C+C5A+CRT+CRDE+C5INC+C5O); (e) TRCT = (TRAF * TRCE)/100. 8 IV. Child mortality Introduction One of the objectives of the Millennium Development Goals (MDGs) and of A World Fit for Children is to reduce the under-five mortality rate by two thirds between 1990 and 2015. Measuring progress towards this goal in countries without a complete system of registering life events becomes a very difficult task and has to be based on household surveys such as MICS. This chapter presents a brief analysis of the levels, trends and differentials in childhood mortali- ty. This information is extremely important for monitoring the progress of this indicator over time, since the methodology used by MICS in data collection and calculation is the same as that used by the IDS of 1997 and 2003. Methodology The analysis of the levels and trends of child mortality in MICS 2008 is based on information on the history of births gathered from women aged 15–49. During the interview, each woman was asked about the total number of children she has borne in her life, including the number of sons and daughters living with her, those who live somewhere else and those who have died. In addition, the women were asked to provide more detailed information about all the children they had borne throughout their entire reproductive life. This information covered the year each child was born, its sex, the type of birth (simple or multiple), the survival of each child and the current age of each living child. If a child had died, the woman was asked at what age it died. The information thus collected makes it possible to calculate directly, for specific periods, the following indicators: Neonatal mortality: the probability of dying in the first month of life (0–30 days); Post-neonatal mortality: the probability of dying after the first month of life, but before rea- ching the child’s first birthday (1–11 months); Infant mortality: the probability of dying in the first year of life (0–11 months); Post-infant mortality: the probability of dying between the first and fifth birthday (12–59 months); Under-five mortality: the probability of dying before the fifth birthday (0–59 months). Mortality levels and tends Table 4.1 shows the rates of neonatal, post-neonatal, infant, post-infant and under-five mortality for the three five-year periods that preceded the survey, which allows one to see the tends over the past 15 years. During the five years preceding MICS (2003–2008), 141 children out of every 1,000 live births died before reaching their fifth birthday. In the same period, for every 1,000 live births, 95 died before completing the first year of life, and of those who survived the first year, 51 per 1,000 died before reaching their fifth year of life. The probability of dying during the first month of life was 38 per 1,000, while 56 per 1,000 live births died between the first and the twelfth months. The data in Table 4.1 show that over the past 15 years there has been a significant reduction in child mortality. However, it is necessary to bear in mind that since the reliability of information about the child’s age and date of death tends to decline with the passage of time, the less recent estimates have lower levels of precision. v v v v v 9 Mozambique – Multiple Indicators Cluster Survey 2008 Table 4.1: Child mortality rates Rates of neonatal, post-neonatal, infant, post-infant and under-five mortality in the five-year periods prior to the survey, Mozambique, 2008 Years prior to the survey Neonatal mortality Post-neonatal mortality Infant mortality Post-infant mortality Under-five mortality 0–4 38 56 95 51 141 5–9 48 73 121 62 175 10–14 52 87 139 90 216 The child mortality trend over time can also be assessed by analysing the MICS 2008 data to- gether with the data from DHS 2003 and IDS 1997. This analysis, which is shown in Graph 4.1, confirms the trend of a reduction in child mortality over the past 15 years. However, the pace of the decline over the most recent five-year period has been slower than that of the previous decade. For example, the mortality rate of children under one year old declined by 34 points between the 1993–1998 and 1998–2003 periods, while the decline was only 6 points between the 1998–2003 and 2003–2008 periods. Graph 4.1 Infant and child mortality trends, Mozambique, 1997, 2003 and 2008 250 225 200 175 150 125 100 75 50 25 0 9891 0991 1991 2991 3991 4991 5991 6991 7991 7991 8991 9991 0002 1002 2002 3002 4002 5002 6002 7002 8002 DHS2003 - IMR DHS1997 - IMR MICS2008 - IMR DHS2003 - U5MR DHS1997 - U5MR MICS2008 - U5MR P er 1 00 0 liv e bi rt hs Mortality differentials In analysing the mortality differentials based on the data from the surveys, it has been difficult to obtain reliable results for some variables due to an insufficient number of cases, which results in imprecise estimates for a five-year period. It is thus recommended that the reference period be expanded to 10 years prior to the survey date (1998–2008) so as to obtain a sufficient number of cases to allow more precise analysis for more variables. Note that the longer reference pe- riod allows the inclusion of more cases in the calculation and makes it possible to obtain more precise estimates. Hence, the estimate of child mortality at the national level is calculated by using as the referen- ce period the five years prior to the survey (2003–2008), but the disaggregated estimates (by province, sex and area of residence) are calculated by taking the ten years prior to the survey 10 (1998–2008) as the reference period. The results of the mortality estimates by selected charac- teristics are shown in Table 4.2. The under-five mortality rate in the ten-year period prior to the survey (1998–2008) is estimated at 157 per 1,000 live births. This figure is higher in rural areas (164 per 1,000) than in urban areas (138 per 1,000). The levels of child mortality differ from one province to another. The northern provinces show the highest rates. Maputo City and Maputo province have lower rates than the other provinces. Table 4.2: Child mortality rates (average in the 10 years prior to the survey) Rates of neonatal, post-neonatal, infant, post-infant, and under-five mortality, in the ten years prior to the survey, by selected characteristics, Mozambique, 2008 Selected characteristics Neonatal mortality (NM) Post-neonatal mortality (PNM) Infant mortality Post-infant mortality Under-five mortality Total 43 64 107 56 157 Area of Residence Urban 41 55 95 47 138 Rural 44 68 111 60 164 Province Niassa 42 58 100 29 126 Cabo Delgado 52 81 133 55 181 Nampula 44 64 109 40 144 Zambézia 59 88 147 69 206 Tete 41 67 108 75 174 Manica 27 66 93 68 154 Sofala 33 47 81 58 134 Inhambane 37 42 79 59 133 Gaza 37 61 98 74 165 Maputo Province 31 37 69 37 103 Maputo City 26 41 67 44 109 Sex Male 46 65 110 56 160 Female 39 63 102 55 152 Mother’s education Never went to school 43 65 108 53 155 Primary 43 67 110 61 164 Secondary + 32 27 59 26 84 Wealth index quintile Poorest 41 78 119 64 175 Second 48 67 115 62 170 Middle 46 74 120 61 173 Fourth 45 51 95 50 140 Richest 31 44 75 39 111 11 Mozambique – Multiple Indicators Cluster Survey 2008 Infant mortality (deaths among children less than a year old) varies between 67 per 1,000 in Maputo City and 147 per 1,000 in Zambézia. Other provinces with particularly high infant mor- tality rates are Cabo Delgado (133 per 1,000), Nampula (109 per 1,000) and Tete (108 per 1,000). As shown in Graph 4.2, the under-five mortality rate also varies significantly between the provin- ces. The highest mortality rates are in Zambézia (206 per 1,000) and in Cabo Delgado (181 per 1,000). Tete has the third highest mortality rate (174 per 1,000). Maputo province and Maputo City have the lowest under-five mortality rates in the country (103 and 109 per 1,000, respecti- vely) while the rate recorded in Gaza (165 per 1,000) was the highest in the southern region. Map 4.1 and Graph 4.2: Child mortality rate, by province (average in the 10 years prior to the survey), Mozambique, 2008 N ia ss a C ab o D el ga do N am pu la Z am bé zi a T et e M an ic a S of al a In ha m ba ne G az a M ap ut o M ap ut o C ity 126 181 144 206200 150 100 50 0 174 154 134 133 165 103 109 Maputo 103 Mortality Rate per 1000 Maputo City 109 Gaza 165 Inhambane 133 Manica 154 Sofala 134 Tete 174 Zambézia 206 Nampula 144 Niassa 126 Cabo Delgado 181 100 - 120 120 - 140 140 - 160 160 - 180 180 - 210 P er 1 00 0 liv e bi rt hs As mentioned in the previous paragraph, the data from MICS 2008 show that child mortality has been declining over the past 15 years. There has been a sharper decline in rural areas and a slower fall in urban areas. As shown in Graph 4.3, data from the two DHS and from MICS show that, in the last decade, the under-five mortality rate has been declining nationwide at an ave- rage of 1.2 points a year (from 150 per 1,000 to 138 per 1,000), while the average annual fall in rural areas was almost 7.3 points (from 237 per 1,000 to 164 per 1,000). A similar pattern may be noted in the evolution over time of the infant mortality rate, which has fallen substantially in rural areas and marginally in urban areas, as can be seen in Graph 4.4. 12 Graph 4.3: Under-five mortality rate by area of residence, Mozambique, 1997, 2003 and 2008 (ave- rage in the 10 years prior to the survey) 14 250 200 150 100 50 0 1993 - 1998 (DHS 1997) 237 192 164 150 143 138 1998 - 2003 (DHS 2003) 2003 - 2008 (MICS 2008) Urban Rural P er 1 00 0 liv e bi rt hs Graph 4.4: Infant mortality rate (children under one year old), by area of residence, Mozambique, 1997, 2003 and 2008 (average in the 10 years prior to the survey) 14 250 200 150 100 50 0 1993 - 1998 (DHS 1997) 101 95 95 160 135 111 1998 - 2003 (DHS 2003) 2003 - 2008 (MICS 2008) Urban Rural P er 1 00 0 liv e bi rt hs The data from this survey show a strong correlation between the level of the mother’s education and child mortality. Thus, under-five mortality is highest among children whose mothers never went to school (155 per 1,000 live births) and lowest among children whose mothers went to school and completed at least secondary education (84 per 1,000 live births). The data from MICS also confirm that mortality tends to be differentiated among socio-econo- mic groups classified on the basis of wealth quintiles. Hence, infant mortality tends to be higher in the groups regarded as poor than in the groups regarded as not poor. According to the data from MICS, infant mortality falls from 119 per 1,000 live births among children living in househol- ds in the lowest wealth quintile, to 75 per 1,000 live births among children in the highest wealth quintile. 13 Mozambique – Multiple Indicators Cluster Survey 2008 V. Nutrition Nutritional status of children Children’s nutritional status is a reflection of their overall health. When children have access to adequate food, are not exposed to repeated illness, and are well cared for, they reach their physical and mental growth potential and are regarded as well nourished. More than half of child deaths throughout the world are related to undernutrition. Undernourished children are more likely to die from common childhood illnesses, and those who survive may repeatedly fall ill, have growth deficiencies and have reduced mental development. Three quarters of the children who die from causes related to undernutrition have only slight or moderate undernutri- tion. They do not show any signs of their vulnerability. The Millennium Development Goal is to reduce by half the percentage of people living in hunger between 1990 and 2015; the goal of A World Fit for Children is to reduce by at least a third the prevalence of undernutrition (insufficient weight) in children under five years of age between 2000 and 2010, paying special attention to children under two years old. Reducing the prevalence of undernutrition will contribute to the goal of reducing child mortality and will also help improve the quality of life and productivity of the population. In a well-nourished population, there is a reference distribution of height and weight for children under the age of five. Undernutrition in a population can be gauged by comparing the children of this population to the reference population. The reference population used in this report is the WHO standard of 20067. 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 an important indicator for measuring levels of undernutrition. Children whose weight-for-age is between two and three standard deviations below the median of the reference population are considered moderately underweight for their age, while those whose weight- for-age is more than three standard deviations below the median are classified as severely underweight for their age. Height-for-age is a measure of linear growth. Children whose height-for-age is between two and three standard deviations below the median of the reference population are considered as short for their age and are classified as having moderate chronic undernutrition (stunting). Those whose height-for-age is more than three standard deviations below the median are classified as suffering from severe chronic undernutrition (severe stunting). Low height-for-age may reflect chronic undernutrition resulting from failure to receive adequate food over long and repeated periods, from recurrent or chronic illness, or from other additional factors. Children whose weight-for-height is between two and three standard deviations below the me- dian of the reference population are classified as suffering from moderate acute undernutrition (wasting), while those whose weight-for-height is more than three standard deviations below the median are regarded as suffering from severe acute undernutrition (severe wasting). Wasting normally results from recent nutritional deficiency or illness. The indicator may reflect signifi- cant seasonal shifts associated with changes in the availability of food or in the prevalence of disease. Finally, children whose weight-for-height is more than two standard deviations above the me- dian of the reference population are classified as overweight. 7 WHO growth standards, methods and development may be consulted at <http://who.int/childgrowth/standards/en/>. 14 In MICS, all children under five were weighed and measured using anthropometric equipment (altimeters) recommended by UNICEF and WHO8. The conclusions in this section are based on the results of these measurements. Table 5.1 shows the percentage of children classified in four categories, based on the anthropo- metric measures taken during the field work9. As shown in Table 5.1, in Mozambique, 18 per cent of children under five have low weight for their age, and of these five per cent are severely underweight. Almost one in every two children (44 per cent) under the age of five are short for their age, or are suffering from chronic undernu- trition, and 4 per cent are suffering from acute undernutrition (low weight for height). Comparing these data with those from IDS 200310, some improvements have occurred in the nutritional status of children under five. As Graph 5.1 shows, the percentage of children with low weight for their age has fallen from 22 per cent in 2003 to 18 per cent in 2008. The percentage of children under five with chronic undernutrition has fallen by 4 percentage points (from 48 per cent in 2003 to 44 per cent in 2008). The prevalence of acute undernutrition fell from 5 per cent to 4 per cent, but this small variation is not statistically significant. Despite these improvements, the levels of child undernutrition, particularly chronic undernutrition, remain very high, according to the WHO classification11. 8 Although the term ‘height’ is used here, children under 24 months old were measured lying down (to obtain the measure of length); vertical height is the standard for measuring older children. 9 8.8 per cent of children were excluded from the analysis (Table A.1 in appendix A), because some children were neither weighed nor measured (3.8 per cent), and some children’s measurements were outside of any plausible variation (1.8 per cent). In addition, a small number of children whose dates of birth are not known (1.6 per cent) and others with missing values for weight or height (1.6 per cent) were also excluded. 10 The anthropometric estimates of DHS 2003 were recalculated based on the reference population of WHO from 2006. The estimates pu- blished in the DHS 2003 report were based on the reference population of NCHS/CDC/OMS. Consult WHO growth standards, methods and development: <http://who.int/childgrowth/standards/en/>. 11 According to the standard classification of the WHO, rates of chronic undernutrition of between 20 and 30 per cent are considered ‘me- dium’, rates between 30 and 40 per cent are considered ‘high’ and rates above 40 per cent are considered ‘very high’; see World Health Organization, Technical report series number 854, WHO, 1995. 