Myanmar - Multiple Indicator Cluster Survey - 2009

Publication date: 2009

Myanmar Multiple Indicator Cluster Survey 2009 - 2010 Ministry of National Planning and Economic Development Ministry of Health UNICEF United Nations Children’s Fund October 2011   The Myanmar Multiple Indicator Cluster Survey (MICS) was carried out by the Department of Planning under the Ministry of National Planning and Economic Development; in collaboration with the Department of Health Planning and Department of Health under the Ministry of Health, Myanmar. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). The MICS Steering Committee and MICS Working Committee were composed of members from the Planning Department, Foreign Economic Relations Department and Central Statistical Organization under the Ministry of National Planning and Economic Development; Department of Health, Department of Health Planning and Department of Medical Research (Central Myanmar) under the Ministry of Health; Department of Educational Planning and Training under the Ministry of Education; Department of Social Welfare under the Ministry of Social Welfare, Relief and Resettlement; Department of Population under the Ministry of Immigration and Population; Department of Progress of Border Areas and National Races and Department of Development Affairs under the Ministry of Progress of Border Areas and National Races; the General Administrative Department under the Ministry of Home Affairs; Myanmar Maternal and Child Welfare Association; and Myanmar Red Cross Society. The survey has been conducted as part of the third round of MICS surveys (MICS3), carried out around the world in more than 50 countries, from 2005, following the first two rounds of MICS surveys that were conducted globally in 1995 and the year 2000. Survey tools are based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Ministry of National Planning and Economic Development and Ministry of Health, Myanmar, 2011. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 Final Report. Nay Pyi Taw, Myanmar. Ministry of National Planning and Economic Development and Ministry of Health, Myanmar.   Cover Photo : ©UNICEF Myanmar/2010/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 i Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Myanmar, 2009-2010 Topic MICS Indicator Number MDG Indicator Number Indicator Value NUTRITION Nutritional status 6 4 Underweight prevalence Moderate 22.6 per cent Severe 5.6 per cent 7 Stunting prevalence Moderate 35.1 per cent Severe 12.7 per cent 8 Wasting prevalence Moderate 7.9 per cent Severe 2.1 per cent Breastfeeding 45 Timely initiation of breastfeeding 75.8 per cent 15 Exclusive breastfeeding rate 23.6 per cent 16 Continued breastfeeding rate at 12-15 months 91.0 per cent at 20-23 months 65.4 per cent 17 Timely complementary feeding rate 80.9 per cent 18 Frequency of complementary feeding 56.5 per cent 19 Adequately fed infants 41.0 per cent Vitamin A 42 Vitamin A supplementation (under-fives) 55.9 per cent 43 Vitamin A supplementation (post-partum mothers) 66.4 per cent Low birth weight 9 Low birth weight infants 8.6 per cent 10 Infants weighed at birth 56.3 per cent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 97.2 per cent 26 Polio immunization coverage 95.9 per cent 27 DPT immunization coverage 95.9 per cent 28 15 Measles immunization coverage 90.7 per cent 31 Fully immunized children 88.6 per cent 29 Hepatitis B immunization coverage 95.9 per cent Tetanus toxoid 32 Neonatal tetanus protection 91.8 per cent Care of illness 33 Use of oral rehydration therapy (ORT) 66.3 per cent 34 Home management of diarrhoea 15.5 per cent 35 Received ORT or increased fluids, and continued feeding 50.3 per cent 23 Care seeking for suspected pneumonia 69.3 per cent 22 Antibiotic treatment of suspected pneumonia 34.2 per cent Solid fuel use 24 29 Solid fuels 94.3 per cent Myanmar Multiple Indicator Cluster Survey 2009 - 2010 ii CHILD MORTALITY Child mortality 1 13 Under-five mortality rate 46.1 per thousand 2 14 Infant mortality rate 37.5 per thousand ENVIRONMENT Water and Sanitation 11 30 Use of improved drinking water sources 82.3 per cent 13 Water treatment 34.5 per cent 12 31 Access to improved sanitation facilities 84.6 per cent REPRODUCTIVE HEALTH Contraception 21 19c Contraceptive prevalence 46.0 per cent Maternal and newborn health 20 Antenatal care 83.1 per cent 44 Content of antenatal care Blood pressure measured 80.1 per cent Urine specimen taken 56.9 per cent Weight measured 63.6 per cent 4 17 Skilled attendant at delivery 70.6 per cent 5 Institutional deliveries 36.2 per cent CHILD DEVELOPMENT Child development 46 Support for learning 57.9 per cent 47 Father's support for learning 44.0 per cent EDUCATION Education 52 Pre-school attendance 22.9 per cent 53 School readiness 39.8 per cent 54 Net intake rate in primary education 74.4 per cent 55 6 Net primary school attendance rate 90.2 per cent 56 Net secondary school attendance rate 58.3 per cent 57 7 Grade promotion from grade 1 to grade 5 93.3 per cent 58 Transition rate to secondary school 95.3 per cent 59 7b Net primary completion rate 54.2 per cent 61 9 Gender Parity Index Primary 1.01 ratio Secondary 1.01 ratio Literacy 60 8 Young female literacy rate 87.8 per cent CHILD PROTECTION Birth registration 62 Birth registration 72.4 per cent 75 Prevalence of orphans 6.6 per cent 78 Children’s living arrangements 5.4 per cent 68 Young women aged 15-19 currently married 7.4 per cent HIV/AIDS HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young women 31.8 per cent 89 Knowledge of mother-to-child transmission of HIV 65.0 per cent 86 Attitude towards people with HIV/AIDS 34.9 per cent 87 Women who know where to be tested for HIV 70.6 per cent 88 Women who have been tested for HIV 17.6 per cent Myanmar Multiple Indicator Cluster Survey 2009 - 2010 iii Contents Summary Table of Findings i Contents iii List of Tables v List of Figures vii List of Abbreviations viii Acknowledgements ix Executive Summary xi I. Introduction 1 Background 1 Survey Objectives 3 II. Sample and Survey Methodology 4 Sample Design 4 Questionnaires 4 Training and Fieldwork 5 Data Processing 7 III. Sample Coverage and the Characteristics of Households and Respondents 8 Sample Coverage 8 Characteristics of Households 8 Characteristics of Respondents 10 IV. Child Mortality 11 V. Nutrition 14 Nutritional Status 14 Breastfeeding 16 Vitamin A Supplements 20 Low Birth Weight 21 VI. Child Health 24 Immunization 24 Tetanus Toxoid 26 Oral Rehydration Treatment 27 Care Seeking and Antibiotic Treatment of Pneumonia 29 Solid Fuel Use 31 VII. Environment 32 Water and Sanitation 32 VIII. Reproductive Health 36 Contraception 36 Antenatal Care 36 Assistance at Delivery 38 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 iv IX. Child Development 40 X. Education 42 Pre-School Attendance and School Readiness 42 Primary and Secondary School Participation 43 Young Female Literacy 47 XI. Child Protection 48 Birth Registration 48 Early Marriage 49 Orphans and Children’s Living Arrangements 50 XII. HIV/AIDS 52 Knowledge of HIV Transmission 52 List of References 56 Appendix A. Sample Design 124 Appendix B. List of Personnel Involved in the Survey 130 Appendix C. Estimates of Sampling Errors 134 Appendix D. Data Quality Tables 176 Appendix E. MICS Indicators: Numerators and Denominators 183 Appendix F. Questionnaires 187 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 v List of Tables Table HH.1: Results of household and individual interviews 59 Table HH.2: Household age distribution by sex 60 Table HH.3: Household composition 61 Table HH.4: Women's background characteristics 62 Table HH.5: Children's background characteristics 63 Table CM.1: Child mortality 64 Table CM.2: Child mortality by background characteristics 64 Table NU.1: Child malnourishment (WHO Standard) 65 Table NU.1A: Child malnourishment (NCHS Standard) 67 Table NU.2: Initial breastfeeding 68 Table NU.3: Breastfeeding 69 Table NU.4: Adequately fed infants 70 Table NU.5: Children's vitamin A supplementation 71 Table NU.6: Post-partum mothers' vitamin A supplementation 72 Table NU.7: Low birth weight infants 73 Table CH.1: Vaccinations in first year of life 74 Table CH.1c: Vaccinations in first year of life (continued) 74 Table CH.2: Vaccinations by background characteristics 75 Table CH.2c: Vaccinations by background characteristics (continued) 76 Table CH.3: Neonatal tetanus protection 77 Table CH.4: Oral rehydration treatment 78 Table CH.5: Home management of diarrhoea 79 Table CH.6: Care seeking for suspected pneumonia 80 Table CH.7: Antibiotic treatment of pneumonia 81 Table CH.8: Knowledge of the two danger signs of pneumonia 82 Table CH.9: Solid fuel use 83 Table CH.10: Solid fuel use by type of stove or fire 84 Table EN.1: Use of improved water sources 85 Table EN.2: Household water treatment 87 Table EN.3: Time to source of water 89 Table EN.4: Person collecting water 90 Table EN.5: Access to sanitary means of excreta disposal 91 Table EN.6: Use of improved water sources and access to improved sanitation 93 Table RH.1: Use of contraception 94 Table RH.2: Antenatal care provider 96 Table RH.3: Antenatal care content 98 Table RH.4: Assistance during delivery 99 Table CD.1: Family support for learning 101 Table ED.1: Early childhood education 103 Table ED.2: Primary school entry 104 Table ED.3: Primary school net attendance ratio 105 Table ED.4: Secondary school net attendance ratio 106 Table ED.4A: Secondary school age children attending primary school 107 Table ED.5: Grade promotion rate from grade 1 to grade 5 108 Table ED.6: Primary school completion and transition to secondary education 109 Table ED.7: Education gender parity 110 Table ED.8: Young female literacy 111 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 vi Table CP.1: Birth registration 112 Table CP.2: Early marriage 113 Table CP.3: Children's living arrangements and orphanhood 114 Table HA.1: Knowledge of preventing HIV transmission 116 Table HA.2: Identifying misconceptions about HIV/AIDS 117 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission 118 Table HA.4: Knowledge of mother-to-child HIV transmission 119 Table HA.5: Attitudes toward people living with HIV/AIDS 120 Table HA.6: Knowledge of a facility for HIV testing 121 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 vii List of Figures Figure HH.1: Age and Sex Distribution of Household Population, Myanmar, 9 2009-2010 Figure CM.1: Infant Mortality and Under 5 Mortality rates by sex, mother's education 13 level and wealth quintile, Myanmar 2009-2010 Figure NU.1: Percentage of children under 5 who are undernourished. Myanmar, 15 2009-2010 Figure NU.2: Percentage of mothers who started breastfeeding within one hour 17 and within one day of birth. Myanmar, 2009-2010 Figure NU.3: Infant feeding patterns by age: Per cent distribution of children aged 19 under 3 years by feeding pattern by age group. Myanmar, 2009-2010 Figure NU.4: Percentage of infants weighing less than 2,500 grams at birth. 23 Myanmar, 2009-2010 Figure CH.1: Percentage of children aged 12-23 months who received the 25 recommended vaccination by 12 months, Myanmar, 2009-2010 Figure CH.2: Percentage of women with a live birth in the last 24 months who are 26 protected against neonatal tetanus. Myanmar, 2009-2010 Figure CH.3: Percentage of children aged 0-59 months with diarrhoea who received 28 oral rehydration treatment. Myanmar, 2009-2010 Figure CH.4: Percentage of children aged 0-59 months with diarrhoea who received 29 ORT or increased fluids, AND continued feeding. Myanmar, 2009-2010 Figure EN.1: Percentage distribution of household members by source of drinking 32 water. Myanmar, 2009-2010 Figure ED.1: Percentage of children aged 36-59 months currently attending early 43 childhood education by area of residence, mother’s education level and wealth quintile. Myanmar 2009-2010 Figure ED.2: Net primary completion rate by area of residence, mother’s education 46 level and wealth quintile. Myanmar, 2009-2010 Figure CP.1: Percentage of children aged 0-59 months whose birth is registered by area of residence, mother’s education level and wealth quintile. 49 Myanmar, 2009-2010 Figure HA.1: Per cent of women who have comprehensive knowledge of HIV/AIDS 53 transmission by education level, Myanmar, 2009-2010 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 viii   List of Abbreviations AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CEU Central Epidemiological Unit CRC Convention on the Rights of the Child CRR Children’s Response Rate CSPro Census and Survey Processing System DHP Department of Health Planning DoH Department of Health DPT Diphteria Pertussis Tetanus EPI Expanded Programme on Immunization GPI Gender Parity Index GPS Global Positioning System HHRR Household Response Rate HIV Human Immunodeficiency Virus IUD Intrauterine Device LAM Lactational Amenorrhea Method LHV Lady Health Visitor MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH Ministry of Health NAR Net Attendance Rate NHC National Health Committee ORS Oral Rehydration Salt ORT Oral Rehydration Treatment RHF Recommended Homemade Fluid PD Planning Department PPS Probability proportional to size PSU Primary sampling unit SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infection TB Tuberculosis TOT Training of Trainers UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization WRR Women’s Response Rate   Myanmar Multiple Indicator Cluster Survey 2009 - 2010 ix Acknowledgements Myanmar Multiple Indicator Cluster Survey (2009-2010) was conducted by Planning Department, Ministry of National Planning and Economic Development and Department of Health Planning, Ministry of Health with the collaborations of other ministries including Ministry of Education, Ministry of Home Affairs, Ministry of Progress of Border Areas and National Races and Development Affairs (Currently Ministry of Border Affairs), Ministry of Immigration, Ministry of Social Welfare, Relief and Resettlement, and NGOs such as Myanmar Maternal and Child Welfare Association, Myanmar Red Cross Society. Deputy Director General of those ministries participated as members of Steering Committee which was chaired by Director General of Planning Department. Deputy Director General of Department of Health Planning acted as secretary for Steering Committee. In addition, Deputy Director General of Department of Health Planning chaired the Technical Committee and directors of the above ministries participated as members. UNICEF Myanmar has provided funding and technical assistance for data collection, analysis as well as publication of report. UNICEF Headquarters in New York and Regional Office in Bangkok have provided knowledge and advice in data processing and report preparation. The Ministry of National Planning and Economic Development and Ministry of Health acknowledge officials from ministries concerned for their valuable suggestions and efforts. In addition, the ministries would like to thank UNICEF for their funding and assistance. Special thanks also go to the Director General Daw Lai Lai Thein, Planning Department who dedicated best of the efforts during the survey and preparing the report. Finally, the ministries thank the report main contributors, officials from Planning Department, Department of Medical Research (Central Myanmar) and UNICEF for their efforts and time in preparing the report. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 x ©UNICEF Myanmar/2010/Nyaung U Pho Cho Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xi Executive Summary Myanmar MICS 2009-2010 was conducted by the Planning Department, Department of Health Planning and the Department of Health. Its main objectives are to provide updated information for assessing the situation of children and women in Myanmar; to furnish data needed for monitoring progress towards the Millennium Development Goals and other internationally agreed goals; and to contribute to the improvement of data collection and monitoring systems in Myanmar. Myanmar MICS 2009-2010 is a nationally representative survey designed to provide estimates at national level, for urban and rural areas and for each of the 17 states and divisions. Data collection was mainly undertaken between October 2009 and March 2010, although data were collected from four clusters already in June 2009. A sample of 29,250 households was selected, of which 29,238 households were successfully interviewed. Data were collected for indicators at household level, as well as for 38,081 individual women aged 15 to 49, and 15,539 children under five. Data are disaggregated by gender, area of residence, education level and wealth quintile. It is notable that most indicators do not show any significant differences between male and female children. Urban areas show better outcomes than rural areas on most indicators. There is wide variation among states and divisions, with Rakhine, Chin and Shan (North) States showing lower coverage than other states and divisions on most indicators. Disparities according to wealth level are also visible on most indicators. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. It is important to note that estimates should be treated with caution, due to the inherent difficulty in collecting accurate birth history data. The Myanmar infant mortality rate has been estimated at 37.5 per 1,000 live births. Under-five mortality rate is estimated at 46.1 per 1,000 live births. Infant and under-five mortality rates are higher in rural than in urban areas. The two lowest wealth quintiles show similar outcomes on child mortality, whereas there is a steady decline in the trend from the middle quintile to the richest. Comparisons across time indicate a decline in levels of infant and under-five mortality rates. Nutrition Nutritional status Children’s nutritional status is a reflection of their overall health. Overall, 22.6 per cent of Myanmar children aged under five are moderately underweight, and 5.6 per cent are severely underweight. 35.1 per cent are moderately stunted or too short for their age, while 12.7 per cent are severely stunted. 7.9 per cent of children are moderately wasted or too thin for their height, and 2.1 per cent are severely wasted. Whereas there is little difference between urban and rural children in terms of wasting, more children in rural areas are underweight and stunted than children in urban areas. Undernourishment in children is more common in Rakhine and Chin than in other states and divisions. When the mother has secondary or higher education, a lower percentage of children are underweight or stunted than if the mother has primary education only, but this difference is not significant for wasting. Undernourishment is more common among children in the poorest households. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xii Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. Three quarters (75.8 per cent) of Myanmar mothers initiate breastfeeding within one hour of birth, and 89.3 per cent of women begin breastfeeding within one day of birth. Mothers in urban areas are more likely to begin breastfeeding within one hour of birth than mothers in rural areas. The proportion of mothers initiating breastfeeding within one hour of birth increases with their level of education, as well as their wealth level. In Myanmar, 23.6 per cent of children are exclusively breastfed up to age six months. The prevalence of exclusive breastfeeding is slightly higher in rural areas than in urban areas. Exclusive breastfeeding rate varies between 1.3 per cent in Rakhine and 40.6 per cent in Kachin. There is no association between the mother’s education level and exclusive breastfeeding. In total, 80.9 per cent of children aged 6-9 months receive breast milk and solid or semi-solid foods. By age 12-15 months 91 per cent of children are still breastfed, and 65.4 per cent of children are still breastfed at age 20-23 months. Continued breastfeeding of children aged 20-23 months is more common in rural areas than in urban areas, and is least common among mothers with secondary or higher education and among the richest mothers. A total of 41 per cent of children aged 0-11 months are adequately fed. Infant feeding patterns are similar across urban and rural locations. Low levels of adequate feeding of infants is mainly due to the low prevalence of exclusive breastfeeding up to six months. Vitamin A supplements Vitamin A is essential for vision and proper functioning of the immune system. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months for all children aged 6-59 months. A total of 55.9 per cent of Myanmar children received a high-dose vitamin A supplement in the last six months. Additionally 11.9 per cent received the supplement more than six months ago, and 21.3 per cent of children received it but the mother or caregiver was unable to specify when. A total of 66.4 per cent of mothers with a birth in the previous two years received a vitamin A supplement within eight weeks of the birth. More mothers in rural areas than in urban areas received the supplement. Low Birth Weight Weight at birth is a good indicator of a mother’s health and nutritional status, as well as the newborn’s chances for survival and growth. Overall, 56.3 per cent of infants were weighed at birth, and 8.6 per cent of infants are estimated to weigh less than 2,500 grams at birth. The proportion of infants being weighed at birth varies across location of residence, mother’s level of education and the economic status of the household. Whereas 81.6 per cent of infants in urban areas are weighed at birth, only 46.1 per cent of infants in rural areas are weighed at birth. Child Health Immunization Immunization plays a key part in reducing child mortality. Immunization data for Myanmar MICS3 were collected from vaccination cards, from midwives’ registers and mothers’ recall if no written record was available. It could be interpreted that copying information from the records of midwives might affect data quality. It was found that 88.6 per cent of children are fully immunized by age one. Tuberculosis immunization coverage is reported as 97.2 per cent, and both polio and DPT immunization coverage were reported as 95.9 per cent. Measles immunization coverage is 90.7 per cent. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xiii Tetanus Toxoid Prevention of maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. As many as 91.8 per cent of Myanmar mothers with a birth in the last 24 months are protected against neonatal tetanus. The proportion of mothers who are protected against tetanus is slightly higher in urban areas (94.6 per cent) than in rural areas (90.7 per cent). There is also a difference according to wealth level. Whereas 87.2 per cent of the poorest women are protected against tetanus, the prevalence reaches 96.2 per cent among the richest women. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Overall, 6.7 per cent of under-five children had diarrhoea in the two weeks preceding the survey. Prevalence is highest in Chin State with 13.1 per cent. Overall, 66.3 per cent of children with diarrhoea in the last two weeks received either oral rehydration salts (ORS) or a recommended home-made fluid. Prevalence of oral rehydration treatment is highest among children in urban areas, children whose mother has secondary or higher education and children in the richest households. Overall, 50.3 per cent of children with diarrhoea received either ORT or increased fluid intake and at the same time continued feeding. Under-five children in urban areas are more likely than children in rural areas to receive ORT or increased fluids and continue feeding when sick with diarrhoea. In terms of socioeconomic differences, 43.8 per cent of diarrhoea cases among the poorest children are properly managed, compared to 65.3 per cent among the richest children. Adequate home management of diarrhoea is lowest among children aged 0-11 months, with 36.5 per cent. Care seeking and Antibiotic treatment of Pneumonia Pneumonia is the leading cause of death in children, in Myanmar and worldwide, and the use of antibiotics in under-fives with suspected pneumonia is a key intervention. Overall, 2.6 per cent of children under five had symptoms of pneumonia during the two weeks preceding interview, and 69.3 per cent of these were taken to an appropriate provider. A higher percentage of children with symptoms of pneumonia were taken to an appropriate provider in urban areas (74.4 per cent) than in rural areas (67.3 per cent). Whereas there is no clear association between children being taken to an appropriate provider and the education level of the mother, children from the richest households (77.3 per cent) are more likely to be taken to an appropriate provider than children from the poorest households (62.5 per cent). A total of 34.2 per cent of under-five children with suspected pneumonia in the two weeks preceding interview received antibiotics. Children whose mother has secondary or higher education (41.1 per cent) are more commonly treated with antibiotics when demonstrating symptoms of pneumonia than children whose mother has primary education (30.8 per cent). Overall, 6.5 per cent of mothers or caregivers of children under five know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptoms for seeking immediate health care are when the child develops a fever or becomes sicker. Awareness of the danger signs of pneumonia or recognition of other symptoms that would cause mothers or caregivers to take the child immediately to a health provider does not vary considerably between urban and rural areas or across other background characteristics. Solid fuel use Cooking and heating with solid fuels lead to high levels of indoor smoke, with a complex mix of health- damaging pollutants. A total of 94.3 per cent of households in Myanmar use solid fuels for cooking. In rural areas and among the poorest households the proportion of households using solid fuels for Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xiv cooking is above 99 per cent. Wood is the most commonly used type of fuel, followed by charcoal. As many as 97.6 per cent of households using solid fuels for cooking have an open stove or fire with no chimney or hood. Richer households (92.8 per cent) cooking with solid fuels less often have an open stove or fire with no chimney or hood than the poorest ones (99.3 per cent). Environment Water and Sanitation Safe drinking water and sanitation are basic necessities for good health. Overall, 82.3 per cent of the population use an improved source of drinking water. While 93.2 per cent of those in urban areas use an improved source of drinking water, 77.6 per cent of those in rural areas do so. Whereas 66.8 per cent of the poorest use an improved source of drinking water, 95 per cent of the richest quintile do so. The most common sources of drinking water are tube well/ bore hole and protected well. Overall, 34.5 per cent of Myanmar households use an appropriate water treatment method, mostly boiling (33.1 per cent) the water. The most common way of treating water is, however, straining it through a cloth, which will not make it safe to drink. Appropriate water treatment is most commonly found among the urban population and in the richest households. For 35 per cent of households, the drinking water source is on the premises, and 50.6 per cent need less than 15 minutes to go to the water source and collect water. Households in urban areas more commonly have water on their premises than those in rural areas. Excluding households with water on their premises, the average time it takes to collect water is 10.1 minutes in rural areas and 7.3 minutes in urban areas. In the majority of households (71.9 per cent) an adult female is the person usually collecting water when the water source is not on the premises. Children’s involvement in water collection is generally low. The tendency of women bearing the main responsibility for water collection is strongest in rural areas and among the poorest households. A total of 84.6 per cent of the population in Myanmar live in households with improved sanitation facilities. In urban areas 94.4 per cent have access to improved sanitation facilities, compared to 80.4 per cent in rural areas. In both rural and urban areas the most common type of sanitation facility is a pit latrine with slab. Population without access to sanitary facilities is found almost exclusively in rural areas, with 9.7 per cent of the rural population being without access to sanitary facilities. Overall, 72.3 per cent of the population both use improved sources of drinking water and have access to a sanitary means of excreta disposal. This figure is highest in the urban areas and among the richest fifth of the population. Reproductive Health Contraception Appropriate family planning is important to the health of women and children by preventing pregnancies that occur too early or too late in life; extending the period between births; and limiting the number of children. In Myanmar, 46 per cent of ever-married women use contraception. The most commonly used method is by injection. Contraceptive use is highest among women in urban areas, those with secondary or higher education, and among the richest women. Ever-married women with two children have the highest usage rate of contraceptives. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xv Antenatal care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Overall, 93.1 per cent of women with a birth in the two years preceding interview received antenatal care at least once during their pregnancy, from any type of provider. Coverage of antenatal care is higher in urban areas (98.3 per cent) than in rural areas (91 per cent). The vast majority of pregnant women with secondary or higher education as well as women in the richest households received antenatal care. Also as many as 86.2 per cent of the poorest women received antenatal care at least once during their pregnancy. A total of 83.1 per cent of ever-married women with a birth in the last two years received antenatal care from a skilled provider. More women in urban areas (95 per cent) than women in rural areas (78.4 per cent) receive antenatal care from a skilled provider. Women with secondary or higher education and who are among the richest quintile have the highest prevalence of receiving antenatal care from a skilled provider. Although prevalence of antenatal care is high, the content of antenatal care differs. In total, 80.1 per cent of women who received antenatal care had their blood pressure measured, 63.6 per cent had their weight measured, and 56.9 per cent had a urine sample taken. All indicators of content of antenatal care vary widely between states and divisions, as well as between urban and rural locations. Percentages on all aspects of antenatal care increase with the education level and wealth level of women. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth. In total, 70.6 per cent of births occurring in the two years preceding MICS interview were attended by skilled personnel. It is notable that in certain locations of the country (Chin and Shan (North)) more than one in ten women delivers without any attendance at all. The prevalence of skilled attendance at delivery is higher in urban areas than in rural areas, and also higher for women with secondary or higher education as well as among the richest women. Over one third (36.2 per cent) of women with a birth in the last two years delivered in a health facility, either government or private. The highest rate of institutional delivery is found in Yangon with 68.9 per cent. As is the case with skilled attendance at delivery, the rate of institutional delivery is higher in urban areas, among women with secondary or higher education and among the richest women. Child Development Adults' engagement in activities with children is an important determinant for children’s mental development in their first three or four years of life. For 57.9 per cent of the under-five children an adult member of household engaged in more than four activities that promote learning and school readiness during the three days preceding the interview. The average number of activities that adults engaged in with children was 3.8. Father’s engagement in one or more such activities was 44 per cent. A higher proportion of children in urban areas than children in rural areas have engaged with an adult member of the household in activities that promote learning. Furthermore, more urban children have been involved in such activities with their father. Education level of both mother and father as well as socioeconomic background is shown to play a role for adult household members’ engagement in activities with children. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xvi Education Pre-school Attendance and School Readiness Attendance to pre-school education in an organized learning or child education programme is important for the readiness of children to school. Overall, 22.9 per cent of Myanmar children aged 36-59 months attend early childhood education. Pre-school attendance in urban areas (39.1 per cent) is more than double that of rural areas (15.9 per cent). Whereas 46 per cent of children in the richest households attend early childhood education, the rate of attendance among the poorest children is as low as 7.6 per cent. Children whose mother has secondary or higher education (35.7 per cent) have a higher attendance of early childhood education than children whose mother has primary education (15.8 per cent). 39.8 per cent of children in the first grade of primary school attended pre-school in the previous year. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals. In Myanmar, 74.4 per cent of five-year-olds attend school, with no difference between girls and boys. Whereas there is only a slight difference between urban and rural areas, it is notable that while 80.7 per cent of children aged five from the richest households are in school, only 63.5 per cent of children from the poorest households have entered primary school. A total of 90.2 per cent of children of primary school age, which is five to nine years, attend school. While only 77.3 per cent of children aged five are in school, 95 per cent of both seven- and eight-year- olds are in school, indicating a tendency for children to begin school late. Only 58.3 per cent of children of secondary school age are in secondary school. The rate is as low as 28.2 per cent among children from the poorest households, compared to 85.5 per cent among children from the richest households. Overall, 11.9 per cent of secondary school aged children attend primary school. Among the poorest, almost one out of five (19.4 per cent) secondary school aged children are still in primary school, compared to 5 per cent of the richest children. The net primary completion rate (percentage of nine-year-olds who are in the last grade of primary school) is 54.2 per cent. Only 31.2 per cent of nine-year-olds from the poorest households have reached the last year of primary school, compared to 78.7 per cent of children from the richest households. The ratio of girls’ to boys’ school attendance is 1.01 for primary and 1.01 for secondary school. Whereas the Gender Parity Index for primary school does not vary much with area of residence or other background characteristics, there is more variance in the ratio of girls to boys in secondary school. Young Female Literacy Being literate is important for young women in enhancing job productivity and employment opportunities, as well as allowing them to access information. In Myanmar, 87.8 per cent of young women aged 15-24 are literate, that is they have attended secondary or higher education, or are able to read a short simple statement. Young urban women have a higher literacy rate than their rural peers, with 94.9 per cent against 84.9 per cent. Among the richest young women, the literacy rate is 96.6 per cent, compared to 69 per cent among young women from the poorest households. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 xvii Child Protection Birth registration The Convention on the Rights of the Child articles 7 and 8 state that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. A total of 72.4 per cent of under-five children have been registered at birth. Whereas 93.5 per cent of children in urban areas are registered at birth, 63.5 per cent of children in rural areas are registered. Children in the richest households and those whose mother has secondary or higher education have a higher rate of birth registration. Among children whose birth is not registered, the main reason is that the mother or caregiver did not know the child should be registered at birth. Early marriage Early marriage, before or around the age of 18, is a reality for many young girls worldwide. In Myanmar, 7.4 per cent of young women aged 15-19 are currently married. Prevalence of early marriage varies by geographic location, and is as high as 22.3 per cent in Shan (East). Girls and young women aged 15-19 are less commonly married if they have secondary or higher education, and if they live in the richest households. Orphans and Children’s Living Arrangements One or both parents of 6.6 per cent of Myanmar children have died. In the age group 15-17, this figure reaches 13.5 per cent, indicating that more than one out of ten Myanmar children lose one or both parents by that age. In total, 5.4 per cent of Myanmar children aged 0-17 do not live with a biological parent, although the parents of most of these children are still alive. In Mon State as many as 18.7 per cent of children live without their biological parents. HIV/AIDS One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and ways of preventing transmission. In Myanmar most of the interviewed women (95.4 per cent) have heard about HIV/AIDS. Only 30.1 per cent of women, however, have comprehensive knowledge of HIV/AIDS, that is, they know at least two ways of preventing HIV transmission and reject three common misconceptions. A greater proportion of urban women (41.2 per cent) than rural women (25 per cent) have comprehensive knowledge of HIV/AIDS. A total of 87 per cent of women know that HIV/AIDS can be transmitted from mother to child, and 65 per cent know all three ways of mother-to-child transmission. There is little difference between urban and rural areas, but the level of awareness varies markedly between states and divisions. Overall 70.6 per cent of women know of a place where they can be tested for HIV, and 17.6 per cent have been tested. Urban women are almost three times as likely as rural women to get tested (33 per cent against 10.5 per cent). Compared to 33 per cent of women in the richest households who have been tested for HIV, 5.9 per cent of women in the poorest households have done so.   ©UNICEF Myanmar/2010/Nyaung U Pho Cho Myanmar Multiple Indicator Cluster Survey 2009 - 2010 1 I. Introduction Background This report is based on the Myanmar Multiple Indicator Cluster Survey, conducted in 2009-2010 by the Planning Department, Department of Health Planning and Department of Health. The survey provides valuable information on the situation of children and women in Myanmar, and was based, in large part, on the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit for Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” Myanmar Multiple Indicator Cluster Survey 2009 - 2010 2 Myanmar acceded to the Convention on the Rights of the Child (CRC) in 1991, and to the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) in 1997. To align with the commitments under the CRC, Myanmar Child Law was enacted in 1993. This law is a comprehensive law on the rights of children and is in line with the CRC. It is to be implemented by the committees on the rights of the child at the different levels; and ministries concerned, such as the Ministry of Social Welfare, Relief and Resettlement, Ministry of Education, Ministry of Labour, and Ministry of Information.   Myanmar has put into place the following objectives in the Fourth Short-Term Five-Year Plan (2006/2007 to 2010/2011): • to extend education and health sectors for human resource development • to carry on for the development of border areas • to carry on for the development of rural areas • to alleviate poverty • to exceed the targets of MDGs in implementing the national plans Subsequently, the National Health Plan was drawn to contribute to the National Economic Plan. This plan covers the second five-year period of Myanmar Health Vision 2030. The main objectives of the National Health Plan (2006-2011) include striving for the development of a health system that will be in conformity with political, economic and social evolution in the country as well as global changes; enhancing the quality of health care and coverage; and accelerating rural health development activities. Children’s health situation is one of the priority areas for Myanmar. Under the guidelines laid down by the National Health Committee (NHC), the Ministry of Health, other related ministries and partner agencies are implementing programmes and projects that are directly or indirectly related to the well- being of children in Myanmar. However, the Five-year Strategic Plan for Child Health Development for 2010-2014 recognizes that a challenge remains in that many interventions for child health have been implemented as separate projects supported by the government and various partners. These do not cover the entire country, and there is some overlap in projects and limited consistency in training. Recognizing that around one-third of all infant deaths occur in the neonatal period, the National Health Plan has given a high priority to newborn health care. Training courses on Essential Newborn Care have been included in pre-service training for doctors, nurses and midwives. Other child survival interventions outlined in the Five-year Strategic Plan for Child Health Development for 2010-2014 include extending the coverage for prevention and treatment of diarrhoea and pneumonia; expanding the coverage of exclusive breastfeeding of infants up to six months; and intensifying the implementation of programmes for treatment of acute moderate and severe malnutrition. This final report presents the results of the indicators and topics covered in the survey. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 3 Survey Objectives The 2009-2010 Myanmar Multiple Indicator Cluster Survey has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Myanmar; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration, the goals of A World Fit for Children (WFFC), and other internationally agreed upon goals, as a basis for future action; • To contribute to the improvement of data and monitoring systems in Myanmar and to strengthen technical expertise in the design, implementation, and analysis of such systems. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 4 II. Sample and Survey Methodology Sample Design The sample for the Myanmar Multiple Indicator Cluster Survey (MICS) was designed to provide estimates on the selected MICS indicators on the situation of children and women at the national level, for urban and rural areas, and for the 17 states and divisions: Kachin, Kayah, Kayin, Chin, Mon, Rakhine, Shan (North), Shan (East), Shan (South), Ayeyarwaddy, Mandalay, Bago (East), Bago (West), Magwe, Sagaing, Tanintharyi, and Yangon. Ten townships in Ayeyarwaddy Division and four townships in Yangon Division affected by Cyclone Nargis in 2008 were excluded from the sampling frame prior to sampling. Five townships in Shan (North) were removed from the sampling frame due to security concerns. Urban and rural areas were identified as the main sampling domains, and the sample was selected in multi-stages. In each state/division, the clusters (primary sampling units) were distributed to urban and rural domains, proportional to the size of urban and rural populations in that state/division. After household listing and mapping activities were carried out within the selected enumeration areas, a sample of 29,250 households was drawn. Forty of the selected enumeration areas were not visited because they were inaccessible due to security concerns during the fieldwork period. These were replaced with other clusters of similar size. Substitution of selected clusters is, however, not a recommended MICS procedure. The geographical location of the 40 clusters which were not accessible was as follows: 1. Kachin State 1 cluster 2. Kayin State 3 clusters 3. Rakhine State 1 cluster 4. Shan (North) State 1 cluster 5. Shan (East) State 19 clusters 6. Shan (South) State 10 clusters 7. Sagaing Division 1 cluster 8. Tanintharyi Division 4 clusters For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years, with two different versions used according to marital status of the woman; and 3) an under-five questionnaire, administered to mothers or caregivers of all children under five living in the household. The Household Questionnaire included the following modules: o Household Listing o Education Myanmar Multiple Indicator Cluster Survey 2009 - 2010 5 o Water and Sanitation Data were also collected about household expenditure, hand washing practices and use of bednets but this information has not been included in the MICS3 report. The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households. Two versions of the questionnaire were used; one for women who currently were, or had ever been, married, and a separate and shorter questionnaire for women who had never been married. The questionnaire for ever-married women included the following modules: o Child Mortality o Tetanus Toxoid o Maternal and Newborn Health o Contraception o HIV knowledge Never-married women were asked only the HIV knowledge module. It was considered too sensitive in the national cultural context to ask unmarried women about issues pertaining to contraceptive use, pregnancy and childbirth. This means that information related to contraceptive use and childbirth of unmarried women was not captured in the data. The Questionnaire for Children under Five was administered to mothers or caregivers of children under five years of age1 living in the households. In most cases the questionnaire was administered to mothers of under-five children; in cases when the mother was not listed in the household roster, a primary caregiver for the child was identified and interviewed. The questionnaire included the following modules: o Birth Registration and Early Learning o Vitamin A o Breastfeeding o Care of Illness o Immunization o Anthropometry The questionnaires are based on the MICS3 model questionnaire2. From the MICS3 model English version, the questionnaires were translated into Myanmar and were pre-tested in Pyan-ka-pyae Village in Pyinmana Township, Mandalay Division during May 2009. Based on the results of the pre- test, modifications were made to the wording and translation of the questionnaires. Questionnaires were not translated into any of the other languages spoken in Myanmar. A copy of the Myanmar MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams measured the weights and heights of children under five. Training and Fieldwork A series of trainings were conducted throughout the country3: o Training for 20 core trainers at central level in Nay Pyi Taw for six days in June 2009 o Three rounds of Trainings of Trainers (TOT) at central level in July and August 2009 1 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 2 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. 3 Training for Myanmar MICS differs from standard recommended MICS procedures in that the time allocated for each training is shorter than the MICS recommendations of 12-14 days. MICS also recommends having only one level of training to ensure that all trainees undergo the same training. In Myanmar, training was arranged in the rainy season which led to difficult travel conditions for attendees. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 6 o State and division level trainings for data editors and enumerators in September and October 2009 o Data entry training in November and December 2009 Initially, training for core trainers was conducted at central level in June 2009. A total of 20 core trainers comprised of senior and mid-level officials from various concerned departments attended the training, which lasted for six days including field practice for two days in Pyan-ka-pyae village, Pyinmana Township. MICS coordinators and team members from the Department of Health Planning (DHP) and the Planning Department (PD), some of whom have medical background and previous experience on conducting MICS, provided trainings. Specialists from the Nutrition Division of the Department of Health (DoH) conducted training on Anthropometry including theoretical background and practical measurements. Core trainers were assigned later as trainers for Training of Trainers (TOT). In July and August 2009, three rounds of Trainings of Trainers (TOT) were conducted in Nay Pyi Taw with participants from central level and each state and division. Participants from five to seven states or divisions, with three to five representatives from each, attended each TOT. Each TOT lasted for 10 days including practice on field work for three days such as map sketching, GPS use, filling in cluster control sheets, interviewing practice using the three sets of questionnaires and anthropometry measurements for under-five children. Field practices were conducted in Ngan-sat, Pyan-ka-pyae and Nat-thu-ye villages in Pyinmana Township for each TOT. A total of 77 trainers attended TOTs, and they became supervisors for data collection teams. State and division level trainings for data editors and enumerators were conducted from September to October 2009 in all 17 states and divisions. Each training lasted for seven days including three days field practice where questionnaire interviewing and anthropometric measurement for under-five children were practiced. These trainings were organized by trainers who had attended at central level TOT, one central level supervisor and one nutritional team leader for anthropometric training. In each state and division level training, 15 to 25 participants were trained. Data entry training was carried out from November to December 2009. Trainings were conducted in the three data entry centres in Nay Pyi Taw, Yangon and Mandalay. Each training lasted for four days each, and a total of six data entry supervisors and 30 data entry operators were trained. After the first round of training for core trainers, data collection was launched in the last week of June 2009 and was carried out by these trainers in four clusters in Mandalay. Actual mass data collection started in October 2009 following the state and division level training and concluded in March 2010. Data collection was supervised by members from the central level monitoring team of the Planning Department, the Department of Health Planning and the Department of Health, and staff from UNICEF. A total of 63 data collection teams collected data throughout the country in 17 states and divisions. In each state or division, there were three to five data collection teams, and each team was composed of one supervisor, one data editor, four enumerators and one field guide. Most of the data editors were Health Assistants, Lady Health Visitors and Public Health Nurses from the Department of Health who had previous experience with anthropometric measurement and survey data collection. Field teams were accompanied by local authorities to facilitate appointment for interview, and in some cases midwives and Lady Health Visitors who helped translate interviews with respondents from a few clusters who could not speak Myanmar. Additionally, midwives assisted in recording data related to immunization. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 7 Data Processing Completed questionnaires from each state/division were sent back to three assigned data entry centres in Yangon, Mandalay and Nay Pyi Taw, where data entry was done for five to seven states or divisions in each centre. A total of 30 data entry operators and six data entry supervisors were involved in entering the data, and 11 microcomputers were used in each centre. Data were entered using the CSPro software. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS3 project and adapted to the Myanmar questionnaire were used throughout. Data entry started in December 2009 and concluded in April 20104. Final consistency checks were then performed using the Statistical Package for Social Sciences (SPSS) Version 18 software programme. Data were analysed using SPSS Version 18 and the model syntax and tabulation plans developed by UNICEF for this purpose, with adaptations to the Myanmar questionnaire.   4 It is recommended MICS procedure to begin data entry simultaneously with fieldwork, so that any problems or inconsistencies in recording of data can be fed back to enumerators early in the fieldwork process. In Myanmar data entry began at a later date than fieldwork because the data entry programme was not yet ready in July. Mass data collection started in October, and data entry began in December. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 8 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 29,250 households selected for the sample, all households were found to be occupied. Of these, 29,238 were successfully interviewed for a household response rate of 100 per cent.5 In the interviewed households, 39,025 women aged 15-49 were identified. Of these, 38,081 were successfully interviewed, yielding a response rate of 97.6 per cent. In addition, 15,574 children under five were listed in the household questionnaire. Questionnaires were completed for 15,539 of these children, which corresponds to a response rate of 99.8 per cent. Overall response rates of 97.5 and 99.7 are calculated for the women’s and under-five’s interviews respectively (Table HH.1). Since the household response rate was 100 per cent, no difference could be seen between urban and rural areas or across the 17 states and divisions of the country. Women’s overall response rate is slightly lower than children’s overall response rate because some women were not available in their home at the time of interview. Kachin State has the lowest women’s response rate (89.5 per cent), followed by Bago (East) Division (94.1 per cent), Mandalay and Sagaing (95.4 and 95.6 per cent respectively). Other states and divisions showed a response rate for women above 98 per cent. Variations in women’s response rates across the country may be due to slight differences in cultural and socioeconomic situation, influencing the daily activities and working status of women. Characteristics of Households The age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 29,238 households successfully interviewed in the survey, 141,269 household members were listed. Of these, 66,712 were male, and 74,557 were female. These figures indicate the average household size at 4.8. Child population (aged 0-14 years) was found to be 30.1 per cent of total population, and labour age population (aged 15-64 years) was 64.2 per cent of total. The elderly population (65 years and older) was 5.7 per cent of total population. Of the survey population, 35.4 per cent were children aged 0-17 years, and 64.6 per cent were adults aged 18 years and above. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, states/division, urban/rural status and number of household members are shown in the table. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The table also shows the proportions of households where at least one child under 18, at least one child under five, and at least one eligible woman aged 15-49 years were found. 5 Response rates were high because the assistance of the Peace and Development Council and Health Departments at local levels were enlisted to give support to the survey, and people in the selected enumeration areas were asked to stay at home during the survey period. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 9 The weighted and unweighted numbers of households are equal at national level, since sample weights were normalized (See Appendix A). Weighted and unweighted numbers of households are also similar for the urban/rural distribution. When looking at the state and divisional level, however, it can be seen that weighted and unweighted numbers differ. In Kayah State, for example, the unweighted number of households is 1,170, while the weighted number is only 145. In Yangon, on the other hand, the unweighted number is 2,550, while the weighted number of households is 4,286. The reason for these differences is variation in size and population density across states and divisions. In smaller states and divisions, such as Kayah, there was over-sampling of households in order to ensure that a representative sample was drawn, and that the number of sampled households would be sufficient to provide reliable estimates. Because of its small population size, Kayah was assigned a low weight, which results in a lower weighted number of households. The same pattern of weighted and unweighted numbers can be seen also for individual women and children. Weighted distribution of households by area of residence shows 29.6 per cent of households were located in urban areas and 70.4 per cent were located in rural areas. Out of the 17 states and divisions, Yangon and Mandalay Divisions have the highest weighted percentage of households (14.7 per cent and 14.5 per cent respectively) followed by Sagaing, Magwe and Ayeyarwaddy (11.2, 9.2 and 8.9 per cent respectively). These are the states and divisions providing the highest contribution to the national estimates. Kayah State had lowest weighted percentage of households (0.5 per cent), Chin State was second lowest (1 per cent) and Shan (East) was third lowest (1.5 per cent). The largest group of households (43.1 per cent) had 4-5 members, and most had male heads of household (83.2 per cent). Forty-two per cent of households had at least one child aged under five years, and 90.6 per cent of households had at least one woman aged 15-49 years. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 10 Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15-49 years and of children under five. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents aged 15-49 years. The table includes information on the distribution of women according to state/division, urban-rural areas, age, marital status, motherhood status of ever-married women, education6, and wealth index quintiles7. It is found that 31.5 per cent of women were residing in urban areas, and 68.5 per cent were residing in rural areas. Regarding the marital status of women, 60.6 per cent were ever-married (including divorced, separated and widowed women) and 39.4 per cent were never-married women. Among ever-married women, 92 per cent had ever given birth. Education status of more than half of the women (51.2 per cent) was secondary and above, while 39.4 per cent of women have primary school. 6.7 per cent of the women have received no education. Some background characteristics of children under five are presented in Table HH.5. These include distribution of children by several attributes: sex, state/division and urban/rural area of residence, age in months, mother’s or caregiver’s education and wealth index quintiles. Out of all under-five children, 51.4 per cent were male and 48.6 per cent were female. It was found that 29.6 per cent of children were residing in urban areas and 70.4 per cent were residing in rural areas. Regarding mothers’ educational status, 45.7 per cent of children had mothers with primary level education, and 41.6 per cent had mothers with secondary or higher education. Also 10.3 per cent of children had mothers without education. It is worth noting that more children under five fall into the poorer wealth quintiles than in the richest. Whereas 24.7 per cent of children under five are found in the poorest households, 17.8 per cent are found in the richest households. 6 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 7 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: persons per sleeping room, types of floor, roof, wall, type of cooking fuel used, electricity, radio, television, mobile phone, land line phone, refrigerator, ownership of watch, bicycle, motorcycle, boat/animal drawn cart, car, motorized boat/ trawlargyi, source of drinking water used, type of sanitary facility). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. ©UNICEF Myanmar/2010/Mya Win Myanmar Multiple Indicator Cluster Survey 2009 - 2010 11 IV. Child Mortality One of the over-arching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. The infant mortality rate is the probability of dying before the first birthday, while the under-five mortality rate is the probability of dying before the fifth birthday. Both are presented as probabilities per thousand live births. The 2009-2010 Myanmar MICS used a direct estimation technique for calculating infant and under-five mortality rates8. The mortality rates were computed from information gathered from the birth history of the Women’s Questionnaire. Ever-married women aged 15-49 years were asked whether they had ever given birth, and if they had, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of their children in chronological order starting with the first child. Women were asked whether a birth was single or multiple; the sex of the child; the date of birth (month and year); survival status; age of the child on the date of the interview if alive; and if not alive; the age at death of each live birth. Both infant and under-five mortality rates can be calculated from these data by dividing deaths for given ages and time periods by exposure to risk in terms of person- years of life lived by the reported children. At the time of developing the questionnaire it was deemed too sensitive in the cultural context to ask unmarried women questions about childbirth or contraceptive use. Child mortality probabilities as calculated in the 2009-2010 Myanmar MICS therefore include only children born to mothers who were married at time of interview, or had been so in the past. Estimates of child mortality are very sensitive to data errors and can in particular suffer from the omissions of deceased children. Estimating child mortality from the self-reporting of mothers presents a number of challenges. Because the death of a child can be difficult to speak about, some women might want to avoid any mention of children who died. Women may also misunderstand the questions and think only children who are still alive should be reported, and so inadvertently omit to mention children who died in early childhood. Estimation of infant mortality, using direct methods, also depends heavily on the correct reporting of age at death as under or over one year. It can be very challenging to obtain accurate reporting of age at death, and heaping on 12 months is common, where, for example, the age of a child who died before the age of one might be rounded upwards to one year. Another issue to consider, which may contribute to data quality problems in mortality estimates, is that some infants who die shortly after birth might be mistaken for stillbirths in the absence of a skilled health provider9. In Myanmar, the rate of institutional delivery is low, and not all births occur in the presence of a skilled birth attendant. Birth asphyxia is a condition where the newborn is deprived of oxygen during delivery. The newborn baby might not be breathing and might have a low heart rate 8 This technique is the one used by the Demographic and Health Survey (DHS) project, and the questionnaire module used for Myanmar MICS is based on the DHS questionnaire. 