15 Mozambique – Multiple Indicators Cluster Survey 2008 Table 5.1: Undernourished children Nutritional status of children under five, by selected characteristics and based on WHO standards, Mozambique, 2008 Selected characteristics Weight for age: (underweight) Height for age: (chronic undernutrition - stunting) Weight for height: (acute undernutrition - wasting) Number of children % B el ow -2 D P % B el ow -3 D P * N um be r of ch ild re n % B el ow -2 D P % B el ow -3 D P ** N um be r of ch ild re n % B el ow -2 D P % B el ow -3 D P ** * % A bo ve + 2 S D Total 18.3 5.1 10,872 43.7 17.6 10,676 4.2 1.3 3.6 10,642 Area of residence Urban 13.8 3.8 3,092 34.7 12.9 3,054 2.9 0.9 4.6 3,033 Rural 20.1 5.6 7,780 47.3 19.5 7,622 4.7 1.5 3.2 7,609 Provínce Niassa 19.3 4.3 622 45.5 19.0 592 5.2 0.9 7.2 588 Cabo Delgado 22.7 5.1 1,080 55.7 21.7 1,073 3.5 0.7 2.3 1,072 Nampula 28.4 11.3 1,630 50.6 29.7 1,583 8.7 3.7 4.2 1,563 Zambézia 21.1 5.7 1,927 45.8 18.0 1,881 5.1 1.4 3.2 1,895 Tete 18.6 4.6 1,057 48.0 19.1 1,053 2.6 0.9 1.6 1,039 Manica 18.5 3.8 534 48.3 16.0 512 3.8 1.2 2.7 510 Sofala 15.9 4.1 1,560 40.5 13.8 1,548 3.2 0.8 2.4 1,550 Inhambane 11.8 2.1 683 34.5 13.0 676 2.8 1.1 3.2 671 Gaza 6.7 1.5 711 34.2 8.8 707 1.3 0.2 3.5 708 Maputo Province 7.8 1.5 630 28.0 8.4 623 2.1 0.4 9.2 618 Maputo City 7.2 1.6 438 24.9 6.6 429 1.8 0.2 5.3 428 Sex Male 20.6 5.6 5,387 46.8 20.2 5,284 4.9 1.3 4.1 5,262 Female 16.0 4.5 5,485 40.7 15.1 5,392 3.5 1.3 3.2 5,380 Age < 6 months 13.1 4.8 1,170 21.4 9.6 1,130 6.9 2.3 6.6 1,106 6–11 months 22.8 8.4 1,244 32.1 11.6 1,224 7.0 1.5 3.4 1,225 12–23 months 21.7 6.2 2,330 47.8 18.7 2,303 5.7 1.9 2.3 2,289 24–35 months 19.5 5.8 2,115 53.4 22.5 2,074 3.5 1.3 4.0 2,075 36–47 months 16.2 3.8 2,111 49.9 20.6 2,067 2.0 0.8 3.9 2,074 48–59 months 15.1 2.1 1,901 42.1 16.2 1,879 2.1 0.4 2.9 1,873 Mother’s education Never went to school 21.1 6.6 3,537 48.7 21.2 3,454 5.1 1.6 3.2 3,451 Primary 18.0 4.7 6,550 43.2 17.0 6,449 4.0 1.3 3.7 6,419 Secondary + 7.4 0.7 781 25.4 6.3 770 1.8 0.1 4.6 769 No reply/don’t know * * 3 * * 3 * * * 3 Wealth index quintile Poorest 23.5 6.9 2,418 51.0 21.9 2,349 5.7 2.1 2.9 2,351 Second 23.5 6.7 2,410 52.2 23.8 2,369 4.7 1.2 2.6 2,372 Middle 20.4 5.8 2,141 46.6 19.4 2,106 5.0 1.5 4.0 2,076 Fourth 13.0 2.7 2,166 37.6 12.6 2,140 3.0 1.0 3.8 2,135 Richest 7.6 2.2 1,737 26.1 7.2 1,712 1.8 0.6 5.3 1,707 * MICS indicador 6; MDG indicador 1.8 ** MICS indicador 7 *** MICS indicador 8 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). The three anthropometric indicators on undernutrition (low weight, height for age and weight for height) show that the nutritional status of children living in urban areas is better than that of children living in rural areas. As Table 5.1 shows, the prevalences of chronic undernutrition and of low weight for age among children in rural areas are 47 per cent and 20 per cent, respectively, compared with 35 per cent and 14 per cent in urban areas. 16 The difference between rural and urban areas has shrunk in the last five years because rates of undernutrition have fallen faster in rural areas. Data from DHS 2003 and MICS 2008 show that the chronic undernutrition rate has been declining at an average of 0.4 percentage points per year (from 37 per cent in 2003 to 35 per cent in 2008) in the cities, while the average annual reduction over the same period in rural areas was one percentage point (from 52 per cent to 47 per cent). Analysis by province shows that chronic undernutrition is more prevalent in the provinces of the north and centre of the country, varying from 41 per cent in Sofala to 56 per cent in Cabo Delgado. The central and northern provinces have chronic undernutrition rates that are ‘very high’ according to the WHO scale. In the southern provinces, the prevalence of chronic under- nutrition varies from 35 per cent in Inhambane and Gaza to 25 per cent in Maputo City (Graph 5.4). Boys have slightly worse undernutrition rates than girls for the three types of undernutrition (low weight, chronic undernutrition and acute undernutrition). This is consistent with the results of DHS 2003. The age pattern (Graph 5.2) shows that chronic undernutrition increases in the first three years of children’s lives (from 21 per cent among children less than 6 months old to 53 per cent among children aged 24–35 months). This pattern, which was expected, is related to the age at which children begin to consume complementary foods, which probably do not have the ideal nutritio- nal composition and are not given with ideal frequency. Also in this phase, when children begin to receive other foods and to move more (crawling and walking), they become more exposed to contamination in water, food and the environment. The high prevalence of chronic undernutrition among children aged 0 to 6 months (21 per cent) is rather unexpected. This may be related to one or more of the following factors: 1) that the nutritional status of the mother was poor before and during pregnancy, 2) low weight at birth, 3) illness, 4) the child was not exclusively breastfed. The level of chronic undernutrition declines slightly among children 3 and 4 years of age (to 50 per cent and 42 per cent, respectively). Acute undernutrition showed the opposite trend: it declined as the age of the child increased, from 7 per cent among children under 6 months old to 2 per cent among children aged 48–59 months. The nutritional status of children varies substantially in relation to the level of education of their mothers. Graph 5.3 shows that almost half of children under five years old whose mothers ne- ver went to school are affected by chronic undernutrition, compared with a quarter of children whose mothers completed at least secondary education. Similar patterns are observed in the prevalence of acute undernutrition and of low weight for age. The level of household wealth is also correlated with the level of undernutrition. In the case of chronic undernutrition, for example, the prevalence rate in the poorest quintile (51 per cent) is double that found in the richest quintile (26 per cent). However, even among households that are in the richest quintile, one in every four children suffer from chronic undernutrition. The MICS data show that 5 per cent of children in urban areas and 3 per cent in rural areas are overweight. The prevalence of overweight by province varies from 9 per cent in Maputo province to 2 per cent in Tete. These figures show that Mozambique is beginning to record the presence of the so-called ‘double burden’ of undernutrition and overweight at the same time. 17 Mozambique – Multiple Indicators Cluster Survey 2008 Graph 5.1: Nutritional status of children under five, Mozambique, 2003 and 2008 14 P er ce nt ag e 100 80 60 40 20 0 2003 (DHS) 2008 (MICS) 22 5 4 48 44 18 Underweight Chronic undernutrition Acute undernutrition * Os dados do IDS 2003 foram recalculados com base na população padrão da OMS do ano 2006 * The data from DHS 2003 were recalculated on the basis of the WHO reference population of 2006. Graph 5.2: Nutritional status of children under five, by age, Mozambique, 2008 P er ce nt ag e < 6 6 - 11 12 - 23 24 - 35 13 7 2 2 21 44 16 Underweight Chronic undernutrition Acute undernutrition 7 6 3 23 22 20 15 32 48 53 50 42 80 70 60 50 40 30 20 10 0 36 - 47 48 - 59 Age in months Graph 5.3: Chronic undernutrition among children under five, by the level of education of their mothers, Mozambique, 2008 14 P er ce nt ag e 100 80 60 40 20 0 Never went to school Primary Secondary or higher 49 43 25 Nacional average: 44% 18 Map 5.1 Chronic undernutrition by province, Mozambique, 2008 Low height for age (moderate & severe) 25 - 30 30 - 35 35 - 40 40 - 45 45 - 50 50 - 55 55 - 60 Maputo 28 Maputo City 25 Gaza 34 Inhambane 35 Manica 48 Sofala41 Tete 48 Zambézia 46 Nampula 51 Niassa 46 Cabo Delgado 56 Breastfeeding and infant feeding Breastfeeding in the first years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers do not feed their children ex- clusively on breast milk in the first six months of life, and a high percentage stop breastfeeding too soon. The Lancet Child Survival Series12 calculated that exclusive breastfeeding during the first six months, and continued breastfeeding with adequate complementary food for at least 18 months thereafter, can together prevent almost 20 per cent13 of deaths among children under five in the world. It is the goal of A World Fit for Children that children should be exclusively breastfed in the first six months of life and continue to be breastfed, while receiving safe, appropriate and adequate complementary foods, until they are two years old or more. WHO and UNICEF make the following recommendations on breastfeeding: Exclusive breastfeeding in the first six months Continued breastfeeding for two years or more Safe, appropriate and adequate complementary foods starting at six months Frequency of complementary feeding: twice a day for children aged 6–8 months; three times a day for children aged 9–11 months. 12 See Jones, G., et al., ‘How many child deaths can we prevent this year?’, The Lancet 2003; vol. 362, pp. 65–71. 13 The exact estimates are: 19 per cent and 13 per cent for exclusive breastfeeding and continued breastfeeding until 11 months; and 6 per cent for adequate complementary feeding. v v v v 19 Mozambique – Multiple Indicators Cluster Survey 2008 The recommended indicators for breastfeeding practices are the following: Start of breastfeeding within the first hour of life Rate of children breastfed at some time Rate of exclusive breastfeeding (< 6 months and < 4 months) Rate of timely complementary feeding (6–9 months) Rate of continued breastfeeding (12–15 and 20–23 months) Frequency of complementary breastfeeding (6–11 months) Children adequately fed (0–11 months) Duration of breastfeeding. Table 5.2a shows the percentage of women aged 15–49, with a live birth in the two years prior to the survey, who began to breastfeed their babies in the first hour after birth, and women who began to breastfeed in the first day after birth (which includes those who began within an hour of birth). The start of breastfeeding in the first hour after birth is recommended in order to stimulate the production of breast milk, so that children can receive colostrum14 in the first days after birth and can benefit from exclusive breastfeeding with success. Of the children who were breastfed, 63 per cent were breastfed in the first hour after birth, and 88 per cent were breastfed in the first day of life. The percentage of children living in rural areas who received breast milk in the first hour after birth and in the first day of life is higher than the percentage of those living in urban areas – 65 per cent and 89 per cent against 60 per cent and 85 per cent, respectively. The analysis by province shows that the provinces of Inhambane, Cabo Delgado and Gaza are those with the lowest percentage of children breastfed in the first hour after birth (36 per cent, 39 per cent and 41 per cent, respectively). The other provinces show percentages above 50 per cent (and Sofala stands out with 92 per cent). Women who never went to school are those with the highest percentage of breastfeeding within the first hour (70 per cent), while the figure for those with secondary education or more is 60 per cent. 14 Colostrum, the milk produced in the first days of the child’s life (a yellowish liquid), normally contains a high concentration of vitamin A, which is essential for the correct functioning of the child’s eyesight and immune system and protects its skin and mucous membranes. v v v v v v v 20 Table 5.2a: Initiation of breastfeeding Percentage of women aged 15–49, with a live birth in the 2 years prior to the survey, who breastfed their children within an hour and within a day after the birth, by selected characteristics, Mozambique, 2008 Selected characteristics Percentage of children who were breastfed: Number of women who had a live birth in the two years prior to the survey In the first hour* In the first day Total 63.2 88.1 5,191 Area of residence Urban 59.6 84.9 1,493 Rural 64.7 89.4 3,698 Province Niassa 77.0 96.2 318 Cabo Delgado 38.8 80.5 527 Nampula 66.6 89.6 895 Zambézia 66.0 85.0 912 Tete 67.9 90.9 535 Manica 61.5 90.4 260 Sofala 91.7 94.7 638 Inhambane 36.4 87.6 312 Gaza 41.4 85.9 325 Maputo Province 60.9 83.2 277 Maputo City 57.6 83.2 191 Months since the last birth < 6 months 63.9 88.2 1,289 6–11 months 62.4 89.1 1,366 12–23 months 63.7 88.1 2,522 Mother’s education Never went to school 69.7 89.9 1,624 Primary 60.1 87.9 3,086 Secondary + 60.0 82.9 439 No reply/don’t know (77.2) (96.0) 42 Wealth index quintile Poorest 68.9 89.0 1,209 Second 66.5 90.0 1,144 Middle 64.3 88.4 1,041 Fourth 54.6 87.8 1,018 Richest 59.4 84.2 778 * MICS indicador 45 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). As Table 5.2b shows, 88 per cent of children under five received colostrum. There are no sig- nificant differences between urban and rural areas. The highest percentages of children who received colostrum are in Tete, 97 per cent, and Maputo province, 95 per cent, while Zambézia (72 per cent), Nampula (86 per cent), Niassa (87 per cent) and Maputo City (88 per cent) have the lowest percentages. The data show that children from the poorest households tend to recei- ve less colostrum than the others. 21 Mozambique – Multiple Indicators Cluster Survey 2008 Table 5.2b: Breastfeeding with colostrum Percentage distribution of children under five who were breastfed, and who took colostrum, by selected characteristics, Mozambique, 2008 Selected characteristics Took colostrum Total Total children under fiveYes No No reply/don’t know Total 88.0 9.9 2.2 100.0 11,336 Area of residence Urban 89.0 8.2 2.8 100.0 3,189 Rural 87.5 10.6 1.9 100.0 8,148 Province Niassa 86.7 12.4 1.0 100.0 660 Cabo Delgado 93.6 5.9 .6 100.0 1,133 Nampula 85.5 9.8 4.6 100.0 1,755 Zambézia 71.5 26.0 2.5 100.0 1,988 Tete 96.5 3.4 .1 100.0 1,132 Manica 94.3 5.0 .7 100.0 585 Sofala 93.8 5.7 .5 100.0 1,560 Inhambane 88.3 8.8 2.9 100.0 713 Gaza 94.4 1.7 3.9 100.0 724 Maputo Province 94.5 2.6 2.9 100.0 643 Maputo City 87.9 7.8 4.3 100.0 444 Age 0–11 months 89.4 9.3 1.3 100.0 2,500 12–23 months 88.7 9.8 1.5 100.0 2,433 24–35 months 86.4 11.4 2.2 100.0 2,185 36–47 months 87.0 9.8 3.3 100.0 2,205 48–59 months 87.9 9.2 2.8 100.0 2,013 Wealth index quintile Poorest 83.5 13.5 3.0 100.0 2,568 Second 88.1 10.6 1.3 100.0 2,515 Middle 89.9 9.1 1.1 100.0 2,245 Fourth 88.6 9.1 2.4 100.0 2,255 Richest 91.0 5.8 3.2 100.0 1,753 Table 5.3a shows the exclusive breastfeeding15 of children in their first six months of life (se- parately for 0–3 months and 0–5 months), as well as complementary feeding of children aged 6–9 months and continued breastfeeding of children at ages 12–15 and 20–23 months. The breastfeeding situation is based on the report of foods and fluids consumed in the 24 hours prior to the interview. The data in this Table show that 48 per cent of children under 4 months old and 37 per cent of 6-month-olds were exclusively breastfed. The prevalence of exclusive breastfeeding in the first 6 months of a child’s life is slightly higher in rural areas (38 per cent) than in urban areas (34 per cent). Among the provinces, exclusive breastfeeding in this age group varies from 53 per cent in Niassa to 14 per cent in Tete. Cabo Delgado province also has a low percentage of children under 6 months old who are exclusively breastfed (18 per cent). There are no significant differences in the rates of exclusive breastfeeding between boys under six months old (38 per cent) and girls (36 per cent). 15 Exclusive breastfeeding means children received only mother’s milk (and vitamins, mineral supplements or medicines). 22 As can be seen from Tables 5.3a and 5.3b, the products that interfere most with exclusive breastfeeding in the first three months of the child’s life are water and solid or semi-solid foods (‘pap’). Table 5.3a: Breastfeeding Percentage of children under 2 years old, by condition of breastfeeding and age in months, and by selected characteristics, Mozambique, 2008 Selected characteristics Children 0–3 months Children 0–5 months Children 6–9 months Children 12–15 months Children 20–23 months E xc lu si ve ly br ea st fe d N um be r of c hi ld re n E xc lu si ve ly B re as tfe d* N um be r of c hi ld re n R ec ei vi ng m ot he r’ s m ilk a nd s ol id /s em i- so lid fo od s ** N um be r of c hi ld re n B re as tfe d* ** N um be r of c hi ld re n B re as tfe d* ** N um be r of c hi ld re n Total 48.4 779 36.8 1,217 83.6 858 91.2 903 54.0 650 Area of residence Urban 41.7 248 34.1 375 83.7 237 85.7 266 36.7 190 Rural 51.5 532 38.0 842 83.6 622 93.4 636 61.1 460 Province Niassa (78.5) 33 (53.0) 58 (97.4) 58 (96.9) 55 (72.4) 33 Cabo Delgado 24.8 77 18.2 126 87.9 107 95.9 79 58.1 59 Nampula 52.4 145 39.5 237 77.8 155 93.5 132 69.9 91 Zambézia 58.8 122 46.8 192 79.5 152 83.7 168 38.9 106 Tete 21.6 77 14.1 118 94.7 76 99.7 84 76.7 81 Manica 48.5 38 34.0 66 86.9 28 94.1 48 49.2 40 Sofala 53.8 107 43.2 155 86.5 118 89.6 126 51.9 80 Inhambane 52.9 41 41.8 62 63.9 41 97.7 59 60.8 58 Gaza (54.3) 59 (44.9) 77 (84.9) 52 (90.7) 64 (34.2) 37 Maputo Province 48.3 43 37.4 70 82.7 37 85.5 55 30.3 43 Maputo City (45.9) 37 (32.5) 56 (77.4) 36 (77.0) 32 (13.0) 21 Sex Male 49.2 423 37.9 649 83.8 448 90.5 426 51.7 320 Female 47.4 356 35.6 568 83.5 411 91.7 477 56.1 330 Mother’s education Never went to school 47.3 234 35.0 375 85.8 269 92.2 252 70.0 199 Primary 50.7 450 38.8 707 82.2 525 92.8 579 49.5 408 Secondary + 40.0 95 31.7 135 86.2 64 74.5 72 22.9 43 Wealth index quintile Poorest 50.4 181 37.5 278 83.3 216 92.7 217 61.6 141 Second 51.8 153 40.9 248 84.9 193 94.8 187 63.6 147 Middle 47.9 150 31.3 253 83.1 186 91.6 152 59.1 121 Fourth 49.4 164 42.2 240 83.1 152 94.2 199 54.5 143 Richest 40.9 131 31.2 198 83.7 112 79.8 148 21.1 97 * MICS indicador 15 ** MICS indicador 17 *** MICS indicador 16 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). At 6–9 months, 84 per cent of children received both mother’s milk and solid or semi-solid foo- ds. Ninety-one per cent of children aged 12–15 months and 54 per cent of those aged 20–23 months continued to be breastfed. Continued breastfeeding of children aged 12–23 months is greater in rural than in urban areas. Maputo City has the lowest rates of continued breastfeeding among children aged 12–15 and 20–23 months, 77 per cent and 13 per cent, respectively. 23 Mozambique – Multiple Indicators Cluster Survey 2008 Exclusive breastfeeding up to 3 months of age is lowest among children in households in the richest quintile (41 per cent), while in the poorest quintile it is 50 per cent. Calculations based on MICS data show that the average duration of breastfeeding among three- year-old children who were not being breastfed at the moment of the survey is 18 months. Graph 5.4 compares the breastfeeding rates found in MICS 2008 with those recorded in DHS 2003. The graph shows that there has been an improvement between 2003 and 2008, since exclusive breastfeeding in the 0–3 month age group has risen from 38 per cent to 48 per cent, while in the 0–6 month age group, it rose from 30 per cent to 37 per cent. Graph 5.4: Exclusive breastfeeding among children aged 0–3 months and 0–6 months, Mozambique, 2003 and 2008 14 P er ce nt ag e 100 80 60 40 20 0 2003 (DHS) 2008 (MICS) 30 38 48 37 0 - 6 months0 - 3 months Table 5.3b and Graph 5.5 shows the detailed pattern of breastfeeding by the age of the child. The data show that the prevalence of exclusive breastfeeding declines rapidly in the first months of life, falling from 57 per cent in the first two months to 17 per cent between 4 and 5 months of age. One in every four children under 6 months of age are breastfed but also receive plain water in addition to breast milk. About 6 per cent of children under 6 months old are breastfed and also receive other liquids (apart from water and milk). 24 Table 5.3b: Breastfeeding and other specific food status, by age Percentage distribution of children under 3 years old by breastfeeding and other food status, and by age group in months, Mozambique, 2008 Selected characteristics Feeding pattern: To ta l N um be r of c hi ld re n E xc lu si ve b re as tfe ed in g B re as tfe ed in g an d pl ai n w at er o nl y B re as tfe ed in g an d liq ui ds /ju ic e B re as tfe ed in g an d ot he r m ilk B re as tfe ed in g an d co m pl em en ta ry fo od W ea ne d (n ot b re as tfe d) Total 7.2 6.7 1.8 0.9 48.0 35.4 100.0 7,109 Age 0–1 months 57.3 25.0 6.5 2.6 7.3 1.3 100.0 369 2–3 months 41.1 26.4 7.8 6.5 16.2 2.0 100.0 402 4–5 months 16.5 23.5 5.6 3.5 50.1 0.8 100.0 430 6–7 months 5.5 9.3 1.8 0.3 82.5 0.4 100.0 431 8–9 months 1.7 7.2 2.0 0.8 85.3 2.9 100.0 425 10–11 months 0.8 2.9 0.8 0.6 92.2 2.8 100.0 434 12–13 months 2.9 3.1 0.9 0.0 88.3 4.8 100.0 433 14–15 months 0.9 6.0 1.6 0.4 79.2 11.8 100.0 465 16–17 months 2.0 5.1 1.3 1.1 77.3 13.2 100.0 446 18–19 months 1.1 2.3 0.7 0.1 76.0 19.9 100.0 444 20–21 months 0.3 3.2 0.7 0.4 62.7 32.7 100.0 305 22–23 months 0.2 1.1 0.7 0.0 40.6 57.4 100.0 341 24–25 months 0.0 0.2 0.0 0.0 23.0 76.8 100.0 403 26–27 months 0.0 0.0 0.4 0.0 12.9 86.8 100.0 396 28–29 months 0.0 0.2 0.0 0.0 8.2 91.6 100.0 391 30–31 months 0.0 0.5 0.0 0.1 6.7 92.7 100.0 343 32–33 months 0.0 0.7 0.0 0.0 5.0 94.2 100.0 318 34–35 months 0.0 0.0 0.0 0.0 2.5 97.5 100.0 335 Graph 5.5: Breastfeeding and specific food status (in percentages), by age (in weeks), Mozambique, 2008 P er ce nt ag e 100 80 60 40 20 0 0 - 1 2 - 3 4 - 5 6 - 7 8 - 9 10 - 1 1 12 - 1 3 14 - 1 5 16 -17 18 - 1 9 20 - 2 1 22 - 2 3 24 - 2 5 26 - 2 7 28 - 2 9 30 - 3 1 32 - 3 3 34 - 3 5 Exclusive breastfeeding Breastfeeding and liquids/juice Breastfeeding and complementary food Breastfeeding and plain water only Breastfeeding and other milk Weaned (not breastfed) 25 Mozambique – Multiple Indicators Cluster Survey 2008 The information on how adequate their diet is in children under 12 months old is shown in Table 5.4. Different criteria are used for adequate food depending on the age of the child. For children aged 0–5 months, exclusive breastfeeding is considered the adequate diet. Children aged 6–8 months are considered adequately fed if they are receiving mother’s milk and complementary foods at least twice a day, while children aged 9–11 months are considered adequately fed if they receive mother’s milk and complementary foods at least three times a day. Table 5.4: Adequately fed children Percentage of children under 6 months old exclusively breastfed, children 6–11 months who were breastfed and received on the previous day solid/semi-solid foods at least the minimum number of times recommended per day, and children under 1 year old adequately fed, by selected characteristics, Mozambique, 2008 Selected characteristics 0– 5 m on th s, e xc lu si ve ly br ea st fe d 6– 8 m on th s, r ec ei ve d br ea st m ilk a nd c om pl em en ta ry fo od s at le as t 2 ti m es in th e pr ev io us 24 h ou rs 9– 11 m on th s, r ec ei ve d br ea st m ilk a nd c om pl em en ta ry fo od s at le as t 3 ti m es in th e pr ev io us 24 h ou rs 6– 11 m on th s, r ec ei ve d br ea st m ilk a nd c om pl em en ta ry fo od s at le as t t he m in im um n um be r of tim es r ec om m en de d pe r da y * 0– 11 m on th s, w er e ap pr op ria te ly fe d ** Number of children aged 0–11 months Total 36.8 63.6 37.1 50.6 43.9 2,509 Sex Male 34.1 64.2 37.6 52.1 42.7 718 Female 38.0 63.3 36.9 50.1 44.4 1,791 Province Niassa 53.0 70.2 73.2 71.5 64.1 144 Cabo Delgado 18.2 62.9 28.2 48.0 34.5 277 Nampula 39.5 61.9 45.4 53.4 46.4 468 Zambézia 46.8 61.9 31.3 46.2 46.5 423 Tete 14.1 76.5 34.7 53.2 33.9 239 Manica 34.0 62.6 33.0 45.1 38.9 119 Sofala 43.2 69.0 21.3 48.7 46.1 323 Inhambane 41.8 32.0 31.1 31.5 36.4 131 Gaza 44.9 64.9 37.6 50.7 47.9 157 Maputo Province 37.4 59.2 41.9 51.2 43.4 124 Maputo City 32.5 65.9 58.4 62.7 46.3 103 Area of residence Urban 37.9 62.9 37.5 50.6 44.3 1,302 Rural 35.6 64.3 36.7 50.7 43.6 1,208 Mother’s education Never went to school 35.0 67.9 31.2 48.3 42.1 797 Primary 38.8 61.8 40.1 51.5 45.4 1,482 Secondary + 31.7 61.5 43.4 53.8 40.8 230 Wealth index quintile Poorest 37.5 67.8 30.3 49.5 43.9 595 Second 40.9 62.2 40.9 51.2 46.6 558 Middle 31.3 62.1 38.2 50.7 41.4 526 Fourth 42.2 61.7 35.2 49.1 45.5 462 Richest 31.2 63.2 43.2 53.6 41.5 367 * MICS indicador 18 ** MICS indicador 19 26 As shown in Table 5.4, 37 per cent of children under 6 months old and 51 per cent of children aged 6–11 months are considered adequately fed. In general, and based on the specific nutri- tion recommendations for each age group, Table 5.4 shows that 44 per cent of children less than a year old (0–11 months of age) are adequately fed, though the percentage varies between the provinces. Tete province stands out with the lowest rate (34 per cent), followed by Cabo Delgado (35 per cent), while Niassa province has the highest rate of adequate feeding (64 per cent). Sofala province, with 21 per cent, has the lowest percentage of children aged 9–11 months who received mother’s milk and complementary foods at least the minimum number of times recommended per day. Table 5.4 also shows that the percentage of children over 6 months old who are adequately fed does not change significantly according to the wealth of the household. This may show that one of the determining factors in undernutrition, in addition to lack of means to buy food, could be insufficient or inadequate knowledge about good practices of feeding infants. Salt iodization Iodine Deficiency Disorders (IDD) are one of the main causes of preventable mental retardation and impaired psychomotor development in young children. The major problem caused by IDD, impaired mental growth and development, contributes in turn to poor school performance, re- duced intellectual ability and poor performance at work. Goitre is the most visible consequence of iodine deficiency. However, mental retardation is the most serious consequence, and is not normally very visible. In its most extreme form, iodine deficiency causes cretinism. It also incre- ases the risks of stillbirths and miscarriages in pregnant women. The most cost-effective and sustainable intervention, recommended internationally to ensure consumption of sufficient amounts of iodine, is the iodization of salt. The indicator is the percen- tage of households who consume adequately iodized salt (> 15 parts per million, or ppm). In Mozambique, all salt produced, marketed and imported for human and animal consumption must be iodized, according to Ministerial Diploma no. 7/2000. In general, the interventions to control iodine deficiency consist of16: Promoting iodization of all quality salt produced in the country; Promoting the use of iodized salt by all households and communities in general; Providing iodine supplementation for lactating women and children aged 7–24 months in the provinces with moderate iodine deficiency. The relevant MICS indicator in this area is the percentage of households who consume properly iodized salt (measured with a rapid-testing kit). The percentage of households who consume iodized salt was calculated along with the respective level of iodization (lower than or higher than 15 ppm). Table 5.5 shows that for about 93 per cent of households, the level of iodization of their kitchen salt was tested. It was found that in 58 per cent of these households, the salt was iodized to some degree (at a level either lower or higher than 15 ppm). This figure is a slight improvement over that found in 2003, when only 54 per cent of households were using iodized salt (DHS 2003). 16 According to Manual do Participante, Orientação para Introdução do Pacote Nutricional Básico ao Nível das Unidades Sanitárias Urbanas e Rurais, 3ª. Versão (Ministry of Health, 2007). v v v 27 Mozambique – Multiple Indicators Cluster Survey 2008 In 25 per cent of households, salt was found containing at least 15 ppm of iodine. But a third (33 per cent) of households were found to use salt that is iodized, but which does not contain the minimum necessary amount of iodine17. In 6 per cent of the households, salt was not available in the house at the moment of the interview. The percentage of households with adequately iodized salt (> 15 ppm) is higher in urban areas (37 per cent) than in rural areas (20 per cent). As shown in Graph 5.5, the percentage of households with adequately iodized salt is lowest in Nampula province (5 per cent) and highest in Gaza (71 per cent). Looking at iodized salt regardless of the quantity of iodine, one notes that Cabo Delgado (30 per cent), Nampula (30 per cent) and Zambézia (41 per cent) are the provinces with the lowest number of households using iodized salt, while Gaza (91 per cent), Inhambane (88 per cent) and Manica (81 per cent) are the provinces with the greatest availability of iodized salt. Table 5.5: Iodized salt consumption Percentage of households which consume adequately iodized salt, by selected characteristics, Mozambique, 2008 Selected characteristics Households in which salt was tested Number of households interviewed Percentage of households with salt test result Total Number of households in which salt was tested, or with no salt Households with no salt Not iodized 0 < 15 ppm 15+ ppm* Total 92.6 13,955 5.7 36.0 33.3 25.1 100.0 13,699 Area of Residence Urban 94.0 4,338 4.3 26.3 32.5 36.9 100.0 4,262 Rural 91.9 9,617 6.3 40.3 33.6 19.7 100.0 9,438 Province Niassa 86.7 833 11.5 14.3 29.0 45.2 100.0 816 Cabo Delgado 90.7 1,512 7.9 62.0 21.8 8.3 100.0 1,487 Nampula 88.8 2,568 6.7 63.8 24.8 4.7 100.0 2,445 Zambézia 95.6 2,532 4.0 54.5 32.2 9.2 100.0 2,523 Tete 92.6 1,281 6.7 26.0 49.0 18.3 100.0 1,272 Manica 92.5 627 7.0 11.7 51.9 29.3 100.0 624 Sofala 97.8 1,108 2.0 17.3 45.7 35.0 100.0 1,106 Inhambane 92.6 946 4.8 6.8 52.5 35.9 100.0 920 Gaza 92.3 845 6.2 2.4 20.8 70.6 100.0 831 Maputo Province 94.3 952 3.8 19.0 29.1 48.1 100.0 933 Maputo City 96.0 751 2.8 13.1 26.5 57.6 100.0 741 Wealth index quintile Poorest 91.3 2,866 7.4 47.6 33.4 11.6 100.0 2,826 Second 91.5 3,029 6.6 45.9 32.4 15.0 100.0 2,965 Middle 91.7 2,975 6.4 38.0 35.6 20.0 100.0 2,916 Fourth 93.1 2,630 5.0 25.7 34.9 34.5 100.0 2,576 Richest 96.0 2,455 2.5 18.7 29.5 49.4 100.0 2,416 *MICS indicator 41 17 Iodized salt is considered adequate when the concentration of iodine is above 15 parts per million (15 ppm). 28 Graph 5.6: Consumption of iodized salt, by province, Mozambique, 2008 70 80 90 100 60 50 40 30 20 10 0 assaiN odagleDobaC alupmaN aizébmaZ eteT acinaM alafoS enabmahnI azaG ecnivorPotupaM latoT Households without salt Salt not iodized 0 < 15 PPM 15+ PPM Ma pu to Cit y The availability of adequately iodized salt (15+ ppm) varies significantly in relation to the wealth quintile of the household (Graph 5.7). It was found that 79 per cent of households in the richest quintile consume iodized salt (regardless of the amount of iodine), in comparison with only 45 per cent in the poorest quintile. Graph 5.7: Consumption of iodized salt, by level of household wealth, Mozambique, 2008 P er ce nt ag e 48 12 49 33 26 Not iodized 0 < 15 PPM 15+ PPM 15 35 46 38 20 19 32 36 34 29 80 70 60 50 40 30 20 10 0 Poorest Second Middle Fourth Richest Vitamin A supplements Vitamin A is essential for the health of the eyes and for adequate functioning of the immune system18. The need for vitamin A increases as children grow or during periods of illness. 18 It is found in foods such as milk, liver, eggs, red- and orange-coloured fruits, red palm oil and dark green leafy vegetables, although the amount of vitamin A readily available to the body from vegetable sources varies widely. 29 Mozambique – Multiple Indicators Cluster Survey 2008 The World Summit on children held in 1990 set the objective of the virtual elimination of vitamin A deficiency and its consequences, including blindness, by about 200019. The critical role of vitamin A for child health and for strengthening the immune system means that controlling de- ficiency in this vitamin is a primary component in child survival efforts and is thus fundamental for achieving the fourth Millennium Development Goal: that of reducing under-five mortality by two thirds by 2015. Based on the directives of UNICEF/WHO, the Mozambican Ministry of Health recommends that all children aged 6–59 months should receive a high-dose vitamin A supplement twice a year. The vitamin A supplement has been distributed to all eligible children through routine health ser- vices in Health Units and through the Integrated Brigades for the Communities since 2002, and also during national child health weeks, which have been held twice a year since 2008. Vitamin A is also administered to all women who have given birth within 4–6 weeks after the bir- th, to compensate for vitamin A requirements during pregnancy and to ensure that the mother’s milk contains sufficient vitamin A. In the six months prior to the survey, 72 per cent of children aged 6–59 months had received a high-dose vitamin A supplement. This broke down into 78 per cent in urban areas and 69 per cent in rural areas (Table 5.6). All the provinces have vitamin A supplementation coverage in excess of 60 per cent. The coverage is above 80 per cent in Manica (85 per cent) and Sofala (81 per cent) and is lowest in Tete (61 per cent) and Zambézia (62 per cent). Analysis of vitamin A supplementation according to age pattern shows that in the six months prior to the survey, it increased from 75 per cent among children aged 6–11 months to 80 per cent in children aged 12–23 months, then declined regularly with age among older children. There is a relationship between the mother’s level of education and the likelihood of vitamin A supplementation. Eighty-five per cent of children whose mothers attended secondary education or higher received the vitamin A supplement, in comparison with 64 per cent of those whose mo- thers did not go to school. The percentage of children who received the supplement in the last six months also increases with the level of wealth of the household, since the children with the highest percentage are those living in households in the richest wealth quintile (81 per cent). 