9 The Myanmar Fertility and Reproductive Health Survey 2007 estimates the prevalence of stillbirths as 1.33 per cent of all pregnancies Myanmar Multiple Indicator Cluster Survey 2009 - 2010 12 and a bluish skin tone. Without emergency health care the baby could die. The mother and any birth attendant without relevant medical expertise might, however, think that the baby was born dead. In such cases the mother would therefore not report the birth of this child to the interviewer. Although there is no evidence to prove the extent to this problem, there is suggestion that it could possibly lead to the under-reporting of deceased children. In addition to issues surrounding mothers’ reporting of mortality, survey-based estimates of infant and under-five mortality rates should be treated with some caution due to sampling issues. Account needs to be taken of sampling error. As infant death is typically a rare event, sampling error for survey- based mortality estimates can be substantial, implying a great deal of uncertainty regarding the true population rate10. Furthermore, in a household survey population groups such as migrants and those living in temporary settlements tend not to be included. In the Myanmar context it also has to be acknowledged that certain areas of the country were excluded from the sampling frame, as mentioned in the methodology section. Areas were excluded due to security concerns, and the area affected by Cyclone Nargis in 2008 was also omitted. The situation of children in the excluded areas might be more precarious than in the rest of the country, and the infant and under-five mortality rates might have shown a higher estimate if these areas were included. Detailed findings of infant mortality and under-five mortality rates per 1,000 live births for national, urban and rural areas by period of analysis of five years are shown in Table CM.1. For the most recent time period of 0-4 years immediately preceding the time of interview, which is from 2005/2006 to 2009/2010, the infant mortality rate for Myanmar has been estimated at 37.5 per 1,000 live births. The under-five mortality rate is 46.1 per 1,000 live births. In urban areas of the country the infant mortality rate is 24.5 per 1,000 live births for the most recent time period, while the under-five mortality rate is 29.1 per 1,000 live births. The corresponding figures for rural areas are 42.8 per 1,000 live births and 52.9 per 1,000 live births respectively. This suggests that children in urban areas are more likely to survive to both their first and fifth birthday than their peers in rural areas. Mortality rates have not been calculated at state/divisional level because the sample size was not considered sufficient to provide reliable estimates. The infant and under-five mortality estimates for the most recent five-year period shows a wide variation by wealth quintile (Table CM.2). Whereas the infant mortality rate for the poorest households is 49.2, it is only 13.2 for the richest households. Along the same lines, the under-five mortality rate is 62.4 among the poorest households and 17.2 among the richest. The two bottom quintiles display very similar outcomes, while from the middle quintile and up to the richest there is a steady decline in mortality of children. Infant and under-five mortality rates also indicate an association with the education level of the mother. Where the mother has primary education only, the infant mortality rate is 43.1 and the under-five mortality rate is 50.9. This contrasts with an infant mortality rate of 26.8 and an under-five mortality rate of 32.9 where the mother has secondary or higher education. Fewer boys than girls survive infancy. While the infant mortality rate is 41.8 for boys, it is 33.0 for girls. For both the national level and rural and urban areas the figures for the most recent five-year period are lower than for the previous two five-year periods, indicating a declining trend in child mortality, although we have to be cautious in drawing conclusions about the existence and strength of this decline. 10 The range of uncertainty has not been calculated for infant and under-five mortality estimates. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 13 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 14 V. Nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one third (between 2000 and 2010), with special attention to children under two years of age. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO Child Growth Standards, which is recommended for use by UNICEF and the World Health Organization. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In MICS, weight and height of all children under five years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 15 Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above two standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (approximately 0.5 per cent of children) and those whose measurements are outside a plausible range are excluded. Percentage of under-five children who are severely or moderately undernourished determined by WHO growth standard is shown in Table NU.1. The similar findings analysed by NCHS standard is shown in Table NU.1A. In Myanmar, nearly one in four children under age five (22.6 per cent) are moderately underweight, and 5.6 per cent are classified as severely underweight (Table NU.1). More than a third of children (35.1 per cent) are moderately stunted or too short for their age, and 7.9 per cent are moderately wasted or too thin for their height. There is no notable difference in the nutritional status of male and female children. Children in rural areas appear more likely to be underweight and stunted than children in urban areas, but there is little difference in level of wasting. About one in four (24.2 per cent) of rural children are moderately or severely underweight, and more than one third (38.4 per cent) of rural children are moderately or severely stunted. Children in Rakhine and Chin States are more likely to be undernourished than other children. In Rakhine, a total of 37.4 per cent of children are either moderately or severely underweight, whereas the underweight prevalence is 30.7 per cent in Chin. Also in Shan (North), Ayeyarwaddy and Magwe around one in four children are underweight. Severe or moderate stunting is as high as 58 per cent in Chin, and 49.9 per cent in Rakhine. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 16 Children’s nutritional status is correlated with the educational level of their mothers, as well as their socioeconomic background. Those children whose mothers have secondary or higher education are less likely to be underweight and stunted compared to children of mothers with primary or no education, whereas variation is smaller for wasting. Distribution across wealth quintiles shows that higher percentages of undernourished children are found in poorer quintiles. For example, among the poorest children 33.1 per cent are moderately underweight and 9.7 per cent of children are severely underweight, contrasting with 13.5 per cent of the richest children who are moderately underweight and 2.7 per cent who are severely underweight. Close to five out of 10 of the poorest children are stunted, compared to one in five of the richest. The age pattern shows that the highest prevalence of underweight is found in children aged 48-59 months, highest coverage of stunting is found in children aged 24-47 months and highest rate of wasting is found in children aged 12-23 months (Figure NU.1). This pattern of wasting is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon, and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for six months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to two years of age and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at six months • Frequency of complementary feeding: two times per day for 6- to 8-month-olds; three times per day for 9- to 11-month-olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate (< 6 months and < 4 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 and 20-23 months) • Timely initiation of breastfeeding (within one hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 provides the proportion of women who start breastfeeding their infants within one hour of birth, and women who begin breastfeeding within one day of birth (which includes those who begin within one hour). Overall, 75.8 per cent of women in Myanmar start breastfeeding within one hour of birth. Rakhine has the lowest rate of initiation of breastfeeding within one hour of birth (44.2 per cent) followed by Bago (East) and Tanintharyi (63.4 and 67.7 per cent respectively). In comparison 91.6 per cent of mothers in Mon begin breastfeeding their baby within one hour of birth. A higher percentage of mothers from urban areas start breastfeeding within one hour of birth than mothers Myanmar Multiple Indicator Cluster Survey 2009 - 2010 17 from rural areas (81.3 per cent vs 73.5 per cent). Percentage of breastfeeding initiated within one hour of birth increases from 67.9 per cent for mothers with no education to 80.5 per cent of mothers with secondary and higher education; while 73.1 per cent of women with primary education breastfeed their baby within one hour of birth. It is also observed that the percentage increases from 67 per cent of mothers in the poorest quintile to 82 per cent of mothers in the richest quintile. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 18 Nearly 90 per cent of women initiate breastfeeding within one day of birth. The level is overall high across the country. Rakhine has the lowest percentage of initiation of breastfeeding within one day of birth (80.7 per cent) followed by Bago (East) and Mandalay (81.6 and 82 per cent respectively). There is little difference between mothers with primary and secondary education, or between women from urban and rural areas, regarding initiation of breastfeeding within one day. It is found that the percentages increase only slightly with increased wealth, from 86.1 per cent of mothers in the poorest quintile to 90.6 per cent of mothers in the richest quintile. In Table NU.3, breastfeeding status is based on the reports of mothers/caregivers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children aged 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately one fourth of children aged less than six months are exclusively breastfed (23.6 per cent), a level considerably lower than recommended. Exclusive breastfeeding rate is slightly higher among infants aged less than four months, at 29.3 per cent. At age 6-9 months, 80.9 per cent of children receive breast milk and solid or semi-solid foods. By age 12-15 months, 91 per cent of children are still being breastfed and by age 20-23 months, 65.4 per cent are still breastfed. Rakhine State has lowest level of exclusive breastfeeding up to age six months (1.3 per cent only) followed by Kayin (9.4 per cent) and Shan (North) (12.9 per cent). The highest prevalence of exclusive breastfeeding up to age six months is found in Mon State with 47 per cent. There is no difference in the feeding pattern for boys and girls. There is also very little difference in feeding patterns between urban and rural areas. Rural mothers (24.8 per cent) appear slightly more likely to exclusively breastfeed their baby up to age six months than urban mothers (20.8 per cent). Whereas there is no difference between urban and rural mothers in their likelihood to continue breastfeeding their baby up to 15 months, continued breastfeeding of children aged 20-23 months is more common in rural areas (68.7 per cent) than in urban areas (58 per cent). Six- to nine- month- old children in urban areas (84 per cent) are slightly more likely than rural children (79.9 per cent) to receive breast milk and solid/mushy food. Looking at the association between the education levels of mothers and feeding pattern of their children, there is very little difference in terms of exclusive breastfeeding and complementary feeding practices between mothers who have primary education and those who have secondary or higher education. The 20-23 months old children whose mothers have secondary or higher education are, however, less likely to be breastfed (57.8 per cent), compared to 70.4 per cent of children whose mothers have primary education. Similarly, no major difference between children of different economic status is found regarding prevalence of exclusive breastfeeding up to six months and complementary feeding for children aged 6-9 months. However, prevalence of continued breastfeeding is lower in the richest quintile for children aged more than 12 months. While 77.5 per cent of the poorest 20-23 month- olds are still being breastfed, this goes down to 48.9 per cent among the richest children. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children receive liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is below 5 per cent. Nearly one half of the children (44.6 per cent) still receive breast milk after two years. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 19 The adequacy of infant feeding in children under 12 months is provided in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they receive breast milk and complementary food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they receive breast milk and eat complementary food at least three times a day. As already noted above, nearly one fourth of children less than six months (23.6 per cent) are exclusively breastfed. While 69.2 per cent of children aged 6-8 months received breast milk and complementary food at least two times in prior 24 hours, nearly half of the children aged 9-11 months (45.2 per cent) received breast milk and complementary food at least three times in prior 24 hours. As a result of these feeding patterns, only 56.5 per cent of children aged 6-11 months are being adequately fed. Adequate feeding among all infants (aged 0-11 months) drops to 41 per cent. Adequate feeding of infants aged 0-11 months is lowest in Kayin State with 23.7 per cent. This is due to low level of exclusive breastfeeding up to six months (9.4 per cent) and low prevalence of 9-11 month-olds receiving breast milk and complementary food three times a day, with only 12.2 per cent. Adequate feeding of infants aged 0-11 months is highest in Kayah with 51.9 per cent. It is interesting to note that infant feeding patterns are very similar across urban and rural locations. The most notable difference is that 9-11 month-olds in urban areas (49.7 per cent) are more likely than their rural peers (43.6 per cent) to receive breast milk and complementary food at least three times a day. Similarly, feeding pattern does not show strong association with the mother’s level of education. The most apparent difference in adequate feeding can be found in children aged 6-8 months, who are more likely to receive breast milk and complementary food at least twice a day if their mother has secondary Myanmar Multiple Indicator Cluster Survey 2009 - 2010 20 or higher education (73.5 per cent) than if their mother has primary education only (65.7 per cent). In the same way, adequate feeding does not show strong association with the mother’s economic background. The poorest 9-11 month-olds are, however, less likely to receive the recommended feeding, at 41.7 per cent, compared to 50.9 per cent of the richest. Vitamin A Supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under- five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted to all children aged 6-59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programmes, the definition of the indicator is the percentage of children 6-59 months of age receiving at least one high-dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Myanmar Ministry of Health recommends that children ©UNICEF Myanmar/2010/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 21 aged 6-11 months be given one high-dose vitamin A capsule, and children aged 12-59 months given a vitamin A capsule every six months. In some parts of the country, vitamin A capsules are linked to immunization services and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a vitamin A supplement within eight weeks of giving birth due to increased vitamin A requirements during pregnancy and lactation. Vitamin A distribution under the national nutrition programme in Myanmar was undertaken in the months of August – September 2009 and in February 2010, coinciding with the MICS fieldwork. Within the six months prior to the MICS interview, 55.9 per cent of children aged 6-59 months received a high dose vitamin A supplement (Table NU.5). Additionally 11.9 per cent did not receive the supplement in the last six months but did receive one prior to that time. Finally, 21.3 per cent of children received a vitamin A supplement at some time in the past, but their mother/caregiver was unable to specify when. Coverage of vitamin A supplementation in the last six months is lowest in Shan (North) (20.4 per cent) followed by Rakhine (32.5 per cent) and Chin State (33.9 per cent). In Shan (North), 26.1 per cent of children have never received a vitamin A supplement. The highest prevalence of vitamin A supplementation in the past six months is found in Kayin, with 84.8 per cent. The age pattern of vitamin A supplementation shows that supplementation in the last six months is lowest, with 36.5 per cent, among children aged 6-11 months, and highest with 62.2 per cent among children aged 12-23 months. The association between mother’s level of education and the likelihood of the child receiving Vitamin A supplementation indicates that the most important factor is whether or not the mother has received education, rather than at which level she has completed her education. There is no significant difference between children whose mothers have primary or secondary and higher education. On the other hand, while 58.5 per cent of children whose mothers have primary education, have received a vitamin A dose in the last six months, the corresponding figure is only 41.7 per cent for children whose mother is without any education. A total of 66.4 per cent of mothers with a birth in the previous two years before the MICS survey received a vitamin A supplement within eight weeks of birth (Table NU.6). This percentage is highest in Shan (East) at 84.9 per cent and Mon at 84.6 per cent, and lowest in Shan (North) at 33.5 per cent. While urban mothers had received a high-dose vitamin A supplement in 61.7 per cent of cases, 68.3 per cent of rural mothers had received the supplement. As is the case with vitamin A supplement among children, there is very little difference in the likelihood of receiving a vitamin A supplement between women of primary and women of secondary or higher education. Women with no education are, however, less likely (57.1 per cent) to receive the supplement than women with primary education (66.4 per cent). Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 22 In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth. Overall, 56.3 per cent of infants are weighed at birth and approximately 8.6 per cent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.7). The likelihood of the infant being weighed at birth varies across location of residence, mother’s level of education and the economic status of the household. In Rakhine as little as 17.1 per cent of infants are weighed at birth and the percentage is also low in Chin at 19.2 per cent. In contrast more than 90 per cent of infants are being weighed at birth in Mon State and Shan (East). Whereas 81.6 per cent of urban infants are weighed at birth, this is considerably lower in rural areas, with 46.1 per cent. Looking at the education level of the mother, it is seen that while 72.5 per cent of infants whose mother has secondary or higher education are weighed at birth, the percentage drops to 46.6 per cent among infants whose mother has primary education. When the mother has no education, the likelihood of the infant being weighed at birth is less than one third (30.3 per cent). The majority of infants from the richest households are weighed at birth (91.1 per cent), contrasting with 30.3 per cent of infants from the poorest households. Variation across states and divisions in prevalence of low birth weight is shown in Figure NU.4. Kayin and Bago (East) have the highest percentage of live births below 2,500 grams (11.1 per cent in each place). The lowest prevalence of low birth weight is found in Shan (East) with 6.2 per cent. Differences across background characteristics such as urban or rural residence, mother’s education level or economic background are not significant. This might be attributed to the wide variations in practice regarding whether or not infants are weighed at birth. 