19 This objective was also approved at the Conference on the Elimination of Hidden Hunger, held in 1991; the International Conference on Nutrition of 1992; and the Special Session of the United Nations General Assembly, held in 2002. 30 Table 5.6: Children who received vitamin A supplements Percentage distribution of children aged 6–59 months, by whether they received a vitamin A supplement during the 6 months prior to the survey, and by selected characteristics, Mozambique, 2008 Selected characteristics Children who: Total Received vitamin A in the last 6 months* Did not receive vitamin A in the last 6 months Are not certain when or whether they received it Total Number of children Total 71.5 27.8 0.7 100.0 10,202 Area of residence Urban 77.7 21.4 0.8 100.0 2,868 Rural 69.0 30.3 0.7 100.0 7,334 Province Niassa 73.0 25.8 1.2 100.0 606 Cabo Delgado 72.7 26.2 1.1 100.0 1,010 Nampula 67.6 31.3 1.1 100.0 1,534 Zambézia 62.3 37.2 0.4 100.0 1,803 Tete 60.9 38.9 0.1 100.0 1,016 Manica 84.9 15.0 0.1 100.0 521 Sofala 81.3 18.4 0.3 100.0 1,420 Inhambane 79.5 19.8 0.6 100.0 654 Gaza 70.3 28.2 1.4 100.0 658 Maputo Province 77.5 20.8 1.7 100.0 585 Maputo City 76.2 23.2 0.6 100.0 397 Sex Male 72.5 26.8 0.6 100.0 5,009 Female 70.4 28.7 0.9 100.0 5,191 NA * * * 100.0 2 Age 6–11 months 74.7 25.1 0.2 100.0 1,292 12–23 months 80.2 19.6 0.2 100.0 2,449 24–35 months 73.9 25.1 1.0 100.0 2,207 36–47 months 64.5 34.5 1.1 100.0 2,232 48–59 months 63.8 35.2 1.1 100.0 2,021 Mother’s education Never went to school 64.1 35.0 0.9 100.0 3,355 Primary 74.0 25.3 0.7 100.0 6,155 Secondary + 84.5 14.7 0.8 100.0 690 No reply/don’t know * * * 100.0 3 Wealth index quintile Poorest 61.7 37.7 0.6 100.0 2,297 Second 69.7 29.2 1.1 100.0 2,275 Middle 73.7 26.0 0.3 100.0 2,002 Fourth 74.7 24.4 0.9 100.0 2,027 Richest 81.0 18.2 0.8 100.0 1,602 * MICS indicator 42 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 31 Mozambique – Multiple Indicators Cluster Survey 2008 Table 5.7: Post-partum vitamin A supplementation Percentage of women aged 15–49 with at least one birth in the two years preceding the survey who received a high-dose vitamin A supplement before the infant was 8 weeks old, by selected characteristics, Mozambique, 2008 Selected characteristics Received vitamin A supplement* Not sure if received vitamin A Number of women Total 65.6 2.7 5,191 Area of residence Urban 73.2 3.5 1,493 Rural 62.5 2.3 3,698 Province Niassa 74.0 4.3 318 Cabo Delgado 76.6 .6 527 Nampula 64.3 3.8 895 Zambézia 57.0 2.3 912 Tete 62.3 4.2 535 Manica 73.9 1.0 260 Sofala 71.9 1.1 638 Inhambane 68.3 2.2 312 Gaza 54.8 2.0 325 Maputo Province 59.7 5.3 277 Maputo City 66.4 2.7 191 Mother’s education Never went to school 58.9 3.5 1,624 Primary 68.0 2.2 3,086 Secondary + 72.6 3.3 439 No reply/don’t know (69.6) (1.1) 42 Wealth index quintile Poorest 57.4 1.8 1,209 Second 63.4 2.7 1,144 Middle 69.2 2.9 1,041 Fourth 69.1 3.4 1,018 Highest 71.8 2.7 778 * MICS indicator 43 Percentages in parentheses are based on 25–49 unwighted cases. Percentages based on less than 25 unweighted cases are not shown (*). As Table 5.7 shows, about two thirds (66 per cent) of women who had a live birth in the two ye- ars prior to MICS received vitamin A supplements within 8 weeks after the birth. The percentage is higher in urban zones (73 per cent) than in rural areas (63 per cent). As for the provinces, the percentage is lowest in Gaza (55 per cent) and highest in Cabo Delgado (77 per cent). The coverage rates of vitamin A supplementation increase with a rise in the mother’s level of education and in the level of household wealth. Low birthweight A baby’s weight at birth is a good indicator of its mother’s health and nutritional status and also of the newborn’s chances for survival, growth and long-term health. Low birthweight may be caused by reduced growth in the uterus (intrauterine growth retardation) or by premature birth (before 37 weeks of gestation). It is generally assumed that, in developing countries, most ca- ses of low birthweight are related to intrauterine growth retardation. Low birthweight (less than 2,500 grams) causes serious health risks to the child, including an added risk of dying during the early months or years of life, and of having impaired immune functions and a high risk of dise- 32 ase. The babies are likely to remain undernourished, with reduced muscle strength throughout their lives. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance at school and their job opportunities as adults. Low birthweight is caused, more than anything else, by the poor health and nutrition of the mo- ther. The factors of greatest impact are poor nutritional status before conception and deficient nutrition during pregnancy. The level of micronutrients (specifically iron and zinc) consumed and the weight gained during pregnancy are particularly important. Furthermore, conditions such as infestation by parasites, diarrhoea, malaria and frequent heavy physical work (such as carrying heavy items) could cause significant difficulties for foetal growth if they occur during pregnancy. The fact that a considerable percentage of babies are not weighed at birth is one of the main challenges in measuring the incidence of low birthweight. Since the children who are weighed may be a biased sample of all births, the weights reported at birth cannot normally be used to estimate the prevalence of low birthweight among all children. Thus, the percentage of babies born weighing less than 2,500 grams is estimated in two ways from the questionnaire: the mother’s assessment of the size of the child at birth (that is, very small, smaller than average, average, larger than average, very large), and the mother’s recollection of the child’s weight, or the weight recorded on the health card, if the child was weighed at birth.20 Fifty-eight per cent of babies were weighed at birth, and it was estimated that 16 per cent wei- ghed less than 2,500 grams (Table 5.8). There are no very significant variations between the provinces (Graph 5.8), since the percentage of underweight children varies from 15 per cent in Tete to 19 per cent in Gaza. The low birthweight percentage does not vary much between urban and rural areas, or in line with the mother’s education. As for the level of wealth, the percentage of newborn infants weighing less than 2,500 grams is 14 per cent among families in the richest quintile and 16 per cent among households in the poorest quintile. 20 For a more detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 33 Mozambique – Multiple Indicators Cluster Survey 2008 Table 5.8: Low birthweight Percentage of live births in the two years prior to the survey who weighed less than 2,500 grams at birth, by selected characteristics, Mozambique, 2008 Selected characteristics Percentage of live births weighing less than 2,500 grams * Percentage of live births weighed at birth ** Number of live births Total 16.0 58.3 5,191 Area of residence Urban 15.8 83.0 1,493 Rural 16.1 48.3 3,698 Province Niassa 15.4 69.0 318 Cabo Delgado 15.7 46.9 527 Nampula 17.5 64.6 895 Zambézia 16.3 38.9 912 Tete 14.5 36.2 535 Manica 14.7 58.1 260 Sofala 14.5 68.4 638 Inhambane 16.0 56.2 312 Gaza 18.6 67.0 325 Maputo Province 15.6 94.5 277 Maputo City 15.6 98.2 191 Mother’s education Never went to school 16.1 41.5 1,624 Primary 16.0 62.3 3,086 Secondary + 15.6 92.6 439 No reply/don’t know (16.7) (51.1) 42 Wealth index quintile Poorest 16.3 39.8 1,209 Second 15.5 47.1 1,144 Middle 16.3 53.8 1,041 Fourth 16.9 70.0 1,018 Richest 14.4 93.8 778 * MICS Indicator 9 ** MICS Indicator 10 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). Graph 5.8: Live births weighing less than 2,500 grams, Mozambique, 2008 N ia ss a C ab o D el ga do N am pu la Za m bé zi a Te te M an ic a S of al a In ha m ba ne G az a M ap ut o M ap ut o C ity P er ce nt ag e 15 16 18 16 14 15 15 16 19 16 16 25 20 15 10 5 34 VI. Child health Child immunization The fourth Millennium Development Goal (MDG) is to reduce child mortality by two thirds be- tween 1990 and 2015. Vaccination is an essential component of this reduction. One of the ob- jectives of A World Fit for Children is to ensure that, at the national level, 90 per cent of children under five are fully immunized, with at least 80 per cent coverage in each district or equivalent administrative unit. In Mozambique, the Ministry of Health has introduced and institutionalized the RED (Reaching Every District) strategy. Making this approach operational and expanding it to cover all 148 districts of Mozambique by 2012 will guarantee that every eligible child and mother benefit from immunization and other interventions for maternal and child survival. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination for pro- tection against tuberculosis; three doses of (DPT)HB against diphtheria, pertussis, tetanus and hepatitis B; three doses of polio vaccine; and vaccination against measles, all by the age of 12 months. The information about what immunizations a child had actually received was obtained in two ways: if the child had a health card, all the dates of vaccinations recorded on it were copied down, and then the interviewees were asked about vaccines that the child had received but which were not on the card, and these too were noted. In cases where no health card was presented, the mothers/caregivers were asked about the vaccinations received. Overall, 85 per cent of the children had health cards (Table 6.2). The percentage of children aged 12–23 months who received each vaccine is shown in Table 6.1. So that only children old enough to be completely vaccinated are counted, the denominator used in this table is the total number of children aged 12–23 months. In the panel above, the numerator includes all children who were vaccinated at any moment before the survey, according to the vaccination card or the mother’s report. On the panel below, only those who were vaccinated before their first birthday are included, as recommended. As for children without vaccination cards, the information given by the mother or by the person looking after the child is used. About 87 per cent of children aged 12–23 months had received a BCG vaccination by the age of 12 months, and the same percentage of children had received the first dose of DPT (Table 6.1). For subsequent doses of DPT, the percentage drops to 81 per cent for the second dose and 70 per cent for the third (Graph 6.1). Likewise, 86 per cent of children received the first dose of polio vaccine before the age of 12 months, but the number falls to 70 per cent for the third dose. The coverage of measles vaccination before 12 months of age is lower than for the other vaccines, at 64 per cent. It is important to note that the measles vaccination coverage is in line with the average for countries of sub-Saharan Africa. However, the percentage of children who had received all the recommended vaccinations by their first birthday is low, at 48 per cent. 35 Mozambique – Multiple Indicators Cluster Survey 2008 Graph 6.1: Rate of immunization before 12 months of age, by dose and type of vaccine, Mozambique, 2008 B C G D P T 1 D P T 2 D P T 3 P ol io 0 P ol io 1 P ol io 2 P ol io 3 M ea sl es A ll P er ce nt ag e 87 87 81 70 67 86 80 69 64 48 100 90 80 70 60 50 40 30 20 10 Table 6.1: Vaccination in the first year of life Percentage of children aged 12–23 months who received specific vaccines, according to information provided by the vaccination card or by the mother, Mozambique, 2008 B C G * D P T 1 D P T 2 D P T 3 * ** P ol io 0 P ol io 1 P ol io 2 P ol io 3 * * M ea sl es ** ** A ll* ** ** N on e Number of children Health card 78.1 79.2 77.3 71.2 61.8 79.1 77.4 71.3 65.8 59.0 2.6 2,449 Information from the mother 9.3 8.8 6.0 2.9 5.3 8.2 4.5 2.1 8.3 1.2 6.2 2,449 Any 87.5 88.1 83.3 74.1 67.1 87.3 81.9 73.3 74.1 60.3 8.8 2,449 Immunized before 12 months of age 86.7 86.9 81.4 70.4 67.1 86.2 80.1 69.5 63.9 48.3 8.9 2,449 * MICS indicador 25 ** MICS indicador 26 *** MICS indicador 27 **** MICS indicador 28; MDG indicador 4.3 ***** MICS indicador 31 Table 6.2 shows the rates of vaccination coverage among children aged 12–23 months who re- ceived the vaccines at any moment up to the date of the survey (even after they were 12 months old). Eighty-eight per cent of the children aged 12–23 months received a BCG vaccination and the first dose of DPT. The percentage receiving the subsequent doses of DPT fell to 83 per cent for the second dose and 74 per cent for the third. Likewise, 87 per cent of children received the first dose of polio vaccine, but the number for the following doses fell, to 82 per cent for the se- cond dose and 73 per cent for the third dose. Measles vaccination coverage is rather lower than that for other vaccines, at 74 per cent. The percentage of children aged 12–23 months who re- ceived all the vaccines at any moment up to the date of the survey (the complete immunization rate) is 60 per cent. It is above 80 per cent in Maputo province and Maputo City, and lower than 50 per cent in the provinces of Zambézia (48 per cent) and Tete (34 per cent) (Graph 6.3). Children living in urban areas of the country have a greater probability of being vaccinated than those who live in rural areas. Fifty-five per cent of children aged 12–23 months who live in rural areas received all the vaccines, compared with 74 per cent of those who live in urban areas. Eleven per cent of children in rural areas did not receive any vaccines, compared with 4 per cent 36 in urban areas. This latter figure also includes children for whom no information is available, either from their health card or from their mother or other person looking after the child. As Graph 6.2 shows, immunization rates at 12 months of age have increased over the decade. The rate of immunization against polio has increased the most, from 54 per cent in 1997 to 70 per cent in 2008. In comparison, there was a lesser increase in the BCG vaccination rate, from 78 per cent in 1997 to 87 per cent in 2008. For all the specific vaccines, the increases in vacci- nation coverage recorded in the 1997–2003 period were greater than those recorded between 2003 and 2008. Graph 6.2: Rate of immunization at 12 months of age among children aged 12–23 months, Mozambique, 1997, 2003 and 2008 14 P er ce nt ag e 100 80 60 40 20 0 1997 (DHS) 2003 (DHS) 2008 (MICS) 78 86 BCG DPT 3 Polio 3 Measles 87 58 55 67 63 70 64 70 54 Graph 6.3: Percentage of children aged 12–23 months who were vaccinated at any moment prior to the date of the survey, by area of residence and province, Mozambique, 2008 60Total AREA OF RESIDENCE Urban Rural PROVINCE Niassa Cabo Delgado Nampula Zambézia Tete Manica Sofala Inhambane Gaza Maputo Province Maputo City Percentage 74 55 56 70 51 48 34 58 72 80 74 82 82 10 20 30 40 50 60 70 80 90 37 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.2: Vaccination in the first year of life Percentage of children aged 12–23 months who received specific vaccines, according to information provided by the vaccination card or by the mother, by selected characteristics, Mozambique, 2008 Selected characteristics B C G D P T 1 D P T 2 D P T 3 P ol io 0 P ol io 1 P ol io 2 P ol io 3 M ea sl es A ll N on e P er ce nt ag e w ith h ea lth ca rd N um be r of ch ild re n Total 87.5 88.1 83.3 74.1 67.1 87.3 81.9 73.3 74.1 60.3 8.8 84.7 2,449 Area of residence Urban 93.0 92.5 91.2 85.9 82.3 92.6 90.5 85.1 85.8 74.3 4.2 89.7 681 Rural 85.4 86.4 80.3 69.6 61.2 85.3 78.6 68.8 69.6 54.9 10.6 82.8 1,768 Province Niassa 91.3 86.2 84.3 74.9 68.1 85.4 83.0 75.4 74.9 56.4 4.4 84.3 157 Cabo Delgado 93.2 96.4 96.5 88.2 71.7 96.8 96.7 86.9 83.8 70.5 1.1 96.3 243 Nampula 82.2 82.4 77.3 63.5 65.5 78.5 71.8 63.0 67.0 51.4 13.0 77.1 360 Zambézia 75.1 77.3 70.2 61.7 43.0 75.7 68.8 60.2 61.7 47.6 20.2 77.2 436 Tete 83.0 85.0 69.9 55.5 43.0 84.7 67.8 54.0 60.0 34.2 10.4 75.1 269 Manica 87.8 88.4 84.4 75.4 75.8 88.3 82.7 72.8 69.2 58.3 9.1 84.4 130 Sofala 93.7 94.2 90.9 81.2 74.9 94.6 91.3 81.3 82.9 72.3 4.5 89.2 313 Inhambane 98.3 96.1 92.9 90.5 88.5 98.3 95.5 91.3 86.9 79.8 1.0 95.7 159 Gaza 97.3 98.4 96.8 89.4 92.8 97.7 95.1 89.9 83.4 73.9 1.1 92.3 150 Maputo Province 90.1 89.2 89.7 87.4 86.0 89.6 89.5 87.2 87.4 81.9 8.0 91.5 148 Maputo City 97.7 96.7 96.1 89.5 95.4 96.5 92.8 86.2 93.0 81.9 2.3 90.1 87 Sex Male 87.7 88.0 83.7 74.4 67.7 87.4 82.8 74.5 75.1 61.0 8.3 84.5 1,194 Female 87.2 88.1 83.0 73.8 66.5 87.2 81.0 72.2 73.1 59.5 9.2 84.8 1,255 Mother’s education Never went to school 85.4 84.9 79.2 66.5 58.5 84.0 77.0 65.4 66.2 53.1 11.7 80.5 748 Primary 87.6 88.9 84.1 75.8 68.8 88.3 83.0 75.6 76.4 61.7 7.9 86.3 1,528 Secondary + 94.9 94.3 94.4 91.7 89.1 92.8 93.3 87.2 87.0 78.5 4.2 88.7 174 Wealth index quintile Poorest 80.1 81.8 74.5 59.4 48.8 80.4 72.0 58.6 62.0 47.2 15.0 78.1 585 Second 83.6 84.4 77.8 67.2 56.5 83.3 75.3 66.7 66.3 50.6 11.4 81.4 544 Middle 88.6 88.1 86.1 79.1 67.3 88.7 85.6 78.2 77.9 61.9 7.2 87.0 443 Fourth 95.0 94.3 89.5 83.3 83.8 92.8 89.1 82.7 81.4 70.7 3.9 89.3 511 Richest 93.0 94.5 93.8 88.9 88.3 94.9 92.9 87.7 89.8 78.8 3.6 90.9 366 Tetanus toxoid One of the strategies to reduce the maternal mortality rate by three quarters (MDG 5) is the elimination of maternal tetanus. A further goal is to reduce the incidence of neonatal tetanus to less than one case per 1,000 live births in every district. Maternal and neonatal tetanus is prevented by ensuring that all pregnant women receive at least two doses of tetanus toxoid vaccine. Women are also considered as protected if the follo- wing conditions are met: Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years Received at least three doses, the last within the previous 5 years Received at least four doses, the last within the previous 10 years Received at least five doses during the woman’s lifetime. v v v v 38 Table 6.3 shows the tetanus protection status among women who had a live birth in the previous 24 months. In all, 79 per cent of these women were protected against tetanus. Most of them (67 per cent) were protected because they had received at least two doses of tetanus toxoid vacci- ne during their most recent pregnancy. 11 per cent were protected because they had received at least two doses of the vaccine, the latest within the previous three years. The percentage of women who had a live birth in the previous 24 months who are protected against tetanus is higher in urban areas (84 per cent) than in rural areas (77 per cent). The coverage rates by province vary from 65 per cent in Zambézia to 95 per cent in Gaza. The co- verage rate increases in line with the education of the mothers, and reaches 85 per cent among mothers with secondary education or higher. Table 6.3: Neonatal protection against tetanus Percentage distribution of mothers who had at least one birth in the previous 24 months protected against neonatal tetanus, by the number of doses received, and by selected characteristics, Mozambique, 2008 Selected characteristics R ec ei ve d at le as t 2 do se s du rin g th e la te st p re gn an cy R ec ei ve d at le as t 2 do se s in th e la st 3 ye ar s R ec ei ve d at le as t 2 do se s in th e la st 5 ye ar s R ec ei ve d at le as t 4 do se s in th e la st 10 y ea rs R ec ei ve d at le as t 5 do se s du rin g lif et im e P ro te ct ed a ga in st te ta nu s * N um be r of m ot he rs Total 66.5 10.6 1.4 0.8 0.1 79.3 5,191 Area of Residence Urban 70.6 11.5 1.0 0.9 0.1 84.0 1,493 Rural 64.9 10.2 1.5 0.8 0.0 77.4 3,698 Province Niassa 81.5 2.7 0.4 0.1 0.2 84.9 318 Cabo Delgado 58.5 19.5 3.1 1.4 0.0 82.5 527 Nampula 68.3 7.3 0.1 0.0 0.0 75.7 895 Zambézia 60.3 4.5 0.1 0.0 0.0 65.0 912 Tete 64.0 12.5 1.1 0.3 0.0 77.9 535 Manica 69.4 14.2 1.8 0.2 0.2 85.8 260 Sofala 66.2 10.9 1.6 0.0 0.0 78.7 638 Inhambane 78.0 9.1 0.4 0.8 0.3 88.5 312 Gaza 58.7 19.7 7.8 8.2 0.2 94.6 325 Maputo Province 72.1 11.6 1.0 0.9 0.0 85.6 277 Maputo City 75.0 16.8 0.8 0.3 0.0 92.9 191 Age 15–19 71.4 6.6 0.2 0.0 0.0 78.1 799 20–24 72.3 11.2 0.7 0.2 0.0 84.4 1,434 25–29 61.7 12.8 2.2 0.8 0.0 77.5 1,275 30–34 63.2 12.0 2.0 1.8 0.2 79.1 849 35–39 63.9 8.6 1.6 1.3 0.2 75.7 574 40–44 57.1 7.6 2.6 3.6 0.2 71.1 176 45–49 64.3 8.4 0.0 0.0 0.0 72.7 84 Mother’s education Never went to school 63.3 10.5 1.3 0.4 0.0 75.5 1,624 Primary 67.2 10.6 1.5 1.0 0.1 80.3 3,086 Secondary + 72.1 11.4 0.7 0.9 0.1 85.3 439 No answer/don’t know (81.3) (5.0) (0.0) (0.0) (0.0) (86.3) 42 Wealth index quintile Poorest 63.7 8.0 0.8 0.0 0.0 72.5 1,209 Second 64.3 10.7 0.8 0.3 0.1 76.1 1,144 Middle 69.9 8.9 1.6 0.8 0.1 81.3 1,041 Fourth 66.5 12.1 2.6 1.7 0.1 83.0 1,018 Richest 69.7 14.5 1.2 1.6 0.0 87.0 778 * MICS indicator 32 Percentages in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 39 Mozambique – Multiple Indicators Cluster Survey 2008 Graph 6.4: Percentage of women who had at least one birth in the last 24 months and were protec- ted against neonatal tetanus, Mozambique, 2008 79Total AREA DE RESIDENCE Urban Rural PROVINCE Niassa Cabo Delgado Nampula Zambézia Tete Manica Sofala Inhambane Gaza Maputo Province Maputo City Percentage 84 77 85 82 76 65 78 86 79 88 95 86 93 10 20 30 40 50 60 70 80 90 100 Oral rehydration treatment In Mozambique, diarrhoea is among the main causes of death in children under five21. Most diarrhoea-related deaths of children are caused by dehydration due to the loss of large amounts of water and electrolytes from the body through liquid faeces. Diarrhoea management – whether through oral rehydration salts (ORS) or through a recommended home-made fluid – can prevent many of these deaths. Increasing the intake of fluids and continuing to feed the child to prevent dehydration and undernutrition are also important strategies for managing diarrhoea. The international objectives are: 1) to reduce by half the number of deaths due to diarrhoea in children under five by 2010 compared with 2000 (A World Fit for Children); and 2) to reduce by two thirds the mortality rate among children under five by 2015 compared with 1990 (Millennium Development Goals). In addition, A World Fit for Children calls for a 25 per cent reduction in the incidence of diarrhoea. The indicators are: Prevalence of diarrhoea Oral rehydration therapy (ORT) Home management of diarrhoea ORT (or increased fluids) and continued feeding. 21 Intestinal infectious diseases are responsible for about 7 per cent of deaths among children under five. (Estudo nacional sobre a morta- lidade infantil, Ministry of Health, 2009). v v v v 40 In the MICS questionnaire, mothers (or caregivers) were asked to report whether the child had had diarrhoea in the two weeks prior to the survey. They were 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, 18 per cent of children under five had diarrhoea in the two weeks preceding the survey (Table 6.4). Diarrhoea prevalence was almost the same in all provinces, but the lowest rate was in Niassa, with 13 per cent. Nampula had the highest percentage of children with diarrhoea (23 per cent). The peak of diarrhoea prevalence occurs in the weaning period, reaching 32 per cent among children aged 6–11 months and 29 per cent among those aged 12–23 months. Table 6.4 also shows the percentage of children receiving various types of recommended liquids during the diarrhoea episode. Some mothers used more than one type of liquid, so the percen- tages do not necessarily add up to 100. About 38 per cent of children received fluids made with ORS, 15 per cent received pre-packaged (commercial) ORS fluids, and 19 per cent received recommended home-made fluids. About 54 per cent of children with diarrhoea received ORT, which means they received ORS or recommended home-made fluids, while 46 per cent did not receive adequate treatment. The rate of ORT use is similar in the urban areas (56 per cent) and in the rural areas (53 per cent). Among the provinces, Sofala recorded the highest rate of use (76 per cent) while Cabo Delgado recorded the lowest rate (44 per cent). The ORT use rate is higher among mothers who attended secondary or higher levels of education (61 per cent) than among those who did not go to school (53 per cent). The ORT use rate is also positively correlated with the level of household wealth. 41 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.4: Oral rehydration treatment Percentage of children aged 0–59 months who had diarrhoea in the last two weeks and received treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), by selected characteristics, Mozambique, 2008 Selected characteristics H ad d ia rr ho ea in th e la st tw o w ee ks N um be r of c hi ld re n O R S fl ui d R ec om m en de d ho m e- m ad e m ix tu re P re -p ac ka ge d O R S fl ui d (a cq ui re d at a p ha rm ac y) N o tr ea tm en t r ec ei ve d R at e of O R T u se * N um be r of c hi ld re n Total 17.6 11,419 37.9 18.8 15.1 46.1 53.9 2,008 Area of residence Urban 18.4 3,243 39.1 21.3 18.3 43.7 56.3 597 Rural 17.3 8,176 37.4 17.8 13.7 47.1 52.9 1,411 Province Niassa 12.8 663 54.3 7.0 33.0 33.0 67.0 85 Cabo Delgado 18.3 1,136 33.4 15.4 3.9 56.1 43.9 208 Nampula 22.9 1,771 39.2 13.3 13.8 54.6 45.4 406 Zambézia 16.5 1,996 24.5 17.4 13.8 52.9 47.1 330 Tete 18.0 1,134 40.3 19.6 1.9 43.8 56.2 204 Manica 16.0 587 40.3 20.1 11.8 37.9 62.1 94 Sofala 15.7 1,575 52.7 43.8 39.0 24.4 75.6 248 Inhambane 15.6 716 30.1 19.2 12.2 46.5 53.5 112 Gaza 19.4 735 47.9 5.2 4.9 45.2 54.8 143 Maputo Province 15.7 655 29.8 13.2 18.0 51.4 48.6 103 Maputo City 17.0 453 29.6 24.8 18.6 38.1 61.9 77 Sex Male 17.3 5,658 38.3 19.6 14.8 44.7 55.3 981 Female 17.8 5,759 37.5 18.1 15.3 47.3 52.7 1,027 Age < 6 months 11.6 1,217 27.2 7.3 4.5 66.6 33.4 141 6–11 months 32.0 1,292 38.7 13.6 9.4 49.1 50.9 414 12–23 months 28.6 2,449 43.1 19.4 14.0 41.9 58.1 700 24–35 months 17.5 2,207 36.6 19.8 20.2 42.3 57.7 385 36–47 months 9.7 2,232 32.3 25.7 18.2 47.5 52.5 216 48–59 months 7.5 2,021 33.3 29.1 28.2 45.4 54.6 152 Mother’s education Never went to school 17.2 3,730 37.4 18.3 14.8 47.2 52.8 641 Primary 17.8 6,861 37.7 18.9 14.6 46.3 53.7 1,224 Secondary + 17.4 825 41.7 20.8 20.2 39.1 60.9 143 No reply/don’t know * 3 . . . . . 0 Wealth index quintile Poorest 18.2 2,574 32.3 16.2 12.7 52.1 47.9 469 Second 16.8 2,523 36.5 20.0 13.7 48.2 51.8 423 Middle 19.4 2,255 38.7 19.8 15.4 45.2 54.8 438 Fourth 17.0 2,267 44.1 19.4 15.6 41.3 58.7 385 Richest 16.3 1,799 39.6 19.2 19.9 40.9 59.1 293 * MICS Indicator 33 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 42 Graph 6.5: Percentage of children aged 0–59 months who had diarrhoea and received oral rehydra- tion treatment (ORT), Mozambique, 2008 Total AREA OF RESIDENCE Urban Rural SEX Male Female AGE < 6 months 6 - 11 months 12 - 23 months 24 - 35 months 36 - 47 months 48 - 59 months MOTHER´S EDUCATION Never went to school Primary Secondary + Percentage 54 56 53 55 53 33 51 58 52 55 53 54 61 10 20 30 40 50 60 70 58 As for feeding practices during diarrhoea, 23 per cent of children with diarrhoea received more liquids than usual, and 75 per cent received the same or less (Table 6.5). Seventy-five per cent ate somewhat less, the same or more than usual (continued feeding); and less than a quarter (23 per cent) of the children ate much less or ate nothing. Only 2 per cent of children with diarrhoea in Niassa province and 4 per cent in Nampula were given more liquids than usual. For Sofala, the figure is above 50 per cent, and it is the only pro- vince with figures this high. Also in Table 6.5, one notes that almost half (47 per cent) of the children who had diarrhoea received ORT, or more fluids than usual, and at the same time kept on feeding. Among the provinces, Nampula, with 27 per cent, had the lowest percentage of children aged 0–59 months who received both oral rehydration treatment and increased food. About 20 per cent of children with diarrhoea benefited from home management of diarrhoea. As the age of the child increases, the likelihood of correct management at home also increases. In about a third of children aged 48–59 months, the diarrhoea was managed correctly at home, while for children under a year old the figure is 12 per cent. 43 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.5: Home management of diarrhoea Percentage of children aged 0–59 months who had diarrhoea in the two weeks prior to the survey, and who took increased liquids and continued to feed during the episode, by selected characteristics, Mozambique, 2008 Selected characteristics H ad d ia rr ho ea in th e la st tw o w ee ks N um be r of c hi ld re n 0– 59 m on th s C hi ld re n w ith d ia rr ho ea w ho d ra nk m or e liq ui ds C hi ld re n w ith d ia rr ho ea w ho d ra nk th e sa m e am ou nt o f o r le ss li qu id s C hi ld re n w ith d ia rr ho ea w ho a te so m ew ha t l es s, th e sa m e, o r m or e fo od C hi ld re n w ith d ia rr ho ea w ho a te m uc h le ss o r no fo od H om e m an ag em en t o f d ia rr ho ea * R ec ei ve d O R T o r flu id s an d in cr ea se d fo od * * N um be r of c hi ld re n 0 –5 9 m on th s w ith d ia rr ho ea Total 17.6 11,419 23.4 74.8 75.3 22.8 19.6 46.9 2,008 Area of residence Urban 18.4 3,243 27.4 70.9 79.1 19.9 24.0 51.1 597 Rural 17.3 8,176 21.7 76.5 73.7 24.1 17.7 45.1 1,411 Province Niassa 12.8 663 2.4 88.8 78.1 15.5 2.4 58.8 85 Cabo Delgado 18.3 1,136 26.7 72.4 74.8 24.2 21.1 35.4 208 Nampula 22.9 1,771 3.9 91.7 53.6 41.8 3.1 27.1 406 Zambézia 16.5 1,996 16.4 82.8 71.8 27.2 10.6 37.9 330 Tete 18.0 1,134 13.0 87.0 87.2 12.8 12.7 52.7 204 Manica 16.0 587 14.6 85.1 83.6 16.1 14.3 54.1 94 Sofala 15.7 1,575 59.8 39.2 93.8 5.4 58.9 77.3 248 Inhambane 15.6 716 32.7 65.4 77.6 20.2 25.4 51.6 112 Gaza 19.4 735 35.8 64.2 78.4 21.6 24.8 51.3 143 Maputo Province 15.7 655 35.2 64.8 84.6 13.1 25.3 53.5 103 Maputo City 17.0 453 39.7 59.6 80.3 19.0 32.7 62.3 77 Sex Male 17.3 5,658 23.1 75.1 71.1 26.4 19.8 45.7 981 Female 17.8 5,759 23.7 74.5 79.3 19.4 19.5 48.1 1,027 Age 0–11 months 22.1 2,509 17.3 81.7 66.4 31.1 11.8 36.2 555 12–23 months 28.6 2,449 23.5 74.6 76.9 21.8 20.1 50.6 700 24–35 months 17.5 2,207 24.2 73.0 77.8 19.8 21.4 52.3 385 36–47 months 9.7 2,232 27.5 71.2 83.9 15.1 25.5 51.0 216 48–59 months 7.5 2,021 37.1 60.5 81.6 16.0 32.9 49.8 152 Mother’s education Never went to school 17.2 3,730 23.9 73.7 77.7 20.7 20.9 47.5 641 Primary 17.8 6,861 22.8 75.9 73.8 24.2 18.4 45.4 1,224 Secondary + 17.4 825 27.1 70.5 77.5 21.2 24.0 57.9 143 No reply/don’t know * 3 . . . . . . 0 Wealth index quintile Poorest 18.2 2,574 17.9 79.4 74.6 22.5 15.1 41.4 469 Second 16.8 2,523 21.2 77.8 74.0 25.0 20.1 45.3 423 Middle 19.4 2,255 20.4 78.3 76.8 20.6 17.3 47.4 438 Fourth 17.0 2,267 29.7 68.7 71.1 28.3 22.1 48.9 385 Richest 16.3 1,799 31.7 65.9 81.5 16.4 26.4 54.8 293 * MICS indicator 34 ** MICS indicator 35 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 44 Graph 6.6: Percentage of children aged 0–59 months who had diarrhoea and received ORT or increased fluids and increased food, Mozambique, 2008 Total AREA OF RESIDENCE Urban Rural SEX Male Female MOTHER`S EDUCATION Never went to school Primary Secondary + AGE 0 - 11 months 12 - 23 months 24 - 35 months 36 - 47 months 48 - 59 months Percentage 47 51 45 46 47 58 36 51 52 51 50 20 40 60 80 100 45 48 Care-seeking and antibiotic treatment of pneumonia Pneumonia is also one the main causes of death among children in developing countries. In Mozambique it is estimated that 10 per cent of deaths of children under five are caused by pneumonia22. The use of antibiotics in children under five with suspected pneumonia is a funda- mental intervention. One of the objectives of A World Fit for Children is to reduce by a third the number of deaths due to acute respiratory infections. Children with suspected pneumonia are those who have a cough accompanied by rapid or difficult breathing and whose symptoms are due to a problem in the chest and not to 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 6.6 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Five per cent of children aged 0–59 months were reported to have had symptoms of pneumonia in the two weeks prior to the survey. This figure reflects a reduction over the last five years, since in 2003 the percentage was 10 per cent. Gaza, with 10 per cent, was the province showing the highest percentage of children with suspected pneumonia, while the province with the lowest rate, 2 per cent, was Niassa. Differences by age were not signifi- cant, varying between 4 and 5 per cent for all age groups. Of the children with suspected pneumonia, 65 per cent were taken to an appropriate health provider and 53 per cent were taken to a health centre or health post. 22 Estudo nacional sobre a mortalidade infantil, Ministry of Health, 2009. v v v v 45 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.6: Care-seeking for suspected pneumonia Percentage of children aged 0–59 months, who in the last two weeks prior to the survey sought treatment in a health unit, by type of agent sought, by selected characteristics, Mozambique, 2008 Selected characteristics H ad a cu te r es pi ra to ry in fe ct io n N um be r of c hi ld re n ag ed 0– 59 m ot hs C en tr al h os pi ta l P ro vi nc ia l/g en er al h os pi ta l R ur al h os pi ta l H ea lth c en tr e/ po st M ob ile b rig ad es O th er p ub lic P riv at e cl in ic D oc to r N ur se P ha rm ac y O th er p riv at e D um ba n en gu e (in fo rm al m ar ke t) C hu rc h F rie nd s/ re la tiv es T ra di tio na l h ea le r O th er s ou rc e A ny a pp ro pr ia te p ro vi de r* N um be r of c hi ld re n Total 4.7 11,419 3.0 3.3 4.5 53.3 0.2 0.6 0.6 0.0 0.1 0.9 0.3 0.8 0.2 3.8 2.8 2.4 65.4 538 Area of residence Urban 5.5 3,243 8.8 9.7 8.0 39.6 0.0 0.0 1.8 0.0 0.3 2.0 0.0 0.0 0.5 5.2 3.4 2.0 66.1 180 Rural 4.4 8,176 0.0 0.2 2.8 60.2 0.4 0.9 0.0 0.0 0.0 0.3 0.5 1.1 0.0 3.1 2.5 2.6 65.0 358 Province Niassa 1.7 663 * * * * * * * * * * * * * * * * * 11 Cabo Delgado 6.4 1,136 0.0 0.0 6.3 71.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.8 4.9 1.5 78.2 72 Nampula 7.1 1,771 6.6 6.8 7.5 51.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 2.6 2.3 1.9 70.8 126 Zambézia 1.9 1,996 * * * * * * * * * * * * * * * * * 37 Tete 2.7 1,134 (0.0) (0.0) (4.0) (41.0) (0.0) (0.0) (0.0) (0.0) (0.0) (5.4) (0.0) (3.7) (0.0) (0.9) (2.9) (2.3) (45.0) 30 Manica 2.7 587 (0.0) (3.0) (4.4) (67.