11 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 23 Myanmar Multiple Indicator Cluster Survey 2009 - 2010 24 VI. Child Health Immunization The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 per cent nationally, with at least 80 per cent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against miliary tuberculosis or TB meningitis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a measles vaccination by the age of 12 months. The standard MICS practice is to ask mothers to provide vaccination cards for children under the age of five, and interviewers copy vaccination information from the cards onto the MICS questionnaire. Different from such a standard procedure, in Myanmar MICS, vaccination information was collected not only from vaccination cards provided by mothers but also from midwives’ registers. The decision to also consider the register of midwives was taken because it was thought that some mothers would have lost their vaccination cards. Also, there are commonly not enough vaccination cards to be distributed to all mothers in some parts of the country. Immunization records could be easily available from responsible midwives and taken as recorded from vaccination card. As already noted in the section describing fieldwork practices, midwives accompanied enumerators during interviews to help with translation and to obtain immunization data when vaccination cards were not present. It could be interpreted that involving midwives in data collection regarding immunization, and to copy information from their records might affect data quality. Midwives are responsible for ensuring that children receive the required vaccinations, and it could be interpreted that they might therefore inadvertently have a tendency to over-report the incidence of immunization. Overall, 96 per cent of children had recorded vaccination information that came from health cards or from midwives’ registers (Table CH.2). If the child did not have recorded vaccination information, the mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and polio, how many times. The percentage of children aged 12-23 months who received each of the vaccinations is shown in Table CH.1. The denominator for the table is comprised of children aged 12-23 months so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the recorded vaccination information or the mother’s report. In the bottom panel, only those who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with recorded vaccination information from vaccination cards or from midwives’ registers. As many as 97.2 per cent of children aged 12-23 months received a BCG vaccination by the age of 12 months, and the first dose of DPT was given to 96.9 per cent. The percentage only marginally declines Myanmar Multiple Indicator Cluster Survey 2009 - 2010 25 for subsequent doses of DPT, and is 95.9 per cent for the third dose (Figure CH.1). Similarly, 97.5 per cent of children received polio 1 by age 12 months and this declines to 95.9 per cent by the third dose. The coverage for measles vaccine by 12 months is slightly lower than for the other vaccines at 90.7 per cent. This is primarily because, although 98 per cent of children received the vaccine, only 90.7 per cent received it by their first birthday. As a result, the percentage of children who had all the recommended vaccinations by their first birthday is as high as 88.6 per cent. In Myanmar, Hepatitis B vaccine is also recommended as part of the immunization schedule. It is given to newborn babies just after birth at the hospital. A total of 96.9 per cent of children aged 12-23 months received first dose of Hepatitis B1 vaccination by the age of 12 months, and the second dose was given to 96.8 per cent. The percentage marginally declines to 95.9 per cent for the third dose. Tables CH.2 and CH.2c show vaccination coverage rates among children aged 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards, midwives’ immunization registers and mothers’/caregivers’ reports. No significant difference can be found in immunization coverage between urban and rural areas, or between male and female children. Shan (North) and Chin States have slightly lower levels of coverage of all immunization (88 and 91 per cent, respectively) than other states and divisions. There is no clear association between immunization coverage and wealth level of the households. While the percentage of 12-23 months-old children with all recommended immunizations does not vary notably between Myanmar Multiple Indicator Cluster Survey 2009 - 2010 26 children of mothers with primary (97.2 per cent) and secondary or higher education (98.7 per cent), there is a small gap down to children of mothers with no education, of whom 90.6 per cent have all recommended immunizations. Tetanus Toxoid One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district. A World Fit for Children goal is to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus requires all pregnant women to receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during their pregnancy, they (and their newborns) are also considered to be protected if the following conditions are met: • Received at least two doses of tetanus toxoid vaccine, the last within the prior three years; • Received at least three doses, the last within the prior five years; • Received at least four doses, the last within 10 years; • Received at least five doses during their lifetime. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 27 Table CH.3 shows the protection status against tetanus of women who have had a live birth within the last 24 months. Figure CH.2 shows the protection of women against neonatal tetanus by major background characteristics. The proportion of mothers with a birth in the previous 24 months protected against neonatal tetanus in Myanmar is 91.8 per cent. Among them, 89.8 per cent of women received at least two doses during last pregnancy and 2 per cent received at least two doses, the last within the prior three years. The percentage of mothers protected against tetanus is lowest in Shan (North) and Chin States (59.5 per cent and 76.4 per cent respectively). Mon State has the highest coverage at 98.9 per cent. A slightly higher proportion of mothers from urban areas (94.6 per cent) are protected against tetanus than in rural areas (90.7 per cent). The coverage of neonatal tetanus protection increases with the level of education of mothers, and wealth quintile. The difference between women with primary (91.5 per cent) and secondary or higher (95.8 per cent) education is small. Noteworthy, however, is the gap down to mothers who have no education, of whom only 76 per cent are protected against tetanus. Among the poorest mothers, 87.2 per cent are protected against tetanus, compared to 96.2 per cent of mothers from the richest households. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea- related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half deaths due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 per cent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • (ORT or increased fluids) AND continued feeding In the MICS interview, mothers (or caregivers) were asked to report whether their child had had diarrhoea in the two weeks prior to the interview. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, 6.7 per cent of under-five children had diarrhoea in the two weeks preceding the interview (Table CH.4). Diarrhoea prevalence was higher in Chin (13.1 per cent), Kachin (10.7 per cent) and Bago (East) (10.7 per cent) than in other states and divisions. The peak of diarrhoea prevalence occurs in the weaning period, among children aged 12–23 months. Table CH.4 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Because mothers were able to name more than one type of liquid, the percentages do not necessarily add up to 100. In total, 60.6 per cent of children with diarrhoea Myanmar Multiple Indicator Cluster Survey 2009 - 2010 28 received fluids from ORS packets, and 13.6 per cent received recommended home-made fluids. As a result, 66.3 per cent of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or RHF), while 33.7 per cent received no treatment. As the prevalence of diarrhoea in the two weeks prior to the interview is not very high, comparisons across states and divisions become indicative because they are based on small numbers of children in each. However, more children in urban areas receive ORT than children in rural areas (77.1 per cent vs. 61.8 per cent). The use of ORT is correlated with mothers’ education level and socioeconomic background. For instance, 64.5 per cent of children whose mother has primary education receive ORT when being sick with diarrhoea, compared to 71.5 per cent of children whose mother has secondary or higher education. Children with diarrhoea from the poorest households received ORT in 58.2 per cent of cases, while the coverage of ORT use among the richest children is 79.2 per cent. Less than one fourth (22.2 per cent) of under-five children with diarrhoea drank more than usual while 77.2 per cent drank the same or less (Table CH.5). Some 70.9 per cent ate somewhat less, the same or more (continued feeding), but 28.7 per cent ate much less or ate almost nothing. Given these figures, 15.5 per cent of children with diarrhoea received increased fluids and at the same time continued feeding. Combining the information in Table CH.5 with that in Table CH.4 on oral rehydration therapy, it is observed that 50.3 per cent of children with diarrhoea either received ORT or fluid intake was increased and, at the same time, feeding was continued, as is the recommended response. Home management of diarrhoea varies by background characteristics, such as area of residence, age of the child, mother’s education level and socioeconomic background. More children in urban areas (57.3 per cent) than in rural areas (47.4 per cent) receive ORT or increased fluids and continue feeding when they are sick with diarrhoea. There is only a slight variation between children of mothers with Myanmar Multiple Indicator Cluster Survey 2009 - 2010 29 primary (48.6 per cent) and secondary or higher (53.9 per cent) education. In terms of socioeconomic status, 43.8 per cent of diarrhoea cases among the poorest children are properly managed, compared to 65.3 per cent among the richest children. Children aged 0–11 months are least likely to receive either ORT or increased fluid and continue feeding, at 36.5 per cent. For all other age groups, more than half of the children receive ORT or increased fluid along with continued feeding. Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children worldwide, and the use of antibiotics in under- fives with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough, accompanied by rapid or difficult breathing and whose symptoms were not due to a problem in the chest and a blocked nose. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia Myanmar Multiple Indicator Cluster Survey 2009 - 2010 30 Table CH.6 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. A total of 2.6 per cent of children aged 0–59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of them, 69.3 per cent were taken to an appropriate health care provider. Just over one fourth (27.1 per cent) of children with symptoms of pneumonia were taken to a private physician while 13.4 per cent were taken to government hospitals, 9.2 per cent were taken to sub-rural health centre and 7.8 per cent to a rural health centre. More children in urban areas visited a private physician (44.8 per cent in urban areas vs. 20.3 per cent in rural areas) or a government hospital (16.9 per cent in urban areas vs. 12.1 per cent in rural areas). More children in rural areas were taken to a rural health centre (2.5 per cent in urban areas vs. 9.9 per cent in rural areas) or a sub-centre (1 per cent in urban areas vs. 12.3 per cent in rural areas). Because the prevalence of suspected pneumonia is not very high, comparisons across states and divisions can not indicate trends because they are based on small numbers of children in each. It can be noted, however, that a higher percentage of children with pneumonia from urban areas were taken to an appropriate health care provider than those in rural areas (74.4 per cent vs. 67.3 per cent). The youngest children, aged 0-11 months, were the most likely to be taken to an appropriate provider when they had symptoms of pneumonia. In this age group, 77 per cent of the children who had symptoms of pneumonia were taken to an appropriate provider. There is no notable difference in the likelihood of being taken to an appropriate provider between the children of mothers with primary and secondary or higher education. Looking at differences in wealth level, children from the richest quintile are more likely to be taken to an appropriate provider when they show symptoms of pneumonia. The percentage increases from 62.5 per cent to 77.3 per cent from the poorest to richest quintile. Table CH.7 presents the use of antibiotics for the treatment of suspected pneumonia in under-fives. In Myanmar, 34.2 per cent of under-five children with suspected pneumonia during the two weeks prior to the interview received an antibiotic. The incidence of antibiotic use is not significantly different between urban and rural areas. The table indicates that antibiotic treatment of suspected pneumonia is lowest among children in the poorest households (29.2 per cent), but it is interesting to note that the highest coverage of antibiotic treatment is found in the second lowest quintile, at 40.2 per cent. More children of mothers with secondary or higher education (41.1 per cent) were treated with an antibiotic when demonstrating symptoms of pneumonia than children of mothers with only primary education (30.8 per cent). Coverage of antibiotic use was highest for children aged 12-23 months (38.2 per cent) and lowest for children aged 36-47 months (27.6 per cent). Issues related to knowledge of danger signs of pneumonia are presented in Table CH.8. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 6.5 per cent of mothers or caregivers of ©UNICEF Myanmar/2010/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 31 children under five know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptoms for taking a child to a health facility are when the child develops a fever (72.7 per cent) and becomes sicker (65.8 per cent). Only 14.8 per cent of mothers identified fast breathing, and 20.5 per cent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Sagaing Division has the smallest proportion of mothers/ caregivers who recognize the two danger signs of pneumonia (0.7 per cent), followed by Magwe (1.4 per cent) and Mon (1.5 per cent). The highest level of recognition of these symptoms is found in Kayin with 17 per cent. The awareness of the danger signs of pneumonia, as well as the recognition of other symptoms that would prompt taking a child immediately to a health care provider, does not vary considerably between urban and rural locations or across other background characteristics, such as mothers’ education level or socioeconomic background. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels produces high levels of indoor smoke, which is a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including carbon monoxide, poly aromatic hydrocarbons, sulphur dioxide and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. As shown in Table CH.9, 94.3 per cent of all households in Myanmar use solid fuels for cooking. Use of solid fuels is lower in urban areas (83.2 per cent) compared to rural areas, (99 per cent), where almost all of the households use solid fuels. The findings show that use of solid fuels is very common among households all over the country except Yangon (74 per cent), and among the richest households (76.7 per cent). Among the poorest households, and also in several states and divisions, the percentage is above 99 per cent. Wood is the most commonly used fuel (63.7 per cent) for cooking purposes, followed by charcoal (28.9 per cent). Wood is used by 80.7 per cent in rural and 23.4 per cent in urban area, whereas charcoal is used by 59.2 per cent of urban households and 16.1 per cent of rural households. Only 4.3 per cent of Myanmar households use electricity for cooking. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while an open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. The type of stove used with a solid fuel is depicted in Table CH.10. Overall, 97.6 per cent of households using solid fuel cook their food on an open stove or fire with no chimney or hood. Only 2.3 per cent use an open stove or fire with chimney or hood. There is no significant difference between urban and rural households. In Chin State 16.6 per cent of households cooking with solid fuels use open stove or fire with chimney or hood, while in most states and divisions more than 94 per cent of the households who use solid fuels for their cooking do so on open stove or fire with no chimney or hood. More richer households who cook with solid fuels have some ventilation to alleviate indoor pollution than poorer ones. While 99.3 per cent of the poorest households cook their food on open stove or fire with no chimney or hood, this percentage decreases to 92.8 for the richest households, of whom 7 per cent have a chimney or hood. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 32 VII. Environment Water and Sanitation Safe drinking water and sanitation are basic necessities for good health. Contaminated drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. The most common cause of bacteriological contamination of water is exposure to faecal matter of human origin. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, as women tend to bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one third. The indicators used in Myanmar MICS are as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Access to improved sanitation facilities The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tube well/bore hole, protected well, protected spring, or rainwater collection. Bottled water is considered as an improved water source only if the household uses an improved water source for other purposes, such as hand washing and cooking. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 33 Overall, 82.3 per cent of the population use an improved source of drinking water – 93.2 per cent in urban areas and 77.6 per cent in rural areas. The lowest coverage of improved sources of drinking water is found in Kayin, with 51.1 per cent and Rakhine with 57.7 per cent. In Shan (East), 99 per cent of the population get their drinking water from an improved source. Among the poorest households 66.8 per cent use an improved source of water, while in the richest households the percentage rises to 95. The source of drinking water for the population varies across states and divisions (Table EN.1). Only 4.1 per cent of Myanmar household population have water piped into their dwelling12. The percentage is as high as 31.3 per cent in Chin State, a location where it is common to use bamboo pipes to bring water from a protected spring into the dwelling (in this case the water at the point of consumption cannot be defined as safe). In Kayah, Tanintharyi and Yangon, 10.6, 11.1 and 11.3 per cent respectively use water piped into dwelling. In contrast, in several states and divisions less than one per cent has water piped into their dwelling. The most common sources of drinking water in Myanmar are tube well/bore-hole (31.5 per cent) and protected well (27.2 per cent), but as many as 10.9 per cent use unprotected wells. The use of unprotected well is high in Kayah (23.8 per cent), Kayin (43.9 per cent) and Rakhine (37.2 per cent). In Magwe 10.6 per cent rely on surface water. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink. Boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all households, for households using improved sources and households using unimproved drinking water sources. In Myanmar, the most common way of treating water is to strain it through a cloth (76.2 per cent), a practice which will not make water safe to drink. While 33.1 per cent of household population boil their water, only 1.4 per cent use a water filter and 0.6 per cent add bleach or chlorine. As many as 12.2 per cent do not use any water treatment method, and 9.5 per cent let their water stand and settle. Overall, 34.5 per cent of the household population use an appropriate water treatment method. Out of those using improved water sources, 35.3 per cent treat their water with an appropriate method, and 31 per cent of those with unimproved water sources do so. 12 The term ‘piped water’ may have been interpreted differently among enumerators, to include not only water piped through the main public pipes, but also self-made structures made of bamboo. ©UNICEF Myanmar/2009/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 34 The urban population is more likely than the rural population to treat their water with an appropriate method, with 39 and 32.6 per cent respectively. The lowest level of appropriate water treatment is found in Bago (West), with 9.2 per cent. Water treatment is also low in Rakhine (18.1 per cent) and Ayeyarwaddy (18.7 per cent). The highest level of household water treatment is found in Kayah (84.3 per cent) and Chin (83.2 per cent), where the preferred method is boiling. Among the poorest households, 25.2 per cent use an appropriate water treatment method, while 40.5 per cent do so in the richest households. The amount of time it takes to obtain water is presented in Table EN.3, and the person who usually collects the water in Table EN.4. Note that these results refer to one round-trip from home to drinking water source. Information on the number of trips made in one day was not collected. The longer it takes to collect water, the less water will be collected. This has a detrimental effect on hygiene, especially for people who are unable to go to the water source to bathe. Table EN.3 shows that for 35 per cent of households, the drinking water source is on the premises. For half of all households (50.6 per cent), it takes less than 15 minutes to get to the water source and bring water, and 10.4 per cent need 15-30 minutes for one round-trip to the water source. Only 0.5 per cent of households spend more than one hour collecting water. Urban-rural differentials show that in urban areas 64.2 per cent of the population have water on their premises, while 31.2 per cent spend less than 15 minutes to collect water. By contrast, in rural areas 24.1 per cent have water on their premises, and 57.8 per cent of the population spend under 15 minutes to collect water. Among the poorest households, only 10.5 per cent have water on their premises, and as many as 17.7 per cent spend 15-30 minutes to collect water. In comparison, 74.5 per cent of the richest households have water on their premises, and most of the remaining households in this category can get their water in less than 15 minutes. Excluding the households with water on their premises, the average time spent in rural areas (10.1 minutes) on collecting water is only slightly higher than in urban areas (7.3 minutes). The highest average time spent collecting water is found in Chin, with 16.8 minutes per round-trip. In Shan (North), Shan (South), Magwe, and Mandalay, households who do not have water on their premises need more than 12 minutes on average to collect water. Table EN.4 shows that in the majority of households (71.9 per cent) an adult female is usually the person collecting water, when the source of drinking water is not on the premises. Adult men collect water in 24.1 per cent of cases, while for the rest of the households, female or male children under age 15 collect water (2.5 per cent and 1.4 per cent). While the use of children for collecting water is generally low, gender differences can be observed among adults, varying across area of residence. In rural areas an adult woman collects the water in 72.7 per cent of households, compared to 66.9 per cent in urban areas. Gender differences in water collection are most pronounced in Rakhine, where an adult woman collects water in 93.4 per cent of households, and men collect water in 5.2 per cent of households. Men’s involvement in water collection is also low in Chin, where men collect water in only 10.2 per cent of households. Only in Yangon do more men (52.7 per cent) than women (43.5 per cent) collect water. Gender differences in water collection also vary according to socioeconomic status. While a woman collects water in 76.5 per cent of the poorest households, and a man in 18.8 per cent; in the richest households, women collect water in 65.5 per cent of the cases and men in 31.9 per cent of cases. Inadequate disposal of human excreta and poor personal hygiene is associated with a range of ailments including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include: flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine, pit latrine Myanmar Multiple Indicator Cluster Survey 2009 - 2010 35 with slab, and composting toilet. Information on sanitary facilities is based on the facility household members access in their homes, and does not capture the type of facility used by household members who leave the home during the day for work or school. Overall, 84.6 per cent of the population of Myanmar live in households with improved sanitation facilities (Table EN.5). The table indicates that access to improved sanitation facilities is strongly correlated with wealth and area of residence. In urban areas 94.4 per cent of the population have access to sanitary means of excreta disposal, compared to 80.4 per cent in rural areas. Residents of Rakhine (48 per cent) and Shan (North) (68.3 per cent) are the least likely to have access to improved facilities. In contrast 93.8 per cent of the population in Yangon have access to improved sanitation facilities. Only 59.8 per cent of the poorest population have access to improved facilities, compared to 98.2 per cent among the richest population. In both urban and rural areas, the most common toilet facility is a pit latrine with slab, which is in 53.5 per cent of the urban households and 69.8 per cent of the rural households. In urban areas it is also common to have a toilet flushing to septic tank/pit (32.3 per cent). This type of facility is in more than half (51.8 per cent) of the richest households in Myanmar, but only 0.2 per cent of the poorest. It is interesting to note that in Rakhine 40.7 per cent of the population have no toilet facilities and use bushes or fields for excreta disposal. In Magwe this percentage is 10.1, and in Chin 9.2. Population without access to sanitary facilities are found almost exclusively in rural areas, with 9.7 per cent of the rural population not having access to sanitary facilities. In contrast less than one per cent in urban areas lack sanitary facilities. While no one in the richest quintile in Myanmar live without a toilet facility, 25.5 per cent of the poorest population have no access to a sanitary facility. An overview of the percentage of household members both using improved sources of drinking water and having access to a sanitary means of excreta disposal is presented in Table EN.6. In Myanmar 72.3 per cent of the population both use improved sources of drinking water and have access to a sanitary means of excreta disposal. This figure is strongly correlated with wealth and area of residence. While two thirds (65.2 per cent) of the rural population both use improved sources of drinking water and have access to a sanitary means of excreta disposal, this proportion rises to 88.8 per cent in urban areas. Use of improved sources of drinking water and access to a sanitary means of excreta disposal is lowest in Rakhine (30.1 per cent). Coverage of improved sanitation facilities and water sources also extends to less than two thirds of the population in Kayin (42.1 per cent), Kayah (59.7 per cent) and Shan (North) (59.7 per cent). The highest coverage of improved sources of drinking water and sanitary excreta disposal facilities is found in Shan (East), with 91 per cent. Only 43.1 per cent of the poorest quintile in Myanmar both use an improved source of drinking water and have access to improved sanitation facilities, contrasting with 93.6 per cent of the richest quintile. ©UNICEF Myanmar/2010/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 36 VIII. Reproductive Health Contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception was reported by 46 per cent of ever-married women (Table RH.1). The most popular method is the injection, which is used by nearly one in three (27.5 per cent) of ever- married women in Myanmar. The next most popular method is the pill, which is used by 11.5 per cent of the ever-married women. Only 2.1 per cent use IUD and 3.6 per cent of women reported female sterilization. Less than one per cent uses male condoms, male sterilization, the lactational amenorrhea method (LAM), abstinence, implants and withdrawal. Contraceptive prevalence among ever-married women is highest in Yangon at 58.7 per cent and almost as high in Bago (West) and Shan (East) at 51.9 and 51.1 per cent respectively. In Chin, contraceptive use is rare; only 7.8 per cent of ever-married women use any method. Other states and divisions with low contraceptive prevalence are Kayah State (32.3 per cent), Kayin (36 per cent), Magwe (38 per cent), Tanintharyi (38.4 per cent), Kachin (38.7 per cent) and Shan (North) (39 per cent). Contraceptive prevalence is higher in urban areas (51.3 per cent) than in rural areas (43.7 per cent). Fewer women over 40 use contraception than in the other age groups. Only 18.6 per cent of ever-married women aged 45–49 use a method of contraception. The highest level of contraceptive prevalence is found among women aged 25-29, with 55.3 per cent. Women’s education level is strongly associated with contraceptive prevalence. The proportion of women using any method of contraception rises from 31.5 per cent among those with no education to 44.3 per cent among women with primary education, and to 52.5 per cent among women with secondary or higher education. Contraceptive use is highest among women with two children, at 53.3 per cent. The coverage is 29.3 per cent among women with no children, while 36 per cent of women with four or more children use contraceptives. The prevalence of contraceptive use increases from 38.3 per cent in the poorest wealth quintile to 51.7 per cent among the richest women. Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide a route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care attendant. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of sexually transmitted infections (STIs) can significantly improve foetal outcomes and improve maternal health. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 37 Adverse outcomes, such as low birth weight, can be reduced through a combination of interventions to improve women's nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits, based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anaemia • Weight/height measurement (optional) Coverage of antenatal care is relatively high in Myanmar, as the findings in Table RH.3 indicate. A total of 93.1 per cent receive antenatal care one or more times during their pregnancy, from any type of provider. The coverage of antenatal care is slightly higher in urban areas (98.3 per cent) than in rural areas (91 per cent). The lowest level of antenatal care coverage is found in Shan (North) with 63.2 per cent, contrasting with 99.6 per cent in Mon State. Most women with secondary or higher education (97.5 per cent) receive antenatal care at least once during pregnancy, compared to 91.7 per cent of women with primary education and 80.3 per cent of women with no education. Nearly all women from the richest households receive antenatal care at least once during pregnancy, while 86.2 per cent of the poorest women do so. The type of personnel providing antenatal care to ever-married women aged 15-49 years who gave birth in the two years preceding the survey is presented in Table RH.2. In Myanmar, 83.1 per cent of women receive antenatal care from a skilled provider. The lowest level of antenatal care from a skilled provider is found in Chin (50 per cent) followed by Shan (North) (53.9 per cent), compared to (96.7 per cent) in Mon. Coverage of antenatal care from a skilled provider is 95 per cent in urban areas and 78.4 per cent in rural areas. Among skilled antenatal care providers, midwives provide the largest proportion of antenatal care (53.7 per cent) followed by medical doctors (20 per cent) and lady health visitors (LHVs) and nurses (9.4 per cent). A larger proportion of women in urban areas receive antenatal care from doctors or lady health visitors and nurses (46.8 per cent and 13.4 per cent respectively for urban and 9.2 and 7.8 per cent respectively, for rural areas), whereas a larger proportion of women in rural areas receive antenatal care from midwives (61.3 per cent for rural and 34.7 per cent for urban areas). The percentage of women receiving antenatal care from doctors and LHVs/nurses increases with women’s education status and wealth quintiles, whereas the reverse finding is observed for midwives. Among women with primary education, 78.4 per cent receive antenatal care from a skilled provider, while 92.2 per cent of women with secondary or higher education receive antenatal care from a skilled provider. The corresponding rate for women with no education is 65.7 per cent. Whereas nearly all (97.4 per cent) of the richest women receive antenatal care from a skilled provider, 70.7 per cent of the poorest women do so. The types of services pregnant women received are shown in Table RH.3. Among women who received antenatal care one or more times during their pregnancy, 80.1 per cent had their blood pressure measured, 63.6 per cent had their weight measured and 56.9 per cent had a urine sample taken. Additionally, 76.9 per cent of women received vitamin B1 tablets, and 83.7 per cent received iron Myanmar Multiple Indicator Cluster Survey 2009 - 2010 38 tablets as part of their antenatal care. It is interesting to note that content of antenatal care varies across the country. Chin, Rakhine and Shan (North) display the lowest percentages on most measures when compared with other states and divisions. In Chin, for example, only 16.2 per cent of the women had a urine sample taken, and 37.3 per cent had their weight measured. In Mon, on the other hand, more than 90 per cent of pregnant women received these services as part of their antenatal care. Fewer women in rural areas than in urban areas received all aspects of antenatal care during their pregnancy. While 94.3 per cent of urban women had their blood pressure measured, 74.4 per cent of rural women had this done. Similarly, 84.5 per cent of urban women had a urine sample taken, compared to 45.8 per cent of rural women. While 88.9 per cent of urban women had their weight measured as part of antenatal care, the corresponding rate for rural women is 53.4 per cent. Coverage rates on all aspects of antenatal care increase with the education level of women and wealth quintiles. For example, it is worth noting that 48.7 per cent of the women with primary education had their urine specimen taken, and 54.6 per cent had their weight measured, while 70.6 per cent of women with secondary or higher education had a urine sample taken and 77.7 per cent had their weight measured. Most (97.8 per cent) of the richest women had their blood pressure measured, 87.1 per cent had a urine sample taken and 90.7 per cent had their weight measured, contrasting with the poorest women of whom 62.9 per cent had their blood pressure measured, 35.7 per cent had a urine specimen taken, and 43.7 per cent had their weight measured. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure that a competent health worker with midwifery skills is present at every birth and that transport is available to a referral facility for obstetric care in case of an emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress towards the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS questionnaire included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant in Myanmar refers to a doctor, nurse or midwife. Although auxiliary midwives receive six months training, they are not taken as skilled attendance for delivery in Myanmar. Table RH.4 shows 70.6 per cent of births occurring in the two years prior to the interview were attended by skilled personnel. This percentage is highest in Shan (East) (94.5 per cent). Chin, Shan (North) and Ayeyarwaddy has a smaller proportion of delivery by skilled personnel (38.9, 42.8 and 54 per cent respectively) than other states and divisions. More than one in three of the births (36.3 per cent) in the two years prior to the MICS interview were delivered with assistance by a midwife. Doctors assisted with the delivery of 28.2 per cent of births, a traditional birth attendant assisted with delivery of 17.7 per cent, auxiliary midwives assisted in 7.6 per cent of births and LHVs/nurses assisted with 6.1 per cent of deliveries. More than half of the women were attended during delivery by a midwife in Tanintharyi (54.2 per cent) and Sagaing (54 per cent), while in Yangon the most common type of birth attendant is a medical Myanmar Multiple Indicator Cluster Survey 2009 - 2010 39 doctor (60.8 per cent). States and divisions with largest proportion of delivery by a traditional birth attendant are Ayeyarwaddy (35.2 per cent), Rakhine (30.2 per cent), Bago (East) (29.6 per cent) and Chin (25.1 per cent). It is notable that in Shan (North) as many as 24.9 per cent of women delivered their baby without any assistance at all. In Chin State this is also high at 10.4 per cent. The proportion of skilled attendance at delivery is higher in urban areas (89.6 per cent) than in rural areas (63 per cent). The smallest proportion of delivery by skilled personnel is found among adolescent females (aged 15–19 years), at 59 per cent. The education level of women and the socioeconomic status of households are associated with the rate of delivery by skilled personnel. The more educated a woman is, the more likely she is to have delivered with the assistance of a skilled attendant (46.8 per cent for women with no education, 62.2 per cent for women with primary education, and 85.3 per cent for women with secondary or higher education). Women from the poorest households received assistance from skilled attendants during delivery in 51 per cent of cases, compared to 96.1 per cent of women from the richest households. Overall, 36.2 per cent of women delivered in a health facility, either government or private. Chin has the smallest proportion of delivery in health facility (5.6 per cent) followed by Rakhine (11.7 per cent), Magwe (16.9 per cent) and Bago (East) (19 per cent). The highest rate of delivery in health facility is found in Yangon, with 68.9 per cent. Prevalence of delivery in health facility varies with women’s background characteristics, similar to assistance at delivery by skilled personnel. While 65.2 per cent of urban babies are delivered in a health facility, only 24.5 per cent of rural babies are delivered in a health facility. Among women with primary education 24.7 per cent delivered in a health facility, compared to 54 per cent of women with secondary or higher education. The corresponding figure for women with no education is only 10.3 per cent. Among the poorest women, as few as 12.4 per cent delivered their baby in a health facility, contrasting with 77.5 per cent of the richest women. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 40 IX. Child Development It is well recognized that a period of rapid brain development occurs in the first three to four years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, adults' engagement in activities with children is an important indicator of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, or drawing things. For over half (57.9 per cent) of the children younger than five years, an adult engaged in more than four activities that promote learning and school readiness during the three days preceding the interview (Table CD.1). The average number of activities that adults engaged in with children was 3.8. The father’s involvement with one or more such activities was at 44 per cent. More adults engage in learning activities with older children than with infants. While adult household members had engaged in learning activities with 40.5 per cent of children aged 0-23 months, the proportion rises to 70.5 per cent among children aged 24-59 months. There are no gender differentials in terms of adult activities with children; neither for household members in general or for fathers. A larger proportion of adults engaged in learning and school readiness activities with children in urban areas (71.2 per cent) than in rural areas (52.4 per cent). More urban fathers engaged in activities with their children (48.5 per cent) than rural fathers (42.1 per cent). Strong variation can be seen by region and socioeconomic status. Adult engagement in activities with children was greatest in Yangon (79.1 per cent) and lowest in Rakhine (33.5 per cent). In Bago (West) 66.2 per cent of fathers had engaged in one or more activity promoting learning, in contrast to 25.1 per cent in Kayah. Adult household members had engaged in learning activities with 75.7 per cent of children in the richest households, as opposed to 41.6 per cent of those living in the poorest households. While 50.3 per cent of children in the richest households had engaged in one or more activities with their father, only 37.4 per cent of children in the poorest households had done so. The education level of adults influences their engagement in learning activities with ©UNICEF Myanmar/2008/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 41 children. Of children whose mother has secondary or higher education, 69.3 per cent experienced an adult household member engaging in four or more learning activities with them in the three days prior to the MICS interview. Among children whose mother has primary education, adult household members had engaged in learning activities with 53.5 per cent of them. Fathers with secondary or higher education were similarly more likely to engage in learning activities with children (51.8 per cent) than fathers with only primary education (44.5 per cent). Myanmar Multiple Indicator Cluster Survey 2009 - 2010 42 X. Education Pre-school attendance and school readiness Attendance to pre-school education in an organized learning or child education programme is important for the readiness of children to school. One of the World Fit for Children goals is the promotion of early childhood education. Overall 22.9 per cent of Myanmar children aged 36–59 months are attending early childhood education. There is no difference between boys and girls. Urban–rural differences are, however, visible with 39.1 per cent of children in urban areas attending early childhood education, compared to 15.9 per cent in rural areas. The highest rate of attendance is found in Kayah, being as high as 60.7 per cent, and the lowest in Rakhine with 5.4 per cent. Children aged 48-59 months are far more likely (32.9 per cent) to attend than 36-47 months old children (13.8 per cent). The mother’s education level considerably influences whether or not a child attends early childhood education. It is found that 35.7 per cent of children whose mothers have secondary or higher education are attending early childhood education, compared to 15.8 per cent of the children whose mothers have primary education only. Socioeconomic status is another important factor. As many as 46 per cent of children in the richest households attend early childhood education, while the rate for the poorest is as low as 7.6 per cent. Table ED.1 also shows the proportion of children in the first grade of primary school who attended pre-school the previous year, an important indicator of school readiness. Overall, 39.8 per cent of children currently attending first grade attended pre-school in the previous year. More than half (52.8 per cent) of first-graders in urban areas had attended pre-school in previous year, compared to 34.4 per cent in rural areas. Mothers’ education is again shown to play a role in children’s enrolment in pre- school. It is found that 44.5 per cent of first graders whose mothers have secondary or higher education attended pre-school in the previous year, compared to 39.7 per cent of first graders whose mothers have primary education. Differences according to socioeconomic status can also be seen, with 34.5 per cent of first graders in the poorest households having had the opportunity to attend pre-school, and 51.7 per cent of the richest children having done so. ©UNICEF Myanmar/2009/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 43 Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment and influencing population growth. The indicators for primary and secondary school attendance include: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Primary school attendance rate of children of secondary school age • Female to male education ratio (or gender parity index - GPI) The indicators of school progression include: • Transition rate to secondary school • Net primary completion rate It should be noted that the indicators do not take into account seasonal variation in school attendance or how regularly children attend school. The Myanmar MICS was conducted from June 2009 to March 2010. The school year in Myanmar begins in June; therefore many of the children living in households that were interviewed in 2010 may have already turned one year older than when they began the school year back in June 2009. Therefore during the data analyses for education indicators children living in households interviewed in 2010 were rejuvenated by one year so they would still be included in the respective net attendance ratios at the age they most likely began the current school year. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 44 Table ED.2 shows the percentage of children aged five, which is the primary school entry age in Myanmar, who are currently attending grade one. As shown, 74.4 per cent of five-year-olds are attending school, with no difference between boys and girls. The difference between urban and rural areas is very slight, with 77.4 and 73.3 per cent respectively. Among the country’s states and divisions, the highest rate is found in Tanintharyi with 93 per cent, compared to 58.6 per cent in Shan (North). While 81.5 per cent of five-year olds whose mothers have secondary or higher education are attending first grade, 75.2 per cent of those whose mothers have primary education have entered school. There is a visible gap between children from the poorest and the richest households when it comes to timely entry in school. While 80.7 per cent of children aged five in the richest households are in first grade, 63.5 per cent of children from the poorest households have entered primary school. Table ED.3 provides the percentage of children of primary school age, which is 5–9 years, attending primary or secondary school. The majority of children of primary school age are attending school (90.2 per cent). This means, however, that close to 10 per cent of the children are out of school. At the national level there is no notable difference between boys and girls. Slightly more children in urban areas (93 per cent) than in rural areas (89.2 per cent) are attending. Primary school-aged children in Tanintharyi are most likely to attend school at 98 per cent, compared to 75.8 per cent in Rakhine. It is interesting to note that while only 77.3 per cent of 5-year-olds are attending school, 95 per cent of both 7- and 8-year-olds are in school, indicating that several children begin school late. A total of 94.9 per cent of children from the richest households are in school, compared to 81.4 per cent from the poorest households. The secondary school net attendance ratio in Myanmar is presented in Table ED.4. More notable than in primary school where 10 per cent of primary school aged children are not attending school at all, is the fact that only 58.3 per cent of the children of secondary school age are attending secondary school. Of the remaining children, some of them are either out of school or attending primary school. The difference in secondary school attendance between urban and rural areas is a lot more pronounced than it is for primary school attendance. While 76 per cent of children in urban areas attend secondary school, the rate in rural areas is 52 per cent. The secondary school attendance rate is as high as 74.7 per cent in Yangon, but only 30.9 per cent in Rakhine. The importance of mothers’ education for children’s school attendance is also here notable. While 83.9 per cent of children whose mothers have secondary or higher education, attend secondary school, only 54.1 per cent of children whose mother has primary education, do so. Where the mother has no education, the rate is 31.2 per cent. It is also interesting to note that secondary school attendance varies according to age. Only half of 10-year-olds ©UNICEF Myanmar/2010/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 45 are in secondary school, but this increases to 67.4 per cent for 11- and 12-year-olds. Only 45.2 per cent of 15-year-olds attend secondary school. Socioeconomic status has a strong impact on attendance in secondary school. Only 28.2 per cent of children from the poorest households are in secondary school, while the figure for children from the richest households is as high as 85.5 per cent. The rate of secondary school age children attending primary school is presented in Table ED.4A. Overall, 11.9 per cent of children aged 10-15 years attend primary school in Myanmar. The findings do, however, vary strongly across the age group. While 40.2 per cent of children aged 10 are still in primary school, from age 13 (3 per cent) and onwards the percentage is very low. More children in rural areas tend to be in primary school despite being of secondary school age, at 13.6 per cent, compared to 7.3 per cent of urban children. In Shan (North) 19.8 per cent of secondary school age children are still in primary school, while the rate drops to 7.2 per cent in Yangon. It is notable that while as many as 19.4 per cent of secondary school age children in the poorest households attend primary school, only 5 per cent of children in the richest households are still in primary school. The grade promotion rate between grade one and grade five is presented in Table ED.5. It should be noted that this rate is calculated based on information regarding which grade children attend in the current year as well as the previous year. Children who dropped out of school at an earlier time than last school year, or children who repeat grades, do not enter the calculation. For Myanmar the grade promotion rate has been calculated as 93.3 per cent. The rate is lowest in Bago (West) at 86.6 per cent, but reaches more than 90 per cent in most states and divisions. Grade promotion rate is highest among children in the richest households at 98.9 per cent, but it is also as high as 83.2 per cent among children in the poorest households. The net primary school completion rate and transition rate to secondary education are presented in Table ED.6. Only 54.2 per cent of children of primary school completion age, which in Myanmar is nine years of age, are attending the last grade of primary education. This value should be distinguished from the gross primary completion ratio which includes children of any age attending the last grade of primary school. As already noted above, there is a tendency for children to begin school later than at age five. The overall percentage of Myanmar children who complete primary school is therefore likely to be higher than the net primary school completion rate. Geographical location has a strong influence on whether children complete primary school on time. A total of 66.6 per cent of 9-year-olds in urban areas are in the last grade of primary school, as opposed to 49.6 per cent of 9-year-olds in rural areas. While 72.3 per cent of 9-year-olds in Tanintharyi are in the last grade of primary, the lowest rate is found in Rakhine with 31.7 per cent. The education level of children’s mothers, as well as their households’ socioeconomic status, is of high importance. It is remarkable that only 31.2 per cent of 9-year-old children from the poorest households have reached the last grade of primary, compared to 78.7 per cent of 9-year-olds from the richest households. A total of 95.3 per cent of the children that successfully completed the last grade of primary school were found to be attending the first grade of secondary school. This rate is lower among children from the poorest households at 87.2 per cent, and reaches 99.6 per cent among children from the richest households. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). The ratios included here are obtained from net attendance ratios rather than gross attendance ratios. The gross ratios can provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary education tend to be boys. The table shows that gender parity for primary school is 1.01 at Myanmar Multiple Indicator Cluster Survey 2009 - 2010 46 the national level, indicating no difference in the attendance of girls and boys to primary school. The exact same result is found for secondary school gender parity. Nonetheless it can be seen that while for primary school this rate remains close to the national average, regardless of socioeconomic status and geographic location, the value for secondary education varies more. In Shan (East) the primary school gender parity index is 1.11, and for secondary school 1.26. This means that more girls than boys attend school, and the tendency becomes more pronounced after reaching secondary school. Secondary school aged girls are at a disadvantage in Rakhine (0.85) and Shan (North) (0.92). ©UNICEF Myanmar/2010/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 47 Young Female Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. In MICS, because only a women’s questionnaire was administered, the results are based only on females aged 15–24 years. Literacy was assessed on the ability of women to read a short, simple statement or on school attendance. Individuals who had secondary or higher education were assumed to be literate and were not asked to do the reading test. The percentage of literate young women is presented in Table ED.8. Overall, 87.8 per cent of young Myanmar women are literate. The percentage is higher in urban areas at 94.9 per cent than in rural areas, at 84.9 per cent. The rate differs markedly with place of residence, with young women in Kachin most likely to be literate (96.4 per cent). Rakhine has the lowest literacy rate with 54.6 per cent. It is interesting to note that only 73.4 per cent of young women with primary education are literate, indicating that one in every four young women who have attended primary school, not counting the ones who have moved on to secondary school, are still unable to read simple sentences about everyday life. Socioeconomic differences are also visible. Among young women in the poorest households, 69 per cent are literate, while among the richest the literacy rate is as high as 96.6 per cent. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 48 XI. Child Protection Birth Registration The Convention on the Rights of the Child articles 7 and 8 state that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator used in MICS is the percentage of children under five years of age whose birth is registered. In Myanmar, birth registration is administered through the Department of Health. Basic health staff and midwives fill in the relevant forms when a child is born and forward them to the Township Medical Office. The only authorized person to sign the birth certificates is the Township Medical Officer. Because of the central role of health staff in the process, children who are born in health facilities are generally more likely to receive a birth certificate than other children. Obstacles in the process tend to include a lack of forms for registration, distances to travel for people living in remote areas and the cost of health staff having to travel to the Township Medical Office. Furthermore, the utility of a birth certificate is not clear. Showing a birth certificate is not required to obtain immunization or for school enrolment but is nevertheless a crucial proof of age. A parallel channel for registering the birth of a child is through the General Administration Department. The local authorities’ letter of endorsement of the birth is often the one used for obtaining a National Registration Card at age 10. During the MICS interview, mothers or caregivers of children under five were asked to show the child’s birth certificate. If the certificate was not shown, they were asked whether the child’s birth had been registered. It was not well specified which type of registration was being asked about, so it is likely that respondents would have reported registration both through health staff and through local administrative authorities. The births of 72.4 per cent of children under five years in Myanmar have been registered (Table CP.1). Births of boys and girls are equally often registered. More births are registered in urban areas, at 93.5 per cent, than in rural areas, at 63.5 per cent. The rate of birth registration varies across states and divisions, with Yangon and Shan (East) highest, at 95.2 and 95.4 per cent respectively, and Chin lowest, at 24.4 per cent. The education of mothers is highly important for the birth of a child to be registered. Whereas 85.3 per cent of children whose mothers have secondary or higher education have birth registration, only 52.4 per cent of children whose mothers have no education have had their birth registered. Along the same lines, 50.4 per cent of children in the poorest 20 per cent of households are registered, while 95.9 per cent of children in the richest quintile are registered. Among children whose births are not registered, the most common reason given is that the main caregiver did not know the child should be registered (34 per cent). Myanmar Multiple Indicator Cluster Survey 2009 - 2010 49 Early Marriage Early marriage, before or around the age of 18, is a reality for many young girls. According to UNICEF's worldwide estimates, over 60 million women aged 20–24 were married/in union before the age of 18. Factors that influence early marriage rates include: the state of the country's civil registration system, which provides proof of age for children; the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. In many parts of the world, parents encourage the marriage of their daughters at an early age in hopes that the marriage will benefit them both financially and socially, while also relieving financial burdens on the family. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered as significant factors in determining a girl's risk of becoming married while still a child. Early marriage can, however, compromise the development of girls and often results in early pregnancy and social isolation, with little education and poor vocational training, thus reinforcing the gendered nature of poverty. The right to 'free and full' consent to a marriage is recognized in the Universal Declaration of Human Rights, with the recognition that consent cannot be 'free and full' when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all Forms of Discrimination Against Women mentions the right to protection from child marriage in article 16, which states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.“ While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights, such as the right to express their views freely, the right to protection from all forms of abuse and the right to be protected from harmful traditional practices, and is frequently addressed by the Committee on the Rights of the Child. Another international agreement related to child marriage is the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages. Young married girls are a unique, though typically invisible, group. Often required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while barely more than children themselves, married girls face constrained decision-making Myanmar Multiple Indicator Cluster Survey 2009 - 2010 50 and reduced life choices. Women who married at a younger age are often more likely to experience domestic violence. Closely related to the issue of early marriage is the age at which girls become sexually active. Women who were married before or around the age of 18 tend to have more children than those who married later in life. Internationally, pregnancy-related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. The indicator selected for Myanmar MICS is the percentage of young women and girls aged 15–19 currently married. As shown in Table CP.2, overall, 7.4 per cent of young women and girls aged 15 -19 in Myanmar are married. More girls and young women in rural areas (8.4 per cent) are married than girls in urban areas (5.1 per cent). Percentages vary strongly across states and divisions, with the highest rate of early marriage found in Shan (East), at 22.3 per cent. This means that one in every five females in Shan (East) is already married by the age of 15–19. Prevalence of early marriage is also high in Shan (North) and Shan (South), at 13.7 per cent and 11.2 per cent respectively. The lowest rate is found in Sagaing at 4.7 per cent. Girls and young women with secondary or higher education are less likely to be married than those with only primary education. The percentage married among young women with secondary and higher education is 5.2 per cent, while 12.4 per cent of girls with primary education only are married. Furthermore, 9 per cent of young women in the poorest 20 per cent of households are married, while on the other hand 4.3 per cent among the richest have entered into marriage. Orphans and Children’s Living Arrangements The care from parents and caregivers is crucial for children of all ages. According to article 18 of the CRC, parents or, as the case may be, legal guardians, have the primary responsibility for the upbringing and ©UNICEF Myanmar/2009/Myo Thame Myanmar Multiple Indicator Cluster Survey 2009 - 2010 51 development of a child; the best interests of the child should be their basic concern. Children rely on their parents or caregivers to provide them with appropriate food, clothes and shelter and to provide them with an environment in which they can fully develop to their best potential. Parents have the responsibility to ensure that their children receive preventive health services, such as immunization, and to seek appropriate medical care in the event of illness. As mentioned in the chapter on child development, it is widely recognized that spending time with adults on activities such as singing songs and reading stories is crucial for a young child’s mental development. Parents likewise can play a central role in children’s education by ensuring their enrolment and attendance in both early childhood education and in school from the appropriate age. Additionally, parents can help children succeed in their education by assisting them with homework and providing time and space for them to study, as much as possible. It is the responsibility of parents to protect children from harm, be healthy role models and to prepare children for life as adults. Children who are orphaned or not living with their parents may receive less adult guidance and support, and may be at increased risk of neglect or exploitation. Table CP.3 shows the percentage of children living with one or both parents and the percentage of orphans. In Myanmar 85.2 per cent of children live with both parents. This percentage does not vary across sex of child, urban and rural areas or socioeconomic status. It does, however, vary between states and divisions. The highest percentage of children living with both parents is found in Kayah and Shan (South) States, at 91.5 per cent each, while the lowest percentage is found in Mon State, at 65.4 per cent. In terms of age, 90.4 per cent of children aged 0-4 years live with both parents, while 78.9 per cent of children aged 15-17 do so. In total, 5.4 per cent of Myanmar children do not live with a biological parent. The highest rate is in Mon with as much as 18.7 per cent, and the lowest is in Rakhine at 1.3 per cent. It is interesting to note that while only 2.9 per cent of children in the poorest wealth quintile live without their parents, 7.1 per cent of children in the richest quintile do not live with their biological parents. Although the reason for children living without their parents was not asked, it is clear that the death of parents is not the primary cause; 3.8 per cent of children in Myanmar do not live with any of their parents, although both parents are alive. This rate is highest in Mon State, at 16.4 per cent. It is also high in Kayin, at 10.3 per cent, followed by Tanintharyi, at 9.2 per cent. Some 8 per cent of children live with their mother only, while only 1.3 per cent of children live with their father only. One or both parents of 6.6 per cent of Myanmar children have died. The rate is highest in Kachin State, at 8.4 per cent and lowest in Kayin, at 3.9 per cent. While 2 per cent of children aged 0-4 have lost one or both parents, 13.5 per cent of children aged 15-17 have lost one or both parents. This suggests that when reaching the age of 15-17, more than 1 of every 10 children will have lost at least one parent. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 52 XII. HIV /AIDS Knowledge of HIV Transmission One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and ways of preventing transmission. Correct information is the first step towards raising awareness and giving young people the tools to protect themselves from infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions although some appear to be universal, for example that sharing food can transmit HIV, or mosquito bites can transmit HIV. The UN General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal as well as the MDG of reducing HIV infections by half include improving the level of knowledge of HIV and its prevention and changing behaviours to prevent further spread of the disease. The HIV module was administered to all women 15-49 years of age. One indicator which is both an MDG and UNGASS indicator is the per cent of young women who have comprehensive and correct knowledge of HIV prevention and transmission. Women were asked whether they knew of the three main ways of preventing HIV transmission – having only one faithful uninfected partner, using a condom every time, and abstaining from sex. The results are presented in Table HA.1. In Myanmar, most of the interviewed women (95.4 per cent) have heard of AIDS. However, the percentage of women who know of all three main ways of preventing HIV transmission is only 45 per cent. Some 75 per cent of women know of having one faithful uninfected sex partner, 70.6 per cent know of using a condom every time, and 57.8 per cent know of abstaining from sex as main ways of preventing HIV transmission. While 86.1 per cent of women know at least one way, 13.9 per cent do not know any of the three ways. The lowest level of awareness of AIDS is found in Shan (North), where 66.6 per cent of women had heard of AIDS. In comparison, in Mon, Bago (West), Magwe, Tanintharyi and Yangon, more than 99 per cent of women had heard of the disease. Regarding prevention of HIV, there is very little difference between urban (47 per cent) and rural (44.1 per cent) areas in knowledge of all three ways of prevention. On the other hand, 91.3 per cent of urban women could identify at least one way, as opposed to 83.8 per cent in rural areas. In Chin State, only 22.2 per cent of women could identify all three ways of preventing HIV transmission, compared with 54.1 per cent in Shan (South). Knowledge of all three ways of prevention does not vary considerably between women with primary (45.5 per cent) or secondary or higher (48.2 per cent) education, although more women with secondary (92 per cent) education than women with primary education (84.7 per cent) are able to identify at least one way. There is, however, a large gap in knowledge when compared with women without any education, of whom only 22.8 per cent can identify all three ways. Knowledge varies with socioeconomic background, but the proportion of women knowing all three ways of prevention is largest in the second-richest quintile (50.2 per cent). The lowest level of knowledge is found among the poorest women, at 37.3 per cent. While 76.7 per cent of women in the poorest households could identify at least one way of preventing transmission, this rises to 90.5 per cent among women in the richest households. Table HA.2 presents the percentage of women who can correctly identify misconceptions concerning HIV. The indicator is based on the two most common and relevant misconceptions in Myanmar, that Myanmar Multiple Indicator Cluster Survey 2009 - 2010 53 HIV can be transmitted by sharing food and by mosquito bites. The table also provides information on whether women know that HIV cannot be transmitted by supernatural means and that HIV can be transmitted by sharing needles. Of the interviewed women, 40.8 per cent reject the two most common misconceptions and know that a healthy-looking person can be infected. Some 75.9 per cent of women know that HIV cannot be transmitted by sharing food, and 66.1 per cent know that HIV cannot be transmitted by mosquito bites, while 59.7 per cent of women know that a healthy-looking person can be infected. Some 55 per cent of urban women can correctly identify misconceptions about HIV/AIDS, as opposed to 34.3 per cent of rural women. In Shan (East), only 26.4 per cent of women reject the two most common misconceptions and know that a healthy-looking person can be infected, while the rate in Yangon is 57.8. Age, educational background and socioeconomic status are also shown to influence awareness. Women aged 20–24 were found to be most likely to identify misconceptions, at 44.6 per cent, while the lowest level of identification of misconceptions was found in the 45-49 age group, at 33.9 per cent. Among women with primary education, 28.4 per cent correctly identified misconceptions, while 55.2 per cent of women with secondary or higher education were able to do so. Among the poorest women, 25.9 per cent rejected the most common misconceptions and know that a healthy-looking person can be infected, as opposed to 57.9 per cent of women in the richest households. Table HA.3 summarizes information from Tables HA.1 and HA.2 and presents the percentage of women who know two ways of preventing HIV transmission and reject three common misconceptions. Comprehensive knowledge of HIV prevention methods and transmission is still fairly low, although there are differences by area of residence. Overall, 30.1 per cent of women are found to have comprehensive knowledge. The percentage is higher in urban areas (41.2 per cent) than in rural areas (25 per cent). Comprehensive knowledge is lowest in Shan (East) (17.5 per cent) and greatest in Yangon (46.3 per cent). As expected, the proportion of women with comprehensive knowledge increases with their level of education (Figure HA.1). While 20.2 per cent of women with primary education Myanmar Multiple Indicator Cluster Survey 2009 - 2010 54 have comprehensive knowledge, this rate rises to 41.7 per cent for women with secondary or higher education. Only 17.3 per cent of women in the poorest households have comprehensive knowledge of HIV/AIDS transmission, compared to 42.5 per cent among the richest women. Knowledge varies with age, being lowest in the 45-49 age group (24.7 per cent) and greatest among the 20–24 age group (32.8 per cent). Comprehensive knowledge of HIV/AIDS transmission among young women aged 15–24 was found to be 31.8 per cent. Knowledge of mother-to-child transmission of HIV is an important first step for women to seek HIV testing when they are pregnant to avoid infection in the baby. Women should know that HIV can be transmitted during pregnancy, delivery and through breastfeeding. The level of knowledge among women aged 15–49 years concerning mother-to-child transmission is presented in Table HA.4. Overall, 87 per cent of women know that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 65 per cent, while 8.3 per cent of women did not know of any specific way. A total of 81.5 per cent of women know that HIV can be transmitted during pregnancy, 73.4 per cent know that HIV can be transmitted during delivery, and 75.6 per cent are aware that HIV can be transmitted through breast milk. There is no notable difference between urban (64.5 per cent) and rural (65.2 per cent) women on their knowledge of ways of HIV transmission from mother to child. In Bago (West), 79.6 per cent of women could identify all three ways HIV can be transmitted from mother to child, while the lowest percentage is found in Shan (North), at 39 per cent. It is interesting to note that the highest percentage of women knowing all three ways of transmission from mother to child is found in the second lowest socioeconomic group with 69.1 per cent. The indicators on attitudes towards people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four questions: 1) would care for family member sick with AIDS; 2) would buy fresh vegetables from a vendor who was HIV positive; 3) thinks that a female teacher who is HIV positive should be allowed to teach in school; and 4) would not want to keep HIV status of a family member a secret. Table HA.5 presents the attitudes of women towards people living with HIV /AIDS. Overall, 65.1 per cent of Myanmar women agree with at least one discriminatory statement about HIV /AIDS. The most negative attitude was expressed against buying vegetables from a person with HIV/AIDS (53.7 per cent), followed by the negative stance against allowing a female HIV-positive teacher to work (41.6 per cent). Considerably fewer women said they would not care for a family member with AIDS (11.8 per cent) or would want to keep it a secret if a family member was HIV-positive (10.7 per cent). There are notable variations on women’s attitudes towards people living with HIV /AIDS according to area of residence, education and socioeconomic background. While 53.7 per cent of urban women agree with at least one discriminatory statement, the rate rises to 70.5 per cent among rural women. The smallest proportion of women agreeing with a discriminatory statement is found in Chin State, at 50.8 per cent, as opposed to 80 per cent in Rakhine. Some 75.6 per cent of women with primary education only, agree with at least one discriminatory statement, compared with 55.3 per cent of women with secondary or higher education. Among women in the poorest households, 78.1 per cent expressed a discriminatory attitude towards people living with HIV/AIDS, while 51.2 per cent of women in the richest households did so. Another important indicator is the knowledge of where to be tested for HIV and the use of such services. Questions related to knowledge among women of a facility for HIV testing and whether they have ever been tested is presented in Table HA.6. In Myanmar 70.6 per cent of women know where they can be tested for HIV, while 17.6 per cent have actually been tested. Of them, a large proportion Myanmar Multiple Indicator Cluster Survey 2009 - 2010 55 has been told the result (91.5 per cent). In total, 82.1 per cent of urban women know of a place to get tested for HIV, compared with 65.3 per cent of rural women. As many as 91.5 per cent of women in Bago (West) know where they can be tested. The lowest level of awareness is found in Rakhine at 45.9 per cent. Similarly, as many as 33 per cent of urban women have been tested, while only 10.5 per cent of rural women have been tested. The highest rate of women who have been tested is in Yangon, at 42 per cent. The lowest rate is found in Chin and Rakhine at 3.3 per cent each. The education level and socioeconomic background of women influence both their knowledge of where to be tested for HIV, and whether they have actually been tested or not. Among women with primary education, 63 per cent know of a place to be tested, and 13 per cent have been tested. In comparison, 82.2 per cent of women with secondary or higher education know where to go for an HIV test and 23 per cent have been tested. One half (50.7 per cent) of women from the poorest households know of a place they can go to for an HIV test, and 5.9 per cent have been tested. Among women from the richest households, 84 per cent know where they can be tested, and 33 per cent have been tested.   Myanmar Multiple Indicator Cluster Survey 2009 - 2010 56 List of References Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16. Filmer, D. and Pritchett, L., 2001. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. UNICEF, 2006. Monitoring the Situation of Children and Women. Multiple Indicator Cluster Survey Manual, New York. Union of Myanmar Ministry of Health. Five-Year Strategic Plan for Child Health Development in Myanmar (2010-2014). Nay Pyi Taw. Union of Myanmar Ministry of Immigration and Population, Department of Population, 2009. Country Report on 2007 Fertility and Reproductive Health Survey. Nay Pyi Taw. United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN www.Childinfo.org. Myanmar Multiple Indicator Cluster Survey 2009 - 2010 57 ©UNICEF Myanmar/2009/Saw Thein Win Myanmar Multiple Indicator Cluster Survey 2009 - 2010 58 59 Ta bl e H H .1 : R es ul ts o f h ou se ho ld a nd in di vi du al in te rv ie w s N um be r of h ou se ho ld s, w om en , a nd c hi ld re n un de r fi ve b y re su lt s of t he h ou se ho ld , w om en 's a nd u nd er -fi ve 's in te rv ie w s, a nd h ou se ho ld , w om en 's a nd u nd er -fi ve 's r es po ns e ra te s, M ya nm ar , 2 00 9- 20 10 A re a St at e/ D iv is io n U rb an Ru ra l Ka ch in Ka ya h Ka yi n Ch in M on Ra - kh in e Sh an (N or - th ) Sh an (E as t) Sh an (S ou - th ) A ye - ya r- w ad dy Ba go (E as t) Ba go (W es t) M ag w e M an - da la y Sa - ga in g Ta ni n- th ar yi Ya ng on To ta l N um be r of h ou se ho ld s Sa m pl ed 8, 34 0 20 ,9 10 1, 26 0 1, 17 0 1, 29 0 1, 17 0 1, 53 0 1, 59 0 1, 41 0 1, 20 0 1, 35 0 2, 91 0 1, 59 0 1, 44 0 2, 16 0 2, 94 0 2, 40 0 1, 29 0 2, 55 0 29 ,2 50 O cc up ie d 8, 34 0 20 ,9 10 1, 26 0 1, 17 0 1, 29 0 1, 17 0 1, 53 0 1, 59 0 1, 41 0 1, 20 0 1, 35 0 2, 91 0 1, 59 0 1, 44 0 2, 16 0 2, 94 0 2, 40 0 1, 29 0 2, 55 0 29 ,2 50 In te rv ie w ed 8, 33 1 20 ,9 07 1, 25 8 1, 17 0 1, 29 0 1, 16 9 1, 53 0 1, 59 0 1, 40 3 1, 20 0 1, 35 0 2, 91 0 1, 59 0 1, 44 0 2, 16 0 2, 93 8 2, 40 0 1, 29 0 2, 55 0 29 ,2 38 Re sp on se r at e 99 .9 10 0. 0 99 .8 10 0. 0 10 0. 0 99 .9 10 0. 0 10 0. 0 99 .5 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 99 .9 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r of w om en El ig ib le 11 ,8 08 27 ,2 17 1, 82 0 1, 71 3 1, 60 9 1, 50 7 1, 87 8 2, 16 9 1, 98 7 1, 32 8 1, 72 8 3, 58 6 2, 23 8 1, 62 3 2, 87 3 4, 15 4 3, 45 1 1, 67 6 3, 68 5 39 ,0 25 In te rv ie w ed 11 ,5 68 26 ,5 13 1, 63 1 1, 68 5 1, 59 0 1, 49 4 1, 87 3 2, 16 8 1, 95 7 1, 31 8 1, 71 7 3, 53 6 2, 10 6 1, 61 7 2, 82 9 3, 96 7 3, 29 8 1, 63 7 3, 65 8 38 ,0 81 Re sp on se r at e 98 .0 97 .4 89 .6 98 .4 98 .8 99 .1 99 .7 10 0. 0 98 .5 99 .2 99 .4 98 .6 94 .1 99 .6 98 .5 95 .5 95 .6 97 .7 99 .3 97 .6 O ve ra ll re sp on se r at e 97 .9 97 .4 89 .5 98 .4 98 .8 99 .1 99 .7 10 0. 0 98 .0 99 .2 99 .4 98 .6 94 .1 99 .6 98 .5 95 .4 95 .6 97 .7 99 .3 97 .5 N um be r of c hi ld re n un de r 5 El ig ib le 4, 25 3 11 ,3 21 94 7 1, 09 7 1, 03 3 92 5 73 6 93 6 89 4 52 9 75 7 1, 39 9 82 1 40 0 86 1 1, 11 2 94 4 59 0 1, 59 3 15 ,5 74 M ot he r/ Ca re ta ke r in te rv ie w ed 4, 23 8 11 ,3 01 92 9 1, 09 7 1, 03 1 92 5 73 6 93 6 89 0 52 9 75 7 1, 39 8 81 7 40 0 86 1 1, 11 2 94 1 58 8 1, 59 2 15 ,5 39 Re sp on se r at e 99 .6 99 .8 98 .1 10 0. 0 99 .8 10 0. 0 10 0. 0 10 0. 0 99 .6 10 0. 0 10 0. 0 99 .9 99 .5 10 0. 0 10 0. 0 10 0. 0 99 .7 99 .7 99 .9 99 .8 O ve ra ll re sp on se r at e 99 .5 99 .8 97 .9 10 0. 0 99 .8 99 .9 10 0. 0 10 0. 0 99 .1 10 0. 0 10 0. 0 99 .9 99 .5 10 0. 0 10 0. 0 99 .9 99 .7 99 .7 99 .9 99 .7 60 Table HH.2: Household age distribution by sex Per cent distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, Myanmar, 2009-2010 Males Females Total Number Per cent Number Per cent Number Per cent Age 0-4 7,521 11.3 7,112 9.5 14,632 10.4 5-9 7,249 10.9 7,074 9.5 14,323 10.1 10-14 6,699 10.0 6,856 9.2 13,555 9.6 15-19 5,768 8.6 6,347 8.5 12,115 8.6 20-24 5,187 7.8 6,299 8.4 11,486 8.1 25-29 5,259 7.9 6,405 8.6 11,664 8.3 30-34 5,206 7.8 5,950 8.0 11,156 7.9 35-39 5,023 7.5 5,717 7.7 10,740 7.6 40-44 4,290 6.4 5,014 6.7 9,304 6.6 45-49 3,650 5.5 3,783 5.1 7,433 5.3 50-54 3,211 4.8 4,156 5.6 7,366 5.2 55-59 2,378 3.6 2,874 3.9 5,252 3.7 60-64 1,874 2.8 2,289 3.1 4,162 2.9 65-69 1,228 1.8 1,606 2.2 2,834 2.0 70-74 1,044 1.6 1,325 1.8 2,370 1.7 75-79 624 0.9 942 1.3 1,566 1.1 80+ 493 0.7 798 1.1 1,291 0.9 Missing/DK 8 0.0 12 0.0 20 0.0 Dependency age groups < 15 21,468 32.2 21,041 28.2 42,510 30.1 15-64 41,846 62.7 48,833 65.5 90,679 64.2 65 + 3,390 5.1 4,671 6.3 8,060 5.7 Missing/DK 8 0.0 12 0.0 20 0.0 Children aged 0-17 25,135 37.7 24,919 33.4 50,054 35.4 Adults 18+/Missing/ DK 41,577 62.3 49,638 66.6 91,215 64.6 Total 66,712 100.0 74,557 100.0 141,269 100.0 61 Table HH.3: Household composition Per cent distribution of households by selected characteristics, Myanmar, 2009-2010 Weighted per cent Number of households Weighted Unweighted Sex of household head Male 83.2 24,334 24,412 Female 16.8 4,904 4,826 State/Division Kachin 2.4 714 1,258 Kayah 0.5 145 1,170 Kayin 2.8 824 1,290 Chin 1.0 298 1,169 Mon 4.6 1,333 1,530 Rakhine 6.2 1,819 1,590 Shan (North) 3.7 1,093 1,403 Shan (East) 1.5 428 1,200 Shan (South) 4.7 1,379 1,350 Ayeyarwaddy 8.9 2,589 2,910 Bago (East) 6.2 1,821 1,590 Bago (West) 5.3 1,562 1,440 Magwe 9.2 2,688 2,160 Mandalay 14.5 4,250 2,938 Sagaing 11.2 3,266 2,400 Tanintharyi 2.5 742 1,290 Yangon 14.7 4,286 2,550 Area Urban 29.6 8,658 8,331 Rural 70.4 20,580 20,907 Number of household members 1 1.2 357 352 2-3 24.5 7,174 6,986 4-5 43.1 12,590 12,375 6-7 21.8 6,386 6,616 8-9 7.2 2,097 2,232 10+ 2.2 634 677 Total 100.0 29,238 29,238 At least one child aged < 18 years 78.4 29,238 29,238 At least one child aged < 5 years 42.0 29,238 29,238 At least one woman aged 15-49 years 90.6 29,238 29,238 62 Table HH.4: Women's background characteristics Per cent distribution of women aged 15-49 years by background characteristics, Myanmar, 2009-2010 Weighted per cent Number of women Weighted Unweighted State/ Division Kachin 2.6 996 1,631 Kayah 0.5 205 1,685 Kayin 2.6 987 1,590 Chin 1.0 370 1,494 Mon 4.1 1,577 1,873 Rakhine 6.3 2,385 2,168 Shan (North) 3.9 1,498 1,957 Shan (East) 1.2 456 1,318 Shan (South) 4.5 1,701 1,717 Ayeyarwaddy 8.1 3,075 3,536 Bago (East) 6.5 2,470 2,106 Bago (West) 4.5 1,697 1,617 Magwe 9.0 3,446 2,829 Mandalay 15.2 5,791 3,967 Sagaing 11.9 4,530 3,298 Tanintharyi 2.4 928 1,637 Yangon 15.7 5,967 3,658 Area Urban 31.5 12,011 11,568 Rural 68.5 26,070 26,513 Age 15-19 15.7 5,984 6,126 20-24 15.7 5,988 5,982 25-29 16.2 6,179 6,117 30-34 15.2 5,787 5,780 35-39 14.7 5,579 5,567 40-44 12.9 4,900 4,882 45-49 9.6 3,663 3,627 Marital status Ever-married 60.6 23,070 23,593 Never-married 39.4 15,011 14,488 Motherhood status of ever-married women Ever gave birth 92.0 21,232 21,835 Never gave birth 8.0 1,838 1,758 Education None 6.7 2,542 3,127 Primary 39.4 15,010 14,652 Secondary + 51.2 19,492 19,396 Non-standard curriculum 2.7 1,037 906 Wealth index quintiles Poorest 18.5 7,035 6,597 Second 19.6 7,475 7,217 Middle 19.8 7,535 7,826 Fourth 20.4 7,781 8,064 Richest 21.7 8,256 8,377 Total 100.0 38,081 38,081 63 Table HH.5: Children's background characteristics Per cent distribution of children under five years of age by background characteristics, Myanmar, 2009-2010 Weighted per cent Number of under-five children Weighted Unweighted Sex Male 51.4 7,980 7,923 Female 48.6 7,558 7,616 State/Division Kachin 3.7 570 929 Kayah 0.9 145 1,097 Kayin 4.5 701 1,031 Chin 1.6 250 925 Mon 4.4 680 736 Rakhine 7.3 1,137 936 Shan (North) 5.4 835 890 Shan (East) 1.3 200 529 Shan (South) 5.3 822 757 Ayeyarwaddy 8.5 1,322 1,398 Bago (East) 6.4 1,000 817 Bago (West) 3.0 461 400 Magwe 7.3 1,138 861 Mandalay 11.0 1,708 1,112 Sagaing 8.8 1,364 941 Tanintharyi 2.3 360 588 Yangon 18.3 2,844 1,592 Area Urban 29.6 4,593 4,238 Rural 70.4 10,946 11,301 Age < 6 months 9.

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