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (74.4 16 Sofala 3.4 1,575 2.2 0.0 2.7 55.1 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.0 1.7 4.8 8.7 0.0 59.4 53 Inhambane 8.0 716 0.0 1.0 3.3 62.8 0.0 0.0 0.0 0.0 0.0 2.4 3.3 4.2 0.0 7.5 4.1 9.9 70.3 57 Gaza 10.0 735 0.0 0.0 2.9 46.5 1.8 4.6 0.0 0.0 0.0 0.8 0.0 0.0 0.0 3.7 0.0 0.0 55.7 74 Maputo Province 5.4 655 6.6 11.9 4.6 44.6 0.0 0.0 (7.1) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (6.4) (0.0) (4.0) (70.8) 35 Maputo City 5.8 453 5.7 12.0 0.0 25.2 0.0 0.0 1.7 0.0 1.9 4.0 0.0 0.0 0.0 4.6 0.0 4.9 46.5 27 Sex Male 5.6 5,658 2.9 4.5 1.6 55.5 0.2 1.1 0.5 0.0 0.2 0.9 0.0 0.6 0.0 3.9 1.7 1.6 66.3 318 Female 3.8 5,759 3.0 1.6 8.8 50.3 0.3 0.0 0.7 0.0 0.0 0.8 0.9 1.0 0.4 3.8 4.2 3.5 63.9 220 NA * 2 . . . . . . . . . . . . . . . . . 0 Age 0-11 months 4.6 2,509 2.9 2.3 4.8 61.3 0.6 0.0 0.9 0.0 0.0 0.5 1.1 0.5 0.8 3.9 0.9 1.5 74.0 115 12-23 months 4.7 2,449 2.7 2.1 5.5 53.9 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0 4.1 1.2 4.4 63.7 115 24-35 months 5.2 2,207 2.8 1.0 3.1 53.4 0.0 0.0 1.2 0.0 0.0 0.1 0.0 3.0 0.0 3.1 3.4 3.8 60.4 115 36-47 months 5.0 2,232 2.1 9.4 4.6 52.9 0.0 0.0 0.6 0.0 0.0 0.5 0.0 0.0 0.0 3.8 3.0 1.2 69.7 111 48-59 months 4.1 2,021 4.7 1.6 4.7 41.8 0.8 4.1 0.0 0.0 0.6 2.4 0.8 0.0 0.0 4.4 6.3 0.4 56.7 82 Mother’s education Never went to school 4.2 3,730 1.7 0.8 5.1 51.5 0.4 2.1 0.0 0.0 0.0 0.6 0.4 1.1 0.0 3.8 2.7 0.3 62.0 157 Primary 4.7 6,861 3.1 4.5 2.8 55.2 0.2 0.0 0.0 0.0 0.2 1.1 0.4 0.7 0.3 4.4 3.1 3.8 65.6 325 Secondary + 6.8 825 5.8 3.9 13.0 47.6 0.0 0.0 5.6 0.0 0.0 0.0 0.0 0.0 0.0 0.8 1.4 0.0 73.3 56 No reply/don’t know * 3 . . . . . . . . . . . . . . . . . 0 Wealth index quintile Poorest 2.9 2,574 0.0 0.0 1.4 55.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.5 0.0 4.3 3.3 0.0 56.7 76 Second 5.3 2,523 0.0 0.0 1.7 64.7 0.5 0.0 0.0 0.0 0.0 0.0 1.4 0.4 0.0 1.8 3.7 3.8 68.2 133 Middle 4.2 2,255 0.0 0.5 8.6 58.3 0.0 3.6 0.0 0.0 0.0 1.1 0.0 0.0 0.0 4.3 2.3 1.6 70.9 95 Fourth 5.4 2,267 4.0 1.4 8.1 45.6 0.5 0.0 0.0 0.0 0.0 2.0 0.0 1.9 0.0 5.2 2.7 3.5 59.1 124 Richest 6.1 1,799 9.9 14.3 2.8 42.7 0.0 0.0 2.9 0.0 0.5 1.0 0.0 0.0 0.8 4.1 1.7 1.7 70.1 110 * MICS indicator 23 Figures in parentheses are based on 25-49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 46 In 52 per cent of children with suspected pneumonia, the cough was accompanied by fever. These situations were recorded more often in rural areas (55 per cent) than in urban areas (46 per cent). The largest numbers of cases of children under five with coughing accompanied by fever were recorded in the provinces of Zambézia, Cabo Delgado and Nampula, with rates above 60 per cent. This phenomenon was noted least in children under 6 months old (45 per cent). Table 6.6a: Cough accompanied by fever Percentage of children aged 0–59 months, with suspected pneumonia and fever in the last two weeks prior to the survey by selected characteristics, Mozambique, 2008 Selected characteristics Pneumonia and fever Total Number of childrenYes No No reply/don’t know Total 52.0 47.6 0.5 100.0 3,389 Area of residence Urban 45.7 53.7 0.6 100.0 1,119 Rural 55.0 44.6 0.4 100.0 2,270 Provínce Niassa 54.6 42.5 2.9 100.0 108 Cabo Delgado 67.9 31.9 0.2 100.0 280 Nampula 65.7 33.4 0.9 100.0 441 Zambézia 68.1 30.5 1.4 100.0 337 Tete 49.3 50.7 0.0 100.0 310 Manica 43.7 56.3 0.0 100.0 186 Sofala 42.9 57.1 0.0 100.0 380 Inhambane 49.5 50.1 0.4 100.0 357 Gaza 48.1 51.7 0.2 100.0 459 Maputo Province 36.4 63.1 0.5 100.0 335 Maputo Cty 38.6 61.1 0.3 100.0 197 Sex Male 53.4 46.3 0.3 100.0 1,692 Female 50.5 48.8 0.7 100.0 1,694 NA * * * * 2 Age < 6 months 44.9 54.5 0.6 100.0 349 6-11 months 58.9 40.6 0.5 100.0 484 12-23 months 54.3 44.8 0.8 100.0 812 24-35 months 51.3 48.4 0.3 100.0 662 36-47 months 51.7 48.1 0.2 100.0 609 48-59months 47.2 52.4 0.4 100.0 472 Mother’s education Never went to school 52.8 46.6 0.5 100.0 956 Primary 54.1 45.5 0.4 100.0 2,117 Secondary + 34.8 64.0 1.2 100.0 316 No reply/don’t know * * * * 0 Wealth index quintile Poorest 58.2 41.4 0.5 100.0 504 Second 58.0 41.7 0.3 100.0 672 Middle 59.4 39.7 0.9 100.0 630 Fourth 48.6 50.9 0.6 100.0 839 Richest 39.8 60.0 0.2 100.0 744 Figures in parentheses are based on 25-49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 47 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.7a shows the use of antibiotics to treat suspected pneumonia in children under five. Twenty-two per cent of under-fives with suspected pneumonia received antibiotics during the two weeks prior to the survey. Antibiotic treatment for suspected pneumonia is more frequent in the country’s urban areas (29 per cent) than in the rural areas (19 per cent). In households where the mother has secondary or higher education, 41 per cent of children received antibio- tics, compared with 26 per cent in households where the mother did not go to school. The use of antibiotics is also related to the wealth of the household, ranging from 28 per cent in households in the richest quintile to 13 per cent in households in the poorest quintile. Table 6.7a: Use of antibiotics to treat pneumonia Percentage of children aged 0–59 months with suspected pneumonia who received antibiotic treatment, by selected characteristics, Mozambique, 2008 Selected characteristics 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 who received antibiotics in the last two weeks Total 22.3 538 Area of residence Urban 28.8 180 Rural 19.1 358 Provínce Niassa * 11 Cabo Delgado 13.4 72 Nampula 36.3 126 Zambézia * 37 Tete (32.5) 30 Manica (42.1) 16 Sofala 33.5 53 Inhambane (5.0) 57 Gaza 22.5 74 Maputo Province (6.6) 35 Maputo City 12.8 27 Sex Male 20.7 318 Female 24.7 220 Age 0–11 months 28.6 115 12–23 months 16.2 115 24–35 months 15.3 115 36–47 months 26.9 111 48–59 months 25.8 82 Mother’s education Never went to school 25.5 157 Primary 17.7 325 Secondary + 40.5 56 Wealth index quintile Poorest 13.0 76 Second 21.2 133 Middle 28.2 95 Fourth 20.1 124 Richest 27.6 110 * MICS indicator 22 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 48 In Table 6.7b, situations related to the mothers’ knowledge of the danger signs of pneumonia are shown. Overall, 16 per cent of the mothers know of two danger signs of pneumonia – rapid and difficult breathing, recognized by 19 per cent in urban areas and 14 per cent in rural areas. The most common symptom identified for taking a child to a health unit is fever (89 per cent). Twenty-four per cent of the mothers identified rapid breathing and 26 per cent difficult breathing as a symptom that obliges them to take a child immediately to a health care provider. With regard to identifying at least two signs of pneumonia, Gaza province presents the lowest per- centage (2 per cent), followed by Inhambane, also with 2 per cent. Nampula province has the highest percentage (36 per cent). Table 6.7b: Knowledge of two danger signs of pneumonia Percentage of mothers/caregivers of children aged 0–59 months, by knowledge of the types of symptoms leading them to take the child immediately to a health unit, and percentage of mothers/caregivers who recognize rapid or difficult breathing as a sign requiring the seeking of immediate care, by selected characteristics, Mozambique, 2008 Selected characteristics Percentage of mothers/caregivers of children aged 0–59 months who think that a child should be immediately taken to a health facility, if the child: M ot he rs /c ar eg iv er s w ho r ec og ni ze th e tw o da ng er s ig ns o f p ne um on ia N um be r of m ot he rs /c ar eg iv er s of ch ild re n ag ed 0 –5 9 m on th s Is n ot a bl e to d rin k or to br ea st fe ed Is il l Is d ev el op in g a fe ve r H as fa st b re at hi ng H as d iff ic ul ty in b re at hi ng H as b lo od in s to ol Is d rin ki ng p oo rly H as o th er s ym pt om s Total 24.5 39.5 88.6 24.4 25.6 25.9 12.6 46.5 15.5 8,196 Area of residence Urban 26.4 38.0 90.0 27.7 30.6 26.6 15.9 49.8 19.2 2,484 Rural 23.7 40.2 88.0 23.0 23.4 25.6 11.2 45.1 13.9 5,712 Province Niassa 25.2 35.3 80.2 16.8 17.0 36.2 9.8 20.0 10.1 482 Cabo Delgado 10.4 12.0 94.0 12.3 12.4 24.0 2.7 58.5 3.3 824 Nampula 58.3 65.3 75.2 48.0 51.0 41.8 40.3 48.5 35.8 1,326 Zambézia 29.3 53.9 87.0 24.0 22.3 25.9 9.6 39.2 15.4 1,391 Tete 17.0 38.5 95.6 34.3 38.0 37.5 4.0 38.4 20.7 790 Manica 5.6 7.8 92.9 7.2 10.8 5.1 6.1 68.2 3.3 392 Sofala 35.6 58.4 94.4 39.3 34.9 39.9 17.7 49.5 25.1 979 Inhambane 2.5 21.1 91.2 2.6 6.2 4.2 1.4 54.6 1.9 554 Gaza 6.2 25.1 94.1 6.5 14.2 5.2 4.1 45.7 1.6 543 Maputo Province 6.9 19.5 91.7 13.4 13.4 8.1 3.2 59.0 7.7 536 Maputo City 8.0 23.0 90.3 12.0 16.0 9.1 5.6 32.4 6.0 380 Mother’s education Never went to school 27.0 45.6 87.0 27.5 26.3 27.2 12.8 42.7 16.2 2,553 Primary 23.5 37.6 89.4 23.3 25.1 25.4 12.9 48.5 15.5 4,935 Secondary + 22.8 30.4 89.1 20.8 27.1 24.3 9.7 46.3 13.1 705 No reply/ don’t know * * * * * * * * * 3 Wealth index quintile Poorest 27.0 45.0 85.7 24.9 24.0 28.8 12.0 42.7 14.8 1,741 Second 26.8 42.4 87.0 26.9 24.9 27.1 12.1 45.4 15.5 1,766 Middle 27.3 40.0 88.1 25.6 28.3 30.1 14.9 45.7 17.3 1,634 Fourth 20.7 37.3 92.1 23.9 25.5 22.7 11.8 50.9 15.5 1,609 Richest 19.8 31.1 90.8 20.1 25.4 19.6 12.2 48.5 14.3 1,447 Figures in parentheses are based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 49 Mozambique – Multiple Indicators Cluster Survey 2008 Solid fuel use Cooking and heating with solid fuels leads to high levels of indoor smoke, which contains a com- plex mixture of pollutants damaging to health. The main problems are the chemicals produced by incomplete combustion, including carbon monoxide, polyaromatic hydrocarbons, sulphur dioxide and other toxic compounds. The use of solid fuels increases the risks of acute respira- tory disease, pneumonia, chronic obstructive pulmonary disease, cancer, possibly tuberculosis, low birthweight, cataracts and asthma. The primary indicator is the percentage of the population who use solid fuels as their primary source of domestic energy for cooking. The great majority of households in Mozambique (97 per cent) use solid fuels for cooking (Table 6.8). Almost all households in rural areas use solid fuels, a percentage which falls to 92 per cent in urban areas. Firewood is the most common fuel, at 82 per cent, followed by charcoal, at 15 per cent. Firewood is the main source of fuel for cooking in all provinces except Maputo City, where charcoal and natural gas are the main sources (65 and 21 per cent, respectively). Table 6.8: Use of solid fuels Percentage distribution of households by the type of fuel they use for cooking, and percentage of households who use solid fuels for cooking, by selected characteristics, Mozambique, 2008 Selected characteristics Main source of energy or fuel used: To ta l S ol id fu el s fo r co ok in g* N um be r of h ou se ho ld s E le ct ric ity N at ur al g as K er os en e/ pa ra ffi n C oa l C ha rc oa l F ire w oo d A ni m al d un g O th er Total 0.7 1.9 0.3 0.1 14.5 82.2 0.3 0.1 100.0 97.0 13,955 Area of residence Urban 1.8 5.9 0.4 0.2 41.9 49.4 0.0 0.3 100.0 91.6 4,338 Rural 0.2 0.1 0.2 0.0 2.1 96.9 0.5 0.0 100.0 99.5 9,617 Province Niassa 0.1 0.0 0.0 0.0 9.7 90.1 0.1 0.0 100.0 99.9 833 Cabo Delgado 0.0 0.0 0.0 0.2 7.4 92.1 0.2 0.0 100.0 99.9 1,512 Nampula 0.5 0.0 0.8 0.0 12.4 85.1 1.1 0.0 100.0 98.6 2,568 Zambézia 0.1 0.0 0.0 0.0 6.1 93.6 0.3 0.0 100.0 99.9 2,532 Tete 0.0 0.0 0.0 0.0 2.2 97.6 0.2 0.0 100.0 99.8 1,281 Manica 0.3 0.0 0.1 0.0 11.3 88.1 0.2 0.0 100.0 99.6 627 Sofala 0.9 2.9 0.2 0.1 29.0 66.8 0.0 0.1 100.0 95.8 1,108 Inhambane 0.1 0.4 0.6 0.1 2.0 96.1 0.4 0.2 100.0 98.7 946 Gaza 0.4 0.3 0.1 0.0 7.4 91.0 0.3 0.6 100.0 98.7 845 Maputo Province 2.6 7.5 0.1 0.1 37.8 51.5 0.0 0.3 100.0 89.5 952 Maputo City 4.8 21.0 0.7 0.2 65.4 7.8 0.0 0.2 100.0 73.3 751 Education of head of household Never went to school 0.3 0.1 0.2 0.0 4.0 95.0 0.3 0.2 100.0 99.2 3,429 Primary 0.3 0.8 0.3 0.1 12.1 86.0 0.4 0.1 100.0 98.6 8,588 Secondary + 3.2 10.9 0.3 0.1 45.4 39.8 0.2 0.1 100.0 85.4 1,802 No reply/don’t know 0.0 0.3 2.2 0.0 15.7 81.7 0.0 0.0 100.0 97.4 137 Wealth index quintile Poorest 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 100.0 100.0 2,866 Second 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 100.0 100.0 3,029 Middle 0.0 0.0 0.3 0.0 0.1 98.2 1.3 0.1 100.0 99.6 2,975 Fourth 0.4 0.0 0.7 0.1 17.1 81.0 0.3 0.4 100.0 98.5 2,630 Richest 3.4 10.9 0.4 0.2 63.8 21.1 0.1 0.1 100.0 85.2 2,455 * MICS indicator 24 50 Firewood is used by about 97 per cent of households in rural areas to prepare their meals, compared with about half of the households in urban areas (49 per cent). In urban areas, a considerable proportion of households use charcoal (42 per cent) or natural gas (6 per cent) as the main source of energy for cooking. The data show that the use of solid fuels varies inversely with the level of education of the head of household and with the wealth of the household. Thus, the greater the level of education of the head of household, the more the use of solid fuel declines, reaching about 85 per cent for heads of household with secondary education or more. Likewise, relatively rich households make relatively smaller use of solid fuel when preparing their food, in comparison with poorer households. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while an open stove or fire, with no chimney or hood, me- ans that there is no protection from the harmful effects of solid fuels. The type of stove used by households who use solid fuels is described in Table 6.9. In Mozambique, almost all households use traditional stoves, with all the consequences this brings for their health. The data (Table 6.9) show no significant difference between provinces, areas of residence and other variables. 51 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.9: Use of solid fuels by type of stove or fire Percentage of households who use solid fuels for cooking, by type of stove or fire, and by selected characteristics, Mozambique, 2008 Selected characteristics Households who use solid fuels for cooking To ta l N um be r of ho us eh ol ds w ho u se so lid fu el s fo r co ok in g Im pr ov ed s to ve (c lo se d) T ra di tio na l s to ve (o pe n) O th er ty pe s of st ov e N o re pl y/ do n’ t kn ow Total 0.4 99.6 0.0 0.0 100.0 13,539 Area of Residence Urban 1.0 99.0 0.0 0.0 100.0 3,971 Rural 0.1 99.8 0.0 0.0 100.0 9,568 Province Niassa 0.6 99.4 0.0 0.0 100.0 832 Cabo Delgado 1.1 98.9 0.0 0.0 100.0 1,510 Nampula 0.4 99.5 0.0 0.1 100.0 2,532 Zambézia 0.0 100.0 0.0 0.0 100.0 2,529 Tete 0.0 100.0 0.0 0.0 100.0 1,279 Manica 0.2 99.6 0.1 0.0 100.0 625 Sofala 0.1 99.9 0.0 0.0 100.0 1,062 Inhambane 1.1 98.7 0.0 0.1 100.0 933 Gaza 0.4 99.6 0.0 0.0 100.0 833 Maputo Province 0.3 99.7 0.0 0.0 100.0 852 Maputo City 0.2 99.8 0.0 0.0 100.0 550 Education of the head of the household Never went to school 0.1 99.8 0.0 0.1 100.0 3,402 Primary 0.2 99.7 0.0 0.0 100.0 8,465 Secondary + 1.9 98.1 0.1 0.0 100.0 1,539 No reply/don’t know 1.1 98.9 0.0 0.0 100.0 134 Wealth index quintile Poorest 0.0 99.9 0.0 0.1 100.0 2,866 Second 0.0 100.0 0.0 0.0 100.0 3,029 Middle 0.0 100.0 0.0 0.0 100.0 2,962 Fourth 0.6 99.3 0.0 0.0 100.0 2,591 Richest 1.7 98.3 0.0 0.0 100.0 2,091 Malaria Malaria is the main cause of death among children under five in Mozambique23. It also con- tributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of home spraying and long-lasting, insecticide-treated mosquito nets, can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended antimalarial tablets. Children with severe malaria symptoms, such as high fever or convulsions, should be taken to a health unit. Children recovering from malaria should also receive extra liquids and food, and the youngest should continue to be breastfed. 23 Malaria is estimated as the main cause of child mortality in Mozambique, responsible for about a third of all deaths among children under five. (Estudo nacional sobre a mortalidade infantil, Ministry of Health, 2009). 52 The questionnaire includes questions on the availability and use of mosquito nets, both at hou- sehold level and among children under five, and on antimalaria treatment and intermittent pre- ventive therapy for malaria among pregnant women. More than half of households (55 per cent) possess at least one mosquito net, treated or not (Table 6.10a). The availability of mosquito nets is higher in urban areas (63 per cent) than in rural areas (52 per cent). Less than half of households in the provinces of Tete (31 per cent), Maputo (45 per cent) and Manica (48 per cent) possess nets. In the remaining provinces, the proportion of households where nets are available is above 50 per cent, ranging from 52 per cent in Gaza to 70 per cent in Cabo Delgado. Table 6.10a: Availability of mosquito nets Percentage of all households who possess at least one mosquito net, by selected characteristics, Mozambique, 2008 Selected characteristics Percentage of households with at least one mosquito net Number of households Total 55.2 13,955 Area of residence Urban 62.5 4,338 Rural 51.9 9,617 Province Niassa 60.5 833 Cabo Delgado 69.7 1,512 Nampula 55.8 2,568 Zambézia 54.9 2,532 Tete 31.3 1,281 Manica 47.5 627 Sofala 67.7 1,108 Inhambane 61.7 946 Gaza 52.1 845 Maputo Province 44.8 952 Maputo City 56.6 751 Education of the head of household Never went to school 41.0 3,429 Primary 57.3 8,588 Secondary + 72.3 1,802 No reply/don’t know 58.4 137 Wealth index quintile Poorest 45.1 2,866 Second 50.3 3,029 Middle 55.1 2,975 Fourth 61.4 2,630 Richest 66.6 2,455 Table 6.10b shows the availability of treated and untreated nets in households with children under five. Rather less than a third (31 per cent) have at least one insecticide-treated net (ITN). There are no significant variations in the availability of ITNs in rural areas (30 per cent) and urban areas (32 per cent). Likewise, the analysis does not show significant differences in re- lation to the level of household wealth. But there is a positive correlation between the level of education of the head of household and the probability that the household will possess an ITN. Less than a quarter (25 per cent) of households headed by individuals who never went to school possess treated nets, compared with 40 per cent of households headed by people with secon- dary education or higher. 53 Mozambique – Multiple Indicators Cluster Survey 2008 Table 6.10b: Availability of insecticide-treated mosquito nets Percentage of households with children under five, by ownership of at least one insecticide-treated net (ITN), by selected characteristics, Mozambique, 2008 Selected characteristics Percentage of households with children under five with at least one mosquito net Percentage of households with children under five with at least one ITN* Number of households with children under five Total 65.2 30.7 7,685 Area of residence Urban 71.8 31.7 2,303 Rural 62.4 30.3 5,382 Province Niassa 71.2 25.2 469 Cabo Delgado 88.6 43.4 790 Nampula 68.8 40.9 1,326 Zambézia 62.4 28.9 1,370 Tete 37.1 20.0 789 Manica 56.8 20.7 373 Sofala 69.8 39.3 841 Inhambane 80.5 33.0 454 Gaza 61.4 27.6 455 Maputo Province 52.7 11.4 489 Maputo City 66.3 19.5 330 Education of head of household Never went to school 54.8 24.5 1,542 Primary 65.5 30.8 5,034 Secondary + 79.0 39.9 1,028 No reply/don’t know 71.2 29.0 81 Wealth index quintile Poorest 54.9 27.3 1,685 Second 62.9 30.5 1,675 Middle 67.9 34.4 1,557 Fourth 69.8 30.6 1,456 Richest 73.4 31.1 1,312 * MICS Indicador 36 The data contained in Table 6.11 show that 42 per cent of children under five slept under some net the night prior to the survey, including about 23 per cent who slept under an insecticide-trea- ted net and 17 per cent under an untreated net. The use of mosquito nets for children under five is more frequent in urban areas (48 per cent) than in rural areas (40 per cent). There were no significant gender disparities. In terms of age, one notes that as age increases, the use of ITNs declines substantially, from 33 per cent in children under one year old to 17 per cent in children aged 48–59 months. 54 Table 6.11: Children sleeping under mosquito nets Percentage of children aged 0–59 months who slept under the protection of a mosquito net on the night prior to the interview, by selected characteristics, Mozambique, 2008 Selected characteristics S le pt u nd er p ro te ct io n of a n et * S le pt u nd er p ro te ct io n of a n in se ct ic id e- tr ea te d ne t * * S le pt u nd er p ro te ct io n of a n un tr ea te d ne t S le pt u nd er p ro te ct io n of a n et b ut d oe s no t kn ow w he th er it is tr ea te d D oe s no t k no w w he th er sl ep t u nd er p ro te ct io n of a n et D id n ot s le ep u nd er pr ot ec tio n of a n et Number of children aged 0–59 months Total 42.1 22.8 17.3 2.0 1.0 56.9 11,419 Area of residence Urban 48.3 25.4 20.2 2.7 1.2 50.4 3,243 Rural 39.7 21.8 16.1 1.7 0.9 59.5 8,176 Province Niassa 43.0 17.0 23.8 2.2 0.3 56.6 663 Cabo Delgado 66.7 33.0 32.6 1.1 1.9 31.5 1,136 Nampula 47.3 33.5 11.8 2.0 0.6 52.1 1,771 Zambézia 43.7 22.6 18.0 3.1 1.2 55.1 1,996 Tete 22.6 14.5 8.0 0.1 0.7 76.7 1,134 Manica 32.6 14.9 16.8 1.0 0.5 66.9 587 Sofala 50.2 29.7 19.3 1.2 0.3 49.5 1,575 Inhambane 43.5 22.1 18.3 3.1 1.8 54.7 716 Gaza 17.3 9.9 6.1 1.3 1.9 80.8 735 Maputo Province 29.5 8.5 16.5 4.5 1.1 69.5 655 Maputo City 41.9 15.5 22.3 4.1 0.7 57.4 453 Sex Male 41.9 22.4 17.3 2.2 .8 57.4 5,658 Female 42.4 23.3 17.3 1.9 1.2 56.4 5,759 NA * * * * * * 2 Age 0–11 months 49.1 32.6 14.6 1.9 0.8 50.1 2,509 12–23 months 43.5 20.9 20.8 1.7 0.7 55.9 2,449 24–35 months 41.9 21.0 18.5 2.4 1.5 56.6 2,207 36–47 months 40.2 20.8 17.0 2.5 0.8 59.0 2,232 48–59 months 34.2 17.3 15.2 1.6 1.2 64.6 2,021 Wealth index quintile Poorest 36.1 20.3 13.9 1.9 0.6 63.4 2,574 Second 41.1 22.2 17.6 1.3 0.8 58.1 2,523 Middle 46.1 26.2 17.8 2.2 1.0 52.8 2,255 Fourth 41.5 21.9 18.2 1.4 1.4 57.1 2,267 Richest 48.1 24.4 19.8 3.9 1.1 50.8 1,799 * MICS indicador 38 ** MICS indicador 37; MDG indicador 6.7 Figures in parentheses is based on 25–49 unweighted cases. Figures based on less than 25 unweighted cases are not shown (*) As for the prevalence and treatment of fever in children under five, the data show that slightly less than a quarter (24 per cent) of children had a fever in the two weeks prior to the survey (Table 6.12). The prevalence of fever was 24 per cent among children less than one year old, reached its peak (30 per cent) among children aged 12–23 months and later declined as the children grew, falling to 19 per cent in children aged 48–59 months. There are no significant differences between urban and rural areas in prevalence of fever. Among the provinces, fever prevalence varies between 33 per cent (Gaza) and 14 per cent (Niassa). 55 Mozambique – Multiple Indicators Cluster Survey 2008 Mothers were asked to report all the medicines given to a child to treat fever, including both me- dicines given at home and medicines given or prescribed at a health unit. Overall, 37 per cent of children with fever in the last two weeks were treated with an “appropriate” antimalarial drug, and 23 per cent received antimalarial drugs within 24 hours of the onset of symptoms. As Table 6.12 shows, there are no significant differences between urban and rural areas, or between boys and girls, or in relation to their mothers’ education or the household wealth quin- tile, as regards the probability of receiving adequate antimalarial drugs and taking them in due time. Table 6.12: Treatment of children suffering from fever with antimalarial drugs Percentage of children aged 0–59 months who had fever in the two weeks prior to the survey and who received antimalarial drugs, by selected characteristics, Mozambique, 2008 Selected characteristics H ad a fe ve r in th e la st tw o w ee ks N um be r of c hi ld re n ag ed 0 –5 9 m on th s Children with fever in the last two weeks who were treated with: N um be r of c hi ld re n w ith fe ve r in th e la st tw o w ee ks A nt im al ar ia l dr ug s: F an si da r/ A rt es un at o A nt im al ar ia l dr ug s: A rt im is in in e A nt im al ar ia l dr ug s: q ui ni ne A nt im al ar ia l dr ug s: o th er an tim al ar ia l d ru g A ny a de qu at e an tim al ar ia l d ru g O th er m ed ic in e: pa ra ce ta m ol O th er m ed ic in e: as pi rin O th er m ed ic in e: ot he r D on ’t kn ow A ny a de qu at e an tim al ar ia l dr ug w ith in 2 4 ho ur s of o ns et o f sy m pt om s* Total 23.5 11,419 33.5 1.8 2.4 1.7 36.7 42.4 4.1 17.3 2.7 22.7 2,686 Area of residence Urban 23.4 3,243 34.7 2.4 3.7 1.5 38.4 51.3 3.3 18.0 1.0 22.9 760 Rural 23.6 8,176 33.0 1.6 1.8 1.8 36.1 38.9 4.4 17.0 3.3 22.7 1,926 Province Niassa 13.9 663 23.8 0.0 0.7 1.9 26.4 49.7 3.3 32.4 0.0 15.4 92 Cabo Delgado 20.1 1,136 42.4 7.3 2.9 0.2 47.4 31.8 1.8 2.3 2.5 31.9 228 Nampula 26.8 1,771 53.0 4.1 4.1 3.7 57.6 41.9 2.7 6.3 1.9 41.8 474 Zambézia 26.0 1,996 11.8 0.0 3.0 2.5 16.9 36.6 8.9 15.0 5.5 10.8 520 Tete 20.4 1,134 30.5 1.1 0.3 1.0 31.7 49.4 8.3 13.5 0.0 25.8 231 Manica 17.3 587 39.1 1.1 0.0 0.6 39.7 60.8 0.6 11.0 1.6 29.2 101 Sofala 21.2 1,575 59.6 1.1 1.3 0.1 60.1 25.4 1.2 6.3 0.0 12.5 334 Inhambane 31.0 716 31.9 1.8 5.3 2.3 37.2 49.3 5.1 37.3 5.4 29.2 222 Gaza 33.2 735 26.1 0.0 0.0 0.3 26.4 52.3 1.3 39.3 4.5 21.5 244 Maputo Province 21.8 655 13.0 0.8 2.0 1.6 16.4 55.3 4.0 32.3 2.0 10.1 143 Maputo City 21.4 453 7.1 0.2 1.6 0.5 9.2 58.6 0.0 33.9 0.8 6.9 97 Sex Male 24.5 5,658 33.7 2.0 2.8 1.5 37.6 42.6 3.3 17.2 2.8 24.1 1,384 Female 22.6 5,759 33.3 1.6 1.9 1.8 35.8 42.2 4.9 17.4 2.5 21.3 1,301 NA * 2 * * * * * * * * * * 1 Age 0–11 months 23.5 2,509 26.2 0.7 1.4 1.4 28.7 43.1 4.7 22.7 3.4 19.3 589 12–23 months 29.6 2,449 35.4 3.0 3.1 1.5 39.6 42.8 3.7 13.9 1.5 25.6 724 24–35 months 24.0 2,207 36.8 1.4 1.7 1.6 37.6 48.3 3.7 16.6 3.8 24.7 530 36–47 months 20.8 2,232 33.2 1.9 3.3 1.7 37.9 36.7 3.8 16.5 2.3 23.7 465 48–59 months 18.7 2,021 37.2 1.8 2.5 2.6 41.0 39.8 5.0 17.3 2.6 18.5 378 Mother’s education Never went to school 21.9 3,730 35.5 1.4 1.8 1.5 38.0 39.2 4.8 13.8 1.5 20.9 816 Primary 25.0 6,861 32.3 2.0 2.7 1.9 36.0 42.3 4.1 18.6 3.4 23.9 1,713 Secondary + 19.1 825 36.6 2.0 1.2 0.3 38.5 61.2 0.8 21.0 0.0 19.1 158 No reply/don’t know * 3 . . . . . . . . . . 0 Wealth index quintile Poorest 23.6 2,574 28.9 1.5 2.3 1.0 32.0 34.2 4.6 13.2 4.7 18.1 607 Second 23.0 2,523 38.5 0.9 2.3 2.5 41.2 34.9 3.5 11.6 2.7 25.5 580 Middle 24.3 2,255 34.9 1.4 2.2 0.9 37.4 43.8 6.8 16.6 1.8 23.7 547 Fourth 25.2 2,267 34.7 3.8 2.7 2.7 39.8 46.5 3.0 22.0 2.5 26.5 572 Richest 21.1 1,799 29.4 1.3 2.4 1.1 31.8 59.2 2.2 26.2 0.9 18.9 380 * MICS indicador 39; MDG indicador 6.8 Percentage in parentheses is based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 56 Pregnant women infected with the malaria parasite run the risk of anaemia, premature birth and stillbirths. Their babies may be underweight, which reduces their probability of surviving their first year of life. For this reason, steps are taken to protect pregnant women by distributing ITNs and providing treatment during antenatal check-ups with drugs to prevent infection by malaria (intermittent preventive treatment or intermittent preventive therapy). In MICS, women were asked about the drugs they had received during their latest pregnancy. Women are con- sidered to have received intermittent preventive therapy if they received at least two doses of SP/Fansidar during pregnancy. Table 6.13: Intermittent preventive treatment against malaria Percentage of women aged 15–49 who gave birth in the two years prior to the survey and who received preventive treatment against malaria during pregnancy, by selected characteristics, Mozambique, 2008 Selected characteristics D ru gs to p re ve nt m al ar ia d ur in g pr eg na nc y S P /F an si da r on ly o nc e S P /F an si da r tw o or m or e tim es * S P /F an si da r bu t n um be r of ti m es no t k no w n C hl or oq ui ne O th er d ru gs D oe s no t k no w th e dr ug N um be r of w om en w ho g av e bi rt h in la st tw o ye ar s Total 67.0 13.3 43.1 0.5 3.0 0.0 5.9 5,191 Area of residence Urban 80.7 14.6 54.6 0.9 2.9 0.0 6.0 1,493 Rural 61.5 12.7 38.5 0.4 3.0 0.0 5.8 3,698 Province Niassa 52.5 13.8 35.9 0.5 0.7 0.2 1.4 318 Cabo Delgado 77.4 24.0 50.3 0.0 0.5 0.0 1.8 527 Nampula 68.4 14.8 34.5 0.3 9.8 0.0 6.9 895 Zambézia 45.6 3.7 22.5 0.2 2.9 0.0 14.6 912 Tete 47.7 16.7 29.1 0.0 1.1 0.0 0.5 535 Manica 77.7 15.1 61.5 0.2 0.1 0.0 0.5 260 Sofala 84.6 10.9 73.3 0.1 0.0 0.0 0.0 638 Inhambane 74.7 12.6 38.2 1.3 2.3 0.0 14.5 312 Gaza 87.6 11.4 65.7 3.5 0.2 0.0 7.2 325 Maputo Province 74.2 13.8 50.5 1.4 2.4 0.0 5.9 277 Maputo City 80.8 20.5 46.9 0.4 7.7 0.0 4.0 191 Education Never went to school 58.4 11.6 40.4 0.2 1.5 0.0 3.9 1,624 Primary 69.2 14.4 42.3 0.6 3.5 0.0 7.2 3,086 Secondary + 83.4 12.4 58.7 1.0 4.6 0.0 3.8 439 No reply/don’t know * * * * * * * 42 Wealth quintile Poorest 54.7 10.5 33.4 0.2 3.3 0.0 6.3 1,209 Second 60.6 12.0 38.0 0.2 2.7 0.0 6.5 1,144 Middle 66.7 15.0 42.4 0.3 2.8 0.1 5.1 1,041 Fourth 75.9 13.9 50.3 1.0 2.1 0.0 7.2 1,018 Richest 84.4 16.3 57.6 1.2 4.3 0.0 3.8 778 * MICS Indicator 40 Percentage in parentheses is based on 25–49 unweighted cases. Percentages based on less than 25 unweighted cases are not shown (*). 57 Mozambique – Multiple Indicators Cluster Survey 2008 In Mozambique, two thirds of pregnant women who gave birth in the two years prior to the survey had some preventive treatment for malaria during pregnancy. This proportion varies in accordance with the area of residence, level of education of the head of household and level of wealth. Thus, the proportions are higher among women who live in urban areas than in rural areas (81 per cent and 62 per cent, respectively). In turn, the prevalence of preventive treatment for malaria among pregnant women varies in direct ratio to the level of education of the head of household and to household wealth. Analysis by province shows that Gaza, Sofala and Maputo City have percentages greater than 80 per cent of women receiving preventive treatment. On the other hand, Niassa (53 per cent), Tete (48 per cent) and Zambézia (46 per cent) have proportions below the national average. It should be noted that among women who gave birth in the two years prior to the survey and who received intermittent preventive treatment against malaria, less than half (43 per cent) re- ceived SP/Fansidar two or more times, while 13 per cent received it once. On the other hand, 6 per cent of the women do not know what drug they received. Graph 6.7: Percentage of women aged 15–49 who gave birth in the two years prior to the survey and who received intermittent preventive treatment against malaria during pregnancy, by selected characteristics, Mozambique, 2008 67 81 61 58 83 55 61 67 76 84 69 Total AREA OF RESIDENCE Urban Rural MOTHER`S EDUCATION Never went to school Primary Secondary + WEALTH QUINTILE Lowest Second Middle Fourth Richest 2010 30 40 60 7050 80 90 58 VII. Environment Water and sanitation Having clean drinking water available is essential for reducing the incidence of diseases caused by consuming unfit water and by poor sanitary conditions (such as malaria, diarrhoeal diseases and cholera). These diseases are key determinants of child mortality, particularly in developing countries. It is estimated that poor hygiene and lack of decent sanitation contribute to about 90 per cent of deaths caused by diarrhoeal diseases in these countries. One of the Millennium Development Goals is to reduce by half, between 1990 and 2015, the percentage of people without sustainable access to drinking water and safe sanitation. The si- milar goal of A World Fit for Children is to reduce the percentage of households without access to hygienic sanitary services and drinking water by at least a third. Water is vital for attaining the other Millennium Development Goals, such as poverty reduction, education, health and gender equality. The list of indicators used in MICS is as follows: Water: Use of improved sources of drinking water Use of water treatment method in the household Time taken to fetch drinking water and return Person who fetches drinking water. Sanitation: Use of sanitation infrastructure Adequate treatment of children’s faeces. Access to drinking water Clean drinking water is a basic necessity for health. Water unfit for drinking can be a significant vehicle for diseases such as trachoma, cholera, typhoid fever and schistosomiasis. Access to clean drinking water, particularly in rural areas, can be of particular importance to women and children, who are the people primarily responsible for fetching water, often over long distances. The percentage distribution of households by improved sources of drinking water is shown in Table 7.1 and Graph 7.1. The households who use improved sources of drinking water are those who use: piped water (inside the house, in the yard, or in a neighbour’s house), a public tap/standpipe, or a protected well/borehole with a hand pump. Bottled water is considered an improved source of water only if the household is also using an improved source of water for other purposes, such as washing hands and cooking. Overall, 43 per cent of households are using an improved source of drinking water, which is an improvement over the 36 per cent recorded in 200424 (Graph 7.3). Of the households who use improved sources, 70 per cent live in urban areas and 30 per cent live in rural areas. 24 QUIBB/IFTRAB 2004, INE v v v v v v 59 Mozambique – Multiple Indicators Cluster Survey 2008 One in five (20 per cent) households surveyed use protected boreholes or wells with a hand pump as their main source of drinking water. This percentage is higher in rural areas (25 per cent) than in urban areas (9 per cent). About 9 per cent obtain water from the public tap or standpipe, and 6 per cent obtain it from a neighbour’s house. Six per cent of the population use tap water outside the house or in the yard, and only 2 per cent obtain water from a tap inside the house. Table 7.1: Use of improved sources of drinking water Percentage distribution of household population according to main source of drinking water and percentage of household members using improved drinking water sources, Mozambique, 2008 Selected characteristics Main source of drinking water To ta l Im pr ov ed s ou rc es o f d rin ki ng w at er * N um be r of h ou se ho ld m em be rs Improved sources Unimproved sources P ip ed in to th e ho us e P ip ed in to y ar d or p lo t P ub lic ta p/ st an dp ip e In n ei gh bo ur ’s h ou se P ro te ct ed w el l o r bo re ho le w ith h an d pu m p B ot tle d/ m in er al w at er W ith ou t h an d pu m p U np ro te ct ed w el l R ai n w at er W at er fr om r iv er s, la ke s O th er In fo rm at io n no t av ai la bl e Total 2.1 5.6 9.2 6.2 19.8 0.1 4.5 36.1 0.2 16.0 0.2 0.0 100.0 43.0 64,214 Area of residence Urban 6.2 16.7 19.7 17.8 9.3 0.2 6.6 20.2 0.3 2.8 0.1 0.0 100.0 69.9 20,952 Rural 0.1 0.3 4.1 0.5 25.0 0.0 3.5 43.8 0.2 22.4 0.2 0.0 100.0 29.9 43,263 Province Niassa 1.1 0.4 5.3 1.8 35.4 0.0 4.7 27.3 0.0 23.7 0.1 0.0 100.0 44.1 3,761 Cabo Delgado 0.5 1.4 5.1 3.0 19.9 0.0 6.4 47.3 0.1 16.2 0.1 0.0 100.0 29.9 6,473 Nampula 2.1 3.9 7.6 5.2 24.3 0.0 2.7 41.5 0.0 12.6 0.2 0.0 100.0 43.1 11,520 Zambezia 0.3 0.9 5.1 2.7 14.7 0.0 2.0 49.5 0.1 24.7 0.0 0.1 100.0 23.6 10,718 Tete 0.0 0.5 8.6 1.6 23.4 0.0 2.2 35.6 0.1 27.7 0.2 0.1 100.0 34.2 5,634 Manica 0.8 1.4 5.4 1.8 22.6 0.0 5.0 36.9 0.0 25.4 0.7 0.0 100.0 32.0 2,965 Sofala 2.7 7.3 14.0 8.1 15.9 0.0 1.5 38.5 0.0 12.0 0.0 0.0 100.0 48.0 6,737 Inhambane 0.6 3.4 6.1 4.0 20.9 0.0 8.9 49.2 2.4 4.5 0.0 0.0 100.0 34.9 4,223 Gaza 1.3 6.4 16.1 5.1 31.8 0.0 8.0 17.5 0.3 11.8 1.7 0.0 100.0 60.7 4,256 Maputo Province 4.1 21.9 12.0 19.8 9.7 0.2 12.3 10.3 0.0 9.5 0.2 0.0 100.0 67.7 4,294 Maputo City 14.5 29.1 24.4 24.2 1.0 1.2 3.9 1.7 0.0 0.0 0.0 0.1 100.0 94.3 3,633 Level of education Never went to school 0.5 2.0 6.0 2.9 22.4 0.0 4.0 39.5 0.1 22.4 0.1 0.0 100.0 33.8 14,461 Primary 1.1 4.1 9.3 5.4 20.0 0.0 4.5 39.1 0.3 15.9 0.2 0.0 100.0 40.0 40,612 Secondary + 9.6 19.3 13.8 15.2 14.6 0.5 4.9 15.6 0.0 6.0 0.4 0.0 100.0 73.1 8,451 No reply/don’t know 1.4 5.9 9.1 7.1 17.6 0.0 6.4 38.2 0.7 12.1 1.5 0.0 100.0 41.1 690 Wealth index quintile Poorest 0.0 0.0 0.0 0.0 12.6 0.0 0.0 58.8 0.0 28.6 0.0 0.0 100.0 12.6 12,862 Second 0.0 0.0 0.5 0.0 22.3 0.0 1.4 51.4 0.1 24.3 0.1 0.0 100.0 22.8 12,826 Middle 0.0 0.0 9.4 1.0 33.9 0.0 6.9 33.3 0.0 15.0 0.2 0.1 100.0 44.4 12,840 Fourth 0.4 2.4 17.5 6.7 22.9 0.0 8.3 30.2 0.5 10.8 0.4 0.0 100.0 49.9 12,845 Richest 9.9 25.8 18.4 23.1 7.5 0.4 5.8 6.8 0.5 1.3 0.4 0.0 100.0 85.1 12,841 * MICS indicador 11; MDG indicador 7.8 Unprotected wells and water from rivers or lakes are the main sources of water for 36 per cent and 16 per cent of households interviewed, respectively. Fetching water from unprotected wells is more frequent in rural areas (44 per cent) than in urban areas (20 per cent). In urban areas, the population uses more water from improved sources, namely, from public taps or standpi- pes (20 per cent), from a neighbour’s house (18 per cent), or piped outside the house/in the yard (17 per cent). The figures for the rural areas are 4 per cent, 1 per cent and 0 per cent, respectively. 60 Graph 7.1: Improved water sources, Mozambique, 2008 Piped into yard or plot, 6% Piped into the house, 2% Bottled/ mineral water, 0% In neighbour´s house, 6% Public tap/ standpipe, 9% Protected well or borehole with hand pump, 20% The analysis by province shows that Maputo City has almost universal access to clean drinking water (94 per cent). The percentage of people who use improved drinking water sources is also higher than the national average in Maputo province (68 per cent), Gaza (61 per cent) and Sofala (48 per cent). The provinces with the lowest rates for using clean drinking water are Zambézia (24 per cent), Cabo Delgado (30 per cent), Manica (32 per cent), Tete (34 per cent) and Inhambane (35 per cent). Table 7.1 also shows that there is a relation between the level of education of the head of hou- sehold and the use of improved sources of drinking water, as well as between the latter and the level of household wealth. Seventy-three per cent of households where the head has secondary education or higher use improved water sources, compared with 34 per cent among those whe- re the head never went to school. Likewise, the use of improved drinking water sources is more frequent in the richest wealth quintile (85 per cent) than in the poorest (13 per cent). Graph 7.2: Access to drinking water by wealth quintile, Mozambique, 2008 14 P er ce nt ag e 100 80 60 40 20 0 13 44 50 23 85 Poorest Second Middle Fourth Richest National average 61 Mozambique – Multiple Indicators Cluster Survey 2008 Graph 7.3: Percentage of households with access to drinking water, Mozambique, 2004 and 2008 P er ce nt ag e 100 80 60 40 20 0 2004 (IFTRAB) 2008 (MICS) 36 23 30 66 70 43 Total Urban Rural There are various ways of treating water to make it safer to drink, such as boiling, adding bleach or chlorine, straining through a cloth, using a water filter, solar disinfection, and letting it stand and settle, among others. MICS asked the households how they treated their water at home to make it safe to drink. The great majority of households (89 per cent) do not treat their water at all (Table 7.2). This percentage is still higher in rural areas (94 per cent). In urban areas, more than one in five households use water treatment methods. This fact is a matter of concern, when one considers that, as Table 7.1 shows, 44 per cent and 22 per cent of households in rural areas fetch water for drinking from unprotected wells and from rivers or lakes, respectively. Adding bleach or chlorine and boiling, each with 5 per cent, are the methods most used by households to treat water for drinking. Paradoxically, treatment of water is more common among those who use water from improved sources (15 per cent) than among those who use water from unimproved sources (5 per cent). At the provincial level, water treatment is most common in Maputo City (27 per cent) and Maputo province (18 per cent), and least common in the provinces of Tete and Cabo Delgado (each 3 per cent) and Zambézia (5 per cent), which are also the provinces with the lowest rate of using safe water sources. Water treatment is more common in households where the head has secondary education or higher (30 per cent) and much less common where the head of household has no schooling at all (4 per cent). It is also more common in households in the richest wealth quintile (28 per cent) and least common in the poorest quintile (2 per cent). 62 Table 7.2: Household water treatment Percentage distribution of household population according to drinking water treatment method used, and percentage of household members who used an appropriate water treatment method, by selected characteristics, Mozambique, 2008 Selected characteristics Water treatment method used in the household N on e B oi lin g A dd b le ac h/ ch lo rin e S tr ai n th ro ug h a cl ot h U se w at er fi lte r S ol ar d is in fe ct io n Le t i t s ta nd a nd s et tle O th er D on ’t kn ow F or a ll dr in ki ng w at er s ou rc es : ap pr op ria te w at er tr ea tm en t m et ho d * N um be r of h ou se ho ld s Im pr ov ed d rin ki ng w at er s ou rc es : ap pr op ria te w at er tr ea tm en t m et ho d N um be r of h ou se ho ld s U ni m pr ov ed d rin ki ng w at er so ur ce s: a pp ro pr ia te w at er tr ea tm en t m et ho d N um be r of h ou se ho ld s Total 88.8 4.8 5.0 0.2 0.1 0.0 1.2 0.2 0.0 9.6 64,214 14.7 30,604 4.9 33,610 Area of residence Urban 78.5 11.2 9.2 0.3 0.2 0.0 1.3 0.4 0.0 19.7 20,952 22.9 16,087 9.2 4,865 Rural 93.8 1.7 3.0 0.1 0.0 0.0 1.2 0.1 0.0 4.7 43,263 5.7 14,518 4.1 28,745 Province Niassa 92.5 3.1 3.1 0.9 0.0 0.0 0.2 0.0 0.2 6.2 3,761 6.9 1,834 5.5 1,927 Cabo Delgado 96.2 1.2 1.6 0.1 0.0 0.0 0.2 0.3 0.0 2.9 6,473 4.2 2,358 2.1 4,115 Nampula 84.6 6.5 3.9 0.0 0.1 0.0 5.2 0.0 0.0 10.2 11,520 18.1 5,280 3.5 6,240 Zambézia 94.7 2.0 3.1 0.3 0.0 0.0 0.2 0.0 0.0 4.9 10,718 9.0 2,756 3.4 7,962 Tete 96.9 1.8 1.0 0.0 0.0 0.0 0.1 0.0 0.0 2.8 5,634 2.7 2,051 2.8 3,583 Manica 83.0 1.3 15.4 0.2 0.0 0.0 0.0 0.0 0.0 16.6 2,965 24.3 1,097 12.0 1,867 Sofala 83.1 6.3 10.0 0.1 0.0 0.0 1.0 0.1 0.0 15.4 6,737 23.1 3,335 7.9 3,402 Inhambane 92.3 3.8 2.9 0.2 0.1 0.0 0.6 0.6 0.0 6.5 4,223 9.8 1,954 3.7 2,269 Gaza 91.9 1.9 5.5 0.1 0.2 0.0 0.4 0.5 0.0 7.3 4,256 8.3 2,937 5.2 1,319 Maputo Province 81.4 8.6 9.7 0.1 0.2 0.0 0.3 0.7 0.0 17.9 4,294 16.8 3,435 22.6 859 Maputo City 72.2 20.4 7.1 0.3 0.6 0.0 0.0 0.0 0.0 27.3 3,633 27.4 3,567 20.3 66 Level of education Never went to school 94.4 1.9 2.3 0.1 0.1 0.0 1.2 0.0 0.0 4.1 14,461 6.4 5,488 2.7 8,973 Primary 91.3 3.4 3.9 0.2 0.1 0.0 1.2 0.2 0.0 7.2 40,612 9.9 18,189 5.0 22,423 Secondary + 67.9 16.7 14.7 0.4 0.2 0.0 1.2 0.5 0.0 30.3 8,451 35.3 6,595 12.6 1,856 No reply/don’t know 85.9 4.5 8.6 0.0 0.0 0.0 2.3 0.0 0.0 11.7 690 10.9 333 12.5 358 Wealth index quintile Poorest 96.1 0.7 1.3 0.3 0.0 0.0 1.3 0.0 0.0 2.0 12,862 1.8 1,623 2.1 11,239 Second 95.7 1.4 1.6 0.0 0.1 0.0 0.9 0.1 0.0 3.1 12,826 2.6 3,111 3.2 9,715 Middle 92.3 2.6 3.2 0.1 0.0 0.0 1.5 0.0 0.0 5.9 12,840 4.6 6,600 7.2 6,240 Fourth 89.4 3.0 5.8 0.3 0.1 0.0 1.5 0.1 0.0 8.7 12,845 9.6 7,536 7.4 5,309 Richest 70.6 16.2 13.1 0.2 0.2 0.0 0.8 0.6 0.0 28.2 12,841 28.8 11,734 22.5 1,106 * MICS indicator 13 The survey also gathered information about the time needed to reach the nearest water source, fetch water and return home. When households have to walk for more than five minutes to ob- tain water from the nearest source, it is probable that they will not use more than the minimum amount needed for hygiene, drinking and cooking (rather than the recommended norm of 20 litres per capita per day). The amount of time the household spends fetching water is shown in Table 7.3. Information on the number of trips made per day was not collected. The results show that only 9 per cent of households in Mozambique have a source of drinking water located on their own premises, which breaks down into 25 per cent in urban areas and 2 per cent in rural areas. About 19 per cent of households take less than 15 minutes to reach the source, fetch the water and return home, and a further 19 per cent take between 15 and 30 minutes. Twenty-five per cent of households take between half an hour and an hour. About 26 per cent of households take an hour or more to reach the water source and return. 63 Mozambique – Multiple Indicators Cluster Survey 2008 Excluding households with water on the premises, the average time taken to reach the nearest source of drinking water, fetch the water and return home is 49 minutes. Households in rural areas spend more time (53 minutes) than those in urban areas (37 minu- tes). At the provincial level, the difference is very significant. Gaza province has the highest average time spent in reaching the nearest source, fetching water and returning home (96 minutes), followed by Cabo Delgado (71 minutes) and Inhambane (65 minutes). Maputo City has the lowest average time spent (15 minutes), followed by Niassa (22 minutes) and Maputo province (28 minutes). In the remaining provinces, the average time spent is between half an hour and an hour. Households where the head has secondary education or higher spend less time fetching drinking water (35 minutes) than households where the head has no education (52 minutes). Table 7.3: Time taken to reach the source, fetch water and return Percentage distribution of households according to time spent to go to water source and return, and average time to source of drinking water, by selected characteristics, Mozambique, 2008 Selected characteristics Time to go to drinking water source and return To ta l A ve ra ge ti m e to g o to d rin ki ng w at er s ou rc e an d re tu rn (m in ut es ) N um be r of h ou se ho ld m em be rs W at er o n pr em is es Le ss th an 1 5 m in ut es 15 m in ut es to le ss th an 30 m in ut es 30 m in ut es to le ss th an 1 ho ur 1 ho ur o r m or e D on ’t kn ow In fo rm at io n no t a va ila bl e Total 9.1 19.4 19.0 25.0 26.3 0.8 0.3 100.0 48.7 13,955 Area of residence Urban 24.6 27.9 15.2 15.4 15.5 0.4 0.9 100.0 37.1 4,338 Rural 2.2 15.5 20.8 29.3 31.1 1.0 0.1 100.0 52.7 9,617 Province Niassa 5.2 34.2 31.1 24.8 4.4 0.1 0.1 100.0 21.9 833 Cabo Delgado 3.8 16.9 17.6 26.4 35.3 0.0 0.0 100.0 70.6 1,512 Nampula 5.1 11.6 18.5 26.9 37.1 0.0 0.7 100.0 52.0 2,568 Zambézia 2.5 18.0 23.6 31.9 20.5 3.3 0.1 100.0 36.0 2,532 Tete 0.5 19.6 29.9 34.6 15.1 0.0 0.3 100.0 32.4 1,281 Manica 6.8 18.6 17.7 27.8 29.0 0.0 0.2 100.0 54.0 627 Sofala 13.4 18.2 16.6 19.5 32.3 0.0 0.0 100.0 55.0 1,108 Inhambane 10.5 18.8 11.5 22.2 36.1 0.8 0.1 100.0 65.0 946 Gaza 8.0 7.6 11.3 19.4 52.3 1.4 0.0 100.0 96.4 845 Maputo Province 29.9 33.7 11.5 14.4 9.2 1.1 0.3 100.0 28.2 952 Maputo City 44.2 36.7 9.0 5.5 2.5 0.0 2.1 100.0 15.3 751 Level of education Never went to school 3.5 15.9 19.4 30.3 29.5 1.2 0.1 100.0 52.4 3,429 Primary 6.9 18.9 20.0 25.2 28.0 0.7 0.2 100.0 49.5 8,588 Secondary + 30.3 27.8 13.6 14.0 12.5 0.4 1.4 100.0 34.6 1,802 No reply/don’t know 12.8 21.4 21.5 24.7 18.5 1.1 0.0 100.0 37.0 137 Wealth index quintile Poorest 0.7 13.7 20.1 30.3 33.8 1.1 0.1 100.0 52.3 2,866 Second 1.3 14.3 21.8 31.5 29.9 1.2 0.0 100.0 52.9 3,029 Middle 1.7 18.5 22.6 28.1 28.2 0.6 0.4 100.0 48.4 2,975 Fourth 7.1 22.1 17.4 23.1 29.2 0.8 0.2 100.0 52.7 2,630 Richest 39.9 30.2 11.8 9.2 7.5 0.2 1.2 100.0 27.1 2,455 64 MICS sought to find out who normally goes to the source to fetch water for the members of the household. Table 7.4 and Graph 7.4 show the percentage distribution of people who normally fetch water for the household. In the great majority of households, the person who fetches water when the source of drinking water is not on the premises is an adult woman (85 per cent). In about 7 per cent of households the person is a girl under 15. Adult men fetch water in only 6 per cent of households. Boys under 15 are charged with fetching water in 1 per cent of households. It is more frequent for adult men to fetch water in urban areas (10 per cent) than in rural areas (5 per cent). Table 7.4: Person who fetches water Percentage distribution of households according to the person who fetches water for the household, by selected characteristics, Mozambique, 2008 Selected characteristics Person who fetches water for the household NA Number of households Adult woman Adult man Girl (under 15 years old) Boy (under 15 years old) Don’t know Total 85.3 6.3 6.5 1.3 0.6 100.0 12,520 Area of residence Urban 78.9 9.7 8.0 2.5 0.9 100.0 3,216 Rural 87.5 5.1 6.0 0.9 0.4 100.0 9,304 Province Niassa 89.1 7.2 2.7 0.5 0.5 100.0 787 Cabo Delgado 90.2 5.0 4.1 0.1 0.6 100.0 1,455 Nampula 78.1 7.1 10.7 2.9 1.3 100.0 2,418 Zambézia 86.2 4.9 7.7 1.0 0.2 100.0 2,382 Tete 93.1 3.1 3.0 0.4 0.4 100.0 1,271 Manica 89.5 6.2 3.0 1.1 0.2 100.0 584 Sofala 90.2 4.7 4.1 0.8 0.2 100.0 960 Inhambane 88.2 6.5 4.5 0.7 0.1 100.0 838 Gaza 81.1 5.4 10.7 2.7 0.1 100.0 765 Maputo Province 72.9 14.4 8.1 3.1 1.5 100.0 658 Maputo City 77.1 14.5 6.2 1.3 0.9 100.0 403 Level of education Never went to school 85.9 4.5 7.4 1.4 0.8 100.0 3,261 Primary 86.4 5.6 6.2 1.2 0.5 100.0 7,916 Secondary + 76.8 15.7 5.4 1.9 0.2 100.0 1,224 No reply/don’t know 79.6 7.4 11.4 0.6 0.9 100.0 118 Wealth index quintile Poorest 89.6 2.8 6.4 0.8 0.5 100.0 2,810 Second 88.8 4.4 5.5 0.8 0.6 100.0 2,954 Middle 86.4 6.3 5.7 1.0 0.6 100.0 2,897 Fourth 81.7 7.6 7.9 2.6 0.2 100.0 2,416 Richest 73.5 14.9 8.3 2.2 1.1 100.0 1,443 At the provincial level, the use of girls under 15 to fetch water is most pronounced in Gaza and Nampula (both with 11 per cent), and Maputo province and Zambézia (both with 8 per cent), while the use of boys under 15 is greatest in Maputo province, Nampula and Gaza (all with 3 per cent). 65 Mozambique – Multiple Indicators Cluster Survey 2008 Graph 7.4: Person who fetches water, Mozambique, 2008 Girl (under 15 years old), 7% Boy (under 15 years old), 1% Adult man, 6% Adult woman, 85% Sanitation Inadequate disposal of human excreta is associated with a range of diseases, including diarrho- eal diseases. Sanitary facilities for the safe elimination of excrement include the following: flush toilets, toilets without flush, improved latrines and improved traditional latrines. Table 7.5 and Graph 7.5 show that only 19 per cent of people in Mozambique live in households that use improved sanitation facilities principally traditional latrine (8 per cent) and latrine (7 per cent). Toilets with and without flush are used by a total of 5 per cent of households. As Graph 7.6 shows, this percentage is a slight improvement when compared with the figures from 2004, when the estimated coverage was 12 per cent (IFTRAB 2004). Almost half the people use improved sanitation facilities in urban areas (47 per cent), while in rural areas, rather more than one in every 20 people use them (6 per cent). In rural areas, the population mainly use latrines without slabs or simply have no sanitation faci- lities. The data show that 54 per cent use the bush, 39 per cent use unimproved latrines, 4 per cent use improved traditional latrines, and only 1 per cent use improved latrines. The most com- mon sanitation facilities in urban areas are unimproved latrines (38 per cent), improved latrines (18 per cent), and

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